Patient-centered care factors and access to care: a path analysis using the Andersen behavior model.

OBJECTIVES: Using the Andersen behavioral model, we examined the complex relationships among geographic access to care, financial disadvantage, patient-centered care factors, and access to care outcomes. STUDY DESIGN: This was a retrospective, cross-sectional study of the US civilian non-institutionalized population. METHODS: Our analytic sample included 15,787 US adults aged 18 years or older who had health insurance coverage for a full year in Medical Expenditure Panel Survey 2014-2015. Structural equation modeling was used to determine the associations among usual source of care, travel time to provider, financial disadvantage, patient-centered care factors (perceived interaction with health provider, shared decision-making, and value of health care), and access to care (perceived access to care and unmet need of health services). RESULTS: Our analysis showed that patient-centered care factors were associated with improved perceived access to care (ß = 0.03 to 0.56, P = .002) and reduced unmet needs of health care (ß = -0.03 to -0.17, P = .03 to < .001). Although longer travel time to provider and having financial disadvantage of paying medical bills had negative effects on access to care outcomes, these associations were mediated by patient-centered care quality factors. CONCLUSIONS: Our findings suggest that better patient-centered care factors are associated with enhanced patient access to care. Efforts that focus on improving patient experience could be an effective approach along with coverage expansion to enhance access to quality care.

High levels of soluble MICA are significantly related to increased disease-free and disease-specific survival in patients with cervical adenocarcinoma.

Downregulation of major histocompatibility complex class I chain-related molecule A (MICA) and upregulation of human leukocyte antigen G (HLA-G) on the tumor cells are important immune escape mechanisms for different epithelial tumors. In addition, upregulation of the soluble forms of the latter molecules in serum leads to peripheral T-cell and natural killer (NK)-cell tolerance. As for cervical cancer, it remains unknown whether soluble MICA (sMICA) and soluble HLA-G (sHLA-G) concentrations are related to tumor characteristics or patient survival rates. We measured sMICA and sHLA-G in pre-treatment sera of a large cohort of cervical cancer patients (n = 366) by enzyme-linked immunosorbent assay (ELISA). We detected a median sMICA of 174.73 pg/ml and a median sHLA-G of 5.35 U/ml. We did not find an association between sHLA-G levels and clinicopathological characteristics. In adenocarcinoma, low sMICA concentration was positively related to recurrent disease, a higher International Federation of Gynecology and Obstetrics (FIGO) stage and vaginal involvement (Mann-Whitney U-test; P = 0.018, P = 0.042 and P = 0.013, respectively). In the latter patient group, high sMICA levels were associated with better disease-free survival (DFS) and disease-specific survival (DSS) (P = 0.011 and P = 0.047). After adjusting for confounding factors, high sMICA proved to be an independent predictor for a better DFS and DSS [HR 0.16; 95% confidence interval (CI) 0.04-0.64; P = 0.009 and HR 0.12; 95% CI 0.03-0.50; P = 0.004]. sHLA-G did not influence survival in cervical cancer patients, regardless of histology. We conclude that cervical adenocarcinoma patients with high sMICA levels have an increased DFS and DSS. This data warrants a prospective trial to study the functional role of sMICA in cervical adenocarcinoma.

Integration of geriatric mental health screening into a primary care practice: a patient satisfaction survey.

