Psychological risk factors for colorectal cancer?

The paper deals with personality correlates of colorectal cancer patients in the framework of the cognitive orientation theory. The cognitive-motivational approach and the construction and testing of a reliable and valid questionnaire for assessing the personality correlates of colorectal cancer are reviewed in the first part. In the second part in a new sample of 230 colorectal cancer patients the themes in the questionnaire are clustered and their structure is tested in a confirmatory factor analysis. Further, following the expectation that colorectal cancer is gender bound, the differences in the themes and belief types are applied to testing differences between men and women corresponding to the medical differences. Finally the questionnaire was applied to identifying the detected personality correlates in an attenuated form in a sample of Crohn’s disease patients who are known to be at risk for colorectal cancer. Discriminant analysis showed that the questionnaire provided a highly significant correct identification of cases of the three groups (165 healthy controls, 90 patients with Crohn’s disease and 230 colorectal cancer patients). The thematic clusters that constitute the personality correlates of colorectal cancer were found to be tendencies for compulsiveness, control of oneself and especially of anger, self effacement, pleasing others, self assertion, distancing oneself from others, keeping regulations, and performing to perfection all ones obligations. The three major foci of these tendencies are perfect duty performance, and two contradictory pairs: self effacement versus self assertion, and closeness to others versus distancing from others. The clusters and the contrasts constitute potentially sources of tension. It is suggested that the identified personality correlates be considered as psychological risk factors for colorectal cancer.     

How Much Public Health in Public Health Nursing Practice?

Public health nursing (PHN) practice is defined by an emphasis on population health issues rather than individually focused clinical interventions, but the actual scope and focus of PHN practice have not been well documented. The purpose of this survey was to investigate the practice activities, priorities, and education of public health nurses in California. Public health nurses in five counties were surveyed about interventions targeted at individual-family, community, and system levels. Summary scales (range: 1-4) were created to measure self-rated PHN activity, importance, and education at each level. Staff were most likely to perform individual-family level interventions (mean score, m=2.55), followed by community (m=1.86) and system-level interventions (m=1.46). Managers rated individual-family level interventions as most important (m=2.91) and community-level interventions (m=2.42) as more important than those at the system level (m=1.99). Individually focused case management was the most frequently performed and highly valued intervention. Staff and manager-directors deemed individual-family interventions as the area in which public health nurses were best educated, followed by community and then system interventions. Results indicate that the population health focus of public health nursing is not reflected in the practice activities, management priorities, or educational preparation of public health nurses.     

Maternal outcomes of cesarean sections: Do generalists’ patients have different outcomes than specialists’ patients?

OBJECTIVE

To compare maternal outcomes of cesarean sections performed by GPs with the outcomes of those performed by specialists.

DESIGN

Retrospective, comorbidity-adjusted study.

SETTING

Mostly small isolated rural hospitals in Ontario, British Columbia, Alberta, and Saskatchewan compared with all levels of specialist obstetric programs offered in Canada.

PARTICIPANTS

Fifteen GPs with less than 1 year of surgical training who performed cesarean sections.

METHOD

Using data from the Canadian Institute for Health Information’s Discharge Abstracts Database for the years 1990 to 2001, we matched each of 1448 cesarean section cases managed by these GPs to 3 cases managed by specialists and looked for comorbidity. In total, we analyzed the outcomes of 5792 cesarean sections.

MAIN OUTCOME MEASURES

Composites of major morbidity possibly attributable to surgery:death, sepsis, cardiac arrest, shock, hypotension, ileus or bowel obstruction,major puerperal infection, septic or fat embolism, postpartum hemorrhage requiring hysterectomy, need for cardiopulmonary resuscitation, or another operation; and all major morbidity: major surgical morbidity, acute coronary syndrome, endocarditis, pulmonary edema, cerebrovascular disorder, pneumothorax, respiratory failure, amniotic fluid embolism, complications of anesthesia, deep vein thrombosis, pulmonary embolism, acute renal failure, and need for mechanical ventilation.

