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PubMed2005

Developing a speciality: regearing the specialist public health workforce.

OBJECTIVES: To identify issues surrounding the future training needs of the specialist public health workforce following the most recent restructuring of the National Health Service (NHS) in England. METHODS: All directors of public health (DsPH) based in strategic health authorities and nine senior staff working in public health at the regional level were invited to participate in a semi-structured telephone interview. RESULTS: Twenty-six people were interviewed. Many interviewees expressed concern that because consultants and specialists in public health will be working in much smaller teams than hitherto, they will have to generalize their skills to cover a much wider range of functions (including board-level duties). This may result in a loss of specialist expertise. Successful public health practice in the new structures will require new ways of interorganizational working that will add an administrative burden to specialists in public health. Also, the creation of a board-level post in each primary care trust (PCT) has resulted in more time spent on corporate responsibilities and less on public health for DsPH, who are often the only fully trained specialist in public health in their PCT. Furthermore, interviewees expressed their anxiety about the lack of diversity in the posts available to specialists in public health and particularly to those newly completing their specialist training. Generally, interviewees felt that traditional public health roles and responsibilities were being eclipsed by corporate and managerial ones. Professional development activities were being carried out, but in a rather ad-hoc fashion. Interviewees were hopeful that public health networks would lead professional development initiatives once they were more established. CONCLUSIONS: It is important that excellence in public health is maintained through a set of accreditable standards, whilst corporate skills, essential to successful public health practice in the new UK NHS, are developed among specialists in public health.

Accreditation↗
PubMed2005

Mercury exposure: medical and public health issues.

Mercury exposure is widespread in the United States with methylmercury as the predominant chemical species and fish and shellfish as the source. Use of more advanced diagnostic techniques and application of population-based risk assessment methodologies have assisted in addressing the impact of mercury exposure on the United States population. Biomonitoring, particularly through analyses of blood mercury, provides both population-based data and exposure information that can be informative for physicians. Data from the National Health and Nutrition Examination Survey (NHANES) beginning in 1999 provide population-based exposure estimates for United States overall. Methylmercury exposures among women of childbearing age are of particular concern because of methylmercury's developmental neurotoxicity. Exposures of concern among women are estimated to occur in between approximately 6% to 8% of the 16-to-49-year-old age group based on data from NHANES; and in approximately 15% of this age and sex group if physiological factors such as the degree of transplacental transport of methylmercury are taken into consideration. Subgroups with high fish consumption (e.g., many island and coastal populations, some persons of Asian ethnicity, some individuals following "healthy" diets) can have methylmercury exposures substantially higher than those reported among the NHANES examinees. These subpopulations are not likely to be aware of their blood mercury concentrations or the possible health outcomes associated with such high blood mercury levels. The American Medical Association has adopted policies that express concerns about methylmercury exposure, and advise patient education. Non-neurological risks for adults associated with methylmercury, including the potential for adverse cardiac outcomes, have not yet been incorporated into risk assessments.

Adult↗
PubMed1986

Coitally active university students: sexual behaviors, concerns, and challenges.

The past fifteen years, in particular, have seen a major increase in the extent to which both adolescents and young adults are engaging in sexual intercourse. While several studies call attention to the increasing incidence among college/university students, the concomitant shifts in the sociopsychological realms of sexuality are also important dimensions which impact upon sexual concerns of youth. Hence, the purposes of this study are to examine the behaviors, attitudes, and concerns of students who have engaged in coitus, as well as any changes they seek in their sex lives. The sample consisted of 123 never-married male and 205 never-married female undergraduate students from a state university. The data were obtained by utilizing an anonymous questionnaire administered to volunteers during regular university classes. Among the coitally active, 67.4% of males were psychologically satisfied after their first sexual experience, but only 28.3% of females. In contrast, 80.9% of males and 28.3% of females reported current psychological satisfaction with their sexual experiences. Significant differences between genders focused on male dissatisfaction with infrequent opportunities for sexual intercourse, lack of variety of sex partners, and insufficient oral-genital stimulation, whereas females expressed concerns relating to lack of stimulation to their breasts, painful sexual intercourse, lack of orgasm during sexual intercourse, and feelings of guilt and fear. An increasing awareness of current sexual behaviors, attitudes, and concerns of university students can help family life educators to meet student needs as they react to changes in interpersonal relationships, families, and society.

Adolescent↗
PubMedDate not supplied

Caring and expressions of stability by urban family caregivers of persons with stroke within African American family systems.

