An interview project with native American people: a community-based study to identify actionable steps to reduce health disparities.

OBJECTIVES: The primary objective of this study was to work with tribal communities to define and develop their own healthcare services and strategies for positive change regarding injection drug use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infection. The secondary objective of this study was to incorporate community capacity building strategies to develop and sustain programming and resources to optimize tribal communities' responsiveness to reduce health disparities. STUDY DESIGN: Semi-structured qualitative interviews. METHODS: Interviews were guided by community-based participatory research (CBPR) principles to create programs, projects, and policy recommendations meaningful to American Indian and Alaska Native (AI/AN) people. RESULTS: The study generated a formative understanding of the context of AI/AN people who inject drugs (PWID) in three distinct AI/AN communities as well as developed local capacity for future programming, projects, and policy. CONCLUSIONS: This study confirms CBPR methods should be part of an iterative cycle to inform policy and programs. CBPR has helped strengthen local research capacity and has formed ongoing relationships between study investigators, local liaisons, and the community that will be essential for next phases of program design and policy implementation. This cycle of CBPR could be replicated in other tribal communities to bring awareness of the opioid epidemic and its effects and to prioritize local indigenous and community-led responses.

The too few mutant selectively affects subgroups of monoaminergic neurons in the zebrafish forebrain.

Monoaminergic neurons are present in small numbers and in multiple distinct locations of the vertebrate CNS. They are involved in important functions such as movement coordination, motivation, and the response to environmental stress. However, the mechanisms involved in their subtype specification are not well understood. In this study, we examined the states of forebrain dopaminergic (DA) and serotonergic (5HT) neurons in larval and adult zebrafish of wild type and the too few mutant. The majority of DA and 5HT neuronal subgroups that were found in adults were established in the 6-day old larval zebrafish. Rather than affecting all monoaminergic neurons in the forebrain, selective subgroups of these neurons are reduced in the too few mutant, starting from the larval stage. Taken together, our study establishes that similar to DA neurons, distinct subtypes of 5HT neurons exist in larval as well as adult zebrafish. The development of a subset of these monoaminergic neurons is dependent on the too few gene product. Thus, this mutant is potentially important for understanding the development as well as the function of forebrain DA and 5HT neurons.

Estimation of fruit and vegetable intake using a two-item dietary questionnaire: a potential tool for primary health care workers.

BACKGROUND AND AIM: High fruit and vegetable intake is associated with health benefits for cancer and cardiovascular disease. An increase is therefore integral in recommendations for the prevention of chronic disease. However, measuring intake requires either extensive dietary assessment or the measurement of specific bio-markers which is neither cheap nor feasible for the routine assessment of an individual's diet in a community or primary care setting. Within the context of a study evaluating a dietary counselling programme to increase fruit and vegetable intake our aim was to assess the use of a simple tool to estimate fruit and vegetable intake. METHODS AND RESULTS: We studied associations between bio-markers [plasma ascorbic acid, beta-carotene and alpha-tocopherol 24-hour urinary potassium excretion] and a two-item fruit and vegetable consumption questionnaire in 271 subjects (105 men and 166 women), aged 18 to 70 years. After controlling for age, sex, vitamin supplement use, smoking and body mass, those reporting a daily intake of > or = 5 portions of fruit and vegetables had higher potassium excretion (difference 15.6 [95% confidence interval: 6.2 to 25.0] mmol/24 h), urinary potassium/creatinine ratio (1.2 [0.5 to 2.0]) and plasma vitamin C (10.0 [-0.9 to 20.8] mumol/L) than those reporting < or = 2.5 portions per day. beta-carotene (p = 0.04), vitamin C (p = 0.01) and potassium excretion (p < 0.001) were associated with fruit rather than vegetable intake. The two-item questionnaire had high specificity; over 3/4 of participants who reported low intake also had bio-markers below the upper third of the distribution. CONCLUSION: Self report of fruit and vegetable intake through a simple questionnaire is confirmed by bio-markers for those eating less than five portions of fruit and vegetables a day. Although the tool is amenable to improvements for the detection of vegetable portions, it may prove useful for monitoring dietary preventive approaches in primary care without the use of invasive and costly biochemical measurements.

