A nurse-managed smoking cessation program for hospitalized smokers

OBJECTIVES

This study evaluated a nurse-managed smoking cessation program for smokers hospitalized for a variety of conditions.

METHODS

Hospitalized patients who smoked prior to hospitalization and who were motivated to quit (n = 660) were randomized to intervention or usual-care groups and followed for the next year. The intervention included a meeting with the nurse-case manager; the use of a videotape, workbook, relaxation audiotape, and nicotine replacement therapy; and nurse-initiated phone contacts after discharge.

RESULTS

The 12-month confirmed cessation rates were 21% and 31% for, respectively, the usual-care and intervention groups (odds ratio = 1.7; 95% confidence interval = 1.1, 2.3).

CONCLUSIONS

A nurse-managed smoking cessation intervention can significantly increase cessation rates for hospitalized patients.

Transgenic model for the discovery of novel human secretory non-pancreatic phospholipase A2 inhibitors

Transgenic mice were created which overexpress human secretory non-pancreatic phospholipase A2 (sPLA2) pansomatically as a potential disease and drug-testing model. The mice were produced using a DNA construct in which the inducible mouse metallothionein gene promoter drives expression of a human sPLA2 minigene. High levels of sPLA2 were detected in several tissues by immunofluorescence localization. Expression in the testes caused hypospermia and male infertility. Circulating catalytically active sPLA2 could be induced to levels observed in patients undergoing a systemic inflammatory response but had no detectable effect on the mice. Therefore, these results suggest that sPLA2 hyperphospholipasemia alone may have only limited pathophysiological consequences. We further show that 3-[3-acetamide-1-benzyl-2-ethylindolyl-5-oxy]propane phosphonic acid LY311727), a potent new inhibitor of phospholipase A2 catalysis developed by our group, dramatically suppresses the circulating enzyme activity in these animals whereas 3-[3-acetamide-1-benzyl-2-propylindolyl-5-oxy]propane phosphonic acid (LY314024), a substantially less potent LY311727 analog, is without effect. These later results thus motivate the further development of this compound as a potential new therapeutic agent and valuable research tool.

A starch-hemoglobin resuscitative compound

A resuscitative compound in freeze-dried form has been synthesized between a modified starch and a tetremerically stabilized hemoglobin. In order to complex the hemoglobin, the starch has been prepared in mono-, di-, tri-, and tetra-aldehyde moieties. The hemoglobin was stabilized with low molecular weight diacids. Electrophoretic densitometric patterns indicate compound formation. The resulting polymers were characterized with respect to oxygen transport (biotonometry), Hill constant and P50. The in vivo evaluation indicates that these compounds are effective in exchange-transfusion experiments with rats to a level of about 85% replacement of whole blood. The final product is a cost-effective acellular resuscitative compound which can be stored in freeze-dried form at room temperature for extended periods of time. This artificial blood substitute can be reconstituted upon the addition of water.

Mapping the lipid-exposed surfaces of membrane proteins

Phospholamban forms a stable complex of five long transmembrane helices. We show that the relative rotational orientation of the helices in the pentameric complex can be distinguished by S-H to S-D exchange of cysteine sulphydryl groups located in the transmembrane segment of the protein and exposed to the lipid environment. Of the three cysteine residues in phospholamban, two residues (Cys 36 and Cys 46) are oriented towards the helix interface and protected from exchange, while the third cysteine (Cys 41) is oriented towards the lipid interface and undergoes exchange with water diffused into the bilayer. Distinguishing the external and internal faces of a membrane protein by sulphydryl exchange provides a general approach for determining the three-dimensional fold of membrane proteins and enhances model building efforts to generate high-resolution structures.

Long-term sun exposure alters the collagen of the papillary dermis. Comparison of sun-protected and photoaged skin by northern analysis, immunohistochemical staining, and confocal laser scanning microscopy

BACKGROUND

Long-term solar irradiation produces both morphologic and functional changes in affected skin. Because collagen is the major structural component of skin, any alteration in its production or degradation could have profound effects on cutaneous functional integrity.

