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[Collecting blood specimens].

For the correct procedure of vein puncture--to collect blood specimens--it is necessary to keep strictly the rules of securing the safety of patient, the one who collects the specimen and also the specimen. The preparation of the patient for the vein puncture, the using of the correct method and vein, the appropriate time of doing this procedure, the using of the sufficient quantity of blood for every blood examination are included to the main elements for the success of the purpose of vein puncture. Another important element for the success of the above procedure is the comfortable and appropriate position of the patient, which gives the blood taker comfort in his work and keeps the patient free from undesirable events. The steps taken after this procedure can help: (a) keeping the vein in a good condition, (b) preventing undesirable events in the point of vein puncture, (c) sending the blood specimen safely to the laboratory, (d) safe disposal of the material used in the procedure. Undesirable events during the vein puncture should be faced immediately. In the newborn children blood specimen is collected from the finger with a different procedure. Also in isolated or mentally ill patients and those under radiation treatment the procedure is different. Those who collect and handle the blood specimens, nurses or laboratory technicians, do face important problems. For the prevention of harmful events special rules must be kept.

Blood Preservation↗

An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants.

OBJECTIVE: To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications. OPTIONS: The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined. OUTCOMES: Reduction of complications associated with long-term use of NSAIDs. EVIDENCE: Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996. VALUES: Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research. BENEFITS, HARMS AND COSTS: Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available. RECOMMENDATIONS: Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision. VALIDATION: These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.

Anti-Inflammatory Agents, Non-Steroidal↗

[Use of hypoprothrombinemia provocation test for early diagnosis of liver disease caused by harmful environmental agents].

The aim of this work has been to assess the feasibility of using Prothrombin Time (PT) Assay before and after administration of Pelentan (Hypoprothrombinemia Provocation (HPP) Test) for early detection of subclinical toxic hepatic injuries. The proposed modification of PT Assay is based on the observation that people with slight hepatic injury receiving small doses of Pelentan (diethylcoumarol) display remarkably longer PT than healthy people receiving similar doses of the chemical. The test group comprised 37 people occupationally exposed to hepatotoxic agents, 85 males permanently abusing alcohol, while 24 clinically healthy people, not exposed occupationally to the toxic agents served as the control. In addition, 26 hepatitis B and/or C virus carriers were also examined. The results show that: 1. HPP test enables assessment of hepatic function in patients with suspected hepatic injury and in people permanently abusing alcohol; 2. low value of serum prothrombin index 24 h and 48 h after the administration of Pelentan is indicative of the positive result of the test; 3. HPP test provides more information on the functional condition of liver than single PT determination by the Quick assay.

Adult↗

Public health investigations of hazardous organic chemical waste disposal in the United States.

Despite marked national concern, the number of published public health investigations of organic chemical hazardous wastes is small. Moreover, the extant literature provides little or no convincing evidence, either positive or negative, as to the question whether waste sites are harmful to human health. In this review, available literature is characterized as to time, place, and person. The majority of studies began 2 years or more after the end of exposure and 10 years after the start of exposure. Vast geographic areas of exposure have never been investigated. The number of study subjects evaluated has generally been too small to detect rare but important effects. The most common determinant of sites chosen for investigation has been the concern of local citizen groups. Several hypotheses are advanced to explain this pattern: methodologic and logistic difficulties; extensive litigation surrounding many waste sites; governmental reorganization which transferred environmental health from public health authority in the 1970s; and the presence of forces which have worked to block active community diagnosis.

Child↗

The evaluation of medical college students' preparation to propagate health education.

The propagation of health education is within the range of nurses' professional duties. It necessitates the use of specific methods and techniques of work. "Inasmuch as the doctor treats, it is the nurse who creates best possible conditions for recovering and keeping health conditions permitting treatment or prevention" (3, 12). The increased level of general education among people and changes in modern nursing make the nurse face new tasks in her work. Nurse must be qualified in the field of health education if she works in the out-patient medical service as well as in hospital. She must be able to convince people about the necessity of changing life style, harmful and improper habits. The fulfillment of this difficult, yet important task may change patient's and his family's health habits and behaviour. So, nowadays the nurse must combine two functions: health-nursing called health-missioner's work with sick-nursing (1, 4, 9). Work in the field of health education requires high level of professional knowledge, skills, methods, recognition of educational and sanitary needs of a social group, personal direct influence based on proper social attitude, which is very important (10, 11). Health education is best and most effectively propagated in situations of individual contact with the patient (7). Patients seeking help in medical service institutions are interested in their health and want to do something in the field (8). The analysis of nurse's and midwife's positions shows that work in out-patient health service and in hospital offers a close contact with the patient and his environment.(ABSTRACT TRUNCATED AT 250 WORDS)

Curriculum↗

Doctors in society. Medical professionalism in a changing world.

