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A study of perceptions of facial hemangiomas in professionals involved in child abuse surveillance.

Facial hemangiomas are common benign tumors of infancy. They can mimic the appearance of bruises and parents report false accusations of child abuse by strangers. We investigated perceptions of facial hemangiomas in two professional groups involved in child abuse surveillance. Thirty health visitors and 30 primary school teachers were sent a clinical case questionnaire about a child with an involuting facial hemangioma with a color photograph of the lesion. Nineteen health visitors (63%) and 18 primary school teachers (60%) responded. Seventy-four percent of the health visitors and 11% of the teachers correctly diagnosed a hemangioma. Fifty percent of the teachers were unable to decide on a diagnosis. However, only one health visitor (5%) and one teacher (5%) thought that the lesion was a nonaccidental injury and would involve a child protection advisor. About one-third of health visitors and one-third of teachers expressed concerns that the child could suffer psychologically from teasing by peers at school and about one-third of health visitors were also concerned about the psychological effects of the lesion on the child's parents. Health visitors and teachers were most unlikely to mistake the facial hemangioma in this study for a nonaccidental injury.

Child↗

PubMed2000

Patients' perceptions of omitted examinations and tests: A qualitative analysis.

OBJECTIVES: To understand the nature of patients' expectations for parts of the physical examination and for diagnostic testing and the meaning patients ascribe to their desires. DESIGN: Qualitative inquiry based on patient interviews and focused on perceived diagnostic omissions as "critical incidents." SETTING: Three general internal medicine practices (21 practitioners) in one mid-sized northern California city. PATIENTS: Of 687 patients visiting these practice sites and completing a detailed questionnaire, 125 reported one or more omissions of care and 90 completed an in-depth telephone interview. This study focuses on the 56 patients interviewed who did not receive desired components of the physical examination or diagnostic tests. MEASUREMENTS: Qualitative analysis of key themes underlying patients' unmet expectations for examinations and tests, as derived from verbatim transcripts of the 56 interviews. MAIN RESULTS: The 56 patients perceived a total of 113 investigative omissions falling into four broad categories: physical examination (47 omissions), conventional tests (43), high-cost tests (10), and unspecified investigations (13). Patients considered omitted investigations to have value along both pragmatic and symbolic dimensions. Diagnostic maneuvers had pragmatic value when they were seen to advance the technical aims of diagnosis, prognosis, or therapy. They had symbolic value when their underlying purpose was to enrich the patient-physician relationship. Patients in this study were often uncomfortable with clinical uncertainty, distrusted empiric therapy, endorsed early detection, and frequently interpreted failure to examine or test as failure to care. CONCLUSIONS: When patients express disappointment at failing to receive tests or examinations, they may actually be expressing concerns about the basis of their illness, the rationale for therapy, or the physician-patient relationship.

Adult↗

PubMed2002

Talking about money: how primary care physicians respond to a patient's question about financial incentives.

Patients sometimes express concern about the influence of "perverse" financial incentives on their care. We recruited a convenience sample of 101 primary care physicians and obtained information on their compensation. Then we audiotaped them as they role-played a response to a videotaped mock patient who asked them how they were paid and how their method of compensation affected clinical decisions. Overall, 36% of the physicians did not give enough information in their role-play response to allow an independent determination of how they were paid. Adopting a broad spectrum of attitudes and approaches, nearly every physician avoided discussing the role of incentives and stressed instead that he or she could be trusted under any circumstance.

Adult↗

PubMed2003

Report of the American Society of Transplantation conference on immunosuppressive drugs and the use of generic immunosuppressants.

Considerable economic and health-related costs are associated with the life-long maintenance immunosuppressive therapy required to prevent transplant rejection. Generic medications have the potential of providing equivalent therapeutic efficacy at a lower economic cost. In 2001, the American Society of Transplantation invited experts to review the data and issues associated with the approval and use of generic immunosuppressants. A summary of that meeting is reported here. The generic medication approval process has been in effect for more than 30 years. All marketed generic cyclosporin formulations have met FDA criteria demonstrating bioequivalence in healthy subjects, and some were also tested in transplant recipients. Most participants agreed that generic narrow therapeutic index immunosuppressive agents provide adequate de novo immunosuppression in low-risk transplant recipients. However, some participants expressed concern regarding the currently unquantified risk that may be associated with switching immunosuppressive agents under uncontrolled circumstances. There was broad agreement among the participants that generic medications should be clearly labeled and distinguishable from innovator drugs, and that patients should be educated to inform their physicians of any switch to or among generic alternatives. There was also strong support in favor of requiring studies to demonstrate bioequivalence in potentially at-risk patient populations, specifically African-Americans and pediatric patients.

