Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of hospitalizations. Interventional studies focusing on the hospital-to-home transition for COPD patients are few. In the BREATHE (Better Respiratory Education and Treatment Help Empower) study, we developed and tested a patient and family-centered transitional care program that helps prepare hospitalized COPD patients and their family caregivers to manage COPD at home.

METHODS

In the study's initial phase, we co-developed the BREATHE transitional care program with COPD patients, family-caregivers, and stakeholders. The program offers tailored services to address individual patients' needs and priorities at the hospital and for 3months post discharge. We tested the program in a single-blinded RCT with 240 COPD patients who were randomized to receive the program or 'usual care'. Program participants were offered the opportunity to invite a family caregiver, if available, to enroll with them into the study. The primary outcomes were the combined number of COPD-related hospitalizations and Emergency Department (ED) visits per participant at 6months post discharge, and the change in health-related quality of life over the 6months study period. Other measures include 'all cause' hospitalizations and ED visits; patient activation; self-efficacy; and, self-care behaviors.

DISCUSSION

Unlike 1month transitional care programs that focus on patients' post-acute care needs, the BREATHE program helps hospitalized COPD patients manage the post discharge period as well as prepare them for long term self-management of COPD. If proven effective, this program may offer a timely solution for hospitals in their attempts to reduce COPD rehospitalizations.

Effective analgesia after bilateral tubal ligation

Postpartum bilateral tubal ligation is a brief surgical procedure with minimal tissue injury, yet postoperative recovery times and analgesia requirements are often disproportionately large. To evaluate the analgesic efficacy of local anesthetic infiltration, 20 parturients scheduled for elective minilaparotomy and bilateral tubal ligation with either spinal or epidural anesthesia participated in this prospective, randomized, controlled, double-blind trial. All patients received IV metoclopramide 10 mg and ketorolac 60 mg intraoperatively, as well as preincisional infiltration of the infraumbilical skin incision with 0.5% bupivacaine. Infiltration of bilateral uterine tubes and mesosalpinx was performed with either 0.5% bupivacaine (n = 10) or isotonic sodium chloride solution (saline) (n = 10). IV meperidine (25 mg every 3 min as needed) was given to treat pain in the postanesthesia care unit (PACU). The total amount of meperidine administered in the PACU was significantly larger in the saline group than in the bupivacaine group. Pain scores at 30, 45, 60, 75, and 90 min postoperatively and on the seventh postoperative day were significantly lower in the bupivacaine group than in the saline group. During tubal ligation, infiltration of uterine tubes and mesosalpinx with 0.5% bupivacaine significantly enhanced analgesia both in the immediate postoperative setting and on the seventh postoperative day compared with infiltration with sodium chloride.

IMPLICATIONS

During bilateral tubal ligation with either spinal or epidural anesthesia, preemptive analgesia using IV ketorolac, IV metoclopramide, and infiltration of the incised skin and uterine tubes with 0.5% bupivacaine allowed 9 of 10 patients to recover with no pain, nausea, vomiting, or cramping and to maintain good analgesia for 7 days postoperatively.

ZO-3, a novel member of the MAGUK protein family found at the tight junction, interacts with ZO-1 and occludin

A 130-kD protein that coimmunoprecipitates with the tight junction protein ZO-1 was bulk purified from Madin-Darby canine kidney (MDCK) cells and subjected to partial endopeptidase digestion and amino acid sequencing. A resulting 19-amino acid sequence provided the basis for screening canine cDNA libraries. Five overlapping clones contained a single open reading frame of 2,694 bp coding for a protein of 898 amino acids with a predicted molecular mass of 98,414 daltons. Sequence analysis showed that this protein contains three PSD-95/SAP90, discs-large, ZO-1 (PDZ) domains, a src homology (SH3) domain, and a region similar to guanylate kinase, making it homologous to ZO-1, ZO-2, the discs large tumor suppressor gene product of Drosophila, and other members of the MAGUK family of proteins. Like ZO-1 and ZO-2, the novel protein contains a COOH-terminal acidic domain and a basic region between the first and second PDZ domains. Unlike ZO-1 and ZO-2, this protein displays a proline-rich region between PDZ2 and PDZ3 and apparently contains no alternatively spliced domain. MDCK cells stably transfected with an epitope-tagged construct expressed the exogenous polypeptide at an apparent molecular mass of approximately 130 kD. Moreover, this protein colocalized with ZO-1 at tight junctions by immunofluorescence and immunoelectron microscopy. In vitro affinity analyses demonstrated that recombinant 130-kD protein directly interacts with ZO-1 and the cytoplasmic domain of occludin, but not with ZO-2. We propose that this protein be named ZO-3.

Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates

Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia (PCA) with meperidine is associated with significantly more neonatal neurobehavioral depression than PCA with morphine. A single dose of epidural morphine (4 mg) decreases postcesarean opioid analgesic requirements and may reduce or prevent neonatal neurobehavioral depression associated with PCA meperidine. Prospectively, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. After umbilical cord clamping, each patient received epidural morphine 4 mg and was randomly allocated to receive either PCA meperidine or PCA morphine. Initial neonatal characteristics, included gestational age, Apgar scores, weight, and umbilical cord gas partial pressures. Brazelton Neonatal Behavioral Assessment Scale (NBAS) examinations were performed on each of the first 4 days of life. Nursing infants (n = 47) were grouped according to maternal PCA opioid in breast milk (meperidine [n = 24] or morphine [n = 23]); bottle-fed infants (n = 56) served as the control group. The three infant groups were equivalent with respect to initial characteristics and NBAS scores on the first 2 days of life. On the third day of life, infants in the morphine group were significantly more alert and oriented to animate human cues compared with infants in the meperidine or control group. On the fourth day of life, infants in the morphine group remained significantly more alert and oriented to animate human auditory cues than infants in the meperidine group. Average PCA opioid consumption through 48 h postpartum was equivalent (0.54 mg/kg morphine and 4.7 mg/kg meperidine); however, even with these small doses, meperidine was associated with significantly poorer neonatal alertness and orientation than morphine. Morphine is the PCA opioid of choice for postcesarean analgesia among nursing parturients.

IMPLICATIONS

Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia with meperidine is associated with more neonatal neurobehavioral depression than patient-controlled analgesia with morphine. In this study, we found that nursing infants exposed to morphine were more alert and oriented to animate human cues than those exposed to meperidine.

Interleukin 10 prevents cytokine-induced disruption of T84 monolayer barrier integrity and limits chloride secretion

BACKGROUND & AIMS

The proinflammatory cytokine interferon gamma (IFN-gamma) disrupts epithelial barrier integrity and attenuates secretagogue-induced chloride secretion. This study tested the efficacy of the anti-inflammatory cytokine interleukin 10 (IL-10) in maintaining epithelial barrier and chloride secretory function in the presence of IFN-gamma.

METHODS

T84 epithelial cell monolayers were treated with IL-10, IFN-gamma, or IFN-gamma plus IL-10. Monolayer barrier integrity was assessed by measurements of electrical conductance, unidirectional mannitol and inulin fluxes, and tight junctional charge selectivity in Ussing chambers. Short-circuit current (Isc) was measured in response to carbachol and forskolin stimulation.

RESULTS

IL-10 attenuated the IFN-gamma-induced increase in electrical conductance and totally prevented the IFN-gamma-induced increase in mannitol and inulin fluxes. IL-10 did not prevent the IFN-gamma-induced abolishment of tight junctional charge selectivity but did attenuate the total increase in sodium and chloride permeability. IFN-gamma and IL-10 both separately reduced peak forskolin and carbachol-stimulated Isc. IL-10 pretreatment further enhanced the IFN-gamma-induced reduction in secretagogue-induced Isc.

CONCLUSIONS

In T84 epithelial monolayers, IL-10 maintains the size, but not the charge, selectivity of the epithelial tight junction in the presence of IFN-gamma. In addition, both IL-10 and IFN-gamma limit carbachol and forskolin-induced increase in Isc.

Contractile reserve in patients with peripartum cardiomyopathy and recovered left ventricular function

OBJECTIVES

Peripartum cardiomyopathy is a rare complication of pregnancy. Thirty percent of patients with this disorder are reported to recover baseline ventricular function within 6 months of delivery, but the ability of these ventricles to respond to hemodynamic stress is unknown. The aim of this investigation was to quantitatively assess the contractile reserve of patients with a history of peripartum cardiomyopathy and recovered left ventricular function.

STUDY DESIGN

Baseline left ventricular contractility was assessed by use of the load and heart rate-independent relationship between end-systolic stress and rate-corrected velocity of fiber shortening. Data were acquired from "recovered" patients (10.5 +/- 11.6 months after delivery) and compared with data from matched nonpregnant controls with use of two-dimensionally targeted M-mode echocardiography and calibrated subclavian pulse tracings that were recorded over a wide range of afterloads (end-systolic stress) generated by methoxamine (1 mg/min) infusion. Contractile reserve was assessed by a dobutamine challenge (5 micrograms/kg/min) and quantified as the vertical deviation of the dobutamine end-systolic stress minus the corrected velocity of fiber shortening data point from the baseline contractility line.