OBJECTIVE

Our purpose was to investigate alterations in the production and morphology of collagen fibers brought about by long-term sun exposure.

METHODS

We compared collagen and collagenase gene expression and collagen immunohistochemical staining and used confocal laser scanning microscopy for morphologic examination of dermal collagen fibers in photodamaged compared with sun-protected skin from the same persons.

RESULTS

Despite a large increase in elastin messenger RNA in sun-damaged skin, collagen and collagenase gene expression remained essentially unchanged. However, striking alterations in the papillary dermis of photoaged skin were found, which revealed large, abnormally clumped elastic fibers and deformed collagen fibers of various diameters, replacing the normal architecture of the papillary dermis.

CONCLUSION

Our data provide evidence for normal collagen gene expression in sun-damaged skin and suggest that degradation and remodeling of collagen take place in the papillary dermis accompanied by deposition of other matrix components, predominantly abnormal elastic fibers.

Social physique anxiety, body esteem, and social anxiety in bodybuilders and self-reported anabolic steroid users

Social physique anxiety, upper body esteem, social anxiety, and body dissatisfaction were examined among self-reported anabolic steroid (AS)-using bodybuilders, non-using bodybuilders, athletically active exercisers, and non-exercising individuals. Results indicate that: (a) the AS-using bodybuilder group had significantly lower levels of social physique anxiety than non-user groups, (b) AS-using bodybuilders have significantly higher upper body strength ratings than do non-users (non-using bodybuilders, athletically active exercisers, and non-exercisers), and (c) no differences among groups on a measure of social anxiety. Implications for further research and intervention are discussed in terms of the differences between anabolic steroids and other substances of abuse.

A comparison of filtered leukocyte-reduced and cytomegalovirus (CMV) seronegative blood products for the prevention of transfusion-associated CMV infection after marrow transplant

We performed a prospective, randomized trial in CMV seronegative marrow recipients to determine if filtered blood products were as effective as CMV-seronegative blood products for the prevention of transfusion-transmitted CMV infection after marrow transplant. Before transplant, 502 patients were randomized to receive either filtered or seronegative blood products. Patients were monitored for the development of CMV infection and tissue-documented CMV disease between days 21 and 100 after transplant. Infections occurring after day 21 from transplant were considered related to the transfusion of study blood products and, thus, were considered evaluable infections for the purpose of this trial. In the primary analysis of evaluable infections, there were no significant differences between the probability of CMV infection (1.3% v 2.4%, P = 1.00) or disease (0% v 2.4%, P = 1.00) between the seronegative and filtered arms, respectively, or probability of survival (P = .6). In a secondary analysis of all infections occurring from day 0 to 100 post-transplant, although the infection rates were similar, the probability of CMV disease in the filtered arm was greater (2.4% v 0% in the seronegative arm, P = .03). However, the disease rate was still within the prestudy clinically defined acceptable rate of < or = 5%. We conclude that filtration is an effective alternative to the use of seronegative blood products for prevention of transfusion-associated CMV infection in marrow transplant patients.

Monoamine oxidases and alcoholism. I. Studies in unrelated alcoholics and normal controls

Low platelet MAO activity has been associated with alcoholism. In order to evaluate the role of MAO genes in susceptibility to alcoholism, we have taken a biochemical and molecular genetic approach. The sample consisted of 133 alcoholic probands who were classified by subtypes of alcoholism and 92 normal controls. For those subjects typed for platelet MAO activity, alcoholics (N = 74) were found not to differ from the non-alcoholics controls (N = 34). Neither was there a significant difference between type I and type II alcoholics or between either subtype and normal controls. However, we do find significant differences between male and female alcoholics, but not between male and female controls. The allele frequency distribution for the MAO-A and MAO-B dinucleotide repeats is different between the alcoholic sample (N = 133) and the normal control sample (N = 92). In a two-way analysis of variance of MAO-B activity as a function of the allelic variation of each marker locus and diagnosis, there is no evidence for mean differences in activity levels for the different alleles. Our findings do not rule out a role for the MAO-B gene in controlling the enzyme activity because the dinucleotide repeats are located in introns.

