Health behavior counseling at annual exams.

OBJECTIVE: To determine if patients expected and desired health behavior discussions at annual exams, and if these discussions motivated high-risk patients to modify a health behavior. METHODS: 1213 patients seen for an annual exam at Gundersen Clinic were sent a survey. Patients were asked if discussions about weight, exercise, tobacco use and stress occurred at their exam. Patients were also asked if the discussions were expected and desired and if the discussions motivated them to modify a health behavior. RESULTS: 571 surveys were returned. Over 50% of high-risk patients for each health behavior had a discussion. Patients who were overweight, obese, smoked or had excess stress were more likely to want and expect discussions than lower risk counterparts. Obese and overweight patients were also more likely to report being motivated to maintain or lose weight. CONCLUSION: Patients in need of weight, smoking and stress management counseling expected and desired behavior discussions and were motivated to modify their behavior.

Enhancing RNA repair efficiency by combining trans-splicing ribozymes that recognize different accessible sites on a target RNA.

Recent reports have demonstrated that trans-splicing ribozymes can be employed to repair mutant RNAs. One key factor that influences RNA repair efficiency is the accessibility of the substrate RNA for ribozyme binding, which is complicated by the fact that RNAs may assume multiple conformations and have proteins bound to them in vivo. Here we describe a strategy to map accessible sites on sickle beta-globin (beta(s)-globin) transcripts in vitro and in vivo and to use this information to enhance RNA repair efficiency. Two sites upstream of the sickle mutation were identified as accessible in some fraction of the beta-globin RNA by mapping with a ribozyme library and the accessibility of those sites was assessed by in vitro cleavage analyses. Ribozymes targeting either site could only convert a certain fraction of the beta(s)-globin RNA to product but not drive the reaction to completion. However, cleavage and splicing reactions were driven further toward completion when the two ribozymes were both added to the reactions, suggesting that the substrate RNA is present in multiple conformations in vitro. These two ribozymes were each able to repair beta(s)-globin transcripts in erythrocyte precursors derived from peripheral blood from individuals with sickle cell disease. Moreover, the relative accessibility of the targeted sites in vivo is as predicted by mapping and in vitro analyses. These results demonstrate that this novel RNA mapping strategy represents an effective means to determine the accessible regions of target RNAs and that combinations of trans-splicing ribozymes can be employed to enhance RNA repair efficiency of clinically relevant transcripts such as beta(s)-globin RNA.

Mild hypercholesterolemia and premature heart disease: do the national criteria underestimate disease risk?

OBJECTIVES: To determine the frequency of hospital admissions for acute coronary syndrome in young adults and to examine the risk factors that predispose to the development of premature heart disease. BACKGROUND: Significant coronary heart disease (CHD) is considered rare in the young adult. Current guidelines do not recommend treatment of mild cholesterol abnormalities for primary prevention of CHD in the young. METHODS: This is a large case series of 449 adults (< or =50 years) admitted to the hospital with acute coronary syndrome. A history of cardiovascular risk factors and lipid profile were recorded. The presence and extent of CHD were established. RESULTS: Mean patient age was 44 +/- 6 years. Documented CHD was present in 61% of hospital admissions. Multivariate analysis revealed that history of hypercholesterolemia, history of smoking and diabetes were independently associated with premature CHD. The fasting lipid profiles were only borderline to mildly abnormal. Serum total cholesterol, low-density lipoprotein (LDL) and triglyceride levels were not different in cases compared with control subjects. Nearly half (49%) of those with LDL levels of > or =160 mg/dl had only one additional risk factor or none. Despite this, a history of hypercholesterolemia had independent and incremental value on other risk factors for the likelihood of premature CHD. CONCLUSIONS: The magnitude of hospital admissions relating to premature CHD is high. In this population, the presence of borderline or mild hypercholesterolemia has significant effects on the development of premature CHD. These observations have significant implications in the development of guidelines for primary prevention of premature CHD.

Efficient evaluation of thyroid nodules by primary care providers and thyroid specialists.

