Stoma formation for functional bowel disease.

OBJECTIVE: To assess the results of stoma formation for functional bowel disease. METHODS: A retrospective study of the indications for and complications of stoma formation in this group. A quality of life questionnaire was sent to the group. RESULTS: A very small proportion of patients with functional bowel disease have a stoma formed (< 1%). Stoma formation is often associated with problems requiring further operations. Their QOL is reported as poor and is improved upon by stoma formation. Most patients with a temporary stoma elected to keep it rather than suffer their previous problems. CONCLUSION: Some patients with functional bowel disease can be successfully managed by stoma formation. Their treatment is difficult, emotionally demanding and labour-intensive.

Retrospective classification of prostate-specific antigen tests: differentiating screening from diagnostic clinical encounters.

To assess the validity of retrospective medical chart review as a method of classifying prostate-specific antigen (PSA) tests as screening or diagnostic services, we reviewed PSA tests ordered at a university hospital (n = 95). PSA tests were reviewed by four raters: medicine resident (RES), oncologist (ONC), urologist (UR), medicine attending (GM)-and the physician who ordered the PSA test (ATTEND) using predefined standardized criteria. Agreement rates by individual rater and ATTEND were 0.79 (GM), 0.80 (ONC), 0.74 (UR), 0.83 (RES), for a composite percent agreement of 0.79. ATTEND incorrectly classified seven tests; exclusion of these tests raised agreement rates to 0.86 (GM), 0.86 (ONC), 0.80 (UR), 0.90 (RES), for a group composite percent agreement of 0.86. Of note, two raters had higher agreement rates when evaluating screening PSA tests than when evaluating diagnostic PSA tests. Standardized criteria applied to medical charts provide a valid method of retrospectively classifying PSA tests.

Current methods of the US Preventive Services Task Force: a review of the process.

The U.S. Preventive Services Task Force (USPSTF/Task Force) represents one of several efforts to take a more evidence-based approach to the development of clinical practice guidelines. As methods have matured for assembling and reviewing evidence and for translating evidence into guidelines, so too have the methods of the USPSTF. This paper summarizes the current methods of the third USPSTF, supported by the Agency for Healthcare Research and Quality (AHRQ) and two of the AHRQ Evidence-based Practice Centers (EPCs). The Task Force limits the topics it reviews to those conditions that cause a large burden of suffering to society and that also have available a potentially effective preventive service. It focuses its reviews on the questions and evidence most critical to making a recommendation. It uses analytic frameworks to specify the linkages and key questions connecting the preventive service with health outcomes. These linkages, together with explicit inclusion criteria, guide the literature searches for admissible evidence. Once assembled, admissible evidence is reviewed at three strata: (1) the individual study, (2) the body of evidence concerning a single linkage in the analytic framework, and (3) the body of evidence concerning the entire preventive service. For each stratum, the Task Force uses explicit criteria as general guidelines to assign one of three grades of evidence: good, fair, or poor. Good or fair quality evidence for the entire preventive service must include studies of sufficient design and quality to provide an unbroken chain of evidence-supported linkages, generalizable to the general primary care population, that connect the preventive service with health outcomes. Poor evidence contains a formidable break in the evidence chain such that the connection between the preventive service and health outcomes is uncertain. For services supported by overall good or fair evidence, the Task Force uses outcomes tables to help categorize the magnitude of benefits, harms, and net benefit from implementation of the preventive service into one of four categories: substantial, moderate, small, or zero/negative. The Task Force uses its assessment of the evidence and magnitude of net benefit to make a recommendation, coded as a letter: from A (strongly recommended) to D (recommend against). It gives an I recommendation in situations in which the evidence is insufficient to determine net benefit. The third Task Force and the EPCs will continue to examine a variety of methodologic issues and document work group progress in future communications.

Stroking human jejunal mucosa induces 5-HT release and Cl- secretion via afferent neurons and 5-HT4 receptors.

