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PubMed2006

PPARs and the placenta.

The discovery of the peroxisome proliferator-activated receptors (PPARs) in 1990s provided new insights in understanding the mechanisms involved in the control of energy homeostasis and in cell differentiation, proliferation, apoptosis and the inflammatory process. The PPARs became thus an exciting therapeutic target for diabetes, metabolic syndrome, atherosclerosis, and cancer. Unexpectedly, genetic studies performed in mice established that PPARgamma are essential for placental development. After a brief description of structural and functional features of PPARs, we will summarize in this review the most recent results concerning expression and the role of PPARs in placenta and of PPARgamma in human trophoblastic cells in particular.

Animals↗
PubMed2005

Specialist public health capacity in England: working in the new primary care organizations.

OBJECTIVES: To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service. STUDY DESIGN: Questionnaire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England. RESULTS: Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably "developing quality and risk management" and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized. CONCLUSIONS: Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams.

England↗
PubMed2006

Bioaccessible arsenic in the home environment in southwest England.

Samples of household dust and garden soil were collected from twenty households in the vicinity of an ex-mining site in southwest England and from nine households in a control village. All samples were analysed by ICP-MS for pseudo-total arsenic (As) concentrations and the results show clearly elevated levels, with maximum As concentrations of 486 microg g(-1) in housedusts and 471 microg g(-1) in garden soils (and mean concentrations of 149 microg g(-1) and 262 microg g(-1), respectively). Arsenic concentrations in all samples from the mining area exceeded the UK Soil Guideline Value (SGV) of 20 microg g(-1). No significant correlation was observed between garden soil and housedust As concentrations. Bioaccessible As concentrations were determined in a small subset of samples using the Physiologically Based Extraction Test (PBET). For the stomach phase of the PBET, bioaccessibility percentages of 10-20% were generally recorded. Higher percentages (generally 30-45%) were recorded in the intestine phases with a maximum value (for one of the housedusts) of 59%. Data from the mining area were used, together with default values for soil ingestion rates and infant body weights from the Contaminated Land Exposure Assessment (CLEA) model, to derive estimates of As intake for infants and small children (0-6 years old). Dose estimates of up to 3.53 microg kg(-1) bw day(-1) for housedusts and 2.43 microg kg(-1) bw day(-1) for garden soils were calculated, compared to the index dose used for the derivation of the SGV of 0.3 microg kg(-1) bw day(-1) (based on health risk assessments). The index dose was exceeded by 75% (18 out of 24) of the estimated As doses that were calculated for children aged 0-6 years, a group which is particularly at risk from exposure via soil and dust ingestion. The results of the present study support the concerns expressed by previous authors about the significant As contamination in southwest England and the potential implications for human health.

Air Pollution, Indoor↗
PubMed2005

Physician-patient communication following invasive procedures: an analysis of post-angiogram consultations.

Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.

Assertiveness↗
PubMedDate not supplied

Quadriparesis following cervical epidural steroid injections: case report and review of the literature.

BACKGROUND CONTEXT: Cervical epidural steroid injections are frequently used in the conservative management of neck pain, cervical radiculitis, and cervical radiculopathy. Between 64-76% of patients who receive injections report subjective pain improvement. Injections are usually well-tolerated with only mild, transient side effects, although a few case reports of patients with adverse effects do appear in the literature. Some clinicians have expressed concerns about epidural injections above the C7-T1 level, and in the use of methylprednisolone epidurally; as yet, neither is a consensus viewpoint. PURPOSE: This case report describes severe adverse effects (quadriplegia and respiratory arrest) associated with an epidural injection into the C6-C7 space. Although the patient's symptoms improved somewhat with supportive care, quadriparesis appears irreversible. No reports of quadriparesis after cervical epidural injection were found in the literature, although other adverse effects have been reported. STUDY DESIGN/SETTING: The patient was injected by a fellowship-trained pain management specialist in an outpatient surgicenter using C-arm fluoroscopic guidance. Immediately he experienced respiratory arrest with quadriplegia. He was intubated and transferred to the hospital, then transferred again to Christiana Health Care Services. METHODS: The patient was hospitalized, treated with steroid protocol within 8 hours, and followed clinically for 6 months. RESULTS: Magnetic resonance imaging within 6 hours of the injury and 6 months later showed no significant findings aside from lordosis (40 degrees angle) of the cervical spine at the C6-C7 level. CONCLUSION: Although evidence is not conclusive, this patient may have suffered a vascular event from a cervical epidural injection.

Cervical Vertebrae↗
PubMed1994

Nurses' responses to organ procurement from nonheartbeating cadaver donors.