OBJECTIVE: Colocation of mental health screening, assessment, and treatment in primary care reduces stigma, improves access, and increases coordination of care between mental health and primary care providers. However, little information exists regarding older adults' attitudes about screening for mental health problems in primary care. The objective of this study was to evaluate older primary care patients' acceptance of and satisfaction with screening for depression and anxiety. METHODS: The study was conducted at an urban, academically affiliated primary care practice serving older adults. Study patients (N = 107) were screened for depression/anxiety and underwent a post-screening survey/interview to assess their reactions to the screening experience. RESULTS: Most patients (88.6%) found the length of the screening to be "just right." A majority found the screening questions somewhat or very acceptable (73.4%) and not at all difficult (81.9%). Most participants did not find the questions stressful (84.9%) or intrusive (91.5%); and a majority were not at all embarrassed (93.4%), upset (93.4%), or uncomfortable (88.8%) during the screening process. When asked about frequency of screening, most patients (72.4%) desired screening for depression/anxiety yearly or more. Of the 79 patients who had spoken with their physicians about mental health during the visit, 89.8% reported that it was easy or very easy to talk with their physicians about depression/anxiety. Multivariate results showed that patients with higher anxiety had a lower positive reaction to the screen when controlling for gender, age, and patient-physician communication. CONCLUSIONS: These results demonstrate strong patient support for depression and anxiety screening in primary care.

Incidence of pertussis in patients of general practitioners in Poland.

We estimated the incidence of pertussis in patients consulting general practitioners (GPs). Between July 2009 and April 2011, we conducted a prospective cohort study of patients attending 78 general practices (158 863 persons overall). We included patients aged ≥ 3 years, with cough lasting 2-15 weeks, who gave informed consent. GPs interviewed eligible patients, collected a blood specimen, and a nasopharyngeal swab. At follow-up 30-60 days after the initial visit, physicians collected a second blood specimen and conducted patient interview. Cases were confirmed by specific IgA and/or IgG antibody titre exceeding significantly the general population background level or detection of bacterial DNA by real-time PCR. During the study period, 3864 patients with prolonged cough consulted the participating GPs, of those 1852 met the inclusion criteria, 1232 were recruited, and 288 were confirmed as pertussis cases (4% by PCR, 96% by serology). The adjusted incidence rate was 201.1/100 000 person-years [95% confidence interval (CI) 133.9-302.0], ranging from 456.5 (95% CI 239.3-870.8) in the 15-19 years group to 94.0 (95% CI 33.4-264.5) in the 25-29 years group. The reporting ratio was 61, ranging from 4 in those aged 3-5 years, to 167 in those aged 65-69 years. The study confirmed high incidence of pertussis in all age groups in the general population, in particular in adults, not appropriately documented by the existing surveillance system.

The benefits of dual-consultant operating in complex breast reconstruction: A retrospective cohort comparison study.

BACKGROUND: Dual-consultant operating (DCO) has been introduced in a multitude of surgical specialities. This retrospective cohort comparison study seeks to delineate any benefits DCO may confer on list utilisation, patient safety and training opportunities. METHODS: A retrospective cohort comparison of all free-flap breast reconstruction cases conducted at a single centre by five consultant plastic surgeons in the period May 2016-May 2020. RESULTS: A total of 281 patient records were used for analysis; 146 cases were dual consultants compared with 135 single consultants, representing 186 and 158 free flaps, respectively. Patient demographics were near identical in terms of patient age, BMI and ASA grade. Operating times were significantly reduced for both unilateral (mean reduction 59.49 min) and bilateral cases (mean reduction 38.14 min) with the presence of dual consultants. The mean length of stay for dual-consultant cases was on average 0.35 days less than for single consultant cases (p = 0.04). Dual-consultant case complications were less severe than those of single consultant cases (mean Clavien-Dindo severity 1.35 vs 0.96, p = 0.05). The rates of trainee one-to-one consultant training were increased in dual-consultant cases when preparing vessels (0.08 vs 0.35, p=<0.01) and performing anastomosis (0.63 vs 0.77, p = 0.03). CONCLUSIONS: DCO for complex breast reconstruction confers significant benefits to operating time, list utility and patient safety whilst protecting training opportunities for trainees. Plastic surgery departments looking to redesign services in the post-SARS-CoV-19 era should consider its adoption into their enhanced recovery protocols.

Sparing of the brain in neonatal undernutrition: amino acid transport and incorporation into brain and muscle.