Expressions of stability by urban family caregivers are the focus of this study. Data presented here were collected as part of a larger ethnographic descriptive study that examined caregivers' (N = 24) experience and the meaning of caring as it influences their ability to care for persons with stroke within their African American family systems. For family caregivers, unmet needs and problems with caregiving may occur as depleted resources are compounded by urban decay in many communities. This study was completed within the Framework of Systemic Organization described by Friedemann, in which families, as open systems, strive for well-being. Stability in the family, a component of well-being, addresses traditions and common behavior patterns rooted in basic values and cultural beliefs. Through data analysis, four themes concerning expressions of stability were identified for all caregivers. Caring expressions of stability are defined as (a) emotional burden; (b) evasion of conflicts; (c) motivation from love and a sense of duty between caregivers, the care recipients, and their families; and (d) a filial, ethereal value. Rehabilitation nurses can incorporate these expressions of stability into their assessment, intervention, and evaluation processes, and thereby increase the potential to strengthen successful caring and stability within the caregivers' family systems.

Adult↗
PubMed2006

The 80-hour duty week: rationale, early attitudes, and future questions.

There is considerable concern and much evidence resident fatigue results in medical errors, some of which have serious consequences. Similarly, fatigue causes poor health in house-staff and places these individuals at greater risk for personal injuries, including motor vehicle accidents. These circumstances led the Accreditation Council on Graduate Medical Education to develop and, on July 1, 2003, to implement guidelines for all residency training programs limiting the time of in-house duty to 80 hours per week. Surveys of orthopaedic residents by the American Academy of Orthopaedic Surgeons, before and right after implementation of these new duty rules, confirm housestaff were working longer than 80 hours before July 2003 and are largely in compliance since that date. Residents generally approve of these changes and are personally happier, but also express concern for a loss of continuity of care and reduced exposure to operative cases. It remains to be demonstrated whether these new rules will improve patient care, enhance housestaff well-being, or influence education.

Accreditation↗
PubMed2003

Identifying ambulatory cancer patients at risk of impaired capacity to consent to research.

Ethicists and others have expressed concerns that some patients with cancer might lack adequate decision-making capacity to give consent for research. Although this concern is plausible, it is not known what patient characteristics might be used to identify those patients who are at risk and who therefore should undergo a formal assessment of decision-making capacity. Forty-five patients with cancer were presented with a description of a randomized controlled trial, accompanied by an Institutional Review Board-approved consent form. Two raters who were blind to all patient characteristics assessed decision-making capacity using the MacArthur Competency Assessment Tool for Clinical Research. These scores were summarized in overall capacity judgments using criteria established by a panel of experts. Subjects also completed a symptom rating scale and a battery of neuropsychiatric tests. No relationship was observed between symptom severity and any domain of decision-making capacity (understanding, appreciation, reasoning, ability to express a choice) or summary judgments. However, several other patient characteristics, including age, education, and selected neuropsychiatric test results, were found to be strongly associated with capacity scores. These data suggest that several patient characteristics, such as age, education, and tests of cognitive functions, may help investigators to identify patients with impaired capacity to give consent for research.

Aged↗
PubMed1996

Environmental health competencies: a survey of nurse practitioner programs.

Because of widespread public and governmental concern about the health effects of environmental hazards and exposure in recent years, and the increasing incidence of environmentally induced diseases, it is important that primary care nurse practitioners possess the knowledge and skills to effectively address environmental health as a component of their practice. A mailed questionnaire survey of 187 United States' nurse practitioner (NP) programs was conducted, with a response rate of 64%, to determine: 1) current and ideal emphasis on environmental health, 2) faculty preparation for teaching environmental health, 3) environmental health competencies expected of graduates, 4) didactic and clinical contact hours devoted to environmental health, and 5) barriers and incentives to greater emphasis on environmental health. Findings reveal that more than two thirds of NP program directors believe there should be greater emphasis on environmental health in their programs, but expressed concerns about overcrowded curricula and lack of faculty preparation as barriers to change. Competencies with the highest mean ratings included understanding the relationship between environmental hazards and human health, accessing information resources related to environmental hazards and health, and counseling clients about how they can reduce risks associated with environmental hazards. The two factors identified as most likely to increase the emphasis on environmental health in NP programs were having nurse faculty with expertise and being able to access information resources related to environmental health. Currently, insufficient attention is given to environmental health in NP education programs.

Clinical Competence↗
PubMed1996

Environmental health competencies: a survey of U.S. nurse practitioner programs.

