Centres for Clinical Education (CCE): developing the health care education of tomorrow--a preliminary report

A new interdisciplinary concept of medical and health care education has been introduced at Karolinska Institute in collaboration with the County Council in Stockholm under the motto Learning together to be able to work together. Centres of Clinical Education are built up in four major hospitals to promote meeting places during clinical education for students from different categories. During a three-year project more than 5000 students from four educational programmes have been involved--medicine, nursing, occupational therapy and physiotherapy. The project started in 1998 and will turn into regular activities in 2002. The Centres consist of three parts. First is the Clinical Training Ward, a ward without patients where manual skills as well as skills in communication are taught, practised and videotaped. Second is the Clinical Education Ward, a student-driven ward where students during two-week periods experience their own professional roles in day-to-day work and learn how to work together. Third is the Multidisciplinary Team, where teachers from the four programmes plan and provide opportunities for students to learn together. Opportunities to meet and learn together have promoted a wider understanding of each professional in health care teams among students and staff. The Centres of Clinical Education provide excellent opportunities to bridge professional borders and to coordinate undergraduate studies and clinical reality.     

Breastfeeding attitudes among counselling health professionals

AIM: The aim of the study was to develop an instrument that can be used for accurate assessment of nurses' and midwives' attitudes toward breastfeeding in a group of midwives, maternity-nursing staff and postnatal nurses experienced in breastfeeding counselling. METHOD: An instrument based on WHO standards was developed to measure breastfeeding attitudes. In all, 168 healthcare professionals filled in the instrument. A factor analysis using maximum likelihood and varimax rotation was performed. Spearman's correlation was used to correlate factorial dimensions and self-described interest in breastfeeding. RESULTS: By means of factor analysis four factors were identified: the "regulating" factor focused on regulating the mothers' breastfeeding management, the "facilitating" factor focused on making it easy for mothers to manage their breastfeeding, the "disempowering" factor focused on giving advice, disregarding the needs of the mother being counselled, and the "breastfeeding antipathy" factor focused on insufficient, basic, breastfeeding knowledge and aversive reactions to breastfeeding. Midwives rated higher on the facilitating factor and breastfeeding antipathy factor and lower on the regulating factor than postnatal nurses. Breastfeeding interest was positively correlated with the facilitating factor, and negatively with the disempowering factor and the breastfeeding antipathy factor. CONCLUSION: This instrument provides a picture of health professionals' attitudes towards breastfeeding. Four factors were identified in order of importance: regulating, facilitating, disempowering, and breastfeeding antipathy factors. Harmful attitudes were identified and suggested a need for educational programmes to help health professionals to reconcile damaging values, in order to improve breastfeeding counselling.     

Cyclooxygenase-2 protein reduces tamoxifen and N-(4-hydroxyphenyl)retinamide inhibitory effects in breast cancer cells

Approximately 30-40% of estrogen receptor alpha (ERalpha)-positive breast tumors express high levels of the cyclooxygenase-2 (COX-2) protein, and these high levels have been associated with a poorer prognosis in breast cancer patients. We speculate that high levels of COX-2 induce drug resistance in ERalpha-positive breast tumors, thus reducing the survival rate of patients with such tumors. Human breast cancer cell lines that express high levels of COX-2 are generally ERalpha negative. To determine whether COX-2 induces drug resistance, plasmids encoding the COX-2 gene were stably transfected into ERalpha-positive MCF-7 human breast cancer cells (MCF-7/COX-2). MCF-7/COX-2 cells were resistant to the selective estrogen receptor modulator tamoxifen but not to its analog, raloxifene. MCF-7/COX-2 cells were also resistant to the retinoid N-(4-hydroxyphenyl)retinamide (4-HPR) but not to its analog, all-trans retinoic acid. In contrast, the sensitivities of MCF-7/COX-2 cells to doxorubicin and paclitaxel were similar to those of the parental MCF-7 cells. We then determined which COX-2 product, prostaglandin E2 (PGE2) or prostaglandin F2alpha is involved in the COX-2-mediated drug resistance. PGE2, but not PGF2alpha, blocked the antiproliferative effects of tamoxifen and 4-HPR. Agonists that activate PGE2 receptors and their downstream kinase effectors, protein kinases A and C, also blocked the growth inhibitory effects of these drugs. Increased levels of Bcl-2 and Bcl-XL proteins have been reported in mammary tumors of COX-2 transgenic mice and in human colon cancer cell lines that have high levels of COX-2. However, we did not observe any changes in Bcl-2, Bcl-XL, or Bax expression induced by COX-2 or PGE2. Here we report the novel findings that COX-2 uses PGE2 to stimulate the activities of protein kinases A and C to induce selectively tamoxifen and 4-HPR resistance in ERalpha-positive breast cancer cells.     

Tri-ethnic variations of co-morbid substance and alcohol use disorders in schizophrenia

OBJECTIVES: This study examined the differential prevalence of substance and alcohol use disorders among European Americans, African Americans, and Latinos with schizophrenia (n = 6424) who received public mental health services in San Diego County during fiscal year 2002-2003. METHODS: Data were obtained from the public mental health database used by the San Diego County Mental Health System. Chi-Square analyses and stepwise logistic regression analyses were used to examine differences regarding the prevalence of substance and alcohol use among clients with schizophrenia and schizoaffective disorder, and to analyze the sociodemographic variables associated with this co-morbidity. RESULTS: Significant differences in the prevalence of diagnosed co-morbidity were found across the ethnic groups. Rates of co-morbid diagnosis among African Americans (25%) were significantly higher than those among European Americans (22%) and Latinos (19%). Logistic regression results revealed ethnicity was a significant predictor of co-morbid substance and alcohol use, as was being homeless and male. Among Latinos, language preference was also a significant predictor. Latinos who denoted English as their primary language were 1.7 times more likely to be diagnosed with co-morbid substance or alcohol use disorders than Latinos who denoted Spanish. CONCLUSIONS: Among people with schizophrenia, there were significant differences in prevalence rates and predictors of diagnosed co-morbid substance and alcohol use disorders. Future research is needed to examine the relationship among language preference, level of acculturation, and subsequent diagnosing barriers for Latinos. Among African Americans, the reasons behind increased co-morbidity rates need to be examined, and homelessness should be carefully addressed among all three ethnic groups.     