Medicine bridges the gap between science and society. Indeed, the application of scientific knowledge to human health is a crucial aspect of clinical practice. Doctors are one important agent through which that scientific understanding is expressed. But medicine is more than the sum of our knowledge about disease. Medicine concerns the experiences, feelings, and interpretations of human beings in often extraordinary moments of fear, anxiety, and doubt. In this extremely vulnerable position, it is medical professionalism that underpins the trust the public has in doctors. This Working Party was established to define the nature and role of medical professionalism in modern society. Britain's health system is undergoing enormous change. The entry of multiple health providers, the wish for more equal engagement between patients and professionals, and the ever-greater contribution of science to advances in clinical practice all demand a clear statement of medicine's unifying purpose and doctors' common values. What is medical professionalism and does it matter to patients? Although evidence is lacking that more robust professionalism will inevitably lead to better health outcomes, patients certainly understand the meaning of poor professionalism and associate it with poor medical care. The public is well aware that an absence of professionalism is harmful to their interests. The Working Party's view, based on the evidence it has received, is that medical professionalism lies at the heart of being a good doctor. The values that doctors embrace set a standard for what patients expect from their medical practitioners. The practice of medicine is distinguished by the need for judgement in the face of uncertainty. Doctors take responsibility for these judgements and their consequences. A doctor's up-to-date knowledge and skill provide the explicit scientific and often tacit experiential basis for such judgements. But because so much of medicine's unpredictability calls for wisdom as well as technical ability, doctors are vulnerable to the charge that their decisions are neither transparent nor accountable. In an age where deference is dead and league tables are the norm, doctors must be clearer about what they do, and how and why they do it. We define medical professionalism as a set of values, behaviours, and relationships that underpin the trust the public has in doctors. We go on to describe what those values, behaviours, and relationships are, how they are changing, and why they matter. This is the core of our work. We have also identified six themes where our definition has further implications: leadership, teams, education, appraisal, careers, and research. The Working Party's definition and description of medical professionalism, and the recommendations arising from them, can be found in Section 5 of this report. If our recommendations are acted upon, we believe that professionalism could flourish and prosper to the benefit of patients and doctors alike. However, the exercise of medical professionalism is hampered by the political and cultural environment of health, which many doctors consider disabling. The conditions of medical practice are critical determinants for the future of professionalism. We argue that doctors have a responsibility to act according to the values we set out in this report. Equally, other members of the healthcare team--notably managers--have a reciprocal duty to help create an organisational infrastructure to support doctors in the exercise of their professional responsibilities. Just as the patient-doctor partnership is a pivotal therapeutic relationship in medicine, so the interaction between doctor and manager is central to the delivery of professional care. High-quality care depends on both effective health teams and efficient health organisations. Professionalism therefore implies multiple commitments--to the patient, to fellow professionals, and to the institution or system within which healthcare is provided, to the extent that the system supports patients collectively. A doctor's corporate responsibility, shared as it is with managers and others, is a frequently neglected aspect of modern practice. The audience for this report is, first and foremost, doctors. But we believe it should be of equal interest to patients, policy-makers, members of other health professions, and the media. All these groups have a vital part to play in discussing and advancing medical professionalism. This report is only the beginning of an effort by the Royal College of Physicians, together with others, to initiate a public dialogue about the role of the doctor in creating a healthier and fairer society. Medical professionalism has roots in almost every aspect of modern healthcare. This Working Party could not hope to solve all the issues and conflicts surrounding professionalism in practice today. But our collective and abiding wish is to put medical professionalism back onto the political map of health in the UK.

Humans↗

Drug use among the urban poor in Kolkata: behaviour and environment correlates of low HIV infection.

