Factors associated with implementation of preventive care measures in patients with diabetes mellitus

BACKGROUND: There is only limited information on the extent to which physicians' characteristics affect the level of care and implementation of guidelines in patients with diabetes mellitus. OBJECTIVE: To identify physician characteristics associated with implementation of measures for preventive care in patients with diabetes mellitus and the distribution of implementation of these measures among them. PATIENTS AND METHODS: A retrospective chart audit of 519 patients eligible for health maintenance organization insurance on December 31, 1994, representing patients with diabetes receiving care from 22 primary care physician-providers of a managed care medical group in suburban North Los Angeles, Calif, and seen by physicians between January 1993 and December 1994. A short retroactive questionnaire for participating physicians was also used. The outcome measures were (1) measurement of serum high-density lipoprotein cholesterol; (2) urinalysis for the detection of proteinuria; and (3) ophthalmology referral for dilated fundus examination. RESULTS: Over a period of 2 years 78% of the patients had a high-density lipoprotein cholesterol determination, 80% had a test for proteinuria, and 62% were referred to an ophthalmologist. After adjustment for patient pool differences, physicians who were perceived by the administration of the medical group as "fast," based on a blinded evaluation of their number of patient encounters per unit time, had an odds ratio of 0.60 (95% confidence interval [CI], 0.37-0.95; P=.03) to obtain a high-density lipoprotein cholesterol determination in their patients and an odds ratio of 0.53 (95% CI, 0.32-0.87; P=.01) to test their patients for proteinuria. In patients requiring insulin, of fast physicians, the odds ratio for a referral for ophthalmology screening was 0.25 (95% CI, 0.07-0.85; P= .03). Duration of time in practice of over 15 years and disagreement with practice guidelines were associated with better outcomes. There was no association between physician sex, internal medicine training, or number of patients with diabetes in the practice and the implementation of outcomes. There was a highly significant association between the implementation of an outcome and the implementation of the other 2, resulting in a nonhomogeneous distribution of health care delivery. Physicians' estimate of their rate of implementation of outcomes, as assessed by the questionnaires, overestimated their actual performance while being in proportion with the documented rates. Most physicians took responsibility for the nonimplementation, accepting that it was an oversight on their part as opposed to an encounter with patient resistance. CONCLUSIONS: Most physicians believe that the lack of implementation of the measures for preventive care in patients with diabetes mellitus is an oversight. The oversight is more prevalent in the practices of busy physicians. The result is a nonhomogeneous distribution of health care. Computer reminders might be the solution.     

Mechanism of biological synergy between cellular Src and epidermal growth factor receptor

Overexpression of both cellular Src (c-Src) and the epidermal growth factor receptor (EGFR) occurs in many of the same human tumors, suggesting that they may functionally interact and contribute to the progression of cancer. Indeed, in murine fibroblasts, overexpression of c-Src has been shown to potentiate the mitogenic and tumorigenic capacity of the overexpressed EGFR. Potentiation correlated with the ability of c-Src to physically associate with the activated EGFR and the appearance of two unique in vivo phosphorylations on the receptor (Tyr-845 and Tyr-1101). Using stable cell lines of C3H10T1/2 murine fibroblasts that contain kinase-deficient (K-) c-Src and overexpressed wild-type EGFR, we show that the kinase activity of c-Src is required for both the biological synergy with the receptor and the phosphorylations on the receptor, but not for the association of c-Src with the receptor. In transient transfection assays, not only epidermal growth factor but also serum- and lysophosphatidic acid-induced DNA synthesis was ablated in a dominant-negative fashion by a Y845F mutant of the EGFR, indicating that c-Src-induced phosphorylation of Y845 is critical for the mitogenic response to both the EGFR and a G protein-coupled receptor (lysophosphatidic acid receptor). Unexpectedly, the Y845F mutant EGFR was found to retain its full kinase activity and its ability to activate the adapter protein SHC and extracellular signal-regulated kinase ERK2 in response to EGF, demonstrating that the mitogenic pathway involving phosphorylation of Y845 is independent of ERK2-activation. The application of these findings to the development of novel therapeutics for human cancers that overexpress c-Src and EGFR is discussed.     

