'People like me don't make things like that': Participatory video as a method for reducing leprosy-related stigma.

The Stigma Assessment and Reduction of Impact project aims to assess the effectiveness of stigma-reduction interventions in the field of leprosy. Participatory video seemed to be a promising approach to reducing stigma among stigmatized individuals (in this study the video makers) and the stigmatisers (video audience). This study focuses on the video makers and seeks to assess the impact on them of making a participatory video and to increase understanding of how to deal with foreseeable difficulties. Participants were selected on the basis of criteria and in collaboration with the community health centre. This study draws on six qualitative methods including interviews with the video makers and participant observation. Triangulation was used to increase the validity of the findings. Two videos were produced. The impact on participants ranged from having a good time to a greater sense of togetherness, increased self-esteem, individual agency and willingness to take action in the community. Concealment of leprosy is a persistent challenge, and physical limitations and group dynamics are also areas that require attention. Provided these three areas are properly taken into account, participatory video has the potential to address stigma at least at three levels - intrapersonal, interpersonal and community - and possibly more.

Degenerative myelopathy in two Boxer dogs.

Degenerative myelopathy (DM) is a common, slowly progressive, debilitating disease reported in several dog breeds, including the German Shepherd Dog and Pembroke Welsh Corgi. Boxer dogs present occasionally for a thoracolumbar myelopathy for which no cause is identified on MRI or cerebrospinal fluid analysis. Despite a lack of a histologic description of DM in the Boxer in the veterinary literature, such dogs are presumed to have DM. Here we report 2 histologically confirmed cases of DM in the Boxer breed in which histologic studies disclosed marked degenerative changes in the spinal cord that were most prominent in the thoracic and cranial lumbar segments. Lesions consisted of myelin vacuolation and degeneration, myelophagocytosis, reactive astrocytosis, and ellipsoid formation most prominent in the lateral and ventral funiculi. We present a detailed histologic description of DM in the Boxer dog and compare it to DM in other purebred dogs.

inlA premature stop codons are common among Listeria monocytogenes isolates from foods and yield virulence-attenuated strains that confer protection against fully virulent strains.

Previous studies showed that a considerable proportion of Listeria monocytogenes isolates obtained from foods carry a premature stop codon (PMSC) mutation in inlA that leads to production of a truncated and secreted InlA. To further elucidate the role these mutations play in virulence of L. monocytogenes, we created isogenic mutants, including (i) natural isolates where an inlA PMSC was reverted to a wild-type inlA allele (without a PMSC) and (ii) natural isolates where a PMSC mutation was introduced into a wild-type inlA allele; isogenic mutant sets were constructed to represent two distinct inlA PMSC mutations. Phenotypical and transcriptional analysis data showed that inlA PMSC mutations do not have a polar effect on the downstream inlB. Isogenic and natural strains carrying an inlA PMSC showed significantly reduced invasion efficiencies in Caco-2 and HepG2 cell lines as well as reduced virulence in oral guinea pig infections. Guinea pigs were also orally infected with a natural strain carrying the most common inlA PMSC mutation (vaccinated group), followed by challenge with a fully virulent L. monocytogenes strain 15 days postvaccination to probe potentially immunizing effects of exposure to L. monocytogenes with inlA PMSC mutations. Vaccinated guinea pigs showed reduced bacterial loads in internal organs and improved weight gain postchallenge, indicating reduced severity of infections in guinea pigs exposed to natural strains with inlA PMSC mutations. Our data support that (i) inlA PMSC mutations are causally associated with attenuated virulence in mammalian hosts and (ii) naturally occurring virulence-attenuated L. monocytogenes strains commonly found in food confer protective immunity.

Salt sensitivity and hypertension in African Americans: implications for cardiovascular nurses.

