Predictors of primary care referrals to a vascular disease prevention lifestyle program among participants in a cluster randomised trial

Background

Cardiovascular disease accounts for a large burden of disease, but is amenable to prevention through lifestyle modification. This paper examines patient and practice predictors of referral to a lifestyle modification program (LMP) offered as part of a cluster randomised controlled trial (RCT) of prevention of vascular disease in primary care.

Methods

Data from the intervention arm of a cluster RCT which recruited 36 practices through two rural and three urban primary care organisations were used. In each practice, 160 eligible high risk patients were invited to participate. Practices were randomly allocated to intervention or control groups. Intervention practice staff were trained in screening, motivational interviewing and counselling and encouraged to refer high risk patients to a LMP involving individual and group sessions. Data include patient surveys; clinical audit; practice survey on capacity for preventive care; referral records from the LMP. Predictors of referral were examined using multi-level logistic regression modelling after adjustment for confounding factors.

Results

Of 301 eligible patients, 190 (63.1%) were referred to the LMP. Independent predictors of referral were baseline BMI ≥ 25 (OR 2.87 95%CI:1.10, 7.47), physical inactivity (OR 2.90 95%CI:1.36,6.14), contemplation/preparation/action stage of change for physical activity (OR 2.75 95%CI:1.07, 7.03), rural location (OR 12.50 95%CI:1.43, 109.7) and smaller practice size (1–3 GPs) (OR 16.05 95%CI:2.74, 94.24).

Conclusions

Providing a well-structured evidence-based lifestyle intervention, free of charge to patients, with coordination and support for referral processes resulted in over 60% of participating high risk patients being referred for disease prevention. Contrary to expectations, referrals were more frequent from rural and smaller practices suggesting that these practices may be more ready to engage with these programs.

Explaining the variation in the management of lifestyle risk factors in primary health care: a multilevel cross sectional study

Background

Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.

This study aimed to examine the relative importance of provider characteristics and attitudes, patient characteristics and consultation factors in determining the rate of assessment and intervention for lifestyle risk factors in PHC.

Methods

A prospective audit of assessment and intervention for lifestyle risk factors was undertaken by PHC nurses and allied health providers (n = 57) for all patients seen (n = 732) over a two week period. Providers completed a survey to assess key attitudes related to addressing lifestyle issues. Multi-level logistic regression analysis of patient audit records was undertaken. Associations between variables from both data sources were examined, together with the variance explained by patient and consultation (level 1) and provider (level 2) factors.

Results

There was significant variance between providers in the assessment and intervention for lifestyle risk factors. The consultation type and reason for the visit were the most important in explaining the variation in assessment practices, however these factors along with patient and provider variables accounted for less than 20% of the variance. In contrast, multi-level models showed that provider factors were most important in explaining the variance in intervention practices, in particular, the location of the team in which providers worked (urban or rural) and provider perceptions of their effectiveness and accessibility of support services. After controlling for provider variables, patients' socio-economic status, the reason for the visit and providers' perceptions of the 'appropriateness' of addressing risk factors in the consultation were all significantly associated with providing optimal intervention. Together, measured patient consultation and provider variables accounted for most (80%) of the variation in intervention practices between providers.

Conclusion

The findings highlight the importance of provider factors such as beliefs and attitudes, team location and work context in understanding variations in the provision of lifestyle intervention in PHC. Further studies of this type are required to identify variables that improve the proportion of variance explained in assessment practices.

Should I and Can I?: a mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care

Background
Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management.

Methods
A cross sectional survey was undertaken with PHC clinicians (n = 59) in three community health teams. Clinicians' beliefs and attitudes were also explored through qualitative interviews with a purposeful sample of 22 clinicians from the teams. Mixed methods analysis was used to compare beliefs and attitudes for those with high and low levels of self reported risk factor management.

Results
Role congruence, perceived client acceptability, beliefs about capabilities, perceived effectiveness and clinicians' own lifestyle were key themes related to risk factor management practices. Those reporting high levels of risk factor screening and intervention had different beliefs and attitudes to those PHC clinicians who reported lower levels.

Conclusion
PHC clinicians' level of involvement in risk factor management reflects their beliefs and attitudes about it. This provides insights into ways of intervening to improve the integration of behavioural risk factor management into routine practice.