OBJECTIVE: To determine whether primary care providers and thyroid specialists at Gundersen Lutheran Medical Center are evaluating thyroid nodules efficiently by following recently published clinical guidelines. STUDY DESIGN: One-year retrospective chart review. PATIENTS AND METHODS: We reviewed patient records from 1996 and tabulated the use of fine-needle aspiration cytology, radionuclide scanning, and thyroid ultrasonography by 49 primary care physicians evaluating 81 thyroid nodules and by 5 thyroid specialists evaluating 29 thyroid nodules. The results were compared with our previous findings and those recently reported by others. RESULTS: Fine-needle aspiration cytology was widely used by both groups of Gundersen Lutheran healthcare providers. Primary care physicians used imaging studies modestly and generated $106 per patient in unnecessary costs. Thyroid specialists occasionally used radionuclide scanning but did not use thyroid ultrasonography; they generated $41 per patient in unnecessary costs. Overall, the introduction of fine-needle aspiration cytology at our institution has reduced the use of radionuclide scanning from 90% to 12% and the use of thyroid ultrasonography from 30% to 10%. We also found that the frequency of surgery in patients with thyroid nodules fell substantially, yet detection of thyroid cancer in the operative specimens increased from 16% to 43% while the cost of removing a thyroid carcinoma decreased from $64,000 to $25,000. CONCLUSIONS: Fine-needle aspiration cytology, adopted as the initial test for diagnosing thyroid nodules by most of our healthcare providers, has reduced the use of imaging studies far below the frequency reported by others and has substantially decreased the cost of thyroid nodule management.

Death and end-of-life planning in one midwestern community.

BACKGROUND: The major health care organizations in a geographically defined area implemented an extensive, collaborative advance directive education program approximately 2 years prior to this study. OBJECTIVES: To determine for a geographically defined population the prevalence and type of end-of-life planning and the relationship between end-of-life plans and decisions in all local health care organizations, including hospitals, medical clinics, long-term care facilities, home health agencies, hospices, and the county health department. METHODS: For more than 11 months, end-of-life planning and decisions were retrospectively studied for all adult decedents residing in areas within 5 ZIP codes. These decedents were mentally capable in the 10 years prior to death and died while under the care of the participating health care organizations. Data were collected from medical records and death certificates. Treating physicians and decedent proxies were also contacted for interviews. RESULTS: A total of 540 decedents were included in this study. The prevalence of written advance directives was 85%. Almost all these documents (95%) were in the decedent's medical record. The median time between advance directive documentation and death was 1.2 years. Almost all advance directive documents requested that treatment be forgone as death neared. Treatment was forgone in 98% of the deaths. Treatment preferences expressed in advance directives seemed to be consistently followed while making end-of-life decisions. CONCLUSIONS: This study provides a more complete picture of death, end-of-life planning, and decision making in a geographic area where an extensive advance directive education program exists. It indicates that advance planning can be prevalent and can effectively guide end-of-life decisions.

Incorporating social support into a community-wide smoking-cessation contest.

Social support for smoking cessation has been identified as a key factor differentiating which individuals are most likely to quit smoking. Attempts to enhance social support in clinic-based programs have generally been unsuccessful. This study investigated a strategy for increasing the involvement of supportive others among participants in a community-based smoking-cessation contest. These smokers were undertaking quit attempts without the supportive environment offered in clinic-based group programs. Subjects included 734 adult smokers who had participated in a smoking-cessation contest in their local community. Contest participants had the option of designating a "support person" who would assist them in quitting smoking and be eligible for prizes if the participant was a contest winner. Follow-up was by telephone survey 3 months after the end of the contest. No differences were observed in demographic or smoking history variables between those who did and did not elect to name a support person. A relatively high proportion (60%) of contest participants elected to identify a support person and self-reported smoking-cessation rates were significantly better among those who named a support person than among those who did not. Identifying a support person was a particularly effective strategy for those with smoking or nonsupportive spouses.

Review of outcomes of atypical squamous cells of undetermined significance papanicolaou smears for 1991 and 1992, with follow-up through 1995.

