Maximizing the quality of the physician-patient encounter.
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Communication↗
Biomedical subjects
L M Sullivan
Publications and source records attributed to L M Sullivan.
The care of older persons with diabetes mellitus: families and primary care physicians.
OBJECTIVES: To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation. DESIGN: A longitudinal observational study, with baseline data being reported herein. SETTING: Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana. PARTICIPANTS: Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics. MAIN OUTCOME MEASUREMENTS: The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters. RESULTS: The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05). CONCLUSION: The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases.
Activities of Daily Living↗
Radiation dose and image quality of double-loaded cassettes.
Some U.S. hospitals double-load x-ray cassettes for certain procedures. Loading two films in the same cassette for portable emergency room (ER), intensive care unit (ICU), or operating room radiographs provides both the referring clinicians and the radiologists with immediate images. Our study demonstrates a cost increase of 15%, an increase in air kerma for a chest x ray from 0.12 to 0.35 mGy (12-35 mrad), slight differences in optical density, image contrast, and spatial resolution under double-loading conditions. Our study shows that double loading cassettes may improve patient care by economically expediting the communication of radiographic findings. The decision to double load portable ICU or ER cassettes must be based on a balance of factors.
Adolescent↗
Interleukin 4 retards dissemination of a human B-cell lymphoma in severe combined immunodeficient mice.
We have examined the antitumor activity of murine interleukin 4 (IL-4) on development of a human B-cell lymphoma (Daudi) in severe combined immunodeficient (SCID) mice. The progression of Daudi cells in SCID mice was followed by histological staining and by flow cytometric analysis of CD20+ cells in spleen, liver, bone marrow, and kidneys. By day 35, CD20+ Daudi cells populate the majority of space in the bone marrow and kidney in vehicle-treated mice. Mice receiving i.p. injections of IL-4, commencing 7 or 14 days after tumor inoculation, exhibit a reduction in tumor burden as well as a decrease in CD20+ cells in both compartments. The antitumor activity of IL-4 does not appear to be due to an antiproliferative effect, since the cytokine does not alter the growth of Daudi cells in vitro, nor does it correlate with any marked cellular infiltrate in tumor-bearing tissues. In 51Cr-release assays, we observed that splenocytes from IL-4-treated mice were capable of lysing YAC-1 but not Daudi cell targets. Our findings demonstrate that: (a) systemic administration of IL-4 retards dissemination of a human B-cell lymphoma in SCID mice; and (b) antitumor activity elicited by IL-4 may not involve a direct effect on proliferation of Daudi cells or on the induction of cytolytic activity.
Animals↗
The effect of GM-CSF and G-CSF on human neutrophil function.
A direct comparison of GM-CSF and G-CSF in a panel of in vitro neutrophil-function assays was performed to investigate any differences in activity profiles. In our modified chemotactic assay, GM-CSF rapidly increased the migratory capacity of polymorphonuclear cells (PMNs) to move toward fMLP and LTB4. In contrast, G-CSF only stimulated PMN migration towards fMLP. GM-CSF, but not G-CSF, increased PMN cytotoxic killing of C. albicans blastospores. The expression of PMN surface antigens associated with Fc- and complement-mediated cell-binding (Fc gamma R1, CR-1 and CR-3), and adhesion signalling (ICAM-1), was increased after the exposure of GM-CSF, but not to G-CSF. In contrast these CSFs demonstrated relative equipotency in their ability to induce PMN anti-bacterial phagocytosis, and to restore the Staphylococcus aureus killing capacity of dexamethasone-suppressed neutrophils. The phagocytic activity of PMNs for opsonized yeast, as well as hexose-monophosphate shunt activity, was equivalent following GM-CSF or G-CSF treatment. We discuss the significance of the difference in activity profiles in this article.
Antigens, Surface↗
The effects of colony stimulating factors on human monocyte cell function.