Cyclosporine↗

PubMed2001

Employee response to major organizational redesign.

A number of health care organizations are currently undergoing major organizational redesign. Despite these efforts, little is known about how these changes are affecting the employees participating in the redesign process. In response to this, a study was undertaken to determine the perceived impact of organizational redesign on nursing staff at 2 acute care hospitals that were undergoing major organizational change. Data were collected through semi-structured focus group interviews conducted on all 3 shifts (days, evenings, and nights). Findings suggest the early redesign period is highly turbulent and difficult for staff. Nurses expressed concern over changes in roles and responsibilities, disruption in work group relationships, loss of resource availability, reduction in quality of care, and alterations in physical and psychological state.

Attitude of Health Personnel↗

PubMed2003

Eating difficulties in girls with Rett syndrome compared with other developmental disabilities.

Rett syndrome arises from a mutation on the X chromosome and occurs with prevalence in the general population in 1:10,000 women. Its major nutritional consequences require that health providers recognize early signs of eating difficulties and slowing of growth parameters. Retrospective record review of 44 girls, in two equal-sized groups matched by age, showed that the Rett syndrome group was significantly different, with lower body weights, more respiratory difficulties, more gastrointestinal symptoms interfering with eating, more swallowing problems, less self-feeding, and lower texture tolerance for chewy and crunchy foods compared with the developmental disability group. Microcephaly was noted for half of the Rett syndrome group compared with seven in the developmental disability group. Parents expressed concern about their child's difficulties in eating; eight of the Rett syndrome girls and 13 of the girls in the developmental disability group were reported to have a poor appetite. Distinctive features of Rett syndrome consistent with those in the literature were documented reasonably well in the nutrition assessment records. Detailed food intake information was analyzed for food texture characteristics to recognize early eating and texture tolerance problems. Recommendations were offered for conducting a thorough nutrition assessment of Rett syndrome patients, including analysis of the texture of consumed foods. Additional recommendations for improving nutrition services to those with Rett syndrome and other developmental disabilities include ruling out microcephaly, early identification of eating difficulties, with modifications in food texture as appropriate, and self-feeding goals.

Anthropometry↗

PubMed1999

Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy in lactating women.

OBJECTIVE: To provide insight into the lived experience of breast feeding, in primiparous women. The main focus was upon women's perceptions related to the adequacy of their breast milk, for the purpose of exclusively nourishing their babies. DESIGN: A longitudinal, phenomenological study involving in-depth, interactive interviews, conducted at 6, 12 and 18 weeks following the birth of the women's babies. PARTICIPANTS AND SETTING: A convenience sample of ten primiparous women were recruited prior to discharge from a maternity unit, in the north of England, in 1998. FINDINGS: Two groups of participants emerged, three who became increasingly confident and empowered by breast feeding and the remaining seven whose confidence progressively diminished, with six of them expressing concern that their breast milk was inadequate. Four major themes related to the participants' perceptions emerged from the analysis: the quest to quantify and visualise breast milk; anxiety regarding the adequacy of their diet; breast feeding as a challenging journey, with most feeling that they had 'fallen by the wayside' (this related partly to inadequate and conflicting advice given by health professionals); and finally, unmet needs for support, nurturing and replenishment in return for 'giving out'. CONCLUSION: Perceived breast-milk inadequacy is underpinned by a complex and synergistic interaction between socio-cultural influences, feeding management, the baby's behaviour, lactation physiology and the woman's psychological state. IMPLICATIONS: Education of midwives and health visitors is required in relation to the needs of breast-feeding mothers within a Western industrialised society. Strong social policy is vital in the UK, to initiate socio-cultural changes, which would enable women who commence breast feeding to perceive it as an empowering and fulfilling experience and not one of 'falling by the wayside'.