5-Hydroxytryptamine (5-HT) release and neural reflex pathways activated in response to mucosal stroking were investigated in muscle-stripped human jejunum mounted in modified Ussing chambers. The mucosa was stroked with a brush at 1/s for 1-10 s. Mucosal stroking resulted in a significant increase in the concentration of 5-HT in the mucosal bath within 5 min. It also was associated with a reproducible positive change (Delta) in short-circuit current (Isc), which was abolished by inhibitors of chloride secretion. Capsaicin and hexamethonium significantly inhibited the DeltaIsc but not the release of 5-HT. The DeltaIsc was inhibited by TTX but not by atropine. It was also inhibited by the 5-HT(3,4) receptor antagonist tropisetron (10 microM) and the 5-HT(4,3) receptor antagonist SDZ-205-557 (10 microM) but not by preferential antagonists of 5-HT(1P), 5-HT(2A), or 5-HT3 receptors. These results suggest that mucosal stroking induces release of mucosal 5-HT, which activates a 5-HT4 receptor on enteric sensory neurons, evoking a neuronal reflex that stimulates chloride secretion.

Long-chain alkenes of the haptophytes Isochrysis galbana and Emiliania huxleyi.

The major alkenes of the haptophytes Isochrysis galbana (strain CCAP 927/14) and Emiliania huxleyi (strains CCAP 920/2 and VAN 556) have been identified by nuclear magnetic resonance spectroscopy and by mass spectrometric analysis of their dimethyl disulfide adducts. The dominant alkene in I. galbana is (22Z)-1 ,22-hentriacontadiene, with 1,24-hentriacontadiene and 1,24-tritriacontadiene present in much lower abundance; (22Z)-1,22-hentriacontadiene also occurs in E. huxleyi (strain CCAP 920/2), together with (2Z,22Z)-2,22-hentriacontadliene (the major hydrocarbon) and (3Z,22Z)-3,22-hentriacontadiene. Minor abundances of 2,24-hentriacontadiene and 2,24-tritriacontadiene are also present in this strain. In contrast, the dominant alkene in E. huxleyi (strain VAN 556) is (15 E,22E)-1,16,23-heptatriacontatriene with the related alkatriene 1,15,22-octatriacontatriene also present and (22Z)-1,22-hentriacontadiene occurring as a minor component. From structural relationships (15E,22E)-1,15,22-heptatriacontatriene is proposed to derive from the same biosynthetic pathway as that of the characteristic C37 alkenones which occur in both E. huxleyi and I. galbana. The C31 and C33 dienes likely derive from chain extension and decarboxylation of (Z)-9-octadecenoic acid or (Z)-7-hexadecenoic acid, using a pathway analogous to that elucidated previously in the chlorophyte Botryococcus braunii. Therefore, long-chain dienes and trienes, which can co-occur in haptophytes, may have distinct biosynthetic pathways.

Lessons from the mammography screening controversy: can we improve the debate?

The debate about breast cancer screening for women in their 40s has become so contentious that effective communication and rational discussion on this topic have been compromised. This contentiousness might be defused by understanding the reasons for it. The debate is less about facts than it is about perceptions and values. There is disagreement about how to fairly describe facts about risk and how to avoid misperceptions that may distort assessment of risk. Other sources of disagreement concern the potential harms of screening, the relative roles of physicians and patients in decision making, and how to factor cost into screening decisions. The entire decision-making process has also been highly charged by single-issue advocacy groups and a kind of gender rivalry. Several approaches might help defuse the debate and improve discussion. First, those on both sides of the debate might agree on several things: 1) that the evidence from clinical trials is widely agreed-upon and thus that a main task now is to factor in the values of individual women who are making decisions; 2) that the values of women may differ substantially and that those differences should be respected; 3) that both individuals and the public should be fully and fairly informed about the pros and cons of screening; and 4) that cost-effectiveness should at least be considered during the decision-making process. Lessons from this debate may apply to other medical problems that have small degrees of risk and whose management is strongly debated.

