International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass.

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Living will completion in older adults.

BACKGROUND: In December 1991, the Patient Self-Determination Act required health care institutions to provide incoming patients with information about living wills (LWs). Although LWs have been legalized in the majority of states, the number of people with a completed LW remains low. This study was designed to learn some of the reasons that so few people have an LW. METHODS: With the use of the health belief model, a questionnaire was designed to characterize the group that already had a completed LW and to identify the barriers older adults perceive in their completion of an LW. Older adults (aged 65 to 90 years) who dined at 10 local nutrition sites were asked to participate. Of the 214 subjects with usable responses, 15% already had executed an LW, 66% planned to complete an LW, and 86% wanted to have an LW. By means of multiple regression and discriminant analysis, the characteristics that defined each group were statistically determined. RESULTS: Two characteristics described those who already had an LW: they were highly educated and did not consider the LW form too long for its purpose. The older adults who planned to complete an LW identified two barriers impeding them: family issues and a need for assistance in completing the form. The majority of the older adults (61%) desired that their physicians initiate discussions with them about an LW. CONCLUSIONS: Conclusions from these data yield recommendations for health care providers toward implementing the act; physician-initiated discussions, community programs, and available information and assistance are needed.

Expression and regulation of phosphate stress inducible genes in Sinorhizobium meliloti.

Sinorhizobium meliloti 104A14 was mutated with transposon Tn5B22, which creates lacZ transcriptional fusions when inserted in the correct orientation relative to the promoter. This promoter reporter allowed us to identify six phosphate stress inducible (psi) genes in S. meliloti that are up-regulated in response to inorganic phosphate (Pi) starvation. The transposon and flanking DNA were cloned from each psi::Tn5B22 reporter mutant and the junction DNA sequenced. High identity/similarity of the inferred peptides with those in major data bases allowed identification of the following genes: dnaK, expC, pssB, ackA, vipC, and prkA. The prkA homolog was also found to be up-regulated in response to carbon starvation and when nitrate replaced ammonium as the nitrogen source. Through allele replacement techniques, PhoB- mutants were generated for the expC, ackA, vipC, and pssB reporter strains. Loss of a functional PhoB resulted in the absence of Pi-sensitive induction in all four genes. These experiments suggest the Pho regulon in S. meliloti includes genes that presumably are not directly linked to Pi acquisition or assimilation. The psi strains were tested for their symbiotic properties under growth conditions that were Pi-limiting or Pi-nonlimiting for the host plant. All were Nod+ and Fix+ except the reporter strain of dnaK transcription, which was less effective than the wild-type strain under both P treatments, indicating DnaK is required for optimum symbiotic function.

Intrathecal baclofen therapy in stiff-man syndrome: a double-blind, placebo-controlled trial.

We performed a double-blind, placebo-controlled trial of intrathecal baclofen (ITB) in stiff-man syndrome. Three patients, unresponsive to current therapy, received 50 micrograms of ITB or placebo on sequential days. Following ITB, all patients demonstrated improvement in reflex EMG activity. The mean reduction in total EMG activity (from all muscles) following stimulation of the medial plantar nerve (cutaneous flexor reflex) was 72% following 50 micrograms of ITB compared with 18% following placebo (ANOVA: significance of F, p < 0.0001). The mean latency to onset of the response was also significantly prolonged for all muscles following ITB (ANOVA: significance of F, p < 0.05). Although reflex EMG activity was reduced in all patients, clinical improvement was evident in only one patient, who differed from the others studied by a longer duration of disease, greater severity of stiffness, less fear of falling, and greater electrophysiologic improvement.

Physician attitudes and beliefs about use of morphine for cancer pain.

The recent literature asserts that mistaken physician beliefs and attitudes are critical barriers to adequate cancer pain relief. To determine the prevalence of 12 proposed myths or misconceptions about morphine use in cancer pain management (CPM), we surveyed all physicians engaged in direct patient care in Duluth, Minnesota (N = 243). A 62% response was obtained. Many physicians misunderstood concepts of morphine tolerance, both to analgesia (51%) and to side effects (39%). Many were unaware of the use of adjuvant analgesics (29%), efficacy of oral morphine (27%), and nonexistent risk of addiction in CPM (20%). Analysis of result by physician age and specialy groups confirmed significant levels of misunderstanding in all subsets. Strategies to change physician attitudes and beliefs regarding morphine in CPM should focus on tolerance concepts, dosing schemes, safety, efficacy, lack of addictive risk, use of drug combinations, and the fact that cancer pain can be relieved.

