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PubMed2002

Family physicians' referral decisions: results from the ASPN referral study.

OBJECTIVE: To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN: Prospective cohort study. POPULATION: All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED: Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS: Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS: Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Decision Making↗
PubMed1999

Does managed care restrictiveness affect the perceived quality of primary care? A report from ASPN. Ambulatory Sentinel Practice Network.

BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction. METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction. RESULTS: Clinicians' reports of inconvenience were significantly associated (P < .001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit. CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients' reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.

Adult↗
PubMedDate not supplied

An exploratory report of chest pain in primary care. A report from ASPN.

Chest pain is important to patients and clinicians because it can signal a threat to life as well as present diagnostic and therapeutic challenges. Because prior clinical research has not provided clear guidance to primary care clinicians, the Ambulatory Sentinel Practice Network was interested in investigating chest pain as it presents and is managed in primary care. A contemporary exploratory study was required to characterize chest pain from a clinical perspective, to test the feasibility of investigating chest pain in a network of primary care practices, and to generate promising areas for investigation. This article provides a detailed distribution of demographic, diagnostic, and therapeutic variables associated with a convenience sample of 832 patients with chest pain. Most of the patients in this study were seen only by primary care clinicians in office settings. There were promising areas identified for further investigation, including an unexpected frequency of costochondritis in black women, clinician uncertainty in the management of patients with chest pain thought to be of gastrointestinal origin, constant vigilance for infrequent myocardial infarctions, perceived discordance between clinician and patient concerning the patient's chest pain, and the methodological requirement of improved delineation of episodes of chest pain.

Adolescent↗
PubMed1988

Patients with new headache in primary care: a report from ASPN.

From a consecutive series of 3,847 headache patients, 1,331 patients who made first visits for new headache to 120 primary care physicians were studied for usual care over a 14-month period. Either tension or vascular headache was the initial diagnosis in 23.8 percent and 12.8 percent of patients, respectively. Nearly one half (47.8 percent) were classified as having headaches other than tension or vascular. A total of 15.3 percent of headaches were undiagnosed or were regarded as a mixture of traditional diagnostic designations. At first visit, most patients (76.6 percent) were managed without diagnostic tests. Drugs were prescribed for 73.6 percent, and advice was given for 58.6 percent. Only 2.0 percent of patients had computerized tomographic scanning ordered at first visit, although at least 46 percent met National Institutes of Health criteria, a finding with potential economic consequences of at least $2 billion. These findings suggest the need for reevaluation of diagnostic categories for headache, reevaluation of strategies for headache management, and further investigations of headache in primary care patients.

Headache↗
PubMed1993

Detection of intracranial tumors, subarachnoid hemorrhages, and subdural hematomas in primary care patients: a report from ASPN, Part 2.

BACKGROUND: The initial diagnosis of intracranial tumor, subarachnoid hemorrhage (SAH), and subdural hematoma (SDH) can be difficult. This study was undertaken to determine the incidence and presenting signs and symptoms of these disorders in primary care settings, and to determine whether a more aggressive investigative strategy for patients with headache is justifiable. METHODS: Weekly return cards and a chart audit were used to collect data over a 19-month period on every patient who had a new diagnosis of intracranial tumor, SAH, or SDH. Age and sex reports were collected annually. RESULTS: Twenty-five new tumors, 17 SAHs, and 8 SDHs were reported in 58 practices (a rate of 12/100,000 patients per year). Only one half of these patients had headaches, and no abnormalities were found on neurological examination of many. Diagnosis was delayed in only four patients with headache caused by a brain tumor and in three patients with SAHs. Diagnosis was delayed in two of the latter because of false-negative CT scans. CONCLUSIONS: Although clinical findings and CT scans are not reliable indicators, clinicians are able to detect the majority of these rare conditions without undue delay by selecting a small subset of patients for further investigation. More extensive use of CT scans appears to be a weak strategy to improve detection of these serious disorders, as increased use would lead to increased health care costs and unintended adverse effects, and provide little benefit.

Adolescent↗
PubMed1993

The effect of parental expectations on treatment of children with a cough: a report from ASPN.