RESULTS

The rate of all major morbidity was higher among GPs’ patients than among specialists’ patients (3.1% vs 1.9%, odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 to2.3, P = .009) as was the rate of major surgical morbidity (2.5% vs 1.6%, OR 1.6, 95% CI 1.1 to 2.4, P = .024). Differences in major morbidity variables were not significant if major postpartum infection was excluded (all major morbidity 1.5% vs 1.1%, major surgical morbidity 1.0% vs 0.8%). Secondary outcomes included rate of transfer to acute care institutions (6.0% vs 1.5%, OR 4.6, 95% CI 3.6 to 6.5, P < .001), mean length of hospital stay (5.2 vs 4.9 days, P= .006), need for blood transfusion (5.9% vs 7.0%, OR 0.76, 95% CI 0.5 to 1.1, P = .11) and frequency of surgical error (0.8% vs 0.7%, OR 1.1, 95% CI 0.6 to 2.3, P = .72).

CONCLUSION

Although major morbidity was higher among GPs’ patients, differences were entirely attributable to the rate of postpartum infection. Infection rates in both groups were far below expected rates. The observation that blood transfusion and surgical error rates were similar suggests that surgical technique was not the cause of differences between groups. We conclude that these GPs with a mean of 4 months’ training subsequently performed cesarean sections with an acceptable degree of safety compared with specialists.     

Apoa5 Q139X truncation predisposes to late-onset hyperchylomicronemia due to lipoprotein lipase impairment

While type 1 hyperlipidemia is associated with lipoprotein lipase or apoCII deficiencies, the etiology of type 5 hyperlipidemia remains largely unknown. We explored a new candidate gene, APOA5, for possible causative mutations in a pedigree of late-onset, vertically transmitted hyperchylomicronemia. A heterozygous Q139X mutation in APOA5 was present in both the proband and his affected son but was absent in 200 controls. It was subsequently found in 2 of 140 cases of hyperchylomicronemia. Haplotype analysis suggested the new Q139X as a founder mutation. Family studies showed that 5 of 9 total Q139X carriers had hyperchylomicronemia, 1 patient being homozygote. Severe hypertriglyceridemia in 8 heterozygotes was strictly associated with the presence on the second allele of 1 of 2 previously described triglyceride-raising minor APOA5 haplotypes. Furthermore, ultracentrifugation fraction analysis indicated in carriers an altered association of Apoa5 truncated and WT proteins to lipoproteins, whereas in normal plasma, Apoa5 associated with VLDL and HDL/LDL fractions. APOB100 kinetic studies in 3 severely dyslipidemic patients with Q139X revealed a major impairment of VLDL catabolism. Lipoprotein lipase activity and mass were dramatically reduced in dyslipidemic carriers, leading to severe lipolysis defect. Our observations strongly support in humans a role for APOA5 in lipolysis regulation and in familial hyperchylomicronemia.     

Efficacy of ampicillin combined with ceftriaxone and gentamicin in the treatment of experimental endocarditis due to Enterococcus faecalis with no high-level resistance to aminoglycosides

OBJECTIVE: This study tests the usefulness of ceftriaxone combined with ampicillin as an alternative to ampicillin plus gentamicin for the treatment of experimental endocarditis due to Enterococcus faecalis without high-level resistance to aminoglycosides. It also determines whether adding ceftriaxone to ampicillin and gentamicin increases the effectiveness against experimental enterococcal endocarditis resulting from E. faecalis. METHODS: Animals with catheter-induced endocarditis were infected intravenously with 108 cfu of the EF91 strain of E. faecalis and were treated for 3 days with ampicillin 2 g every 4 h administered as 'human-like' (H-L) pharmacokinetics, plus gentamicin 1 mg/kg every 8 h H-L, or ceftriaxone 2 g every 12 h H-L alone or combined with gentamicin 6 mg/kg every 24 h administered subcutaneously. RESULTS: The results of therapy for experimental endocarditis resulting from EF91 showed that the combination of ampicillin plus ceftriaxone was as effective as ampicillin plus gentamicin. The triple combination did not improve on the overall efficacies of the two-drug combinations. CONCLUSIONS: Because of its lower nephrotoxicity, ampicillin plus ceftriaxone may be a useful alternative therapy for E. faecalis endocarditis in selected patients.     

