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Biomedical subjects

M Stevens

Publications and source records attributed to M Stevens.

At least 37 records · Page 2Linked to original sources
PubMed2001

Preventing falls in older people: impact of an intervention to reduce environmental hazards in the home.

OBJECTIVES: To evaluate the impact of an intervention to reduce fall hazards in the homes of older people. DESIGN: The intervention was administered to the 570 subjects in the experimental arm of a randomized controlled trial, with follow-up of subjects for 1 year. SETTING: Community-based seniors living in Perth, Australia. PARTICIPANTS: People age 70 and older. INTERVENTION: Registered nurses delivered the intervention. It consisted of a home hazard assessment, an educational strategy on general fall hazard reduction and ways to reduce identified home hazards, and the free installation of safety devices: grab rails, nonslip stripping on steps, and double-sided tape for floor rugs and mats. All intervention subjects received the home hazard assessment, and 96% received the educational strategy. Grab rails were installed in 77% of homes, rugs were stabilized in 8%, and nonslip step stripping was installed in 36%. MEASUREMENTS: Hazard prevalence was assessed at baseline in all homes and 11 months later in a random sample of 51 homes. Action taken in response to the intervention was assessed by a self-completed postal questionnaire completed 11 months after the intervention. RESULTS: All homes had at least one fall hazard. The most prevalent were floor rugs and mats (mean of 14 per home), stepovers (Stepovers are structural changes to the height of the floor that were designed to be stepped over rather than stepped upon, for example, the lip of a shower or a bath side.) (mean of seven per home), steps (mean of four per home), and trailing cords (mean of two per home). The intervention was associated with a small but significant reduction in four of the five most prevalent hazards. The mean number of unsafe rugs and mats was reduced by 1.57 per house (95% confidence interval (CI) = 0.91-2.24); the mean number of unsafe steps was reduced by 0.61 per house (95% CI = 0.28-0.94); the mean number of rooms with trailing cords was reduced by 0.43 per house (95% CI = 0.10-0.76); and the mean number of unsafe chairs was reduced by 0.10 per house (95% CI = 0.02-0.18). Safety devices were installed in 81.9% of homes. Advice on modifying specific hazards identified on the home hazard assessment resulted in over 50% of subjects removing hazards of floor rugs and mats, trailing cords, and obstacles. The general education message prompted less activity to reduce these hazards than did the advice on identified hazards. CONCLUSIONS: Fall hazards are ubiquitous in the homes of older people. The intervention resulted in a small reduction in the mean number of hazards per house, with many study subjects taking action but removing only a few hazards. The impact of the intervention in achieving self-reported action to reduce hazards was high.

Accidental Falls↗
PubMed2001

Preventing falls in older people: outcome evaluation of a randomized controlled trial.

OBJECTIVES: To evaluate the outcome of an intervention to reduce hazards in the home on the rate of falls in seniors. DESIGN: Randomized controlled trial, with follow-up of subjects for 1 year. SETTING: Community-based study in Perth, Western Australia. PARTICIPANTS: People age 70 and older. INTERVENTION: One thousand eight hundred seventy-nine subjects were recruited and randomly allocated by household to the intervention and control groups in the ratio 1:2. Because of early withdrawals, 1,737 subjects commenced the study. All members of both groups received a single home visit from a research nurse. Intervention subjects (n = 570) were offered a home hazard assessment, information on hazard reduction, and the installation of safety devices, whereas control subjects (n = 1,167) received no safety devices or information on home hazard reduction. MEASUREMENTS: Both groups recorded falls on a daily calendar. Reported falls were confirmed by a semistructured telephone interview and were assigned to one of three overlapping categories: all falls, falls inside the home, and falls involving environmental hazards in the home. Analysis was by multivariate modelling of rate ratios and odds ratios for falls, corrected for household clustering, using Poisson regression and logistic regression with robust variance estimation. RESULTS: Overall, 86% of study subjects completed the 1 year of follow-up. The intervention was not associated with any significant reduction in falls or fall-related injuries. There was no significant reduction in the intervention group in the incidence rate of falls involving environmental hazards inside the home (adjusted rate ratio, 1.11; 95% CI = 0.82-1.50), or the proportion of the intervention group who fell because of hazards inside the home (adjusted odds ratio, 0.97; 95% CI = 0.74-1.28). No reduction was seen in the rate of all falls (adjusted rate ratio, 1.02; 95% CI = 0.83-1.27) or the rate of falls inside the home (adjusted rate ratio, 1.17; 95% CI = 0.85-1.60). There was no significant reduction in the rate of injurious falls in intervention subjects (adjusted rate ratio, 0.92; 95% CI = 0.73-1.14). CONCLUSIONS: The intervention failed to achieve a reduction in the occurrence of falls. This was most likely because the intervention strategies had a limited effect on the number of hazards in the homes of intervention subjects. The study provides evidence that a one-time intervention program of education, hazard assessment, and home modification to reduce fall hazards in the homes of healthy older people is not an effective strategy for the prevention of falls in seniors.