OBJECTIVES: Our aim was to review 1,754 consecutive Papanicolaou (Pap) smears from 1991 to 1992 to evaluate initial findings and disease progression through December of 1995. METHODS: The study used analysis of data in the Gundersen Lutheran Medical Center Colposcopy Clinic's computerized registry. A total of 1,754 patients were followed, and findings were analyzed for progression and age-related outcomes. RESULTS: At initial evaluation by a trained ACOG member colposcopist, 11% of patients with atypical squamous cells of undetermined significance (ASCUS) Pap smears had histologically confirmed cervical intraepithelial neoplasia (CIN) I lesion and 7% a CIN II or III lesion. After a negative initial evaluation for an ASCUS Pap smear, an additional 8.4% smears went on to to demonstrate histologically confirmed CIN II or III, and an additional 4.7% revealed a CIN I. CONCLUSIONS: An ASCUS Pap smear requires evaluation by a care provider trained in colposcopy and management of abnormal Pap smears.

Is a twelve-percent cesarean section rate at a perinatal center safe?

OBJECTIVE: Our purpose was to examine the pregnancy and neonatal outcomes at a perinatal center with a consistent cesarean section rate approximately half the national average. STUDY DESIGN: Ten years of vaginal delivery and cesarean section rates (1983 to 1992) and 5 years of mortality and morbidity outcomes (1988 to 1992) were compared with national health statistics and national health objectives. RESULTS: The cesarean section rate during the 10-year period ranged from 10% to 15%, with an average of 12.5%. The cesarean section rate for the 5 years during which maternal and neonatal outcome data were obtained was 11.3%. The forceps and vacuum extraction rates during that time were consistently less than 5%. The nurse-midwifery service delivered approximately 36% of all babies during this period. In an examination of maternal mortality, we discovered only one death during the 5-year interval. The rate of maternal admission to the intensive care unit after delivery was 0.2%. The percent of women who received blood transfusions was 1%. The average length of stay for both vaginal and cesarean section deliveries declined steadily across the whole interval and was 2.5 days for a vaginal delivery and 5.5 days for a cesarean section. An examination of neonatal morbidity and mortality revealed an admission rate to the intensive care unit of less than 6%. The distribution of Apgar scores indicated less than 4% of neonates had scores < or = 3 at 1 minute; 0.5% had scores < or = 3 at 5 minutes. The neonatal death rate was 614 per 100,000 births, and fetal mortality was 729 per 100,000 births from 1988 to 1992. CONCLUSIONS: The lowest safe cesarean section rate is not known; it will undoubtedly vary with location and patient mix. We believe that we have been able to establish a rate of cesarean section one half of the national average with good maternal and fetal outcomes. This has been accomplished through a vigorous prenatal care program, excellent perinatal and infertility services, a vigorous program of vaginal birth after cesarean section, and a competent nurse-midwifery service.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels.

OBJECTIVE: Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity. STUDY DESIGN: A prospective observational study was performed. RESULTS: A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels. CONCLUSIONS: Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

A meta-analysis of smoking prevention programs after adjustment for errors in the unit of analysis.

This article presents the results of a meta-analysis designed to test the prevailing view that we largely understand why adolescents start to smoke and how to delay it. This view has developed even though none of the major reviews of the last 12 years has adjusted for the important methodological problems that all of those reviews identified as common in the published literature. School-based smoking prevention programs based on peer or social-type programs, published between 1974 and 1991, were included in this meta-analysis. Treatment characteristics were used to predict an effect size after adjustment for study design and population characteristics, and in particular, after a post hoc correction for errors in the original unit of analysis. The results suggest that the average effect for peer or social-type programs is likely to be quite limited in magnitude, and that the reduction in smoking may be only 0.10 standard deviation units, or perhaps 5%. Even under optimal conditions, the reduction in smoking may be only 0.50 to 0.75 standard deviation units, or perhaps 20%-30%.

Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable silver-impregnated cuff for prevention of catheter-related infections.

OBJECTIVE: To determine if an attachable silver-impregnated cuff is effective in reducing subclavian hemodialysis catheter-related infections. DESIGN: Prospective, randomized, nonblinded study. SETTING: Community teaching hospital. PATIENTS: One hundred one acute and chronic renal failure patients requiring subclavian venipuncture and catheterization. After randomization, 47 patients underwent subclavian catheterization with a silver-impregnated cuff (Ag-CC), and 54 patients had routine catheter (RC) placements. MEASUREMENTS: Multiple presumed predictor variables for catheter-related infections, exit site infection rate, bacteremia rates, and semiquantitative cultures of all catheters.

