Effect of algae or fish oil supplementation and porcine maternal stress on the adrenal transcriptome of male offspring fed a low-quality protein diet.

Offspring adrenal function may be negatively affected in utero by maternal stressors such as microbial infection. Maternal supplementation with immunomodulatory compounds such as omega-3 polyunsaturated fatty acids (n-3 PUFA) may help minimize the adverse effects of maternal stress on fetal hypothalamic-pituitary-adrenal development and improve offspring health. Presently, n-3 PUFA sources are primarily fish-based, but n-3 PUFA microalgae (AL) may be an alternative. Previously, it was determined that maternal AL or fish oil (FO) supplementation to sows, in addition to maternal stress induced by Escherichia coli lipopolysaccharide (LPS) challenge appeared to have a greater influence on the stress response of male offspring compared to females. To further elaborate on these findings, this study assessed the effects of maternal AL or FO supplementation combined with a maternal LPS challenge on adrenal gene expression in male offspring fed a nursery diet containing low-quality protein sources. Forty-eight sows were fed gestation diets starting on gestation day (gd) 75 containing either 3.12% AL, 3.1% FO, or a control diet containing 1.89% corn oil. On gd 112, half the sows in each treatment were administered 10 â€‹µg/kg LPS i.m. Piglets were weaned at 21 days of age onto a common low-quality plant-based protein diet, and one week after weaning, four piglets per sow were administered 40 â€‹µg/kg LPS i.m. Two hours later, the piglets were euthanized to obtain adrenal tissue, and total RNA was extracted to carry out transcriptome analysis using the Affymetrix GeneChip WT Plus assay and subsequent validation by real-time PCR. Analysis revealed that adrenal steroidogenesis, fatty acid metabolism and immune function were significantly influenced by maternal diet and stress. Increased expression of immune-related genes including lymphocyte antigen 96, TLR-2 and NF-κB suggests that maternal AL supplementation may increase offspring sensitivity to inflammation after weaning. Decreased expression of lymphocyte antigen 96 in male offspring from sows receiving maternal LPS challenge also suggests a possible role of maternal stress in diminishing the offspring immune response to immune stress challenge. Increased expression of the genes encoding the 11BHSD2 enzyme in offspring from sows fed FO may also reduce the magnitude of the stress response. These data provide insight to the immune and metabolic mechanisms that may be influenced by maternal diet and stress.

Detection and survey of coffee ringspot virus in Brazil.

Coffee ringspot virus (CoRSV) a member of the proposed genus "Dichorhavirus", was surveyed on commercial and research farms spanning an area responsible for the majority of Coffea arabica production in Brazil. Virus-infected plants were found at one hundred percent of locations (n = 45) sampled. All cultivars, regardless of cherry color, were found to serve as hosts, suggesting that there is limited resistance in commercially employed germplasm. Reverse transcription PCR analysis revealed that the virus is contained within symptomatic lesions, with little systemic spread throughout leaves. Phylogenetic analysis based on the ORF1 (nucleocapsid) gene identified a strong geo-spatial relationship among isolates, which clustered into three clades. Despite low genetic diversity among isolates, variation in symptom expression was observed in the experimental host Chenopodium quinoa. Our analyses support the hypothesis that the spread of CoRSV is constrained by the clonal expansion of thelytokous populations of Brevipalpus phoenicis. The widespread occurrence of this virus suggests that it is much more prevalent than previously thought.

On traditional dental extraction: case reports from Dinka and Nuer en route to restoration.

Ritual dental extraction among Sub-Saharan African populations has been practised for centuries, yet little is known about the removal process for any ethnic group. Dinka and Nuer refugees to the US requested replacements for missing anterior teeth removed during childhood. Among 36 Sudanese refugees, 238 individual extractions had been performed. Three retained canine/incisor root fragments; their cases are presented, including memories of the tooth-extraction ritual.

Pharmaceutical care program for patients with reactive airways disease.

A pharmaceutical care program for patients with reactive airways disease (RAD) is described. A pharmaceutical care program for patients with RAD was developed and implemented at 36 CVS pharmacies. The impact on patient outcomes, pharmacist job satisfaction, and other variables is currently being evaluated in a controlled trial with more than 1100 patient enrollees. Guiding the program are the beliefs that pharmacists must have clinically relevant, patient-specific data to provide appropriate care; that pharmacists must have adequate training to provide pharmaceutical care; that the program must be sensitive to organizational barriers, particularly time demands; and that there must be ongoing support for the program. The program has five components: (1) computer display of patient-specific data for patients enrolled in the study, (2) distribution of tailored patient education materials, (3) use of a resource guide to facilitate the implementation of pharmaceutical care, (4) strategies to reinforce and facilitate the program, and (5) pharmacist training. While developed for community pharmacies, the program is applicable to most ambulatory care pharmacy practices. A pharmaceutical care program for patients with RAD was developed for use in community pharmacies.

