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Postpartum hemorrhage (PPH) is a medical emergency that is the primary cause of nearly one-quarter of all maternal deaths worldwide. Prelicensure nursing students are often underprepared to respond to obstetrical emergencies, such as PPH, due to a lack of exposure in the clinical setting. Simulation is used to aid students in developing knowledge, skills, and attitudes in clinical learning and emergency scenarios. The purpose of this pilot study was to evaluate student knowledge before and after participation in a high-fidelity simulation of a patient experiencing PPH. Student confidence and satisfaction after the experience was also assessed. Findings demonstrated that high-fidelity simulation significantly increased student knowledge related to PPH nursing care (p = 0.001). Student perceived confidence and satisfaction were also aggregately rated at 95% after the simulation experience. The PPH scenario utilized is described, and implications of implementing simulation in prelicensure nursing programs are discussed.

Background The results remain mixed regarding improved student academic performance and satisfaction when 2-stage collaborative testing (CT) is used in nursing education. Purpose The purpose of this study was to evaluate student academic performance and perceived satisfaction after a CT experience and to compare academic performance between a CT and non-CT cohort. Methods A quantitative design was used to evaluate the effect of CT on academic performance by comparing examination scores and item difficulty values (IDVs) within a CT cohort (n = 111) and between the CT cohort and non-CT retrospective cohort (n = 105). A faculty-created survey was used to measure student-perceived satisfaction in the CT cohort. Results Student examination scores increased after the CT experience on a duplicate unit examination. The IDVs on 8 content-specific duplicate final examination items 1 month after the CT experience were significantly increased. There were no significant differences in the IDVs on the 8 content-specific items between a CT and non-CT retrospective cohort. Conclusions Collaborative testing is an active learning modality that can be used in nursing programs to aid students in their learning of specific nursing concepts.

Introduction: The unpredictable nature of the COVID-19 pandemic portends further uncertainty in patient decisionmaking. This study explores decisional conflict and patientspecific concerns for people undergoing otolaryngologic surgery during the pandemic. Method: This was a prospective, single-institution, crosssectional study of English-speaking adults undergoing otolaryngologic surgery, conducted from April 22 to August 31, 2020. Individuals who were non-English speaking, lacked autonomous medical decision-making capacity, underwent emergent surgery, or had a communitive disability were excluded. The primary outcome of decisional conflict was measured using the validated “SURE” screening questionnaire. Relationships between decisional conflict and patient demographics were assessed via bivariate analyses, multivariable logistic regression, and conjunctive consolidation. The secondary outcome of patient-specific concerns was obtained through open-ended interview and qualitatively assessed using thematic analysis with open coding. Results: There was a 41% response rate (182 of 444 patients). The median age was 60.5 years (range 18-88);92 patients (51%) were women. Decisional conflict was more prevalent in non-White compared with White participants (difference 18%;95% CI, 0.6%-37.0% and adjusted odds ratio 3.0;95% CI, 1.2-7.4). Combining information from multiple variables through conjunctive consolidation, the group with the highest rate of decisional conflict was non- White patients with no college education, receiving urgent surgery. “Intraoperative” and “postoperative concerns” were the most common patient-specific concerns. Among those patients reporting concerns about COVID-19, the majority had decisional conflict. Conclusion: This study highlighted factors associated with decisional conflict and emphasized the need for physicians to engage in shared-decision making with patients. The COVID- 19 pandemic contributed to decisional conflict. Consistent discussion of risks and benefits is essential. The role of race and decisional conflict needs further study.