A simplified method for treating Graves' disease with radioactive 131I.

We reviewed the medical records of 53 patients treated in 1986 for Graves' disease with moderate doses of 131I. The cumulative incidence of hypothyroidism at 3 and 12 months after therapy was 38 and 80%, respectively. The hyperthyroidism, however, was rapidly cured and only 4(7.5%) patients required a second dose of 131I. In a separate study of 21 patients with Graves' disease, we determined that the 4-hour 123I uptake measurement was as reliable as the standard 24-hour test for supporting the diagnosis of hyperthyroidism. We also demonstrated that the 4-hour uptake accurately predicted the 24-hour uptake. Based on these findings and a review of the literature, we believe that either a 4 or 24-hour 123I uptake study followed by the administration of a fixed dose of 131I (10 or 15 mCi) provides a convenient and cost-effective method for treating Graves' disease.

Intraclass correlation among common measures of adolescent smoking: estimates, correlates, and applications in smoking prevention studies.

Most adolescent smoking prevention studies employ designs in which classrooms, schools, school districts, or sometimes whole communities are assigned to treatment conditions while observations are made on individual students. The critical design feature in such community trials is the nesting of intact social groups within treatment conditions. This combination requires that the treatment effect be assessed against the between-group variance; unfortunately, that variance is usually larger than for randomly constituted groups and its precision is usually less than that for the within-group variance. These factors often combine to reduce power so that it is almost impossible to detect important treatment effects in an otherwise well designed and properly executed study. To address these problems, investigators need good estimates of the intraclass correlation for the variables of interest, which together with the number of observations per unit determine the magnitude of the extra variation in the nested design. The purpose of this paper is to describe the methods and results from a study designed to generate estimates of intraclass correlation for common outcomes in adolescent smoking prevention studies and to discuss the use of these estimates in the planning of new studies.

Evaluating the thirty minute interval in emergency cesarean sections.

BACKGROUND: This study was done to evaluate what percent of emergency cesarean sections are begun within the 30 minute interval between decision and incision time and to evaluate morbidity associated with this time interval. STUDY DESIGN: A retrospective patient-control study of records from 75 patients undergoing emergency cesarean sections and two different control groups was undertaken. RESULTS: Sixty-three percent of emergency cesarean sections were begun in less than 30 minutes. A significantly greater number of infants in the group that delivered in less than 30 minutes experienced five minute Apgar scores less than six. There was no significant differences in maternal morbidity associated with emergency cesarean sections. CONCLUSIONS: The 30 minute interval is obtainable in a large number of patients but did not have a beneficial effect on neonatal morbidity. There was no significant morbidity seen in the patients who underwent emergency cesarean section. Other measurements of emergency preparedness should be considered other than the 30 minute rule.

Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting.

The Edinburgh Postnatal Depression Scale (EPDS) is a validated instrument developed specifically to identify women experiencing postpartum depression (PPD). This study sought to determine the extent of postpartum depression in our population and the maternal characteristics associated with it and to also determine if the scale increased practitioner awareness and treatment of PPD. Two hundred eighty-seven women from the total population completing the EPDS in 1991 (n = 1,139) were randomly selected for retrospective chart review to identify relationships between maternal characteristics and elevated EPDS scores. Charts were also reviewed for outcomes related to depression for the six-month period after delivery. Statistical analysis of the data revealed that 17.4% of the total population had an EPDS score of > or = 10, indicating a potential risk of developing PPD. Eight percent scored > or = 13, suggesting that further assessment was necessary. Marital instability, lack of medical insurance and a history of depression were the factors found to correlate most significantly with elevated EPDS scores. The physicians and midwives providing service for our population were interviewed, and 83% reported that the EPDS had increased their awareness of PPD, while 92% reported having referred for treatment patients with high EPDS scores. Use of the EPDS scale can improve practitioner awareness and aid in the diagnosis of PPD. Several easily identifiable variables are associated with PPD.