Early strabismus surgery for thyroid ophthalmopathy

OBJECTIVE: To determine whether strabismus surgery during active thyroid ophthalmopathy is beneficial for selected patients. DESIGN: Case series. PARTICIPANTS: Eight patients with severe restrictive strabismus due to thyroid ophthalmopathy underwent early strabismus surgery and were followed for a minimum of 16 months after their initial surgery. INTERVENTION: All eight patients underwent strabismus surgery while their thyroid ophthalmopathy was evolving. MAIN OUTCOME MEASURES: Success was determined by the ability to fuse in the primary position at distance and near without an abnormal head position, and the absence of vision-threatening complications related to strabismus surgery. RESULTS: All eight patients achieved successful long-term alignment. Four patients (50%) required more than one operation. CONCLUSIONS: Strabismus surgery during active thyroid ophthalmopathy can result in long-term stable alignment and may be a useful alternative in selected patients with marked disability due to thyroid ophthalmopathy.     

Age-related differences in management of heart disease: a study of cardiac medication use in an older cohort. Pacemaker Selection in the Elderly (PASE) Investigators

Bone mass, bone metabolic markers, and calcium regulation hormones were measured in members of an Antarctic wintering team who stayed at the Japanese Antarctic station, Syowa (latitude: south 69 degrees 00', longitude: east 39 degrees 35') for 1 year. Subjects included 31 healthy Japanese males, aged 24-51 years (mean age 34.5 years) at the beginning of this study, ingesting 488 IU/day of vitamin D and 550.9 mg/day of calcium per person. The long-term coefficient of variation (CV) of the equipment used in the assessments of bone mass was 0.67% in single X-ray absorptiometry (SXA), 0.17% in the speed of sound (SOS) by quantitative ultrasound method (QUS), and 0.63% in broadband ultrasound attenuation (BUA) by QUS. The seasonal changes in the calcaneal bone mineral density (BMD) by SXA were not significant, whereas the SOS measured by QUS decreased during the measurement period (0.55%, p < 0.001), and BUA increased (1.9%, p < 0.01). Bone-specific alkaline phosphatase and osteocalcin levels increased significantly during summer (p < 0.001) and urinary calcium level decreased significantly during winter (p < 0.05). Urinary pyridinoline and deoxypyridinoline levels decreased significantly at the end of winter (p < 0.001). Serum 1,25(OH)2D3 level did not change significantly, whereas serum 25(OH)D3 level decreased significantly during winter (p < 0.001). Serum parathyroid hormone (PTH) level significantly increased at the end of winter (p < 0.01), although both PTH level and 25(OH)D3 level remained within the normal range. We concluded that the 25(OH)D3 level in subjects who stayed in Antarctica for 1 year decreased significantly with the reduction in duration of sunshine, but there were no clear changes in bone mass.     

Dietary amino acids as new and novel agents to enhance allograft survival

Little is known about the long-term effects of fluoride-releasing materials on carious dentine in vivo. The aim was to investigate the 2-year influence of a resin-modified glass ionomer cement (RM-GIC) and amalgam on the bacteriological counts of carious dentine that remained under class I restorations. To enable a split-mouth design, 33 molar pairs in 33 patients (mean age 15.1 years, SD 1.4) were selected, based on clinically and radiographically diagnosed occlusal dentine caries. The enamel of the carious molars was removed, and the carious dentine was sampled under aseptic conditions just beneath the dentinoenamel junction. The molars were alternately restored with RM-GIC or amalgam without further removal of carious dentine. The samples were processed for microbiological determination of total viable counts (TVC), mutans streptococci (MS), and lactobacilli (LB). The molar pairs of 25 patients were reevaluated after 2 years using the same clinical techniques and were permanently restored after complete caries removal. Both materials showed a substantial decrease in numbers of TVC and LB of the carious dentine after the 2-year period. Compared to amalgam, the decrease in the numbers of LB was significantly more pronounced for RM-GIC. No microorganisms were detected in only 11 molars (6 RM-GIC and 5 amalgam) after the 2-year period. Based on this study, we suggest that complete removal of carious dentine is still the best conservative treatment, irrespective of the restorative material used.     

