The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes

OBJECTIVE

The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy.

METHODS

This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used.

RESULTS

We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5).

CONCLUSION

This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

Improving the quality of care for patients with advanced epithelial ovarian cancer: Program components, implementation barriers, and recommendations

The high lethality of ovarian cancer in the United States and associated complexities of the patient journey across the cancer care continuum warrant an assessment of current practices and barriers to quality care in the United States. The objectives of this study were to identify and assess key components in the provision of high‐quality care delivery for patients with ovarian cancer, identify challenges in the implementation of best practices, and develop corresponding quality‐related recommendations to guide multidisciplinary ovarian cancer programs and practices. This multiphase ovarian cancer quality‐care initiative was guided by a multidisciplinary expert steering committee, including gynecologic oncologists, pathologists, a genetic counselor, a nurse navigator, social workers, and cancer center administrators. Key partnerships were also established. A collaborative approach was adopted to develop comprehensive recommendations by identifying ideal quality‐of‐care program components in advanced epithelial ovarian cancer management. The core program components included: care coordination and patient education, prevention and screening, diagnosis and initial management, treatment planning, disease surveillance, equity in care, and quality of life. Quality‐directed recommendations were developed across 7 core program components, with a focus on ensuring high‐quality ovarian cancer care delivery for patients through improved patient education and engagement by addressing unmet medical and supportive care needs. Implementation challenges were described, and key recommendations to overcome barriers were provided. The recommendations emerging from this initiative can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families.

Quality‐directed recommendations for ovarian cancer care delivery are developed across 7 core program components, with a focus on ensuring high‐quality care delivery by addressing unmet medical and supportive care needs. These recommendations can serve as a comprehensive resource guide for multidisciplinary cancer practices, providers, and other stakeholders working to provide quality‐directed cancer care for patients diagnosed with ovarian cancer and their families.

Measured performance of filtration and ventilation systems for fine and ultrafine particles and ozone in an unoccupied modern California house

This study evaluated nine ventilation and filtration systems in an unoccupied 2006 house located 250 m downwind of the I-80 freeway in Sacramento, California. Systems were evaluated for reducing indoor concentrations of outdoor particles in summer and fall/winter, ozone in summer, and particles from stir-fry cooking. Air exchange rate was measured continuously. Energy use was estimated for year-round operation in California. Exhaust ventilation without enhanced filtration provided indoor PM_2.5 that was 70% lower than outdoors. Supply ventilation with MERV13 filtration provided slightly less protection, whereas supply MERV16 filtration reduced PM_2.5 by 97-98% relative to outdoors. Supply filtration systems used little energy but provided no benefits for indoor-generated particles. Systems with MERV13-16 filter in the recirculating heating and cooling unit (FAU) operating continuously or 20 min/h reduced PM_2.5 by 93-98%. Across all systems, removal percentages were higher for ultrafine particles and lower for black carbon, relative to PM_2.5 . Indoor ozone was 3-4% of outdoors for all systems except an electronic air cleaner that produced ozone. Filtration via the FAU or portable filtration units lowered PM_2.5 by 25-75% when operated over the hour following cooking. The energy for year-round operation of FAU filtration with an efficient blower motor was estimated at 600 kWh/year.

A pilot study of topical imiquimod therapy for the treatment of recurrent extramammary Paget's disease

OBJECTIVE

The objective of this prospective pilot study was to assess the clinical and histologic effects of topical imiquimod therapy on recurrent extramammary Paget's disease of the vulva.

METHODS

Patients with biopsy-proven recurrent extramammary Paget's disease presenting to the gynecology outpatient services at two participating institutions were recruited for conservative treatment with 5% imiquimod cream from 2007 to 2011. The topical cream was to be applied 3 times per week for 12weeks. Punch biopsy and photography were performed at baseline and at the 12-week time point.

RESULTS

Eight patients from two institutions were enrolled. Complete clinical and histologic response was achieved in 6 (75%) patients by the 12-week follow-up appointment. Of the two remaining patients, one had a complete clinical response but no significant histologic response; the other patient was removed from the study protocol secondary to intolerable local irritation. Two patients continue to have no evidence of disease after a median follow-up of 35months. Five are alive with disease. No patients progressed to invasive cancer while receiving therapy.

CONCLUSION

Topical 5% imiquimod cream is a safe and feasible option for women suffering from recurrent extramammary Paget's disease of the vulva, and should be considered as a viable alternative to surgical management. Given the rare nature of this disease, additional multi-institutional prospective studies should be conducted to explore the efficacy of this treatment regime.

Neuroendocrine tumors in the ovary: histogenesis, pathologic differentiation, and clinical presentation

OBJECTIVE

Primary neuroendocrine tumors in the ovary are rare. These tumors arise from the neuroendocrine cell system of ovarian stroma and surface epithelium, and may also arise from teratoma. We present four primary ovarian neuroendocrine tumors and compare clinicopathologic findings based on tumor histogenesis and site of origin.

DESIGN

Four primary ovarian neuroendocrine tumors were identified from our 10-year departmental archives. H&E slides and immunostains were reviewed and the diagnoses were confirmed. Clinical history, imaging studies, and follow-up data were obtained from medical records.

