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Study Design: We performed genomic screening, statistical linkage analysis, and fine mapping of 202 families with at least 2 individuals with idiopathic scoliosis., Objective: To identify regions on chromosome 19p13 statistically linked to the phenotypic expression of idiopathic scoliosis., Summary of Background Data: Idiopathic scoliosis is a common structural curvature of the spine affecting otherwise healthy children. Presently, no clear consensus exists regarding the underlying abnormality or genetic determinants of this disease., Methods: Model-independent linkage analysis of qualitative and quantitative traits related to scoliosis was used to screen genotyping data from 391 markers in 202 families (1198 individuals). Subsets of families with probands having a curve > or = 30 degrees were dichotomized based on the most likely mode of inheritance for each family (autosomal dominant or X-linked dominant). Fine mapping was performed to show linkage to candidate regions on chromosome 19., Results: When the threshold of disease was set at a curvature of > or = 30 degrees, qualitative linkage analysis revealed significant results at 2 successive markers on chromosome 19., Conclusion: The data confirm a previously reported genetic locus on chromosome 19 as potentially significant in the etiology of idiopathic scoliosis.

Study Design: A study was conducted to determine the potential association between a specific aggrecan gene polymorphism and familial idiopathic scoliosis (FIS)., Objectives: To determine the allelic distribution of the exon 12 polymorphism within a sample of families with FIS., Summary of Background Data: FIS is a structural curvature of the spine where the underlying genetic etiology has not been established. The aggrecan locus has been linked to multiple skeletal disorders. A polymorphism, within the aggrecan gene, was previously reported to be associated with curve severity in individuals with scoliosis., Methods: Fifty-eight families with FIS were genotyped for the aggrecan exon 12 polymorphism using a polymerase chain reaction method. Model-independent sib-pair linkage analyses and tests of association were performed to analyze the genetic effects of the exon 12 polymorphism., Results: Linkage analyses of a genomic screen performed on a subgroup of 48 families with a most likely to be X-linked dominant mode of inheritance of FIS showed marginally significant results on chromosome 15q25-26 (P < 0.05). The overall distribution of the alleles was consistent with previously reported literature; no evidence of association and marginal significance of linkage was found between the polymorphism and FIS or the degree of lateral curvature., Conclusions: Despite the negative association reported here, further investigation of the gene and its potential association to FIS is required.

Background and Purpose: The incidence of West Nile virus (WNV) has increased in the United States since 1999. A small percentage of people with WNV develop West Nile neuroinvasive disease (WNND) with encephalitis and flaccid paralysis. The purpose of this report is to describe the physical therapist management and outcomes for a patient with WNND and the therapist's efforts to use an evidence-based practice approach in the management of a patient with this disease., Case Description: The patient was an active 55-year-old woman in excellent health who became acutely ill with asymmetrical lower-extremity weakness. The physical therapist reviewed the available literature, consulted with medical and physical therapist experts and the patient, and elected to use a poliovirus "period of recovery" approach combining intensive strengthening and monitoring of fatigue., Outcomes: The patient progressed from an initial nonambulatory status to ambulation with a single-point cane at week 18 after onset of symptoms. She began to ambulate without an assistive device by week 20. The patient returned to work part-time by week 22 and full-time by week 43., Discussion: These outcomes demonstrate the recovery of a patient with WNND after an intensive strengthening program.

Kyphoscoliosis, a three-dimensional deformity of spinal growth, is characterized by a curvature in the coronal plane (scoliosis) in conjunction with thoracic kyphosis in excess of the normal range in the sagittal plane. We identified kyphoscoliosis within members of seven families (53 individuals) originally ascertained as part of a large collaborative study of familial idiopathic scoliosis. Model-independent linkage analysis of a genome-wide microsatellite screen identified areas suggestive of linkage on chromosomes 2q22, 5p13, 13q, and 17q11. Single-point and multipoint analyses of an additional 25 flanking microsatellite markers corroborated linkage to these regions, with areas on chromosomes 5p13, 13q13, and 13q32 being the most significant (P < 0.005). Analyses of single nucleotide polymorphism (SNP) markers in the candidate region on chromosome 5 narrowed the region to approximately 3.5 Mb (P < 0.05), with the most significant P values (P < 0.01) occurring in approximately a 1.3-Mb region. Candidate loci in this region include IRX1, IRX2, and IRX4 of the Iroquois Homeobox protein family. On chromosome 13, single-point and multipoint analyses resulted in multiple SNPs having P values < 0.05 within five candidate genes: Osteoblast-specific factor 2 or periostin, forkhead box O1A, A-kinase anchor protein 11, TBC1 domain family member 4, and glypican 5, thus supporting the potential relevance of this region in the pathogenesis of kyphoscoliosis.