Anxiety↗

PubMed1999

Ability and attitudes to mathematics of post-registration health-care professionals.

A small study was conducted to investigate the mathematical abilities and attitudes to mathematics teaching of a sample of students embarking upon post-registration courses in health care. Mathematical ability showed a number of deficiencies of some concern. Expressed attitudes to mathematics teaching led to a discussion of the nature of mathematics teaching and some recommendations for remedial action.

Adult↗

PubMed2002

In vitro plant regeneration from leaf-derived callus of Cimicifuga racemosa.

Cimicifuga racemosa (L.) Nutt., also known as Black Cohosh, is among the top 10 selling medicinal herbs in the United States. The rhizomes have been used to relieve menopausal discomfort. This plant is wild crafted and conservationists have expressed concerns with the sustainability of C. racemosa. Excised tissues from young leaves of C. racemosa were cultured on Murashige and Skoog's medium (MS) supplemented with various concentrations of NAA and TDZ for production of callus. The optimum callus growth and maintenance was in 1.0 microM NAA plus 0.5 microM TDZ. Two-month-old calli were sub-cultured on different concentrations of cytokinins (BA, kinetin, 2ip, TDZ) or in combination with GA(3) for shoot induction. The rate of shoot induction and proliferation was higher in MS media supplemented with 2.0 or 4.0 microM of TDZ. Concentrations of TDZ greater than 4.0 microM suppressed shoot growth. Adding 3.5 microM of GA(3) into media containing BA increased shoot growth. The presence of GA(3) with kinetin or TDZ did not affect shoot production. For rooting, shoots were transferred to MS medium with activated charcoal supplemented with various auxins (IAA, IBA and NAA), roots were noticed 20 days after transference. Activated charcoal was an essential component for vigorous rooting formation. Our results suggest that conservation of C. racemosa is possible through in vitro multiplication of leaf-derived callus.

Cimicifuga↗

PubMed2006

Gene doping.

Together with the rapidly increasing knowledge on genetic therapies as a promising new branch of regular medicine, the issue has arisen whether these techniques might be abused in the field of sports. Previous experiences have shown that drugs that are still in the experimental phases of research may find their way into the athletic world. Both the World Anti-Doping Agency (WADA) and the International Olympic Committee (IOC) have expressed concerns about this possibility. As a result, the method of gene doping has been included in the list of prohibited classes of substances and prohibited methods. This review addresses the possible ways in which knowledge gained in the field of genetic therapies may be misused in elite sports. Many genes are readily available which may potentially have an effect on athletic performance. The sporting world will eventually be faced with the phenomena of gene doping to improve athletic performance. A combination of developing detection methods based on gene arrays or proteomics and a clear education program on the associated risks seems to be the most promising preventive method to counteract the possible application of gene doping.

Doping in Sports↗

PubMed1986

Disparate uptake of 99mTcO4- and 125I- in thyroid cells in culture.

Pertechnetate (99mTcO4-) is a large anion that is thought to be trapped but not organified by the thyroid. In order to determine its usefulness in discriminating trapping from organification in thyroid cell culture, the uptake of 99mTcO4- has been compared to that of 125I- both in sheep thyroid cells and in FRTL5 cells, a functional rat thyroid cell line. We found that uptake of both isotopes was dependent on TSH or agents that raised intracellular cAMP levels and was displaceable with iodide in both cell types. However in rat cell line 99mTcO4- uptake was up to eight-fold higher than 125I- uptake, and 99mTcO4- but not 125I- uptake was doubled by methimazole treatment. A considerable proportion of 99mTcO4- but not 125I- taken up by the FRTL5 cell but not the sheep cells was precipitable with TCA. This proportion was increased by methimazole treatment. We also found marked differences in sensitivity to ouabain between the two cell types. These results illustrate the differences between species in 125I- and 99mTcO4- transport and support the concerns expressed by Socolow and Ingbar (1967) in using 99mTcO4- as a direct and precise indicator of iodide transport activity.

Animals↗

PubMed1996

Legalizing assisted suicide--views of physicians in Oregon.