RESULTS

Patients' ages ranged from 26 to 63. All patients presented with abdominal discomfort and unilateral or bilateral ovarian masses. MRI and CT scans from cases 1 and 2 revealed a solid ovarian mass with no extra-ovarian extension. In case 1, the patient also had a cystic mass in the opposite ovary and an elevated urine 5-HIAA. Microscopically, case 1 revealed a well-differentiated carcinoid tumor with no surface epithelial involvement, and a mature teratoma in the contralateral ovary. Case 2 revealed a stromal carcinoid within the ovarian parenchyma. Imaging studies from cases 3 and 4 showed large complex masses with peritoneal implants and ascites. In both cases 3 and 4, tumor grossly involved both ovarian parenchyma and surface epithelium with multiple pelvic implants. In addition, liver metastases were present in case 4. Microscopically, these tumors were poorly differentiated carcinoma with neuroendocrine differentiation. Histologic sections revealed extensive necrosis, and both cases showed positivity for neuroendocrine markers.

CONCLUSIONS

Primary neuroendocrine tumors in the ovary are rare and consist of a group of heterogeneous malignancies that express similar immunohistochemical markers. Primary neuroendocrine tumors that are limited to the ovarian parenchyma often arise from ovarian stroma and teratoma, and are carcinoid tumors with a good prognosis. Neuroendocrine tumors that arise from surface epithelium or dedifferentiate from de novo carcinoma often involve both ovarian stroma and surface epithelium and clinically present as aggressive malignancies with poor prognoses.

Comparison of the ribonucleic Acid subunits of reovirus, cytoplasmic polyhedrosis virus, and wound tumor virus

Double-stranded ribonucleic acid (RNA) from intact cytoplasmic polynedrosis virus (CPV) and wound tumor virus (WTV) was analyzed by polyacrylamide gel electrophoresis. Using RNA from type 3 reovirus as a standard, it was calculated that CPV-RNA consisted of 9 subunits corresponding to a molecular weight of 12.7 x 10(6) and WTV-RNA consisted of 12 subunits corresponding to a molecular weight of 15.5 x 10(6).

Mobile phones. precautionary options

Mobile phones have been in use for over two decades and are ubiquitous in the western world for at least ten years. There has been scientific interest and public concern about the possibility of adverse health effects from this relatively new use of non-ionising electromagnetic energy both at the level of the handset and the base station. The proliferation of base transmitter stations in the early 1990's caused a resurgence of interest in the possible health effects of low level RF in general and several significant studies investigated the issue generally using broadcast transmitters as a more predictable source of exposure. Handsets, although of much lower power are closely coupled to the users body and deserve special attention, which they have received. From this research, a high level of assurance of safety has emerged and this is reflected in secure international exposure standards allowing more or less unrestricted use of the technology from a public health point of view. Nonetheless, some research remains unsettled, the science is incomplete in some areas and in the minds of some the unknown provides an uncomfortable level of risk. This debate is unlikely to see an early resolution and so precautionary approaches are increasingly supported. There are a wide range of actions, which have been regarded as precautionary, but ultimately minimisation of public exposure is likely to be the only strategy which could provide a benefit if any risk is later found. There are practical ways of achieving this, but not all proposed strategies seem to recognise them.

Vancomycin-induced linear IgA bullous disease presenting as toxic epidermal necrolysis

Linear IgA bullous dermatosis (LABD) is a rare autoimmune vesiculobullous disorder characterized by variable clinical presentations that may mimic bullous pemphigoid, dermatitis herpetiformis, cicatricial pemphigoid and erythema multiforme. A few cases of drug-induced LABD that clinically resembled toxic epidermal necrolysis (TEN) have been reported. A subset of patients with LABD have been found to be drug-induced; the most common drug being vancomycin. The diagnosis of LABD is confirmed by the presence of a linear band of IgA along the basement membrane zone on direct immunofluorescence microscopy. We report a case of a 77-year-old man who presented to us with vancomycin-induced LABD that presented clinically as TEN. He had a complete recovery over a 3-week period following discontinuation of the vancomycin and the addition of oral dapsone therapy. It is important to be aware that drug-induced LABD can mimic TEN.

Evaluating a fear appeal message to reduce alcohol use among "Greeks"

OBJECTIVE

To evaluate the impact of a fear appeal message on college students' drinking behavior using the extended parallel process model.

METHOD

A survey was administered to a random sample of undergraduates (n=224) in 38 national fraternal organizations.

RESULTS

Both perceived efficacy and perceived threat were significantly correlated with drinking behavior. There was a significant difference both in drinking behavior and attendance at alcohol-free events between those who heard and those who did not hear the message.

CONCLUSIONS

Theoretically based fear appeal messages may be a useful way to promote responsible drinking among college students.

Using social marketing to develop and test tailored health messages

OBJECTIVE

To advance and promote procedures to evaluate tailored health messages based on the 4 Ps of social marketing (SM).

METHOD

Three studies are presented for heuristic purposes to show the evolution and application of a "research plan" to 3 phases of SM research that address the 4 Ps.

RESULTS

Qualitative and quantitative methods provide useful information to develop messages and to evaluate message efficacy for public health campaigns, to recruit participants to interventions, and/or to influence program adherence and participant retention.

CONCLUSIONS

Formal, systematic research methods offer a viable means to evaluate the potential of SM constructs.

Racial differences in eating disorder attitudes, cigarette, and alcohol use

OBJECTIVE

To compare eating disorder attitudes, cigarette, and alcohol use between black and white college women.

METHOD

Four validated, self-report questionnaires were administered.

RESULTS

Black women reported significantly less substance use. However, substance use, regardless of race, was significantly related to eating disorder symptoms, and women at highest risk for an eating disorder reported the highest levels of substance use. Also significantly related to eating disorder symptoms were negative affect reduction and weight control as reasons for substance use.

CONCLUSIONS

Black and white women at highest risk for an eating disorder also exhibit the greatest potential for substance use.