Race and mammography use in two North Carolina counties.

OBJECTIVES: This study investigated racial differences in mammography use and their association with physicians' recommendations and other factors. METHODS: The study used 1988 survey data for 948 women 50 years of age and older from the New Hanover Breast Cancer Screening Program. Racial differences in terms of physician recommendation, personal characteristics, health characteristics, and attitudes toward breast cancer and mammography were examined. Factors at least minimally associated with race and use were included in multivariate logistic regression analyses to examine the effect of race while controlling for other factors. RESULTS: In comparison with White women. Black women were half as likely to report ever having had a mammogram (27% vs 52%) and having a mammogram in the past year (17% vs 36%). Black women also significantly less often reported physician recommendation (25% vs 52%). Although Black and White women differed significantly in other characteristics, multivariate logistic regression analyses indicated that physician recommendation accounted for 60% to 75% of the initial racial differences in mammography use. CONCLUSIONS: Understanding physicians' recommendations for breast cancer screening is a critical first step to increasing mammography use in disadvantaged populations.

The role of the 5-HT4 receptor in Cl- secretion in human jejunal mucosa.

5-Hydroxytryptamine (5-HT) is a mediator of chloride ion (Cl-) secretion in the intestine which can be seen as a rise in short circuit current (Isc) in the Ussing chamber model. We investigated the 5-HT receptor mediating 5-HT-induced Cl- secretion in the human jejunum in vitro. Jejunal segments obtained from patients having gastric bypass surgery for obesity, were stripped of muscularis and mounted in Ussing chambers and short-circuited. The 5-HT receptor agonist-induced change (delta) in Isc was recorded in the presence and and absence of 5-HT receptor antagonists. The rank order of agonist potency was: 5-HT > 5-methoxytryptamine > renzapride (BRL 24924 > alpha-methyl-5-HT >> 2-methyl-5-HT. In the presence of Cl(-)-free media or 100 microM furosemide, 5-HT-induced delta Isc was significantly reduced. It was also antagonized by > or = 1 microM tropisetron (a 5-HT 3/5-HT4 receptor antagonist) and > or = 10 nM GR 113808 (a selective 5-HT4 receptor antagonist) with pA2 values of 6.5 and 7.9, respectively. Another 5-HT4 receptor antagonist, SC 53606 (0.1 microM), antagonized the 5-HT-induced response with a pA2 of 7.3 5-HT1-like/5-HT2 (methysergide), 5-HT1P [N-acetyl-5-hydroxytryptophyl 5-hydroxytryptophan amide (5-HT-DP], 5-HT2A (ketanserin) and 5-HT3 (ondansetron) receptor antagonists and tetrodotoxin, had no significant effect on the EC50 for 5-HT. In conclusion, this study demonstrates that in the human muscle-stripped jejunum in vitro, 5-HT induced change in short circuit current is mediated by a 5-HT4 receptor via a non-neural pathway.

5-Hydroxytryptamine-induced Cl- transport is mediated by 5-HT3 and 5-HT4 receptors in the rat distal colon.

