Internet connectivity among rural Alabama veterans: baseline findings from the Alabama Veterans Rural Health Initiative Project.

INTRODUCTION: The purpose of this secondary data analysis was to characterize the Internet usage of rural veterans (n=201) who had either never enrolled, or had previously enrolled but not accessed, Veterans Affairs (VA) health services in at least 2 years. The VA Office of Rural Health (ORH)(ie part of the United States Government Department of Veterans Affairs) is a government agency with the mission to improve access and quality of care for enrolled rural and highly rural US veterans. The ORH seeks to use evidence-based policies and innovative practices to support the unique needs of enrolled veterans residing in geographically remote areas. These individuals represent a population considered to experience health disparities secondary to reduced health care access. METHODS: This study explored the role of the Internet in providing health information and information regarding VA services to rural Caucasian and African American veterans in the southeastern USA. African Americans were significantly younger (50.32 years, SD=13.50, range 22-85 years) than Caucasian rural veterans (58.50 years, SD=13.82, range 21-85 years). RESULTS: A small majority of veterans (n=107; 53.23%) reported 'going on-line to use the Internet or World Wide Web, or to send and receive e-mail'. Among Internet users, multivariate logistic regression showed that neither age nor race/ethnicity predicted using the Internet to access health information or information regarding VA services. CONCLUSION: In comparison with population norms, rural veterans displayed lower usage of the Internet; however, there were few practical age differences between young, middle-aged and older rural veterans in use of the Internet for seeking health information. These results suggest a tremendous potential for online outreach efforts to rural veterans seeking health information and information regarding VA services and benefits. The US Federal Government's VA Office of Rural Health is investing in technology-based services and will need to disseminate information regarding the availability of these services to rural veterans.

Late-onset X-linked sideroblastic anemia. Missense mutations in the erythroid delta-aminolevulinate synthase (ALAS2) gene in two pyridoxine-responsive patients initially diagnosed with acquired refractory anemia and ringed sideroblasts.

X-linked sideroblastic anemia (XLSA) is caused by mutations of the erythroid-specific delta-aminolevulinate synthase gene (ALAS2) resulting in deficient heme synthesis. The characteristic hypochromic, microcytic anemia typically becomes manifest in the first three decades of life. Hematologic response to pyridoxine is variable and rarely complete. We report two unrelated cases of highly pyridoxine-responsive XLSA in geriatric patients previously diagnosed with refractory anemia and ringed sideroblasts. A previously unaffected 77-yr-old male and an 81-yr-old female were each found to have developed severe hypochromic, microcytic anemia with ringed sideroblasts in the bone marrow, which responded dramatically to pyridoxine with normalization of hemoglobin values. Sequence analysis identified an A to C transversion in exon 7 (K299Q) of the ALAS2 gene in the male proband and his daughter. In the female proband a G to A transition was identified in exon 5 (A172T). This mutation resulted in decreased in vitro stability of bone marrow delta-aminolevulinate synthase activity. Each patient's recombinant mutant ALAS2 enzyme had marked thermolability. Addition of pyridoxal 5'-phosphate in vitro stabilized the mutant enzymes, consistent with the observed dramatic response to pyridoxine in vivo. This late-onset form of XLSA can be distinguished from refractory anemia and ringed sideroblasts by microcytosis, pyridoxine-responsiveness, and ALAS2 mutations. These findings emphasize the need to consider all elderly patients with microcytic sideroblastic anemia as candidates for XLSA, especially if pyridoxine responsiveness is demonstrated.

Effects of Computerized Cognitive Training on Gait Speed in Community Dwelling Older Adults, A Pilot Study.