Femoral shaft fractures and supracondylar elbow fractures are two of the most common major pediatric injuries managed by the general orthopedic surgeon. Therapeutic choices frequently are influenced by many factors, including associated injuries, fracture type, and the child's age, social situation, and economic issues. Nonsurgical management of femoral shaft fractures has been a preferred and cost-effective treatment for most age groups, but recently the use of surgical techniques has gained popularity with the overall goal of rapid mobilization of the child. Supracondylar elbow fractures are diagnostically challenging and can result in severe acute and long-term complications. An understanding of fracture presentation, anatomic detail, and surgical applications will optimize the chances for successful outcomes.

Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality.

We study the role of health benefits in an employer's compensation strategy, given the overall goal of minimizing total compensation cost (wages plus health-insurance cost). When employees' health status is private information, the employer's basic benefit package consists of a base wage and a moderate health plan, with a generous plan available for an additional charge. We show that in setting the charge for the generous plan, a cost-minimizing employer should act as a monopolist who sells "health plan upgrades" to its workers, and we discuss ways tax policy can encourage efficiency under cost-minimization and alternative pricing rules.

Study Design: A genomic screen and statistical linkage analysis of 202 families with at least two individuals with idiopathic scoliosis was performed., Objectives: To identify candidate regions or the autosomal loci that may be involved in the expression of familial idiopathic scoliosis., Summary of Background Data: A large sample of families with individuals having idiopathic scoliosis (202 families; 1,198 individuals) was ascertained; diagnoses were based on physical examination and radiographic criteria., Methods: Model-independent linkage analysis of qualitative and quantitative traits (degree of lateral curvature) related to scoliosis was used to screen genotyping data from 391 markers in the 202 families. Subsets of families were determined before genotyping based on the most likely mode of inheritance for each family (autosomal dominant vs. X-linked dominant). Fine mapping results corroborated linkage in the primary candidate regions., Results: Candidate regions on chromosomes 6, 9, 16, and 17 were considered to have the strongest evidence for linkage across all subsets considered., Conclusion: Linkage analyses have identified several candidate regions, a significant step in defining the genetic etiology of this disorder.

Unlabelled: The dial osteotomy, an acetabular reorientation procedure based on radiographs, was developed by R. H. Eppright for treatment of hip dysplasia; however, long-term results are not recorded. The aim of this study was to evaluate retrospectively the results of the dial osteotomy as done in 37 patients (44 hips) at an average followup of 12.6 years. Articular pressures with the application of a time and pressure algorithm were calculated from radiographs to correlate calculated intraarticular pressures with progression of degenerative disease. Clinical results at followup were 32 (73%) satisfactory and 12 (27%) unsatisfactory hips. Six (13%) hips failed between 10-20 years (average 14.7 years). A satisfactory result correlated with the preoperative functional score. Radiographically, the anterior center-edge angle increased from an average of 6.7 degrees to 37.9 degrees. At followup, radiographic indices of degeneration indicated that eight (18%) hips had improved, 18 (41%) had stabilized, and 18 (41%) had deteriorated. Severin indices improved in 21 (48%) hips. Joint space width at followup provided the only correlation between radiographic parameters and clinical result. Contact pressures were reduced from 4.45 MPa to 1.12 MPa. The cumulative exposure to articular pressures averaged 61.6 MPa-years, and did not correlate with radiographic parameters or clinical success., Level of Evidence: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

The present study aimed to determine whether tobacco use cessation rates observed in controlled trials of a hospital-based tobacco use cessation program could be replicated when the program was disseminated to a wide range of hospitals in a two-stage process including implementation and institutionalization phases. Using a nonrandomized, observational design, we recruited six hospitals to participate in the study. The research team helped implement the program during the first year of participation (implementation) and then withdrew from active involvement during the second year (institutionalization). The mean 6-month self-reported cessation rates were 26.3% (range = 17.6%-52.8%) for the implementation phase and 22.7% (range = 12.9%-48.2%) for the institutionalization phase. Hospitals with paid professionals providing the program had the best outcomes. Inpatient tobacco use cessation programs are feasible to implement and should target a 6-month self-reported cessation rate of at least 25%.