Pharmaceutical care in chain pharmacies: beliefs and attitudes of pharmacists and patients.

OBJECTIVE: To discuss with pharmacists and patients with reactive airways disease their beliefs about pharmaceutical care and the pharmacist's role in health care, obstacles to providing pharmaceutical care in community pharmacies, and strategies to overcome these obstacles. DESIGN: Two focus groups of patients, two focus groups of pharmacists. PARTICIPANTS: Thirteen patients with reactive airways disease and 11 chain pharmacists. MAIN OUTCOME MEASURES: Qualitative reports on the pharmacist's role in health care delivery and obstacles to implementing pharmaceutical care programs. RESULTS: Pharmacists wished to provide pharmaceutical care, and patients were supportive of pharmacists' involvement in their health care. Both viewed counseling as an important role for pharmacists and believed that pharmacists should work with patients' physicians. Reported obstacles included lack of time, inadequate privacy, and pharmacists' lack of direct access to patients' physicians. Pharmacists and patients believed pharmacists should have access to patient-specific clinical data. CONCLUSION: Focus groups provided valuable information for designing pragmatic pharmaceutical care. The obstacles and possible solutions identified through the discussions represent fertile ground for designing innovative pharmaceutical care programs.

Restricting medicaid payments for transportation: effects on inner-city patients' health care.

BACKGROUND: Prior approval programs have been used to control spiraling costs of Medicaid, but they are rarely formally assessed. We evaluated the effect of a change in Indiana Medicaid's policy (effective October 1, 1993) requiring prior approval to pay transportation costs. METHODS: We performed a historical cohort study comparing the health care utilization of Medicaid patients during the first 6 months of 1993 versus the first 6 months of 1994. Subjects included all Medicaid patients who visited any inpatient or outpatient site affiliated with an inner-city public hospital in the first 6 months of 1993 (N = 23,015) and 1994 (N = 23,707). RESULTS: These Medicaid patients made 82,961 visits in the first 6 months of 1993 and 79,809 visits in the first 6 months of 1994. Visits to hospital-based primary care clinics declined 16% (P < 0.001), which was partially offset by a 7% increase in visits to neighborhood health centers (P < or = 0.001). Emergency and urgent visits fell by 8%; visits for medication refills fell by 18% (P < 0.001 for each). Hospitalizations increased slightly in 1994, with no change in the number of inpatient days. There was no change in inpatient or outpatient nontransportation charges. There were no systematic reductions in selected aspects of preventive care. However, there were fewer emergency and urgent visits among patients with reactive airway disease. CONCLUSIONS: Requiring prior approval for transportation was associated with reductions in visits for primary care visits and refilling prescriptions without measurable short-term effects on charges or selected clinical parameters. Neighborhood health centers partially ameliorated the decline in primary care visits.

Measuring patient satisfaction for quality improvement.

BACKGROUND: Surveys used for health plan quality reporting are generally administered annually to health plan enrollees to assess satisfaction with both the health plan and health care services. Therefore, surveys may lack sensitivity to measure the effects of patient-focused, quality improvement initiatives that could demonstrate results in a shorter time period. OBJECTIVES: We describe the development and testing of a multidimensional, visit-specific measure of satisfaction with primary care that may be used in quality improvement. METHODS: Conducted in five adult and pediatric primary care sites serving a commercial, largely managed-care population, the survey includes the Medical Outcomes Study Visit-Specific Questionnaire, the American Board of Internal Medicine Patient Satisfaction Questionnaire, and locally developed items. We assessed the instrument's reliability, validity, and utility for quality improvement. RESULTS: For both adult and pediatric samples, three factors emerged: satisfaction with the provider, satisfaction with access, and satisfaction with the office. Satisfaction with the provider and with the office were independently correlated with overall satisfaction in both samples; satisfaction with access was significantly correlated with overall satisfaction only for adults. For adults, patients who disenrolled from the health plan were less satisfied with the office compared with patients who remained with the health plan. Finally, for adults, we detected significant differences across practice sites in terms of satisfaction with office and access; for children, there were intersite differences in terms of satisfaction with provider, office, and access. CONCLUSIONS: We have support for the reliability and validity of this instrument that has identified differences in satisfaction between practice sites that may be used for quality improvement.

Measuring quality of life in a way that is meaningful to stroke patients.