Rates of tyrosine and lysine transport and incorporation into protein were measured in control and undernourished weanling rats. Undernutrition was induced by feeding lactating dams a low protein diet (12 percent casein) from birth to day 21. At weaning, body and brain weights of undernourished rats were 50 percent and 88 percent, respectively, of control values. Lysine and tyrosine transport rates into skeletal muscle were reduced by over 75 percent, more than twice the reduction seen in brain. Rates of amino acid incorporation into muscle protein were reduced by approximately 50 percent; the change in rate of incorporation into brain protein was not statistically significant. These data indicate that, in spite of marked retardation of amino acid transport into brain, the brain seems fully capable of maintaining normal rates of protein synthesis.

Efficacy of PD-1 blockade in cervical cancer is related to a CD8+FoxP3+CD25+ T-cell subset with operational effector functions despite high immune checkpoint levels.

BACKGROUND: Cervical cancer (CxCa) is mainly a locally invading disease that metastasizes to loco-regional lymph node basins before involving distant organs in more advanced stages. Local immune potentiation of tumor-draining lymph nodes (TDLN) may thus protect against tumor progression. METHODS: To identify therapeutic targets for local immune modulation, multi-parameter flow cytometric T-cell profiling of primary cervical tumors (PT) and TDLN (n = 37) was performed. The in-vitro effect of PD-1 blockade on T-cell reactivity to HPV16 E6 oncoproteins was determined in cultures of TDLN and PT single cell suspensions (n = 19). Also, intracellular cytokine staining (ICS) upon anti-CD3 stimulation was performed in metastatic TDLN (LN+) and PT (n = 7), as well as multiplexed immunofluorescence histochemistry staining (n = 8). RESULTS: Our data revealed elevated rates of activated regulatory T cells (aTregs) and of central or effector memory CD8+ T cells in metastatic TDLN (LN+) as compared to tumor-free TDLN (LN-), and equally high or even higher rates of these subsets in PT. Both memory subsets co-expressed multiple immune checkpoints. PD-1 blockade significantly enhanced detectable E6-specific T-cell responses in 4/5 HPV16+ LN+ and in 1/5 HPV16+ PT. Whereas aTreg rates were higher in anti-PD-1 non-responders, in responders elevated levels of CD8+FoxP3+CD25+ T cells were observed, which correlated with the efficacy of PD-1 blockade (P = 0.018). This subset was characterized by an early effector memory phenotype with particularly high levels of co-expressed PD-1, CTLA-4, TIM-3 and LAG-3 checkpoints, but, rather than exhausted, was shown upon polyclonal activation to produce higher levels of Granzyme-B and effector cytokines as compared to its CD8+FoxP3- counterparts. CONCLUSION: These observations support local PD-(L)1 blockade to interrupt loco-regional immune suppression in CxCa and control metastatic spread to TDLN. Furthermore, our data identify CD8+FoxP3+CD25+ T cells as therapeutic targets, which may also serve as predictive biomarker for PD-(L)1 checkpoint blockade.

Impact of (chemo)radiotherapy on immune cell composition and function in cervical cancer patients.

New treatments based on combinations of standard therapeutic modalities and immunotherapy are of potential use, but require a profound understanding of immune modulatory properties of standard therapies. Here, the impact of standard (chemo)radiotherapy on the immune system of cervical cancer patients was evaluated. Thirty patients with cervical cancer were treated with external beam radiation therapy (EBRT), using conventional three-dimensional or intensity modulated radiation therapy without constraints for bone marrow sparing. Serial blood sampling for immunomonitoring was performed before, midway and at 3, 6 and 9 weeks after EBRT to analyze the composition of lymphocyte and myeloid-cell populations, the expression of co-stimulatory molecules, T-cell reactivity and antigen presenting cell (APC) function. Therapy significantly decreased the absolute numbers of circulating leukocytes and lymphocytes. Furthermore, the capacity of the remaining T cells to respond to antigenic or mitogenic stimulation was impaired. During treatment the frequency of both CD4+ and CD8+ T cells dropped and CD4+ T cells displayed an increased expression of programmed cell death-1 (PD-1). In vitro blocking of PD-1 successfully increased T-cell reactivity in all five samples isolated before radiotherapy but was less successful in restoring reactivity in samples isolated at later time points. Moreover, (chemo)radiotherapy was associated with an increase in both circulating monocytes and myeloid-derived suppressor cells (MDSCs) and an impaired capacity of APCs to stimulate allogeneic T cells. T-cell reactivity was slowly restored at 6-9 weeks after cessation of therapy. We conclude that conventional (chemo)radiotherapy profoundly suppresses the immune system in cervical cancer patients, and may restrict its combination with immunotherapy.