Accidental Falls↗
PubMed2001

Complications of an intra-arterial injection from an inferior alveolar nerve block.

BACKGROUND: Unintended intravascular injections from inferior alveolar nerve blocks result in frustrating complications, both systemically and locally. It is imperative that the dentist diagnose the complication and treat it appropriately. Sometimes, several reactions occur simultaneously. CASE DESCRIPTION: The authors present a case report that illustrates some of the many complications resulting from inferior alveolar nerve block injections. In this case, complications developed from intra-arterial injection of local anesthetic. The facial skin, intraoral structures and eye were affected. Within 60 minutes of the injection, all structures returned to their normal state. Prompt diagnosis and reassurance usually calm the patient. CLINICAL IMPLICATIONS: Even when clinicians use the utmost care, by aspirating before the injection and noting anatomical landmarks, intra-arterial injections can occur during inferior alveolar nerve blocks. Fortunately, permanent damage to nerves, facial and oral tissues, and eyes is rare. The practitioner should diagnose and treat the problems appropriately to avoid any irreversible complications.

Adult↗
PubMed2001

Recombinant human bone morphogenetic protein-2 accelerates healing in a rabbit ulnar osteotomy model.

BACKGROUND: Approximately 5% to 20% of fractures have delayed or impaired healing. Therefore, it is desirable to develop new therapies to enhance fracture-healing that can be used in conjunction with traditional treatment methods. The purpose of this study was to evaluate the ability of a single application of recombinant human bone morphogenetic protein-2 to accelerate fracture-healing in a rabbit ulnar osteotomy that heals spontaneously. METHODS: Bilateral mid-ulnar osteotomies (approximately 0.5 to 1.0 mm wide) were created in seventy-two skeletally mature male rabbits. The limbs were assigned to one of three groups: those treated with an absorbable collagen sponge containing recombinant human bone morphogenetic protein-2, those treated with an absorbable collagen sponge containing buffer, and those left untreated. In the first two groups, an 8 20-mm strip of absorbable collagen sponge containing either 40 g of recombinant human bone morphogenetic protein-2 or buffer only was wrapped around the osteotomy site. The rabbits were killed at two, three, four, or six weeks after surgery. In addition, twenty-four age-matched rabbits were used to provide data on the properties of intact limbs. The retention of recombinant human bone morphogenetic protein-2 at the osteotomy site was determined with scintigraphic imaging of (125)I-labeled recombinant human bone morphogenetic protein-2. After the rabbits were killed, the limbs were scanned with peripheral quantitative computed tomography to assess the area and mineral content of the mineralized callus. The limbs were then tested to failure in torsion, and undecalcified specimens were evaluated histologically. RESULTS: Gamma scintigraphy of (125)I-recombinant human bone morphogenetic protein-2 showed that 73% +/- 6% (mean and standard deviation) of the administered dose was initially retained at the fracture site. Approximately 37% +/- 10% of the initial dose remained at the site one week after surgery, and 8% +/- 7% remained after two weeks. The mineralized callus area was similar in all groups at two weeks, but it was 20% to 60% greater in the ulnae treated with recombinant human bone morphogenetic protein-2 than in either the ulnae treated with buffer or the untreated ulnae at three, four, and six weeks (p < 0.05). Biomechanical properties were similar in all groups at two weeks, but they were at least 80% greater in the ulnae treated with recombinant human bone morphogenetic protein-2 at three and four weeks than in either the ulnae treated with buffer (p < 0.005) or the untreated ulnae (p < 0.01). By four weeks, the biomechanical properties of the ulnae treated with recombinant human bone morphogenetic protein-2 were equivalent to those of the intact ulnae, whereas the biomechanical properties of both the ulnae treated with buffer and the untreated ulnae had reached only approximately 45% of those of the intact ulnae. At six weeks, the biomechanical properties were similar in all groups and were equivalent to those of the intact ulnae. The callus geometry and biomechanical properties of the ulnae treated with buffer were equivalent to those of the untreated ulnae at all time-points. CONCLUSIONS AND CLINICAL RELEVANCE: These findings indicate that treatment with an absorbable collagen sponge containing recombinant human bone morphogenetic protein-2 enhances healing of a long-bone osteotomy that heals spontaneously. Specifically, osteotomies treated with recombinant human bone morphogenetic protein-2 healed 33% faster than osteotomies left untreated. The results of this study provide a rationale for testing the ability of recombinant human bone morphogenetic protein-2 to accelerate healing in patients with fractures requiring open surgical management.