OBJECTIVE: To identify predictors of poststroke quality of life. BACKGROUND: Health-related quality of life (HRQOL) measures assess the impact of disease on the physical, emotional, and social aspects of patients' lives. Although HRQOL measures are used increasingly, factors associated with HRQOL poststroke and the ability of stroke-specific versus generic HRQOL measures to predict patient-reported HRQOL are not well known. METHODS: A total of 71 patients were evaluated 1 month postischemic stroke with a new stroke-specific HRQOL measure-the SS-QOL-and the SF-36, a generic HRQOL measure. Stroke severity, impairments, and functional limitations were also measured. Demographic variables and outcome measure scores were compared between patients rating their overall HRQOL the same as pre-stroke versus those with overall HRQOL worse than prestroke. Independent predictors of overall HRQOL were identified using multivariable modeling. RESULTS: Variables associated with better overall HRQOL were higher (better) SS-QOL and Barthel Index scores, and lower (better) NIH Stroke Scale and Beck Depression Inventory scores. Independent predictors of good overall HRQOL were the SS-QOL score (odds ratio [OR], 2.97; 95% CI, 1.3, 7.1; p = 0.01) and NIH Stroke Scale score (OR, 0.69; 95% CI, 0.47, 0.99; p = 0.05). Demographic factors and SF-36 scores were not associated with overall HRQOL ratings. CONCLUSIONS: Stroke-specific quality of life score and patient impairments predict patient-reported overall health-related quality of life (HRQOL) poststroke. SF-36 scores were not associated with overall HRQOL ratings. Disease-specific HRQOL measures are more sensitive to meaningful changes in poststroke HRQOL and may thus aid in identifying specific aspects of poststroke function that clinicians and "trialists" can target to improve patients' HRQOL after stroke.

Development of a stroke-specific quality of life scale.

BACKGROUND AND PURPOSE: Clinical stroke trials are increasingly measuring patient-centered outcomes such as functional status and health-related quality of life (HRQOL). No stroke-specific HRQOL measure is currently available. This study presents the initial development of a valid, reliable, and responsive stroke-specific quality of life (SS-QOL) measure, for use in stroke trials. METHODS: Domains and items for the SS-QOL were developed from patient interviews. The SS-QOL, Short Form 36, Beck Depression Inventory, National Institutes of Health Stroke Scale, and Barthel Index were administered to patients 1 and 3 months after ischemic stroke. Items were eliminated with the use of standard psychometric criteria. Construct validity was assessed by comparing domain scores with similar domains of established measures. Domain responsiveness was assessed with standardized effect sizes. RESULTS: All 12 domains of the SS-QOL were unidimensional. In the final 49-item scale, all domains demonstrated excellent internal reliability (Cronbach's alpha values for each domain >/=0.73). Most domains were moderately correlated with similar domains of established outcome measures (r2 range, 0.3 to 0.5). Most domains were responsive to change (standardized effect sizes >0.4). One- and 3-month SS-QOL scores were associated with patients' self-report of HRQOL compared with before their stroke (P<0.001). CONCLUSIONS: The SS-QOL measures HRQOL, its primary underlying construct, in stroke patients. Preliminary results regarding the reliability, validity, and responsiveness of the SS-QOL are encouraging. Further studies in diverse stroke populations are needed.

Effects of multidisciplinary case management in patients with chronic renal insufficiency.

PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient). CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.

Dimensions and correlates of physician work satisfaction in a midwestern city.

OBJECTIVES: The purpose of this study was to examine the dimensions of physician work satisfaction across a variety of medical specialties and practice settings. METHODS: A modified version of the Scheckler et al survey instrument was mailed to all physicians in Marion County, Indiana. Forty-two percent (777) of the eligible physicians responded. Exploratory factor analysis and internal consistency measures were used to assess the instrument's validity and reliability. Multivariable linear regression was used to predict global and summary scale scores. RESULTS: Four dimensions of physician work satisfaction were identified: relationships with patients (k = 6, alpha = 0.81), autonomy in clinical decision-making (k = 8, alpha = 0.81), office resources (k = 7, alpha = 0.87), and professional relationships (k = 5, alpha = 0.82). Most (73%) of the physicians were satisfied with their overall practice, and the majority were also satisfied with their income. Significant differences were observed in the sources and magnitude of physician work satisfaction across medical specialty, practice setting, and financial arrangement. Physicians in private practice were most satisfied with their overall practice and office resources, whereas physicians in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decision-making. Physicians not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practice. Among primary care physicians, family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their medical practices. CONCLUSIONS: The modified version of the Scheckler et al instrument is a reliable and valid measure of physician work satisfaction. Increases in the market share of managed care have differentially affected the work satisfaction of physicians based on their medical specialty, practice setting, and financial arrangements.