BACKGROUND: In older adults declines in gait speed have been identified as predictors of functional decline and have been found in those with cognitive dysfunction. Cognitive training interventions that emphasize addressing executive function (EF) have resulted in a transfer effect from training cognitive processes into improved function. However research examining the effects of an EF specific computerized cognitive training (CCT) program on gait speed (GS) is limited. OBJECTIVES: To compare the effects of a six week EF specific CCT program on GS in community dwelling older adults using a pretest/posttest experimental design with subgroup comparisons based on a cutoff GS of 1.0m/s. SETTING: Home based. PARTICIPANTS: Forty independent living older adults (>65 years) without diagnosed cognitive impairment participated in either the intervention or control groups. INTERVENTION: A six week long progressively challenging EF focused CCT program was performed at home. MEASUREMENTS: Demographic variables, cognitive function (Trail-Making Test Part B) and GS were measured at baseline at week 7. Between group comparisons were completed for the whole sample initially with subgroup comparisons performed based on participants' initial GS (Slow walkers: GS<1.0m/s; Fast Walkers: GS>1.0m/s). RESULTS: No differences in GS were found for the whole population, but subgroup analyses restricted to slow walkers demonstrated a statistically significant improvement in GS after 6 weeks of CCT (µ =0.33 m/s, p = 0.03). Other outcomes measures were not statistically different at posttest. CONCLUSIONS: Older adults who walk at speeds <1.0m/s may benefit from a progressively challenging CCT program when self-administered in the home.

Structure of human hemoglobin C: a disease with intraerythrocytic crystals.

Crystals of human cyanomethemoglobin C (beta 6A3 glu leads to Lys) crystallized in the orthorhombic space group P212121, A = 158(1), B = 65.5(4), C = 54.9(5) A with Z =4. Single crystal electron micrographs show filaments parallel to the b direction. The molecules are unusually densely packed compared to other hemoglobin crystals, and this may be related to the ease of intraerythrocytic crystallization.

Regulation of haem biosynthesis in normoblastic erythropoiesis: role of 5-aminolaevulinic acid synthase and ferrochelatase.

The development of haem biosynthetic enzyme activity during normoblastic human erythropoiesis was examined in seven patients. The first and last enzymes of the haem biosynthetic pathway, ALA synthase and ferrochelatase, were assayed by radiochemical/high performance liquid chromatographic (HPLC) methods. An assay for ferrochelatase activity in human bone marrow was developed. Enzyme substrates were protoporphyrin IX and 59Fe2+ ions. 59Fe-labelled haem was isolated by organic solvent extraction/sorbent extraction followed by reversed-phase HPLC. Optimal activity occurred at pH 7.3 in the presence of ascorbic acid, in darkness and under anaerobic conditions. Haem production was proportional to cell number and was linear with time to 30 min. The assay was sensitive to the picomolar range of haem production. ALA synthase and ferrochelatase activity was assayed in four highly purified age-matched erythroid cell populations. ALA synthase activity was maximal in the most immature erythroid cells and diminished as the cells matured with an overall five fold loss of activity from proerythroblast to late erythroblast development. Ferrochelatase activity was, however, more stable with less than a two fold change in activity observed during the same period of erythroid differentiation. Maximal activity occurred in erythroid fractions enriched with intermediate erythroblasts. These results support sequential rather than simultaneous appearance of these enzymes during normoblastic erythropoiesis. Quantitative analysis of relative enzyme activity however indicates that at all times during erythroid differentiation ferrochelatase activity is present in excess to that theoretically required relative to ALA synthase activity since ALA and haem are not produced in stoichiometric amounts. The lability of ALA synthase versus the stability and gross relative excess of ferrochelatase activity indicates a far greater role for ALA synthase in the regulation of erythroid haem biosynthesis than for ferrochelatase.

Crystallography and oriented single crystal electron microscopy of hemoglobin deer II, a hemoglobin that exhibits matchstick-shaped erythrocytes.

Deer hemoglobin beta chain type II has been crystallized and preliminary diffraction data and oriented single crystal transmission electron micrographs have been obtained. The crystals are monoclinic P21 with Z = 4. The electron micrographs show a herringbonelike structure in the ab plane with open rectangular solvent channels and a fiber-like arrangement of molecules perpendicular to this plane.