Because of widespread public and governmental concern about the health effects of environmental hazards and exposure in recent years, and the increasing incidence of environmentally-induced diseases, it is important that primary care nurse practitioners possess the knowledge and skills to effectively address environmental health as a component of their practice. A mailed questionnaire survey of 187 U.S. nurse practitioner (NP) programs was conducted, with a response rate of 64%, to determine: 1) current and ideal emphasis on environmental health, 2) faculty preparation for teaching environmental health, 3) environmental health competencies expected of graduates, 4) didactic and clinical contact hours devoted to environmental health, and 5) barriers and incentives to greater emphasis on environmental health. Findings reveal that more than two-thirds of NP program directors believe there should be greater emphasis on environmental health in their programs, but expressed concerns about overcrowded curricula and lack of faculty preparation as barriers to change. Competencies with the highest mean ratings included understanding the relationship between environmental hazards and human health, accessing information resources related to environmental hazards and health, and counseling clients about how they can reduce risks associated with environmental hazards. The two factors identified as most likely to increase the emphasis on environmental health in NP programs were having nurse faculty with expertise and being able to access information resources related to environmental health. Currently, insufficient attention is given to environmental health in nurse practitioner education programs.

Curriculum↗
PubMedDate not supplied

Selective mutism: are primary care physicians missing the silence?

To survey parents of children with selective mutism (SM) in regard to (1) the role of the primary care physician in the diagnosis of SM; (2) the social and school consequences of SM; and (3) their opinion of the effectiveness of different treatment modalities, a 39-item written survey was mailed to 27 parents with at least one child diagnosed with SM on the basis of diagnostic and statistical manual IV-text revision (DSM IV-TR) criteria. Twenty-seven parents (100%), with a total of 33 children with SM, completed the survey. There were 24 girls and 9 boys. The mean age when parents had strong concerns about symptoms of SM was 3.8 years, but diagnosis did not occur until nearly a year later. Twenty-three (69.7%) of the children with SM were never diagnosed accurately or referred by their primary care physicians. SM caused important school/social problems for 17 (51.5%) of the children. Speech therapy was provided for 36.4% of children and was thought to have been helpful for 30% of them. Behavior modification was the treatment for 45.5% of children and perceived to be helpful for 66.7% of them. Selective serotonin re-uptake inhibitor pharmacotherapy was prescribed for 17 (51.5%) of the children and believed to be effective for 11 (65%) of them. Primary care physicians in this study rarely diagnosed accurately or referred children with SM in a timely fashion, even though symptoms of the condition were generally very apparent and parents had expressed concern. Behavioral modification, pharmacotherapy with SSRIs, and early intervention are viable treatment options. Early diagnosis is key to preventing long-term effects of this condition.

Adolescent↗
PubMed1998

Validation of a model predicting enrollment status in a chemoprevention trial for breast cancer.

We evaluated the performance of a regression model in predicting enrollment status in a chemoprevention trial for breast cancer using a population independent of that from which the model was derived. In years 1 and 2 of recruitment, questionnaires were completed by eligible participants following attendance at informational meetings about the Breast Cancer Prevention Trial. The variables in the original model, based on women recruited in year 1, included not being able to take estrogen replacement therapy (ERT), concern about the side effects of tamoxifen, the possibility of getting a placebo, the out-of-pocket expenses associated with the trial, and disagreement with the statement "significant others would be reassured if the respondent was taking tamoxifen." These variables were used to predict enrollment status of women newly recruited to the trial in year 2. Among the 89 women in the study population who responded to the questionnaire, 66% did not enroll in the trial. By applying the original logistic regression model, enrollment status in the trial was correctly predicted for 72% of year 2 questionnaire respondents. Age and risk scores, as binary variables, were used in a derived logistic model to determine whether they provided additional predictive information on enrollment status. The resulting four-factor model, which predicted nonenrollment, included: age of > or = 50 years, not being able to take ERT, expressed concern that significant others would not be reassured if the respondent was taking tamoxifen, and concern about out-of-pocket expenses associated with the trial. This model correctly classified 76% of the respondents. The logistic regression models performed reasonably well in predicting enrollment status. Not being able to take ERT remained the strongest factor predicting nonenrollment. More research is needed to evaluate factors that motivate persons to seek participation in primary chemoprevention trials in culturally diverse populations.

Anticarcinogenic Agents↗
PubMed2003

[NF-kappa B and prostatic adenocarcinoma].

Nuclear factor of kappa B (NF-kappa B) is a multipolar nuclear transcription factor, and adjusts many gene expressions concerned with immunization, apoptosis, inflammation, neoplasia and metastasis. Recently, NF-kappa B has become a kind of hot spot in the studies of neoplasia, infiltration, metastasis and drug resistance. NF-kappa B can serve as an ideal target molecular approach to the promising gene therapy. This article reviews recent advances in studies on the structure and function of NF-kappa B, and the relationship between NF-kappa B and prostatic adenocarcinoma infiltration, metastasis and tactics of gene therapy.