Hypertension is a major public health problem in the U.S. Salt sensitivity is an important factor associated with hypertension and its complications, yet it has not been addressed in the nursing literature. Salt sensitivity is a directionally appropriate rise or fall in blood pressure when salt is added or removed, respectively. The change in blood pressure in salt-sensitive subjects occurs to a degree exceeding random blood pressure fluctuations. Salt sensitivity is present in 30% of normotensive and over 50% of hypertensive persons. It is more prevalent among African Americans, older persons, and individuals with renal insufficiency or diabetes. This paper provides nurses with an overview of salt sensitivity and its significance in hypertension. It presents conceptual and operational definitions of salt sensitivity, identifies factors contributing to its development, and describes implications for nursing practice.

Using NOC outcome of risk control in prevention, early detection, and control of hypertension.

Hypertension is a major health problem addressed by nurses in all settings. This article reviews long-term hypertension outcomes and asserts the need to use intermediate outcomes focusing on prevention and early detection to effect change in the prevalence of hypertension and its complications. The Nursing Classification Outcome of Risk Control is presented as a framework to evaluate the state of the science and to develop a research agenda related to hypertension "Risk Control."

Identification of cardiovascular risk: use of a cardiovascular-specific genogram.

Cardiovascular disease (CVD) affects nearly 50 million Americans of all ages, races, and educational levels. Many of the risk factors for CVD are modifiable and public health nurses (PHNs) are in unique position to impact this major health problem because of their access to individuals, families, and groups. Addressing this major health problem requires early identification of those at risk for CVD. This article describes the implementation of a cardiovascular-specific genogram (CVSG) which can be used to identify persons at risk for CVD. Rationale for the development of this disease-specific tool and suggestions for its clinical application are discussed. The genogram was distributed to the parents of 100 6th grade students. All of the respondents reported cardiovascular risk factors present in at least one of three generations examined. The risk factors in the two younger generations were at the primary and secondary levels of prevention and were modifiable with intervention. Only the older generation in this sample had tertiary level risk factors. The CVSG can easily be incorporated into all aspects of public health nursing practice, from assessment for case finding to planning and implementing disease management strategies. The CVSG can identify individuals, families, and groups at risk for CVD allowing the nurse to focus attention on those most at risk, and to implement proactive assessment, screening, and educational programs.

Fuzzy cluster analysis of positive stress tests: comparison with stress echocardiography and nuclear perfusion imaging in patients with triple vessel and left main coronary disease.

Fuzzy cluster analysis (FCA) was used to classify 166 outpatient positive treadmill stress tests as mildly, moderately, or severely abnormal. The method combines ST-segment change with five other stress test variables, and then computes a similarity measure to determine how closely each patient's stress test resembles a prototypical mildly, moderately, or severely abnormal stress test. All patients had coronary angiography within 1 month of their stress tests. For the 45 patients with triple vessel disease (TVD), FCA classified 34 of these stress tests as severely abnormal (sensitivity = 75%). For the 22 patients with left main disease (LM), FCA classified 19 stress tests as severely abnormal (sensitivity = 86%). For the combined group with high-grade disease (TVD + LM), the sensitivity was 79%. A literature review shows that for stress echocardiography, multiple exercise-induced wall motion abnormalities have a sensitivity in the 70-80% range for patients with high-grade disease. For nuclear stress testing, the high-risk pattern of multiple reversible defects, with or without increased lung uptake, has a sensitivity in the range of 70-80% for patients with high-grade disease. Thus classification of a positive stress test as severely abnormal by FCA has a sensitivity comparable to high-risk patterns on stress echocardiography and nuclear stress testing in patients with TVD or LM.

The effectiveness of therapeutic touch: a meta-analytic review.

The purpose of this article is to explore the adequacy of published scientific evidence supporting therapeutic touch as a nursing intervention. Meta-analytic techniques were used to integrate the research-based literature published in the past decade. The results seem to indicate that therapeutic touch has a positive, medium effect on physiological and psychological variables. It is impossible to make any substantive claims at this time because there is limited published research and because many of the studies had significant methodological issues that could seriously bias the reported results. Resolving these methodological issues is imperative for therapeutic touch research to move forward.