We used a panel of functional assays to compare directly the pattern and potency of GM-CSF and M-CSF on monocyte activity associated with cell-mediated immune defense. GM-CSF and M-CSF were found to be equivalent both in their capacity to stimulate human monocyte functions in vitro and in their pattern of monocyte activation. The two CSFs were effective in inducing monocyte chemotaxis towards either fMLP or LTB4 at equivalent concentrations across a panel of donors. GM-CSF and M-CSF demonstrated equipotency in the induction of monocyte phagocytosis of heat-killed baker's yeast and in the regulation of the hexose-monophosphate shunt (NBT reduction). Both were also found to be equivalent in preventing steroid (dexamethasone)-induced suppression of monocyte anti-bacterial (Candida albicans) and anti-fungal (Staphylococcus aureus) phagocytic capacities. GM-CSF was somewhat more effective than M-CSF in stimulating monocyte C. albicans killing at a lower E:T ratio.
Cell Count↗
IL-4 induces neutrophilic maturation of HL-60 cells and activation of human peripheral blood neutrophils.
IL-4 is a T-helper cell derived cytokine that has effects on myelomonocytic cell maturation and activation. We have studied the effect of IL-4 on neutrophilic maturation using the cell line HL-60 and found that it has a profound effect on the maturation and activation of the cell line. The treatment of HL-60 cells with recombinant hu IL-4 (0.15 to 15.0 ng/ml) induced a shift in the percentage of HL-60 cells staining positive for chloroacetate esterase enzyme activity (indicating commitment to the neutrophilic lineage). IL-4 increased surface expression of the neutrophil-lineage antigen WEM G11, the complement receptors CR3 (CD11b) and CR1 (CD35), but not for the monocyte differentiation antigen CD14. IL-4 treated HL-60 cells demonstrated enhanced Fc- and complement-mediated phagocytic capacity and increased hexose-monophosphate shunt activity. In addition, IL-4 was capable of sustaining the neutrophil maturation of HL-60 cells that had been pre-treated for 24 h with DMSO. To investigate the effect of IL-4 on the mature neutrophil, we studied freshly isolated and rested human peripheral blood neutrophils. In the absence of other stimuli, neutrophils were induced by IL-4 to have significantly elevated phagocytic responses. The response was specific since treatment with anti-human IL-4 abolished phagocytic stimulation. Finally, IL-4 treatment also stimulated resting neutrophils to migrate toward zymosan-activated serum (ZAS) and human IL-5. The results demonstrate that IL-4 is a potent maturation factor for myelocytes to become neutrophils and that IL-4 can stimulate resting mature neutrophils.
Antigens, CD↗
A comparison of various methods of collecting self-reported health outcomes data among low-income and minority patients.
In a randomized trial of different data collection methods, we challenged the untested assumption that reliable data cannot be obtained from lower-income and/or minority patients by self-administered questionnaires. We tested three methods of data collection among a sample of lower-income and minority patients (n = 697) in Indianapolis at a site for the Type II Diabetes Patient Outcomes Research Team. The study included a questionnaire literacy screening instrument to assess patients' functional literacy. Based on their functional literacy, patients were randomized to one of three methods of data collection: mail-out/mail-back, hand-out/assisted, or the in-home interview. We constructed a tiered system for reassigning nonresponders to alternative methods of data collection, using the in-home interview as the fall-back strategy. We compared the response rates, item completion rates, and internal consistency reliabilities of self-reported health status measures between patients with and without literacy limitations and across the three methods of data collection. Patients with and without literacy limitations, across methods of data collection, provided high-quality data, as evidenced by high item completion rates (> 84%) and high reliability assessments (internal consistency reliability coefficients > .80) for each health status measure. As part of the tiered study design, nonresponders randomized to either the mail-out/mail-back or the hand-out/assisted method were interviewed. These patients were significantly older, had significantly lower education and income levels, and had significantly poorer self-reported visual function as compared with those who responded to the originally assigned method. We conclude that expensive, labor-intensive data collection methods, such as in-home interviews, are not necessary for many low-income, minority patients to generate high-quality, reliable health status data. Using appropriate screening instruments, those patient subgroups needing special help can be screening instruments, those patient subgroups needing special help can be identified and targeted for more expensive data collection methods. This tiered approach has policy implications for the cost, feasibility, and quality of data collection in health outcomes research.