Animals↗
PubMed2000

Prospective validation of renal function-based carboplatin dosing in children with cancer: A United Kingdom Children's Cancer Study Group Trial.

PURPOSE: Carboplatin dosing in adults with cancer is based on renal function. The purpose of the current study was to validate a previously developed pediatric carboplatin-dosing formula. PATIENTS AND METHODS: Thirty-eight pediatric patients were randomized to receive a carboplatin dose calculated according to surface area or a renal function-based dosing formula. On the next course of therapy, the alternative dosing method was used for each patient. Carboplatin pharmacokinetics (based on free plasma platinum concentrations) were measured after both courses. RESULTS: The mean observed areas under the carboplatin concentration-versus-time curve (AUCs) after renal function- and surface area-based dosing were 98% and 95% of the target AUCs, respectively. The variation in the observed AUC was significantly less after renal function-based dosing (F test, P =.02), such that 74% of courses had an observed AUC within +/- 20% of the target value, versus 49% for courses after dosing according to surface area. Only one of 22 courses at the center with the most experience with renal function-based dosing was associated with an AUC outside +/- 20% of the target value, versus nine of 22 courses after surface area-based dosing in the same center. There was a relationship (r(2) =.71) between carboplatin AUC and thrombocytopenia in 10 neuroblastoma patients treated with a combination of carboplatin, vincristine, etoposide, and cyclophosphamide. CONCLUSION: Renal function-based carboplatin dosing in children results in more consistent drug exposure than surface area-based drug administration.

Adolescent↗
PubMed2000

Role of insulin receptor substrate-2 in interleukin-9-dependent proliferation.

Interleukin-9 (IL-9) stimulation results in JAK, STAT and IRS1/2 phosphorylation. The role of IRS adaptor proteins in IL-9 signaling is not clear. We show that IL-9 induces IRS2 phosphorylation and association with phosphatidylinositol-3 kinase (PI 3-K) p85 subunit in TS1 cells and BaF/9R cells, which proliferate upon IL-9 stimulation. We observed a PI 3-K-dependent phosphorylation of protein kinase B (PKB) in TS1 cells, but not in BaF/9R, nor in other IL-9-dependent cell lines. Finally, 32D cells that were transfected with the IL-9 receptor but lack IRS expression survived in the presence of IL-9. Ectopic IRS1 expression allowed for IL-9-induced proliferation, in the absence of significant PKB phosphorylation.

Animals↗
PubMed2000

A comparison of stavudine plus lamivudine versus zidovudine plus lamivudine in combination with indinavir in antiretroviral naive individuals with HIV infection: selection of thymidine analog regimen therapy (START I).