Background: Standard office-based approaches to controlling hypertension show limited success. Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent, regular blood pressure (BP) monitoring. We tested the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy, based on patients' reports of home BP., Methods: We randomized outpatients requiring drug therapy for hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria to receive usual medical care only (UC, n = 76) or usual care plus nurse care management intervention (INT, n = 74) over a 6-month period., Results: Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC: 14.2 +/- 18.1 versus 5.7 +/- 18.7 mm Hg systolic (P < .01) and 6.5 +/- 10.0 versus 3.4 +/- 7.9 mm Hg diastolic, respectively (P < .05). At 6 months, we observed one or more changes in drug therapy in 97% of INT patients versus 43% of UC patients, and 70% of INT patients received two or more drugs versus 46% of UC. Average daily adherence to medication, measured by electronic drug event monitors, was superior among INT subjects (mean +/- SD, 80.5% +/- 23.0%) than among UC subjects (69.2 +/- 31.1%; t(113) = 2.199, P = .03). There were no significant adverse drug reactions in either group., Conclusions: Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension.

Background: Although men hospitalized with cardiovascular disease (CVD) show high smoking-cessation rates, similar data for women are lacking. We tested the efficacy of smoking-cessation intervention in women hospitalized for CVD., Methods and Results: In this randomized controlled trial conducted from 1996 to 2001, 277 women diagnosed with CVD (mean age 61+/-10 years) were randomly assigned within 1 of 12 San Francisco Bay Area hospitals to a usual-care group (UG; n=135) or intervention group (IG; n=142). Baseline histories were obtained, and interviews to ascertain self-reported smoking status occurred at 6, 12, 24, and 30 months after hospitalization. The UG received strong physician's advice, a self-help pamphlet, and a list of community resources. The IG received strong physician's advice and a nurse-managed cognitive behavioral relapse-prevention intervention at bedside, with telephone contact at intervals after discharge. The groups were similar demographically and had smoked cigarettes for a median of 38 (IG) or 40 (UG) years. Time to resumption of continuous smoking was assessed by Kaplan-Meier analysis, and risk differences between groups were determined. Time smoke-free was significantly greater for the IG than the UG (P=0.038). Point prevalence for nonsmoking at the interviews was somewhat greater for the IG than the UG (P>0.15 at all times)., Conclusions: Cognitive behavioral intervention resulted in longer average times to resumption of smoking, but in these 2 groups of older women with limited social and financial resources, long-term success rates were similar. Systematic identification of smokers and even the brief intervention afforded the UG yielded a high smoking-cessation rate over time.

Using tools developed by NCQA, Rand, and other institutions, health plans and providers can take an aggressive stance toward managing hypertension. This effort has led to gains in blood pressure control in some populations, greater recognition of the importance of controlling hypertension, and increased attention to processes that promote higher-quality health care.

More than one third of all Americans have high or high-normal blood pressure and are at risk for stroke, cardiovascular disease, kidney disease, and heart failure. Many of these are not diagnosed or are inadequately treated. The large number of untreated individuals at risk for the complications of hypertension, or who have not achieved goal pressures on therapy, require a concerted effort by health care professionals to screen and treat this condition. Aggressive identification and treatment of even high-normal hypertension can reduce adverse outcomes. The importance of aggressive management is outlined in this article.

Objective: This study evaluated the efficacy of a nurse-care management system designed to improve outcomes in patients with complicated diabetes., Research Design and Methods: In this randomized controlled trial that took place at Kaiser Permanente Medical Center in Santa Clara, CA, 169 patients with longstanding diabetes, one or more major medical comorbid conditions, and HbA(lc) >10% received a special intervention (n = 84) or usual medical care (n = 85) for 1 year. Patients met with a nurse-care manager to establish individual outcome goals, attended group sessions once a week for up to 4 weeks, and received telephone calls to manage medications and self-care activities. HbA(lc), LDL, HDL, and total cholesterol, triglycerides, fasting glucose, systolic and diastolic blood pressure, BMI, and psychosocial factors were measured at baseline and 1 year later. Annualized physician visits were determined for the year before and during the study., Results: At 1 year, the mean reductions in HbA(lc), total cholesterol, and LDL cholesterol were significantly greater for the intervention group compared with the usual care group. Significantly more patients in the intervention group met the goals for HbA(1c) (<7.5%) than patients in usual care (42.6 vs. 24.6%, P < 0.03, chi(2)). There were no significant differences in any of the psychosocial variables or in physician visits., Conclusions: A nurse-care management program can significantly improve some medical outcomes in patients with complicated diabetes without increasing physician visits.