International trade agreements: a threat to tobacco control policy.

International covenants establish a role for governments in ensuring the conditions for human health and wellbeing, which has been recognised as a central human right. International trade agreements, conversely, prioritize the rights of corporations over health and human rights. International trade agreements are threatening existing tobacco control policies and restrict the possibility of implementing new controls. This situation is unrecognised by many tobacco control advocates in signatory nations, especially those in developing countries. Recent agreements on eliminating various trade restrictions, including those on tobacco, have expanded far beyond simply international movement of goods to include internal tobacco distribution regulations and intellectual property rules regulating advertising and labelling. Our analysis shows that to the extent trade agreements protect the tobacco industry, in itself a deadly enterprise, they erode human rights principles and contribute to ill health. The tobacco industry has used trade policy to undermine effective barriers to tobacco importation. Trade negotiations provide an unwarranted opportunity for the tobacco industry to assert its interests without public scrutiny. Trade agreements provide the industry with additional tools to obstruct control policies in both developed and developing countries and at every level. The health community should become involved in reversing these trends, and help promote additional measures to protect public health.

A new class of antituberculosis agents.

Long-chain lipid envelopes are characteristic of mycobacteria such as those that cause tuberculosis and leprosy. Inhibition of fatty acid synthesis or elongation is a strategy demonstrated to be clinically effective against M. tuberculosis. A new class of compounds designed to inhibit the beta-ketoacyl synthase reaction of fatty acid synthesis has been developed. Of >30 compounds described, the most active were acetamides containing alkylsulfonyl substituents. Inhibitory activities were acutely sensitive to net charge, chain length, and degree of unsaturation. The most active compound 5 (alkyl = C(10)) contained a single methylene spacer between the sulfone and carboxamide and exhibited an MIC of 0.75-1.5 microg/mL, comparable to first-line antituberculosis drugs. These compounds are species-specific, exhibiting no significant activity against bacterial species other than M. tuberculosis and closely related strains. The synthesis, biological activity, and specificity of these compounds are described.

Gallium-67-citrate scanning of renal parenchymal malacoplakia.

UNLABELLED: The purpose of this article is to review the potential role of nuclear medicine scanning, especially with 67Ga, in the presumptive diagnosis and clinical management of patients with renal parenchymal malacoplakia (RPMP), a rare disease associated with coliform bacterial infection of the kidney and characterized by chronic unresolving inflammatory infiltrates containing von Hansemann macrophages in the renal parenchyma. METHODS: Published cases of RPMP were collected from the archival literature by searching the MEDLINE database and by reviewing bibliographic references contained in articles on malacoplakia. Data on the clinical features and radiographic evaluation of patients with RPMP were extracted from the clinical case reports. RESULTS: Forty-three cases of RPMP published over the past 20 yr were identified. Ten of the 43 patients (23%) had 67Ga scanning as a component of their diagnostic evaluation. In all 10 patients, renal uptake of 67Ga was classified as intense. Two of those 10 patients had serial 67Ga scanning performed to assess response to antibiotic treatment; both patients exhibited decreased uptake or complete resolution of abnormal renal uptake over time, a finding also exhibited by our patient. CONCLUSION: Intense renal uptake of 67Ga, typically in the clinical setting of fever, progressive renal failure and nephromegaly, strongly supports a diagnosis of RPMP. In those patients receiving prolonged antimicrobial therapy for RPMP, resolution of abnormal 67Ga uptake over time may provide an objective endpoint for treatment.

The U.S. Preventive Services Task Force Guide to Clinical Preventive Services, Second Edition. AMA Council on Scientific Affairs.

A resolution, introduced by the American College of Preventive Medicine at the 1996 American Medical Association (AMA) Annual Meeting, asked the AMA to recommend to physicians the use of the United States Preventive Services Task Force's Guide to Clinical Preventive Services, Second Edition. In response to that resolution, the AMA's Council on Scientific Affairs has reviewed and evaluated this publication. The recommendations of the Council on Scientific Affairs on the use of the Guide to Clinical Preventive Services, Second Edition, by clinicians and medical educators are included in this report. These recommendations were adopted as AMA Policy at the AMA Annual Meeting in June 1997.