Protein metabolism in the small intestine during cancer cachexia and chemotherapy in mice.

The impact of cancer cachexia and chemotherapy on small intestinal protein metabolism and its subsequent recovery was investigated. Cancer cachexia was induced in mice with colon 26 adenocarcinoma, which is a small and slow-growing tumor characteristic of the human condition, and can be cured with 100% efficacy using an experimental nitrosourea, cystemustine (C6H12ClN3O4S). Both healthy mice and tumor-bearing mice were given a single i.p. injection of cystemustine (20 mg/kg) 3 days after the onset of cachexia. Cancer cachexia led to a reduced in vivo rate of protein synthesis in the small intestine relative to healthy mice (-13 to -34%; P < 0.05), resulting in a 25% loss of protein mass (P < 0.05), and decreased villus width and crypt depth (P < 0.05). In treated mice, acute cytotoxicity of chemotherapy did not promote further wasting of small intestinal protein mass, nor did it result in further damage to intestinal morphology. In contrast, mucosal damage and a 17% reduction in small intestinal protein mass (P < 0.05) were evident in healthy mice treated with cystemustine, suggesting that the effects of chemotherapy on the small intestine in a state of cancer cachexia are not additive, which was an unexpected finding. Complete and rapid recovery of small intestinal protein mass in cured mice resulted from an increase in the rate of protein synthesis compared with healthy mice (23-34%; P < 0.05). Northern hybridizations of mRNA encoding components of the major proteolytic systems suggested that proteolysis may not have mediated intestinal wasting or recovery. A major clinical goal should be to design methods to improve small intestinal protein metabolism before the initiation of chemotherapy.

Adherence to early mobilisation: Key for successful enhanced recovery after liver resection.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes. METHOD: All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups. RESULTS: During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection. CONCLUSIONS: Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.

The structure of a cytochrome oxidase-lipid model membrane.

The structure of "membranous cytochrome oxidase" has been investigated by X-ray diffraction, optical polarization spectroscopy and EPR spectroscopy. These studies indicate that the cytochrome oxidase molecules are oriented symmetrically in the membrane profile with a significant portion of their mass occurring within the extravesicular surface of the membrane; the oxidase molecultes span the membrane profile; the distribution of the oxidase molecules over the plane of these membranes is non-crystalline; the oxidase molecules contain bundles of alpha-helical polypeptide chain segments where the average orientation of the helices is normal to the membrane plane; and the average heme orientation within the oxidase molecules is such that the normal to the heme plane lies in the plane of the membrane.

No alteration in gene expression of components of the ubiquitin-proteasome proteolytic pathway in dystrophin-deficient muscles.

Increased expression of critical components of the ubiquitin-dependent proteolytic pathway occurs in any muscle wasting condition so far studied in rodents where proteolysis rises. We have recently reported similar adaptations in head trauma patients [Mansoor et al. (1996) Proc. Natl. Acad. Sci. USA 93, 2714-2718]. We demonstrate here that the increased muscle protein breakdown seen in mdx mice only correlated with enhanced expression of m-calpain, a Ca(2+)-activated proteinase. By contrast, no change in mRNA levels for components of the ubiquitin-proteasome proteolytic process was seen in muscles from both mdx mice and Duchenne muscular dystrophy patients. Thus, gene expression of components of this pathway is not regulated in the chronic wasting that characterizes muscular dystrophy.

Incidence and duration of breast-feeding in a health maintenance organization population.

