Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care.

BACKGROUND: Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults. METHODS: Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality. KEY RESULTS: There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%). CONCLUSIONS: Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.

Testing of an oral dosing technique for double-crested cormorants, Phalacocorax auritus, laughing gulls, Leucophaeus atricilla, homing pigeons, Columba livia, and western sandpipers, Calidris mauri, with artificially weather MC252 oil.

Scoping studies were designed to determine if double-crested cormorants (Phalacocorax auritus), laughing gulls (Leucophaues atricilla), homing pigeons (Columba livia) and western sandpipers (Calidris mauri) that were gavaged with a mixture of artificially weathered MC252 oil and food for either a single day or 4-5 consecutive days showed signs of oil toxicity. Where volume allowed, samples were collected for hematology, plasma protein electrophoresis, clinical chemistry and electrolytes, oxidative stress and organ weigh changes. Double-crested cormorants, laughing gulls and western sandpipers all excreted oil within 30min of dose, while pigeons regurgitated within less than one hour of dosing. There were species differences in the effectiveness of the dosing technique, with double-crested cormorants having the greatest number of responsive endpoints at the completion of the trial. Statistically significant changes in packed cell volume, white cell counts, alkaline phosphatase, alanine aminotransferase, creatine phosphokinase, gamma glutamyl transferase, uric acid, chloride, sodium, potassium, calcium, total glutathione, glutathione disulfide, reduced glutathione, spleen and liver weights were measured in double-crested cormorants. Homing pigeons had statistically significant changes in creatine phosphokinase, total glutathione, glutathione disulfide, reduced glutathione and Trolox equivalents. Laughing gulls exhibited statistically significant decreases in spleen and kidney weight, and no changes were observed in any measurement endpoints tested in western sandpipers.

Lethal and sub-lethal effects of Deepwater Horizon slick oil and dispersant on oyster (Crassostrea virginica) larvae.

In April 2010, crude oil was spilled from the Deepwater Horizon (DWH) oil platform for 87 days, coincident with the spawning season and recruitment of the oyster, Crassostrea virginica, in the Gulf of Mexico. Impacts of acute exposures to surface-collected DWH oil (HEWAF), dispersed oil (CEWAF) and dispersant alone (Corexit 9500A(®)) on planktonic larval stages of C. virginica (veliger, umbo and pediveliger) were tested in the laboratory. Exposures to HEWAF, CEWAF and dispersant were toxic to larvae impairing growth, settlement success and ultimately survival. Larval growth and settlement were reduced at concentrations of tPAH50 ranging from 1.7 to 106 µg L(-1) for HEWAF and 1.1-35 µg L(-1) for CEWAF, concentrations well within the range of water sampled during the DWH oil spill. Sublethal effects induced by oil and dispersant could have significant ecological implications on oyster populations and on the whole estuarine ecosystem.

Impacts of Deepwater Horizon oil and associated dispersant on early development of the Eastern oyster Crassostrea virginica.

The explosion of the Deepwater Horizon (DWH) oil platform resulted in large amounts of crude oil and dispersant Corexit 9500A® released into the Gulf of Mexico and coincided with the spawning season of the oyster, Crassostrea virginica. The effects of exposing gametes and embryos of C. virginica to dispersant alone (Corexit), mechanically (HEWAF) and chemically dispersed (CEWAF) DWH oil were evaluated. Fertilization success and the morphological development, growth, and survival of larvae were assessed. Gamete exposure reduced fertilization (HEWAF: EC201h=1650µg tPAH50L(-1); CEWAF: EC201h=19.4µg tPAH50L(-1); Corexit: EC201h=6.9mgL(-1)). CEWAF and Corexit showed a similar toxicity on early life stages at equivalent nominal concentrations. Oysters exposed from gametes to CEWAF and Corexit experienced more deleterious effects than oysters exposed from embryos. Results suggest the presence of oil and dispersant during oyster spawning season may interfere with larval development and subsequent recruitment.

Deep intronic KRIT1 mutation in a family with clinically silent multiple cerebral cavernous malformations.

Loss-of-function mutations in CCM1/KRIT1, CCM2/MGC4607 and CCM3/PDCD10 genes are identified in the vast majority of familial cases with multiple cerebral cavernous malformations (CCMs). However, genomic DNA sequencing combined to large rearrangement screening fails to detect a mutation in 5% of those cases. We report a family in which CCM lesions were discovered fortuitously because of the investigation of a developmental delay in a boy. Three members of the family on three generations had typical multiple CCM lesions and no clinical signs related to CCM. No mutation was detected using genomic DNA sequencing and quantitative multiplex PCR of short fluorescent fragments (QMPSF). cDNA sequencing showed a 99-nucleotide insertion between exons 5 and 6 of CCM1, resulting from a mutation located deep into intron 5 (c.262+132_262+133del) that activates a cryptic splice site. This pseudoexon leads to a premature stop codon. These data highly suggest that deep intronic mutations explain part of the incomplete mutation detection rate in CCM patients and underline the importance of analyzing the cDNA to provide comprehensive CCM diagnostic tests. This kind of mutation may be responsible for apparent sporadic presentations due to a reduced penetrance.