Dependent care, caregiver burden, hardiness, and self-care agency of caregivers

This is a partial replication of a descriptive correlation study that examined the relationship between dependent care, caregiver burden, health-related hardiness, and self-care agency of caregivers. Data from this replication were compared with those of the previously reported study. Data were collected from a home health agency and a radiation-oncology unit. A moderate significant negative correlation was found between objective burden and dependent care. Moderate significant positive correlations were found between self-care agency scores and the commitment/challenge and control subscales of health-related hardiness scores. The major difference between this study and the previous one was in the level of subjective burden. Even though caregivers reported greater levels of subjective burden, the correlation with self-care agency and hardiness was nonexistent. The small subsample of male caregivers (n = 14) prevented a statistical comparison with the previous data; however, in the pooled sample previous findings were supported.

Cataracts after bone marrow transplantation: long-term follow-up of adults treated with fractionated total body irradiation

PURPOSE

To determine the risk of, and risk factors for, developing cataracts after bone marrow transplantation.

METHODS AND MATERIALS

Four hundred and ninety-two adults who underwent bone marrow transplantation in Seattle were followed for 2 to 18 (median, 6) years. Before transplantation, patients received a preparative regimen of chemotherapy plus total body irradiation (TBI) (n = 407) or chemotherapy alone, without TBI (n = 85). TBI was administered in a single dose of 10 Gy (n = 74) or in fractionated doses totaling 12-15.75 Gy (n = 333). The risk of cataracts was determined for groups of patients with respect to the type of preparative regimen received and other pretransplant and posttransplant variables.

RESULTS

One hundred and fifty-nine patients (32%) developed cataracts between 0.5 to 11 (median, 2.3) years after transplantation. The probability of cataracts at 11 years after transplantation was 85%, 50%, 34%, and 19% for patients receiving 10 Gy of single-dose TBI, > 12 Gy fractionated TBI, 12 Gy fractionated TBI, and no TBI, respectively (p < 0.0001). Among those developing cataracts, the severity was greater in patients after single-dose TBI (59% probability of surgical extraction) than after > 12 Gy fractionated TBI, 12 Gy fractionated TBI, or no TBI (33%, 22% and 23%, respectively). Patients given corticosteroids after transplant had a higher probability of cataracts (45%) than those without steroids (38%) (p < 0.0001). In a proportional hazards regression model, the variables that were correlated with an increased probability of cataracts were single-dose TBI (relative risk (RR) = 2.46) and steroid therapy (RR = 2.34), while a decreased probability of cataracts was correlated with a nonTBI preparative regimen (RR = 0.41). The yearly hazard of developing cataracts in recipients of single-dose TBI was highest during the third year after transplantation, while in recipients of fractionated TBI, the hazard was distributed among years one through seven. The probability of cataracts in all groups reached a plateau at 7 years after transplantation, after which the development of cataracts was extremely unlikely.

CONCLUSION

TBI is the major risk factor for developing cataracts after BMT. Single-dose TBI results in the highest risk of cataracts. However, the risk of cataracts in recipients of fractionated-TBI is significantly higher than in patients who receive no TBI. In addition to TBI, steroid therapy is an independent risk factor for cataracts after BMT.

An empirically derived typology of families: I. Relationships with adult health

In this report we describe the development and partial validation of an empirically derived typology of families based on 11 family variable composites derived from the California Family Health Project. Our goal was to use the typology to condense and integrate the findings from previous analyses of a large group of family variables and to account for differences in the self-reported health of adult family members. Exploratory and confirmatory cluster analyses conducted separately by gender classified 97% of the sample into four parallel types for husbands and wives: Balanced, Traditional, Disconnected, and Emotionally Strained. A 1-way MANOVA indicated that all 11 family variable composites significantly differentiated the four family types for husbands and wives. Significant differences among the four family types were also found on 10 demographic and other family variables, using ANOVA. Using MANOVA, we compared the four family types on 12 self-reported health and well-being variables by gender. Both husbands and wives from Balanced and Traditional families reported higher health scores than spouses from Disconnected and Emotionally Strained families, but no single profile of health scores was unique to a particular family type. The four family types provide an integrated and comprehensive framework for describing the family in health research.