ESR and HPLC-EC analysis of the interaction of hydroxyl radical with DMSO: rapid reduction and quantification of POBN and PBN nitroxides

The low stability of hydroxyl radical (OH.)-derived nitroxides is a limiting factor for direct spin-trapping of OH. in biological systems. The latter experimental difficulty is partly solved with the introduction of dimethyl sulfoxide (DMSO) into the studied systems. Hydroxyl radical oxidizes DMSO to methyl radical, which forms relatively stable nitroxides. The results of the present work provide evidence that in alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (POBN) and alpha-phenyl-N-tert-butylnitrone (PBN) spin-trapping experiments aimed to detect methyl radical in biological systems, the nitroxides formed can be reduced to their ESR-"silent" hydroxylamine derivatives. The nitroxides and their hydroxylamine derivatives were successfully analyzed by HPLC with electrochemical (EC) and UV detection. The lowest limits of UV and EC detection of POBN/CH3 hydroxylamine was evaluated to be in the micro- and nanomolar range, respectively. In parallel ESR and HPLC-EC analysis of the metabolism of menadione by either HepG2 cells or isolated rat hepatocytes in the presence of DMSO, the HPLC-EC method has proven to be more sensitive in detecting the production of methyl radical. The use of the HPLC-EC detection of POBN/CH3 and PBN/CH3 is expected to be advantageous in detection of hydroxyl radical in biological systems in the presence of DMSO.     

Hormonal factors in the development of differences in strength between boys and girls during adolescence: a longitudinal study

The mitochondrial transition pore (MTP) is implicated as a mediator of cell injury and death in many situations. The MTP opens in response to stimuli including reactive oxygen species and inhibition of the electron transport chain. Sporadic Parkinson's disease (PD) is characterized by oxidative stress and specifically involves a defect in complex I of the electron transport chain. To explore the possible involvement of the MTP in PD models, we tested the effects of the complex I inhibitor and apoptosis-inducing toxin N-methyl-4-phenylpyridinium (MPP+) on cyclosporin A (CsA)-sensitive mitochondrial swelling and release of cytochrome c. In the presence of Ca2+ and Pi, MPP+ induced a permeability transition in both liver and brain mitochondria. MPP+ also caused release of cytochrome c from liver mitochondria. Rotenone, a classic non-competitive complex I inhibitor, completely inhibited MPP(+)-induced swelling and release of cytochrome c. The MPP(+)-induced permeability transition was synergistic with nitric oxide and the adenine nucleotide translocator inhibitor atractyloside, and additive with phenyl arsine oxide cross-linking of dithiol residues. MPP(+)-induced pore opening and cytochrome c release were blocked by CsA, the Ca2+ uniporter inhibitor ruthenium red, the hydrophobic disulfide reagent N-ethylmaleimide, butacaine, and the free radical scavenging enzymes catalase and superoxide dismutase. MPP+ neurotoxicity may derive from not only its inhibition of complex I and consequent ATP depletion, but also from its ability to open the MTP and to release mitochondrial factors including Ca2+ and cytochrome c known to be involved in apoptosis.     

Comparison of fixation disparity curve variables measured with the Sheedy Disparometer and the Wesson Fixation Disparity Card

BACKGROUND: Previous studies suggest differences in the fixation disparity curves obtained with the Sheedy Disparometer and the Wesson Fixation Disparity Card, the two most commonly used methods for measuring fixation disparity. In one study the investigators proposed that the differences do not exist for subgroups divided by phoria. The purpose of this paper is to try to clarify this issue by use of two large sets of data. METHODS: Dissociated phorias were measured by the von Graefe method. Fixation disparity curves were plotted using the Disparometer and the Wesson card. RESULTS: Type I fixation disparity curves were most common with the Wesson card. Type II curves were found more often with the Disparometer than with the Wesson card. The x-intercepts were shifted in the base-in (BI) direction with the Wesson card compared to the Disparometer. The y-intercepts were shifted in the exo direction with the Wesson card compared to the Disparometer. The differences were statistically significant regardless of whether the dissociated phoria was exo or eso. The slope of the fixation disparity curve was steeper with the Wesson card than with the Disparometer. The difference was statistically significant for exophores but not for esophores. The differences between results obtained with the two instruments are not consistent from one subject to another as shown by high standard deviations of the differences. CONCLUSIONS: The fixation disparity curves measured with these two instruments are different. Fixation disparity parameters obtained from one of these instruments cannot be used with normative findings from the other.