Antibiotics increase functional abdominal symptoms.

OBJECTIVES: Data suggest that subjects with irritable bowel syndrome are more likely to report a recent course of antibiotics. This study tests the hypothesis that a course of antibiotics is a risk factor for an increase in the number of functional bowel complaints over a 4-month period in a general population sample. METHODS: We initiated a prospective case-control study in three general practices in South London. Consecutive patients aged 16-49 attending their general practitioner with non-GI complaints and given a prescription for antibiotics were invited to participate. Comparison subjects who had not had antibiotics for 1 yr were identified from the practice records by age group, gender, and previous general practitioner visits. Fifty-eight antibiotic and 65 control patients agreed to participate. Questionnaires covering demographic, GI, and psychological data were sent at recruitment and at 4 months. Seventy-four percent of subjects completed the study. The number of symptoms at follow-up compared to that at recruitment. RESULTS: Twenty of 42 antibiotic subjects (48%) versus 11/49 control subjects (22%) demonstrated one or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 3.14 [1.27-7.75]) (chi2 = 6.4, p = 0.01). Ten of 42 antibiotic subjects (24%) versus 3/49 control subjects (6%) demonstrated two or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 4.79 [1.22-18.80]) (chi2 = 5.8, p = 0.02). CONCLUSIONS: Functional bowel symptoms come and go, but subjects who are given a course of antibiotics are more than three times as likely to report more bowel symptoms 4 months later than controls.

Detailed immunohistology of Pax6 protein and tyrosine hydroxylase in the early zebrafish brain suggests role of Pax6 gene in development of dopaminergic diencephalic neurons.

Spatiotemporal developmental dynamics of Pax6 protein containing (i.e., Pax6) cells were investigated immunohistochemically in embryonic and postembryonic zebrafish brain sections (especially at 2 and 5 day), allowing for a neuroanatomically detailed resolution previously only reported for the mouse. Besides strikingly close correspondences of early Pax6 domains - including many spatiotemporal changes - in mouse and zebrafish brains, some critical differences were noted. There is no pallial (i.e., cortical) Pax6 expression domain in the ventricular proliferative layer in the zebrafish as in the mouse. The main pallial Pax6 domain in the zebrafish is comparable to the migrating stream of Pax6 cells at the pallial-subpallial boundary. This indicates that some developmental functions of Pax6 (i.e., inhibition of subpallial cell migration into pallium by Pax6 migrating stream) might be shared with the mouse and maybe all vertebrates, while others (i.e., control of intrapallial neuronal radial migration via Pax6 expressing radial glia cells) may be special for mammals. Another prominent feature in the early zebrafish forebrain is that the alar plate ventral thalamic Pax6 domain extends far caudolaterally into the periphery of the basal plate posterior tuberculum and hypothalamic inferior lobe. This indicates that the alar plate ventral thalamus invades the forebrain basal plate and contributes to the development of basal forebrain structures. The close spatiotemporal association of Pax6 cells and TH cells of the ventral thalamus indicates a local role of Pax6 in the development of ventral thalamic (as recently demonstrated in the mouse) and, maybe, posterior tubercular TH cells. However, our confocal microscopical analysis of zebrafish brain sections double-immunostained for Pax6 and TH did not reveal cells double-labeled for these two proteins in this location, but rather indicates an inductive interaction of Pax6 cells onto TH cells.

Do income questions and seeking consent to link medical records reduce survey response rates? A randomised controlled trial among older people.

Traditional measures of socioeconomic status may not be reliable for older people and income may be a useful measure for research into inequalities in health. At the same time, researchers increasingly wish to link survey findings to individual data taken from medical records. For this, consent must be sought. To examine whether questions on household income and seeking consent for medical record linkage affected response rates, a postal health survey of patients aged 65 to 74 was undertaken in an inner London practice. The overall response rate was 62.8%. In this study, the inclusion of an income question or seeking consent to access medical records did not reduce response rates to a health survey among older people.

The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease.