Objective Cognitive performance in trauma-exposed populations, such as combat Veterans, has been shown to be worse than in nonexposed peers. However, cognitive performance has typically been within the normal range (within 1 SD of normative mean), and the prevalence of clinically significant cognitive dysfunction (i.e., performance more than 1 SD below the mean on multiple measures in a domain) in younger adults with trauma exposure remains unknown. The objective of our study was to measure this. Method We applied Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) cutoffs for clinically significant cognitive dysfunction (>1 SD below the mean in multiple measures within a domain) in the domains of memory, executive function, and attention to a sample of combat-exposed Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND; N = 368, mean age = 31.7 years, 90% men) Veterans. We then compared psychiatric, physiological, and neural measures, as well as functional outcomes, between those with and without cognitive dysfunction. Results Veterans with cognitive dysfunction (n = 129, 35.1%) had lower premorbid reading ability and more severe psychological distress, including increased anxiety, depression, posttraumatic stress disorder (PTSD), sleep difficulties, pain, and alcohol consumption. Those with cognitive dysfunction also had worse functional outcomes, with mild but significant disability. In contrast, we found associations between outcome and age, traumatic brain injury, physiological and neural measures to be weak or not significant. Conclusions Together, this suggests that premorbid abilities and trauma-related psychological symptoms contribute significantly to cognitive dysfunction in OEF/OIF/OND Veterans, and that neurological insult and aging may play less of a role. Cognitive dysfunction may be at least partially ameliorated by treating trauma-related symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective The objective of this study is to evaluate patient and provider satisfaction with telemedicine encounters across 3 otolaryngology practices. Study Design Cross-sectional survey. Setting A military community hospital, an academic military hospital, and a nonmilitary academic center. Methods A telephone-based survey of patients undergoing telemedicine encounters for routine otolaryngology appointments was performed between April and July 2020. Patients were asked about their satisfaction, the factors affecting care, and demographic information. A provider survey was emailed to staff otolaryngologists. The survey asked about satisfaction, concerns for reimbursement or liability, encounters best suited for telemedicine, and demographic information. The results were analyzed with descriptive statistics and a multivariable logistic linear regression model to determine odds ratios. Results A total of 325 patients were surveyed, demonstrating high satisfaction with telemedicine (average score, 4.49 of 5 [best possible answer]). Patients perceived “no negative impact” or “minor negative impact” on the encounter due to the lack of a physical examination or face-to-face interaction (1.86 and 1.95 of 5, respectively). High satisfaction was consistent across groups for distance to travel, age, and reason for referral. A total of 25 providers were surveyed, with an average satisfaction score of 3.44 of 5. Providers reported “slight” to “somewhat” concern about reimbursement (40%) and liability (32%). Conclusion Given patients’ and providers’ levels of satisfaction, there is likely a role for telemedicine in otolaryngology practice that may benefit patient care independent of the COVID-19 pandemic.

In interventional radiology (IR), registered nurses provide moderate sedation under the direction of the provider performing the procedure. The nurses identified a need to have more standardized education and training, inclusive of clinical issues, such as airway management, distress, capnography, and others. As nurse-administered moderate sedation continues to advance in part because of advances in IR procedures, nurses will need thorough continuing education to ensure safe and quality care for their patients. The purpose of this study was to explore educational interventions that will assist IR nurses administering moderate sedation in their perceived importance, knowledge, confidence, competence, and satisfaction. A pre/post survey intervention design was used to assess the change in nurses' perceived importance, confidence, competence, and satisfaction after an American Nurses Credentialing Center (ANCC)-approved educational online program and an airway management practicum by the Department of Anesthesia. Statistically significant findings from pre to post ANCC educational program including, specifically, the airway management training with anesthesia personnel had a p value of

Objective The cochlear implant (CI) improves quality of life for people who are severely and profoundly deafened, allowing implantees to perceive speech at levels similar to those of individuals with normal hearing. However, patients with CIs generally report a reduced appreciation of music after implantation. We aimed to systematically review the English-language literature for studies evaluating music enjoyment and perception among adult patients with CIs. Data Sources A systematic review of PubMed/MEDLINE, Scopus, Embase, and the Cochrane Library. Review Methods The PRISMA statement was utilized to identify English-language studies reporting music appreciation among adults with CIs. Two independent reviewers performed searches through May 2017. Included studies investigated parameters related to music enjoyment and music perception, including (1) pitch and timbre perception, (2) noise-canceling algorithms, and (3) the presence of dissonant chords, lyrics, or visual cues. Results A total of 508 articles were screened for relevance. Forty-one full-text articles were evaluated, and 18 met final inclusion criteria. Studies used heterogeneous methods of outcome measurement for identifying music appreciation. The outcome measures suggest that rhythm and lyrics are important components of enjoyment. Patients with CIs had difficulty with pitch and timbre perception. Conclusion The heterogeneous outcome measures identified in this systematic review suggest that rhythm and lyrics are important components of enjoyment, while patients with CIs had difficulty with pitch and timbre perception. Because there is no standardized reporting metric for music appreciation among adult patients with CIs, a standardized validated outcome-measuring tool is warranted.