Transfer of preventive health programs to physicians' practices through medical organizations.

BACKGROUND: Transferring new information to practicing physicians is a complex and often faulty process. Effective transfer is a challenging goal that requires a strategy for reaching large numbers of physicians throughout the country in a short time. However, methods for disseminating preventive health techniques such as smoking cessation have not been well organized. Smoking is the single most important preventable cause of premature mortality, so dissemination of research-based smoking-cessation techniques to physicians' practices is a priority for the National Cancer Institute (NCI). METHODS: NCI recruited national, professional medical organizations to collaborate in disseminating smoking-cessation techniques. The goal was to co-sponsor 50 Train-the-Trainer (TT) seminars that would prepare 2,000 professionals as volunteers to instruct their colleagues in smoking-cessation techniques. NCI provided all materials, faculty (nine professionals), advance logistics, CME credits, and follow-up. The co-sponsor organizations helped develop the training plan, promoted training among their members, enrolled professionals to be trained, and made logistical arrangements for the training sites. RESULTS: During the 4 years of the program, NCI recruited 11 national organizations as co-sponsors; conducted 53 TT seminars in 22 states and Washington, DC; and trained 2,098 professionals as smoking-cessation trainers, who practice nationwide. The many lessons learned provide the basis for recommendations that can assist others who want to work with professional organizations. CONCLUSION: The National Cancer Institute demonstrated that national organizations of medical professionals can help to disseminate effectively a research-based smoking-cessation program. Twelve recommendations are presented to help others disseminate preventive health techniques nationwide.

Screening the public for depression through the Internet.

OBJECTIVE: Despite increased public screening, many individuals with depression remain undetected or untreated. This study explored the performance of an Internet-based program in screening for depression. METHODS: The Centers for Epidemiological Studies Depression (CES-D) scale was adapted as an online screening test. The program advised persons whose score indicated a high probability of depression to seek treatment and asked them to complete a survey of attitudes and preferences that could be printed and taken to a health professional. Responses were collected anonymously for epidemiologic research. Demographic characteristics of participants were compared with those of the U.S. population and participants in previous community screenings. The costs of the program were calculated. RESULTS: The CES-D scale was completed 24,479 times during the eight-month study period. The respondents' median age category was 30 to 45 years, and almost 30 percent were male; 58 percent (N=14,185) screened positive for depression, and fewer than half of those had never been treated for depression. The proportion of younger individuals was larger than in previous public screenings, but was still lower than that in the U.S. population. Our sample contained a lower proportion of minorities than the U.S. population (16.6 percent versus 28.3 percent). Sunk costs totaled $9,000, and additional marginal costs to maintain the system totaled $3,750. CONCLUSIONS: The Internet provides a continuously available, inexpensive, easily maintained platform to anonymously screen a large number of individuals from a broad geographic area. However, older adults and minorities may visit screening sites less frequently than other populations.

Unilateral lumbosacral facet joint dislocation associated with vertical shear sacral fracture.

An 18-year-old woman involved in a motor vehicle accident sustained a vertical shear fracture of the sacrum accompanied by unilateral dislocation of the L5-S1 joint. Evaluation of the patient's injuries was defined by computed axial tomography. Through a posterior midline incision, open reductions of the dislocated L5-S1 joint and of the sacral fracture were performed. Reduction was followed by anterior stabilization of the symphysis pubis. The patient remained neurologically intact after surgery.

Smoking cessation in office practice.