Assessing inner-city patients' hospital experiences. A controlled trial of telephone interviews versus mailed surveys.

OBJECTIVES: Obtaining accurate and representative patient-centered data may be difficult among poor, inner-city patients because of changing addresses, variable access to telephones, and a higher prevalence of illiteracy than in the populations in which many survey instruments were developed and tested. Assumptions about the usefulness of mailed surveys versus telephone interviews may not hold for the urban poor. Therefore, identifying the most efficient mode of survey administration in this population becomes an important methodological question. METHODS: We conducted a randomized trial of patients discharged from the inpatient medicine service of an urban teaching hospital to compare telephone interview with mailed self-administration of a detailed instrument for measuring patients' experiences with hospital care. Our primary outcomes were response rate, missing data, and data collection costs. Patients were excluded if they were not discharged to home or were mentally or physically unable to complete mailed or telephone interviews. The research assistant contacted eligible patients while hospitalized, informed them of the postdischarge survey, and obtained current phone numbers and addresses. Patients then were randomized to receive a 116-item satisfaction survey via one of two survey methods: mail-first (mailed surveys with follow-up on nonrespondents by telephone) or telephone-first (telephone interviews with follow-up of nonrespondents by mail). RESULTS: Of the 252 patients enrolled, 130 were randomized to the mail-first and 122 to the telephone-first method. Response rates were higher with the telephone-first (73%) compared with the mail-first method (50%; P < 0.0001). Surveys obtained by the telephone-first method had fewer missing data (0.7 +/- 2.39) for those items not involved in skip patterns compared with the mail-first method (7.1 +/- 12.3; P < 0.001) and were 42% less expensive per completed survey ($26.32 versus $37.35; P < 0.0001). CONCLUSIONS: In this survey of patients served by an urban teaching hospital, a strategy of telephone interviews with mail follow-up proved less expensive and yielded a higher response rate with more complete data than using a method where mailed surveys were followed by back-up telephone interviews. In addition, we believe that the improved response rate for telephone interviews compared with those reported in the literature for similar populations is the result of informing inpatients of the survey and obtaining telephone numbers and addresses in the hospital.

Correlates of health care satisfaction in inner-city patients with hypertension and chronic renal insufficiency.

Barriers to effective health care are potential contributors to the increased prevalence of hypertension and hypertension-related renal disease observed in black patients. We have enrolled 333 primarily elderly (mean age 69 years) black (87%) patients with hypertension and chronic renal insufficiency into a prospective randomized trial testing the effect of intense multidisciplinary management on progression of chronic renal insufficiency. These patients have an average 6 years of education and $400-$800 monthly household income: 57% have diabetes. Our baseline data include the Patient Satisfaction Questionnaire administered by home interviewers who also recorded sociodemographic data, medications and questionnaires regarding medication compliance and symptoms related to anti-hypertensive drugs. Inpatient and outpatient vital signs, test results and diagnoses came from patients' computerized medical records. We used multiple linear regression to identify correlates of overall satisfaction. We also analyzed three subscales: access to care, financial aspects and interpersonal manner of physicians. We included only variables with univariate correlations (P < 0.05) in the models. Decreased overall satisfaction correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01), and higher diastolic blood pressure (P = 0.08). Decreased satisfaction with access to care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001) and decreased medication compliance (P = 0.08). Decreased satisfaction with financial aspects of care correlated with more symptoms related to anti-hypertensive drugs (P < 0.001), lower medication compliance (P = 0.01) and more proteinuria (P = 0.02). Finally, decreased satisfaction with interpersonal manner of physicians correlated with lower medication compliance (P < 0.001), lower albumin (P = 0.01) and sodium (P = 0.04), and higher diastolic blood pressure (P = 0.04). These cross-sectional baseline data describe a group of mostly black inner-city patients with hypertension and chronic renal insufficiency in whom decreased satisfaction with care correlates with decreased medication compliance, increased symptoms related to anti-hypertensive drug therapy, higher diastolic blood pressure and more proteinuria. Our prospective study may help determine whether improving satisfaction improves compliance and blood pressure control, and forestalls complications in this high-risk population.

Computerizing guidelines to improve care and patient outcomes: the example of heart failure.

Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into a network of physicians' interactive microcomputer workstations are reported. The task proved difficult because the guidelines often lack explicit definitions (e.g., for symptom severity and adverse events) that are necessary to navigate the AHCPR algorithm. They also focus more on errors of omission (not doing the right thing) than on errors of commission (doing the wrong thing) and do not account for comorbid conditions, concurrent drug therapy, or the timing of most interventions and follow-up. As they stand, the heart failure guidelines give good general guidance to individual practitioners, but cannot be used to assess quality or care without extensive "translation" into the local environment. Specific recommendations are made so that future guidelines will prove useful to a wide range of prospective users.

Clinical correlates of functional status in patients with chronic renal insufficiency.

Patients with end-stage renal disease (ESRD) are known to have significantly reduced functional abilities, as measured by the Sickness Impact Profile (SIP). We investigated the clinical correlates with SIP scores in a cohort of patients with lesser degrees of renal dysfunction recruited from an academic general medicine practice (mean calculated creatinine clearance, 25 mL/min). Of 603 eligible patients with chronic renal insufficiency (CRI) defined as a serum creatinine greater than 1.5 mg/dL and a calculated creatinine clearance less than 50 mL/min on two occasions more than 6 months apart, 360 (60%) agreed to participate. These patients were primarily elderly (mean age, 69 years) black (83%), women (69.2%), with an average of 6 years of education and a household income of $400 to $800 per month; 92% had hypertension and 57% had diabetes. The SIP was administered in-home by trained interviewers. Independent variables included demographic data, education, income, and medications (via interviewers), vital signs taken by a renal nurse, and diagnostic test results and diagnoses from patient's computerized records. The total SIP score was the dependent variable, and its physical and psychosocial subscales were also investigated. Variables with univariate correlations with total SIP (P < 0.05) were included in a multiple regression analysis. All variables with a multivariable P value less than 0.10 were included in the final model. The mean SIP score was 24.5 +/- 15.6, higher than that found in patients on dialysis. Significant (P < 0.05) independent correlates with higher SIP scores (greater disability) were lower educational level and income, prior diagnoses of coronary artery disease and stroke, and lower serum albumin.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hypertension and type II diabetes on renal function in an urban population.

End-stage renal disease is a devastating complication of essential hypertension and type II diabetes mellitus, conditions that commonly occur together. We and others have previously suggested that the outcome of both conditions may be influenced by more aggressive treatment. We examined a large general medicine outpatient population; 72% were black and 41% were diabetic (95% type II). Decreased renal function, defined as a serum creatinine greater than or equal to mg/dL, developed in 18.1%. A multivariable logistic regression analysis identified glucose control, systolic blood pressure level, and male gender as indicators of decreased renal function. These data suggested that both glucose and blood pressure control may decrease the frequency of impaired renal function. However, when these variables were controlled, blacks still had almost twice the risk for renal dysfunction of whites. The data draw attention to, and elucidate the exceptionally high incidence of renal dysfunction in hypertensive blacks with or without diabetes. Further, they may explain the inordinate numbers of blacks with hypertension requiring dialysis. Prospective trials to test the efficacy of blood pressure and glucose control on the course of renal disease in hypertensive and/or type II diabetic patients are warranted.

International food component data system.

The International Network of Food Data Systems planning conference recommends establishing nomenclature and a system of coding for use in INFOODS. The International Food Naming System would facilitate collection, tabulation, storing, and retrieval of information. The system consists of two files for each food: one describing the name in a standardized manner and another reporting chemical and biological data. The two files are linked by International Food Number (IFN). Food names consist of controlled terms called facets: origin, part, process, stage of maturity, and grade. Within each facet, such elements as genus, species, variety (scientific name) and generic name, breed or kind, and strain (English name) are defined. Elements are assigned numerical codes to facilitate sorting and storage. Carefully defined standard descriptions are used in each facet. Each descriptor is assigned an alphabetic code, an unlimited number allowing an open-ended flexible system. IFN may be incorporated into a computerized data management system and stored data searched and sorted for information retrieval on given parameters, e.g., country, state, laboratory, or kind of package. Data can be summarized to obtain averages, ranges, and standard deviations. Summarized data, linked with the International Food Names by the IFN, may be printed out in desired format.

N2 and CO vibrational CARS and H2 rotational CARS spectroscopy of CH4/N2O flames.

Broadband CARS spectra of N2 and CO have been obtained from the postflame gases of rich CH4/N2O flames using the nonplanar BOXCARS technique. The temperature and concentration of both N2 and CO in these flames were estimated from CARS spectra with the aid of model calculations and agreed with standard thermochemical predictions. In addition, several pure rotational H2 CARS transitions, certain of which had been previously unobserved, were seen in several spectral regions, most notably in both the CO and NO CARS regions. These observations are important in future modeling of CARS data.