In the rat distal colon, 5-hydroxytryptamine (5-HT)-induced Cl- secretion is seen as a rise in short circuit current (Isc). We investigated the 5-HT receptor mediating 5-HT-induced Cl- secretion in the rat distal colon. Rat distal colon was prepared either by stripping away the muscularis propria with the neural ganglia, or by leaving it intact. The tissue was mounted in Ussing chambers and short circuited. 5-HT receptor agonist-induced changes (delta) in Isc were recorded in the presence and absence of 5-HT receptor antagonists. In stripped preparations, the rank order of potency of agonists was: 5-HT > 5-methoxytryptamine > alpha-methyl-5-HT >> 2-methyl-5-HT. 5-HT and 5-methoxytryptamine-induced changes in Isc were antagonized by > or = 0.3 microM tropisetron with pA2 values 6.5 and 6.4, respectively. The 5-HT4 antagonist, SC 53606, antagonized the 5-HT-induced response with a pA2 of 7.2. 5-HT1-like (methysergide), 5-HT1P (N-acetyl-5-hydroxytryptophyl 5-hydroxytryptophan amide (5-HTP-DP)), 5-HT2A (ketanserin) and 5-HT3 (ondansetron) receptor antagonists had no significant effect on the 5-HT response in stripped tissue. 3 microM forskolin, or 10 microM 3-isobutyl-1-methyl-xanthine (IBMX), decreased the EC50 and increased the maximum 5-HT response. The 2-methyl-5-HT and 5-HT-induced delta Isc in the unstripped colon preparation were antagonized by the 5-HT3 antagonist, ondansetron (0.3 nM), and 2-methyl-5-HT activity was abolished by pretreatment with tetrodotoxin. In conclusion, 5-HT-induced delta Isc is neurally mediated via a 5-HT3 receptor, and non-neurally mediated via a 5-HT4 receptor in the rat distal colon.

Medicare reimbursement for preventive care. Changes in performance of services, quality of life, and health care costs.

A randomized, controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians' offices for patients aged 65 years or older. A total of 1,914 patients from 10 primary-care medical practices in central North Carolina were randomized within practices to an intervention and a usual-care control group. The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages (thus making these services free for patients), regular prompting of physicians to routinely schedule preventive care visits, a new office system in which nurses carried out many preventive procedures, and a form for charting preventive care. The performance of screening tests dramatically increased in the intervention group relative to control (P < 0.001), but there was evidence of lack of follow-up of abnormal findings by physicians. At the 2-year follow-up, there were minimal differences between intervention and control groups in health-related quality-of-life indicators. Relative to the $294 per patient 3-year cost to Medicare for waivered services, the intervention was reimbursed-cost neutral or slightly cost reducing ($190 over 3 years) for Medicare. It is concluded that adding reimbursement for preventive services to Medicare--even with the office systems changes made in this study--will not by itself lead to effective implementation of preventive services in community medical practices. To enhance patient benefit from preventive services, greater attention needs to be focused on an organized approach to patient follow-up.

Implementing continuous quality improvement in primary care: implications for preventive services.

The implementation of CQI must be done in a manner that capitalizes on the challenges of primary care, including the professional autonomy of the physician, the availability of data, issues of cost and efficiency of service, and the expanding role of patient expectations in quality care. Analysis of these factors is based on an ongoing study designed to help community-based primary care practices increase the utilization of prevention and early detection services offered to patients.

Improving clinical breast examination training in a medical school: a randomized controlled trial.

To evaluate a new program for teaching clinical breast examination, a class of 156 second-year medical students were randomized into an experimental group (practice and feedback on silicone breast models and women volunteers) and a control group (lecture only). During a simulated practical clinical examination routinely conducted at the end of the second year, the experimental group students used more suggested palpation techniques during a patient examination (4.6 vs 2.0; p < 0.0001) and found more simulated lumps in a silicone model (4.7 vs 4.4; p < 0.05). Practice with immediate feedback is more effective than lecture alone in teaching clinical breast examination.

Difficulties in diagnosis of carcinoma of the breast in patients less than fifty years of age.

