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PubMed1998

Misuses and misunderstandings of boundary theory in clinical and regulatory settings.

OBJECTIVE: This paper outlines a number of misapplications of boundary theory in both regulatory settings and clinical situations. METHOD: The authors review clinical vignettes that illustrate the difference between boundary crossings, which lead to productive work in psychotherapy, and boundary violations, which are harmful to the patient and exploit the patient's vulnerable position. They also discuss developments in the field that have led to an excessively rigid and defensive posture on the part of some clinicians that may lead to less than optimal psychiatric treatment. They survey recent developments in the wording of state statutes that broadly define sexual misconduct in psychotherapy. RESULTS: This review of the current status of boundary theory in both the law and clinical practice suggests that an overreaction has occurred that requires corrections. CONCLUSIONS: The critical role of context must be considered whenever a boundary problem has been alleged, and boundaries must be regarded as flexible standards of good practice rather than lists of generically forbidden behavior.

Expert Testimony↗
PubMed1981

The seated man (Homo Sedens) the seated work position. Theory and practice.

Modern furniture in schools, factories and offices is constructed in such a way that no one can use it properly. Each day people sit for many hours hunched over their tables in postures extremely harmful to the back. No one should be surprised that more than half of the population today is complaining of backache. In no other field of human activity is a similar gap between theory and reality found. A closer study of 'normal' sitting postures will explain why nobody is able to sit in the 'ideal' position. First of all, the eye in this position is at a distance of 50-60 cm from the book or working material and the axis of vision is horizontal. In addition, this posture requires at least 90 degrees flexion of the hip joint, yet the normal human being can only bend 60 degrees . A considerably better sitting posture can be obtained if the table is tilted about 10 degrees . In this way the book is brought closer and at a better angle to the eye. The worst bending of the neck is thus avoided. Furthermore, the seat can, with advantage, be tilted 20 degrees forward to reduce the flexion of the lumbar region. By both these means the extra 30 degrees flexion, which is the most strenuous part of flexion, is avoided.

Journal Article↗
PubMed2003

Screening for postpartum depression in an inner-city population.

OBJECTIVE: This study was undertaken to determine the prevalence of positive screens for postpartum depression by using the Edinburgh Postnatal Depression Scale (EPDS) in an inner-city population. STUDY DESIGN: At their postpartum visits, women who were seen in two inner-city practices between February 20 and April 30, 2002, self-administered the EPDS. A threshold of 10 or more points was selected as a positive screen for postpartum depression. If the patient responded that she had thoughts of harming herself or others, she was referred immediately for social work or psychiatric evaluation. Otherwise, providers were blinded to the results of the screen. RESULTS: Of the 443 patients who were scheduled for postpartum visits during this time period, 285 (64%) patients presented for their postpartum visit. One hundred twenty-one (42%) of these patients participated in the study and 1 patient did not complete the questionnaire. Twenty-seven (22%) of the 121 patients had a positive screen for postpartum depression. Eight patients (6.6%) reported experiencing suicidal ideation within the previous week. Without use of the screening tool, providers identified 16 (13%) patients who they thought were at risk for postpartum depression. Of those 16 patients, 14 had positive screens on the EPDS. Eight patients eventually had clinical depression diagnosed. There was a significant relationship between women with elevated scores on the EPDS and a personal history of depression (P <.0006), history of prior treatment for depression (P <.0001), and feeling depressed during the pregnancy (P <.0001). Providers failed to comment on the patient's mood in 34 (28%) of the 121 patients. CONCLUSION: A larger than expected number of women had a positive screen for postpartum depression in our population. This unexpected finding suggests the need for more resources to be directed toward the research, identification, and treatment of postpartum depression in inner-city populations.

Adolescent↗
PubMedDate not supplied

Use of standardized patients during a psychiatry clerkship.