The influence of macroeconomic factors on primary issues in the Brazilian market

This research analyses the influence of the macroeconomic factors on the primary issue of stocks and debentures in the Brazilian market. Previous studies have agreed on the importance of aspects of the economic situation on a company’s capital structure, but have not established a relationship between the macroeconomic variables and the level of aggregate debt; we can mention Procianoy and Caselani (1997) and Terra (2003) as examples of this. According to Leal (2000), the limitations of the Brazilian capital market suggest that management takes advantage of moments of euphoria in the market - whether caused by a reduction in the rate of interest or by the return being offered by the equity market - to raise funds at rates that are more advantageous to the company. This characterizes the first evidence we have of opportunistic behavior influencing a company’s financing decisions. Eid Jr. (1996) provides us with the first evidence of this opportunistic behavior in his research in which 47% of those interviewed said that they chose fund sources that are economically more advantageous.

Reading comprehension in primary school: textbooks, curriculum and assessment

This study describes the reading comprehension processes present in the most widely sold textbooks at the fourth grade level in Portugal and discusses how they compare to international assessments of reading literacy. We adopted the Progress of International Reading Literacy Study framework to categorize the questions in the textbooks. Our analyses revealed that they focus heavily on the retrieval of explicitly stated information to the detriment of higher level comprehension skills. Portuguese fourth grade textbooks rarely challenge students to make connections between their knowledge and the ideas in the texts and to adopt a critical and evaluative reading stance. This is in sharp contrast to what students are asked to do in the Progress of International Reading Literacy Study, conducted every five years since 2001, and it may help explain the poor results Portuguese students have in national assessment and in PISA. The findings are discussed in light of the curriculum frameworks currently adopted in Portugal and suggestions are made as to how we can improve reading literacy achievement.

CDX2, a highly sensitive and specific marker of adenocarcinomas of intestinal origin - An immunohistochemical survey of 476 primary and metastatic carcinomas

CDX2 is a recently cloned homeobox gene that encodes an intestine-specific transcription factor, expressed in the nuclei of epithelial cells throughout the intestine, from duodenum to rectum. While expression of CDX2 protein in primary and metastatic colorectal carcinomas has been previously documented, neither the sensitivity nor the specificity of CDX2 expression, as determined by immunohistochemistry, for colorectal adenocarcinoma has been determined. We performed an immunohistochemical survey of 476 tumors with a monoclonal antibody, CDX2-88, including 89 tumors from the colon and duodenum and 95 tumors from other gastrointestinal sites, including the esophagus, stomach, pancreatobiliary system, gastrointestinal carcinoids, and liver. CDX2 was expressed uniformly (that is, in 76-100% of tumor cells) in all but one of the evaluated colorectal and duodenal tumors. High-level expression of CDX2 was also found, however, in mucinous ovarian carcinomas and adenocarcinomas primary to the urinary bladder of which 64% and 100% were positive, respectively. Gastric, gastroesophageal, and pancreatic adenocarcinomas and cholangiocarcinomas all showed similar, heterogeneous patterns of CDX2 expression. Most tumors in each group showed CDX2 expression by a minority of cells, whereas a substantial minority of cases in each group was completely negative and a smaller minority was uniformly positive. Gastrointestinal carcinoids gave similarly varied results, but the majority (58%) was negative. Hepatocellular carcinomas showed no expression of CDX2. Only very rare examples of carcinomas of the genitourinary and gynecologic tracts, breast, lung, and head and neck showed significant levels of CDX2 expression. In this study of primary and metastatic epithelial tumors, uniform CDX2 expression is demonstrated to be an exquisitely sensitive and highly, but incompletely, specific marker of intestinal adenocarcinomas. Compared with villin, a previously described marker of GI adenocarcinomas, CDX2 demonstrated superior sensitivity and comparable specificity. CDX2 expression can be seen, however, in selected non-GI adenocarcinomas such as mucinous ovarian carcinomas and adenocarcinomas of the urinary bladder.