BACKGROUND: No clinical trial results directly comparing two nucleoside analog pairs in a drug regimen for HIV that includes a protease inhibitor are available. OBJECTIVE: To compare the safety and efficacy of stavudine (d4T) + lamivudine (3TC) with zidovudine (ZDV) + 3TC, each in combination with indinavir (IDV). DESIGN: Randomized, open-label, multi-center. SETTING: Fifteen HIV clinical research centers. PATIENTS: Two-hundred and four antiretroviral-naive HIV-1-infected-patients with CD4 cell counts > or = 200 x 10(6)/l and HIV-1 RNA > or = 10,000 copies/ml (bDNA assay), modified to 5000 copies/ml. INTERVENTION: d4T 40 mg twice a day, 3TC 150 mg twice a day plus IDV 800 mg every 8 h compared with ZDV 200 mg every 8 h (modified to 300 mg every 12 h) plus 3TC and IDV. MEASUREMENTS: Primary endpoint: plasma HIV-1 RNA < 500 copies/ml. Additional endpoints: HIV-1 RNA < or = 50 copies/ml; change from baseline in HIV-1 RNA and CD4 cell counts; safety and adverse events. RESULTS: For HIV-1 RNA, 62% of patients on d4T + 3TC + IDV and 54% of patients on ZDV + 3TC + IDV had < 500 copies/ml HIV RNA at weeks 40 through 48 [90% confidence interval, -0.204 to 0.036; P= 0.213], with 49% and 47% respectively achieving < or = 50 copies/ml at 48 weeks (90% CI, -0.134 to 0.096; P = 0.834). Median change in CD4 cell counts at 48 weeks was +227 x 10(6)/l and +198 x 10(6)/l for the d4T- and ZDV-containing arms, respectively. The median time-weighted average change from baseline in CD4 cell counts was significantly greater at 48 weeks in the d4T-containing arm (142 x 10(6)/l versus 110 x 10(6)/l; P = 0.033). Serious adverse events were not significantly different between treatment arms, but there were significant differences for frequency of adverse events of all severity with increased nausea and vomiting in the ZDV-containing arm, and increased diarrhea and rash in the d4T-containing arm. CONCLUSIONS: These results support the choice of d4T + 3TC as a nucleoside analog pair in combination with a protease inhibitor in an initial HIV treatment regimen.

Anti-HIV Agents↗
PubMed2000

A comparison of stavudine, didanosine and indinavir with zidovudine, lamivudine and indinavir for the initial treatment of HIV-1 infected individuals: selection of thymidine analog regimen therapy (START II).

OBJECTIVE: Comparison of stavudine (d4T), didanosine (ddI) and indinavir (IDV) with zidovudine (ZDV), lamivudine (3TC) and IDV in HIV-1 infected patients. DESIGN: Randomized, open-label. SETTING: Fourteen HIV Clinical Research Centers. PATIENTS: Two-hundred and five patients with less than 4 weeks antiretroviral treatment, naive to 3TC and protease inhibitors and with CD4 cell counts > or = 200 x 10(6)/l and plasma HIV-1 RNA levels > or = 10,000 copies/ml. INTERVENTIONS: Stavudine 40 mg and ddI 200 mg twice daily plus IDV 800 mg every 8 h compared with ZDV 200 mg every 8 h or 300 mg twice daily, 3TC 150 mg twice daily plus IDV. MAIN OUTCOME MEASURES: The proportion of patients with plasma HIV-1 RNA levels < 500 copies/ml and < or = 50 copies/ml and changes in CD4 cell counts were compared. RESULTS: In an analysis of the primary endpoint, 61% of patients on d4T + ddI + IDV and 45% of patients on ZDV + 3TC + IDV had all HIV-1 RNA values obtained between weeks 40 and 48 < 500 copies/ml [95% confidence interval (CI) for the difference between proportions, 1.7-30.3%; P = 0.038]. In an intent-to-treat analysis, the percentage of all patients randomized with all HIV-1 RNA levels < 500 copies/ml between 40 and 48 weeks were 53% for the d4T + ddI + IDV arm and 41% for the ZDV + 3TC + IDV arm (95% CI, -1.4% to 25.7%; P = 0.068). At 48 weeks 41% and 35% were < or = 50 copies/ml for the stavudine- and ZDV-containing arms respectively (P > 0.2). The median time-weighted average increases in CD4 cells count over 48 weeks were 150 x 10(6)/l cells for the d4T arm and 106 x 10(6)/l cells for the ZDV arm (P= 0.001). The occurrence of serious adverse events was not significantly different between arms. CONCLUSION: The combination of stavudine, ddl and IDV resulted in potent antiretroviral effects over a 48-week period, comparable or superior to zidovudine, 3TC and IDV supporting the use of stavudine, ddI and a protease inhibitor as an initial antiretroviral treatment.