Transglutaminase function in epidermis

Surface epithelial cells, such as the epidermal keratinocyte, undergo a process of terminal cell differentiation that results in the construction of a multilayered epithelium. This epithelium functions to protect the organism from the environment. Transglutaminases, enzymes that catalyze the formation of isopeptide protein-protein cross-links, are key enzymes involved in the construction of this structure. This brief review will focus on the role of these enzymes in constructing the epidermal surface.     

Exercise-induced reduction in obesity and insulin resistance in women: a randomized controlled trial

OBJECTIVES: To determine the effects of equivalent diet- or exercise-induced weight loss and exercise without weight loss on subcutaneous fat, visceral fat, and insulin sensitivity in obese women. RESEARCH METHODS AND PROCEDURES: Fifty-four premenopausal women with abdominal obesity [waist circumference 110.1 +/- 5.8 cm (mean +/- SD)] (BMI 31.3 +/- 2.0 kg/m2) were randomly assigned to one of four groups: diet weight loss (n = 15), exercise weight loss (n = 17), exercise without weight loss (n = 12), and a weight-stable control group (n = 10). All groups underwent a 14-week intervention. RESULTS: Body weight decreased by approximately 6.5% within both weight loss groups and was unchanged in the exercise without weight loss and control groups. In comparison with controls, cardiorespiratory fitness improved within the exercise groups only (p < 0.01). Reduction in total, abdominal, and abdominal subcutaneous fat within the exercise weight loss group was greater (p < 0.001) than within all other groups. The reduction in total and abdominal fat within the diet weight loss and exercise without weight loss groups was greater than within controls (p < 0.001) but not different from each other (p > 0.05). Visceral fat decreased within all treatment groups (p < 0.008), and these changes were not different from each other. In comparison with the control group, insulin sensitivity improved within the exercise weight loss group alone (p < 0.001). DISCUSSION: Daily exercise without caloric restriction was associated with substantial reductions in total fat, abdominal fat, visceral fat, and insulin resistance in women. Exercise without weight loss was also associated with a substantial reduction in total and abdominal obesity.     

Personality factors and emotional responses to pregnancy among IVF couples in early pregnancy: a comparative study

BACKGROUND: Little is known as to whether negative experiences associated with infertility and IVF treatment persist after successful treatment. The aim of the study was to compare couples who have conceived after IVF and couples who have conceived naturally regarding personality factors and emotional responses to pregnancy. METHODS: Fifty-seven women pregnant after IVF and 55 male partners and 43 women who had conceived naturally and 39 male partners were recruited from university IVF clinics and antenatal clinics in Stockholm. The subjects were interviewed about their socio-demographic background. They completed scales of personality traits, anxiety, emotional responses to pregnancy, marital adjustment and reactions to recalled infertility while in pregnancy week 13 (range 11-17). RESULTS: The results showed that the IVF women had more muscular tension and were more anxious about loosing the pregnancy than the control women. The IVF women with high infertility distress were more anxious about loosing the pregnancy and less ambivalent than the women with lower distress. The IVF men had more somatic anxiety, indirect aggression, guilt, and were more detached and more anxious about loosing the pregnancy and less ambivalent than the control men. The IVF men with high infertility distress were more anxious about the baby not being normal than the men with lower infertility distress. CONCLUSIONS: The women and men who had conceived after IVF differed on a number of personality dimensions and emotional responses to the pregnancy from that of the women and the men who had conceived naturally. The results suggest that IVF couples may need additional emotional support in early pregnancy.     

Genetic testing for hereditary colorectal cancer in children: long-term psychological effects

Children who carry a gene mutation for familial adenomatous polyposis are virtually certain to develop colorectal cancer without annual endoscopic screening and a colectomy when polyps appear. Predictive genetic testing can identify children who need regular surveillance. While the medical benefits of genetic testing are clear, the psychological effects have not been well studied. We evaluated the long-term psychological effects of genetic testing in 48 children and their parents. In each family, one parent was a known APC gene mutation carrier. Before genetic testing, and three times afterward, participants completed measures of psychological functioning, which, for children, included depression and anxiety symptoms, and behavior problems and competencies. Parents completed a measure of depression symptoms. Data were collected at 3-, 12-, and 23-55 months after disclosure. Twenty-two children tested positive; 26 children tested negative. Mean length of follow-up was 38 months. There were no clinically significant changes in mean psychological test scores in children or parents, regardless of the children's test results or the sex of the affected parent. However, the group of children who tested positive and had a mutation-positive sibling showed significant, but subclinical, increases in depression symptoms. Furthermore, several individual mutation-negative children with a positive sibling had clinical elevations in anxiety symptoms at one or more follow-up. Behavior problems declined for all groups, and behavior competence scores remained unchanged. We conclude that most children do not suffer clinically significant psychological distress after testing. However, because some children showed clinically significant anxiety symptoms, long-term psychological support should be available to those families with both mutation-positive and mutation-negative children, and with multiple mutation-positive children. Our findings should call for a multidisciplinary approach to genetic testing for children.