BACKGROUND: HIV infection in injecting drug users (IDUs) has worked as a driving force for further spread of the virus in other population groups. Major metropolitan cities such as Mumbai, Kolkota, Chennai and Delhi have seen a diffusion of injecting drug use within the last decade. The prevalence of HIV infection among injectors ranges from 2% to 30%. Identifying effective interventional elements that have kept the prevalence of HIV low for the past 7 years among IDUs of Kolkata is thus of public health importance. METHODS: A purposive sample of opioid/opiate users was studied. Primary and secondary data on drug users, law-enforcement environment, records at drug treatment centres, jail admission data related to the 'Narcotic Drug and Psychotropic Substance Act' and interventions in other risk groups were collected. Laboratory tests for HIV, hepatitis B surface antigen and syphilis were done on consenting IDUs (n=129) and non-IDUs (n=120). For univariate and multivariate analysis, IDUs were taken as cases and non-IDUs as controls. RESULT: Of the IDUs, 2% were positive for HIV. No non-IDU was HIV-positive. Significantly more non-IDUs (10% v. 4%, p=0.05) were positive for syphilis. Sharing injection equipment within the past 6 months was reported by 71% of IDUs; sharing partners were stable and ranged from 1 to 3. More IDUs compared to non-IDUs reported being in touch with intervention programmes. The police has been tolerant to needle-syringe exchange and oral sublingual buprenorphine substitution conducted in Kolkata. Unlike in the early 1990s, non-IDUs did not switch to injecting during non-availability of brown sugar in the latter half of the 1990s and instead sought tratment. The availability of high quality heroin (>20%-50%) was low and the proportion of moderate quality heroin (>10%-20%) went up during these times due to increased police seizures. No intervention exists in jails despite the fact that a large number of drug users spend time in jail. CONCLUSION: Stable and few injection equipment-sharing partners of IDUs, launching of early targeted interventions among IDUs and sex workers in the city, police tolerance to harm reduction activities and preference of non-IDUs for detoxification during heroin draught periods have kept HIV prevalence at a low level among drug users of Kolkata for the past 7 years. immediate launching of interventions for drug users in jails seems necessary. Similar multi-pronged strategies with targeted and environmental intervention could work in other settings as well.

Adolescent↗

Return to work/work retention outcomes of a functional restoration program. A multi-center, prospective study with a comparison group.

STUDY DESIGN: This was a study of a standardized functional restoration program that included 11 centers in seven states, involving 303 patients in the treatment group and 94 patients in the comparison group. OBJECTIVE: To illustrate the positive effect a functional restoration program has on return to work rates and work retention regardless of previous surgical intervention. SUMMARY OF BACKGROUND DATA: Data were obtained from the initial and discharge evaluations as well as at 6- and 12-month follow-up. METHODS: Patients received a standardized work capacity assessment upon entrance and were recommended to the program if they adhered to specific entrance criteria. Treatment patients received the same evaluation at discharge. RESULTS: Significant improvement in functional abilities, actual return to work, and work retention were noted in the treatment group regardless of treatment intervention. CONCLUSIONS: This study demonstrated improved return to work rates and work retention with surgical and nonsurgical patients after their participation in a functional restoration program.

Adult↗

[Medical and biological studies of Ukrainian scientists in Antarctic region].

People adaptation problem in Antarctic conditions, prophylactics of the desinchronostic disturbances, destability of psycho-emotion state, pathological manifestation of the heart-vessel system, tasks of regional waste influences on the people organism are not insolvable up to now and is the base of medical-biological researches. In accordance with the peculiarities of the geographical positions of Academician Vernadsky station and long period of staying in extremely conditions of Antarctic the medical-physiological researches will executed on the each stage. During the selection of candidates for the work at Ukrainian Antarctic station we studied new medico-biological criteria including genetic markers with aim to forecast antagonism functional state during wintering. At the period of staying in Antarctic in the conditions of season inversions and hour belts removals it will executed the researches of biorhythmological peculiarities of the psychophysiological function and heart-vessel system states, outer system of breathing and biochemistry indexes of people fluids. It was shown that the biggest part of disturbances in organisms functional system at the period of Antarctic winter has an ability to restoration after returning to homeland. However, disturbances in immunology system state are prolonged, harmful influence of solar radiation are revealed on the people sight, especially, when one use the not recommended lighting filters. With the purpose of prophylactic of desynchronic disturbances, which was find after wintering at the more then 90% expedition personnel, it was worked out an non invasion methods of correction by using the individual polychromatic influence on organism. It is studied the teleconnection results of long period staying of expedition staff in Antarctic. It was established, that Ukrainian members of expedition have the fixed number of radionuclids of Cesium in organism. After staying in Antarctic radionuclids of Cesium in organism do not reveal.

Adaptation, Physiological↗

Runaways: a growing social and family problem.

The problem of the juvenile runaway is one of increasing magnitude, and it is causing considerable alarm among lay and professional people. As the age of the runaway becomes younger and the harmful consequences of being away from home increase, public attention has focused on the problem. Family physicians are in a unique position to provide both preventive and remedial help to runaways and their families. Some of the ways in which physicians may play a significant role in this serious problem include individual and family counseling to anticipate and prevent such episodes and counseling to strengthen the adolescent-parent relationship following a running away episode.