Echocardiographic assessment of coronary blood flow velocity during controlled hypotensive anesthesia with nitroglycerin

OBJECTIVE

To determine the effect of nitroglycerin on coronary blood flow velocity during controlled hypotensive anesthesia in humans.

DESIGN

Internally controlled prospective study.

SETTING

Single university hospital.

PARTICIPANTS

Twenty American Society of Anesthesiologists class I and II patients undergoing general anesthesia for surgical resection of a malignancy.

INTERVENTIONS

General anesthesia was induced with thiopental, fentanyl, and succinylcholine and maintained with isoflurane and vecuronium. Transesophageal echocardiography was used to evaluate left ventricular wall motion and blood flow velocity in the left anterior descending coronary artery. Intravenous nitroglycerin was used to reduce systolic arterial pressure to 60 to 70 mmHg. Intravenous albumin 5% was administered to maintain pulmonary capillary wedge pressure >5 mmHg.

MEASUREMENTS AND MAIN RESULTS

The left anterior descending coronary artery was visualized clearly in 16 of 20 patients. At a mean nitroglycerin dose of 16+/-14 microg/kg/min, peak diastolic left anterior descending flow velocity increased significantly from 32.5+/-10.3 cm/sec to 44.7+/-14.6 cm/sec (p = 0.0103). None of the patients developed any ST-segment changes.

CONCLUSIONS

During nitroglycerin-induced hypotensive anesthesia, coronary blood flow as assessed by peak diastolic left anterior descending flow velocity is preserved or increased in most patients. Increases in left anterior descending flow velocity are predictably achieved only at nitroglycerin doses >5 microg/kg/min. Intraoperative transesophageal echocardiography is useful in monitoring coronary flow velocity responses to controlled hypotensive anesthesia.

Evaluation of a screening test for female college athletes with eating disorders and disordered eating

OBJECTIVE

To develop a screening test to detect female college athletes with eating disorders/disordered eating (ED/ DE). No validated eating disorder screening tests specifically for athletes have been available.

DESIGN AND SETTING

In this cross-sectional study, subjects from a large midwestern university completed 3 objective tests and a structured diagnostic interview.

MEASUREMENTS

A new test, developed and pilot tested by the researchers (Athletic Milieu Direct Questionnaire, AMDQ), and 2 tests normed for the general population (Eating Disorder Inventory-2, Bulimia Test-Revised) were used to identify ED/DE athletes. A structured, validated, diagnostic interview (Eating Disorder Examination, version 12.OD) was used to determine which test was most effective in screening female college athletes.

SUBJECTS

Subjects included 149 female athletes, ages 18 to 25 years, from 11 Division I and select club sports.

RESULTS

ED/DE subjects (35%) were found in almost every sport. Of the ED/DE subjects, 65% exhibited disordered eating, 25% were bulimic, 8% were classified as eating disordered not otherwise specified (NOS), and 2% were anorexic. The AMDQ more accurately identified ED/DE than any test or combination of items. The AMDQ produced superior results on 7 of 9 epidemiologic analyses; sensitivity was 80% and specificity was 77%, meaning that it correctly classified approximately 4 of every 5 persons who were truly exhibiting an eating disorder or disordered eating.

CONCLUSIONS

We recommend that the AMDQ subsets, which met statistical criteria, be used to screen for ED/DE to enable early identification of athletes at the disordered eating or NOS stage and to initiate interventions before the disorder progresses.

Health communication and professional preparation: health educator credibility, message learning, and behavior change

Health education graduate students were surveyed to assess perceptions of their professional responsibility to be role models of healthy behaviors, characteristics of a professional role model, and related socializing experiences during professional preparation. A total of 233 randomly selected health education graduate students participated in this study nationwide. Significant inverse associations were found between students' year in graduate school and sense of excellence as a role model, graduate program satisfaction, and professional commitment (all ps < 0.05). Students' sense of professional marketability and competence to role model were statistically significant in predicting their perception that role modeling healthy behaviors is a professional responsibility, F(2, 215) = 110.25, p = 0.00001. Positive associations also were found between students' desire to improve fitness behavior, nutrition, and weight and/or body fat ratio with self-ratings as role models (all ps < 0.05). Implications for the profession and preparation are provided.

Role modeling: an opportunity for the health education specialist

It is the responsibility of the profession to determine what is right, reasonable, and ethical health education practice. Opportunities within the profession abound to deliberate about the responsibility of health education specialists to role model positive health behaviors. Davis summarized the espoused perspectives nicely: We owe it to our profession and to our students to personally travel as far on the wellness continuum as behavioral choices will permit.... Health educators do have a special responsibility to be positive health role models by fulfilling their health potential and modeling the healthiest behaviors of which they are capable. All health educators need to accept for themselves the responsibilities that we assign to others.

Accuracy of self-reported body weight: Stepped Approach Model component assessment

This study was conducted to investigate innovative solutions to a measurement problem pertaining to self-reported body weight data as a key component of the Stepped Approach Model (SAM) of service delivery. Subjects (n = 223) were randomly assigned to one of two conditions: Informed Group (of self-report and weight measurement) + six body weighing habit items (IG, n = 113) and Uninformed Group (of self-report and weight measurement) + one body weight item (UG, n = 110). A t-test indicated that IG subjects reported significantly more accurately, t(194) = 2.99, P = 0.002, and with significantly less variability than UG subjects, F(109,112) = 1.95, P < 0.0005. A multiple regression of absolute difference weight (observed--self-reported weight) on observed weight revealed consistent accuracy across the weight range for IG subjects, whereas UG subjects' accuracy decreased as body weight increased. The slope of the IG did not significantly differ from 0, t(218) = 1.44, P = 0.150, but did significantly differ from the slope of the UG, t(218) = 2.78, P = 0.006. The following conclusions are noted when IG conditions are used: (1) a three-component strategy designed for maximum effect size results in accurate reporting across the entire weight range, (2) self-reported body weights under prescribed conditions can be used as valid 'proxies' for observed measurements, and (3) SAM proponents can rely on the validity of self-report body weight as a credible basis for decisions about changing intervention steps and evaluating intervention efficacy.