Brain-dead donors (ie, heartbeating cadaver donors) have been an accepted source of transplantable organs for many years. Clinicians in some medical centers are considering nonheartbeating cadaver donors (ie, patients who decide to discontinue life-support measures and become organ donors) as another source of transplantable organs. This study explored registered nurses' responses to caring for nonheartbeating cadaver donors and described their intentions to care for such donors, their reactions to caring for them, and the meaning of these reactions and intentions. The nurses interviewed expressed resentment at the intrusion of technology; they preferred brain-dead status in organ donors; they feared legal repercussions from families; they speculated about nonheartbeating cadaver donors' ability to feel pain, and they expressed concern about withdrawing life-support measures, honoring patients' wishes, allocating nursing care as a scare resource, and witnessing family members' pain.

Adult↗
PubMed1999

Assessing medical students' competence in obtaining informed consent.

BACKGROUND: Medical schools increasingly place emphasis on preparing students to perform routine, ethically important clinical activities with sensitivity and acumen. A method for evaluating students' skills in obtaining informed consent that was created at our institution is described. METHODS: Formal assessment of medical students' professional attitudes, values, and ethics skills occurs in the context of three required and developmentally attuned comprehensive examinations. A videotaped station tested senior medical students' ability to obtain informed consent from a standardized patient who expresses concern about undergoing cardiac catheterization. Two checklists were completed by the patient. Videotapes were reviewed by a faculty member, and students' reactions to the assessment experience were documented. RESULTS: Seventy-one senior students participated, and all performed well. Mean scores of 6.3 out of 7 (range 5 to 7, SD = 0.5) on the informed consent checklist and 8.7 out of 9 (range 6 to 9, SD = 0.5) on the communication skills checklist were obtained. Students endorsed the importance of the skills tested. CONCLUSIONS: This method of examining medical students' abilities to obtain informed consent has several positive features and holds promise as an ethics competence assessment tool.

Adult↗
PubMed2002

Periareolar mediastinoscopy: a new technique.

Biopsy of anterior mediastinal or aortopulmonary nodes is usually accomplished through a left anterior mediastinostomy. Cosmetic concerns expressed by patients about scars in the neck or the upper chest led us to consider a new periareolar approach for mediastinoscopy. This technique has been used successfully in 10 patients.

Adult↗
PubMed1997

Video-assisted thoracic surgery: has technology found its place?

BACKGROUND: Since the introduction of minimally invasive surgical techniques in thoracic surgery in 1990, video-assisted thoracic surgery (VATS) has become the approach for many thoracic operations. The role of VATS has slowly evolved but has not been clearly defined. To better understand the role of VATS, we undertook a survey of practicing thoracic surgeons. METHODS: A questionnaire was sent to members of the General Thoracic Surgery Club asking the role of VATS in their practice and their opinions regarding appropriate applications, advantages, and limitations of the approach. RESULTS: Two hundred of the 229 members (87.3%) responded to the questionnaire. In this largely academic (66.3%) group of thoracic surgeons, 72% of whom had more than 10 years experience in general thoracic surgery, VATS was the preferred approach (> 50% response) for the management of pleural disease, lung biopsy, recurrent pneumothorax, and sympathectomy. A majority of respondents thought that VATS was an acceptable approach for the diagnosis of the indeterminate pulmonary nodule and of anterior and posterior mediastinal masses, and for the management of early empyema, clotted hemothoraces, secondary pneumothorax, limited lung cancer treatment, and benign esophageal disease. Video-assisted thoracic surgery was thought to be unacceptable or investigational by a majority for thymectomy, lobectomy, and lung volume reduction operations. Video-assisted thoracic surgery still represents only a small portion of the thoracic procedures performed, but there is a gradual increase in its rate of use, although 38.1% expressed concern regarding overuse. The main limitation was thought to be in the management of oncologic disease. CONCLUSIONS: It appears that VATS is a valuable addition to the practice of thoracic surgery, but significant limitations exist. Although there appear to be many specific indications defined, there is still a significant evolutionary component.

Attitude of Health Personnel↗
PubMed1997

A survey on minimally invasive coronary artery bypass grafting.

BACKGROUND: There is increasing interest in performing minimally invasive coronary artery bypass grafting. To evaluate the current level of acceptance and utility of this procedure a survey of 162 cardiothoracic surgeons was conducted. RESULTS: Currently only 16% of surveyed surgeons performed more than 10 minimally invasive coronary artery bypass grafting procedures. Most were less than 55 years old and in private practice. The majority predicted that it will be indicated in less than 25% of coronary artery bypass grafting cases and considered minimally invasive coronary artery bypass grafting a modification of existing techniques rather than investigational. Most believed exposure and stabilization of the coronary arteries on the beating heart to be the most challenging part and expressed concern with quality of the anastomosis. CONCLUSIONS: We conclude that minimally invasive coronary artery bypass grafting is rapidly gaining acceptance in younger surgeons as techniques are improved. Despite concerns with adequacy of anastomosis the procedure is not considered investigational and follow-up is not rigorous.

