Using Practice Facilitation to Increase Rates of Colorectal Cancer Screening in Community Health Centers, North Carolina, 2012-2013: Feasibility, Facilitators, and Barriers.

INTRODUCTION: Practice facilitation involves trained individuals working with practice staff to conduct quality improvement activities and support delivery of evidence-based clinical services. We examined the feasibility of using practice facilitation to assist federally qualified health centers (FQHCs) to increase colorectal cancer screening rates in North Carolina. METHODS: The intervention consisted of 12 months of facilitation in 3 FQHCs. We conducted chart audits to obtain data on changes in documented recommendation for colorectal cancer screening and completed screening. Key informant interviews provided qualitative data on barriers to and facilitators of implementing office systems. RESULTS: Overall, the percentage of eligible patients with a documented colorectal cancer screening recommendation increased from 15% to 29% (P < .001). The percentage of patients up to date with colorectal cancer screening rose from 23% to 34% (P = .03). Key informants in all 3 clinics said the implementation support from the practice facilitator was critical for initiating or improving office systems and that modifying the electronic medical record was the biggest challenge and most time-consuming aspect of implementing office systems changes. Other barriers were staff turnover and reluctance on the part of local gastroenterology practices to perform free or low-cost diagnostic colonoscopies for uninsured or underinsured patients. CONCLUSION: Practice facilitation is a feasible, acceptable, and promising approach for supporting universal colorectal cancer screening in FQHCs. A larger-scale study is warranted.

Receptors for thyroid-stimulating hormone and thyroid hormones in human ovarian tissue.

Dysfunction in thyroid regulation can cause menstrual and ovulatory disturbances, the mechanism of which is not clear. The distribution and activity of the thyroid-stimulating hormone (TSHR), and the thyroid hormone receptors (TR) alpha1, alpha2 and beta1 in human ovarian tissue and in granulosa cells was studied using immunohistochemistry, reverse-transcriptase polymerase chain reaction (RT-PCR), quantitative PCR and immunoassays. Strong immunostaining of TSHR, TRalpha1 and TRbeta1 was observed in ovarian surface epithelium and in oocytes of primordial, primary and secondary follicles, with minimal staining in granulosa cells of secondary follicles. Granulosa cells of antral follicles expressed TSHR, TRalpha1 and TRbeta1 proteins. Messenger RNA for all receptors was present in ovarian tissue. Mature human granulosa cells expressed transcripts for 5' deiodinases types 2 and 3, but not type 1, indicating the possibility of conversion of peripheral thyroid hormone thyroxin (T(4)). Granulosa cells stimulated with TSH showed a significant increase in cAMP concentrations after 2 h of culture (P = 0.047), indicating activation through TSHR. Stimulation with T(4) resulted in increased extracellular signal-regulated kinase 1 and 2 activation after 10, 30, 60 min and 24 h. These data demonstrate that TSH and thyroid hormone receptors may participate in the regulation of ovarian function.

CONNECT Workshops to Enhance Physician and Patient Experience: Interviews Reveal the Physician Perspective.

INTRODUCTION: Physicians' relationships with patients are a critical determinant of job satisfaction, and patients who experience compassionate care have better outcomes. The CONNECT workshop at Seattle Children's teaches communication strategies to optimize both patient and physician experience. This article describes participants' experiences during the workshops and the impact on their subsequent behaviors and satisfaction. METHODS: Thirteen semistructured interviews were conducted with physicians, representing 11 specialties. Researchers used a series of immersion-crystallization cycles through which they iteratively immersed themselves in the data by reviewing all transcripts and coming up with key themes. According to thematic findings, they adjusted the interview guides, adding or deleting probes. After crystallizing an initial list of key themes, they created a codebook, coded using qualitative analysis software and met after coding each transcript to discuss their codes, add, and change codes, and recode when necessary. RESULTS: Researchers identified 2 thematic responses concerning workshop experience. Physicians valued colleague interaction (Theme A) and appreciated the nonprescriptive curriculum (Theme B). Likewise, 3 themes reflecting workshop impact also emerged. Physicians reported the workshop encouraged presence and self-awareness during patient encounters (Theme C). They learned to address patient-driven concerns (Theme D), and learned empathetic strategies to connect more deeply with patients (Theme E). CONCLUSION: This study offers perspectives from a diverse group of physicians concerning their experience with the communication workshop, including the opportunity for physicians to focus on self-discovery, authenticity, connect on a deeper level with colleagues, and adopt key strategies to enhance interactions with patients.