Detection of eIF4E gene amplification in breast cancer by competitive PCR

BACKGROUND

Initiation factor eIF4E binds to mRNA as the initial step for protein translation. Overexpression of the eIF4E oncoprotein has been found in breast cancer but not in benign breast tissue. The objective of this study is to determine if eIF4E oncoprotein overexpression is associated with eIF4E gene amplification in breast cancer using Western blots and competitive polymerase chain reaction (PCR).

METHODS

Unknown concentrations of DNA extracted from breast specimens were amplified by PCR using a set of primers spanning intron 2/exon 3 of the eIF4E gene. In the same PCR tube, an internal control consisting of a known concentration of an eIF4E DNA template with 20-base pair (bp) deletion was used as the competitive reference standard (CRS) for competitive PCR. Gel electrophoresis of the PCR products was performed and the bands quantified by densitometry. eIF4E gene amplification was then determined relative to a nonamplified gene (gastrin). Using an anti-eIF4E rabbit antibody, Western blots were performed on benign and malignant breast specimens. Quantification was accomplished by developing blots with a color assay using nitro blue tetrazolium (NBT) and 5-bromo-4-chloro-3-indolyl phosphate (BCIP), scanned and analyzed by densitometry.

RESULTS

Twenty-two breast specimens (14 cancer, 8 control) from patients were examined for eIF4E gene amplification and oncoprotein expression. In all fourteen specimens from stage I-III breast cancer patients, eIF4E overexpression was detected at 3- to 30-fold ( 16.71 +/- 7.83) elevations. Similarly, all 14 specimens demonstrated eIF4E gene amplification by competitive PCR (3.69 +/- 1.27). In the eight benign breast specimens examined, all were negative for eIF4E overexpression and gene amplification.

CONCLUSIONS

Overexpression of eIF4E was associated with eIF4E gene amplification in breast cancer specimens. No overexpression or gene amplification was detected in benign breast tissues. eIF4E gene amplification may be one mechanism for eIF4E oncoprotein overexpression.

Peer helping/involvement: an efficacious way to meet the challenge of reducing alcohol, tobacco, and other drug use among youth?

Peer-led drug prevention programs for middle school youth are reviewed as to whether or not they are a vital resource in an overall effort to minimize the use of alcohol, tobacco, and other drugs (ATOD). The paper focuses on the following: a) results of a 120-study meta-analysis of school-based drug prevention programs and positive program features; b) considerations for falsely concluding that peer programs are ineffective; c) features of two model or stellar programs that compared interactive (peer leadership) to teacher/researcher-led (non-interactive) programs that followed National Peer Helpers Association (NPHA) Programmatic Standards; and d) suggestions for designing and implementing high-quality, peer-led programs. The authors conclude that interactive peer interventions for middle school students are statistically superior to non-interactive didactic, lecture programs led by teachers/researchers. Programs implemented according to NPHA Programmatic Standards may eliminate Type II (false negative) and III ("implementation failure" or ineffectively designed and implemented program) errors. Opportunities for prudent application of well-designed peer programs appropriately implemented and evaluated must remain a salient priority.

Self-administered interventions: a health education strategy for improving population health

A case is presented for using self-administered interventions (SAIs) as a viable public health education/promotion option. SAIs are promulgated as a means to more fully participate in projected health care changes. One readily available opportunity is to incorporate SAIs into managed care organizations concerned about balancing costs and care, and responsible for the health care of the populations they serve. SAIs are both clinical and 'population-based' strategies that are viable alternatives to 'usual' care because SAIs offer a means to enhance reach, efficiency and efficacy when used independently or as part of a sequential, systematic series of interventions. SAIs also have other advantages such as being easily shared, disseminated, reusable and capable of including a valuable, inexpensive human resource, trained peer helpers or volunteers. The SAIs of minimal intervention and self-instruction have been widely used with a variety of lifestyle behaviors associated with cardiovascular disease. Research from the weight management literature is used as a heuristic illustration of the application of SAIs, and to describe the nature and potential of SAIs as public health strategies to meet health care challenges of the future related to service delivery.

Nitric oxide improves transpulmonary vascular mechanics but does not change intrinsic right ventricular contractility in an acute respiratory distress syndrome model with permissive hypercapnia

OBJECTIVE

To test the hypothesis that in a swine model of acute respiratory distress syndrome (ARDS) with permissive hypercapnia, inhaled nitric oxide would improve transpulmonary vascular mechanics and right ventricular workload while not changing intrinsic right ventricular contractility.

DESIGN

Prospective, randomized, controlled laboratory trial.

SETTING

University research laboratory.

SUBJECTS

Eleven swine (30 to 46 kg).

INTERVENTIONS

The swine were anesthetized, intubated, and paralyzed. After median sternotomy, pressure transducers were placed in the right ventricle, pulmonary artery, and left atrium. An ultrasonic flow probe was placed around the pulmonary artery. Ultrasonic dimension transducers were sutured onto the heart at the base, apex, left ventricle (anterior, posterior, free wall), and right ventricle (free wall). An additional transducer was placed in the interventricular septum. A surfactant depletion model of ARDS was created by saline lung lavage. Nitric oxide was administered at 2, 4, and 6 parts per million (ppm), in a random order, under the condition of permissive hypercapnia (Paco2 55 to 75 torr [7.3 to 10.0 kPa]).