Physician acquisition of cancer pain management knowledge.

Insufficient physician education in cancer pain management (CPM) is one of the major factors contributing to inadequate pain relief of cancer patients throughout the world. A survey of all physicians in direct patient care in Duluth, MN, (N = 243) was conducted to determine where they learned about CPM and how they would like to further their knowledge. Responses from 150 physicians (62%) have been analyzed, especially focusing on physician age and specialty. Statistically significant differences (p less than 0.001) document that residency training programs have been including CPM in their curricula since 1978 and that medical schools have not. Additional significant sources of CPM have been consultations with expert physicians, conferences and the literature. When asked how they would like to learn more about CPM, 84% of all physicians indicated that local conferences would be most effective. Physicians in various specialties indicated their differing preferences, too. This study suggests that improvements in CPM can occur through these mechanisms.

Patients and family members: the role of knowledge and attitudes in cancer pain.

Cancer pain theoretically comprises sensory, affective, and cognitive dimensions, implying that patients and family members perceive and report cancer pain based on these factors. The study reported here investigated the relationship between specific knowledge and attitudes (cognitive factors), and patients' and family members' reports of pain due to cancer. The relationship between cognitive factors and reports of cancer pain was investigated in interviews with 122 patients and their family members. Pain was measured using the Brief Pain Inventory; knowledge and attitudes were measured using a form previously developed by the authors. Patients' and family members' reports of patient pain and performance status were highly correlated, although family members consistently reported more pain and disability. Using regression analysis, cognitive factors were strongly related to family reports of patients' pain (R2 = 0.27), but contributed little to explaining pain reported by patients themselves (R2 = 0.06). Improved understanding of patients' pain assessments depends on further investigation of other cognitive factors and of sensory and affective factors. Family members' assessments of pain are significantly related to appropriate knowledge and attitudes.

Improving cancer pain management in communities: main results from a randomized controlled trial.

The purpose of this randomized controlled community trial is to evaluate the effects of a community intervention utilizing opinion leaders and educational strategies on the cancer pain management knowledge, attitudes, and the practices of physicians and nurses, and cancer pain reported by patients. Six Minnesota communities participated in the study. The three communities randomized to the intervention received educational programs over 15 months. The clinical community opinion leaders participated in a minifellowship, developed community task forces, and interacted with their peers. This strategy was reinforced with community outreach programs, clinical practice guidelines, educational materials, and media events. The primary study end point was patients' pain intensity score. Comparing intervention to control communities, pain prevalence declined slightly, pain management index improved slightly, pain intensity scores increased slightly, patient and family attitude scores did not change, and physicians' and nurses' knowledge and attitude scores improved slightly. None of these changes, however, reached statistical significance. Participation in at least one intervention program improved physicians' and nurses' knowledge and attitude scores that approached statistical significance. Our results suggest that community opinion leaders combined with other educational programs may improve cancer pain management, but this strategy requires further study. The results suggest that more intense intervention application may be effective. Effective strategies to improve cancer pain management remain elusive.

Physician knowledge and attitudes about cancer pain management: a survey from the Minnesota cancer pain project.

The purposes of the study were to determine the knowledge and attitudes about cancer pain management (CPM) among practicing physicians in six Minnesota communities and to determine the physician-related barriers to optimal CPM. Eligible community physicians were surveyed by telephone. The study analyzed responses of 145 physicians (response rate, 87%). The majority of the physicians were primary care specialists (73%). Significant knowledge deficits were identified in nine of 14 CPM principles, but inappropriate attitudes were found in only two of nine CPM concepts. Medical specialty had the strongest influence on knowledge and attitudes, with primary care physicians having significantly better outcomes than surgeons or medical subspecialists. Effective education strategies must address knowledge deficits, attitudes, and motivations of the relevant peer group influencing physicians, as well as those of individual physicians. The Minnesota Cancer Pain Project is testing strategies to enhance CPM by physicians and improve patient outcomes.

Interscalene blocks for chronic upper extremity pain.

A study of 25 patients was carried out to determine the efficacy of interscalene block (ISB) for the treatment of chronic upper extremity pain. An RSD score was used to categorize these patients. Seventeen of the 25 patients had less pain after ISB, and 14 also had increased range of motion of the affected limb. Patients with reflex sympathetic dystrophy (RSD)/causalgia, as well as other chronic pain conditions, improved. ISB was compared with stellate ganglion block (SGB) in patients undergoing both treatments. ISB seemed to be at least as effective as SGB for treatment of RSD/causalgia and may have some advantages over SGB. The role of somatic and sympathetic blockade is discussed.