Study Design: A genomic screen and statistical linkage analysis of a large sample of families with individuals having idiopathic scoliosis was performed., Objectives: To identify an X-linked susceptibility locus involved in the expression of familial idiopathic scoliosis., Summary of Background Data: A large sample of families with individuals having idiopathic scoliosis (202 families; 1198 individuals) were diagnosed through physical examination and radiographic criteria, and genomic screening and genetic linkage analyses were performed., Methods: Model-independent linkage analysis was used to screen genotyping data from 15 X-linked markers in 202 families (1198 individuals). Families were stratified based on the ratio of the likelihood of an X-linked dominant (XLD) inheritance model relative to that of an autosomal dominant (AD) model. Both model-independent and model-dependent linkage analyses were used to identify potential candidate regions., Results: When the entire set of families were analyzed with model-independent methods, no result was significant at the 0.05 level for any of the markers. However, when the families were stratified based on the ratio of the likelihood of the X-linked dominant to autosomal dominant mode of inheritance, results from model-dependent linkage analysis of 15% of the families most likely to have X-linked dominant inheritance showed six adjacent markers with positive lod score values and a maximum lod score of 1.69 (theta = 0.2) at marker GATA172D05. A lod score of 2.23 at this same marker was found in a single family with six affected individuals., Conclusion: The results suggest that a region on the X chromosome may be linked to the expression of familial idiopathic scoliosis in a subset of these families.

A program of in situ experiments, supported by laboratory studies, was initiated to study diffusion in sparsely fractured rock (SFR), with a goal of developing an understanding of diffusion processes within intact crystalline rock. Phase I of the in situ diffusion experiment was started in 1996, with the purpose of developing a methodology for estimating diffusion parameter values. Four in situ diffusion experiments, using a conservative iodide tracer, were performed in highly stressed SFR at a depth of 450 m in the Underground Research Laboratory (URL). The experiments, performed over a 2 year period, yielded rock permeability estimates of 2 x 10(-21) m(2) and effective diffusion coefficients varying from 2.1 x 10(-14) to 1.9 x 10(-13) m(2)/s, which were estimated using the MOTIF code. The in situ diffusion profiles reveal a characteristic "dog leg" pattern, with iodide concentrations decreasing rapidly within a centimeter of the open borehole wall. It is hypothesized that this is an artifact of local stress redistribution and creation of a zone of increased constrictivity close to the borehole wall. A comparison of estimated in situ and laboratory diffusivities and permeabilities provides evidence that the physical properties of rock samples removed from high-stress regimes change. As a result of the lessons learnt during Phase I, a Phase II in situ program has been initiated to improve our general understanding of diffusion in SFR., (Crown Copyright 2002 Published by Elsevier Science B.V.)

The etiology of familial idiopathic scoliosis is unknown. The role of genetic factors in the development of this disorder has been well documented; however, reports of the specific mode of genetic inheritance are inconclusive. These facts, combined with the phenotypic variability of this disorder suggest that the genetic expression of idiopathic scoliosis may be dependent on multiple factors and genetic interactions. Strategies to resolve the complex nature of this condition include genome-wide scanning of an extended family or, alternatively, a well-characterized population of families affected with idiopathic scoliosis.

External fixation of pediatric femoral shaft fractures has the advantages of minimal dissection and early weight bearing. However, it is associated with slow healing and potential for refracture. Some surgeons have proposed that axial dynamization may improve the speed and strength of callus formation. to test this hypothesis, we performed a randomized controlled trial using 53 femur fractures in 52 patients between 1995 and 1999. Patients were randomized to receive dynamic or static fixation. Average time until early callus formation was 23.2 days for dynamic fixation and 24.9 days for static fixation (P = 0.627). Average time until complete radiographic healing was 70.1 days for dynamic fixation and 63.1 days for static fixation (P = 0.370). Similarly, the differences in time to fixator removal and to full weight bearing did not reach statistical significance. The conclusion was that axial dynamization of external fixation for pediatric femur fractures has no significant effect on time to healing or frequency of complications.

The etiology of adolescent idiopathic scoliosis (AIS), the most common form of scoliosis, is unclear. Researchers with divergent perspectives have tried to better define this etiology. Genetics, growth hormone secretion, connective tissue structure, muscle structure, vestibular dysfunction, melatonin secretion, and platelet microstructure are major areas of focus. In this article, we review the literature in these areas and present the consensus on proposed hypotheses. Studies that simplify the etiology to a single factor have been inconclusive or unsuccessful. Most likely, the etiology is multifactorial, and reported associations are links in pathogenesis rather than etiologic factors. Research is needed to better define the role of all factors in AIS development.