BACKGROUND: A previous retrospective study of children with cough raised questions about how physicians diagnose acute bronchitis. We hypothesized that if the physician perceives a parental expectation that an antibiotic is needed, it is more likely that a child with a cough will be diagnosed as having bronchitis and treated with an antibiotic. METHODS: Data were collected prospectively in 44 primary care practices in the Ambulatory Sentinel Practice Network. Variables examined included elements of the patient's history and physical examination, diagnoses made, and treatments prescribed. RESULTS: Data regarding 1398 patients were collected. A parental expectation that a prescription for an antibiotic would be given was associated with an increased likelihood of a diagnosis of bronchitis (relative risk 2.04, 95% confidence limits, 1.76 to 2.35, P < .001), and was second only to the physical finding of rales in the magnitude of its association with that diagnosis. The only other diagnosis associated with parental expectation of an antibiotic was viral upper respiratory tract infection, where parental expectation of treatment with an antibiotic was associated with a 49% reduction in the probability of that diagnosis. CONCLUSIONS: The expectations of parents of children with a cough appear to influence physician decision making.

Adolescent↗
PubMed1998

The family APGAR and psychosocial problems in children: a report from ASPN and PROS.

BACKGROUND: Our study examined whether the lack of social support as measured by the Family APGAR was related to parents' and physicians' identification of child psychosocial problems and sociodemographic and symptom characteristics of the children screened. METHODS: The parents of 9626 children, ages 4 to 15 years, seen for outpatient medical visits participated in this national study. Parents completed the Family APGAR and the Pediatric Symptom Checklist (PSC), a measure of psychosocial dysfunction. Physicians rated the presence of a new or recurrent psychosocial problem in the child. RESULTS: Children from families with a lack of social support were 4.3 times as likely to receive scores indicating impairment on the PSC and 2.2 times as likely to be identified as having psychosocial problems by physician report. Families with low social support were significantly more likely to report low parental educational achievement, single parent status, and a history of mental health services for the child. Fifty percent of children from families with low social support were identified as having a psychosocial problem by either the PSC or physician rating, or both; however, only 21% of the children identified with psychosocial impairment by these two measures had scores indicating poor family functioning on the Family APGAR. CONCLUSIONS: A lack of family social support is associated with child psychosocial dysfunction as assessed by two different measures. However, the Family APGAR was not a sensitive measure of child psychosocial problems, and thus it supplements, but does not replace, information concerning the child's overall psychosocial functioning.

Adolescent↗
PubMed2025

Fetal-like reversion in the regenerating intestine is regulated by mesenchymal asporin.

Mesenchymal cells and the extracellular matrix (ECM) support epithelium during homeostasis and regeneration. However, the role of the mesenchyme in epithelial conversion into a fetal-like regenerative state after damage is not known. We modeled epithelial regeneration by culturing intestinal epithelium on decellularized small intestinal scaffolds (iECM) and identify asporin (Aspn), an ECM-bound proteoglycan, as a critical mediator of epithelial fetal-like reprogramming. After damage, transient increase in Aspn expression by the pericryptal fibroblasts induces epithelial transforming growth factor &#x3b2; (TGF-&#x3b2;)-signaling via CD44 and promotes timely epithelial reprogramming. Temporal control of Aspn is lost in old mice, and after damage, the persistently high level of Aspn stagnates epithelium in the regenerative state. Increase in Wnt signaling can resolve the stagnated regenerative program of the old epithelium, promoting restoration of tissue function. In summary, we establish a platform for modeling epithelial injury responses ex&#xa0;vivo and show that the mesenchymal Aspn-producing niche modulates tissue repair by regulating epithelial fetal-like reprogramming.

Animals↗
PubMed2000

Correlation of neurosurgical subspecialization with outcomes in children with malignant brain tumors.