OBJECTIVES: This study assessed stages of change in fat intake, physical activity, and cigarette smoking during a randomized controlled trial of behavioral counseling. METHODS: Twenty general practices (primary health care centers) were randomized to lifestyle counseling by behavioral methods or to usual health promotion. A total of 883 patients were selected for the presence of 1 or more of the following risk factors: cigarette smoking, high cholesterol, or a combination of a high body mass index and low physical activity. Stage of change (precontemplation, contemplation, preparation, and action/maintenance) was assessed at baseline and after 4 and 12 months. RESULTS: The odds of moving to action/maintenance for behavioral intervention vs control patients at 4 months were 2.15 (95% confidence interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The likelihood of achieving action/maintenance was related to baseline stage for all 3 behaviors. CONCLUSIONS: Brief behavioral counseling based on advice matched to stage of readiness for change may be valuable in encouraging healthy lifestyles among patients in primary care at raised risk of cardiovascular disease.

The teleostean (zebrafish) dopaminergic system ascending to the subpallium (striatum) is located in the basal diencephalon (posterior tuberculum).

Tyrosine hydroxylase immunohistochemistry is used to demonstrate catecholaminergic neuronal populations in the fore- and midbrain of adult zebrafish (Danio rerio). While no catecholaminergic neurons are found in the midbrain, various immunoreactive populations were found in the diencephalon (hypothalamus, posterior tuberculum, ventral thalamus, pretectum) and telencephalon (preoptic region, subpallium, olfactory bulb). The posterior tubercular catecholaminergic cells include three cytological types (small round, large pear-shaped, and bipolar liquor-contacting cells). Furthermore, the retrograde neuronal tracers DiI or biocytin were applied to demonstrate ascending projections to the basal telencephalon (incl. the striatum). A double-label approach was used - together with tyrosine hydroxylase immunohistochemistry - in order to visualize neurons positive for tyrosine hydroxylase and a retrograde tracer. Double-labeled cells were identified in two locations in the posterior tuberculum (i.e, small round neurons in the periventricular nucleus of the posterior tuberculum and large pear-shaped cells adjacent to it). They are interpreted as the teleostean dopaminergic system ascending to the striatum, since previous work [16] established that no noradrenergic neurons exist in the forebrain of the adult zebrafish.

Sociodemographic and psychological predictors of changes in dietary fat consumption in adults with high blood cholesterol following counseling in primary care.

The associations between sociodemographic variables, psychological factors, and changes in dietary fat consumption over 4 months were assessed in a randomized controlled trial of behavioral counseling versus standard advice. Patients were 141 men and 150 women, with an average age of 52.1 years and total cholesterol level of 7.27 mmol/l (278 mg/dl). Smokers, younger patients, and those with greater body mass index had higher fat intake at baseline. Behavioral counseling led to greater reductions in fat intake than did standard advice. Self-efficacy and ratings of benefits of low-fat diets were related to fat consumption at baseline, and changes in these measures were correlated with changes in fat intake. Family support, baseline anticipated regret, and (for the behavioral counseling group only) baseline behavioral intentions predicted reductions in fat intake. The results indicated that psychosocial variables associated cross-sectionally with fat consumption do not necessarily predict change and that factors involved in the process of change and the prediction of change need to be differentiated.

Psychosocial predictors of changes in physical activity in overweight sedentary adults following counseling in primary care.

BACKGROUND: Increasing regular physical activity in adults at elevated risk of cardiovascular disease is an important target for preventive medicine. This study evaluated demographic, social and cognitive predictors of self-reported changes in physical activity after 4 and 12 months in a randomized trial of behavioral counseling in primary care. METHOD: Data were analyzed from 234 male and 271 female sedentary patients with a body mass index of 25-35 (age 49.1 years, SD 11.2 years), who had been counseled by nurses in general practice using stage-matched behavioral methods or standard health promotion and who were reassessed after 4 months. A total of 187 men and 231 women were reassessed after 12 months. RESULTS: Physical activity at baseline was associated with educational status, having a partner who exercised, perceived barriers, and self-efficacy. Changes over 4 months were greater with behavioral counseling, in non-smokers and in patients with higher ratings of motivation to change and self-efficacy at baseline. Changes over 12 months were greater with behavioral counseling and were predicted in the behavioral group by social support variables, perceived benefits, and barriers. Stage of readiness to change predicted increased activity at 4 but not 12 months. CONCLUSIONS: Social support and cognitive variables predict increased physical activity following counseling in primary care of sedentary overweight adults. Different factors are relevant to short- and long-term modifications in behavior.