Objectives: This article describes the demographic, psychosocial, and medical characteristics and smoking patterns of women hospitalized with cardiovascular disease (CVD) enrolled in the Women's Initiative for Nonsmoking (WINS) trial., Design: Study design is a randomized clinical trial with cross-sectional baseline data., Setting: Women enrolled during a 27-month period from 10 hospitals in the San Francisco Bay Area., Participants: Subjects included 277 women., Results: The women's ages ranged from 33 to 86 years, with a mean age of 60.7 (+/-10) years. Most (51%) were college graduates, had attended some college or had postgraduate degrees; 40% were married; 76% were white. Median income was between 30,000 dollars and 35,000, but 27% of the women had incomes less than 15,000 dollars per year. The women smoked a median of 20 cigarettes per day (range, 1-90). Median age when women began smoking was 18.6 years; average number of years smoked was 40; and 78% had made more than 2 previous attempts to quit. On a 10-point scale, 71% of the women rated their confidence to quit smoking (self-efficacy) as 5 or greater. According to the Burnam Depression Screener, 56.7% were depressed., Conclusions: This is the largest study describing the smoking patterns of women hospitalized with CVD. These women were older, white, had smoked for many years, were moderately to highly addicted to tobacco, had few financial resources, and a large proportion were depressed. These important psychosocial factors need to be taken into account when planning smoking cessation interventions for women with CVD.

Idiopathic scoliosis is a highly prevalent disorder, familial in nature, with marked clinical variability. The purpose of this study was to characterize idiopathic scoliosis in a large series of families to be used for a genome-wide search. One hundred thirty-one multigenerational families (892 individuals) with at least two affected individuals were studied. Data obtained included curve pattern, treatment, and back pain. Maximum curvature as a continuous variable was evaluated using t tests for dichotomous characteristics and linear correlation for continuous variables. An analysis of familial loading was done. Four hundred forty-four individuals were classified as affected (82% female; 18% male). The right thoracic and left lumbar curves had the highest mean curvature (49 degrees). Mean curve size was greater in individuals with back pain. Back pain was most prevalent in the right thoracic and left lumbar curve pattern. The Pearson correlation coefficient between the number of affected family members and the maximum degree of curvature was 0.16, suggesting that the greater the lateral curvature, the higher the proportion of family members affected with scoliosis. The sample population is consistent with those of previous studies in relation to gender and curve size. Statistically, the familial nature of this disorder is supported.

Women's Initiative for Nonsmoking (WINS) is a randomized clinical trial designed to test the efficacy of a nurse-managed smoking cessation and relapse prevention intervention designed specifically for women. The WINS intervention is rooted in social learning theory, specifically that of self-efficacy. It is a multimedia approach that provides education, counseling, and telephone follow-up that meet the smoking cessation intervention guidelines established by the Agency for Health Care Policy and Research. The WINS intervention has been successfully implemented in more than 140 women and has proven to be feasible and well accepted by both the women and their health care providers. Although the intervention in the protocol-driven randomized clinical trial was begun in the hospital, it is anticipated that nurses in any setting, inpatient or outpatient, who serve populations at risk for cardiovascular disease, peripheral vascular disease, lung cancer, or pulmonary disease could successfully provide the intervention.

Current population studies characterize idiopathic scoliosis as a single-gene disorder that follows the patterns of mendelian genetics, including variable penetrance and heterogeneity. The role of melatonin and calmodulin in the development of idiopathic scoliosis is likely secondary, with indirect effects on growth mechanisms. Reported abnormalities of connective tissue, skeletal muscle, platelets, the spinal column, and the rib cage are all thought to be secondary to the deformity itself. Although no consistent neurological abnormalities have been identified in patients with idiopathic scoliosis, it is possible that a defect in processing by the central nervous system affects the growing spine. The true etiology of idiopathic scoliosis remains unknown; however, it appears to be multifactorial.

Adolescent idiopathic scoliosis is a highly prevalent disorder of the spine, occurring in phenotypically normal individuals for unknown reasons. The role of genetic factors in this condition has been widely documented through clinical observations and population studies. Multiple areas of research, including connective tissue, neuromotor mechanisms, hormonal system, and biomechanics, have been explored for a potential relationship to the cause of idiopathic scoliosis; however, no clear evidence supports any one area as a etiologic factor of this disorder. The main difficulty of most investigations is to determine whether the observed abnormalities are primary or secondary features in the scoliotic deformity. It is hoped that continued research efforts will aid in the understanding of this disorder in an effort to improve the ability to assign a more specific prognosis.