The locus coeruleus (LC) plays a central role in regulating human cognition, arousal, and autonomic states. Efforts to characterize the LC’s function in humans using functional magnetic resonance imaging have been hampered by its small size and location near a large source of noise, the fourth ventricle. We tested whether the ability to characterize LC function is improved by employing neuromelanin-T1 weighted images (nmT1) for LC localization and multi-echo functional magnetic resonance imaging (ME-fMRI) for estimating intrinsic functional connectivity (iFC). Analyses indicated that, relative to a probabilistic atlas, utilizing nmT1 images to individually localize the LC increases the specificity of seed time series and clusters in the iFC maps. When combined with independent components analysis (ME-ICA), ME-fMRI data provided significant gains in the temporal signal to noise ratio relative to denoised single-echo (1E) data. The effects of acquiring nmT1 images and ME-fMRI data did not appear to only reflect increases in power: iFC maps for each approach only moderately overlapped. This is consistent with findings that ME-fMRI offers substantial advantages over 1E data acquisition and denoising. It also suggests that individually identifying LC with nmT1 scans is likely to reduce the influence of other nearby brainstem regions on estimates of LC function.HighlightsManual tracing of locus coeruleus increased specificity of seed time seriesManual tracing of locus coeruleus increased specificity of intrinsic connectivityMulti-echo fMRI increased temporal signal-to-noise ratio compared to single-echo fMRIConnectivity maps across methodologies overlapped only moderatelyMeasurement of LC function benefits from multi-echo fMRI and tracing ROIs

Sustained attention is a fundamental cognitive function underlying many activities in daily life including workplace safety, but its natural variation throughout the day is incompletely characterized. To examine time-of-day variation, we collected a large online data set (N = 6,363) with participation throughout the day and around the world on the gradual-onset continuous performance task, a sensitive measure of sustained attention. This allowed us to examine accuracy, attentional stability, and strategy. Results show that both accuracy and attentional stability peak between 9:00 and 11:00 a.m. and progressively decline throughout the day, whereas strategy is more stable.

Little evidence exists regarding the marginal decrease in health-related quality of life (HRQoL) in relation to the presence of hypertension among a Hispanic population based on US population-based research. This cross-sectional study used data from the 2014 to 2015 Medical Expenditure Panel Survey (MEPS). The target population was comprised of Hispanic community-dwelling residents with hypertension in the USA. The independent variable was the presence of hypertension. The dependent variable was HRQoL, which was measured using the Short Form-12 (SF-12) physical health composite scale (PCS) and mental health composite scale (MCS). A total of 13,933 members of the Hispanic population met the study inclusion criteria, and the estimated population size was 36,440,400 Hispanics. Among them, 82.9% did not have any hypertensive condition (n = 11,466), while 17.7% had some hypertensive condition (n = 2467). SF-12 PCS scores (95% CI) were 46.62 (45.68–47.57) in the Hispanic population with hypertension and 51.62 (51.1–52.14) in the Hispanic population without hypertension. SF-12 MCS scores (95% CI) were 52.67 (52.07–53.27) in patients without hypertension and 50.35 (49.45–51.26) in the Hispanic population with hypertensive conditions. The presence of hypertension was associated with lower HRQoL in the Hispanic population. Based on our findings, we suggest that healthcare providers should monitor a hypertensive minority population for anxiety and mood disorders and recommend psychiatric assessment and treatment if appropriate.