MEASUREMENTS AND MAIN RESULTS

We evaluated the pulmonary vascular and right ventricular effects of permissive hypercapnia, with and without inhaled nitric oxide, by measuring variables of transpulmonary vascular mechanics and right ventricular function. These variables included mean pulmonary arterial pressure, right ventricular total power, right ventricular stroke work, transpulmonary vascular efficiency, and right ventricular intrinsic contractility. Data were obtained after lung injury under the following conditions: a) normocapnia (Paco2 35 to 45 torr [4.7 to 6.0 kPa]) and nitric oxide at 0 ppm; b) hypercapnia and nitric oxide at 0 ppm; c) hypercapnia and nitric oxide at 2, 4, and 6 ppm; and d) repeat measurements with hypercapnia and nitric oxide at 0 ppm. In ARDS with permissive hypercapnia, inhaled nitric oxide therapy (2 to 6 ppm) improved transpulmonary vascular mechanics and right ventricular workload by lowering pulmonary arterial pressure (29.6 +/- 1.3 vs. 24.6 +/- 1.0 mm Hg, p = .0001), increasing transpulmonary vascular efficiency (13.9 +/- 0.5 vs. 16.1 +/- 0.7 L/W-min, p = .0001), decreasing right ventricular total power (142 +/- 9 vs. 115 +/- 9 mW, p = .001), and decreasing right ventricular stroke work (653 +/- 37 vs. 525 +/- 32 ergs x 10(3), p = .001). Inhaled nitric oxide did not change right ventricular contractility, as measured by preload-recruitable stroke work.

CONCLUSIONS

Inhaled nitric oxide ameliorated any negative effects of hypoxic and hypercapnic pulmonary vasoconstriction. The beneficial effects of inhaled nitric oxide are related to alterations in right ventricular afterload and not intrinsic right ventricular contractility. The improved cardiopulmonary effects of inhaled nitric oxide with permissive hypercapnia potentially expand the use of nitric oxide in ARDS and other conditions in which this strategy is employed.

Healthy body weights: an alternative perspective

The primary purpose of this roundtable discussion of the American Health Foundation is to establish healthy weight standards for adults. In most large, long-term, well-designed studies, the lowest morbidity and mortality rates occurred in adults at weights that yielded BMIs (in kg/m2) between 19 and 25. Best body fat percentages averaged between 12% and 20% for men and 20% and 30% for women. However, statistical values are not applicable to everyone and their strict application may be counterproductive. We believe that most weight-associated health problems result from a cascade of events associated with abnormal blood concentrations of insulin, glucose, or lipids that occur when fat cells become full and insulin-insensitive, and lose their protective functions. Indexes associated with high risk in obese persons often return to normal with appropriate physical activities, dietary habits, and a small weight loss even when body weight and percentage body fat remain above recommended amounts. We believe that statistically derived standards for body weight and percentage body fat are appropriate for use as a screening test but should be downplayed as strict guidelines for all.

Interest in a stepped approach model (SAM): identification of recruitment strategies for university alcohol programs

This study evaluates interest in a stepped approach model (SAM) of service delivery and identifies variables to enhance recruitment to alcohol programs. Subjects were 2,443 college student drinkers (1,420 men and 1,023 women) at a large midwestern university (selected by stratified systematic sampling) who completed a questionnaire on drinking behavior and interest in five intervention steps. Results indicated that there was more interest in interventions that required less time, which supports predictions of SAM. Overall lack of interest peaked at 67% for men and 65% for women and did not change significantly across the last three steps of SAM, which included traditional interventions of group and individual counseling. The data suggest that the stepped approach is more viable than conventional approaches, recruitment is unquestionably an exigent research priority because of the overwhelming lack of interest in alcohol programs, and specific variables that were identified may be important for recruiting particular subgroups.

In acute lung injury, inhaled nitric oxide improves ventilation-perfusion matching, pulmonary vascular mechanics, and transpulmonary vascular efficiency

Acute respiratory distress syndrome continues to be associated with significant morbidity and mortality related to ventilation-perfusion mismatch, pulmonary hypertension, and right ventricular failure. It has been suggested that inhaled nitric oxide, which is a selective pulmonary vasodilator, may be effective in the treatment of acute respiratory distress syndrome; however, the effects of nitric oxide on cardiopulmonary interactions are poorly understood. We therefore developed a model of acute lung injury that mimics the clinical syndrome of acute respiratory distress syndrome. In our model, inhaled nitric oxide significantly reduced pulmonary artery pressure, pulmonary vascular resistance, and pulmonary vascular impedance. In addition, inhaled nitric oxide improved transpulmonary vascular efficiency and ventilation-perfusion matching, which resulted in increased arterial oxygen tension. Although arterial oxygen tension increased, oxygen delivery did not improve significantly. These data suggest that by improving ventilation-perfusion matching and arterial oxygen tension while lowering pulmonary vascular resistance and impedance, nitric oxide may be beneficial in patients with acute respiratory distress syndrome. However, additional measures to enhance cardiac performance may be required.

Recruitment to a university alcohol program: evaluation of social marketing theory and stepped approach model

BACKGROUND

This study was a first initiative to evaluate the application of social marketing theory (SMT) to increase attendance at an alcohol abuse education program for university residence hall students and to ascertain whether aggressive recruitment strategies are necessary as part of the stepped approach model (SAM) of service delivery.