Behavioural counselling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial.

OBJECTIVE: To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease. DESIGN: Cluster randomised controlled trial. PARTICIPANTS: 883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity. INTERVENTION: Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity. MAIN OUTCOME MEASURES: Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months. RESULTS: Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation. CONCLUSIONS: Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge.

Attitudes to cardiovascular health promotion among GPs and practice nurses.

BACKGROUND: Cardiovascular health promotion is an important element of national health strategy, but doubts have been raised about current methods, and attitudes among general practice staff are ambivalent. OBJECTIVES: We aimed to assess attitudes to cardiovascular health promotion, opinions about efficacy and perceptions of skills in lifestyle counselling in GPs and nurses from the same practices. METHOD: A questionnaire survey of 107 GPs and 58 practice nurses from 19 group practices (100% response rate). RESULTS: Practice nurses were seen to have the main responsibility for cardiovascular health promotion. Although attitudes to health promotion were generally positive, lack of training in lifestyle counselling was perceived to be a problem. Few responders believed that they were very influential in helping people change their lifestyles. Beliefs about the effectiveness of lifestyle counselling were mixed, with cigarette smoking, physical inactivity and obesity being seen as difficult to change. Beliefs in the effectiveness of lifestyle counselling were associated with positive attitudes towards health promotion and greater confidence in training. No association between personal health behaviour and attitudes towards health promotion were observed. CONCLUSIONS: It is recognized that health promotion involves more than the provision of simple information and advice, but GPs and practice nurses lack confidence in lifestyle counselling skills. The attitudes of health professionals are crucial to the implementation of prevention strategies and require regular review.

Did knowledge, opinions, background, and health authority advice influence early prescribing of the novel Alzheimer's disease drug donepezil in general practice?--national postal survey.

BACKGROUND: Donepezil was licensed in the UK in February 1997 for the treatment of Alzheimer's disease. AIMS: To determine the advice from health authorities about prescribing Alzheimer's disease drugs. To determine whether the first general practitioners who prescribed donepezil in England differed from non-prescribers in terms of knowledge, opinions, background, and the prescribing-advice issued by their health authority. METHODS: National postal survey of pharmaceutical advisors. Structured postal survey of all general practitioners in England who prescribed donepezil to two or more patients within the first 6 months of launch, compared with a random sample of non-prescribers. RESULTS: Pharmaceutical advisors' survey: 75/100 pharmaceutical advisors responded, of whom 83% indicated that general practitioners should not initiate prescribing of Alzheimer's disease drugs and 63% said that they should not prescribe, even under shared care arrangements. General practitioner survey: 311/473 (66%) prescribers and 484/947 (51%) non-prescribers responded after two mailings. Prescribers were similar to non-prescribers in terms of demographic and practice characteristics, knowledge about Alzheimer's disease, diagnostic and initial management strategies, and the prescribing advice from health authorities. Prescribers were significantly more likely than non-prescribers to strongly agree/agree that new drugs should be prescribed for mild (p=0.0008) and moderate (p=0.003) Alzheimer's disease, that they should normally be initiated (p=0.003) and monitored by a general practitioner (p<0.0001), and that financial constraints should not be a consideration (p=0.0001). CONCLUSION: Early prescribers differed from non-prescribers in their opinions about using Alzheimer's disease drugs. Future research should examine methods to promote nationally equitable and rational prescribing of new drugs.

Risk factors for urinary tract symptoms in women: beliefs among general practitioners and women and the effect on patient management.