Adolescent↗
PubMed2000

Association between HIV in pregnancy and antiretroviral therapy, including protease inhibitors and low birth weight infants.

OBJECTIVE: To determine the incidence of low birth weight infants born to HIV seropositive women and to demonstrate any effects of antiretroviral therapy on birth weight. METHODS: Retrospective review of all obstetrical medical records from January 1, 1995 through June 30, 1998 to identify HIV seropositive women. We evaluated their antiretroviral therapy, CD4 counts, and birth weights of their newborns. We conducted detailed review of the clinical and laboratory findings for the HIV-infected untreated patients, women who received ZDV antepartum alone, and those who received PIs as part of antiretroviral treatment. RESULTS: The frequency of low birth weight infants was significantly increased in HIV seropositive compared to HIV seronegative parturients. Low birth weight infants were more frequent among HIV infected women with lower CD4 counts but the association was not statistically significant. Women who received no antepartum treatment, antepartum only ZDV, and those treated with PIs had significantly more low birth weight infants than did comparison groups. HIV seropositive women also had high frequencies of several obstetrical risk factors for low birth weight infants. CONCLUSION: The present study showed a significantly increased frequency of low birth weight infants among HIV infected women and especially the subgroups of infected women who received no antepartum treatment, antepartum ZDV only, and those treated with PIs. This association, however, may be related to the presence of many other preterm obstetrical risk factors noted in this study. Increasing numbers of HIV seropositive women are being treated with PIs according to the Centers for Disease Control (CDC) guidelines. If PIs are a cause of low birth weight infants, women taking these drugs may have incremental risk of low birth weight.

Adolescent↗
PubMed2000

Effect of cigarette promotions on smoking uptake among adolescents.

BACKGROUND: The purpose of this study was to evaluate the association between receptivity to cigarette promotions and smoking uptake in a cohort of adolescents. METHODS AND MEASURES: This was a prospective cohort study of 480 4th- to 11th-grade students conducted in three rural Vermont K-12 schools. Cigarette use was determined by self-report at baseline, 12 months (survey 2), and 21 months (survey 3). Proportional odds models were used to evaluate smoking uptake as a function of baseline measures of cigarette use, receptivity to cigarette promotions, and confounding factors, including grade, parental education, peer smoking, and family smoking. Adolescents were receptive to cigarette promotions if they owned or were willing to use a personal item bearing a cigarette brand logo [cigarette promotional item (CPI)]. Smoking status was measured using a 6-point ordinal index that combined experience and attitudes: 0 = never smoker/not susceptible to smoking, 1 = never smoker/susceptible to smoking, 2 = puffer (1 cigarette or less in lifetime), 3 = non-current experimenter (2-99 cigarettes in lifetime/none in past 30 days), 4 = current experimenter, and 5 = smoker (> or =100 cigarettes in lifetime). RESULTS: The 480 students were equally distributed across grade at baseline. Environmental exposure to smoking was high, and 30% were receptive to cigarette promotions at baseline. Higher levels on the smoking index at baseline were associated with higher grade in school, peer smoking, and receptivity to cigarette promotions. One hundred eighty-five students (38.5%) had moved to a higher category on the smoking index by survey 3, of whom 30 had become smokers. Receptivity to cigarette promotions at baseline was significantly associated with higher smoking uptake, with 48.7% of receptive students moving up one or more categories on the smoking index [adjusted proportional odds 1.9 (95% CI 1.3, 2.9)]. Acquisition of receptivity to cigarette promotions was also associated with increased smoking uptake, with those becoming receptive in surveys 2 or 3 having significantly higher odds of progression [3.6 (1.8, 7.0) and 2.9 (1.5, 5.5), respectively] compared with those who did not change. Conversely, those who were receptive at one point but became non-receptive in surveys 2 or 3 had lower odds of progression [0.4 (0.2, 0.9) and 0.5 (0.3, 1.1), respectively]. CONCLUSIONS: This study supports a close linkage between tobacco promotional activities and uptake of smoking among adolescents beyond baseline descriptions of receptivity to cigarette promotions. Over time, the likelihood of smoking uptake is increased when an adolescent acquires a CPI or becomes willing to use one and is decreased when an adolescent who owns a CPI loses it or becomes unwilling to use it. This provides strong evidence that elimination of cigarette promotional campaigns could reduce adolescent smoking.