Genotoxicity in primary human peripheral lymphocytes after exposure to radiopacifiers in vitro

Taking into consideration that DNA damage plays an important role in carcinogenesis, the purpose of this study was to evaluate whether some radiopacifiers widely used in clinical practice are able to induce genetic damage in primary human cells in vitro. Human peripheral lymphocytes obtained from 10 healthy volunteers were exposed to barium sulphate (BaSO(4)), zirconium oxide (ZnO(2)) and bismuth oxide (Bi(2)O(3)) at final concentrations ranging from 1 to 1000 mu g/mL for 1 h at 37 degrees C. The negative control group was treated with vehicle control (phosphate buffer solution) for 1 h at 37 degrees C and the positive control group was treated with hydrogen peroxide (at 100 mu M) for 5 min on ice. Results were analyzed by the Friedman non-parametric test. The results pointed all compounds tested out did not induce DNA breakage in human peripheral lymphocytes as depicted by the mean tail moment and tail intensity in all concentrations tested. In summary, our results indicate that exposure to these radiopacifiers may not be a factor that increases the level of DNA lesions in human peripheral lymphocytes as detected by single cell gel (comet) assay.

Digital Radiographic Evaluation of the Level of Alveolar Bone Crest in External Hexagon Implants Submitted to 2 Types of Implant Abutments Under Immediate Loading

Purpose: The aim of this study was to evaluate by means of digital radiography the behavior of the alveolar bone crest in external hexagon implants following the use of 2 different types of abutments, one for conventional cemented prosthesis and one for modified cemented prosthesis.Methods: Ten external hexagon implants (platform 4.1) were placed in 5 patients. Initial instrumentation was carried out to obtain primary stability of the temporary prostheses under immediate loading. Each patient received both abutments for conventional and modified cemented prosthesis. Standardized digital periapical radiographies were performed at times T0 (immediately after implant placement) and T1 (4 months after implant placement). A straight line was initially established from the implant platform to the distal and mesial periimplantar marginal bone tissue (immediately in contact with the implant) and measured by digital radiography, using Sidexis version 2.3 (Sirona Dental Systems GmbH, Bensheim, Germany) software. The data were submitted to paired-samples t-test analysis.Results: There was no significant difference between the conventional and modified cemented prosthesis. In both cases, t-test results were within the null hypothesis level.Conclusion: The abutment for the modified cemented prosthesis resulted in no significant radiographic difference of alveolar bone crest height, when compared with the conventional cemented prostheses.

Luxation injuries in primary teeth: a retrospective study in children assisted at an emergency service

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Migraine is the Most Prevalent Primary Headache in Individuals with Temporomandibular Disorders

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Annual and short-term variability in primary productivity by phytoplankton and correlated abiotic factors in the Jurumirim Reservoir (São Paulo, Brazil)

A variabilidade anual da produção fotossintética (PP) pelo fitoplâncton na zona da barragem da Represa de Jurumirim (São Paulo, Brasil) foi medida após um estudo no período de três anos sucessivos, com o objetivo de identificar padrões recorrentes e suas causas. Medidas da variabilidade da PP em escala diária foram obtidas em dois períodos do ano (estações seca e chuvosa). Nenhum padrão recorrente foi verificado nos dados de PP, visto não haver relação de sua variabilidade com nenhum fator hidrológico (precipitação, nível e vazão de água e washout) nem, aparentemente, com as condições nutritivas da água. A análise de componentes principais revelou que a PP e a taxa de assimilação foram mais elevadas na época do ano em que o conteúdo de PO4(3-) e N-NH4+ foi mais baixo e quando as razões Z EU/Z MIX foram mais elevadas. A produtividade primária/área pode ser estimada pela razão entre a produtividade volumétrica máxima e o coeficiente de extinção vertical da luz. Entretanto, a biomassa integrada na Z EU foi um pobre preditor da produtividade primária/área. Nenhuma correlação foi encontrada entre a temperatura da água com a produtividade primária (por área e volumétrica máxima). em conseqüência, o estudo da PP em três anos sucessivos mostrou que o padrão de variabilidade é tipicamente caótico. em relação às medidas de curta duração, maior PP foi encontrada na estação seca do que na chuvosa. em ambos os períodos, a variabilidade da PP (por área) foi de aproximadamente 35-40%. O padrão foi atribuído não somente à variação na concentração dos nutrientes mas também à magnitude de penetração de luz na água associado ao regime de circulação. Um comentário sobre a relação entre produção primária pelo fitoplâncton com produção pesqueira é também apresentada.

