Patients’ perceived involvement in care scale:

This report describes the development of the Perceived Involvement in Care Scale (PICS), a self-report questionnaire for patients, and its relation to primary care patients’ attitudes regarding their illnesses and the management of them. The questionnaire was administered to three independent samples of adult primary care patients. Patients’ satisfaction and their attitudes regarding their illnesses are evaluated after their medical visits. This instrument is designed to examine three relatively distinct factors: 1) doctor facilitation of patient involvement, 2) level of information exchange, and 3) patient participation in decision making. Of these factors, doctor facilitation and patient decision making were related significantly to patients’ satisfaction with care. Doctor facilitation and information exchange related consistently to patients’ perceptions of post-visit changes in their understanding, reassurance, perceived control over illness, and expectations for improvement in functioning. The role of physicians in enhancing patient involvement in care and the potential therapeutic benefits of physician facilitative behavior are addressed.     

Prevalence and determinants of impaired glucose metabolism in frail elderly patients: the Belgian Elderly Diabetes Survey (BEDS)

BACKGROUND: Although diabetes in elderly persons is generally type 2, the metabolic abnormalities associated with aging suggest that elderly persons may differ from younger persons with type 2 diabetes. In addition, nonobese elderly persons with type 2 diabetes show a marked impairment in insulin release accompanied by mild insulin resistance, whereas obese elderly persons have marked insulin resistance in the presence of "adequate" levels of insulin. Other factors that could adversely affect glucose tolerance in aging include drug use, associated disease, and other stressful conditions commonly encountered in geriatric inpatients units. The authors' objectives in this study were 1) to prospectively assess the prevalence of glucose homeostasis abnormalities among elderly hospitalized patients and the degree to which it reflects abnormalities in insulin secretion or insulin sensitivity using homeostasis model assessment of fasting glucose, insulin, and C-peptide; and 2) to define the social, functional, pathologic, and nutritional characteristics of persons with impaired glucose tolerance or diabetes. METHODS: Ninety-eight patients underwent a comprehensive geriatric assessment. Determinants of glucose homeostasis were assessed using the homeostasis model assessment, which provides estimates of beta-cell function (%B) and insulin sensitivity (%S). RESULTS: Twelve patients (12%) had fasting glucose concentrations greater than 110 mg/dl. Four patients had impaired fasting glucose levels greater than 110 mg/dl but less than 126 mg/dl (IFG group), and 8 patients had levels greater than 126 mg/dl (type 2 diabetes group). Except for a higher proportion of women in the IFG-diabetes group, the latter did not exhibit significant differences in functional, morbidity, or nutritional characteristics compared with the normal glucose tolerance group. The entire cohort (n=98) presented with a mean (+/-SD) %B of 71%+/-47% and a mean %S of 208%+/-198%. Compared with the normal glucose tolerance group, the IFG-diabetes group had a fasting glycemia level of 142+/-24 mg/dl (vs 92+/-9 mg/dl), a %B of 43%+/-21% (vs 74%+/-45%), and a mean %S of 126%+/-113% (vs 219%+/-205%). CONCLUSIONS: These data confirm the high prevalence of impaired glucose metabolism among elderly people, although the usual risk factors were not significantly increased. Marked beta secretory defects seem to be the rule, whereas a significant degree of insulin resistance is unusual.     

Sacropelvic resection and intraoperative electron irradiation in the management of recurrent anorectal cancer

PURPOSE: To provide local control and palliation of pain, a multimodality approach, including external beam radiation therapy, surgical resection, and intraoperative electron irradiation (IOERT), has been used for patients with locally advanced anal or recurrent rectal cancers involving the sacrum. METHODS: Sixteen consecutive patients (11 males; 5 females; ages, 44–76) underwent surgical exploration, sacrectomy, and IOERT, between 1990 and 1994. RESULTS: Proximal extent of resection was S2–3 in four patients, S3–4 in five, and S4–5 in five. Two patients had resection of the anterior table of the sacrum. Margins were clear in 11, close in 3, and microscopically involved in 2 patients. Operative times ranged from 6 to 17 (median, 12.5) hours, and blood loss ranged from 300 to 12,600 (median, 3,350) ml. No operative deaths resulted. Major postoperative complications occurred in eight patients (50 percent): posterior wound infections and dehiscence, urinary leak, and ileal fistula. Five (31 percent) and 3 (19 percent) patients developed no or minor complications, respectively. Intensive Care Unit stay was one night for all patients, and overall hospital stay ranged from 11 to 30 (median, 16.5) days. Follow-up was available on all 16 patients. Kaplan-Meier survival was 68 percent at one year and 48 percent at two years. At the time of analysis, 9 of 16 patients were alive. Of the nine alive patients who responded to a questionnaire, eight reported a reduction in pain and improved quality of life postoperatively. CONCLUSIONS: Sacropelvic resection, in conjunction with IOERT, provides palliation and offers potential for cure in patients with locally advanced or recurrent anorectal cancer.Supported in part by a grant from the Centro Nazionale Ricerche, (National Institute of Scientific Research), Rome, Italy and American Cancer Society Career Development Award.Read at meeting of The American Society of Colon & Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Electrical isolation of pulmonary veins in patients with atrial fibrillation: reduction of fluoroscopy exposure and procedure duration by the use of a non-fluoroscopic navigation system (NavX).