METHOD

SMT and public health strategies that include focus groups, in-depth interviews, and intercept interviews were used to develop recruitment materials in a Test Hall. These new recruitment materials were introduced to the residents in the Treatment Hall (N = 727) and were compared to the Usual Care, Control Hall (N = 706) which received the recruitment materials normally provided to residents as well as to three Historical Halls separately and combined which had used the Usual Care recruitment materials in the past.

RESULTS

The Treatment Hall percentage attendance was significantly superior (0.001 < p < 0.05) in all comparisons. The percentage attendance did not differ significantly from marketing literature expectations. The projections for campus-wide attendance for residence hall students were between 207 and 243 participants and for nationwide attendance, 36,900 +/- 8,185.

CONCLUSIONS

The results suggest that the SMT and public health methods used are helpful in developing recruitment strategies and are an important initial step of the SAM and that a "minimal intervention" recruitment strategy is a cost-effective approach that can have a dramatic impact.

Social Problem-Solving Inventory for Adolescents (SPSI-A): development and preliminary psychometric evaluation

This article describes a multiphase developmental process and psychometric evaluation of the Social Problem-Solving Inventory for Adolescents (SPSI-A). The SPSI-A consists of the following three scales: Automatic Process, Problem Orientation, and Problem-Solving Skills. The three subscales of the Problem Orientation Scale include Cognition, Emotion, and Behavior. The four subscales of the Problem-Solving Skills scale consist of Problem Identification, Alternative Generation, Consequence Prediction, and Implementation/Evaluation/Reorganization. Preliminary internal consistency, stability, content, construct, and criterion validity data are presented for freshmen and sophomore high school students. Collectively, the data provide evidence that the SPSI-A is a promising measure of adolescent problem-solving skills and motivation.

A stepwise procedure for evaluating irritant materials in normal volunteer subjects

1. The cutaneous response to a known irritant has been assessed in human volunteer subjects using both clinical scoring and two non-invasive instrumental methods; erythema measurement using an erythema meter and capillary blood flow using a laser Doppler device. 2. Aqueous solutions (0.5% and 1%) of sodium hydroxide were applied to back skin for 3, 15 and 60 min with assessments immediately after removal and at 1, 24 and 48 hours. 3. Increased erythema was seen with increasing duration of exposure and an increase was also seen at 1 h, 24 h and 48 h after removal of the patch. The results obtained with the erythema meter paralleled the clinical erythema scores. However, the laser Doppler device showed the greatest changes immediately after removal of the patch with subsequent readings showing a gradual decrease. 4. Statistical analysis of the data has been carried out to determine the accuracy and precision of the assessment procedures and to determine the minimum test panel size for detecting irritant reactions. 5. Comparison between back and forearm skin indicated a greater sensitivity to sodium hydroxide on the back. 6. The results of this study define an ethical approach to testing irritant materials in human subjects and provide the basis for the development of a classification system for cutaneous irritants.

Reducing alcohol consumption among university students: recruitment and program design strategies based on Social Marketing Theory

Recruitment of program participants and development of appealing comprehensive alcohol abuse prevention programs is an exigent priority for university campuses due to the serious physical and emotional consequences related to alcohol consumption. A sample of 67 students from a large midwestern university completed a survey based on Social Marketing Theory (SMT) which was developed to improve recruitment and enhance the design of comprehensive alcohol abuse prevention programs. The results indicate that recruitment may be optimized by providing a flexible, convenient, low-cost program that encourages friends' participation, communicates alcohol-related risks and offers university credit or refund as participation incentives. The design of alcohol abuse prevention programs may be enhanced by emphasizing the positive outcomes of reducing alcohol consumption, improving the quality and quantity of alternatives to the social atmosphere connected with drinking, and soliciting respected opinion leaders (physicians and parents) to communicate alcohol reduction messages. This project is a first initiative to 'fill the gap' in the social marketing research literature by providing formative information pertinent to recruitment and design of alcohol reduction programs specifically for college students.

Is adipose tissue oversold as a health risk?

A high percentage of body fat is considered to be the primary cause of risks associated with high body weight. Yet body fat content per se may not cause the risks. The contribution of obesity to risks may be because overfilled adipose tissue cannot remove offending substances from circulation. The ability to remove excess glucose, lipids, and offending materials from circulation, not the amount of body fat, may be the important factor. People with large, partially filled adipose depots may have less risk than people with small, but filled adipose depots. This concept is supported by many studies. Energy restriction in genetically obese animals greatly increases longevity and slows signs of aging even while the animals remain obese. Weight reduction often corrects weight-associated medical problems in obese persons without returning body-fat levels to normal. Statistically generated desirable body-fat contents or desirable height-weight tables may have little meaning for individuals and may cause more harm than good. Because these standards are not appropriate for some people, they should be discarded as a guide for all. More emphasis should be placed on healthy lifestyles and less on body-fat percentages.

Extremes in body mass index: probability of healthcare expenditures

BACKGROUND

This study was conducted as a first initiative to investigate the relationship between body mass index [BMI, weight(kg)/height(m)2] and healthcare expenditures by third party providers for lifestyle-related diseases and disorders.

METHOD

Data were analyzed for 383 individuals who were continuously employed and covered by the same comprehensive health insurance plan during a 2-year baseline period followed by a 5-year observation period. A multiple logistic regression analysis that adjusted for covariates was used to ascertain whether BMI and baseline expenditure status separately or in combination influenced the probability of healthcare expenditures during the observation period.