Adolescent↗
PubMed2000

Groningen active living model (GALM): stimulating physical activity in sedentary older adults; first results.

BACKGROUND: A significant proportion of older adults in The Netherlands does not regularly participate in leisure-time physical activity. The Groningen Active Living Model (GALM) was developed to change this situation for the better. In this article the first results with respect to the validation of the model are presented. METHODS: We obtained cross-sectional data from a sample of 392 potential participants. Scores on the potentially causal variables (self-efficacy, social support, perceived fitness, and enjoyment) and the stages of change give a first indication of the potential validity of the GALM behavioral change model. RESULTS: Seventeen percent of the subjects could be categorized as in the precontemplation stage, 42% in the contemplation/preparation stage, and 39% in the action/maintenance stage. Data with respect to stages of change were missing for 2% of the subjects. Scores on all potentially causal variables rose significantly from the precontemplation to the action/maintenance stage. Discriminant analysis resulted in a canonical correlation of 0.58 between the precontemplation and the contemplation/preparation stages and 0.59 between the contemplation/preparation and action/maintenance stages; respectively, 82.6 and 78.3% of the subjects had been classified correctly. CONCLUSIONS: The results found in this study support our hypothesis, as described in the conceptual theory of the GALM behavioral change model. For a more comprehensive validation of the model's action theory and conceptual theory, follow-up measurements are required.

Aged↗
PubMed2000

Improved detection and differentiation of poleroviruses infecting beet or rape by multiplex RT-PCR.

Three distinct species of virus inducing yellowing of beet, Beet mild yellowing virus (BMYV), Brassica yellows virus (BrYV, synonym BWYV) and Beet chlorosis virus (BChV) have been characterised from the genus Polerovirus. Until recently, no available tools were available to allow accurate and reliable distinction of the three species. Based on previous nucleotide sequence alignments and phylogenetic studies, we show that the use of molecular methods enabled the discrimination of these three beet Polerovirus species, but with differences in efficiency and specificity. Primers CP+ and CP- encompassing ORF-3, which encodes the coat protein, allowed the amplification by RT-PCR of a fragment of 563 bp for all isolates. Molecular methods such as SSCP or RFLP were able to discriminate these fragments by utilizing the differences in sequence. However, SSCP is a highly sensitive technique and was not suitable for the distinction of the Polerovirus species, because all isolates tested displayed a unique pattern. Analysis of the ORF3 RT-PCR products, digested with SmaI, RsaI and AccI restriction enzymes revealed four distinct patterns specific for the three species. However, point mutations can alter the RFLP patterns, making the interpretation of the results difficult. Primers were designed to amplify specifically sequences corresponding to ORF-0 of the three viral species. By using the three new sets of ORF-0 specific primers and CP+/CP- primers in a single multiplex RT-PCR, the detection and discrimination of the three beet Polerovirus species was possible in infected plants. The multiplex RT-PCR method provides a reliable and highly sensitive method to detect and identify viral species and will be of great interest for epidemiological studies of beet poleroviruses.