Adenocarcinoma↗
PubMed2006

Breast implant surveillance reports to the U.S. Food and Drug Administration: maternal-child health problems.

There is continuing concern that women who receive breast implants may be at increased risk for adverse reproductive outcomes or experience problems with breastfeeding. It is unknown whether exposure to biomaterials in breast implants may have teratogenic effects or leach into breast milk causing postnatalproblems. We studied the Food and Drug Administration (FDA) experience by analyzing a case series of adverse event reports received and entered into the FDA's Manufacturer and User Facility Device Experience (MAUDE) database or the Device Experience Network (DEN) database by December 31, 2002 regarding women with breast implants. Reports were critically reviewed for lactation difficulties, reproductive problems (spontaneous abortion, delayed conception) and medical conditions among offspring, including neonatal, infant, and childhood diseases and congenital defects that were attributed to implants. We identified 339 reports that described maternal-child adverse events. Nearly half of these reports (46%) described actual problems with breastfeeding or expressed concern that implants would be unsafe or interfere with breastfeeding. Forty-four percent of reports (n=149) described either nonspecific or specific signs, symptoms, or illnesses in children. An additional 3.5% of reports (n=12) detailed a congenital anomaly believed by the reporter to be caused by breast implants.

Adolescent↗
PubMed1997

Medical decisions concerning the end of life: a discussion with Japanese physicians.

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed.

Adult↗
PubMed2003

Embryo donation for medical research: attitudes and concerns of potential donors.

BACKGROUND: The recent derivation of embryonic stem cell lines from human blastocysts and related implications for regenerative medicine has intensified a longstanding debate about the use of human embryos for research purposes. However, studies have shown that few couples with stored embryos opt to donate them for research. Herein, the attitudes and concerns of potential embryo donors to donation of surplus embryos for medical research were examined. METHODS: From a total of 509 couples who had stored frozen embryos and who had received a questionnaire about embryo donations for medical research, 152 women (30%) and 123 male partners (24%) responded. Embryos had been stored for a mean of 2.25 years (range 3 months to 12 years). RESULTS: Some 10% of respondents indicated it probable, and 34% possible, that they would donate their surplus embryos for research in the future. Women respondents whose embryos had been stored longer, and those committed to the practice of a religion, were more worried about their embryos. Respondents positively disposed to donation commented on their desire not to waste embryos, a desire to help infertile couples, and/or to advance scientific knowledge. Those with negative views commented on the embryo as a potential child and expressed concerns about a perceived lack of control over the type of research to be carried out. CONCLUSIONS: Findings indicate a need for tailored education and counselling about embryo donation for medical research.

Adult↗
PubMedDate not supplied

Parental perceptions of their child's asthma: management and medication use.

INTRODUCTION: Adequate treatment for asthma depends on accurate assessment and intervention by the parent and child and timely communication with the provider. These actions by the parent may be affected by their understanding of asthma management and their concerns about medications being prescribed. This research reports parental experiences with their children with asthma, specifically their beliefs, knowledge, and attitudes about asthma management, including medication use. METHODS: Data reported are from a study investigating parental attitudes and beliefs affecting antiinflammatory medication use in childhood asthma. These qualitative findings emerged from one-on-one semistructured qualitative interviews with 18 parents of children 2 to 18 years of age who were from diverse racial and socioeconomic backgrounds and who represented the spectrum of illness severity. RESULTS: Eight main themes within the domain of asthma management and medication use were identified: "I know my child," "trial and error," "partnership," "need for education," "negotiating responsibility," "hassles with medication administration," "preferences," and "the benefits outweigh the risks of side effects." DISCUSSION: These themes emphasize parents' need to partner with providers in their child's asthma management, as well as their need for ongoing asthma education. Parents also expressed concern about adverse effects of antiinflammatory medication but acknowledged the importance of controlling asthma symptoms. Based on these findings, systematic practice changes are recommended that provide regular opportunities for parent and child asthma education in a structured asthma wellness or "tune-up" visit.

Adolescent↗
PubMed2000

Assessing potential health risks from microcystin toxins in blue-green algae dietary supplements.

