Chronic illness management: what is the role of primary care?

An estimated 99 million Americans live with a chronic illness. Meeting the needs of this population is one of the major challenges facing the U.S. health care system today and in the future. Dozens of studies, surveys, and audits have revealed that sizable proportions of chronically ill patients have not received effective therapy and do not have optimal disease control. The consistent findings of generally substandard care for many chronic conditions have spurred proposals that care be shifted to specialists or disease management programs. Published evidence to date does not indicate any clear superiority of these alternatives to primary care. The defining features of primary care (that is, continuity, coordination, and comprehensiveness) are well suited to care of chronic illness. A rapidly growing body of health services research points to the design of the care system, not the specialty of the physician, as the primary determinant of chronic care quality. The future of primary care in the United States may depend on its ability to successfully redesign care systems that can meet the needs of a growing population of chronically ill patients.     

Identification of signal transduction pathways that modulate dibutyryl cyclic adenosine monophosphate activation of stanniocalcin gene expression in neuroblastoma cells

Stanniocalcin (STC) is a new mammalian polypeptide hormone and appears to be a regulator of neuronal function. We have already shown that the induction of STC mRNA and protein expression by cAMP is integral to neuroblastoma cell differentiation, particularly neurite outgrowth. In this study, we examined the cAMP pathway in greater detail. Some common neuritogenic agents, euxanthone (PW1) and trans-retinoic acid (RA), were studied for possible interactions with the dibutyryl cAMP (dbcAMP)-mediated response. Our results showed that STC mRNA induction by dbcAMP was mediated by protein kinase A-cAMP response element binding protein (CREB) pathway, accompanied with phosphorylation of CREB and a reduction of p50, p65, and phosphorylated inhibitor kappaBalpha levels. Using a synthetic peptide nuclear factor-kappaB SN50, stimulation of dbcAMP-mediated STC expression was observed; indicating the nuclear translocation of nuclear factor kappaB might possibly repress STC expression. dbcAMP-induced STC mRNA expression was enhanced by PW1. In contrast, RA had highly suppressive effects. Cotreatment of cell with PW1 and cAMP provoked an increase in phosphorylated CREB (pCREB). Conversely, cotreatment with RA suppressed pCREB. The results highlighted the importance of phosphorylation of CREB in mediating STC gene expression. Taking a step further to dissect the possible regulatory pathways involved, with the aid of phorbol 12-myristate 13-acetate or ionomycin, additive effects on STC gene expression were observed. The induction was aided by further elevation of pCREB, which was completely abolished by G? 6976, a Ca2+-dependent protein kinase C (PKC) alpha and PKCbeta1 inhibitor. Our results indicated that cross-talk with PKC and/or Ca2+ signaling pathways might sensitize cAMP-mediated effects, on CREB phosphorylation and STC gene expression.     

Problems and solutions: two concepts of mankind in cognitive-behavior therapy

Scientific theories that are concerned with experience and behavior of human beings always include anthropological core assumptions. This applies in particular to psychotherapeutic theories. These anthropological core assumptions (i.e., concepts of mankind) affect techniques that are derived from these theories but they also have a great influence on acceptance and spreading of psychotherapeutic methods. This article examines the concept of mankind in cognitive-behavior therapy. In this connection two highly differing conceptions of the human being are identified: the early behavioristic black-box model and the conception of the human being as an actively performing subject ("man the scientist") in the framework of the self-management approach and in cognitive therapy. The image problem of today's behavior therapy, the lack of application of efficient methods of behavior therapy and problems in finding a professional identity as a behavior therapist can be seen as stemming from the differing concepts of mankind. To solve these problems we propose: an integrative concept of mankind, an increased emphasis of a cooperative therapist-patient relationship, and the taking into account of unconscious processes.     

Autosomal dominant inherited neuropathies with prominent sensory loss and mutilations: a review

Hereditary sensory neuropathies (HSNs) are rare disorders characterized by progressive distal sensory loss, predominantly affecting the lower limbs. Foot ulcers, severe skin and bone infections, arthropathy, and amputations are frequent and feared complications. Occasionally, patients complain of spontaneous shooting or lancinating pain. Autonomic fibers can be affected to a variable degree. Patients with HSN can also have severe distal weakness, and some HSN variants have therefore been classified among the hereditary motor and sensory neuropathies (HMSNs). Molecular genetic studies of autosomal dominant inherited neuropathies with prominent sensory loss and ulceromutilating features have assigned the genetic loci for HMSN type 2B (Charcot-Marie-Tooth syndrome type 2B) and HSN type 1 to chromosomes 3q13-22 and 9q22.1-22.3, respectively. However, some families with HSN have been excluded for linkage to these loci, suggesting further genetic heterogeneity. Recently, disease-causing mutations in the SPTLC1 gene have been identified in patients with HSN type 1. In this review, we discuss the hallmark features associated with the distinct genetic subtypes of autosomal dominant inherited HSN and provide genotype-phenotype correlations.     

Seriously Emotionally Disturbed Youth: A Needs Assessment

A desire to improve outcomes for children and families led Erie County, New York to collaborate with the University at Buffalo Department of Family Medicine on a needs assessment of children with emotional disturbance. Demographic and behavioral characteristics, as well as service needs were identified through case-based interviews conducted with key informants who provided services to children with emotional disturbance. Family interviews were conducted whenever possible. Results demonstrate a need for enhanced case management, service coordination, services specific to children and families, and expanded community-based services.     

Linear scleroderma "en coup de sabre" coexisting with plaque-morphea: neuroradiological manifestation and response to corticosteroids

A 24 year old woman in the 33rd week of pregnancy developed progressive neurological complications with right sided hemiparesis in association with the occurrence of linear scleroderma "en coup de sabre" (LSCS) and pre-existing plaque-morphea, already being treated by balneophototherapy. Further progression of neurological symptoms led to a caesarean section with the delivery of a healthy child. Brain magnetic resonance imaging (MRI) showed focal T2 signal increases in the left frontoparietal region directly adjacent to the area of LSCS. Cerebrospinal fluid analysis revealed oligoclonal bands, suggesting an intracerebral inflammatory process. Subsequent pulsed corticosteroid treatment led to a remission of neurological symptoms and to a marked resolution of the MRI lesions.     

Evaluation of surface finish and polish of eight provisional restorative materials using acrylic bur and abrasive disk with and without pumice

This study evaluated the effects of two finishing techniques and pumice polishing on the surface roughness of eight different provisional materials. Provisional materials included polymethylmethacrylate-based Alike, Snap, Trim and Jetand composite-based provisional materials Temphase, Protemp 3 Garant, Luxatemp and Integrity. Baseline surface roughness was measured by a profilometer, then the provisional materials were finished using extra fine acrylic burs or medium abrasive disks. The surface roughness of each sample was measured following finishing using a profilometer as previously stated. Each surface was then polished with pumice and the surface roughness was measured again. The data were analyzed using repeated measures of ANOVA and Bonferroni pairwise comparisons (alpha = 0.05). The results indicated that with composite provisional materials, the unfinished surfaces are smoother than with bur or abrasive-disk finished surfaces. Pumice application did not smooth the surface finish for all materials. The different types of provisional materials required different finishing techniques to produce the smoothest finishes.