OBJECTIVE: Standardized patients are used in teaching medical students and evaluating their clinical skills during the psychiatric clerkship. The purpose of this study was to evaluate whether the addition of a Psychiatry Clinical Standardized Patient Examination (PCX) during the third-year clerkship improved students' performances on the psychiatry component of the Clinical Competency Examination (CCX) that is used at our institution to prepare fourth-year students for the National Board of Medical Examiners Step 2 Clinical Skills Exam (Step 2 CSA). METHOD: Scores on the CCX were analyzed by two-by-two tables (yes/no response to each clinical competency item versus took/did not take PCX) using Fisher's exact test. RESULTS: Of the 469 students who took the CCX between 2002 and 2004, 246 students also took the PCX. Compared to students who did not take the exam, students who took the PCX were significantly more likely (p<0.05) to receive positive ratings on the CCX items for professionalism, addressing patients' stressors at work and home and inquiring about thoughts of harm to self or others. CONCLUSIONS: The implementation of the PCX during the psychiatry clerkship significantly improved student performance on several important components of the CCX, which is used to prepare students for the Step 2 CSA. This suggests that the use of standardized patients during the clerkship may help students improve their interviewing and interpersonal skills.

Adult↗
PubMed2025

Radiation Without Borders: Unraveling Bystander and Non-Targeted Effects in Oncology.

Radiotherapy (RT) remains a cornerstone of cancer treatment, offering spatially precise cytotoxicity against malignant cells. However, emerging evidence reveals that ionizing radiation (IR) exerts biological effects beyond the targeted tumor volume, manifesting as radiation bystander effects (BEs) and other non-targeted effects (NTEs). These phenomena challenge the traditional paradigm of RT as a localized intervention, highlighting systemic and long-term consequences in non-irradiated tissues. This comprehensive review synthesizes molecular, cellular, and clinical insights about BEs, elucidating the complex intercellular signaling networks gap junctions, cytokines, extracellular vesicles, and oxidative stress that propagate damage, genomic instability, and inflammation. We explore the role of mitochondrial dysfunction, epigenetic reprogramming, immune modulation, and stem cell niche disruption in shaping BEs outcomes. Clinically, BEs contribute to neurocognitive decline, cardiovascular disease, pulmonary fibrosis, gastrointestinal toxicity, and secondary malignancies, particularly in pediatric and long-term cancer survivors. The review also evaluates countermeasures including antioxidants, COX-2 inhibitors, exosome blockers, and FLASH RT, alongside emerging strategies targeting cfCh, inflammasomes, and senescence-associated secretory phenotypes. We discuss the dual nature of BEs: their potential to both harm and heal, underscoring adaptive responses and immune priming in specific contexts. By integrating mechanistic depth with translational relevance, this work posits that radiation BEs are a modifiable axis of RT biology. Recognizing and mitigating BEs is imperative for optimizing therapeutic efficacy, minimizing collateral damage, and enhancing survivorship outcomes. This review advocates for a paradigm shift in RT planning and post-treatment care, emphasizing precision, personalization, and systemic awareness in modern oncology.

Humans↗
PubMed2000

Agents, not objects: our fights to be.

People who have been diagnosed and treated for major mental illness have an insider expertise that can provide invaluable insight into the mysteries of people's often inexplicable movement in and out of madness. The author vividly describes his passages from identity-seeking young adult to mental hospital patient to psychologist and mental health system critic. The harmful, life-threatening treatments he experienced are examined as part of our society's propensity to treat people who are different as deviant and relegate them to ineffective and harmful medical interventions. Alternatives to psychiatric hospitalizations are promoted as more positive options for people going through confusing and frightening life-changing experiences. The article concludes with the author's ideas about what is necessary and helpful when working with someone who has been labeled with a major mental illness and what is counterproductive and harmful.

Attitude to Health↗
PubMed2003

Dietary guidelines: some issues to consider before initiating revisions.