The fractal dimension of atrial fibrillation: a new method to predict left atrial dimension from the surface electrocardiogram.

BACKGROUND: Previous studies have shown inconsistent relationships between left atrial size and various characteristics of atrial fibrillation seen on the surface electrocardiogram. The purpose of this study was to determine if the fractal dimension of atrial fibrillation derived from the ECG would be useful in predicting left atrial size. METHODS: The fractal dimension (D) was calculated using resting 12-lead ECGs from 53 patients (age 48-90) in chronic atrial fibrillation (greater than one year duration). D is the slope of the log/log plot of total length of a strip of atrial fibrillation against progressively decreasing lengths of measurement, plus one. Left atrial size was determined by standard M-mode echocardiography. RESULTS: When D was large (greater than 1.14), all patients had a left atrial size of 4.6 cm or greater. When D was small (less than 1. 09), all patients had a left atrial size of 4.6 cm or smaller. Values of D between 1.09 and 1.14 showed no relationship to atrial size. Larger values of D were associated with a higher degree of irregularity, roughness, and complexity in the surface ECG rhythm strips. CONCLUSIONS: In patients with chronic atrial fibrillation, the fractal dimension D derived from the surface ECG may be useful in predicting left atrial size.

A phosphate binding assay for sevelamer hydrochloride by ion chromatography.

Sevelamer hydrochloride is a cross-linked polymeric amine; it is the active ingredient of Renagel capsules. Renagel is indicated for the control of hyperphosphatemia in patients with end-stage renal disease. An in vitro phosphate-binding assay is required to measure the drug's efficacy. The assay developed for this purpose involves mixing the drug (polymer) with a solution of known phosphate concentration, filtering off the polymer-phosphate complex, and quantitating the unbound phosphate concentration by ion chromatography. The binding capacity, reported as mmol of phosphate bound g of polymer(-1), is calculated from the calculated amount of bound phosphate and the weight of polymer used. The method has been validated for accuracy, precision, linearity, range, and ruggedness.

Fuzzy cluster analysis--a new method to predict future cardiac events in patients with positive stress tests.

Several studies have shown that combining the change in the ST-segment with another exercise variable improves the predictive value of stress testing. However, no method has been able to combine many stress test variables with the ST-segment change simultaneously and help the clinician better predict future cardiac events. Fuzzy Cluster Analysis (FCA) was used to combine 5 stress test variables with ST-segment deviation to classify each of 232 positive outpatient stress tests as mildly, moderately, or severely abnormal. Cardiac events were recorded in these 3 patient groups up to 96 months (mean 65 months) after the stress tests. Coronary angiography was performed on 159 of these patients within 1 month of their stress tests. FCA better separated the 3 event-free survival curves than classifying the stress tests by three ST-segment (0.5-1.5 mm, 2-2.5 mm, > 3 mm) groups (p < 0.05). At 2 years, 90% of the FCA mild group were compared with 70% for the 0.5-1.5 mm group (p < 0.01). Moderate and severe tests by FCA separated patients with an intermediate from those with a poor prognosis while the 2-2.5 mm and 3 mm or more ST-segment curves did not (p < 0.05). FCA showed overall better correlation with coronary score (r = 0.71) than did the graded ST-segment groups (r = 0.48). FCA predicted both mild and high-grade (triple-vessel and left main) coronary disease better than ST-segment alone. Thus FCA better predicts future cardiac events in patients with positive stress tests than the ST-segment alone. This combined with its usefulness in predicting the extent of coronary disease provides the basis of a clinical strategy for managing patients with positive stress tests.

The negative effect of the clinical model of "health": implications for health care policy.