There can be no question that smoking is a modern version of plague; that, as Camus points out, the public does not comprehend its true nature. As in the metaphorical community in Camus' narrative, the struggle of individuals against the pestilence (including official obstruction) is imperative. Physicians have multiple opportunities to join the war against tobacco. This article has shown how one may help individual patients in smoking cessation or interruption of its initiation and has suggested other activities by which physicians can become health promotion specialists. By assisting in the process by which smoking loses its appeal, educating community leaders and medical organizations, and becoming exemplars of prohealth activity, we can make a difference in the health of our communities and our patients.

Is the lemon test an index of arousal level?

On the basis of numerous studies, it was predicted that salivary output to lemon juice would increase in a noisy relative to a quiet environment. Following the accepted procedure (Corcoran, 1964) salivary output to lemon juice was measured under quiet conditions; then experimental subjects selected a level of noise 'just too loud for comfort' and the salivary index was reassessed. Controls were treated identically except that both measures were conducted in the quiet. It was found that salivation increased in noise, and the weight of saliva produced correlated with the level of noise chosen.

Nicotine dependency and adolescents: preventing and treating.

Teenage tobacco use is an increasingly prevalent health problem in this country. Three thousand teenagers become regular smokers each day. This article reviews adolescent tobacco use and its health dangers; a brief-office intervention for tobacco cessation in adolescents is described.

Efficacy of testing for illegal medication in horses.

The efficacy of testing for illegal drugs in race horses was surveyed by evaluating 27 questionnaires received from 28 racing jurisdictions polled. Large variations in the number of samples tested and drugs detected were reported. Some jurisdictions reported only illegal medications, whereas others also reported permitted medications. To facilitate comparison, stimulants, depressants, local anesthetics, narcotic analgesics, and tranquilizers were classified as hard drugs. Other drugs, which are legal in some jurisdictions, were classified as soft. To evaluate the efficacy of testing, positive test results were compared for hard drugs only. Positive test results varied from zero in some jurisdictions for some years to 14.8/1,000 samples tested for one small jurisdiction in one year. The mean rates over the years 1975 to 1983 varied from 0.2 to 6.5/1,000, with a modal positive test result of about 1/1,000. Beside the fact that prerace blood testing is less effective than is postrace urine testing, no cause for these variations in the positive test results could be identified. The positive test results also were compared for jurisdictions with differing medication rules for phenylbutazone (PBZ). Jurisdictions that did not allow PBZ had a mean positive test result for hard drugs of about 1.3 +/- 0.9/1,000 samples tested. Jurisdictions that allowed more liberal use of PBZ had a mean positive test result for hard drugs of about 1.3 +/- 1.0/1,000 samples tested. Seemingly, the presence of PBZ in equine forensic samples did not reduce the ability of forensic laboratories to detect the use of hard or illegal drugs.

The potential of consumer health informatics.

OBJECTIVES: To describe the rapidly evolving field of consumer health informatics (CHI), which is empowering the patient and the public. DATA SOURCES: Published articles, research studies, and government reports pertaining to interactive health communication and CHI. CONCLUSIONS: Application of CHI can provide information to patients and the public, promote self-care, enable informed decision-making, promote healthy behaviors, and promote peer information exchange and social support. Quality, research methodology, and accessibility must all be increased to ensure that CHI achieves its potential to improve the nation's health. IMPLICATIONS FOR NURSING PRACTICE: With the advent of the internet, the profusion of consumer health-related web sites, online support groups, and electronic patient-centered communications present new challenges for clinical practice. Health care providers have important roles in helping their patients as well as the public locate, assess, and interpret health information.

Availability of tobacco products to minors.

Availability of tobacco products is a key factor in the initiation of smoking or use of smokeless tobacco by minors. Existing laws limiting such use are usually not enforced. The ability of minors to purchase tobacco products in Wichita, Kansas, was compared with results in previous reports. In a variety of retail stores, access to both cigarettes and smokeless tobacco was found to be significantly less than that found in other studies. Vending machines, however, were universally accessible. Sufficient retail outlets allowed purchase to ensure that minors who are determined to buy could supply themselves with tobacco. Strategies to limit the access of tobacco to minors are discussed.