An empirically derived typology of families: II. Relationships with adolescent health

In this report from the California Family Health Project, we describe the relationship between an empirically derived family typology based on parent data, and the self-reported health and well-being of 151 adolescent offspring. The typology is comprised of four family types: Balanced, Traditional, Disconnected, and Emotionally Strained. Three adolescent health indices were constructed from 13 self-reported health variables using principal components and multidimensional scaling analyses: Physical Health, Emotional Health, and Alcohol Abstinence. ANOVA indicated that Physical Health was significantly different among adolescents in the four family types. The findings varied, however, depending upon whether the typology was based on mothers' or fathers' appraisals of the family. In the father-based typology, adolescents from Traditional families scored highest while those from Emotionally Strained and Balanced families scored lowest. In the mother-based typology, adolescents from Balanced, Traditional, and Emotionally Strained families scored equally high, while those from Disconnected families scored significantly lower than those from the other three family types. Differences on Abstinence were significant only in the father-based typology. Adolescents from Traditional and Emotionally Strained families drank less than adolescents from Disconnected families. No significant differences among adolescents were found for Emotional Health, and adolescent gender did not interact significantly with family type to affect any of the three health indices. Traditional and Disconnected family types had offspring who clearly stood apart with higher and lower health scores, respectively. The results are discussed in terms of the current literature on social environment and health.

Fungal liver infection in marrow transplant recipients: prevalence at autopsy, predisposing factors, and clinical features

To determine the prevalence of fungal liver infection at autopsy in marrow transplant recipients, we reviewed autopsy results for the period 1980-1989. Cases were compared to randomly chosen autopsied controls without fungal infection. Fungal liver infection was found in 67 (9%) of 731 patients. Fungal cultures of liver lesions were positive for 34 of 67 patients, most of whom had been culture-positive for the same fungal species (largely Candida) during life. Multivariate analysis revealed that independent predictors of fungal liver infection were deep fungal infection after transplantation (RR, 35), colonization or superficial infection after transplantation (RR, 13), and severe liver dysfunction caused by veno-occlusive disease of the liver and/or graft-versus-host disease (RR, 7). Clinical and laboratory findings during the last month of life revealed no differences between cases and controls. Liver imaging studies performed during the last 15 days of life had a sensitivity of only 18% for detecting fungal liver lesions.

Blepharophimosis syndrome is linked to chromosome 3q

Blepharophimosis syndrome (BPES, blepharophimosis eyelid syndrome) is a distinctive congenital eyelid malformation which can occur sporadically or be inherited in an autosomal dominant fashion. Previous reports have described associated cytogenetic abnormalities on chromosome 3q. We have ascertained and sampled two BPES families with apparent autosomal dominant inheritance and have tested for linkage with 17 polymorphic markers on 3q. Multipoint analysis generated a maximum LOD score of 3.23 using the markers RHO, ACPP and D3S1238. No evidence of genetic heterogeneity was observed. These studies provide the first non-cytogenetic evidence that a defective gene responsible for BPES is located on 3q22.

Aural tuberculosis

Since the advent of antituberculous therapy, tuberculosis of the ear has decreased in incidence; but of late, cases of both pulmonary and otologic tuberculosis are on the rise. In addition, the treatment of aural tuberculosis is now more difficult due to resistance to one or more of the routinely used antituberculous pharmacotherapeutic agents. Urban areas and selected populations have been particularly endangered by the re-emergence of this disease. In light of this developing situation, three cases of aural tuberculous infections are presented. Typical and atypical presentations of the disease, including history, signs, symptoms, and radiographic findings are discussed, as are treatment options. The importance of aural tuberculosis as part of the general increase in incidence and resistance of the disease is examined.

