Arterial hypertension: lessons from patient education

The face of hypertension has been changing rapidly over the last few decades, from a serious disease to a cardiovascular risk factor. Patient education has been instrumental in bringing about tremendous improvements in hypertension-related mortality, morbidity, life expectancy, and life quality. Patient education has evolved from an adjunct to medical therapy to an intervention in its own right. In this process patient education tasks and techniques themselves have undergone remarkable developments, driven by evolving patient needs due to medical progress. The same is true for the roles of patients and health care providers. Dealing with hypertension is a behavior change process which demands serious learning efforts from all parties involved, patients, health practitioners and health care administrators alike. This paper focuses therefore on patient education for preventive behavior change and risk factor management. Special emphasis will be placed on processes and tools for effective patient education.     

T-cell receptor peptide-MHC interactions: biological lessons from structural studies

We have constructed a zebrafish genetic linkage map consisting of 705 simple sequence-length polymorphism markers (SSLPs). The map covers 2350 centimorgans (cM) of the zebrafish genome with an average resolution of 3.3 cM. It is a complete map in genetic mapping terms (there is one linkage group for each of the 25 chromosomes), and it has been confirmed by somatic-cell hybrids and centromere-mapping using half-tetrad analysis. The markers are highly polymorphic in the zebrafish strains used for genetic crosses and provide a means to compare genetic segregation of developmental mutations between laboratories. These markers will provide an initial infrastructure for the positional cloning of the nearly 600 zebrafish genes identified as crucial to vertebrate development,and will become the anchor for the physical map of the zebrafish genome.     

Cardiovascular sequelae and risks of obesity

Obesity is a well documented separate risk factor for metabolic and vascular diseases which may reduce life expectancy for overweight people. This is expected to create soon a major health economic problem in more or less all western countries because the numbers of morbidly obese people increase steadily. It is a type of visceral android fat deposition which bears a high risk to develop vascular remodelling processes causing coronary and cerebral artery disease with all its consequences. The various biochemical processes which may contribute to cause these vascular lesions in obesity are discussed by the author and the various resulting clinical findings are described. Further the chance is emphasized to reduce by weight reduction the risks of obesity since regression of vascular changes may result by an even moderate loss of weight.     

Cardiovascular disease risks in adolescent males

Although primary prevention efforts aimed at reducing heart disease have focused on adults, there is evidence that risk factors for heart disease are likely to be present in children and adolescents. To identify the risk factors present in adolescent boys, 82 male adolescents were enrolled in a study. Blood pressure, cholesterol, percent body fat, and body mass index (BMI) were measured along with data collection pertaining to diets, substance use, stress, and family history of heart disease. A statistically significant number of adolescent male subjects had high blood pressure, high cholesterol, high percent body fat, and high BMI and used substances associated with heart disease (smoking cigarettes, smokeless tobacco, alcohol, and amino acids). Thus, interventions must begin early in life if heart disease is to be prevented.     

Mathematical coupling in medical research: lessons from studies of oxygen kinetics

BACKGROUND: Smooth muscle hamartoma is an uncommon lesion. Diagnosis is usually made at birth in infants presenting a plaque with minimal or no infiltration and covered with long dark hairs. Congenital forms with multiple plaques are rarely reported. CASE REPORT: A 5-day-old infant (normal pregnancy and delivery) had plaques localized on the buttocks, the left thigh, leg and shoulder and the right ankle. The plaques were minimally infiltrative and covered with long black hairs. Histology examination showed hyperplastic smooth muscle bundles with varying orientation. The diagnosis was smooth muscle hamartoma. The rest of the clinical examination was normal. CONCLUSION: This case of congenital smooth muscle hamartoma showed a particular form with partially regressive multiple plaques.     

The pathogenesis of polycystic ovary syndrome: lessons from ovarian stimulation studies

In polycystic ovary syndrome (PCOS) the ovary produces markedly increased amounts of both androgens and estrogens in response to gonadotropin stimulation. Distinctive responses of 17-hydroxyprogesterone and androstenedione to ovarian stimulation testing suggest that ovarian hyperandrogenism is a result of dysregulation of theca cell androgen production which is intrinsic to the ovary. The occurrence of hyperestrogenism together with hyperandrogenism in PCOS suggests that whatever the abnormality of local regulatory factors of steroidogenesis, it affects granulosa as well as theca cells. Dysregulation is often associated with an increase in the number of follicles which evade atresia and reach the 2-8 mm stage of development. Autocrine/paracrine factors, especially those which are FSH-dependent, likely play an important role in the pathogenesis of the ovarian abnormality. Both LH and insulin hypersecretion probably play a secondary role in PCOS by amplifying the preexisting ovarian dysregulation. Because FSH secretion is under tight long-loop negative-feedback control and LH is not, hyperandrogenism is the primary clinical manifestation of dysregulation of steroid production in PCOS. However, anovulation in PCOS is most likely a result of excessive estrogen and inhibin production by multiple, small follicles which inhibit FSH secretory dynamics sufficiently to prevent selection of a dominant follicle.     