Aged↗
Determination of hprt mutant frequencies in T-lymphocytes from a healthy pediatric population: statistical comparison between newborn, children and adult mutant frequencies, cloning efficiency and age.
Somatic cell mutant frequencies at the hprt locus of the X-chromosome were measured with the T-lymphocyte cloning assay in a healthy pediatric population. Assays were performed on 49 subjects (29 males and 20 females) ranging in age from 0.08 to 15.2 years. A statistical analysis of the thioguanine-resistant (TGr) mutant frequency (MF), unselected cloning efficiency (CE) and age was performed using data obtained in this study and those previously obtained in our laboratory on 66 newborn umbilical cord blood samples and 230 adult blood samples. For statistical comparisons pediatric subjects were divided into 4 groups. Group I included cord blood samples (age 0 years); Group II were subjects between 0 and 5 years; Group III were between 6 and 11 years and Group IV were between 12 and 17 years. The ln MF of Groups I and II were significantly lower than Groups III and IV (p < 0.05). The mean ln MF for each of Groups I-IV was significantly lower than the adult value. The cloning efficiency for Group I was significantly lower than that for Groups II-IV and adults. The relationships among the ln MF, unselected CE and age were expressed by the equations: ln (MF) = 0.945 -2.453 CE (p < 0.001) and ln (MF) = 0.114 + 0.063 age (p 0.004). The slope coefficients for unselected CE and age were significantly different from adults (p < 0.05). Regression analysis of combined data from Groups I-IV and adults were performed using both age and unselected CE as well as terms to reflect differences in their relationships with ln MF in adults and children. The results showed that the intercept and the age coefficients differ significantly for children and adults after adjustment for CE and yielded the following equations: ln (MF) = 0.548 -1.676 CE + 0.075 age, (Groups I-IV) and ln (MF) = 2.263 -1.676 CE + 0.014 age (adults). An alternative statistical model using ln (age ), ln (MF) = 0.381 -1.767 CE + 0.673 ln (age + 1), (p < 0.001), describes the rapid increase in MF with age that levels off in late adolescence. These findings demonstrate the changing influence of age on mutant frequency in the pediatric population as compared to the adult populations. These studies also illustrate that the increase in background somatic mutant frequencies at the hprt locus in T-lymphocytes is not linear from birth to adolescence and is significantly different from that seen in the adult population.(ABSTRACT TRUNCATED AT 400 WORDS)
Adolescent↗
Suppression of the allogeneic response by human IL-10: a critical role for suppression of a synergy between IL-2 and TNF-alpha.
The effect of IL-10 on T-cell activation by alloantigens in primary mixed lymphocyte reaction (MLR) was examined. IL-10 strongly suppressed proliferation and cytokine synthesis observed in this reaction. To determine the cytokine synthesis inhibition that was critical for the IL-10 induced suppression of proliferation in MLR, the effect of exogenous cytokines (IL-1 alpha, IL-1 beta, IL-2, IL-4, IL-6, IFN-gamma, or TNF-alpha) on this suppression was examined. None of these cytokines, when used at high concentration, was able to completely restore proliferation in the MLR to the levels observed in the absence of IL-10. However, IL-2 and TNF-alpha, when added alone at high concentration, could partially overcome the IL-10 induced suppression of proliferation in MLR. Moreover, when a combination of IL-2 and TNF-alpha was added at suboptimal doses to IL-10-suppressed MLR, complete restoration of the proliferative response was obtained. The ability of IL-10 to suppress proliferation in MLR was dependent on the type of cells used as stimulators. Thus, IL-10 suppressed proliferation in MLR when allogeneic normal peripheral blood mononuclear cells (PBMC), highly purified monocytes or B cells, were used, but not when B-cell lines were used as stimulators. Investigation of the effect of IL-10 on cytokine synthesis revealed that when B-cell lines were used as stimulators of MLR, IL-10 suppressed IFN-gamma and IL-2 synthesis but was unable to suppress TNF-alpha production. In contrast, CSA, which inhibited proliferation in MLR induced by B-cell lines, also inhibited TNF-alpha. IL-2 and IFN-gamma synthesis. Together these data suggest that the suppression of MLR by IL-10 requires the effective inhibition of both IL-2 and TNF-alpha production to suppress a synergy between these two cytokines.