Birth Order and health: major issues.

Birth Order has been described as a variable with a complex relationship to child and adult outcomes. A review of the medical literature over the past 5 years identified 20 studies that investigated the relationship between Birth Order and a health outcome. Only one of the studies established a relationship between Birth Order and a health outcome: third and fourth-born children have a higher incidence of accidents that result in hospitalization. The other demonstrated relationships are each explained by intervening variables or methodological limitations. Although Birth Order is not a strongly independent explanatory factor in understanding health outcomes, it is an important marker variable. Statistically significant relationships between Birth Order and health outcomes yield insights into the ways a family influences an individual's health.

Arthritis in Indian country: determining the prevalence and effects.

OBJECTIVE: This project was designed to determine the prevalence of self-reported arthritis and its effect on the daily lives of Chippewa Indian people on tribal lands in Wisconsin. DESIGN AND METHODS: After review and approval by the LCO Tribal Council and the University of Minnesota Human Subjects Committee, face-to-face interviews with randomly selected tribal residents were conducted, followed by focus group formation, and medical chart reviews. RESULTS: Eighty-one percent (N = 82) of the eligible sample were interviewed. Fifty-six percent (N = 46) self-reported a diagnosis of arthritis, either by physician report or description of symptoms confirmed by a rheumatologist. Seventy-eight percent of this group (N = 36) reported limitations in their activities that can be attributed to arthritis. Only half of the medical charts included the diagnosis of arthritis or any tests to document its diagnosis. CONCLUSIONS: In this Chippewa population, the prevalence of and limitations due to arthritis are extremely high. Reasons for this need further investigation. The implications of these findings for tribal and health planning include housing, community activities, and medical services to accommodate the needs of this group.

Health needs of people living below poverty level.

BACKGROUND AND OBJECTIVES: Low-income populations, especially persons without health insurance, suffer disproportionately with a variety of chronic ailments, postpone getting medical care, and have shorter life spans. This study was conducted to better understand the health care needs and behaviors of people living in poverty. METHODS: Participants for the study were recruited through agencies serving low-income and homeless people, neighborhood businesses, churches, and subsidized housing units. All participants were adults who had incomes below 200% of the federal poverty level. Subjects completed face-to-face interviews to answer questions about demographics and their concerns about health care. Quantitative and qualitative analyses were performed. RESULTS: A total of 750 people were interviewed, with 729 providing usable data. Thirty-seven percent of subjects reported spending at least part of the previous year without health insurance. Fifty-six percent of these individuals were persons who were employed but whose employers did not provide health insurance. Reported health concerns were access to care (reported by 21% of subjects), costs of care (13%), and ability to purchase medications (15%). Forty-five percent of subjects reported receiving mental health services; these subjects were concerned about their ability to continue receiving care and to afford medications. CONCLUSIONS: The portion of the low-income population that is uninsured for part or all of a year is greater than in published reports. The health behaviors of this group are easily understood when coverage (if any), level of income, age, and health care needs are considered.

Prevention of violence.

Primary care physicians can easily incorporate efforts toward the primary and secondary prevention of family violence into their practices. By designing a preventive effort using the phases of the family life cycle, a developmentally appropriate system of prevention is created. The anticipatory guidance at each (annual) visit acknowledges family transitions and assures the family that abuse is a health issue and that the physician is a resource for issues of violence prevention. Using the FLC, the first phase is Coupling, when there is a risk of partner violence that continues as long as there is a partnership. Pregnancy and childbirth bring concerns of child neglect and battery. Older children are at additional risk for child sexual abuse. As families age, risks develop for elder abuse, too. The regular discussion of these issues raises the awareness that the potential for family violence continues over the life span and allows the physician opportunities to assess the risk of violence in that family and make appropriate preventive referrals. Primary care physicians are optimally positioned to address violence and its prevention in the office: they know and care for family units over time. Physicians are respected and trusted advisors who can become effective in preventing violence.

Community responses to violence.