BACKGROUND: Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS: From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS: Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS: Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

Adult↗

PubMed2002

Long-term effects of cochlear implants in children.

OBJECTIVE: Since 1987, when the use of multichannel cochlear implants was initiated in children, candidacy has expanded; many thousands of children have received these devices, and results have revealed a wide range of performance. However, few long-term studies exist on a large population of these children. There have been concerns expressed that cochlear implant function might degrade over time, that devices and electrodes might migrate and extrude in the growing child, or that there might even be a deleterious effect of long-term stimulation of the cochlear nerve. The purpose of this study was to explore the long-term effects of implantation as a function of performance over time, reimplantation, and educational factors. STUDY DESIGN AND SETTING: We studied 81 children who received implants at a major academic medical center and were followed for 5 to 13 years. RESULTS: Results revealed significant gains in speech perception, use of oral language, and ability to function in a mainstream environment. There was no decrease in performance over time and no significant incidence of device or electrode migration or extrusion, and device failure did not cause a deterioration in long-term outcome. CONCLUSIONS: Multichannel cochlear implants in children provide perception, linguistic, and educational advantages, which are not adversely affected by long-term electrical stimulation.

Adolescent↗

PubMed2001

Evaluation of a successful vancomycin-resistant Enterococcus prevention intervention in a community of health care facilities.

BACKGROUND: In April 1997, vancomycin-resistant enterococci (VRE) emerged in several health care facilities in the Siouxland region and a VRE Task Force was formed. From 1997 through 1999, an evaluation of VRE prevalence at 30 facilities was performed. METHODS: In 1999, we conducted a survey and focus groups of health care workers to address initial reactions to VRE, feasibility of the Task Force recommendations, and lessons learned. RESULTS: Personnel at 29 (97%) facilities surveyed completed the questionnaire, and 15 health care workers from 11 facilities participated in 5 focus groups. The outcomes of expanded education and improved awareness of VRE for patients and health care workers were ranked the No. 1 priority overall and by long-term care facility personnel. Respondents agreed that Task Force recommendation adherence had significantly improved infection control (83%) and that the Task Force was an appropriate mechanism to coordinate infection control efforts (90%). Focus groups commented that it was most difficult to educate family members about VRE; they expressed concern about variation between VRE policies, especially between acute care and long-term care facilities, and about the quality of life of isolated patients. CONCLUSIONS: Our data illustrate that this intervention has been far-reaching and include the development of a health care infrastructure that may be used as a model to address additional health care issues (eg, emerging pathogens or biological threats).

Enterococcus↗

PubMed2002

Carotid artery closure for endarterectomy does not influence results of angioplasty-stenting for restenosis.

OBJECTIVE: Carotid angioplasty and stenting (CAS) has been recommended by some authors for the management of postendarterectomy restenosis. However, some authors have expressed concern about the influence of primary closure and patch angioplasty performed during carotid endarterectomy (CEA) on the incidence rate of complications after CAS. METHODS: We analyzed our consecutive series of 54 CAS procedures performed for restenosis after prior CEA. These procedures accounted for 75% of the 72 CAS procedures performed at our institution for all indications during the last 4 years. Of these 54 patients, 28 (52%) were men and 26 (48%) were women, with a mean age of 69 years. The mean clinical follow-up period was 18 months (range, 1 to 48 months). The mean interval between prior CEA and CAS was 16 months (range, 6 to 62 months). Nineteen patients were symptomatic (35%), and 35 were asymptomatic (65%). The mean severity of restenosis was 84% +/- 7% (standard deviation). The mean residual stenosis after CAS was 8% +/- 3% (standard deviation). RESULTS: Among the 54 prior CEAs, eight cases were performed with primary closure (15%), five procedures used patch closure with autologous vein (9%), and 41 operations used Dacron patch closures (76%). All patients were managed successfully with CAS with predeployment angioplasty with low profile balloons, self-expanding stents, and poststent angioplasty to approximate the transverse diameter of the carotid artery. No instances of contrast extravasation, arterial disruption, or subintimal dissection were observed. One stroke (1.8%), a retinal infarction with partial field of vision loss, occurred in a patient with prior CEA and Dacron patch closure, and no deaths were observed in the series. CONCLUSION: Performance of CAS for restenosis after CEA with autologous or synthetic patch angioplasty was technically successful in all 54 procedures. The method of closure of the arteriotomy during CEA, primary closure or patch angioplasty, did not influence the incidence of complications.