Antibodies, Monoclonal↗
Stimulation of cytolytic activity by interleukin-10.
Interleukin-10 (IL-10), originally identified as an inhibitor of cytokine and monokine synthesis [e.g., IL-2, interferon-gamma (IFN-gamma), and tumor necrosis factor (TNF-alpha)], modulates a wide range of immunologic activities. In the present study we have examined the induction of non-major histocompatibility complex-restricted cytolytic activity in human peripheral blood mononuclear cells (PBMCs). PBMCs incubated with human IL-10 for 3 days were used as effector cells in cytotoxicity (i.e., 51Cr release) assays against a panel of human tumor cells. In a concentration-dependent manner. IL-10 stimulated or potentiated lytic activity against several human tumor cell lines. Induction of cytolytic activities by IL-10 was neutralized by anti-IL-10 monoclonal antibodies but not by antibodies against IFN-gamma or TNF-alpha. Co-incubation of PB-MCs with IL-10 and IL-2 or IL-10 and IFN-alpha augmented cytolytic activity, in particular at lower effector-to-target ratios. IL-2-induced release of TNF-alpha was dramatically reduced by IL-10; however, the expression of lymphokine-activated killer (LAK) activity was not affected. PBMCs preactivated with IL-10 before addition of IL-2 displayed higher levels of LAK activity. Inhibition of IL-2-driven LAK activity by IL-4 is alleviated by IL-10. Finally, IL-10 is not affected by inhibitors of IL-2, such as IL-4 and transforming growth factor-beta. Potential application of IL-10 to anti-tumor therapies is discussed.
Antibodies, Monoclonal↗
Potential interaction of interleukin-4 with endogenous cytokines in vivo.
We employed alginate-entrapped cells secreting recombinant murine interleukin-4 (IL-4) to study the effect of IL-4 on hematopoietic cells of normal mice. The most dramatic effect was registered in an increase in the neutrophils and to a lesser extent the monocytes. A small increase in the CD4+, CD8+ and B220+ populations was also observed. Serum IgE levels also increased dramatically. All of these increases could be specifically inhibited with anti-IL-4. Antibodies to granulocyte-macrophage colony-stimulating factor, IL-3 and IL-5 could also inhibit some IL-4-mediated actions suggesting an interplay between these cytokines in vivo.
Alginates↗
Human IL-10 reduces the number of IL-4-induced IgE B cells in cultures of atopic mononuclear cells.
We investigated the effect of recombinant human IL-10 on IL-4- and antigen-driven human peripheral blood mononuclear cell cultures derived from atopic donors. These cultures were phenotyped for the percentage of B cell (CD20 HLA-DR) population by flow cytometry and for intracellular IgE using epifluorescence microscopy. The addition of IL-4 (100 U/ml) to these cultures resulted in an increase in the percentage of IgE B cells. However, the percentage of IgE B cells in cultures coincubated with IL-10 (2 or 20 ng/ml) and IL-4 was reduced to the level of medium control. Peripheral-blood mononuclear (PBMN) cultures driven with dust mite allergen demonstrated a significant increase in cellular proliferation, as measured by 3[H] thymidine uptake, and in the percentage of IgE B cells. The coaddition of IL-10 (2 or 20 ng/ml) to these cultures significantly inhibited both proliferation and the mean percentage of IgE B cells. The inhibitory effect of IL-10 on IgE B cell percentages in both the IL-4- and the allergen-driven cultures, and on allergen-driven proliferation, was dependent upon the presence of monocytes. Interestingly, the inhibitory effect of IL-10 on allergen-driven proliferation in the atopic PBMN cultures was reversible by the coaddition of exogenous IFN gamma (1 ng/ml) and IL-2 (2 U/ml). The addition of IL-2 (2 U/ml) partially reversed IL-10-inhibited allergen-driven proliferation while alone IFN gamma had no effect (1 ng/ml). In fact, the addition of IFN gamma (1 ng/ml) in the absence of either IL-10 or IL-2 (2 U/ml) partially inhibited allergen-driven proliferation.(ABSTRACT TRUNCATED AT 250 WORDS)
B-Lymphocytes↗
Factors influencing pain management: a nursing perspective.