America has no overall health policy agenda that provides direction for improving the health of the nation. Historically, policies have focused on financing medical care. However, the philosophical model underlying that care is disease, not health, oriented. Health is only implicitly conceptualized and then only as the absence of disease. While the clinical model has provided for technological excellence and sophisticated medical care, it has also led to many problems within the health care delivery system. Skyrocketing costs; decreased access to care; poor health outcomes; and significant disparities in health among groups in America are the result of policies based on the model's limited conceptualization of health. This article describes the pervasiveness of the clinical model in influencing health policy. It analyzes both the health and economic outcomes of such policies, and explains the necessity of developing policy from a broader perspective of health. Using a nested model of health is encouraged. This allows policy makers to clearly visualize both the level of client and the focus of care that is being addressed. Delineating the focus of care may help in the development of policies that are truly aimed at improving the health of the nation.

Teaching population-focused practice to baccalaureate nursing students: a clinical model.

As the future of healthcare changes, there will be an increased demand for community-focused care, especially in the areas of health promotion and disease prevention. However, to meet these future demands, nurses must develop a population-focused, wellness-oriented approach to practice. This article briefly describes why many nurses may lack this focus, and then presents a model for teaching these essential community health principles to baccalaureate nursing students. The model uses a secondary school as the setting for the community health clinical experience.

Fuzzy cluster analysis of positive stress tests, a new method of combining exercise test variables to predict extent of coronary artery disease.

Fuzzy set theory is useful in the analysis of data having a graded degree of abnormality. Previous studies using sharp cutoff points between normality and abnormality have resulted in general guidelines for the interpretation of positive stress tests, but do not enable the clinician to simultaneously combine several stress test variables, each having a range of abnormality. In this study, positive stress test results from 109 patients were reviewed. An angiogram recorded within 1 month of the stress tests showed that 100 patients had coronary artery disease (CAD) (15 had left main CAD, and 27 had 3-vessel, 30 had 2-vessel, and 28 had 1-vessel disease) and 9 were normal. Six variables were selected for fuzzy cluster analysis: ST-segment change, difference between resting systolic and peak exercise systolic blood pressure, total treadmill time, peak exercise heart rate as a percentage of 100% predicted maximum for age, time to onset of angina, and duration of repolarization abnormalities. The analysis used a similarity measure to compute how closely each stress test resembled a prototypical mildly, moderately, or severely abnormal stress test. Stress tests classified by this method showed better correlation with the extent of CAD than the degree of ST-segment depression alone. Unlike tests with mild degrees of ST depression (0.5 to 1.5 mm), tests classified as mild by the method virtually excluded high-grade CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

After-hours telephone calls to general and subspecialty internists: an observational study.

OBJECTIVE: To study the after-hours telephone calls received by practicing general and subspecialty internists. DESIGN: Observational study. SETTING: Forty-four internal medicine private practices in Long Island, New York, consisting of 70 physicians (31 general internists, 39 internists with subspecialty training). PATIENTS/PARTICIPANTS: All calls received by an answering service after office hours with the caller requesting to speak to one of the physicians in the study. Of the 8,444 total calls, 2,950 were to generalists and 5,494 were to subspecialists. MEASUREMENTS AND MAIN RESULTS: For both groups, most calls came from patients (46.3%), followed by physicians (26.0%), then hospitals (22.2%). For patient calls to the generalists, those concerning infectious disease (15.4%), nonspecific symptoms (11.1%), medication-related questions (9.7%), and gastrointestinal (GI) complaints (9.4%) were the most common. For those calls to the specialists, GI (14.2%), infectious disease (10.9%), medication-related (10.0%), and nonspecific symptom (9.0%) complaints represented the most common patient calls. Although GI and cardiology specialists received proportionally more patient calls related to their specialities, the specialty group, like the generalist group, received calls in all the major areas of internal medicine. Patient calls for problems well outside the traditional scope of internal medicine accounted for 2.9% of the calls to the generalists and 1.9% of the calls to the specialists. About 44% of the patient calls to both groups were for potentially serious problems. After 11:00 PM both groups saw a decrease in the proportions of minor and trivial calls. CONCLUSIONS: These observations support the concept of broadly based medical training for both internal medicine generalists and subspecialist in preparation for the variety of telephone calls they will deal with after office hours. Practitioners should take steps to reduce the high number of medication-related patient calls.