A breast-feeding incidence and duration study in a heterogeneous population confirmed the increased incidence of breast-feeding reported among American women. Of 632 women delivering between May and August of 1980, 66% chose to breast-feed, a decision determined to be significantly related to race, age, marital status, and parity. Cesarean deliveries discouraged breast-feeding, whereas nursing immediately after delivery and keeping the infant in the room during the hospital stay encouraged breast-feeding. Of 417 women who were breast-feeding, 58% had stopped by four months postpartum, a decision found to be related significantly to race, age, and receiving formula in the hospital. Formula supplementation in the hospital was associated with a shorter breast-feeding period. The most rapid decline in breast-feeding occurred in the first two weeks postpartum. Because this is the period in which women are most likely to discontinue breast-feeding, it could be a productive target period for support and assistance by health professionals.

CSF beta-amyloid, cognition, and APOE genotype in Alzheimer's disease.

OBJECTIVES: We examined the relationship between CSF amyloid beta peptide (A beta) concentration and AD severity in 31 probable AD patients and explored whether APOE genotype modifies this relationship. BACKGROUND: A beta deposition in AD brains has been correlated with disease severity and with APOE-epsilon4 allele frequency. Few studies have examined the effects of APOE genotype on the relationship between CSF A beta and disease severity in an antemortem sample. METHODS: Patients carried the clinical diagnosis of probable AD and did not have serious medical illness, current or past diagnosis of mood disorder, schizophrenia or alcoholism, or current psychotic features. The Mini-Mental State Examination (MMSE) was administered to the patient within 3 months of CSF collection. CSF was analyzed for A beta1-40 and A beta1-42 by sandwich ELISAs, and APOE genotype was determined by PCR run from blood. Correlations were performed between MMSE score and A beta1-40 and A beta1-42 concentrations while controlling for potential confounding variables. RESULTS: CSF measures of A beta1-40 and A beta1-42 concentrations were correlated with each other (r = 0.56, df = 28, p < 0.01). CSF A beta1-40 and A beta1-42 concentrations were positively correlated with MMSE score. The negative association between CSF A beta measures and disease severity remained significant after controlling for age (A beta1-40 and MMSE score: r = 0.46, df = 28, p = 0.01; A beta1-42 and MMSE score: r = 0.35, df = 28, p = 0.05). Among the APOE-epsilon3/3 homozygotes there was a significant positive correlation only between A beta1-42 and MMSE score (A beta1-42, r = 0.94, p = 0.02; A beta1-40, r = 0.79, p = 0.11). CONCLUSIONS: We hypothesize that an increased deposition of A beta in plaques results in decreased CSF A beta concentration. The stronger relationship between MMSE score and CSF A beta, specifically in APOE-epsilon3/3 homozygotes, suggests that patients with APOE-epsilon3/3 genotype may have different pathogenic mechanisms than the other genotypes for A beta deposition or clearance.

Cutaneous infection at dog bite wounds associated with fulminant DF-2 septicemia.

Severe DF-2 sepsis with disseminated intravascular coagulopathy developed following dog bites in two patients who had undergone prior splenectomy. Eschariform lesions developed at the site of the animal bite in both patients. DF-2 is an unusual animal-borne slow-growing gram-negative rod that can cause fulminant sepsis in splenectomized patients. Splenectomized patients should be aware of the hazards from a dog bite. The presence of eschariform lesions in such patients should provide a clinical clue to the presence of DF-2 infection.

Duodenal perforation: a rare complication of neonatal nasojejunal tube feeding.

Continuous nasojejunal drip is a common method of feeding low-birthweight neonates because it is relatively free of complications and provides nutritional requirements. We recently encountered a case of duodenal perforation caused by a feeding catheter. Recommendations are made that can prevent this complication in the future.

Screening for glaucomatous visual field loss with frequency-doubling perimetry.