Objective: To compare treatment fidelity among treatment arms in the Telephone Assessment and Skill-Building Kit study for stroke caregivers (TASK II) with respect to: 1) protocol adherence; 2) intervention dosage and 3) nurse intervener perspectives. Design: A randomized controlled clinical trial design. Setting: Urban, community, midwestern United States. Subjects: A total of 254 stroke caregivers (mean ±SD age, 54.4 ±11.8 years), 55 (22.0%) males and 199 (78.4%) females) randomized to the TASK II intervention ( n=123) or an Information, Support, and Referral comparison group ( n=131). Interventions: TASK II participants received the TASK II Resource Guide; Information, Support, and Referral participants received a standard caregiver brochure. At approximately 8 weeks after discharge, both groups received 8 weekly calls from a nurse, with a booster call 4 weeks later. Measures: Protocol adherence was evaluated with the TASK II Checklist for Monitoring Adherence. Intervention dosage was measured by the number of minutes caregivers spent reading materials and talking with the nurse. Nurse intervener perspectives were obtained through focus groups. Results: Protocol adherence was 80% for the TASK II and 92% for the Information, Support, and Referral. As expected, intervention dosage differed between TASK II and Information, Support, and Referral with respect to caregiver time spent reading materials (t=-6.49; PConclusions: These findings substantiate treatment fidelity in both study arms of the TASK II stroke caregiver intervention trial (NIH R01NR010388; ClinicalTrials.govNCT01275495).

Impaired attention is the hallmark consequence of prenatal cocaine exposure (PCE), affecting brain development, learning, memory and social adaptation starting at an early age. To date, little is known about the brain structures and neurochemical processes involved in this effect. Through focusing on the visual system and employing zebrafish as a model, we show that PCE reduces expression of dopamine receptor Drd1, with levels reduced in the optic tectum and other brain regions, but not the telencephalon. Organism-wide, PCE results in a 1.7-fold reduction in the expression of the dopamine transporter (dat), at baseline. Acute cocaine administration leads to a 2-fold reduction in dat in drug-naive larvae but not PCE fish. PCE sensitizes animals to an anxiogenic-like behavioral effect of acute cocaine, bottom-dwelling, while loss of DAT due to genetic knockout (DATKO) leads to bottom-dwelling behavior at baseline. Neuronal calcium responses to visual stimuli in both PCE and DATKO fish show tolerance to acute cocaine in the principal regions of visual attention, the telencephalon and optic tectum. The zebrafish model can provide a sensitive assay by which to elucidate the molecular mechanisms and brain region-specific consequences of PCE, and facilitate the search for effective therapeutic solutions.

Children with gender variance and their parents struggle with negativity on a daily basis due to ignorance regarding their issues and needs. This study explored professionals’ views of these issues and needs via a qualitative Internet survey. Responses were examined using content and thematic analysis. The dominant identified needs for gender-variant children according to the professionals were to feel accepted, acknowledged and respected. Parents’ needs included emotional support and guidance, information, and access to competent, caring professionals. Implications of the study's findings were the need for professional training, funding for education and research, and efforts to reduce the social stigma associated with gender variance.

As torso flexion and repetitive lifting are known risk factors for low back pain and injury, it is important to investigate lifting techniques that might reduce injury during repetitive lifting. By normalizing lumbar posture to a subject's range of motion (ROM), as a function of torso flexion, this research examined when subjects approached their range of motion limits during dynamic lifting tasks. For this study, it was hypothesized that experienced lifters would maintain a more neutral lumbar angle relative to their range of motion, while novice lifters would approach the limits of their lumbar ROM during the extension phase of a straight-leg lift. The results show a statistically significant difference in lifting patterns for these two groups supporting this hypothesis. The novice group maintained a much more kyphotic lumbar angle for both the flexion (74% of the lumbar angle ROM) and extension phases (86% of the lumbar angle ROM) of the lifting cycle, while the experienced group retained a more neutral curvature throughout the entire lifting cycle (37% of lumbar angle ROM in flexion and 48% of lumbar angle ROM in extension). By approaching the limits of their range of motion, the novice lifters could be at greater risk of injury by placing greater loads on the supporting soft tissues of the spine. Future research should examine whether training subjects to assume more neutral postures during lifting could indeed lower injury risks.