Matching physician practice style to patient informational issues and decision-making preferences. An approach to patient autonomy and medical paternalism issues in clinical practice.

The movement away from traditional medical paternalism toward increased patient autonomy presents difficult practical and ethical problems for the physician treating the wide variety of patients seen in clinical practice. A review of the literature supports the concept of matching the physician's practice style with both patient informational issues and the patient's desire to actively participate in medical decision making. Studies also support that this matching principle not only improves physician-patient relationships but is ethically defensible and results in improved clinical outcomes. This article presents such a patient-physician match model as an aid to the practicing clinician.

Enhanced oxygen delivery by perflubron emulsion during acute hemodilution.

A high-concentration 90% w/v perflubron (perfluorooctyl bromide [PFOB]) emulsion (Oxygent HT) is being evaluated as an oxygen carrier for use during surgery. This study was done to assess oxygen delivery by Oxygent HT during acute normovolemic hemodilution. Anesthetized mongrel dogs, instrumented with femoral and pulmonary artery catheters, were hemodiluted to a hematocrit of 25% with 3:1 (v/v) of Ringers-lactate (R-L). Dogs were then ventilated with 100% O2 and hemodiluted to a Hct approximately 11% with 1.5 (v/v) of colloid (autologous plasma and 5% albumin). Dogs then received either 3.3 mL/kg Oxygent HT (n = 5) or 3.3 mL/kg R-L (n = 4), and were monitored for 3 hours. Total oxygen delivery (DO2), blood oxygen content, cardiac output, mixed venous PO2, and mixed venous Hb saturation was higher in Oxygent HT treated dogs compared to the R-L controls. The percentage of total DO2 contributed by perflubron-dissolved oxygen was about 8-10% and accounted for 25-30% of total oxygen consumption (VO2). The percentage of VO2 contributed by Hb-carried oxygen was significantly higher in R-L controls (46 +/- 4%) than in the treated dogs (15 +/- 3%), indicating that the availability of the perflubron-dissolved oxygen allowed for a reserve of oxygen to remain available in the red blood cells.

Characterization and mechanism of side-effects of Oxygent HT (highly concentrated fluorocarbon emulsion) in swine.

Perfluorooctyl bromide is an oxygen-carrying perfluorocarbon presently under development as an artificial blood substitute (Oxygent HT). Intravenous (i.v.) Oxygent HT elicits a mild side-effect profile in man characterized by early onset headache and nausea and delayed onset fever. Early onset flushing has also been observed. Species of Artiodactyla are sensitive to particulate injections and demonstrate a transient pulmonary hypertensive response thought to be associated with the large number of pulmonary intravascular macrophages found in these species. Because of this sensitivity, we chose the swine as a model for further investigations. In anesthetized and conscious swine, i.v. Oxygent HT transiently increased mean pulmonary artery pressure (mPAP) and caused flushing. Both effects peaked at 30 min post injection and were resolved by 2 hrs. Plasma thromboxane B2 (TxB) increased in response to Oxygent HT. Oxygent HT-induced changes in mPAP, flush, and plasma TxB were blocked by aspirin and ibuprofen. Dexamethasone and SQ 29,548 (thromboxane receptor antagonist) blocked the mPAP increase. In conscious swine, Oxygent HT caused a febrile response which was blocked by ibuprofen or dexamethasone. Thus, both early- and late-onset effects of Oxygent HT in swine are blocked by interference with the arachidonic acid cascade. These findings suggest that the 2-phase "flu-like" syndrome induced by Oxygent HT is secondary to the release of products of the arachidonic acid cascade and may be effectively prophylaxed in man with corticosteroids or long plasma half-life cyclooxygenase inhibitors.