Pes planus is a term frequently used in describing flatfoot; however, no study has objectively defined flatfoot. We evaluated the single leg stance footprint of 40 feet in 21 people with no history of foot problems, using pressure-sensitive film and a Harris mat. The medial and lateral aspects of the forefoot, midfoot, and hindfoot were assessed. The midfoot was further analyzed by dividing the medial midfoot force by the total midfoot force. The mean medial midfoot force/total midfoot force was 11.1% (SD = 6.5%). Pes planus was defined as the medial midfoot force/total midfoot force > 24.0% (mean + 2 SD). A population associated with pes planus (124 feet in 63 patients with Marfan syndrome) was then evaluated in the same fashion. Although the mean medial midfoot force/total midfoot force was not statistically different (16.0%), a distinct group of patients (25%) had forces that were outside the range of normal midfoot forces.

This study extends the results of a large randomized clinical trial of a multicomponent in-hospital smoking cessation intervention for general hospitalized smokers by examining subgroups of patients who responded to the intervention. The results, obtained using signal detection analysis, produced 6 subgroups of patients with varying degrees of intervention responsiveness. The subgroup most responsive was marked by 100% confidence to quit smoking at baseline. Among patients with less than 100% confidence, confidence interacted with age, depressed mood scores, addiction scores, and alcohol intake to discriminate 5 additional subgroups. Discussion focuses on how this information can be used in clinical decision making to treat subpopulations of smokers and directs attention to possible areas of underlying biopsychosocial processes that may interact to affect successful long-term cessation.

The feet of Marfan patients are typically described as pes planovalgus. We evaluated the single-leg-stance footprint of 124 feet in 63 patients with the Marfan syndrome by using pressure-sensitive film and a Harris mat. Forty feet in 21 people with no history of foot problems were evaluated as normal controls. The medial and lateral aspects of the fore-, mid-, and hindfoot were assessed. The midfoot was further analyzed by dividing the medial midfoot force by the total midfoot force. The mean medial midfoot force/total midfoot force (MM/TM) in the control population was 11.1% (SD, 6.5%). Pes planus was defined as the MM/TM force > 24.0% (mean + 2 SD). The mean MM/TM force in the Marfan group was not statistically different (16.0%) from controls. The distribution, however, revealed two distinct types of weight-bearing patterns. Of the Marfan group, 74.8% had medial forces within the standard distribution of the normal control population. Only 25.2% of the Marfan patients had forces that were outside the range of normal midfoot forces and were defined as pes planus. Analysis of the patient's ligamentous laxity and the foot function in the Marfan population revealed no statistically significant correlation to the type of weight-bearing pattern of the foot.

Objective: To document the practices and attitudes of the US physician members of the Society for Adolescent Medicine (SAM) regarding adolescent abortion and contraception, as well as physician willingness to prescribe medical abortion if approved by the Food and Drug Administration (FDA)., Design: Cross-sectional questionnaire survey. Participants. The entire physician membership of SAM (N = 1001) was surveyed. A total of 713 physicians responded, with 668 usable surveys yielding an adjusted response rate of 70%., Results: Of the respondents, 81% were trained as pediatricians; 58% had additional adolescent medicine training. Ninety-six percent prescribed contraception for their patients. Sixty-one percent of respondents identified abortion as an option for pregnant adolescents in all circumstances, whereas 4% believed abortion should never be an option. Eighty-nine percent referred their patients for abortions; 90% were aware of medications to induce abortions medically. If these medications (methotrexate and misoprostol, RU-486) were FDA-approved, 42% would prescribe them for their patients; 34% were unsure. Fifty-four percent believed if medical abortions were routinely available, they should be available from primary care physicians. Physicians were significantly more likely to consider prescribing medical abortions if the physician were female, offered postcoital contraception, performed Norplant insertions, referred adolescents for abortions, or performed postabortion medical checkups. Physicians were no more likely to consider prescribing medical abortions according to physician age, specialty training, or date of residency training. Religious affiliation per se was not associated with likelihood of prescribing medical abortions, but Catholic physicians were significantly less likely to consider prescribing medical abortions., Conclusions: Virtually all SAM physician respondents (96%) reported that abortion for pregnant adolescents should be available under some circumstances. Forty-two percent would prescribe medical abortion if the medications were FDA-approved, suggesting that medical abortion would potentially be available to adolescents from a larger group of physicians than is currently available.