Adolescent↗

Adolescent substance use: brief interventions by emergency care providers.

Use of tobacco, alcohol and other drugs plays a major role in adolescent morbidity and mortality. When under the influence of alcohol or other drugs, adolescents are at increased risk for injuries, unprotected sex, or interpersonal violence. Alcohol and other drugs are major factors in adolescent deaths, contributing to motor vehicle crashes, homicides, and suicides. Adolescents tend to have shorter substance use histories therefore they often experience emergency/acute care health treatment resulting from substance use related trauma and/or overdose. Substance use screening of adolescents who present to an Emergency Department (ED) is vitally important. The CRAFFT is a valid and reliable screening tool that was developed for use with adolescents. If an adolescent screens positive, then the next step is to determine their stage of use and readiness for change in preparation for doing a brief intervention. Helping patients to recognize the potential relation between their substance use and health related consequences, may motivate them to decrease their use for harm reduction. Motivational interviewing is an effective, evidence-based approach to helping people change their high risk behavior.

Adolescent↗

A body-mind-spirit model in health: an Eastern approach.

Under the division of labor of Western medicine, the medical physician treats the body of patients, the social worker attends to their emotions and social relations, while the pastoral counselor provides spiritual guidance. Body, mind, cognition, emotion and spirituality are seen as discrete entities. In striking contrast, Eastern philosophies of Buddhism, Taoism and traditional Chinese medicine adopt a holistic conceptualization of an individual and his or her environment. In this view, health is perceived as a harmonious equilibrium that exists between the interplay of 'yin' and 'yang': the five internal elements (metal, wood, water, fire and earth), the six environmental conditions (dry, wet, hot, cold, wind and flame), other external sources of harm (physical injury, insect bites, poison, overeat and overwork), and the seven emotions (joy, sorrow, anger, worry, panic, anxiety and fear). The authors have adopted a body-mind-spirit integrated model of intervention to promote the health of their Chinese clients. Indeed, research results on these body-mind-spirit groups for cancer patients, bereaved wives and divorced women have shown very positive intervention outcomes. There are significant improvements in their physical health, mental health, sense of control and social support.

Adult↗

The role of altruistic behavior in generalized anxiety disorder and major depression among adults in the United States.

BACKGROUND: Although previous studies found protective associations of altruistic behaviors (AB) with positive mental health outcomes, these studies were limited to unspecified mental health outcomes and non-nationally representative studies. It is needed to examine the association of AB with generalized anxiety disorder (GAD) and major depression (MD). METHODS: Data collected from the National Survey of Midlife Development in the United States (MIDUS) in 1995-1996 for those aged between 25 and 74, who completed both the telephone survey and the self-administered questionnaire (N=4,242) were analyzed. GAD and MD were measured by telephone on the basis of the Composite International Diagnostic Interview, while AB was measured by the questionnaire. Multivariate logistic regression was used to observe the independent effects of AB on GAD and MD. RESULTS: AB had a weak protective effect on GAD. However, AB had a significant and independent harmful effect on MD after controlling for demographic variables (gender, age, working status, and marital status). LIMITATIONS: Since the MIDUS study is cross-sectional, the causality of the associations between AB with GAD and MD cannot be established. Other possible confounders that explain these associations were not controlled. CONCLUSION: AB might be recommendable to prevent GAD, but on the other hand, it could be a risk factor for individuals having MD. Longitudinal studies are needed to explore the mechanism of the onset of GAD and MD through enhanced AB.

Adult↗

Monitoring in neuroanaesthesia: update of clinical usefulness.

The aim of specific monitoring in neuroanaesthesia is to detect, as quickly as possible, intraoperative ischaemic insults so that the brain and the spinal cord may be protected from harmful and frequently inevitable events due to the type of surgery, patient positioning, haemodynamic changes or any intercurrent event. New monitors are being introduced into the operating theatre, but only a few are considered to be an absolute standard of care in neurosurgery, e.g. facial nerve monitoring for surgery of acoustic neuromas and recording of evoked potentials during repair of scoliosis. In the past decade, new monitoring devices have moved from the experimental stage to the operating theatre and although most are still in a phase of technological development and/or definition of their field of applicability they are being used as guides for clinical practice in those instances where cerebral well-being might be impaired. The metabolic consequences of hyperventilation, pharmacological electroencephalogram burst suppression, hypothermia, etc. can now be assessed in the operating theatre. Non-invasive monitoring is being rapidly integrated into our daily work because of its lack of secondary effects. Nevertheless, each new development is regarded as an addition rather than as a substitute for existing equipment. The perfect combination of monitors to provide essential information during an individual surgical procedure to influence a better patient outcome, is still uncertain and needs extensive clinical research.