OBJECTIVE: This study was performed to evaluate the association between the type of neurosurgeon (general or pediatric) and either the extent of tumor removal or the frequency of complications in children undergoing malignant brain tumor resections. METHODS: Data were analyzed from three recent Children's Cancer Group studies: two on medulloblastomas/primitive neuroectodermal tumors and one on malignant gliomas. Neurosurgeons were classified as general neurosurgeons, as designated pediatric neurosurgeons in their institutions, or as members of the American Society of Pediatric Neurosurgeons (ASPN), which requires pediatric neurosurgical experience and practice standards. RESULTS: Data forms from 732 children were analyzed; 485 were from children with medulloblastomas/primitive neuroectodermal tumors, and 247 were from children with malignant gliomas. Operations were performed by 269 neurosurgeons, including 213 general neurosurgeons, 29 designated pediatric neurosurgeons, and 27 ASPN members. The mean number of operations per surgeon was 1.8, 4.9, and 7.6 for general neurosurgeons, designated pediatric neurosurgeons, and ASPN members, respectively. There was a significant relationship between the extent of tumor resection or the amount of residual tumor and the type of neurosurgeon. Designated pediatric neurosurgeons and ASPN members were more likely to remove more than 90% of the tumor and to leave less than 1.5 cc of residual tumor than were general neurosurgeons (P<0.05). In these studies, the probability of extensive tumor removal correlated with the number of operations the neurosurgeon performed (P<0.01). Neurological complications occurred in the following proportion of cases: general neurosurgeons, 23%; designated pediatric neurosurgeons, 32%; and ASPN members, 18%. CONCLUSION: Pediatric neurosurgeons are more likely than general neurosurgeons to extensively remove malignant pediatric brain tumors. In these tumors, extent of removal has been demonstrated to influence survival.

Brain Neoplasms↗
PubMed1998

Publication patterns of the American Society of Pediatric Neurosurgeons. Is there support among members for peer-reviewed pediatric neurosurgical journals?

The American Society of Pediatric Neurosurgeons (ASPN) has expressed a commitment to have all of its members' qualifying research efforts published in peer-reviewed pediatric neurosurgical journals such as Pediatric Neurosurgery. To test this commitment, citations from January 1985 through December 1994 were analyzed for all 76 current members of the ASPN. The citations were divided into those of general or adult neurosurgical interest, and those of pediatric neurosurgical interest based upon title, key words, and/or abstract. Each pediatric neurosurgical citation was further classified by topic, and by the type of journal in which it appeared (pediatric neurosurgical, general or adult neurosurgical, and other pediatric or adult journal, subspecialty journal, or basic science journal). A total of 1,887 individual author citations were identified during the study period; of these, 1,586 citations (84%) were classified as pediatric neurosurgical citations. These included 1,391 citations from peer-reviewed publications and 195 citations from Concepts in Pediatric Neurosurgery. As a society, the ASPN published only one third of its citations in peer-reviewed pediatric neurosurgery journals; the remainder were cited in general neurosurgical or other journals. Even when only citations from neurosurgical journals (in which pediatric neurosurgeons were more likely to be primary authors and therefore to have more control over the journal of publication) were analyzed, less than 50% of citations appeared in peer-reviewed pediatric neurosurgery journals. Nearly three quarters of ASPN members failed to provide even a modest commitment--publishing 51% or more of their pediatric citations in peer-reviewed pediatric neurosurgical journals. When the analysis was again limited to only those citations published in neurosurgery journals, over half of the members failed this '51% rule'. These results suggest the need for a firmer commitment from ASPN members to publish in peer-reviewed pediatric neurosurgery journals.

Humans↗
PubMed1991

AIDS in primary care: a report from the Ambulatory Sentinel Practice Network.