Aged↗

PubMed1996

Heterodimer formation and activity in the human enzyme galactose-1-phosphate uridylyltransferase.

One of the fundamental questions concerning expression and function of dimeric enzymes involves the impact of naturally occurring mutations on subunit assembly and heterodimer activity. This question is of particular interest for the human enzyme galactose-l-phosphate uridylyl-transferase (GALT), impairment of which results in the inherited metabolic disorder galactosemia, because many if not most patients studied to date are compound heterozygotes rather than true molecular homozygotes. Furthermore, the broad range of phenotypic severity observed in these patients raises the possibility that allelic combination, not just allelic constitution, may play some role in determining outcome. In the work described herein, we have selected two distinct naturally occurring null mutations of GALT, Q188R and R333W, and asked the questions (i) what are the impacts of these mutations on subunit assembly, and (ii) if heterodimers do form, are they active? To answer these questions, we have established a yeast system for the coexpression of epitope-tagged alleles of human GALT and investigated both the extent of specific GALT subunit interactions and the activity of defined heterodimer pools. We have found that both homodimers and heterodimers do form involving each of the mutant subunits tested and that both heterodimer pools retain substantial enzymatic activity. These results are significant not only in terms of their implications for furthering our understanding of galactosemia and GALT holoenzyme structure-function relationships but also because the system described may serve as a model for similar studies of other complexes composed of multiple subunits.

Alleles↗

PubMed2002

Teaching bioethics at (or near) the bedside.

Many teachers of bioethics often express concern, in their writings and otherwise, about the theoretical basis (or lack of it) of bioethics and the allied issue of relativism. The companion articles by Tong and Momeyer are in this vein and rightly address such issues within the context of a liberal arts education. This article addresses such issues in a different venue, i.e., bioethics teaching in the clinical sphere of health care institutions. It presumes to suggest that many of these theoretical concerns, as well as the threat of relativism, seldom arise in this sphere. Rather, a broad based, well accepted body of moral truth has been fashioned over the last quarter century and it is this that clinical bioethics regularly keys to and to which most moral dilemmas are referred for resolution. The various forms of this pedagogy, e.g., case consultations or institutional policy statements, are charted out in this regard, as well as the often tactical character of much of this teaching, i.e., not "what should we do?", but "how might we best do it?". The article then goes on to conclude with a reflection on the use and abuse of power in clinical bioethics teaching and consultation.

Bioethics↗

PubMed2006

Television advertising and children: lessons from policy development.

AIM: To conduct a policy review of the regulations related to food advertising on television aimed at children. DESIGN: The study consisted of documentary analysis of relevant legislation and policy documents related to children's advertising from both industry and non-governmental organisations at a global level and in 20 countries. This was supported with semi-structured telephone interviews with individuals from 11 countries. RESULTS: The initial findings resulted in a listing of regulatory impacts from which we developed a taxonomy of regulatory schemes. There was a tension between the development of legislation to cover this area and the use of voluntary agreements and codes. This tension represents a food industry/civic society split. The food and advertising industries are still engaged in a process of denying the impact of advertising on food choice and children as well as commissioning their own research. Outright bans are unusual, with most countries addressing the situation through voluntary agreements and self-regulation. We found a deep division over the way forward and the role and place of legislation. Policy-makers expressed concerns that national legislation was increasingly less relevant in dealing with broadcast media transmitted from outside national boundaries and therefore not subject to the receiving countries' laws but to the laws of the country from which they were transmitted. CONCLUSIONS: The options for the regulation of advertising targeted at children range from (1) a complete ban on advertising as in the case of Sweden, through (2) partial restrictions on advertising by type of food, target group or limits on the amount of advertisements or times shown, to (3) continuation of self-regulation by the advertising and food industries. There is a global dimension to regulation that needs to be built in, as national frontiers are no barriers to broadcast media and public health nutrition needs to ensure that its concerns are heard and addressed.

Advertising↗