Canada↗
PubMed2001

Knowledge, attitudes and practices regarding evidence-based medicine and outcome assessment: a survey of British Columbia cataract surgeons.

BACKGROUND: While the advantages of practising evidence-based medicine are well-documented, it is frequently suggested that doctors' attitudes are a major roadblock to its implementation. We carried out a survey to determine the knowledge, attitudes and practices of British Columbia cataract surgeons regarding evidence-based medicine and outcome assessment. METHODS: The survey was conducted in the spring of 1999. The study population was drawn from the directory of the British Columbia College of Physicians and Surgeons. A 16-item questionnaire designed to elicit the knowledge of, attitudes toward and use of evidence-based medicine and outcome assessment was sent to all surgeons performing cataract surgery in British Columbia. RESULTS: Of the 103 eligible participants, 70 (68%) returned completed questionnaires. Surgeons affiliated with the University of British Columbia were more likely to respond than those not affiliated with the university (81% vs. 58%) (p < 0.05). Most surgeons (89%) viewed the responsibility of monitoring quality of care as primarily their own. Although 79% of the respondents felt that outcome assessment is an effective method for determining quality of care, less than half (49%) reported that they routinely include some form of outcome assessment in their clinical practice. There was wide variation in the respondents' understanding of the nature of outcome assessment and evidence-based medicine. Respondents professed little inclination or motivation to committing time or resources to an outcome program. They also expressed concerns over the use of outcome data for external management activities. INTERPRETATION: Cataract surgeons in British Columbia clearly appreciate the advantages of outcome assessment, but translation of this understanding into practice is limited. There appears to be a need for further education on outcome assessment and evidence-based medicine through academic bodies and professional societies.

British Columbia↗
PubMed1990

Subjective experiences of magnetic resonance imaging.

Clinical experience with the new technology of magnetic resonance imaging (MRI) has indicated that the procedure may produce anxiety in a number of patients, to the extent that occasionally a patient may be unwilling to undergo the procedure. A study of patients' subjective experiences of MRI was therefore conducted and these were compared with those of patients undergoing computed tomography (CT). Initial interviews with 15 MRI and 15 CT patients led to the development of a questionnaire which was administered to a further 40 patients in each setting. No significant differences were found between those factors identified as unpleasant in MRI and those of CT, with the exception of the confined space of MRI; 40% of the MRI patients found this unpleasant by comparison with only 15% of the CT patients. Principal components analysis of the concerns expressed suggested three factors, to do with the machine itself, the environment of the machine, and the social interactions involved. Patients finding the procedures unpleasant tended to be those with high initial levels of anxiety, little experience of diagnostic procedures, and believing themselves to have cancer.

Adolescent↗
PubMed2002

Evaluation of an emergency contraception introduction project in Kenya.

The Consortium for Emergency Contraception introduced Postinor-2, a progestin-only EC product, into Kenya as part of its work to expand access to EC in developing countries. Introduction activities included registering Postinor-2, training providers, and developing provider and client materials. We surveyed family planning clients and providers to assess the impact of these activities. Knowledge of EC among clients and providers improved between the baseline and evaluation surveys. More women and providers had heard of EC and more providers were distributing it. Support for access to EC in Kenya also improved. The results indicate, though, that further information is needed. Only one-fifth of women at the evaluation had heard of EC and almost half of the women expressed concerns about EC at baseline and evaluation. More research and experience using novel ways of informing women about EC in Africa is needed, and information needs to address women's concerns.

Ambulatory Care Facilities↗
PubMed1988

Determination of the molecular size distribution of immunoglobulin G (IgG) in intravenous IgG-albumin formulations by high-performance liquid chromatography.

Recent reports have expressed concern about the safety of intravenous human immunoglobulin G (IgG) preparations. Evidence seems to indicate that aggregates in these formulations are responsible for several adverse reactions in some patients, including anaphylaxis and dyspnea. Therefore, monitoring the molecular size distribution of IgG in these products is essential for ensuring their safety. This paper describes a sensitive and precise two-stage high-performance liquid chromatographic method for determining the molecular size distribution profile of IgG in an intravenous formulation stabilized with albumin. In the first step, all molecular forms of IgG are separated from all molecular forms of albumin by anion-exchange chromatography. In the second stage, a portion of the collected IgG fraction is re-chromatographed by size-exclusion chromatography and separated into its aggregate, dimer, and monomer components. Although some minor losses of aggregate do occur in the procedure, the overall molecular size distribution is not significantly affected. The method described is both time-efficient and accurate, and represents an improvement over existing methods.

Albumins↗
PubMed2002

Perceived safety climate, job demands, and coworker support among union and nonunion injured construction workers.