BACKGROUND: Despite the importance of the epidemic of acquired immune deficiency syndrome (AIDS), little is known about the incidence and prevalence of AIDS in the patient population of primary care physicians. This study was designed as an initial step in evaluating the impact of this disease on primary care practices. METHODS: We conducted a survey to characterize the AIDS cases in the Ambulatory Sentinel Practice Network (ASPN). ASPN is a practice-based primary care research network. In 1987 it was composed of 65 practices and 193 clinicians serving approximately 270,000 patients in the United States and Canada. Clinicians representing each practice were asked to report the number of AIDS patients that their practice cared for between January 1982 and December 1987. They were further asked to characterize relevant data for these patients. RESULTS: Thirty-nine prevalent cases of AIDS were reported in ASPN from January 1982 through December 1987. Seventy-nine percent of the patients were male, 15 to 44 years of age; three patients (7.6%) were female; and all cases had at least one risk factor for AIDS. An expected number of cases for the 194,973 patients of 47 practices was calculated using age-sex register data and nationally based rates from 1986. The projected number, 13, corresponded with the number of AIDS cases, 11 and 15, reported from ASPN practices in 1986 and 1987, respectively. CONCLUSIONS: This survey suggests that AIDS is at least as prevalent in the primary care practices in ASPN as predicted using national estimates, and may, in fact, be more prevalent. Primary care clinicians need to be prepared to assume a major role in addressing the AIDS epidemic.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Characterization of pathotype-specific epitopes of newcastle disease virus fusion glycoproteins by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and post-source decay sequencing.

Matrix-assisted laser desorption/ionization (MALDI) time-of-flight (TOF) mass spectrometry (MS) was used to characterize the F2 polypeptide of the fusion (F) protein of an avirulent isolate (VRI 82-6409) of Newcastle disease virus (NDV) that was previously identified by immunochemical screening as having a variant cleavage activation sequence in its fusion protein precursor (F0). The major glycoform of the intact F2 polypeptide of the VRI 82-6409 isolate was 89 Da smaller than the F2 polypeptide of the avirulent V4 isolate of the Queensland strain of NDV. Analysis of AspN protease digests of the F2 polypeptides by MALDI/TOF-MS, with and without high-performance liquid chromatographic (HPLC) separation, showed this mass difference to be due to a combination of differences in the extents of glycosylation and an amino acid difference in the AspN peptides derived from the C-termini of the F2 polypeptides. Accuracies achieved in analysis of the AspN peptides allowed the identification of this amino acid difference as glutamic acid in the VRI 82-6409 isolate compared with glycine in the V4 isolate. Analysis of fragments formed by post-source decay (PSD) of ions of the C-terminal AspN peptides localized the difference to the C-terminal residues of the respective F2 polypeptides. The present study demonstrated that MALDI/TOF-MS is a highly effective technique for the characterization of NDV variants identified by immunochemical screening of pathotype-specific epitopes at the C-termini of their F2 polypeptides.

Amino Acid Sequence↗
PubMed2005

Polymorphism in signal transduction is a major route through which osteoarthritis susceptibility is acting.

PURPOSE OF REVIEW: In the last year there has been considerable success in the identification of genes harbouring susceptibility for primary osteoarthritis. This report brings the reader up-to-date by focusing on three of the more compelling finds. RECENT FINDINGS: A UK group reported an association of the FRZB gene with hip osteoarthritis in females. FRZB codes for secreted frizzled-related protein 3, an antagonist of Wnt signalling. The Wnt signal transduction pathway is critical for normal development and is also active in adult tissues. Secreted frizzled-related protein 3 helps to maintain articular cartilage and the associated alleles at FRZB reduce the activity of this important protein. A Japanese group has reported an association of the asporin gene ASPN with knee and hip osteoarthritis and an association of the calmodulin 1 gene CALM1 with hip osteoarthritis. Asporin is a cartilage extracellular protein that regulates the activity of transforming growth factor-beta. Calmodulin is an intracellular protein that interacts with a number of proteins involved in signal transduction. The associated alleles at ASPN and CALM1 reduce the ability of chondrocytes to express the genes encoding aggrecan and type II collagen. Since these are essential structural components of articular cartilage, the ASPN and CALM1 associations are predicted to adversely affect the maintenance of cartilage. SUMMARY: The FRZB, ASPN and CALM1 results are compelling and highlight that polymorphism in signal transduction pathways is a major component of osteoarthritis susceptibility. This is an exciting observation since signal transduction pathways are malleable and therefore potentially amenable to intervention and modification.

Calmodulin↗
PubMed2001

The treatment of cerebrospinal fluid shunt infections. Results from a practice survey of the American Society of Pediatric Neurosurgeons.