RESULTS

Patients with peripartum cardiomyopathy and matched controls had normal baseline heart rates, blood pressures, ventricular dimensions, and left ventricular function. Contractile reserve, however, was reduced in patients with recovered peripartum cardiomyopathy (0.30 +/- 0.12 vs 0.17 +/- 0.04 circ/sec, p < 0.03).

CONCLUSIONS

Women with a history of peripartum cardiomyopathy who have regained normal resting left ventricular size and performance have decreased contractile reserve revealed by the use of a dobutamine challenge test. Ventricles of these women may respond suboptimally to hemodynamic stress in spite of evidence of recovery by routine echocardiographic evaluation.

Gender differences in the support networks of caregivers

Nurses in home care and long-term care settings play an important role in assisting family caregivers of elders who are cognitively impaired to sustain personal support while caregiving. Research has shown that such support is associated with positive health status. The characteristics of the caregiver's social network provide information about the potential for support. The purpose of this study was to describe and compare the social networks of men and women caregivers in terms of the composition of the social network and the size of the available, utilized and conflicted social networks. The possible relationship between the demographic characteristics of caregivers and the size and composition of their social networks was also examined. In comparison to men, the conflicted social networks of women were larger and comprised of more family members. For women, age, years of caregiving and socioeconomic status were not significantly related to the size of their social network. However, younger men and men of higher socioeconomic status reported significantly larger available social networks than other men. Knowledge of the gender differences in network size and composition that were identified in this study contributes to nurses' ability to identify caregivers who may be at risk for inadequate social support. In conjunction with the findings from related studies these results have implications for nursing assessment and intervention in home care and long-term care settings.

Cross-sectional and prospective relationships between physical morbidity and depression in older adolescents

OBJECTIVE

To examine cross-sectional and prospective associations between major depressive disorder (MDD), physical morbidity (disease and injury), health-related reductions in activities, and functional impairment in adolescents.

METHOD

Data on depression and health-related variables were available for a sample of 1,410 adolescents (aged 14 to 18 years) at point of entry into the study and approximately 1 year later.

RESULTS

Girls were more likely to have been treated for a disease and to have a health-related reduction in activities, whereas boys were more likely to have been treated for an injury. The expected cross-sectional associations were found between disease, reductions in activities, functional impairment, and depression, but the association between injury and depression was not significant. Prospective analyses suggest that functional impairment and disease are risk factors for future MDD and that MDD is a risk factor for future functional impairment and disease.

CONCLUSIONS

The robust prospective associations between MDD and functional impairment suggest that the impact of disease on depression is particularly strong when it disrupts important behavior patterns. Clinically, the results emphasize the importance of assessing health-related variables in depressed adolescents and of assessing depression in those with functional impairment or disease.

Behavior change at the worksite: does social support make a difference?

PURPOSE

This study examines whether social support for behavior change at work is associated with changes in employee heart disease risk factors.

DESIGN

A prospective correlational design was used with data sets collected 12 months apart.

SETTING

Twenty-five small to medium worksites in Oregon. SUBJECTS. Participants were 689 men and 421 women volunteers who participated in two health assessments at the worksite on company time.

MEASURES

Demographic characteristics, gender, social support, smoking behavior, dietary fat intake, and total blood cholesterol.

RESULTS

Employees reporting strong social support at work for not smoking and for limiting dietary fat were less likely to smoke (r = -.11, odds ratio [OR] = .86) and to consume fat in their diets (r = -.10) at baseline. Employees who reported the most change in social support over a 12-month period were most likely to have stopped smoking (r = .15, OR = 1.31). Social support at baseline, however, was unrelated to change in smoking, dietary fat, or total blood cholesterol in a prospective design. Although women reported more social support at work than did men, no differential gender effects of social support were reported on heart disease risk status or change in risk status.

CONCLUSION

Baseline social support at work did not predict future behavior change. The observed association between social support and lifestyle may be better explained as cognitive rationalization than by the impact of social support on behavior.

A treatment model for women substance users

This paper sets forth a multifaceted program which consists of drug user women-centered counseling plus ancillary services based on the five basic steps of Freire's empowerment theory. The program is designed to increase self-awareness, skills, and knowledge acquisition, to reduce feelings of isolation by broadening interpersonal networks, includes activities to enhance assertiveness and communication skills, and parenting education to counteract inappropriate mother-child interaction as well as to positively influence role modeling. Both transportation and child care are recommended ancillary services.