BACKGROUND: Urinary tract symptoms are common in women. A variety of risk factors have been investigated in the past. One of the more likely risk factors for these symptoms is recent sexual intercourse; another is diaphragm use. Morbidity levels are increasing, although effective antibiotic treatment is available. AIM: To study the beliefs of women and their general practitioners (GPs) about urinary tract symptoms and to determine how these may affect management. METHOD: An interview survey with 113 women consulting with urinary tract symptoms and the 22 GPs they consulted. RESULTS: Doctors and women have similar beliefs about the 'causes' of urinary tract symptoms, but the relative importance differs. Both acknowledge the association with sexual intercourse but fail to communicate about this during the consultation. Patients reported being embarrassed on their own and their GP's behalf if sensitive subjects were raised. Doctors failed to ask women what they thought had caused the symptoms and were also unlikely to suggest to them likely causes. They also reported reticence to do more than prescribe, at least in first consultations, and half of the doctors routinely prescribed antibiotics, regardless of a near patient diagnostic urinary stick test result. The advice given was not necessarily evidence based. CONCLUSIONS: GPs need to be more aware of the risk factors associated with urinary tract symptoms in women and should formulate their advice accordingly. The reticence to discuss sensitive subjects by both GPs and patients has implications for the ability to broach sexual matters in any consultation in which they are not the reason or focus for that consultation.

Some forebrain connections of the gustatory system in the goldfish Carassius auratus visualized by separate DiI application to the hypothalamic inferior lobe and the torus lateralis.

The neuroanatomical connections of the diencephalic torus lateralis and inferior lobe of the goldfish (Carassius auratus) were studied by retrograde and anterograde labeling with the carbocyanine dye DiI. Both structures have afferents originating in the central zone of the dorsal telencephalic area as well as in the supracommissural nucleus of the ventral telencephalic area, and in the secondary gustatory, tertiary gustatory, and posterior thalamic nuclei. Both structures investigated have efferents to the tertiary gustatory and posterior thalamic nuclei, as well as to the dorsal hypothalamus (dorsal hypothalamic neuropil) and superior reticular formation. The torus lateralis receives additional afferents from the secondary general visceral nucleus and, sparsely, from the dorsal tegmental nucleus. The inferior lobe receives additional afferents from the medial zone of the dorsal telencephalic area, as well as from the suprachiasmatic, posterior pretectal, central posterior thalamic, caudal preglomerular, two tegmental nuclei (T1 and T2), corpus mamillare, and, sparsely, from the cerebellar valvula. The inferior lobe has additional efferents to the dorsal and ventral thalamus and subglomerular nucleus. The lateral torus and inferior lobe are also mutually interconnected. The lateral torus and inferior lobe map topographically onto the vagal-related (intraoral) or onto the facial-related (extraoral) portions, respectively, of both the secondary and tertiary gustatory nuclei. Because the posterior thalamic nucleus is reciprocally connected with the lateral torus and inferior lobe and is further known to project in turn to the area doralis telencephali, it likely represents a quaternary gustatory projection nucleus to the telencephalon in cyprinids. Whereas the lateral torus seems to be exclusively involved with gustatory and general visceral systems, the inferior lobe has inputs from additional sensory (e.g., octavolateralis, visual) systems, and, thus, likely represents a multisensory integration center.

Readiness to change health behaviours among patients at high risk of cardiovascular disease.

OBJECTIVE: To determine readiness to change dietary intake of fat, physical exercise and smoking, using a classification based on the stages of change model, among patients in a primary care population selected to have greater than normal risk of coronary heart disease. METHODS: We recruited 883 patients from general practices in the south of England who had one or more of the following cardiovascular risk factors: current cigarette smoking, total cholesterol level 6.5-9.0 mmol/l and a body mass index of 25-35 kg/m2 coupled with a lack of regular physical exercise. Measures of cardiovascular risk factors were obtained, together with questionnaire measures of stage of readiness to change smoking behaviour, dietary intake of fat and level of physical exercise. RESULTS: Patients with high cholesterol levels had a different degree of readiness to reduce dietary fat from that of those with low cholesterol levels. Patients who were overweight and inactive reported a greater readiness to increase their physical activity than did those who were not overweight and not inactive. Readiness to change any of the three behaviours was not affected by the presence of more than one modifiable risk factor. However, patients who were contemplating or preparing to stop smoking were also more ready to increase physical activity than were those who were not considering stopping smoking. CONCLUSIONS: Risk classification has an impact upon patients' readiness to change modifiable cardiovascular risk behaviours. The relationships between readiness to change various behaviours suggest that there are synergies in counselling strategies and methods of identifying patients who might be especially responsive.