Loss of sexual desire, often termed “hypoactive sexual desire” is a common problem among women of all ages. It has many different presentations and causes. Therapeutic success depends very much on understanding the nature of the symptom and identifying the possible responsible cause or causes in the particular patient. Two cases are presented of women who were referred for treatment of hypoactive sexual desire disorder in whom the underlying problem had not been identified by the referring therapist. Both women had lost sexual desire because of leakage of fluid from the urethra during orgasm. From the history and description of this occurrence it is evident that the women had different causes for the leakage and hence required different treatment. In one women, the leakage resulted from urinary incontinence and she was successfully treated by vaginal weights. The second woman experienced “female ejaculation” and was successfully treated by sex education and therapy. Following intervention, both women rega...

Purpose To review the body of literature addressing polypharmacy in individuals aged 60 years and older to (a) determine primary care providers’ definition of polypharmacy, (b) explore how polypharmacy was assessed in primary care, and (c) seek tested interventions that address polypharmacy. Data sources A systematic review of electronic bibliographic databases (e.g. EBSCOHost, InfoTrac, OVID, FirstSearch, and FirstSearch Deluxe) utilizing the search terms “polypharmacy,”“polypharmacy and elderly,”“polypharmacy and research,” and “multiple medications” for the period January 1991 to October 2003 was completed. The search was supplemented with online site searches of relevant journals and review of reference lists of each article. Conclusions Results of the literature review revealed that polypharmacy continues to be a significant issue and little research has been conducted regarding the methods primary care providers utilize to assess polypharmacy. Also, there is a gap in the literature regarding the interventions implemented by primary care providers to address polypharmacy. Implications for practice The following definition of polypharmacy in clinical practice might be more practical: the use of medications that are not clinically indicated. Selecting appropriate limits for numbers of medications may be counterproductive in populations with multiple comorbidities.

Clitstim (Vielle™) is a finger-cot shaped device that has been designed to increase digital clitoral stimulation when worn on a finger. Effects on the sexual response of 16 female volunteers of Clitstim-use and non-use (control) were compared in a randomized within subject study in which each subject reported on four episodes of Clitstim-use and four control episodes of masturbation. Orgasm latency was timed using a stop clock. Clitstim-use, compared to non-use, was associated with a shorter orgasm latency (5.57 vs. 13.05 minutes, p=0.005), an increased orgasm attainment rate (95.3% vs. 82.8%, p=0.044) and enhanced ease of attaining orgasm (4.25 vs. 3.0, p=0.005). Clitstim-use was also associated with increased orgasmic satisfaction (4.0 vs. 3.0, p=0.001). On the basis of these results, Clitstim may be helpful in the treatment of women who experience difficulty or delay in attaining orgasm. The improvement in orgasm consistency with Clitstim-use may be useful in the management of other forms of f...

A single mid-cycle blood sample was obtained from 15 premenopausal female patients presenting with lifelong absence of sexual drive and from a control group of women with intact sexual drive. Serum levels of testosterone, 5-dihydrotestosterone (5-DHT), 17 beta oestradiol, sex hormone binding globulin, and prolactin were measured and indices of free testosterone and 5-DHT were derived. During the menstrual cycle in which the blood samples were obtained, the study subjects kept a diary of their sexual desire and activities. The only endocrine parameter that is significantly different between the two groups is free testosterone, which is lower in the patients than in the control women. Associations between endocrine parameters and indices of sexual behavior were examined. In the control group, average daily sexual thoughts correlates positively with total testosterone, free testosterone index, and free 5-DHT. Feeling of "need for sex" correlates positively with free 5-DHT index and free testosterone index. Experience of sexual thoughts correlates with need for sex, and average frequency of masturbation correlates negatively with age. In both groups, average coital frequency correlates with free testosterone index.

This paper reports on selected aspects of a research project commissioned by the English National Board for Nursing, Midwifery and Health Visiting (ENB) to investigate the relationship between teaching, support, supervision and role modelling in clinical areas, within the context of Project 2000 diploma courses. The paper will focus upon findings which related to the role of the nurse teacher in practice settings. These were derived from interviews with students, practitioners and nurse teachers in three Project 2000 centres in England, and from a series of case studies in practice settings providing learning experiences for students undertaking the adult and mental health branches of Project 2000 diploma courses. Findings are discussed in relation to four broad areas: u • establishing a role for nurse teachers within the practice team; • preparation of practitioners for their role in student learning; helping students to link theory and practice; and • the nurse teacher's role in developing practice.