PURPOSE: To conduct a preliminary evaluation of the efficacy of the frequency-doubling contrast test as a means of screening for glaucomatous visual field loss. METHODS: Contrast thresholds for frequency-doubled stimuli were obtained under four test conditions: superior hemifield, inferior hemifield, and central (5 degrees radius) targets using a method of adjustment (MOA); superior hemifield, inferior hemifield, and central targets using a modified binary search (MOBS); four quadrant stimuli and the central target using MOBS; and 16 stimuli (four per quadrant) and the central target using MOBS. One eye each of 36 patients with early (12), moderate (12), and advanced (12) glaucomatous visual field loss was tested, as was one eye each of 36 age-matched normal control subjects. RESULTS: For hemifield stimuli, the MOBS test procedure had better test-retest reliability, lower individual variation, and greater separation of the normal population and the population with glaucoma than did the MOA procedure. The use of progressively smaller, more localized stimuli produced successively better separation of glaucomatous and age-matched normal control eyes. Area under the Receiver Operating Characteristic curve was 0.81 for hemifield stimuli (sensitivity and specificity, 70% to 75%), 0.91 for quadrant stimuli (sensitivity and specificity, 83% to 85%), and 0.965 for the 16 stimuli (sensitivity 93%, specificity 100%). Test time was approximately 1.3 minutes for hemifields, 1.5 minutes for quadrants, and 5 minutes for the 16 targets. CONCLUSIONS: Preliminary results indicate that the frequency-doubled contrast test provides a quick, efficient means of screening for glaucomatous visual field loss. Test time is relatively short, test-retest reliability is good, and sensitivity and specificity for detection of glaucomatous visual field loss is very good. The use of the MOBS staircase procedure and small, localized stimuli result in the best performance for screening purposes. An expanded normative database and the use of more rapid suprathreshold screening strategies should enhance further the efficacy of this test.

Role of scientific data in health decisions.

The distinction between reality and models or methodological assumptions is necessary for an understanding of the use of data--economic, technical or biological--in decision-making. The traditional modes of analysis used in decisions are discussed historically and analytically. Utilitarian-based concepts such as cost-benefit analysis and cannibalistic concepts such as "acceptable risk" are rejected on logical and moral grounds. Historical reality suggests the concept of socially necessary risk determined through the dialectic process in democracy.

A moral history of the evolution of a caste of workers.

Using a dialectic method of philosophic inquiry, the actual ethical, legal, and social situation associated with genetic testing of beryllium-exposed workers in Department of Energy nuclear weapons facilities for markers of chronic beryllium disease is described. The cultural evolution of a caste system in a similar situation, and its social and biological implications, among uranium miners in the Erz Gebirge of Central Europe and on the Colorado Plateau of the United States, marked by suicide and lung disease, including cancer, is also described. The historically persistent social disease resulting from these situations. The Masada Syndrome, named from an analogous situation in biblical times, is characterized. Cultural intervention, a necessary condition for the ethical progression of the Human Genome Project, is outlined.

Smoking, respiratory symptoms, and pulmonary function among a population of Hispanic farmworkers.

We conducted a cross-sectional study in the agricultural Central Valley to evaluate the prevalence of respiratory symptoms, smoking status, and pulmonary function in Hispanic California farmworkers. Of 759 farmworkers completing questionnaires and spirometry, 747 were Hispanic. The prevalences of current, former, and never smokers (29, 17, and 54 percent, respectively) were comparable to rates in other studies of Hispanics, but daily cigarette consumption (median-five for men and three for women) was lower than in comparison populations. Prevalences of chronic cough, chronic phlegm, and persistent wheeze were low (1.6, 5.1, and 2.8 percent, respectively). Current smoking, increased age, female sex, and working greater than or equal to 8 months per year in agriculture were associated with increased prevalence of respiratory symptoms. Adjusted lung function was higher than for reference populations. Hispanic California farmworkers have a similar smoking prevalence to other Hispanic populations, but lower respiratory symptom prevalences and higher pulmonary function are consistent with lower daily cigarette consumption and the "healthy worker effect."