Chromosomal imbalances detected in primary bone tumors by comparative genomic hybridization and interphase fluorescence in situ hybridization

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparative ablation rate from a Er : YAG laser on enamel and dentin of primary and permanent teeth

This study was conducted to analyze the ablation rate and micromorphological aspects of microcavities in enamel and dentin of primary and permanent teeth using a Er:YAG laser system. Micromorphological evaluation has been performed in terms of permanent teeth; however, little information about Er: YAG laser interaction with primary teeth can be found in the literature. Because children have been the most beneficiary patients with laser therapy in our offices, it is extremely necessary to compare the effects of this kind of laser system on the enamel and dentin of permanent and primary teeth. In this study, we used eleven intact primary anterior exfoliated teeth and six extracted permanent molar teeth. We used a commercial laser system: a Er: YAG Twin Light laser system (Fotona Medical Lasers, Slovenia) at 2940 nm, changing average energy levels per pulse ( 100, 200, 300, and 400 mJ) producing 48 microcavities in enamel and dentin of primary and permanent teeth. Primary teeth are more easily ablated than are permanent teeth, when related to enamel or dentin. However, while this laser system is capable of slowly revealing the enamel's microstructure, in dentin only the lowest laser energies permit this kind of observation, more easily decomposing the original tissue aspect, when related to primary or permanent teeth. Statistically, the only different factor at the 5% level was an energy per pulse of 400 mJ, confirming the results found in SEM. Our results showed that dentin in both primary and permanent teeth is less resistant to Er: YAG laser ablation; this fact is easily observed under SEM observation and through the ablation rate evaluation.

Periphyton on natural substratum in jurumirim reservoir (São Paulo, Brazil): Community biomass and primary productivity

Seasonal variation in the biomass and primary productivity of the periphyton on natural substratum (internodes of Echiiwchloa polystaclya HBK Hitch.) was studied during one year (from August 1993 to July 1994) in a lagoon with permanent connection with a river. We also analysed the relationships between the hydrological regime, climatic conditions and physico-chemical variables of water with the biological compounds of the periphyton. Values of dry mass, ash-free dry mass, chlorophyll a and phaeophytin of periphyton ranged from 0.55±0.24 g m-2 to 7.86±4.93 g m-2; 0.28±0.18 g m-2 to 3.72±2.23 g m-2; 0.57±0.09 mg m-2 to 15.57±4.52 mg m-2; 0.03±0.03 mg m-2 to 4.74±3.46 mg m-2, respectively. The primary productivity of periphytic algae measured by C14 method ranged from 6.45±1.29 mg C m-2 h-1 to 52.88± 7.55 mg C m-2 h-1. The biomass showed a peak in October 1993, February and April 1994. Higher value of primary productivity was recorded in December 1993 and January 1994 and was due to the peculiar light and nutrition conditions during this period. We conclude that biomass and productivity of the community are controlled mainly by hydrological regime (fluctuations of water level). © INTERNATIONAL SCIENTIFIC PUBLICATIONS.

Genotoxicity in primary human peripheral lymphocytes after exposure to regular and white mineral trioxide aggregate

Objective: Taking into consideration that DNA damage plays an important role in carcinogenesis, the purpose of this study was to evaluate whether regular and white mineral trioxide aggregate (MTA) are able to induce genetic damage in primary human cells. Study design: Human peripheral lymphocytes obtained from 10 healthy volunteers were exposed to 2 presentation forms of MTA at final concentrations ranging from 1 to 1000 μg/mL for 1 hour at 37°C. The negative control group was treated with vehicle control (phosphate buffer solution, PBS) for 1 hour at 37°C and the positive control group was treated with hydrogen peroxide (at 100 μM) for 5 minutes on ice. Results were analyzed by the Friedman nonparametric test. Results: The results pointed out that either regular or white MTA in all concentrations tested did not induce DNA breakage in human peripheral lymphocytes as depicted by the mean tail moment. Conclusion: In summary, our results indicate that exposure to MTA may not be a factor that increases the level of DNA lesions in human peripheral lymphocytes as detected by single cell gel (comet) assay. © 2006 Mosby, Inc. All rights reserved.