Researcher readiness for participating in community-engaged dissemination and implementation research: a conceptual framework of core competencies.

Participating in community-engaged dissemination and implementation (CEDI) research is challenging for a variety of reasons. Currently, there is not specific guidance or a tool available for researchers to assess their readiness to conduct CEDI research. We propose a conceptual framework that identifies detailed competencies for researchers participating in CEDI and maps these competencies to domains. The framework is a necessary step toward developing a CEDI research readiness survey that measures a researcher's attitudes, willingness, and self-reported ability for acquiring the knowledge and performing the behaviors necessary for effective community engagement. The conceptual framework for CEDI competencies was developed by a team of eight faculty and staff affiliated with a university's Clinical and Translational Science Award (CTSA). The authors developed CEDI competencies by identifying the attitudes, knowledge, and behaviors necessary for carrying out commonly accepted CE principles. After collectively developing an initial list of competencies, team members individually mapped each competency to a single domain that provided the best fit. Following the individual mapping, the group held two sessions in which the sorting preferences were shared and discrepancies were discussed until consensus was reached. During this discussion, modifications to wording of competencies and domains were made as needed. The team then engaged five community stakeholders to review and modify the competencies and domains. The CEDI framework consists of 40 competencies organized into nine domains: perceived value of CE in D&I research, introspection and openness, knowledge of community characteristics, appreciation for stakeholder's experience with and attitudes toward research, preparing the partnership for collaborative decision-making, collaborative planning for the research design and goals, communication effectiveness, equitable distribution of resources and credit, and sustaining the partnership. Delineation of CEDI competencies advances the broader CE principles and D&I research goals found in the literature and facilitates development of readiness assessments tied to specific training resources for researchers interested in conducting CEDI research.

Effectiveness of percutaneous flexor tenotomies for the management and prevention of recurrence of diabetic toe ulcers: a systematic review.

BACKGROUND: Diabetic toe ulcers are a potentially devastating complication of diabetes. In recent years, the percutaneous flexor tenotomy procedure for the correction of flexible claw and hammer-toe contraction deformities has been proposed as a safe and effective technique for facilitating the healing of toe-deformity related diabetic ulcers. The aim of this review is to critically appraise the evidence for the effectiveness of this surgical procedure in achieving ulcer healing, prevention of re-ulceration, and to summarise the rate of post-operative complications. METHOD: A search of medical databases, was performed to locate relevant literature. Titles were screened prior to abstract and full text review to identify articles relevant to the research question. Search terms included truncations of "tenotomy", "toe", "hallux", "digit", "diabetes" and "ulcer". Peer reviewed primary research study designs specified as suitable for systematic reviews by the Centre for Reviews and Dissemination were included. Studies were excluded if they used a concurrent secondary procedure or included non-diabetic patients without reporting outcomes separately. Included studies were appraised for quality using the Methodological Index for Non-Randomised Studies tool. Levels of evidence were subsequently assigned to each outcome of interest (healing rate and prevention of re-ulceration). RESULTS: From a total search yield of 42 articles, 5 eligible studies (all case series designs) were identified for inclusion. Included studies were of low-to-moderate methodological quality when assessed using the MINORS tool. A total of 250 flexor tenotomy procedures were performed in a total of 163 patients. Included studies generally reported good healing rates (92-100 % within 2 months) post-op follow-up), relatively few recurrences (0-18 % at 22 months median post-op follow-up), and low incidences of infection or new deformity. Transfer ulcers developing on adjacent areas as a result of shifted pressure were reported by several authors. The validity of these results is undermined by methodological limitations inherent to case series designs such as a lack of control groups, non-randomised designs, as well as inconsistent reporting of post-intervention follow-up periods. There was level 4 evidence for the flexor tenotomy procedure in facilitating ulcer healing and preventing re-ulceration. CONCLUSION: More definitive research evidence is needed in this area to determine whether or not the flexor tenotomy is a safe and effective treatment option for people with, or at risk of developing diabetic toe ulcers. Whilst the available literature reports that the procedure may be associated with high healing rates, relatively low recurrence rates and low incidences of post-op complications, methodological limitations restrict the value of these findings.