Despite the universally accepted importance of compliance, strategies known for more than two decades to be effective are not routinely incorporated into clinical practice. For the benefits of primary and secondary prevention to be realized in diverse population groups and settings, emphasis must be placed on implementing strategies at the patient, provider, and organization levels. Current knowledge of compliance strategies, if integrated into a multilevel approach, offers enormous promise for decreasing risk and improving patient outcomes.

At least one third of hospital admissions for heart failure result from noncompliance with therapeutic regimens, both dietary and pharmacologic. In chronic diseases, noncompliance with both lifestyle modification and medication regimens is a major health problem. Patients frequently stop taking their medications because they consider them ineffective or because they experience unpleasant side effects. In asymptomatic conditions, patients may believe they do not need the medication and may not even fill their prescription. If they do obtain the medications, they may forget to take them regularly. Educational efforts and behavioral techniques can improve patient compliance in chronic, asymptomatic conditions, but one of the most effective strategies remains improved patient-physician communication.

The effectiveness of heart failure management in clinical practice is limited by physicians' suboptimal utilization of effective medications, patients' poor adherence to dietary sodium limitation and optimal drug therapy, and the lack of systematic monitoring of patients after hospitalization. The present study evaluated the feasibility and safety of MULTIFIT, a physician-supervised, nurse-mediated, home-based system for heart failure management that implements consensus guidelines for pharmacologic and dietary therapy using a nurse manager to enhance dietary and pharmacologic adherence and to monitor clinical status by frequent telephone contact. Fifty-one patients with the clinical diagnosis of heart failure were followed for 138 +/- 44 days. Daily dietary sodium intake fell by 38%, from 3,393 to 2,088 mg (p = 0.0001); average daily medication doses increased significantly (lisinopril: 17 to 23 mg, p <0.001; hydralazine: 140 to 252 mg, p = 0.01). Functional status and exercise capacity improved significantly (p = 0.01). Compared with the 6 months before enrollment and normalized for variable follow-up, the frequency of general medical and cardiology visits declined by 23% and 31%, respectively (both p <0.03); emergency room visits for heart failure and for all causes declined 67% and 53%, respectively (both p <0.001). Hospitalization rates for heart failure and for all causes declined 87% and 74%, respectively (p = 0.001), compared with the year before enrollment. The MULTIFIT system enhanced the effectiveness of pharmacologic and dietary therapy for heart failure in clinical practice, improving clinical outcomes and reducing medical resource utilization.

Adolescent idiopathic scoliosis is a genetic disorder of unknown etiology. Scoliosis is a clinical feature of inherited connective-tissue disorders including Marfan syndrome. Mutations within the gene of FBN1 (fibrillin 15), a component of the extracellular matrix, are now linked to Marfan syndrome and similar clinical phenotypes. This study investigated the potential association of structural genes encoding for extracellular matrix components of FBN1, elastin, and one of the polypeptides of type-I collagen (COL1A2) with familial adolescent idiopathic scoliosis. Eleven pedigrees, including 96 individuals, were identified in which adolescent idiopathic scoliosis segregated in an apparent autosomal dominant pattern. Fifty-two individuals were determined to be affected with scoliosis. Genomic DNA was analyzed by genetic linkage utilizing four intragenic markers for the structural genes of FBN1, elastin, and COL1A2. Collectively, our results exclude the structural genes of FBN1, elastin, and COL1A2 as candidate genes within these families. However, when viewed individually, specific markers cannot be excluded within all of the families. This information complements previously reported data that fibrillin production and matrix incorporation from scoliotic fibroblasts in vitro are normal in more than 80% of patients studied.

Objectives: This study evaluated a nurse-managed smoking cessation program for smokers hospitalized for a variety of conditions., Methods: Hospitalized patients who smoked prior to hospitalization and who were motivated to quit (n = 660) were randomized to intervention or usual-care groups and followed for the next year. The intervention included a meeting with the nurse-case manager; the use of a videotape, workbook, relaxation audiotape, and nicotine replacement therapy; and nurse-initiated phone contacts after discharge., Results: The 12-month confirmed cessation rates were 21% and 31% for, respectively, the usual-care and intervention groups (odds ratio = 1.7; 95% confidence interval = 1.1, 2.3)., Conclusions: A nurse-managed smoking cessation intervention can significantly increase cessation rates for hospitalized patients.