Brassica↗
PubMed2000

Ineffectiveness of the SUPPORT intervention: review of explanations.

BACKGROUND: The aim of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments -- SUPPORT -- was to improve the care of seriously ill patients by improving decision-making for patients with life-threatening illnesses. Several theories have been proposed to explain why the SUPPORT intervention was unsuccessful at improving outcomes. OBJECTIVE: To review and discuss explanations offered by others regarding why the SUPPORT intervention failed to have a discernible impact on its prespecified outcome measures. DESIGN: A descriptive review of published articles and book chapters, with synthesis of data-based and conceptual insights. METHODS: The Medline, Bioethicsline, and Ethx databases were searched for citations to SUPPORT articles between 1994 and the end of 1998. This search was supplemented by other published materials that had come to the authors' attention. RESULTS: The critiques and explanations regarding the reasons the SUPPORT intervention did not improve outcomes were catalogued and organized into 11 major categories, the first 10 of which are explored in the present study: (1) the inception cohort was biased against an effect of the intervention, (2) the intervention was not implemented as designed, (3) the intervention failed because nurses were too readily ignored, (4) the intervention was too polite, (5) the intervention presented information ineffectively, (6) the intervention did not focus on primary care physicians, (7) the intervention falsely dichotomized do not resuscitate (DNR) decisions, (8) the intervention needed more years on site or an earlier start with each patient, (9) the intervention required more appropriate outcome measures, (10) the intervention was irrelevant because usual care is not seriously flawed, (11) the conceptual model behind SUPPORT was fundamentally flawed in aiming to improve individual, patient-level decision-making as the way to improve seriously ill, hospitalized patients' experiences. CONCLUSIONS: Although some of the critiques were found to raise important concerns, we conclude in each case that the explanation offered is inadequate to explain the failure of the intervention. We urge further reflection on the fundamental assumptions that informed the design of that intervention and refer the reader to a more comprehensive treatment of that issue in the companion paper in this volume.

Communication↗
PubMed2000

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment.

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Decision Making↗
PubMed2000

Diabetic peripheral neuropathy: evidence for apoptosis and associated mitochondrial dysfunction.

We hypothesized that diabetic sensory neuropathy is associated with activation of apoptosis and concomitant mitochondrial dysfunction. Studies were performed in excised intact and acutely dissociated dorsal root ganglion (DRG) neurons from control and streptozotocin-induced diabetic rats with decreased peripheral nerve conduction velocities (NCV). Apoptosis was increased in acutely dissociated DRG neurons from 3- to 6-week-old diabetic rats. Basal mitochondrial membrane potential (deltapsi) was significantly more positive in DRG neurons from diabetic rats. Depolarization with glutamate resulted in significantly more positive deltapsi and delayed recovery of deltapsi in neurons from diabetic rats. Restoration of euglycemia for 2 weeks with insulin implants normalized NCV, deltapsi, and apoptosis. Intact and acutely dissociated neurons from diabetic rats demonstrated decreased Bcl-2 levels and translocation of cytochrome C from the mitochondria to the cytoplasm. Neither levels of Bax nor levels of Bcl-XL were altered in diabetic neuropathy. Apoptosis associated with mitochondrial dysfunction may contribute to the pathogenesis of diabetic sensory neuropathy.

Animals↗
PubMed2000

The Groningen Enjoyment Questionnaire: a measure of enjoyment in leisure-time physical activity.

The purpose of this study was to develop a short and easily used questionnaire to measure enjoyment in leisure-time physical activity. The first part of the study involved the questionnaire's composition. A set of 30 positively formulated potential items was generated and subsequently completed by 59 subjects. We used these results to trim the questionnaire to 10 items. In the second part of the study, the questionnaire was administered to 82 subjects and research was done into reliability and validity. The results indicate that the Groningen Enjoyment Questionnaire can be considered reliable and valid.

Aged↗