Assessing Health Disparities in Rural Hawaii Using the Hoshin Facilitation Method

CONTEXT: Health disparities between rural and urban communities are well documented. There are many suggested causes and many proposed solutions but no one-size-fits-all answer. The most successful community interventions have been introduced by communities themselves. However, before communities invest in such interventions, each group must identify and prioritize their needs. PURPOSE: This article describes the Hoshin facilitation method as a practical option assisting communities in assessing their needs and gaining consensus for future steps. METHODS: Thirty-four meetings were held in 11 rural communities in Hawaii using the Hoshin process to identify factors that impact rural health. Themes were identified by constant comparative analysis and thematic frequency described. Commonality of responses between communities was examined. Informal feedback was collected from meeting participants. FINDINGS: There was a great deal of commonality between community responses, with economic factors, drug use, lack of community leadership, lack of health care services and access to services, lack of healthy activities for youth, and poor public education being the most common issues noted. Group involvement in the meetings was high, and the facilitation method received positive feedback from participants. CONCLUSIONS: The Hoshin facilitation method is a very useful tool to help communities rapidly identify and prioritize areas for programmatic attention.     

Correlates of cognitive dysfunction in an ambulatory elderly population

Mini-Mental State Examination (MMSE) scores were studied in an ambulatory elderly population to identify correlates with self-reported signs, symptoms, diseases, drugs and laboratory values. A total of 1,264 subjects were studied including 844 women and 420 men. In this study, 5.0% of men and 5.3% of women scored less than 24 on the MMSE. A linear-regression model revealed eleven factors of significance in predicting scores on the MMSE. The most important predictors were age (p less than 0.0001), self-reported memory loss (p less than 0.0001), complaints of swollen feet or ankles (p less than 0.0010), the total number of diseases reported (0.0006) and the serum lactate dehydrogenase concentration (p less than 0.0098). Results suggest that cognitive function in the elderly is not related to the general level of health or consistently affected by specific disease states.     

Ileus of the large intestine caused by endometriosis. Report of 2 cases and review of the literature

Two cases of distal colonic obstruction due to endometriosis prompted the authors to elaborate on problems implied in diagnosis and therapy of this rare cause of ileus. Accurate preoperative diagnosis was usually not obtainable from case histories, endoscopy, and X-ray checks. Only emergency operations should be performed on ileus cases (colostomy, Hartmann's operation). Hormonal and surgical treatment should then be continued in consultation with the gynaecologist. Resections should be minimised and mutilating interventions (rectal amputation) avoided.     

Environmental and developmental signals modulate proline homeostasis: evidence for a negative transcriptional regulator.

In many plants, osmotic stress induces a rapid accumulation of proline through de novo synthesis from glutamate. This response is thought to play a pivotal role in osmotic stress tolerance [Kishor, P. B. K., Hong, Z., Miao, G.-H., Hu, C.-A. A. and Verma, D. P. S. (1995) Plant Physiol. 108, 1387-1394]. During recovery from osmotic stress, accumulated proline is rapidly oxidized to glutamate and the first step of this process is catalyzed by proline oxidase. We have isolated a full-length cDNA from Arabidopsis thaliana, At-POX, which maps to a single locus on chromosome 3 and that encodes a predicted polypeptide of 499 amino acids showing significant similarity with proline oxidase sequences from Drosophila and Saccharomyces cerevisiae (55.5% and 45.1%, respectively). The predicted location of the encoded polypeptide is the inner mitochondrial membrane. RNA gel blot analysis revealed that At-POX mRNA levels declined rapidly upon osmotic stress and this decline preceded proline accumulation. On the other hand, At-POX mRNA levels rapidly increased during recovery. Free proline, exogenously added to plants, was found to be an effective inducer of At-POX expression; indeed, At-POX was highly expressed in flowers and mature seeds where the proline level is higher relative to other organs of Arabidopsis. Our results indicate that stress- and developmentally derived signals interact to determine proline homeostasis in Arabidopsis.     

Parity and bone mineral density in middle-aged women

A retrospective study was carried out to determine the relationship between parity and bone mineral density (BMD) in middle-aged women. Eight hundred and twenty-five woman aged 41–76 years were recruited from four general practice registers in Cambridge. Subjects were unselected as to their health status. Each subject completed a detailed health questionnaire. Participation rate was 50%. The main outcome measure was BMD measured at the spine (L2–4,n=825) and hip (neck, intertrochanter and Ward's triangle;n=817) by dual-energy X-ray absorptiometry (DXA) using the Hologic QDR-1000 densitometer. It was found that the unadjusted mean BMD was significantly higher at all sites among the parous women (p=0.031 to <0.00001), and remained significantly higher at the femoral neck (p=0.025), intertrochanter (p=0.001) and Ward's triangle (p=0.045) after adjusting for age and body mass index (BMI). Similar findings were seen after stratifying for potential confounding variables. There was a consistent upward trend of BMD with increasing parity at all sites. Parity remained a significant independent predictor of BMD at all sites after controlling for age, BMI, menopausal status, oral contraceptive and hormone replacement therapy use, smoking status and breast-feeding status in multiple linear regression analyses. There was, on average, a 1.0% increase in BMD per live birth. Our findings therefore suggest a positive relationship between parity and bone mass.     