Prognostic models and the propensity score

Subjects in observational studies of exposure effects have not been randomized to exposure groups and may therefore differ systematically with regard to variables related to exposure and/or outcome. To obtain unbiased estimates and tests of exposure effects one needs to adjust for these variables. A common method is adjustment via a parametric model incorporating all known prognostic variables. Rosenbaum and Rubin propose adjustment by the conditional exposure probability given a set of covariates which they call the propensity score. They show that, at any value of the propensity score, covariates are on average balanced between exposure groups. Thus matching on the propensity score leads to unbiased estimators and tests of exposure effect. However, the validity of the method depends on knowing the exposure probability. This quantity is usually not known in observational studies and needs to be estimated.

The impact of chronic illness on the health and well-being of family members

Examined is the impact of dementia on the physical and mental health of all family members caring for an ill parent/spouse. The sample included 97 spouses of patients diagnosed with either Alzheimer's disease or vascular dementia, 186 offspring, and 97 offspring spouses or "in-laws." Multiple regression tested the association between severity of the illness and family member health and well-being. Severity was significantly associated with health and well-being for spouses, offspring, and in-laws, regardless of the amount of caregiving, demonstrating the potential cascading effect of the illness through the family. Use of services displayed no direct association with spouse health and well-being, but service utilization interacted with illness severity. The relationship between severity of illness and spouse health was lower under conditions of high service utilization than under conditions of low service utilization.

Alzheimer's disease: the impact of the family on spouses, offspring, and inlaws

This article reports the findings from a study designed to identify qualities of the multigeneration family system that affected the relationship between the demands of Alzheimer's disease on the family and the health and well-being of (a) spouses, (b) offspring, and (c) offspring's spouses or "inlaws." Members of 97 families of patients with Alzheimer's disease, recruited from four University-affiliated Alzheimer's Centers, completed detailed questionnaires and participated in a 45-minute telephone interview to assess care-strain, personal stress, appraisals of three major domains of family life (World View, Structure/Organization, and Emotion Management), and three health and well-being indices (Anxiety/Depression, Somatic Symptoms, and Well-Being). Multivariate multiple regression equations, run separately for each of the three groups of family respondents and each of the three family domains, indicated: (1) no significant associations between the severity of the elder's disease and family member health and well-being; (2) female family members reported poorer health and well-being than male family members; and (3) caregiver strain was negatively associated with family member health and well-being. Further, appraised family qualities were associated with the health and well-being of the three groups of respondents differently: directly for offspring, interactively with severity of patient disorder for inlaws, and not at all for spouses. The data suggested that some family qualities served a protective function, whereas others exacerbated the negative effects of caregiving by affecting personal health and well-being. The findings are interpreted in terms of the different roles and expectations for care-giving placed on spouses, offspring, and inlaws. It is suggested that programs of intervention for patients with Alzheimer's and other chronic diseases should focus on the multigeneration family as the context for care, rather than only on the primary caregiver.

Risk factors for repeatedly reactive HIV-1 EIA and indeterminate western blots. A population-based case-control study

OBJECTIVE

Causes of indeterminate results of Western blot testing (IWB) for human immunodeficiency virus (HIV) type 1 include seroconversion, HIV-2 cross-reactivity, and autoimmune disease, but most IWB results remain unexplained. This case-control study assessed risk factors for IWB results, including early HIV infection, other retroviral infection, autoantibodies, and other medical conditions.

DESIGN

Prospective study to determine HIV seroconversion rate, with a case-control design to assess other risk factors for IWB. Cases (persons with one or more repeatedly reactive HIV-1 enzyme immunoassay with IWB), their current sexual partners, and controls (persons with negative enzyme immunoassay and Western blot results) were recruited from blood banks, health department and prenatal clinics, and private providers in Washington and Oregon.