Humoral mechanisms in the pathogenesis of postprandial hypotension in patients with essential hypertension

OBJECTIVE: To examine the role of catecholamines and insulin in the development of postprandial hypotension (PPH) in hypertensive patients. PATIENTS: Forty patients with essential hypertension (25 men, 15 women, mean age 68 +/- 2 years). METHOD: Blood pressure and heart rate were recorded in all subjects immediately after a 1903 kJ test meal and at 15-minute intervals for up to 1 hour after the meal. At these time points, circulating levels of norepinephrine, epinephrine, dopamine and C-peptide were measured. RESULTS: Twenty-three patients (58%) had PPH. By 15 minutes norepinephrine had significantly increased in PPH-negative subjects while it rose more slowly in PPH-positive patients and peaked by 45 minutes after the meal. Norepinephrine levels in 15 minutes were lower in PPH-positive than in PPH-negative ones (159.8 +/- 9.7 vs. 212.3 +/- 21.1 pg/ml, p = 0.01). Epinephrine levels rose only in PPH-negative subjects and did not differ significantly at the different time points. However, the area under curve analysis showed significantly lower epinephrine values in PPH-positive subjects (2903 + 247 pg.min.ml-1 vs. 3710 + 284 pg.min.ml-1, p = 0.03). Dopamine increased in both groups, although it was lower in subjects with PPH during the entire study (15 minutes: 68.6 +/- 3.7 vs. 93.7 +/- 11.7 pg/ml, p = 0.02; 30 minutes: 68.8 +/- 3.7 vs. 86.1 +/- 7.7 pg/ml, p = 0.03; 45 minutes: 60.5 +/- 4.2 vs. 79.7 +/- 5.2 pg/ml, p = 0.006). The postprandial C-peptide response did not differ between patients with PPH and those without PPH. CONCLUSIONS: In patients with essential hypertension, a marked decline in postprandial systolic blood pressure is associated with lower postprandial levels of norepinephrine, epinephrine and dopamine as compared to subjects without postprandial hypotension. This indicates that impaired sympatho-adrenal activation after ingestion of a meal may contribute to the development of PPH. Insulin appears not to be involved in the pathogenesis of postprandial hypotension.     

Aggression on inpatient units: Clinical characteristics and consequences

Aggression and violence are widespread in UK Mental Health Trusts, and are accompanied by negative psychological and physiological consequences for both staff and other patients. Patients who are younger, male, and have a history of substance use and psychosis diagnoses are more likely to display aggression; however, patient factors are not solely responsible for violence, and there are complex circumstances that lead to aggression. Indeed, patient–staff interactions lead to a sizeable portion of aggression and violence on inpatient units, thus they cannot be viewed without considering other forms of conflict and containment that occur before, during, and after the aggressive incident. For this reason, we examined sequences of aggressive incidents in conjunction with other conflict and containment methods used to explore whether there were particular profiles to aggressive incidents. In the present study, 522 adult psychiatric inpatients from 84 acute wards were recruited, and there were 1422 incidents of aggression (verbal, physical against objects, and physical). Cluster analysis revealed that aggressive incident sequences could be classified into four separate groups: solo aggression, aggression–rule breaking, aggression–medication, and aggression–containment. Contrary to our expectations, we did not find physical aggression dominant in the aggression–containment cluster, and while verbal aggression occurred primarily in solo aggression, physical aggression also occurred here. This indicates that the management of aggression is variable, and although some patient factors are linked with different clusters, these do not entirely explain the variation.