Investigation of thermoregulatory characteristics in patients with Prader-Willi syndrome.

A survey instrument is used to assess temperature regulation characteristics in children with Prader-Willi syndrome (PWS) compared to 3 control groups: sibs of PWS patients (SIB), neurodevelopmentally handicapped children (ND), and age and gender matched well children (WC). Significant differences were found between PWS patients, SIB controls, and WC controls in the prevalence of febrile convulsions, fever-associated symptoms, and temperature less than 94 degrees F. No differences were noted in any variable between the PWS patients and the ND controls, suggesting that these abnormalities are not unique to PWS, but can occur in any neurodevelopmentally handicapped individual, further suggesting these do not necessarily reflect syndrome-specific hypothalamic abnormalities.

Development of a screening tool for prediction of children at risk for lead exposure in a midwestern clinical setting.

OBJECTIVE: Universal screening for childhood lead poisoning is becoming quite common, with many states having legislation requiring screening. We set out to determine whether a questionnaire could be used to identify children at risk for exposure to lead to determine whether selective screening of those at risk was possible. METHODS: Parents of 370 children 12 to 36 months of age having well-child examinations completed a questionnaire and their children were screened by a fingerstick capillary blood lead test at two clinics. RESULTS: Of patients from clinic A, 5.4% had lead levels > or = 10 micrograms/dL compared with 16.8% of those from clinic B (P < .001). This difference between clinics could not be explained by the demographic characteristics of the patients or by differences in their potential exposures to lead. We evaluated the five questions suggested by Centers for Disease Control and Prevention for anticipatory guidance for their ability to identify children with elevated blood lead levels. In clinic A, this instrument had a sensitivity of 76.9% and a negative predictive value of 96.5%. In clinic B, it had a sensitivity of 63.6% and a negative predictive value of 81.4%. Based on an assessment of significant items from a large questionnaire, we determined five questions that were the best predictors of risk. On the basis of this risk assessment, 100% of the children from clinic A with elevated lead levels and 90.9% of the children from clinic B with elevated lead levels were classified as being at "high risk." Had this risk assessment been used as an initial screen in this sample, 40% of the patients from clinic A and 37% of the patients from clinic B would not have been screened with a blood lead test, because they were classified as being at "low risk." CONCLUSIONS: Results of this study suggest that there is great variability in the prevalence of elevated lead levels and potential risks between clinics within a fairly homogeneous community; however, selective screening with a community-specific questionnaire may be feasible if the prevalence is low and the risks to the population are known.

Factors that influence weight loss in the puerperium.

A study group of 795 women was followed with frequent weight measurements and questionnaires about their activities for 6 months postpartum. The mean (+/- SD) net weight gain from the first prenatal visit to 6 months postpartum was 1.4 +/- 4.8 kg. Weight gain during prenatal care was the variable most highly correlated to weight loss. Return to work outside the home, parity, and smoking also correlated significantly to weight loss. Breast-feeding, exercise, season of the year, age, and marital status were not correlated. Route of delivery was related to weight loss at 2 and 6 weeks, but not at 6 months. Counseling women about weight gain during pregnancy and weight loss requires an understanding of these variables with a long-term perspective of at least 6 months.

Community attitudes toward public policies to control alcohol, tobacco, and high-fat food consumption.

We report the results of a survey conducted in upper-midwestern communities to assess public attitudes toward policy level interventions to moderate the use of alcohol, tobacco, and high-fat food. Four hundred thirty-eight women and 383 men were asked to indicate how much they favored or did not favor 29 policy proposals. Results showed that regulatory controls in all three areas were favored by the general public. Support was strongest for alcohol and tobacco controls, less so for high-fat food. Interventions designed to protect children and youths were most strongly endorsed, followed by restrictions on advertising and direct control over conditions of sale. Women favored all interventions more than men. There was a strong positive association between age and support for measures to moderate alcohol use. Individuals reporting least personal use of alcohol, tobacco, and high-fat foods were most in favor of control policies. The results of this survey indicate specific measures that might be most readily enacted and what segments of the population are likely to be most and least receptive.