Pain management is an integral part of the daily practice of PACU nurses. Despite increased understanding of pain and advanced pain-management methods, the experience of moderate to severe pain continues for many patients. This article reviews factors that influence nurses' pain management. These factors include the difficulty involved with measuring pain and the characteristics and educational preparation of the nurse. Common misconceptions and corrections to these misconceptions are summarized, and implications for practice are given. Suggestions for continuing education, including resensitizing nurses to pain management, increasing nurses' knowledge base, and examining personal factors and inherent beliefs, are given.
Attitude of Health Personnel↗
Measurement of HPRT mutant frequencies in T-lymphocytes from healthy human populations.
Somatic cell mutant frequencies at the hprt locus of the X-chromosome were measured with the T-lymphocyte cloning technique in healthy human populations. A statistical analysis was performed of assays from 232 individuals (77 males and 155 females) ranging in age from 19 to 80 years. Data from 4 donor groups were compiled: (a) 132 participants in a study of identical and fraternal twins; (b) 17 health care workers studied as part of an assessment of the risks of handling chemotherapeutic drugs; (c) 62 women with benign breast masses; and (d) 21 normal laboratory and office personnel. The relationship between age and mutant frequency (MF) was expressed by the equation: ln MF = 1.46 + 0.018 age (P < 0.001). Thus, MF increased by about 2% per year. Increases in cloning efficiency (CE) reduced the MF, as shown in the equation: ln MF = 2.91 - 1.32 CE (P < 0.001). CE was significantly related to age (CE = 0.47 - 0.002 age, P = 0.038), and the interdependent relationship between MF, age and CE expressed by the equation: ln MF = 1.99 - 1.13 CE + 0.016 age was significant at the P < 0.001 level. There was no statistically significant effect of donor gender or smoking history on MF in our population, but CE was significantly lower in males (P < 0.001). These findings confirm the importance of age and CE as factors which influence the thioguanine-resistant MF in circulating T-lymphocytes from normal adults.
Adult↗
High-risk profiles for nursing home admission.
A statewide probability sample of 1,625 Massachusetts elderly was studied prospectively over a decade to identify risk profiles for long-term care (LTC) institutionalization. Previous admission to a LTC institution, age, basic ADL disability, and restricted outside mobility were the strongest individual predictors of institutionalization. Examining profiles of risk factors dramatically increased the ability to predict 10-year risk of admission.
Aged↗
Robustness of the t test applied to data distorted from normality by floor effects.
In calculus, plaque, and gingivitis trials, measures are taken on subjects both prior to the use of an active treatment and after its use. When the trial is short-term, or when a cleaning of the mouth takes place after the baseline measurement, distributions of such measures (e.g., the Volpe-Manhold score or the Löe and Silness scale) are approximately normally distributed above zero but also can have a proportion of subjects who attain scores of zero. When the effects of an active treatment are compared with those of a control, the two-independent-sample t test can be applied to outcome scores or to differences between the baseline and outcome scores. Robustness of these t tests, in the presence of distributions "distorted" from normality as described, was investigated by computer simulation. In general, both t tests produced actual significance levels which were close to nominal significance levels, even in the presence of small samples and distributions in which as many as 50% of the subjects attained scores of zero.
Clinical Trials as Topic↗
Response comparability of family and staff proxies for nursing home residents.
Response comparability on a wide variety of factual and judgmental information regarding nursing home residents was assessed for two proxy groups: family and staff. Family proxies had the most information. Family and staff proxies are not interchangeable. A general lack of response comparability suggests that proxies for nursing home residents should be selected in relation to the type of data needed and the time period of interest.
Activities of Daily Living↗