A qualitative analysis of perceptions and barriers to therapeutic lifestyle changes among homeless hypertensive patients

BackgroundHomeless individuals have higher rates of hypertension when compared to the general population. Therapeutic lifestyle changes (TLCs) have the potential to decrease the morbidity and mortality associated with hypertension, yet TLCs can be difficult for homeless persons to implement because of competing priorities.ObjectivesTo identify: (1) Patients' knowledge and perceptions of hypertension and TLCs and (2) Barriers to implementation of TLCs.MethodsThis qualitative study was conducted with patients from an urban health care for the homeless center. Patients ≥18 years old with a diagnosis of hypertension were eligible. Three focus groups were conducted at which time saturation was deemed to have been reached. Focus group sessions were audio recorded and transcribed for data analysis. A systematic, inductive analysis was conducted to identify emerging themes.ResultsA total of 14 individuals participated in one of the 3 focus groups. Most were female (n = 8) and African-American (n = 13). Most participants were housed in a shelter (n = 8). Others were staying with family or friends (n = 3), living on the street (n = 2), or had transitioned to housing (n = 1). Participants had a mixed understanding of hypertension and how TLCs impacted hypertension. They were most familiar with dietary and smoking recommendations and less familiar with exercise, alcohol, and caffeine TLCs. Participants viewed TLCs as being restrictive, particularly with regard to diet. Family and friends were viewed as helpful in encouraging some lifestyle changes such as healthy eating, but less helpful in having a positive influence on quitting smoking. Participants indicated that they often have difficulty implementing lifestyle changes because of limited meal choices, poor access to exercise equipment, and being uninformed about recommendations.ConclusionsDespite the benefits of TLCs, homeless individuals experience unique challenges to implementing TLCs. Future research should focus on developing and testing interventions that facilitate TLCs among homeless persons. The findings from this study should assist health care practitioners, including pharmacists, with providing appropriate and effective education.     

Survey of Geriatricians on the Effect of Fecal Incontinence on Nursing Home Referral

OBJECTIVES: Determine the effect of fecal incontinence (FI) on healthcare providers' decisions to refer patients for nursing home (NH) placement. DESIGN: Survey. SETTING: Questionnaires were e‐mailed to participants' homes or offices. Participants could also volunteer at the 2008 American Geriatric Society annual meeting in Washington, DC. PARTICIPANTS: Two thousand randomly selected physician members and all 181 nurse practitioner members of the American Geriatrics Society were surveyed. MEASUREMENTS: The survey presented a clinical scenario of a 70‐year‐old woman ready for discharge from a hospital and asked about the likelihood of making a NH referral if the patient had no incontinence, urinary incontinence (UI) alone, or FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested using the chi‐square test. RESULTS: Seven hundred sixteen members (24.7% response rate) completed the first survey, and 686 of the 716 (96%) completed the second. FI increased the likelihood of NH referral (RR=4.71, P<.001) more than UI did (RR=1.90, P<.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (P<.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (P<.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral. CONCLUSION: FI increases the probability that geriatricians will refer to a NH. More‐aggressive outpatient treatment of FI might delay or prevent NH referral, improve quality of life, and reduce healthcare costs.     

The European Trauma Course (ETC) and the team approach: Past,present and future

The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements.This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.     

The cholinomimetic agent carbachol induces headache in healthy subjects

The parasympathetic nervous system is likely to be involved in migraine pathogenesis. We hypothesized that the cholinomimetic agonist carbachol would induce headache and vasodilation of cephalic and radial arteries. Carbachol (3 µg/kg) or placebo was randomly infused into 12 healthy subjects in a double-blind crossover study. Headache was scored on a verbal rating scale from 0–10. Velocity in the middle cerebral artery (V_MCA) and diameter of the superficial temporal artery (STA) and radial artery (RA) were recorded. Nine participants developed headache after carbachol compared with three after placebo. The area under the curve for headache was increased after carbachol compared with placebo both during infusion (0–30 min) ( P  = 0.042) and in the postinfusion period (30–90 min) ( P  = 0.027). Carbachol infusion caused a drop in V_MCA ( P  = 0.003) and an increase in STA diameter ( P  = 0.006), but no increase in the RA diameter ( P  = 0.200). In conclusion, the study demonstrated that carbachol caused headache and dilation of cephalic arteries in healthy subjects.     