Background The Gender Feeling Amplitude (GFA) is a 68-item list of words and phrases with which to identify the feelings and severity of a young person’s distress regarding their gender identity and gender diversity, and takes ~1 min to administer. Method: For this pilot study, 67 adolescents and youth who sought support, confirmation or intervention (either via themselves or their parents) regarding gender diversity or gender transition were given the GFA in a face-to-face meeting before the beginning of an assessment procedure for gender diversity. Forty-three assigned females and 24 assigned males aged between 10 and 20 years were analysed by frequency of item, age and assigned gender. Results: Of the 68 items, those circled by close to 50% or more of the participants were ‘self-conscious’, ‘awkward’ and ‘don’t fit in’. One-third or more circled the words ‘shy’, ‘supported’, ‘hopeful’, ‘discomfort’, ‘as if I’m not being seen properly’, ‘forced to be something I’m not’, ‘depressed’ and ‘stressed’. Conclusion: Comparisons showed some variations in responses by both assigned gender and age, and the discussion includes ways the GFA may be able to assist a health practitioner with explorations of gender diversity and interventions for counselling.

BACKGROUND: Hormone replacement therapy (HRT) may play a role in the development of lung cancer and subsequent survival. Results from studies exploring these issues are inconsistent. A retrospective study in a rural population was conducted to determine whether a history of HRT use is associated with survival of postmenopausal women with lung cancer. METHODS: A retrospective medical chart review of 648 postmenopausal women, diagnosed with a first primary lung cancer between1995 and 2005, was conducted in a regional hospital in Paducah, Kentucky. History of HRT use was collected. Log-rank test and multivariate Cox regression analysis were performed to examine the effects of HRT on survival. RESULTS: The median survival for women with a history of HRT use was 16.4 months, compared with 10.5 months for women without a history of HRT use. However, this difference in survival was not statistically significant (hazard ratio, 1.09; 95% confidence interval, 0.82-1.44). Women with a history of HRT use were younger on average (64.3 years) at diagnosis than women without a history of HRT use (69.5 years, P < .01). Cigarette smoking was adversely associated with survival (P = .03), as were age (P < .01) and TNM stage (P < .01). CONCLUSIONS: In contrast to previous studies, within this population, a history of HRT use in postmenopausal lung cancer patients was not associated with decreased survival. Because most of the published studies on this issue are retrospective, the discrepant findings reflect the complexity of the role of HRT use in the survival of lung cancer patients. Cancer 2009. © 2009 American Cancer Society.

Satisfaction is a critical outcome for the healthcare system and an important influence on subsequent interactions with that system, yet findings have been inconsistent. This paper examined satisfaction as a multidimensional construct and focused on the interrelated influences of ethnicity and language, the potential confounding effects of economic resources and health status, and the possible role of perceived barriers to service delivery.The study was based on a phone survey conducted in 2005 of a stratified random sample of 207 Massachusetts patients in the National Breast and Cervical Cancer Early Detection Program, which used case managers to increase the rates of diagnostic testing among uninsured women at risk of breast or cervical cancer. Ethnicity, primary language, economic resources, and health status were each related to particular dimensions of patient satisfaction, but mostly independent of perceived barriers to program participation.The findings indicated that adequate evaluation of public health programs must conceptualize and measure satisfaction as multidimensional and supported the prediction of "segmented assimilation theory" that satisfaction can decline with time in the U.S.

Coronary heart disease (CHD) remains the leading cause of death in the United States. Immune mechanisms have been recently proposed to play an important role in the development of atherosclerotic plaques in CHD. Heat shock proteins and oxidized low-density lipoprotein are proinflammatory substances that have been shown to have an important role in the pathogenesis of atherosclerosis, and are now targets for clinical vaccine development. In addition, a vaccine has been developed to inhibit cholesteryl ester transfer protein. It is now recognized that many medications used to combat plaque development and rupture have significant anti-inflammatory effects and these effects are critical for drug efficacy. The influenza vaccine is associated with an atheroprotective effect. In addition, a nicotine vaccine, an antiangiotensin vaccine, and an anti-obesity vaccine may play a therapeutic role in modifying known risk factors for the development of atherosclerosis and its complications. This article reviews these vaccines as possible additions to the armamentarium of atheroprotective treatment modalities.