Development of a new diabetes medication self-efficacy scale and its association with both reported problems in using diabetes medications and self-reported adherence.

BACKGROUND: Although there are several different general diabetes self-efficacy scales, there is a need to develop a self-efficacy scale that providers can use to assess patient's self-efficacy regarding medication use. The purpose of this study was to: 1) develop a new diabetes medication self-efficacy scale and 2) examine how diabetes medication self-efficacy is associated with patient-reported problems in using diabetes medications and self-reported adherence. PATIENTS AND METHODS: Adult English-speaking patients with type 2 diabetes were recruited from a family medicine clinic and a pharmacy in Eastern North Carolina, USA. The patients were eligible if they reported being nonadherent to their diabetes medicines on a visual analog scale. Multivariable regression was used to examine the relationship between self-efficacy and the number of reported diabetes medication problems and adherence. RESULTS: The diabetes medication self-efficacy scale had strong reliability (Cronbach's alpha =0.86). Among a sample (N=51) of mostly African-American female patients, diabetes medication problems were common (6.1±3.1) and a greater number of diabetes medications were associated with lower medication adherence (odds ratio: 0.35; 95% confidence interval: 0.13, 0.89). Higher medication self-efficacy was significantly related to medication adherence (odds ratio: 1.17; 95% confidence interval: 1.05, 1.30) and inversely related to the number of self-reported medication problems (ß=-0.13; P=0.006). CONCLUSION: Higher diabetes medication self-efficacy was associated with fewer patient-reported medication problems and better medication adherence. Assessing medication-specific self-efficacy may help to identify medication-related problems that providers can help the patients address, potentially improving adherence and patient outcomes.

Distribution of cyclooxygenase-1, cyclooxygenase-2, and cytosolic phospholipase A2 in the luteal phase human endometrium and ovary.

OBJECTIVE: To identify the distribution of the enzymes cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2), and cytosolic phospholipase A(2) (cPLA(2)) in the human ovary and endometrium. DESIGN: Prospective clinical study. SETTING: Hospital-based unit for reproductive health and research laboratories. PATIENT(S): Twenty-nine healthy fertile women with normal menstrual cycles. INTERVENTION(S): Endometrial and ovarian biopsy samples were obtained from healthy, fertile women in the luteal phase of the menstrual cycle or during caesarean section. MAIN OUTCOME MEASURE(S): Pinopode formation and immunohistochemical staining of cPLA(2), COX-1, and COX-2. RESULT(S): In the endometrium, the immunostaining of cPLA(2) was most intense in the luminal epithelium when pinopodes were present. The staining of both COX-1 and COX-2 was most intense in the epithelial cells, with the stroma staining positive only for COX-2. The endometrial vessels expressed COX-2 but not COX-1. The staining of COX-1 and COX-2 was intense on the surface epithelial cells on the outer lining of the ovary. CONCLUSION(S): This study details the distribution of these prostaglandin synthase enzymes and emphasizes their importance for the functions of both the endometrium and the ovary.

Growth differentiation factor-9 promotes the growth, development, and survival of human ovarian follicles in organ culture.

Growth differentiation factor-9 (GDF-9) is a growth factor and a member of the TGFbeta superfamily that is secreted by oocytes in growing ovarian follicles. In the current study we cultured human ovarian follicles within slices of ovarian cortical tissue in the presence and absence of recombinant rat GDF-9. Ovarian tissue was obtained by biopsy during cesarean section (31 women) or gynecological laparoscopy (3 women). The mean age (+/-SD) of the women who donated tissue was 32.8 +/- 5.0 yr (range, 19-41 yr). In these biopsies a total of 900 follicles were analyzed. A significantly higher proportion of cultured primordial follicles showed growth initiation and reached the secondary stage of development in the presence of GDF-9. In serum-free cultures after 7 d, 53% of the follicles had reached the secondary stage with GDF-9 vs. 31% in the control group (P < 0.01). Follicle viability was also improved in the presence of GDF-9 after 7 d in culture (74% GDF-9 vs. 48% control), which resulted in a smaller reduction in follicle numbers due to atresia. Treatment with GDF-9 in vitro promoted the survival and progression of human follicular development to the secondary stage. This oocyte-derived factor may be essential for the development of somatic cells in early human follicles and useful in designing culture conditions for maturation of follicles and oocytes in vitro.