Early elevation of soluble CD14 may help identify trauma patients at high risk for infection

BACKGROUND: Elevated levels of soluble CD14 (sCD14) have been implicated in both gram-positive and gram-negative sepsis, and it has been associated with high mortality in trauma patients who become infected. METHODS: Eleven healthy volunteers and 25 adult trauma patients with multiple injuries and a mean Injury Severity Score of 32 participated. Whole blood was obtained at intervals. Immunohistochemistry was used to quantify membrane CD14 (mCD14), by flow cytometry and plasma levels of sCD14 by enzyme-linked immunosorbent assay. Analysis of variance and Student's T test with Mann-Whitney posttest were used to determine significance at p < 0.05. RESULTS: On posttrauma day 1, sCD14 was significantly different in the plasma of infected patients compared with normal controls (7.16 +/- 1.87 microg/mL vs. 4.4 +/- 0.92 microg/mL, p < 0.01), but not significantly different from noninfected patients. The percentage of monocytes expressing mCD14 in trauma patients did not differentiate them from normal controls; however, mCD14 receptor density did demonstrate significance in septic trauma patients (n = 15) versus normal controls on posttrauma day 3 (p = 0.0065). CONCLUSION: On the basis of our data, mCD14 did not differentiate infected and noninfected trauma patients, although trauma in general reduced mCD14 and elevated sCD14. Interestingly, 100% of patients who exceeded plasma levels of 8 microg/mL of sCD14 on day 1 after injury developed infections. Therefore, early high expressers of sCD14 may be at higher risk for infectious complications after trauma.     

Oestrogen receptor isoforms, their distribution and relation to progesterone receptor levels in breast cancer samples.

Oestrogen receptors (ER) in breast cancer tumours are highly heterogeneous. In this study, the variability in the profile of ER isoforms and its relation to progesterone receptor (PgR) levels in breast tumours has been studied. Using high resolution isoelectric focusing (IEF) 4 ER isoforms can be detected with pI values of 6.1 (corresponding to the 8S ER), and 6.3, 6.6 and 6.8 (all of which have a sedimentation pI values of 6.1 (corresponding to the 8S ER), and 6.3, 6.6 and 6.8 (all of which have a sedimentation coefficient of approximately 4S in sucrose density gradients). Data were obtained on the soluble receptors from supernatants of 66 ER-positive primary breast tumour homogenates using high resolution IEF. In 43 of these samples PgR levels were also measured. The isoform at pI 6.6 was present in 97.0% of tumours, the isoform at pI 6.1 in 83.3%, the pI 6.3 isoform 39.4% of tumours and the pI 6.8 isoform in only 33.3% of tumours. Only 12.1% of tumours studied contained the full complement of ER isoforms (pI 6.1, 6.3, 6.6 & 6.8). The ER isoforms at pI 6.1 & 6.8 were only found in PgR-positive (> 10 fmol PgR/mg protein) tumours. Some tumours contained only a single ER isoform at pI 6.6 or 6.1, but those at pI 6.3 and 6.8 were never found singly. Tumours containing 3 or 4 ER isoforms had significantly higher levels of PgR (> 90 fmol/mg protein) than those with only 1 or 2 (P < 0.001). The presence of ER isoforms at pI 6.3 and pI 6.8 also significantly correlated with high levels of PgR (P < 0.001). This variability in the ER isoform profile of breast tumours and their correlation with PgR levels may have a bearing on prognosis and tumour response to endocrine therapy.