RESULTS

After controlling for age, gender, and smoking status, probability of healthcare expenditures for lifestyle-related medical problems was significantly (P < 0.04) greater during the observation period for adults with high as well as low BMIs plus baseline expenditures and lowest for subjects whose BMIs were in the midrange regardless of their baseline expenditures. Odds of expenditures increased significantly (P = 0.0079) with age of nonsmokers, but was approximately constant and high for smokers at all ages. The absence of any significant interaction of either smoking status or age with BMI indicated that the relationship between BMI and the log odds of expenditures was consistent across age and smoking categories.

CONCLUSIONS

The analyses support the conclusion that the highest probability of expenditures occurs with the combination of baseline insurance expenditures and BMI extremes and the lowest probability occurs when BMIs are near 26 or 27 (approximately 19% above the ideal of 22). The findings also provide further justification for focusing on extremes in body weight as health priorities.

Health services at large public institutions: funding, utilization, and staffing

When a mandatory health fee policy for students on campuses of the State University of New York (SUNY) was instituted in fall 1991, the projection was that the policy, which was at the option of individual institutions, would result in significant changes for SUNY health service operations. The changes would affect funding sources, staffing requirements, utilization rates, and services offered. In the past, the SUNY system had been inconsistent in health fee policies. This study was conducted to assist in implementing the mandatory health service fees. The authors surveyed 53 public higher education institutions viewed as comparable to the University at Buffalo in terms of location in an equivalent state, enrollment of 10,000 or more students, similar academic disciplines, average SAT scores, faculty salaries, and graduate enrollment. Two institutions that no longer met the original criteria were not included. The final tabulation was based on data from 42 institutions, for a return rate of 82%. Survey results showed that public higher education institutions are significantly altering traditional practices associated with student healthcare. Health services are providing more specialty services, increasing the focus on wellness and health education, seeking accreditation, and increasing student representation in decision making. In addition, funding sources have shifted dramatically, with a larger percentage of the student health budget derived directly from fees assessed to students and a much smaller percentage derived from institutional or state appropriations.

Smoking cessation interventions for university students: recruitment and program design considerations based on social marketing theory

BACKGROUND

Audience variables with social marketing implications for university campuses were investigated to identify prepromotional campaign strategies for the design of smoking cessation interventions and for subject recruitment.

METHODS

A first survey based on a stratified systematic probability sample of 2,998 college students at a large midwestern university identified 313 smokers. A total of 263 (response rate = 84%) participated in a second telephone survey, and results were based on the 193 (73%) respondents who still smoked.

RESULTS

Recruitment implications indicate that potential participants are predominantly lower classmen in their early 20s who are unmarried, childless, white, full-time domestic students. Smoking habits are moderate but well-established and confined almost exclusively to cigarette smoking. An average of three attempts to quit smoking was reported, and the majority of respondents rated their interest and intention to quit as "somewhat" to "very likely." The best publicity options for programs are campus newspapers as well as grocery stores and gas stations, where most cigarettes are purchased. Program design implications suggest that accessibility, affordability, convenience, flexibility, social support, and behavioral prompts/cues are important factors to consider.

CONCLUSIONS

This study is a first initiative to "fill the gap" in the social marketing research literature by providing recruitment and program design information specifically for developing a smoking cessation campaign for university campuses.

A time-series analysis of longitudinal weight changes in two adult women

This study was conducted to examine individual longitudinal serial trends in body weight of two moderately obese adult women. Self-measured daily weights (over 5000 data points for subject 1 and over 3500 for subject 2) were averaged for each month and analyzed using a time-series analysis approach. The best statistical model for both women indicated a significant upward trend (gain 30 and 22 lb, respectively) interrupted by linear decreases (P less than 0.05) during weight loss programs over the 16- and 10-year observation periods, respectively. The women participated in six and eight weight control programs, respectively, and consistently lost weight, averaging 9.17 +/- 1.85 lb and 8.00 +/- 3.57 lb. Both subjects regained weight after dieting, in a period approximately 2.25 times as long as the diet. Numerous weight fluctuations occurred and one subject lost and then regained 10 percent of her body weight during two 5-year periods. Results are examined in terms of a possible weight increase protection benefit, as well as the deleterious medical potential that may occur with numerous weight loss attempts. Suggestions for future research are provided regarding weight cycling, seasonal variations, set point theory, aging effects, and the use of self-directed weight loss initiatives in conjunction with formal weight reduction programs. This study may serve as a prototype for exploring weight fluctuation using time-series analyses and for further investigating the etiology and clinical management of obesity.

Identification of campaign recruitment strategies for a stepped smoking cessation intervention for a college campus

A rapproachement of the Stepped Approach Model of health care delivery and Ajzen's Theory of Planned Behavior was used to identify campaign recruitment strategies for a stepped smoking cessation intervention for a college campus. The study examines outcome expectancies, outcome evaluations, and interest in participating in smoking cessation programs presented in graduated steps of intervention intensity. Telephone surveys were conducted with a probability sample of 191 student smokers. A significant negative trend indicates that the steps are ordered cost-effectively. Scheffé a posteriori tests also reveal that interest in Step 1 (pamphlets and brochures) was significantly higher than interest in any other step, including those representing traditional health care services (i.e., groups and individual treatments). The two strongest predictors of interest in each step were attitudes about participation and control beliefs; normative expectations about program participation discriminated between respondents with high or low interest in Steps 2 through 5. It was concluded that attitudes and control beliefs should be the focus of initial program promotion for college smoking cessation campaigns. Emphasis on attitudes, control beliefs, and especially perceived norms could be helpful in advancing unsuccessful participants to the next more intensive program in a stepped intervention.