This paper presents two main questions that need to be answered before deciding to revise dietary guidelines: Is there really a need to revise existing guidelines? and How is dietary risk management to be integrated into dietary guidelines? Any group assigned the task of evaluating and possibly revising existing guides must answer these questions. It is also critically important to specify the exact target group and purpose for any dietary guideline since the questions need to be answered in context. This paper addresses some of the implications of the recent report on Dietary Reference Intakes for macronutrients in its venture into the area of risk management. A major conclusion of the paper is that nutrition has entered a new era and that henceforth, as never before, risk management, the assessments of likelihood of benefit and risks of harm-as well as costs human and financial of our actions-and recommendations must take a very prominent position in our work. This is not a role for which most nutritionists are prepared and hence it must be seen as a major challenge in the preparation of food guides in the future.

Canada↗
PubMed1998

Support for harm-reduction among staff of specialized addiction treatment services in Ontario, Canada.

In a mail survey of staff of specialized addiction treatment services in Ontario, respondents from different types of services varied in their level of support for a variety of harm reduction initiatives. Across all types of services support was common for needle exchange services (82-95% in favour) and for short-term non-abstinence goals for clients with alcohol or drug problems (51-98% in favour). However, mean ratings for the effectiveness of methadone maintenance were negative or near zero, and only in assessment/referral and out-patient samples did the majority (61% in each case) have a positive view of methadone maintenance programmes. Only a minority of respondents (15% to 35%) indicated support for the prescription of heroin to heroin addicts. In multivariate analyses, support for harm-reduction strategies was found to be positively related to belief in the effectiveness of pharmacological and cognitive-behavioural interventions and working in an out-patient treatment service, and negatively related to belief in interventions based on the disease model.

Journal Article↗
PubMed1996

The effect of labor force participation on coronary heart disease risk factors among middle-aged women: a cross-sectional study in a Japanese rural district.

This study examined labor force participation as a risk factor for coronary heart disease. The participants were 224 women aged 45 to 64, residing in a rural district in Japan. The working women spent a significantly greater number of working hours (paid and unpaid) and had a more "Westernized" food preference than homemakers. After adjusting for physical, psychosocial, and behavioral covariates, working women had significantly lower systolic blood pressure and blood glucose levels than homemakers. The "healthy worker effect" did not explain these differences. Middle-aged rural Japanese women who worked outside the home were slightly healthier than homemakers, despite their less healthy lifestyle. Total working hours were positively associated with systolic and diastolic blood pressures and total cholesterol in multiple regression analyses, which suggests that work overload has a harmful effect. A more suitable social environment is required if f Japanese working women are to enjoy a healthier life.

Journal Article↗
PubMed2000

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

Career Choice↗
PubMed2004

Semen quality and sedentary work position.

Increased scrotal temperature can, in experimental settings, markedly disturb the production of semen. Sedentary work position may increase the temperature of the scrotum, but previous studies have failed to determine whether changes in scrotal temperature caused by sedentary work actually do affect semen quality. This study was carried out to elucidate the possible harmful effects of sedentary work on sperm count and other semen characteristics. In 1981-1983 a semen sample was obtained from 3119 men who attended an infertility workup in one of four Danish fertility centres. A total of 2517 men returned a postal questionnaire with information on life style, leisure time activities, occupational history and job duties. Information on job specific work position was obtained from The Danish Work Environment Cohort study 1990 (DWECS). In this analysis DWECS data for a total of 1747 men was included from men aged 18-39 years with >30 h of work per week. For all job titles represented in the DWECS, the mean proportion of sedentary work was estimated. The sperm cell concentration was 30.6 million/mL among men in the quintile with lowest job specific sedentary work compared with 40.5 million/mL in the highest quintile. The difference was, however, not statistically significant. Stratification on infertility period, educational level of the man, fertility centre, and fertility-related disease of the spouse did not influence the results. The analyses do not suggest that sedentary work is a risk factor for abnormal semen characteristics.

Adult↗
PubMed2004

Acute effects of noise on blood pressure and heart rate.