AIMS: The aim of the study was to investigate the feasibility of performing segmental pulmonary vein (PV) isolation guided by the NavX (Endocardial Solutions, St Jude Medical, Inc., St Paul, MN, USA) system without the three-dimensional (3D) geometric reconstruction option and whether the use of NavX system will reduce the radiation exposure and procedure duration. METHODS AND RESULTS: The study included 64 patients with symptomatic paroxysmal or permanent atrial fibrillation, in whom PV isolation was performed using fluoroscopic guidance (n=32) or the NavX system (n=32). Pulmonary vein mapping with a circular mapping catheter allowed the identification and localization of myocardial connections between the PV and the left atrium. PV isolation was performed by radiofrequency ablation of these connections at the atrial aspect of the PV ostium. Primary success rate for isolated PVs did not differ significantly in patients ablated under fluoroscopic guidance vs. those ablated under guidance of NavX system [100/107 PVs (93.5%) vs. 120/124 PV (96.8%; P=n.s.)]. Compared with fluoroscopy guided procedures, NavX-guided procedures showed a significant reduction in the fluoroscopy time (75.8+/-24.5 vs. 38.9+/-19.3 min, P<0.05), total X-ray exposure (93.2+/-51.6 vs. 56.6+/-37.9 Gy cm(2), P=0.03), and total procedural time (237.7+/-65.4 vs. 188.6+/-62.7 min, P=0.01). The mean follow-up was 9.5+/-3.0 months. One patient in each group was lost to follow-up. Seven-day Holter monitoring showed that 23 of 31 patients (74.2%) in the NavX-guided group and 21 of 31 patients (67.7%) in the fluoroscopy-guided group were in sinus rhythm (P=0.57). CONCLUSION: The 3D visualization of the catheters by NavX system allows a rapid and precise visualization of the mapping and ablation catheters at the PV ostia and markedly reduces fluoroscopy time, total X-ray exposure, and procedural duration during PV isolation compared with ablation performed under fluoroscopy guidance.     

Adaptation from invisible flicker

Human ability to resolve temporal variation, or flicker, in the luminance (brightness) or chromaticity (color) of an image declines with increasing frequency and is limited, within the central visual field, to a critical flicker frequency of approximately 50 and 25 Hz, respectively. Much remains unknown about the neural filtering that underlies this frequency-dependent attenuation of flicker sensitivity, most notably the number of filtering stages involved and their neural loci. Here we use the process of flicker adaptation, by which an observer's flicker sensitivity is attenuated after prolonged exposure to flickering lights, as a functional landmark. We show that flicker adaptation is more sensitive to high temporal frequencies than is conscious perception and that prolonged exposure to invisible flicker of either luminance or chromaticity, at frequencies above the respective critical flicker frequency, can compromise our visual sensitivity. This suggests that multiple filtering stages, distributed across retinal and cortical loci that straddle the locus for flicker adaptation, are involved in the neural filtering of high temporal frequencies by the human visual system.     

Heterodimeric complexes of Hop2 and Mnd1 function with Dmc1 to promote meiotic homolog juxtaposition and strand assimilation

Saccharomyces cerevisiae Hop2 and Mnd1 are abundant meiosisspecific chromosomal proteins, and mutations in the corresponding genes lead to defects in meiotic recombination and in homologous chromosome interactions during mid-prophase. Analysis of various double mutants suggests that HOP2, MND1, and DMC1 act in the same genetic pathway for the establishment of close juxtaposition between homologous meiotic chromosomes. Biochemical studies indicate that Hop2 and Mnd1 proteins form a stable heterodimer with a higher affinity for double-stranded than single-stranded DNA, and that this heterodimer stimulates the strand assimilation activity of Dmc1 in vitro. Together, the genetic and biochemical results suggest that Hop2, Mnd1, and Dmc1 are functionally interdependent during meiotic DNA recombination.     

Empowering patients to link to care and treatment: qualitative findings about the role of a home-based HIV counselling,testing and linkage intervention in South Africa

To explore the barriers and facilitators of linkage to and retention in care amongst persons who tested positive for HIV, qualitative research was conducted in a home-based HIV counselling and testing (HBCT) project with interventions to facilitate linkages to HIV care in rural KwaZulu-Natal, South Africa. The intervention tested 1272 adults for HIV in Vulindlela of whom 32% were HIV positive, received point-of-care (POC) CD4 testing and referral to local HIV clinics. Those testing positive also received follow-up visits from a counsellor to evaluate linkages to care. The study employed a qualitative methodology collecting data through in-depth semi-structured interviews. Respondents included 25 HIV-positive persons who had tested as part of HBCT project, 4 intervention research counsellors who delivered the HBCT intervention and 9 government clinic staff who received referrals for care. The results show that HBCT helped to facilitate linkage to care through providing education and support to help overcome fears of stigma and discrimination. The results show the perceived value of receiving a POC CD4 result during post-test counselling, both for those newly diagnosed and those previously diagnosed as HIV positive. The results also demonstrate that in-depth counselling creates an “educated consumer” facilitating engagement with clinical services. The study provides qualitative insights into the acceptability of confidential HBCT with same day POC CD4 testing and counselling as factors that influenced HIV-positive persons’ decisions to link to care. This model warrants further evaluation in non-research settings to determine impact and cost-effectiveness relative to other HIV testing and referral strategies.