Community level efforts are effective in the reduction of violence. Community-level interventions have three goals: to prevent the escalation of risk for violence among the families in the community, to assist families at risk of or using violence, and to protect victims of abuse. To prevent violence or reduce its prevalence, community groups need to collaborate to reduce the community-level risk factors. Assisting families and protecting victims of violence requires coordination of community services, including law enforcement, schools, therapists, courts, child care, and social services. All of these goals can best be achieved through the efforts of a community level, multidisciplinary council or board that directs the programs. A community process to establish an integrated program involves several steps. The leaders that are identified need to represent all the disciplines and the entire geographic area involved in the project. Once the leaders start meeting, the baseline information and plan can be developed. Then the project itself can be undertaken, with the support of the media and other appropriate organizations. Several examples of effective projects document this process and its success; the best efforts involve coalitions of private and governmental agencies working together. Physicians are integral to this process. The practice of medicine provides opportunities every day to prevent and intervene in potential cases of abuse and violence. Also, by participating actively in the community, physicians can be effective leaders to change attitudes and behaviors and institute programs toward reducing violence.

Treatment of child abuse.

Standards of care have recently been established for the diagnosis and treatment of child abuse. This article addresses the key areas of treatment with which each primary care physician should be acquainted. As part of a community-based approach to this problem, the physician can positively impact the prognosis for the victimized child and his or her family.

Legal considerations in cases of child abuse.

Child abuse is a common pediatric problem that can be recognized and treated appropriately by all primary care physicians who care for children. One of the necessary skills in this process involves being prepared to interface with the legal system. The physician is mandated to report suspected child abuse according to his or her state laws. He or she must be aware of the legal recourses for child protection in cases when the child remains at risk. When interacting with the child, a number of legal considerations can guide the physician in obtaining information with history, physical examination, and specimen collection. Finally, the physician may be called to testify. An understanding of how to prepare for court and how to conduct oneself in court is the final necessary skill for the primary care physician who sees children. This article provides the primary care physician with a practical understanding of the legal considerations in child abuse.

Two hospice quality of life surveys: a comparison.

This study's objective tested the utility of two quality of life (QOL) forms in a hospice setting. The compared forms were the McGill Quality of Life Questionnaire (MQOL) and the Hospice Quality of Life Index-Revised (HQLI). Using a crossover design, hospice nurses first administered one survey to eligible patients and then, in the study's second phase, administered the other survey to newly enrolled eligible patients. Nurses were interviewed regarding each form and possible changes in patient care that were made due to the assessment. Hospice care plans were reviewed looking for specific changes as a result of the surveys. The results showed that the QOL assessments were useful for the nurses in planning the care of the hospice patients and that the MQOL was preferred by the nurses over the HQLI.

Domestic violence among family practice patients in midsized and rural communities.

BACKGROUND: This study was designed to determine the prevalence and character of domestic violence among female patients at three family practice clinics (FPCs) in communities of varying sizes. METHODS: Structured interviews with 127 consecutive, consenting women were conducted in three FPCs in midwestern communities with populations of 85,000, 8000, and 3000. The main outcome measures included patient self-reports of emotional, social, physical, and sexual violence, and reasons for their clinic visit. RESULTS: Women at the clinics in the smaller communities were significantly older, reflecting their communities' demographics. Fewer women in the larger community than in the rural settings reported currently having a violent partner (12% vs 25%, P = .01). In the total sample, 46% reported violence from a previous or current partner. Emotional and social abuse were associated with moderate violence (eg, slapping and pushing), severe violence (eg, punching and kicking), and use of weapons. Sexually abused women were emotionally abused and often physically battered. Forty-six percent of currently battered women reported abuse at least once a week, and most (81%) visited their respective clinics for episodic care. CONCLUSIONS: Domestic violence is a prevalent health problem in all family practice settings. The finding that women in the larger community were less likely to be in a current battering relationship may reflect the effectiveness of local intervention programs. Because battered women present primarily for episodic care, physicians should routinely screen for battery, provide education about violence, assess the danger, review safety plans, and refer women appropriately.

An investigation of the effect of 2 sedation regimens on patient mood state following upper extremity surgery using local anesthesia.

Sedation techniques for patients undergoing minor outpatient surgery frequently include a variety of intravenous agents. The present study was designed to look for differential effects of 2 different sedation regimens on perioperative mood states. Twenty-two patients undergoing upper extremity surgery using local anesthesia were randomized to receive either propofol or midazolam intravenously for intraoperative sedation. Subjects were asked to complete a Profile of Mood States survey before and after surgery. The results of this survey were examined for differences in mood between the 2 groups that may be attributable to differences in drug effect. No significant differences were identified between propofol or midazolam regarding their effect on patient mood. Patients in both groups experienced a reduction in perioperative anxiety.