The authors assessed the acute effects of exposure to noise on systolic and diastolic blood pressure, and heart rate, among 46 workers in a midwestern auto assembly plant. Workers wore ambulatory blood pressure monitors and personal noise dosimeters during one work shift. After adjustment for covariates of cardiovascular function, systolic and diastolic blood pressure, along with heart rate, were shown to be significantly positively associated with noise exposure. Although the long-term effect of these associations is not known, results from other studies suggest that they may be harmful. Replication of this study with a larger number of subjects, monitored for several days and in a variety of work settings, is recommended to verify these findings. The results of this and other studies imply that reducing acute noise exposure reduces cardiovascular stress.

Adult↗
PubMed2004

A perspective from countries using organized screening programs.

Cancer screening may be offered to a population opportunistically, as part of an organized program, or as some combination of the preceding two options. Organized screening is distinguished from opportunistic screening primarily on the basis of how invitations to screening are extended. In organized screening, invitations are issued from centralized population registers. In opportunistic screening, however, due to the lack of central registers, invitations to screening depend on the individual's decision or on encounters with health care providers. The current article outlines key differences between organized and opportunistic screening. In the current study, literature searches were performed using PubMed and MEDLINE. Additional data were assembled from interviews with health officials in the five countries investigated and from the authors' personal files. Opportunistic screening was found to be distinguishable from organized screening on the basis of whether screening invitations were issued from centralized population registers. Organized screening programs also assumed centralized responsibility for other key elements of screening, such as eligibility requirements, quality assurance, follow-up, and evaluation. Organized programs focused on reducing mortality and morbidity at the level of the population rather than at the level of the individual. Thus, programs did not necessarily offer the most sensitive screening test for a particular cancer, and tests sometimes were offered at suboptimal intervals with respect to individual-level protection. Nonetheless, organized systems paid greater attention to the quality of screening, as measured by factors such as cancer detection rates, tumor characteristics, and false-positive biopsy rates. As a result, participants in organized screening programs received greater protection from the harmful effects associated with screening. In addition, organized programs worked more systematically toward providing value for money in an inevitably resource-limited environment. Although organized and opportunistic models of screening can yield similar uptake rates, organized programs exhibited greater potential ability to reduce cancer incidence and mortality, because of the higher levels of population coverage and centralized commitment to quality and monitoring; were more likely to be cost-effective; and offered greater protection against the harmful effects associated with poor quality or overly frequent screening.

Cost-Benefit Analysis↗
PubMed2006

[Attitudes to medical errors and patient injury among doctors and medical students].

BACKGROUND: As health care providers most of us will experience that patients are harmed by medical treatment. Our attitudes and reactions to this part of the medical reality are therefore important. MATERIAL AND METHODS: 103 medical students and 156 hospital doctors (surgeons and anaesthetists) at a university hospital were asked to answer a questionnaire anonymously. RESULTS: 81 students (80 %) and 69 hospital doctors (44 %) responded. Students were more worried about the possibility of harming patients, and 78 % of the students had considered dropping out because of this. 88 % of the doctors answered that they had done mistakes that could have had consequences and 71 % answered that they had done mistakes that had consequences. If an error does not cause harm, both students and doctors were reluctant to share the event with others. Doctors were less interested in placing guilt than students. When the error had caused harm, the students were less willing than the doctors to inform others, including the patient. The doctors are sure that they themselves will support and help a colleague who tells them about an error, but they did not think that their department had a system to handle situations like that. INTERPRETATION: To be able to learn from errors, it is important to consider all adverse events, also those that do not cause patient injury. It is important that health care workers understand why they should report, that the actual reporting is perceived as a positive experience and that it feels safe to do so. Supporting health care workers after errors and patient harm is vital to keep the caregivers in work. There are still areas for improvement before a just culture combined with sound error management is achieved. Medical students need more knowledge about patient safety.

Attitude of Health Personnel↗
PubMed2005

Impact of a positive hepatitis C diagnosis on homeless injecting drug users: a qualitative study.