Objective: To determine how employment as a resident physician (resident) affects breastfeeding practices and experiences., Design: Cross-sectional questionnaire survey., Setting: US resident physicians in the second half of their postgraduate year three (PGY3)., Participants: 1500 questionnaires were mailed at random to female 1990 graduates of American medical schools. After eliminating unusable surveys, an adjusted response rate of 45% produced 450 surveys; 60 delivered a child during residency., Interventions: None. MEASUREMENT/MAIN RESULTS: Forty-eight (80%) of 60 residents who delivered initiated breastfeeding, and continued for the duration of their maternity leave (mean, 7 weeks). With a return to residency half (24) of those who had initiated breastfeeding discontinued breastfeeding. The breastfeeding rate dropped to 15% (9/60) at 6 months. Residency work schedule was the most common reason (80%) for discontinuing breastfeeding. Of the 24 residents who continued breastfeeding while working, 83% pumped breast milk during their work shifts; 79% felt there was insufficient time during work, and 42% reported no appropriate place at work to express milk. Only 54% who continued felt supported by their attending physicians for their efforts to breastfeed; 67% felt colleagues were supportive., Conclusions: The breastfeeding initiation rate for resident mothers was in compliance with the Healthy People 2000 guidelines, but the rate at infant age 6 months fell well below the goal of 50%. Modifiable factors in residents' work sites include both physical and emotional accommodations to encourage resident mothers to breastfeed.

1. Despite the merits of physical activity reducing the risk of hypertension and showing other health benefits, Americans continue to be relatively sedentary. 2. Low to high intensity physical activities result in a reduction in both systolic and diastolic blood pressure in middle aged to older adults. Individuals can obtain benefits by engaging in aerobic exercise, a wide variety of leisure time activities, short bouts of exercise, and even isometric work. 3. Behavioral techniques of contracting, self monitoring, and relapse prevention training offer important methods to help clients adopt and maintain physical activity.

Unlabelled: Little is known about the use of depot medroxyprogesterone acetate (Depo-Provera, DMPA) in U.S. adolescents before the FDA approved its usage for contraception in 1992., Purpose: To determine the experience with DMPA use in adolescents for contraception in the United States., Methods: A questionnaire survey was sent to U.S. physicians identified as adolescent health care providers., Result: DMPA had been prescribed by 41% of surveyed physicians who prescribe contraception for adolescents. Eighty-five percent of patients continued use beyond nine months and 40% continued beyond 21 months. Sixty-seven percent of physician/respondents reported using DMPA in mentally retarded patients., Conclusions: Many providers used DMPA for contraception in adolescents prior to its FDA approval for contraception. DMPA has a high rate of continuation of use as a contraception in adolescents.

Objective: To evaluate the efficacy of a physician-directed, nurse-managed, home-based case-management system for coronary risk factor modification., Design: Randomized clinical trial in which patients received a special intervention (n = 293) or usual medical care (n = 292) during the first year after acute myocardial infarction., Setting: 5 Kaiser Permanente Medical Centers in the San Francisco Bay area., Patients: 585 men and women aged 70 years or younger who were hospitalized for acute myocardial infarction., Intervention: In the hospital, specially trained nurses initiated interventions for smoking cessation, exercise training, and diet-drug therapy for hyperlipidemia. Intervention after discharge was implemented primarily by telephone and mail contact with patients in their homes. All medically eligible patients received exercise training; all smokers received the smoking cessation intervention; and all patients received dietary counseling and, if needed, lipid-lowering drug therapy., Outcome: Smoking prevalence and plasma low-density lipoprotein cholesterol (LDL) concentrations were measured 2 months after infarction, and functional capacity was measured 6 months after infarction., Results: In the special intervention and usual care groups, the cotinine-confirmed smoking cessation rates were 70% and 53% (P = 0.03), plasma LDL cholesterol levels were 2.77 +/- 0.69 mmol/L and 3.41 +/- 0.90 mmol/L (107 +/- 30 mg/dL and 132 +/- 30 mg/dL) (P = 0.001), and functional capacities were 9.3 +/- 2.4 METS and 8.4 +/- 2.5 METS (P = 0.001), respectively., Conclusion: In a large health maintenance organization, a case-management system was considerably more effective than usual medical care for modification of coronary risk factors after myocardial infarction.

1. The National Cholesterol Education Program ATP II Report clearly defines those individuals most likely to benefit from drug therapy for treatment of cholesterol. 2. Knowing the choice of drugs, method of action, administration hints, and side effects of these agents is important for occupational health nurses. 3. The nurse's role in providing education, defining techniques to enhance compliance to medications, and reinforcing change in lifestyle behaviors is key to the client's success in maintaining life long therapy for cholesterol management.