Anesthesia↗

Employees' perspectives on ethically important aspects of genetic research participation: a pilot study.

PURPOSE: Insights from genetic research may greatly improve our understanding of physical and mental illnesses and assist in the prevention of disease. Early experience with genetic information suggests that it may lead to stigma, discrimination, and other psychosocial harms, however, and this may be particularly salient in some settings, such as the workplace. Despite the importance of these issues, little is known about how healthy adults, including workers, perceive and understand ethically important issues in genetic research pertaining to physical and mental illness. METHOD: We developed, pilot tested, and administered a written survey and structured interview to 63 healthy working adults in 2 settings. For this paper, we analyzed a subset of items that assessed attitudes toward ethically relevant issues related to participation in genetic research on physical and mental illness, such as its perceived importance, its acceptability for various populations, and appropriate motivations for participation. RESULTS: Our respondents strongly endorsed the importance of physical and mental illness genetic research. They viewed participation as somewhat to very acceptable for all 12 special population groups we asked about, including persons with mental illness. They perceived more positives than negatives in genetic research participation, giving neutral responses regarding potential risks. They affirmed many motivations for participation to varying degrees. Men tended to affirm genetic research participation importance, acceptability, and motivations more strongly than women. CONCLUSION: Healthy working persons may be willing partners in genetic research related to physical and mental illnesses in coming years. This project suggests the feasibility and value of evidence-based ethics inquiry, although further study is necessary. Evidence regarding stakeholders' perspectives on ethically important issues in science may help in the development of research practices and policy.

Adult↗

Vasovagal syncope and anaesthetic practice.

We surveyed anaesthetists working in North-West England and in North Wales concerning episodes of vasovagal syncope encountered in their practice. Eighty-eight anaesthetists described 109 such events occurring in either patients or their relatives and the estimated frequency of syncope was 1 in 5000 anaesthetic episodes. The patient syncopal episodes were triggered by venous cannulation in 16 instances and regional or local techniques in 20 instances. Thirty-three of the 53 patients were in the upright position when syncope occurred. Thirty-nine of the 56 relatives were male partners of female patients and four of these partners suffered some morbidity. The results of the survey are consistent with our current knowledge of the pathophysiology of vasovagal syncope, which is summarized, and also highlight the common anaesthetic scenarios where fainting is most likely to occur. Given this information anaesthetists will be in a better position to avoid such potentially harmful episodes in the future.

Adult↗

Job insecurity and health.

As employers respond to new competitive pressures of global capitalism through layoffs and the casualization of labor, job insecurity affects a growing number of workers. It appears to harm mental health, but less is known about its effects on physical health and health behaviors and the mechanisms through which it may act. The prevailing individual-centered conceptualization of job insecurity as the perception of a threat to job continuity precludes systematic investigation of the social patterning of its health effects. Analysis of data from a 1994 Canadian national probability sample of adults determined that high levels of job insecurity lowered self-rated health and increased distress and the use of medications, but had no impact on heavy drinking. The findings support one possible mechanism of action whereby job insecurity reduces feelings of control over one's environment and opportunities for positive self-evaluation; these psychological experiences, in turn, have deleterious health consequences. There is little evidence of social patterning of this relationship by gender, education, household income, age, marital status, and social support at work.

Adult↗

Impact of a social influence intervention on condom use and sexually transmitted infections among establishment-based female sex workers in the Philippines: a multilevel analysis.

The authors assessed the relative impact of structural and social influence interventions on reducing sexually transmitted infections (STIs) and HIV risk behavior among female sex workers in the Philippines (N = 897). Four conditions included manager influence, peer influence, combined manager-peer influence, and control. Intervention effects were assessed at the establishment level in multilevel models because of statistical dependencies among women employed within the same establishments. Control group membership predicted greater perceived risk, less condom use, less HIV/AIDS knowledge, and more negative condom attitudes. Combination participants reported more positive condom attitudes, more establishment policies favoring condom use, and fewer STIs. Manager-only participants reported fewer STIs, lower condom attitudes, less knowledge, and higher perceived risk than peer-only participants. Because interventions were implemented at the city level, baseline and follow-up city differences were analyzed to rule out intervention effects due to preexisting differences.

Acquired Immunodeficiency Syndrome↗