Validating genetic risk associations for ovarian cancer through the international Ovarian Cancer Association Consortium.

The search for genetic variants associated with ovarian cancer risk has focused on pathways including sex steroid hormones, DNA repair, and cell cycle control. The Ovarian Cancer Association Consortium (OCAC) identified 10 single-nucleotide polymorphisms (SNPs) in genes in these pathways, which had been genotyped by Consortium members and a pooled analysis of these data was conducted. Three of the 10 SNPs showed evidence of an association with ovarian cancer at P< or =0.10 in a log-additive model: rs2740574 in CYP3A4 (P=0.011), rs1805386 in LIG4 (P=0.007), and rs3218536 in XRCC2 (P=0.095). Additional genotyping in other OCAC studies was undertaken and only the variant in CYP3A4, rs2740574, continued to show an association in the replication data among homozygous carriers: OR(homozygous(hom))=2.50 (95% CI 0.54-11.57, P=0.24) with 1406 cases and 2827 controls. Overall, in the combined data the odds ratio was 2.81 among carriers of two copies of the minor allele (95% CI 1.20-6.56, P=0.017, p(het) across studies=0.42) with 1969 cases and 3491 controls. There was no association among heterozygous carriers. CYP3A4 encodes a key enzyme in oestrogen metabolism and our finding between rs2740574 and risk of ovarian cancer suggests that this pathway may be involved in ovarian carcinogenesis. Additional follow-up is warranted.

Moving beyond the keg party: a daily process study of college student drinking motivations.

Theoretical models of alcohol consumption assert that young adults endorse multiple drinking motives, including drinking to cope with negative experiences and to enhance positive experiences. Social contacts may be important to both pathways. This study applied daily process methodology to determine the relationship between college student drinking in different contexts and daily social contacts and moods. Each afternoon for 3 weeks, 122 undergraduates (43% men, 57% women) logged onto a secure Web site during specified hours to report daily activities, moods, and contacts. Hierarchical linear modeling analyses provided support for motivational models and the context-specific nature of motivated drinking. Individual differences were revealed for each motivation. These findings highlight the importance of studying within-person processes using daily process designs.

Middle manager involvement in strategy development in not-for profit organizations: the director of nursing perspective--how organizational structure impacts on the role.

AIM: An attempt was made to link organizational structure and strategic management and, in the process, to identify how organizational structure impacts on the strategic management role of Directors of Nursing working in acute care hospitals in the Republic of Ireland. BACKGROUND: Directors of Nursing are recognized as holding a pivotal role in health care delivery. The need for their involvement in strategic management is acknowledged, yet it is not clear if this role is influenced by organizational structure. It is recognized that strategic involvement increases the likelihood that middle managers' initiatives will be in line with top management's concept of corporate strategy. KEY ISSUES: The principal thesis is that organizational members will exercise a higher level of strategic consensus if they have been initially involved in the development of strategy. CONCLUSION: The study was undertaken in not-for-profit health service organizations, through a series of 25 semi-structured interviews with Directors of Nursing. The review of the literature was undertaken simultaneously with grounded theory analysis of the interviews. This research suggests that structure does impact on the role, conferring both positive benefits and negative consequences. Structure is identified in this study, in terms of organizational hierarchy, and the locus of control pertaining in each organization. Two predominating structure models are discussed and analysed.

The role of psychosocial factors in the progression of hepatocellular carcinoma.

The number of deaths per year from hepatocellular carcinoma (HCC) exceeds 250000, placing it sixth as the cause of death from cancer worldwide. The primary etiology of most cases of HCC in the US is hepatitis B and/or C. Extensive research has demonstrated that the relationship between hepatitis B infection and the progression to HCC is mediated by the immune system. A substantial, but unrelated literature, describes the relationship between psychosocial factors (e.g., stress, psychiatric morbidity), immune system reactivity, and disease progression in patients with cancer. However, the role of these factors in the progression of HBV-HCC has not been explored. An understanding of the relationship among virology, immunology, and behavior in the development and recurrence of HCC may provide alternative methods for secondary prevention of HCC (e.g., behavioral) until a vaccine and/or pharmacological treatments are developed, feasible, and affordable.

Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial.

CONTEXT: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low. OBJECTIVE: To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment. DESIGN: Group-level randomized controlled trial conducted June 1996 to July 1999. SETTING: Forty-six primary care clinics in 6 community-based managed care organizations. PARTICIPANTS: One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression. INTERVENTIONS: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment. MAIN OUTCOME MEASURES: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions. RESULTS: Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period. CONCLUSIONS: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

The lumbrical provocation test in subjects with median inclusive paresthesia.

OBJECTIVE: To investigate the value of the Lumbrical Provocation Test (LPT) in predicting carpal tunnel syndrome (CTS) among patients with symptoms suspicious for CTS. DESIGN: Prospective unigroup technique with blinded comparison of a clinical diagnostic test with 2 commonly used methods of diagnosing CTS: electrodiagnosis and a hand diagram. SETTING: Outpatient veterans referred by a heterogeneous group of specialists and generalists to a Veterans Affairs medical center electrodiagnostic laboratory. PATIENTS: Ninety-six consecutive patients who were referred to the electrodiagnostic laboratory with median inclusive paresthesia were evaluated. INTERVENTIONS: LPT: hold hand as fist for 1 minute (to evaluate changes in paresthesia); electrodiagnostic evaluations: median and ulnar mixed nerve, antidromic sensory, and motor latencies; and hand symptom diagram to describe pain. MAIN OUTCOME MEASURES: Evaluation of symptoms of paresthesia (with or without pain) inclusive of the median nerve distribution distal to the wrist. Prevalence sensitivity, specificity, and positive and negative predictive value of LPT, and electrodiagnosis, and hand diagram tests. RESULTS: Compared with the findings obtained with electrodiagnosis, the sensitivity of the LPT was.37; specificity,.71; positive predictive value,.59; and negative predictive value,.50. Compared with the findings obtained with the use of the hand diagram as a clinical measure, the sensitivity of the LPT was.43, specificity,.71, positive predictive value,.59, and negative predictive value,.56. CONCLUSION: The LPT has minimal use in predicting CTS in patients with median inclusive paresthesia compared with 2 commonly used methods of diagnosing CTS.

Mutational analysis of the PTEN gene in human uterine sarcomas.

OBJECTIVE: Uterine sarcomas are rare, lethal cancers, and little is known about their molecular etiology. The PTEN gene is located on chromosome 10q23.3, a region that displays frequent loss of heterozygosity in human uterine sarcomas. PTEN mutations have been described in 40% to 60% of uterine adenocarcinomas. To determine whether the PTEN gene is involved in the pathogenesis of uterine sarcoma, we analyzed deoxyribonucleic acid from uterine sarcomas and cell lines. STUDY DESIGN: Single-strand conformation analysis and direct sequencing of deoxyribonucleic acid were used to screen for PTEN mutations. RESULTS: Silent polymorphisms were detected in 2 of 36 primary uterine sarcomas. A 4-base pair deletion and a point mutation producing a stop codon were identified in 1 cell line. CONCLUSIONS: Mutational inactivation of PTEN does not play a major role in uterine sarcoma tumorigenesis, and another gene or genes on chromosome 10q may be implicated as a cause of these cancers. Differences in the molecular alterations underlying the development of uterine sarcomas and adenocarcinomas are significant.

Daily interpersonal experiences, context, and alcohol consumption: crying in your beer and toasting good times.

The authors explored a multidimensional view of drinking, whereby social and solitary drinking represent distinct behaviors associated with positive and negative experiences, respectively. Using daily diary methodology and multilevel analytic strategy, the authors examined, over 30 days, the within-person association of negative and positive experiences and alcohol consumption in different contexts and focused on interpersonal experiences. On days with more negative interpersonal experiences, participants engaged in more solitary drinking (i.e., drinking at home and alone), whereas on days with more positive interpersonal experiences they drank more in social contexts. The authors also demonstrated that individuals high on neuroticism drank more in solitary contexts on days with more negative interpersonal experiences, relative to those with lower neuroticism. These findings lend support to models linking daily drinking motivation and context-dependent drinking behavior.

Treatment provider awareness of the possible impact of the internet on the treatment of sex offenders: an alert to a problem.

This study evaluated treatment providers' perceptions of the impact of the Internet on the treatment of sex offenders. This study surveyed all of the agencies in South Carolina that provide treatment services for sex offenders. Analysis indicated that (a) most treatment providers were unaware of the potential negative impact of the Internet on their treatment efforts with clients, (b) most treatment providers had no policy restricting their clients' Internet use, (c) the overwhelming majority of treatment providers felt that they were poorly equipped to deal with this issue, and (d) almost all of the treatment providers felt that probation and parole would be of little assistance in helping them monitor their clients' use of the Internet. Implications of the findings for improving treatment services for sex offenders were explored and discussed.