Delay in diagnosis of carcinoma of the breast is a significant cause of medical malpractice suits in the United States. Although less than one-third of the patients with carcinoma of the breast are less than 50 years of age, more than two-thirds of these suits involve women less than 50 years of age. To see whether or not there are medical factors that make diagnosis in young women more difficult, we reviewed all patient visits to the East Carolina University (ECU) Breast Clinic between 1 January 1988 and 30 June 1991. Women less than 50 years of age had many more patient visits (1,567 versus 838 visits) and many fewer carcinomas detected (38 versus 100 visits) than women who were more than 50 years old. The sensitivity and positive predictive value of mammography were significantly lower in young women than older women (68 versus 91 percent, p < 0.005, and 28 versus 53 percent, p < 0.001, respectively). Physical examination in young women was also less satisfactory. Tumors were more ill-defined and the percent that were easily palpable were significantly lower (45 versus 72 percent, p < 0.01). Furthermore, there was a basic difference in the reason tumors were not palpable in each age group. In older women, tumors were nonpalpable because they were small (mean size 1.0 versus 4.1 centimeters, p < 0.01), whereas in younger women, the non-palpable tumors were large (mean size 4.0 versus 3.4 centimeters), suggesting that they were not palpable because of background mammary density or diffuse growth pattern rather than size. Data from the Breast Cancer Detection Demonstration Project were analyzed and also suggested that carcinomas are more difficult to diagnose in young women. The percent of carcinomas that were not detectable by either mammogram or physical examination were inversely proportional to age and ranged from 36 percent at 40 years of age to 9 percent at 75 years of age. In addition, data from Blue Cross and Blue Shield and the ECU Breast Clinic indicated that it costs at least twice as much to diagnose each carcinoma in women less than 50 years of age. In conclusion, we believe that currently available techniques for diagnosis of carcinoma of the breast are not satisfactory for women less than 50 years of age and that this, rather than physician error, may account for the large number of malpractice suits in this age group.

Life-sustaining treatments during terminal illness: who wants what?

OBJECTIVE: To determine patient characteristics associated with the desire for life-sustaining treatments in the event of terminal illness. DESIGN: In-person survey from October 1986 to June 1988. SETTING: 13 internal medicine and family practices in North Carolina. PATIENTS: 2,536 patients (46% of those eligible) aged 65 years and older who were continuing care patients of participating practices, enrolled in Medicare. The patients were slightly older than the 65+ general population, 61% female, and 69% white, and most had one or more chronic illnesses. MEASUREMENTS AND MAIN RESULTS: The authors asked the patients whether they would want each of six different treatments (hospitalization, intensive care, cardiopulmonary resuscitation, surgery, artificial ventilation, or tube feeding) if they were to have a terminal illness. The authors combined responses into three categories ranging from the desire for more treatment to the desire for less treatment. After adjustment for other factors, 53% of women chose less treatment compared with 43% of men; 35% of blacks vs 15% of whites and 23% of the less well educated vs 15% of the better educated expressed the desire for more treatment. High depression scores also were associated with the desire for more treatment (26% for depressed vs 18% for others). CONCLUSION: Patients' choices for care in the event of terminal illness relate to an intricate set of demographic, educational, and cultural factors. These results should not be used as a shortcut to determine patient preferences for care, but may provide new insights into the basis for patients' preferences. In discussing choices for future life-sustaining care, physicians need to explore with each individual the basis for his or her choices.

Increasing mammography utilization: a controlled study.

BACKGROUND: Despite the effectiveness of breast cancer screening for women older than 50 years of age, only about one third of these women in the United States receive annual mammography. PURPOSE: This study was designed to determine if a community-wide intervention could increase use of mammography screening for breast cancer. Secondary end points were determination of changes in women's knowledge and attitudes toward mammography and physicians' self-reported screening practices. METHODS: We conducted a controlled study from January 1987 through January 1990 in two eastern North Carolina communities--New Hanover County (the experimental community) and Pitt County (the control community). Before development and implementation of the intervention program in New Hanover County and after the program had been in operation for 1 year, 500 women of ages 50-74 years and all primary-care physicians in each community were interviewed by telephone. In these interviews, we determined the use of mammography for breast cancer screening and the knowledge and attitudes about it. We also established the number of screening mammograms performed in 1987 and 1989 in each county and reviewed medical records to determine the percentage of women the physicians had referred for mammograms. RESULTS: The percentage of women who reported receiving a mammogram in the previous year increased from 35% to 55% in the experimental community and from 30% to 40% in the control community (difference of differences, 10%; P = .03 after adjustment for race, education, age, and having a regular doctor; 95% confidence interval, 1%-18%). Increases were greater in New Hanover County regardless of age, race, income, and education. However, the increase was less for Black women than for White women, both overall and in most demographic subgroups. The total number of mammograms performed increased 89% in the experimental community and 45% in the control community. Women's knowledge about mammography changed little, but the intention to get a mammogram increased 30% in New Hanover County, compared with a 17% increase in Pitt County--a statistically significant difference (P < .01). Physician reports and medical record reviews in the two communities showed similar increases in the number of mammograms ordered. CONCLUSIONS: A community-wide effort to increase use of breast cancer screening was successful, but more work must be done to reach the National Cancer Institute's goal of annual mammograms for 80% of women of ages 50-74.