It is our impression that the management strategy for infected cerebrospinal fluid (CSF) shunts varies significantly among pediatric neurosurgeons. The purpose of this paper is to present the results of a practice survey on the treatment of shunt infections which was distributed to all active members of the American Society of Pediatric Neurosurgeons (ASPN). Eighty-four of 129 ASPN members (65%) responded to the survey. Most ASPN members remove the shunt and place an external ventricular drain (EVD) to treat Staphylococcus epidermidis (59.5%), S. aureus (64.3%) and gram-negative rod infections (67.9%). The second most common method of treatment was externalization of the shunt (33.3, 29.8 and 25%, respectively). The duration of antibiotic treatment was extremely variable. When the shunt was removed and an EVD inserted, the duration of antibiotic treatment for S. epidermidis and S. aureus ranged from 5 to 21 total days (2-21 days of sterile cultures). For gram-negative rod infections treated with shunt removal and an EVD, the total duration of antibiotic therapy ranged from 5 to 24 days (2-37 days of sterile cultures). The majority of ASPN members remove the infected CSF shunt and place an EVD for the management of shunt infections. Significant variation exists in the duration of antibiotic therapy. Determining the most effective duration of antibiotic therapy in an effort to shorten hospitalization and minimize complications without sacrificing efficacy will require further study.

Anti-Bacterial Agents↗
PubMed1991

An analysis of reasons for discontinuing participation in a practice-based research network.

Now that primary care practice-based research networks are known to be feasible, it is important to learn more about the reasons practices participate and withdraw. The Ambulatory Sentinel Practice Network (ASPN) experience presents a special opportunity to study 32 practices that withdrew from the Network since it began in 1982. One hundred percent of these practices responded to a structured telephone survey. The desire to be part of a group doing research (47%) and response to recruitment by an esteemed colleague (28%) were the most important reasons for joining the Network. Changes within the practice (50%), the additional burdens associated with ASPN (22%), and lack of support among practice colleagues and staff (13%) were the most important reasons for withdrawing. Six suggestions were made that could have helped these practices continue in ASPN. Thirteen percent of practices that withdrew rejoined the Network at a later date. Eight years after initiating investigations, 70% of the practices that were ever part of ASPN remained fully involved.

Primary Health Care↗
PubMedDate not supplied

The development and management of a primary care research network, 1978-87.

The Ambulatory Sentinel Practice Network (ASPN) was created to increase the knowledge of primary care. Building on the experiences of other national and regional primary care research networks, ASPN has evolved as a North American network including practices in 25 U.S. states and four Canadian provinces in 1987. This paper summarizes ASPN's growth and development since 1978, the involvement of the ASPN practices, and the mechanisms used in developing and managing studies.

Ambulatory Care Information Systems↗
PubMed2002

Differences in the solution structures of the parallel beta-helical pectate lyases as determined by limited proteolysis.

The pectate lyase family of proteins has been shown to fold into a novel domain motif, the right-handed parallel beta-helix. As a means of gaining insight to the solution structure of the pectate lyases, the enzymes were subjected to limited proteolytic digestion by the endoproteases AspN, GluC and trypsin. The effects of proteolytic cleavage on enzymatic activity were determined, and the early products of proteolysis were identified by capillary electrophoresis, MALDI-TOF mass spectrometry and HPLC. A single peptide bond between Lys158 and Asp159 in pectate lyase B (PLb) was cleaved by both AspN and trypsin, with no detectable hydrolysis of PLb by GluC. Pectate lyase E (PLe) was hydrolyzed by trypsin between Lys164 and Asp165, a bond on an analogous loop structure found to be susceptible to proteolytic attack in PLb. AspN and GluC preferentially hydrolyzed peptide bonds (at Asp127 and Glu124, respectively) on another loop extending from the central beta-helical core of PLe. A single beta-strand of the central cylinder of the pectate lyase C (PLc) molecule was susceptible to all three proteases used. These data demonstrate that the most susceptible peptide bonds to proteolytic scission within the native enzymes lie on or near one of the three parallel beta-sheets that compose the core domain motif Despite the proximity of the proteolytic cleavages to the catalytic sites of the enzymes, significant retention of lyase activity was observed after partial proteolysis, indicating preservation of functional tertiary structure in the proteolytic products.

Binding Sites↗