Kit ligand and c-Kit are expressed during early human ovarian follicular development and their interaction is required for the survival of follicles in long-term culture.

The receptor tyrosine c-Kit and its cognate ligand, c-Kit ligand (KL, stem cell factor, SCF), are involved in ovarian follicular development in several animal species. We studied the expression of KL and c-Kit using in situ hybridization and immunohistochemistry in donated human ovarian cortical tissue. The KL transcripts were expressed in granulosa cells of primary follicles, whereas the expression of c-Kit was confined to the oocyte and granulosa cells in primary and secondary follicles. We employed an ovarian organ culture using firstly serum-containing and then serum-free medium to study the effects of KL and an anti-c-Kit antibody, ACK2, on the development and survival of ovarian follicles in vitro. Culture of ovarian cortical slices for 7 days resulted in a 37% increase in the number of primary follicles and a 6% increase in secondary follicles. The proportion of viable follicles decreased in all cultures. The addition of KL (1, 10 and 100 ng/ml) into the culture media did not affect the developmental stages of the follicles or the proportion of atretic follicles. Inclusion of ACK2 (800 ng/ml) in the culture medium significantly increased the proportion of atretic follicles on days 7 (49 vs 28% in control cultures) and 14 (62 vs 38%) of culture. In conclusion, c-Kit and KL are expressed in human ovaries during follicular development. Blocking the c-Kit receptor induces follicular atresia. The KL/c-Kit signaling system is likely to control the survival of human ovarian follicles during early follicular development.

Benefits of 8-bromo-guanosine 3',5'-cyclic monophosphate (8-br-cGMP) in human ovarian cortical tissue culture.

Guanosine 3',5'-cyclic monophosphate (cGMP) is an important intracellular second messenger in many cells of the body; however, its importance in the ovary is only now being realized. The effects of the cGMP analogue 8-bromo-guanosine 3',5'-cyclic monophosphate (8-br-cGMP) were tested on human ovarian follicle development and survival using an established tissue culture method. Ovarian biopsies were collected from 27 women (mean age 32 years) undergoing Caesarean sections or gynaecological operations. Tissue was cut into small pieces and cultured in the presence or absence of 5 mmol/l 8-br-cGMP for 7 and 14 days. 8-br-cGMP enhanced the rate of follicle growth to the secondary stage after both 7 and 14 days of culture. Furthermore, it significantly improved the proportion of viable follicles when compared with control cultures. All cultured follicles reaching the secondary stage were smaller than those uncultured. This suggests that although granulosa cells were stimulated to proliferate and form a double layer, the cells themselves did not become larger as usually occurs with maturation and differentiation. Oestradiol production was greater in the 8-br-cGMP-containing cultures after 12 days compared with control cultures, presumably due to the concurrent increase in the proportion of secondary follicles. In the early stages of human ovarian tissue culture, 8-br-cGMP may be a necessary component as both a growth enhancer and survival factor.

Human ovarian tissue cultures: extracellular matrix composition, coating density and tissue dimensions.

Human ovarian tissue can be successfully cryopreserved for fertility preservation. Optimal use of this approach requires the development of reliable restoration methods, including in-vitro culture of follicles. A culture system has been established, but improvement of the basic handling and techniques is necessary. Ovarian biopsies were collected from 33 women, cut into small pieces and cultured for 7-14 days on an extracellular matrix. Three separate studies investigated tissue dimensions (slices and cubes), coating density of extracellular matrix (diluted, thin and thick), and different extracellular matrix compositions (regular Matrigel, growth factor reduced Matrigel and laminin). Initial recruitment of primordial follicles and reduction in follicle viability was observed in all cultures compared with uncultured tissue. After 7 days of culture, more viable follicles were present in the cubed tissue, which also showed significant activation of growth, observed in tissue slices only after 14 days of culture. A diluted coating of Matrigel supported a greater proportion of viable follicles in 7-day cultures, whereas composition of the extracellular matrix had no effect. Human ovarian follicles can grow and develop in vitro within cortical tissue, and may benefit from culture as cubes on diluted Matrigel. This technique may provide a solution to the successful recovery and growth of follicles from frozen human ovarian tissue even though it will take time and much more optimization before it can be used in clinical practice.