Mammography and age: are we targeting the wrong women? A community survey of women and physicians.

To determine mammography use among women with a broad range of ages, the authors surveyed women aged 30 to 74 years and physicians practicing primary care in two eastern North Carolina counties. Twenty-five percent of women in their 30s had ever had a mammogram, and 34% intended to have one in the coming year. From 45% to 52% of women in their 40s, 50s, and 60s had ever had a mammogram, and 55% to 57% intended to have one in the next year. Thirty-seven percent of women aged 70 to 74 years had ever had a mammogram, and 40% intended to have one in the following year. Nineteen percent of physicians reported screening nearly all women aged 30 to 39 years, and 14% screened few women aged 50 to 74 years. Younger women were more worried about breast cancer than older women and assessed their risk as higher, attitudes that were generally associated with higher mammography utilization. These community surveys suggest that mammography use may be excessive among younger women; older women continue to be underscreened.

Prevention and early detection activities in primary care: new directions for implementation.

Physicians in primary care generally do not perform recommended prevention and early detection services. Many factors influence the utilization of these services; however, often not considered and/or well understood is the very process whereby these services are adopted within the primary care setting. Understanding the process, and factors affecting the process, suggest new directions for designing and implementing effective intervention strategies which increase the use of such services. New directions include the importance of identifying a discrepancy between what the practice is doing vis-à-vis what it should be doing as the first stage in the adoption process; the identification of the particular stage within the overall adoption process which best characterizes the practice and tailoring specific interventions to the requirements of that stage; emphasizing the reshaping of work actually performed within the practice beyond simply changing knowledge and attitudes of physicians and support personnel; recognition that there is a changing set of expectations to which the practice is at risk to be held accountable in any litigation; and finally that the interventions have realistic time expectations.

Prompting physicians for preventive procedures: a five-year study of manual and computer reminders.

Prompting physicians increases performance of preventive procedures, but the long-term effects of prompting, and of different types of prompting (manual versus computer), on various procedures is unclear. Nor has the effect of the optional enrollment of patients by physicians into a prompting system been studied. We examined performance of eight preventive procedures in a university-based general medical practice during three successive periods over five years: no prompting, nurse-initiated prompting, and computerized prompting. Performance of seven prompted procedures for all patients (regardless of whether they had been enrolled) was significantly increased over the five-year period from 38% (no prompting) to 43% (nurse prompting) to 53% (computer prompting). Among the procedures, influenza vaccination (12% to 59%) and mammography (4% to 33%) showed the greatest increases in performance, while fecal occult blood testing and Pap smears showed no increase or slight declines. Enrollment of patients in the optional prompting system was strongly related to performance. Overall performance of procedures for the enrolled group increased to 68%, while that of the unenrolled group remained at 37%. However, after we adjusted for differences in the percentage of patients enrolled, overall performance for the nurse system (49%) differed little from that for the computer system (55%). Manual and computer prompts had similar effects, but the computer system prompted for more patients. Though prompting remained effective five years after initiation, performance did not increase for unenrolled patients or for some procedures. Understanding these patient- and procedure-specific barriers not addressed by prompting is necessary to increase further physician performance of preventive procedures.