Purdue stepped approach model: application to pharmacy practice

The Purdue Stepped Approach Model (PSAM) of service delivery is applied to pharmacy practice. The PSAM offers a method to organize interventions in a systematic and sequential manner according to the amount and type of resources required to achieve optimal patient health status. The model also provides an approach to integrating the expertise of other healthcare professionals into the provision of pharmacy services (e.g., health educators, psychologists, nurse practitioners, exercise physiologists), addresses economic costs and differential modes of reimbursement, and provides suggestions for future research. Examples are included to facilitate application of the PSAM in pharmacy and implications for holistic healthcare or health promotion in pharmacy practice are discussed.

A meta-analytic evaluation of couples weight-loss programs

Applied Hedges and Olkin's (1985) statistical meta-analytic procedures to summary data from all published studies that compared behavioral weight-control programs that formally involved partners in treatment (couples programs) to similar programs in which subjects participated alone (subject-alone programs). Based on tests of effect sizes, couples programs are significantly superior to subject-alone programs at posttreatment (p less than .05). A nearly significant (p = .06) statistical superiority for couples programs versus subject-alone programs is also found at 2- to 3-month follow-up, but not thereafter. The couples programs differed in the kinds of social support provided by partners, and the most productive kinds of partner support remain to be identified. In particular, the use of partners in providing social support to subjects after formal therapy has ended is still an area of largely unexplored potential.

Minimal intervention and arthritis treatment: implications for patient and physician compliance

A rationale based on a public health perspective for using minimal intervention programs in the treatment of arthritis is presented. Minimal interventions are relatively inexpensive, relatively free from side effects, and produce therapeutic effects that range from statistically significant to clinically important. Empirical evidence regarding the relative efficacy of minimal intervention programs continues to accumulate in general preventive medicine. Extension to arthritis treatment and control is recommended. This will require (1) practitioners to recognize the public health perspective, (2) consensus judgment that a treatment is likely to produce therapeutic benefits at little cost and with minimal side effects, and (3) empirical validation of efficacy based on clinical trial results. It is concluded that the concept of minimal intervention could increase physicians' use of such treatments and thereby increase the therapeutic benefits to patients suffering from arthritic disease.

Partner weight status and subject weight loss: implications for cost-effective programs and public health

This study examined the difference in body changes of subjects with overweight partners and those with normal weight partners. The 9 subjects with normal weight partners lost significantly more weight than the 14 subjects with overweight partners by the end of the one-year treatment program (27.9 lbs versus 20.2 lbs, respectively) and at 3-month follow-up (29.6 lbs vs. 17.3 lbs, respectively). It was also found that both overweight and normal weight partners lost weight incidental to treatment but as expected, body changes of overweight partners significantly decreased over time whereas body changes of normal weight partners did not. Overweight partners and subjects lost statistical equivalent amounts of weight but there was a significant correlation at posttreatment between body changes of subjects in the overweight partner group and their partners. It was concluded that if body changes of both subjects and their overweight partners are considered, couples programs might be a cost-effective and important public health approach because two individuals lose weight as inexpensively as one and more people are treated. Researchers are encouraged to report weight status and body changes of both subjects and partners in order to understand more fully the relationship between partner weight status and subject weight loss.

Families and intensive care nurses: comparison of perceptions

This study compared family members' and nurses' perceptions on families' needs when a relative was hospitalized in an intensive care unit (ICU). Family members (N = 32) and nurses (N = 23) complete equivalent 44-item questionnaires. Both family members and nurses agreed that the greatest needs of families were anxious at admission (P less than 0.05). Families and nurses seemed satisfied in the Participation/Information and Emotional Support categories, but more disagreements were noted in these areas. More nurses perceived families as not wanting to participate in patient care (P less than 0.003), felt that families did not have enough time to visit (P less than 0.004), believed that families were comfortable expressing their feelings (P less than 0.02) but thought families were uncomfortable asking questions (P less than 0.01). It was concluded that families be prepared for the patient's condition and appearance, and for the hospital milieu in order to cope more effectively with excessive stress in time of crisis. Concordance in perceived needs of family members and care providers may lead to greater need satisfaction and it is advocated that both the patient and the family (rather than the patient alone) be the focus of treatment because of the relationship between social support and patient recovery.

Weight changes in a couples program: negative association of marital adjustment

This study investigated the difference in weight changes of subjects who rated their marriages as more adjusted vs subjects who rated their marriages as less adjusted. Twenty-six moderately obese subjects were assigned to one of two groups based on their initial scores on the Locke-Wallace Marital Adjustment Scale (MAS). The 10 subjects in the "moderately unhappy" group (MAS less than or equal to 99) lost significantly more weight than the 16 subjects in the "relatively happy" group (MAS greater than or equal to 100) at the end of the one-year treatment program (29.9 lb vs 20.4 lb) and at 3-month follow-up (27.7 lb vs 17.8 lb). Significantly more subjects in the unhappy group also reached ideal weight than subjects in the happy group (50% vs 7.7%). Subjects' initial MAS scores were significantly and negatively correlated with weight changes at post-treatment and follow-up; partners' MAS scores at the end of treatment were also significantly and negatively correlated to subjects' weight losses at post-treatment. None of the couples was initially maritally distressed but one couple met this criterion (MAS less than or equal to 85) by the end of treatment and follow-up. It was concluded that marital counseling is not a prerequisite for weight counseling, couples' marital adjustment does not improve as the subject loses weight and a moderate level of marital dissatisfaction does not seem to be an insurmountable barrier to successful weight loss and may be an advantage for some individuals.