RESULTS

Of 244 cases enrolled, 206 were followed up for 6 months or longer, and six (3.0%; 95% confidence interval [CI], 0.7% to 5.3%) with recent HIV risk behaviors seroconverted. The Western blot banding patterns differed among groups; cases usually had p17 or p24 bands, while controls and cases' sexual partners usually had polymerase bands. Conditional logistic regression indicated that independent risk factors for IWB among male cases and controls were a tetanus booster in the past 2 years (odds ratio, 3.2; 95% CI, 1.2 to 8.6) and sexual contact with a prostitute (odds ratio, 3.0; 95% CI, 1.0 to 9.5). Independent risk factors for women were parity (odds ratio, 1.2; 95% CI, 1.02 to 1.4) and autoantibodies, either rheumatoid factor or antinuclear antibodies (odds ratio, 2.3; 95% CI, 1.03 to 5.6). No cross-reactivity was detected with HIV-2, human T-lymphotrophic virus type 1, feline immunodeficiency or feline leukemia, or bovine immunodeficiency viruses.

CONCLUSIONS

Evaluation of persons with reactive HIV-1 enzyme immunoassays and IWB should include an assessment of HIV risk and other possible risk factors, such as alloimmunization (ie, parity or recent immunization) or autoantibodies (ie, antinuclear antibodies and rheumatoid factor). The relationship of IWB among men who reported sex with prostitutes is intriguing and warrants further study.

A case-management system for coronary risk factor modification after acute myocardial infarction

OBJECTIVE

To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification.

DESIGN

Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction.

SETTING

5 Kaiser Permanente Medical Centers in the San Francisco Bay area.

PATIENTS

585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction.

INTERVENTION

In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy.

OUTCOME

Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction.

RESULTS

In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 +/- 0.69 mmol/L and 3.41 +/- 0.90 mmol/L (107 +/- 30 mg/dL and 132 +/- 30 mg/dL) (P = 0.001), and functional capacities were 9.3 +/- 2.4 METS and 8.4 +/- 2.5 METS (P = 0.001), respectively.

CONCLUSION

In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.

Risk factors for transmission of Mycobacterium tuberculosis in a primary school outbreak: lack of racial difference in susceptibility to infection

Recent data have suggested that there are racial differences in the susceptibility to infection by Mycobacterium tuberculosis. An opportunity to test this suggestion was afforded by an outbreak of tuberculosis in a racially mixed elementary school in St. Louis County, Missouri. A physical education teacher was discovered to have cavitary pulmonary tuberculosis. Of 343 students in the school, 176 (51 percent) were found to be tuberculin skin test positive (> or = 5 mm induration by Mantoux method); 32 children had abnormal chest radiographs. More frequent contact with the physical education teacher was associated with infection (p < 0.001). Black children were no more likely to be infected than were white children (relative risk (RR) = 0.98, 95% confidence interval (CI) 0.78-1.22). However, black children who were tuberculin positive had larger skin reactions than did white children (mean, 18.9 vs. 16.6 mm, p < 0.001) and were more likely to have abnormal chest radiographs (RR = 2.76, 95% CI 1.44-5.27). Among tuberculin-positive children, low body mass index (less than 10th percentile) was associated with active disease (RR = 2.90, 95% CI 1.45-5.80). The analysis of race was unchanged after controlling for sex, body build, and level of contact with the physical education teacher. Widespread tuberculous infection resulted from contact with a highly infectious staff person. Thin body build was a risk factor for active disease. Black children were no more susceptible to infection than were white children, although they more commonly developed radiographic evidence of active disease.

B-scan ultrasonic measurement of the lumbar spinal canal as a predictor of industrial back pain complaints and extended work loss

B-scan ultrasonic measurements of lumbar spinal canal diameter were examined as predictors of industrial back pain complaints and extended work loss. Baseline data were collected on 3,020 Washington State aircraft manufacturing workers, and over a mean 3.7-year follow-up period 352 subjects reported industrial back pain complaints. Mean canal measurements of subjects with industrial back pain complaints were smaller at all spinal levels than in subjects without complaints. The mean differences between the groups, however, were extremely small (0.07 mm to 0.51 mm), and not all levels were statistically significant. The relative risk for an L5-S1 measurement 2 standard deviations below the mean was 1.4, yet the measurement explained less than 1% of the uncertainty in predicting complaints. No association was found between canal measurements and claims with extended work loss of greater than one month. The imprecision of the measurements and poor predictive ability indicate that B-scan ultrasonography, as used in this study, is of dubious screening value.