PURPOSE OF THE STUDY The purpose of this conceptual model of nursing and health policy-based study was to identify the frequency and correlates of activities performed by nurse case managers. PRIMARY PRACTICE SETTINGS Massachusetts Women's Health Network (WHN) contracting organization sites for breast and cervical cancer and cardiovascular disease risk screening. METHODOLOGY AND SAMPLE Twenty nurse case managers were interviewed. RESULTS More time was spent performing client service activities than bureaucratic activities. Frequently performed client service activities were tracking test results, finding/connecting with clients, assessing client needs, and educating clients. The most frequently performed activity was documenting services; the least, discharging clients. Client service activity frequency was correlated with client caseload size, social barriers, overall workload, satisfaction with the way activities are carried out in the WHN, special training in WHN policies and procedures, and contracting organization service delivery arrangements. Bureaucratic activity frequency was correlated with caseload size, workload, months as a WHN case manager, system barriers, satisfaction with the way activities were carried out in the WHN, and special training. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Documentation requires a great deal of WHN nurse case managers' time, which perhaps could be more productively spent with clients. Thus, more efficient ways to document services need to be identified. Additional research is needed to determine similarities and differences in activities performed by WHN nurse case managers and other case managers working in cancer and cardiovascular disease screening programs. Strategies need to be identified to remove all barriers that interfere with performance of case manager practice activities. Strategies are needed to reduce client fear of bills, overcome scheduling constraints, and improve translation services to lessen language barriers to effective communication.

Recombinant class 2 plasminogen activator inhibitor (PAI-2) was used in an approach to probe the formation and location of enzymatically active urokinase-type plasminogen activator (u-PA) sites on the surface of cultured human rhabdomyosarcoma cells (RD cells). Activation of pro-u-PA on the cell surface and consequent binding of PAI-2 was dependent on the addition of native plasminogen to serum cultures of the cells. Inhibition of the enzyme activity of surface-bound u-PA by the added PAI-2 resulted in a 79% reduction in the capacity of the RD cells to generate cell surface-associated plasmin activity from bound plasminogen. Under these conditions, the PAI-2 probe was localized at focal adhesions of RD cells, where it colocalized with both extracellular u-PA and intracellular vinculin antigens in double immunofluorescence labeling. Specificity of the probe's interaction with cell surface-bound u-PA was confirmed by blocking with a monoclonal antibody to human u-PA, which could also inhibit the formation of bound plasmin activity. These results showed the assembly of the plasmin-generating system at focal adhesions and the accessibility of bound u-PA on which it depends to added PAI-2. Therefore, PAI-2 has the potential both to localize at sites of tumor expression of functionally active u-PA and simultaneously to inhibit cell surface plasminogen activation.

Two siblings are described, ages 49 and 45 years, having a distinct hereditary motor and sensory neuropathy (HMSN) with severe peroneal nerve involvement. The neuropathic symptoms began in childhood. Both patients have sensorineural deafness. The proband was found to have a cardiac conduction abnormality in the absence of known ischemic heart disease. Electrodiagnostic studies were consistent with a demyelinating peripheral neuropathy. The presence of parental consanguinity and absence of affected individuals in succeeding or preceding generations suggested that the sensorimotor neuropathy in this family is inherited in an autosomal recessive manner. The sural nerve of the proband had significant loss of myelinated fibers and demyelination but few regenerating myelinated fibers and no onion-bulbs. The pathological findings, while nonspecific, are not characteristic of the hypertrophic, neuronal or intermediate types of HMSN.

The proband and her paternal grandmother had bilateral breast carcinoma and the Peutz-Jeghers syndrome. An ovarian sex cord tumor with annular tubules was an incidental finding when oophorectomy was performed as treatment of the proband's premenopausal breast cancer. Because there are previous reports of breast cancer in patients with this syndrome, the Peutz-Jeghers gene may be associated with an increased risk of breast tumors.