The presence of blue-green algae (BGA) toxins in surface waters used for drinking water sources and recreation is receiving increasing attention around the world as a public health concern. However, potential risks from exposure to these toxins in contaminated health food products that contain BGA have been largely ignored. BGA products are commonly consumed in the United States, Canada, and Europe for their putative beneficial effects, including increased energy and elevated mood. Many of these products contain Aphanizomenon flos-aquae, a BGA that is harvested from Upper Klamath Lake (UKL) in southern Oregon, where the growth of a toxic BGA, Microcystis aeruginosa, is a regular occurrence. M. aeruginosa produces compounds called microcystins, which are potent hepatotoxins and probable tumor promoters. Because M. aeruginosa coexists with A. flos-aquae, it can be collected inadvertently during the harvesting process, resulting in microcystin contamination of BGA products. In fall 1996, the Oregon Health Division learned that UKL was experiencing an extensive M. aeruginosa bloom, and an advisory was issued recommending against water contact. The advisory prompted calls from consumers of BGA products, who expressed concern about possible contamination of these products with microcystins. In response, the Oregon Health Division and the Oregon Department of Agriculture established a regulatory limit of 1 microg/g for microcystins in BGA-containing products and tested BGA products for the presence of microcystins. Microcystins were detected in 85 of 87 samples tested, with 63 samples (72%) containing concentrations > 1 microg/g. HPLC and ELISA tentatively identified microcystin-LR, the most toxic microcystin variant, as the predominant congener.

Bacterial Toxins↗
PubMed1990

Hypoxic effects on corneal morphology and function.

Normal corneal metabolism depends on a critical level of oxygen, below which a series of acute corneal responses occur, including an increase in stromal lactate, a reduction in intercellular pH, and an increase in corneal hydration. These acute responses are reversible when normal oxygen is restored; however, it has been shown that chronic exposure to low oxygen levels can result in permanent morphologic changes in the corneal endothelium. Clinicians have expressed concern that these observed structural changes may also be accompanied by alterations in corneal physiology. Whether such effects occur is not known, since it has been difficult to assess human corneal function accurately. Recently, we have developed an in vivo test, able to measure overall corneal hydration control, that can be used to study the effects of hypoxia on corneal function. This test provides information on several characteristics of hydration control, one of which is the percent corneal thickness recovery per hour (PRPH) after inducing corneal swelling. In this study, we assumed that corneal hypoxia accompanies both extended and polymethylmethacrylate (PMMA) contact lens wear and that the dose received is related to the years of past lens wear. Using this paradigm, we explored the relationship of hypoxic dose to an endothelial polymegethism index (EPI), endothelial cell density (ECD), and PRPH in 36 subjects with varying contact lens wearing histories. Based on multiple regression analysis, the relative change (expressed as percent per year) associated with hypoxic dose (adjusted for age and gender) was found to be dose-dependent and corresponded to estimated changes of 1.70%/yr, -0.25%/yr, and -1.26%/yr, with 95% confidence limits of (-0.3, 3.7), (-1.4, 0.9), and (-2.6, 0.06) for EPI, ECD, and PRPH, respectively. These preliminary data suggest that hypoxic exposure alters endothelial morphology and reduces corneal function; however, it is important to indicate that this was a exploratory investigation with several limitations, and that therefore these results should be viewed as preliminary until more definitive studies are completed.

Adolescent↗
PubMed2004

Experiences of patients who were early adopters of electronic communication with their physician: satisfaction, benefits, and concerns.

OBJECTIVE: To explore the experiences of patients who were early adopters of e-mail communication with their physicians. METHODS: Patients' experiences were assessed with an Internetbased survey of 1881 individuals and in-depth telephone follow-up interviews with 56 individuals who used e-mail to communicate with providers. Two investigators qualitatively coded interview comments independently, with differences adjudicated by group consensus. RESULTS: A total of 311 (16.5%) of the 1881 individuals reported using electronic mail to communicate with their physicians. Compared with the population-based Behavioral Risk Factor Surveillance Survey, users of e-mail with physicians were twice as likely to have a college education, were younger, were less frequently ethnic minorities, and more frequently reported fair/poor health. Among the 311 patients who used e-mail with their physicians, the most frequent topics were results of laboratory testing and prescription renewals. However, many of the 311 users (21%) also reported using asynchronous e-mail inappropriately to convey urgent or sensitive issues (suicidality, chest pain, etc). Almost all (95%) perceived that e-mail was more efficient than the telephone. Important benefits uncovered from the interviews were that some patients felt more emboldened to ask questions in e-mail compared with face-to-face communication with doctors, and liked the ability to save the e-mail messages. Users also expressed concerns about privacy. CONCLUSION: Patients that use electronic communication with their physicians find the communication efficient for disease management. Further patient education about inappropriate use of e-mail for urgent issues is needed.

Adolescent↗