BACKGROUND: Increasing numbers of injecting drug users are presenting to primary care and a growing number of general practices are specifically providing care for homeless people. Injecting drug users are at the greatest risk of hepatitis C infection and homeless drug misusers, because of their drug-taking behaviour and patterns, have been identified as being at greater risk of harm of blood-borne diseases than the general population. However, little work has been conducted with injecting drug users or homeless people who have hepatitis C and little is known about how the virus may affect them. AIM: To explore the impact of a positive hepatitis C diagnosis on homeless injecting drug users. DESIGN OF STUDY: This study employed qualitative research. In-depth interviews allowed the exploration of the impact of a potentially life-threatening diagnosis within the context of a person's expressed hierarchy of needs. SETTING: A primary care centre for homeless people in the north of England. METHOD: In-depth interviews about the impact of a positive hepatitis C diagnosis on their lives were conducted with 17 homeless injecting drug users who had received a positive hepatitis C diagnosis. The interviews were audiotaped, transcribed, and analysed using the framework approach. RESULTS: Receiving a positive diagnosis for hepatitis C resulted in feelings of shock, devastation, disbelief, anger, and questioning. A positive diagnosis had lasting social, emotional, psychological, behavioural, and physical effects on homeless injecting drug users, even years after the initial diagnosis. Most responders were diagnosed by a doctor in primary care or by hospital staff; however, not all had sought testing and a number were tested while inpatients and were unaware that blood had been taken for hepatitis C virus serology. CONCLUSIONS: The implications for clinical policy and primary care practice are discussed, including the issues of patient choice, confidentiality, and pre- and post-test discussions. Posttest discussions should be followed up with additional social, psychological, and medical support and counselling.

Adult↗
PubMed2002

Using a harm reduction approach with clients who have alcohol/drug dependencies in a spinal cord rehabilitation program.

BACKGROUND: Dissatisfied with the frequently adversarial nature of relationships with clients who use alcohol or drugs while rehabilitation inpatients, and the often less than optimal outcomes for these individuals, the Spinal Cord Program at the G.F. Strong Rehabilitation Center in Vancouver, BC, decided to pilot a new approach. OBJECTIVE: The goal of the pilot project is to promote successful rehabilitation, including less conflict in rehabilitation, a completed rehabilitation program, and continued connection after discharge if needed. METHOD: A dedicated team was formed and trained to work with these clients using harm reduction principles. PARTICIPANTS: From its inception in December 2000, through May 2001, the team worked with 6 inpatients, 12% of admissions to the Spinal Cord Program during that period. RESULTS: Outcomes based on the above goals have been positive. There have been no discharges against a client's will or instances of significant conflict with the team. Several clients have returned to the center for assistance or to visit post-discharge. Only 1 client left rehabilitation prematurely.

Alcoholism↗
PubMed1987

Religious-based denial in the NICU: implications for social work.

Families of critically ill infants in the neonatal intensive care unit may be placed in the emotionally charged position of making treatment decisions about their infants, including the withholding of medical treatment. Some families, unable to deal with these issues, cope through a harmful form of religious denial; the eternal belief in a miracle. This article discusses the concept of death, religious-based denial, and health care team reactions to such family dynamics. The role of the social worker is reviewed in regard to: (1) dealing with his/her own feelings about religious-based denial (2) advocating for families, and (3) supporting and consulting with staff around this sensitive area.

Counseling↗
PubMed1983

[Populations of harmful rodents on commercial swine-breeding farms and their effect on the technology of swine feeding].

The effect was studied of the swine-feeding technology in five industrial complexes on the population density of the harmful rodents in them. This made it necessary to estimate the population density of the rodents in each productional section of the swine-breeding complexes, and to work out their technologic characteristic on the nutrition principle. It was established that the population density of rodents correlated positively with their access to feeds. In sections where rated, mechanical, and protected feeding was prectised the number of rodents were considerably lower than in sections with unrated feeding of pigs. It is believed that the rat invasion of the buildings in the industrial swine-breeding complexes is a factor that contributes to the rise of populations of harmful rodents, while the vast access to feeds is of greater importance chiefly for their further development.

Animal Feed↗