Positive and negative daily events, perceived stress, and alcohol use: a diary study.

Using daily diary methodology, the authors examined over 60 days the within-person associations among positive and negative daily experiences, perceptions of stress, desire to drink, and alcohol consumption in a sample of 83 regular drinkers. Multilevel regression analyses indicated that days on which individuals reported more positive and negative nonwork events were also days they reported higher levels of desire to drink and actual consumption. Days on which individuals reported more negative work events were also days they reported a greater desire to drink, and days on which individuals reported more positive and negative health events were also days they reported lower levels of desire to drink and actual consumption. Weak evidence was found for the mediating effects of perceived stress in these associations. Several of the within-person associations varied as a function of gender, neuroticism, and drinking to cope; no moderating effects were found for extraversion.

Palliative care and end-of-life issues.

As stated, the goal of palliative care is the achievement of the best quality of life for patients and their families. It incorporates many aspects of care: providing physical comfort, psychosocial and spiritual support, and providing various services in order to achieve this goal. The skills described should be a priority in the practice of all types of medicine because the goal of palliative care is among the central tenets of the medical profession.

Homocysteine, folate, methylation, and monoamine metabolism in depression.

OBJECTIVES: Previous studies suggest that folate deficiency may occur in up to one third of patients with severe depression, and that treatment with the vitamin may enhance recovery of the mental state. There are, however, difficulties in interpreting serum and red cell folate assays in some patients, and it has been suggested that total plasma homocysteine is a more sensitive measure of functional folate (and vitamin B12) deficiency. Other studies suggest a link between folate deficiency and impaired metabolism of serotonin, dopamine, and noradrenaline (norepinephrine), which have been implicated in mood disorders. A study of homocysteine, folate, and monoamine metabolism has, therefore, been undertaken in patients with severe depression. METHODS: In 46 inpatients with severe DSM III depression, blood counts, serum and red cell folate, serum vitamin B12, total plasma homocysteine, and, in 28 patients, CSF folate, S-adenosylmethionine, and the monoamine neurotransmitter metabolites 5HIAA, HVA, and MHPG were examined. Two control groups comprised 18 healthy volunteers and 20 patients with neurological disorders, the second group undergoing CSF examination for diagnostic purposes. RESULTS: Twenty four depressed patients (52%) had raised total plasma homocysteine. Depressed patients with raised total plasma homocysteine had significant lowering of serum, red cell, and CSF folate, CSF S-adenosylmethionine and all three CSF monoamine metabolites. Total plasma homocysteine was significantly negatively correlated with red cell folate in depressed patients, but not controls. CONCLUSIONS: Utilising total plasma homocysteine as a sensitive measure of functional folate deficiency, a biological subgroup of depression with folate deficiency, impaired methylation, and monoamine neurotransmitter metabolism has been identified. Detection of this subgroup, which will not be achieved by routine blood counts, is important in view of the potential benefit of vitamin replacement.

A daily process approach to coping. Linking theory, research, and practice.

For decades, coping researchers have used between-person designs to address inherently within-person questions derived from theory and clinical practice. The authors describe recent developments in the use of within-person, process-oriented methods that examine individuals intensively over time. Ongoing studies of stress and alcohol consumption, the effects of depression on adaptational processes, and the temporal dynamics of coping with chronic pain demonstrate that by tracking rapidly fluctuating processes such as mood and coping close to their real-time occurrence, daily process designs offer unique insights into conceptually and clinically challenging questions. Such designs also provide new opportunities to examine the purported mechanisms of therapeutic interventions. Despite its demands on participants and investigators, daily process research offers fresh opportunities to link psychological theory, research, and practice.

Mood and alcohol consumption: an experience sampling test of the self-medication hypothesis.

In this investigation the authors applied the experience sampling method to prospectively test the self-medication hypothesis. In vivo reports gathered in the context of daily life demonstrated that nervousness was the only negative mood state to predict increases in alcohol consumption later in the course of the day. Further examination of this within-person relationship demonstrated that men were more likely to consume alcohol when nervous than were women, but this association was unrelated to family history of alcoholism, problem drinking patterns, or trait anxiety and depression. Consistent with the self-medication hypothesis, cross-sectional analyses also confirmed that alcohol consumption was generally associated with lower levels of nervousness; this effect varied by several demographic and clinical variables. These findings are discussed in terms of the diversity of reasons for alcohol consumption and their potential for explaining problem drinking.