The acceleration transducer – an assessment of its precision in comparison with a force displacement transducer

A new and simple acceleration transducer (ACT)–based system of neuromuscular monitoring has recently been introduced. The precision of this transducer has been evaluated as compared to a conventional force displacement transducer (FDT) in the present study. Ten progressions of spontaneous recovery from atracurium–induced block with simultaneous measurements using the ACT on one hand and the FDT on the other were studied. Five individuals undergoing elective surgery in modified neurolept anaesthesia and one ICU–patient requiring prolonged neuromuscular blockade, sedated with pentobarbital, were included. Measurements were carried out on the latter patient on 5 consecutive days. Train–of–four (TOF) stimulation was used, readings were given in twitch heights (TH) (Tl/control value), and when four responses were obtained in TOF–ratios (T4/T1). Linearity was achieved after logit–transformation and the values regressed on time for each progression of recovery. Analysis of variance was applied to the regressions for the TH and TOF–ratio readings of each transducer. No significant differences were found, either between variation due to differences between slopes or variation due to technical error between the two transducers. The study indicates that the ACT is equal to the FDT with regard to precision in clinical recordings on atracuriumrelaxed individuals.     

Galanin-like innervation of rat submandibular and sublingual salivary glands: origin and effect on acinar cell membranes.

The distribution and source of a galanin-like innervation of rat salivary glands has been examined. Additionally, submandibular and sublingual acinar cell membrane responses to galanin or a cholinergic agonist were studied. Galanin-immunoreactive fibers were observed throughout the submandibular and sublingual glands in association with ducts and acini. A subset of submandibular ganglion cells expresses galanin immunoreactivity. Parasympathectomy resulted in a marked decrease in galanin immunoreactivity in the glands. Sympathectomy resulted in marked reduction of dopamine beta-hydroxylase immunoreactivity with no appreciable change in galanin immunoreactivity. Retrograde labeling experiments demonstrated that galanin-immunoreactive sensory neurons in the trigeminal ganglion do not innervate the submandibular or sublingual gland. These results indicate that the galanin-like innervation of rat salivary glands is derived from parasympathetic nerves to the glands. Since rat sublingual glands contain largely mucous acini while rat submandibular gland acini are seromucous, electrophysiological responses to galanin and the muscarinic agonist, bethanechol, were compared. Agonist-induced voltage shifts varied between the two glands. The galanin-induced response at the level of the resting membrane potential in submandibular acinar cells was a hyperpolarization, while that in sublingual acinar cells was a depolarization. There was also a greater voltage dependence to the galanin-induced submandibular response than to the sublingual response. Differences were also noted in the acinar cell response to cholinergic stimulation between these glands. These results demonstrate the existence of a galanin-like innervation to salivary glands that may be functionally relevant. Moreover, the results challenge the idea that agonist-induced membrane responses are similar among acinar cells of different glands.     

Mündung eines Megaureters mit aplastischer Niere in eine Samenblasenzyste Fallbericht einer laparoskopischen Intervention

Zusammenfassung Unilaterale Samenblasenzyste, ipsilaterale Ureterektopie und ipsilaterale Nierenaplasie sind die Komponenten eines seltenen Missbildungskomplexes des männlichen Urogenitaltraktes. Klinisch im Vordergrund steht eine retrovesikale zystische Raumforderung im kleinen Becken, die unspezifische Symptome verursachen kann. Die Differentialdiagnose umfasst u. a. Zysten des Müller-Ganges, des Sinus urogenitales bzw. des Ductus ejaculatorius und der Prostata. Es wird der Fall eines 14-jährigen Jungen mit zystischer linker Samenblase dargestellt. Präoperativ bestand der Verdacht auf eine ipsilaterale Nierenagenesie, jedoch stellte sich intraoperativ eine Nierenaplasie mit ektoper Harnleitermündung in die Samenblase dar. Die 8 cm große Samenblase und die ipsilaterale aplastische Niere konnten erfolgreich durch einen laparoskopischen Eingriff entfernt werden. Vorteile des laparoskopischen Vorgehens im Vergleich mit der offen-chirurgischen Technik sind in der besseren Darstellung der intrapelvinen Strukturen, dem kurzen Krankenhausaufenthalt und in der schnellen Rekonvaleszenz des Patienten zu sehen. Anhand der Literatur wird auf Klinik, Diagnostik, Differentialdiagnose und therapeutisches Vorgehen dieser Anomalie eingegangen.     

Push-and-pull enteroscopy using the double-balloon technique/double-balloon enteroscopy

Push-and-Pull enteroscopy/Double balloon enteroscopy (PPE/DBE) allows enteroscopy of the entire small bowel, or at least a substantial part of it. The complication rate is acceptably low. Severe complications such as pancreatitis and perforation were encountered in the literature in approximately 1% of all diagnostic PPE/DBEs. It can be expected that the complication rate of therapeutic PPE/DBEs is higher, comparable with the conventional endoscopy. The diagnostic yield is high, at approximately 75%, as is the therapeutic yield. The option of carrying out endoscopic therapy (in approximately 40%–50% of cases in the Western hemisphere) is an important aspect. Angiodysplasias are the main bleeding source, at least in Western countries. Using the PPE/DBE device, endoscopic treatments such as endoscopic hemostasis using injection and argon plasma coagulation, polypectomy, endoscopic resection, balloon dilation, and foreign-body extraction have become feasible even in the small intestine and can generally be performed safely and without relevant technical problems. Medical therapy can be started in up to 20% of cases—e.g., after a new or changed diagnosis of Crohn's disease. Surgical therapy is required in 10–20% of cases, due to malignant tumors or complex stenoses, for example. The main indication is mid-gastrointestinal bleeding.