Opioid antagonist adjuncts to epidural morphine for postcesarean analgesia: maternal outcomes

This prospective, randomized, controlled investigation compared the effects of three prophylactic mu-opioid antagonists, epidural butorphanol (BU) 3 mg, epidural nalbuphine (NB) 10 mg, and oral naltrexone (NX) 6 mg, on postcesarean epidural morphine analgesia. After randomization, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. When the umbilical cord was clamped, each patient received one epidural solution (containing morphine 4 mg plus either saline or treatment drug), and one oral capsule (containing either placebo or treatment drug) in a double-blind manner. Maternal outcomes included pain and satisfaction [assessed with 100-mm visual analog scales (VAS)], and the incidence and severity of respiratory depression, somnolence, pruritus, nausea, and emesis. Through the first 12 h postpartum, the BU group achieved significantly greater analgesia than the morphine sulfate (control) (MS), NB, and NX groups, a significantly lower incidence of severe pruritus than the MS group, and significantly greater satisfaction than MS and NX groups. Epidural morphine and BU promoted better analgesia and satisfaction than any previously documented postcesarean regimen.

Peripartum heart failure associated with prolonged tocolytic therapy

beta-Adrenergic receptor agonist tocolysis has been reported to cause noncardiogenic pulmonary edema. We report an association between chronic terbutaline therapy and cardiomyopathy in peripartum women. Among 15 gravidas who had peripartum heart failure, 4 had received prolonged terbutaline tocolysis. Although those four patients had completely normalized ventricular function, only 7 of the 11 others recovered. We suggest that gravidas receiving long-term beta-sympathomimetic tocolysis undergo close evaluation of cardiac function.

Plasma exchange in a rat model of autoimmune glomerulonephritis

Using an original technique permitting repeated plasma exchange in the rat, we have tested this therapeutic approach in animals actively immunised with horseradish peroxidase, and in rats with HgCl2-induced autoimmune glomerulonephritis. Plasma exchange effectively removes circulating IgG anti-horseradish peroxidase antibodies from the sera of immunised rats. When applied to the model of HgCl2-induced antiglomerular basement membrane glomerulonephritis in Brown-Norway rats, this technique is also remarkably effective. In these rats, proteinuria is abolished during the plasma exchange treatment period and no circulating antiglomerular basement membrane antibodies can be detected. These antibodies are, however, found in the ultrafiltrates of exchanged rats. Serum IgE, characteristically elevated in HgCl2-treated rats, is also markedly diminished in exchanged rats. Control rats treated with infusions of fresh frozen plasma or with heparin alone did not show any improvement in disease severity. These results suggest that plasma exchange alone can attenuate antiglomerular basement membrane nephritis in HgCl2-treated rats. This observation may be of relevance for the treatment of human antiglomerular-basement membrane-mediated glomerulonephritis.

Markarian 348: a tidally disturbed seyfert galaxy

Combined optical and radio images of galaxies can provide new insights into the sizes, masses, and possible evolution of these objects. Deep optical and neutral hydrogen images of Markarian 348, a type 2 Seyfert galaxy, show that it is a gigantic spiral (perhaps the largest known non-cluster galaxy). Measurements of the neutral hydrogen velocity field and spiral structure, and detection of an optical "tidal plume," all provide evidence that it has been subject to tidal disruption. The measured velocities yield a mass-to-light ratio for this object (within a radius of 130 kiloparsecs from its nucleus) that is similar to the ratio found for the inner regions of most galaxies of similar type. This is one of the few cases where detailed velocity measurements have demonstrated that a galaxy with an active nucleus has been subject to extensive tidal perturbation.

Age Differences in Health Attitudes and Beliefs: Aging and/or Cohort Effects?

The study examines age differences in selected health attitudes and beliefs. Using one indicator for cohort effects and one indicator of aging effects, an attempt is made to identify the origins of these age differences. The study population is comprised of a random sample of 2603 adults from a large health maintenance organization. The subjects participated in an indepth household interview. Analytic approaches include bivariate to multivariate methods. The findings indicate that there are significant age differences in health attitudes and beliefs and that both aging and cohort contribute to these differences. The findings must be interpreted as only tentative. However, they do highlight the need to examine the degree to which these health attitudes and beliefs are actually predictive of medical care utilization and other health and illness behaviors. The policy and research implications are discussed.