PROBLEM: This study evaluated injured construction workers' perceptions of workplace safety climate, psychological job demands, decision latitude, and coworker support, and the relationship of these variables to the injury severity sustained by the workers. METHODS: Injury severity was assessed using the Health Assessment Questionnaire (HAQ), which evaluates functional limitations. Worker perceptions of workplace variables were determined by two instruments: (a) the Safety Climate Measure for Construction Sites and (b) the Job Content Questionnaire (JCQ). RESULTS: The overall model explained 23% of the variance in injury severity, with unique contributions provided by union status, the Safety Climate Score, and Psychological Job Demands. A positive significant correlation was found between injury severity and the Safety Climate Scores (r = .183, P = .003), and between the Safety Climate Scores and union status (r = .225, P < .001). DISCUSSION: There were statistically significant differences between union and nonunion workers' responses regarding perceived safety climate on 5 of the 10 safety climate items. Union workers were more likely than nonunion workers to: (a) perceive their supervisors as caring about their safety; (b) be made aware of dangerous work practices; (c) have received safety instructions when hired; (d) have regular job safety meetings; and (e) perceive that taking risks was not a part of their job. However, with regard to the 49-item JCQ, which includes Coworker Support, the responses between union and nonunion workers were very similar, indicating an overall high degree of job satisfaction. However, workers who experienced their workplace as more safe also perceived the level of management (r = -.55, P < .001) and coworker (r = -.31, P < .001) support as being higher. IMPACT ON INDUSTRY: The findings of this study underscore the critical need for construction managers to alert workers to dangerous work practices and conditions more frequently, and express concern and praise workers for safe work in a manner that is culturally acceptable in this industry. Workplace interventions that decrease the incidence and severity of injuries, but that are flexible enough to meet a variety of potentially competing imperatives, such as production deadlines and client demands, need to be identified.

Accidental Falls↗
PubMed1989

Subspecialization and general urology.

Subspecialization within urology is growing, affecting not only teaching and research but the general practice of urology as well. To evaluate present attitudes towards subspecialization a questionnaire was sent to the membership of the Western Section of the American Urological Association. The responses from 561 members (53 per cent) were tabulated by computer and analyzed. Of those in private practice 16 per cent consider themselves to be subspecialists, although half of these have had no formal training. More subspecialize in oncology, andrology and gynecology than in pediatric urology. Opinions toward issuing certificates of special competence are mixed but opposition to board certification is general. A majority of respondents believe that subspecialization might provide better care for some patients but would increase costs, especially for tertiary care. It would not result in inferior care for patients not having access to the subspecialist. Subspecialization would be expected to reduce the economic return to the nonspecialist without increasing it for the specialist. Respondents believe that it would advance diagnosis, treatment and research in special areas, and improve training and competence but at greater expense. Finally, they express concern that subspecialization may well restrict the experience and competence of general urologists and cause conflict.

Attitude of Health Personnel↗
PubMed1987

Patient-spouse agreement on the drinking behaviors of alcoholics.

Because investigators have expressed concern about the validity of alcoholism self-report measures, attention has been focused on the use of spouse or other collateral ratings of patient drinking behaviors. Previous studies have shown that spouse ratings of alcoholics on the Self-Administered Alcoholism Screening Test (SAAST) were reliable and a valid means of screening for alcoholism. In the current study, our objectives were to attempt to replicate the earlier findings in a new and larger sample and to determine whether the various content dimensions of the SAAST show similar patient-spouse agreement. The SAAST results of 240 patient-collateral pairs showed that the mean percentage agreement over the 35 items of the SAAST was 76.5%. Patient-spouse agreement ranged from 84.7% on the component "family alcohol problems" to 68.5% on "loss of control." When patients were classified as alcoholic or nonalcoholic on the basis of spouse ratings on the SAAST, correct classification occurred 98% of the time. Correct conjoint classification by both patient and spouse occurred 95.4% of the time. Thus, we found a high level of agreement between patient and spouse on the SAAST ratings and confirmed that spouse SAAST ratings of drinking behavior of patients provide a reliable diagnosis of alcoholism.

Adult↗
PubMed1989

Five years' experience of combined impedance and audiometric screening at school entry.

Many papers and pilot studies have considered whether school entry auditory screening should include testing with tympanometry. Some of these papers expressed concern that this type of screening would lead to an excessive number of failures and an overloading of ENT facilities. School children in the Worcester district have been screened at school entry using tympanometry, combined with pure tone audiometry, for the past five years. This paper describes how the combined screening programme was set up, and the advantages that have accrued. It also shows that combined testing has not significantly increased the number of children referred to ENT. The author suggests that this combined tympanometry and audiometric screening should become the accepted way to screen school entrants.

Acoustic Impedance Tests↗