Nutrient effects: discrepancy between data from controlled trials and observational studies

We describe the successful postoperative pain management in an 11-month-old infant who underwent bilateral thoracotomy, using continuous infusions of bupivacaine into two directly placed paravertebral catheters. Haemodynamic parameters and pain scores were measured 1-2 h for 60 h while the infusions were continued and, intermittently, blood samples were taken for subsequent measurement of serum bupivacaine concentrations. The technique provided effective pain relief and the infant required no other analgesia postoperatively. There were no adverse haemodynamic consequences or complications relating to either catheter placement or drug infusions. Serum concentrations of bupivacaine remained below toxic levels throughout the study period, though accumulation did occur.     

Understanding intercellular interactions and cell adhesion: lessons from studies on protein-metal interactions

To understand cell-cell interactions and the interactions of cells to non-biological materials, studies on binding forces between cellular proteins and between proteins and non-biological material such as metal surfaces are essential. The adsorption of proteins to solid-water interfaces is a multifactorial and a multistep process. First steps are determined by long-range interactions where surface properties such as hydrophobicity, distribution of charged groups, ion concentrations and pH play important roles. In later steps structural rearrangements in the protein molecule and dehydration effects become more important making the adsorption process often irreversible. In the following we demonstrate that protein A and tubulin have a specific type of interaction to metal surfaces probably as an intermediate step in the adsorption process. The proteins were attached to the tip of a microfabricated cantilever in such a way that only one molecule interacts with the surface. By recording force-distance curves with an atomic force microscope the adhesion forces of single molecules binding to gold, titanium and indium-tinoxid surfaces were measured.     

Involving patients: lessons from PACE

In the fourth part of our PACE series, based on the King's Fund Promoting Action on Clinical Effectiveness programme, the first article reviews the experiences of 16 PACE projects that offer tips for involving patients in programmes to implement evidence-based practice, quality initiatives and clinical governance arrangements. The second article provides a more detailed example of one project.     

Immunoconjugates: lessons from animal models

Monoclonal antibody-mediated cancer therapy has evolved through a challenging chain of problems and solutions. The very limited therapeutic success obtained with unarmed monoclonal antibodies has increased the interest in different antibody-based targeting strategies, and numerous preclinical and even clinical studies with immunoconjugates have now been conducted. We comment here on the messages implicit in a recent report on a doxorubicin-anti-carcinoma antibody conjugate and from several other studies.     

Health sector reform: lessons from China

As a result of China's transition to a socialist market economy, its rural health services have undergone many of the changes commonly associated with health sector reform. These have included a decreased reliance on state funding, decentralisation of public health services, increased autonomy of health facilities, increased freedom of movement of health workers, and decreased political control. These changes have been associated with growing inequality in access to health services, increases in the cost of medical care, and the deterioration of preventive programmes in some poor areas. This paper argues that the government's strategy for addressing these problems has overemphasised the identification of new sources of revenue and has paid inadequate attention to factors that influence provider behaviour. The strategy also does not address contextual issues such as public sector employment practices and systems of local government finance. Other countries can learn from China's experience by taking a systematic approach to the formulation and implementation of strategies for health sector reform.     

Psychological measures: practical issues in observational studies and clinical monitoring

Psychological measures are important because they can influence the expression of pain and physical function in patients with arthritis. A number of instruments are now available that measure psychological distress and how we as individuals manage stress. These instruments have undergone extensive validation, although more work is required to evaluate the performance of these instruments measuring change over time. One way to interpret psychological measures and to evaluate how they change over time is to use normative comparisons that are conditional on time and other relevant covariates, using statistical methods such as quantile regression. Such methods have been used to interpret the developmental, educational, and physical growth of children. We can use similar methods to interpret observational studies and to guide decisions within the context of clinical practice.     

Promoting choice: lessons from managed Medicaid

Drawing on the education, enrollment, and assignment experiences of seven states with mandatory Medicaid managed care programs, this paper finds that the vast majority of enrollees will choose their own health plan if the system is explicitly designed with this in mind (as in Minnesota and Oregon). These experiences provide lessons on ways to 1) align program design with state priorities; (2) increase the level of choice (by coordinating enrollment and eligibility processes, broad-based educational strategies, and personalized attention); (3) improve the quality of choice; and (4) design state contracting processes to support choice and continuity of care.