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PubMed1993

Pharmaceuticals and public policy: learning from the New Zealand experience.

Pharmaceuticals provide a useful analytical prism through which to view a wider range of policy issues in the health arena. The fundamental characteristics of pharmaceuticals are shared by many other health care items and raise important policy questions in five key institutional areas: the market, science, the State, the professions, and the public. In one way or another the key policy issues raised in each one of these areas concern fundamental questions of restraint and regulation: the ability of the market to exert the normal disciplines of price competition on pharmaceuticals; the extent to which the claims of intellectual property conflict with the norms of scientific advance; the reconciliation of the different functions of the State, particularly in the management of risk; the efficacy of traditional mechanisms of self-regulation and peer review in the health professions; and the implications of pharmaceuticals for broader questions of social control. These issues are illustrated from the recent experience of a country, New Zealand, that has undergone major deregulation and restructuring of State activities. Conclusions are drawn for policy development in the pharmaceuticals area.

Drug Approval↗
PubMed2005

Incorporating social anxiety into a model of college student problematic drinking.

College problem drinking and social anxiety are significant public health concerns with highly negative consequences. College students are faced with a variety of novel social situations and situations encouraging alcohol consumption. The current study involved developing a path model of college problem drinking, including social anxiety, in 316 college students referred to an alcohol intervention due to a campus alcohol violation. Contrary to hypotheses, social anxiety generally had an inverse relationship with problem drinking. As expected, perceived drinking norms had important positive, direct effects on drinking variables. However, the results generally did not support the hypotheses regarding the mediating or moderating function of the valuations of expected effects and provided little support for the mediating function of alcohol expectancies in the relations among social anxiety and alcohol variables. Therefore, it seems that the influence of peers may be more important for college students than alcohol expectancies and valuations of alcohol's effects are. College students appear to be a unique population in respect to social anxiety and problem drinking. The implications of these results for college prevention and intervention programs were discussed.

Adolescent↗
PubMed2005

The effects of modeling dietary restraint on food consumption: do restrained models promote restrained eating?

Sixty-nine female undergraduates completed the restraint scale, a dieting checklist, and the Eating Attribution Style Questionnaire (EASQ). The participants were exposed either to no model, a peer model who behaviorally demonstrated dietary restraint, or a peer model who behaviorally and verbally demonstrated dietary restraint. The participants had an opportunity to consume food as part of a taste test. The findings revealed that attribution style, but not restraint or current dieting status, moderated the effects of exposure to the peer models. Females who had an internal attribution style for indulgent food consumption decreased their consumption of food as a function of the dietary restraint of the models, whereas females who had an external attribution style for indulgent food consumption increased their consumption of food as a function of the dietary restraint of the models. The latter disinhibitory effect was attributed to negative social comparison and learned helplessness. The results supported the conclusion that the effectiveness of modeling dietary restraint is dependent on the attribution style of the observers.

Adolescent↗
PubMed2000

Cosmeceuticals.

The author uses kinetin, a plant-derived nucleotide, as an example to summarize the approach to advising a patient on a new product. (1) Does it penetrate the stratum corneum? Topically applied nucleotides can penetrate human skin, and one of the most active and useful of these for the treatment of actinic keratoses, 5-fluorouracil (5-FU), is used widely in dermatology. 5-FU derives some of its benefit from its uptake, specifically in actinic keratoses, which do not have a complete epidermal barrier. The molecule is able to penetrate the stratum corneum. It is not clear that topically applied nucleotides have the same degree of penetration on photodamaged skin without actinic keratoses. (2) Is there a plausible biochemical mechanism of action? 5-FU has a well-known mechanism of action (i.e., the inhibition of DNA/RNA synthesis by incorporation of a false pyrimidine analog). The mechanism of action for furfuryladenine in human skin remains unknown and needs to be shown. If furfuryladenine functions as an antioxidant, it may be useful as a photoprotectant. This function does not account for a mechanism of action for the reversal of photoaging, however. (3) Are there published peer-reviewed, double-blinded, placebo-controlled, statistically significant clinical trials to substantiate the efficacy claim? Peer-reviewed, double-blinded, statistically significant clinical trials on furfuryladenine have not been published to date. The field of cosmeceuticals presents a quandary. The list of cosmeceuticals for the dermatologist to assess grows longer each year. It is possible that some of the active ingredients are beneficial physiologically in human skin and that they can offer specific benefits, such as photoprotection. Further research needs to be conducted to validate these claims. It also is likely that a wide variety of molecules purported to be active in human skin do not have any physiologic benefit in human skin. Only further research can answer these difficult questions.

Clinical Trials as Topic↗
PubMed1995

Think globally, act locally: an approach to implementation of clinical practice guidelines.

BACKGROUND: In an environment of concern about the rising costs of medical care, the Vermont Program for Quality in Health Care (VPQHC; the program) was incorporated in 1988 as a nonprofit organization and in 1989 was made a peer review organization by the state legislature. The program acts a resource center for health care in Vermont, coordinating three functions: implementation and maintenance of a statewide database for healthcare quality; training for health care providers in continuous quality improvement (CQI) methods and support for their CQI projects; and focusing clinical study group work on specific diagnoses or procedures. METHODS: The program uses a seven-step process for implementing CQI: pick a process (modify a nationally developed guideline or develop a new guideline); select a team of people involved in doing the work; establish goals and key quality factors; document the clinical process; determine what and how to measure; measure and analyze data; and modify the process to improve. GUIDELINE: This article describes the implementation of a guideline from the American College of Obstetricians and Gynecologists (ACOG) on cesarean section (C-section). Except for a few specific contraindications, the ACOG paper states that it is reasonable to encourage vaginal birth after C-section. A related set of criteria from ACOG states that the benchmark for emergency C-section should be 30 minutes from the decision to proceed with an emergency C-section until the baby is born. CASE STUDY: State C-section rates from 1985-1990 showed wide variation by hospital. Such wide variation is based as much on practice style as on sound science. C-section rates (primary and repeated) were measured, plotted, and shared with Vermont hospitals. Successful vaginal birth after C-section (VBAC) rates from the statewide data-base also were shared. Based on these data, one hospital, Hospital A, developed a plan to lower its repeated C-section rate and improve its VBAC rate. Hospital A collected and reviewed local data, which showed interesting variations. The time from decision to birth became the focus of the overall project; Hospital A designed its project to study events during the time from decision to birth. RESULTS: Most recent data (1992-1993) from Hospital A shows improvement in three areas. First, 89% of patients having emergency C-sections met the goal of a 30-minute time frame from decision to incision. Second, the VBAC success rate for the same time period increased to 85.7% from 69% in the previous year, and from a mere 7% before the implementation of the project. Third, the percentage of total C-sections that were repeat C-sections fell to 36% from a high of 51%. In a follow-up evaluation, one-third of the C-section performed from October 1, 1993, to July 31, 1994 were performed because of patient refusal to attempt VBAC, suggesting that there is a communitywide culture that influences behavior. A major effort at patient education on VBAC is underway. CONCLUSIONS: Think globally, act locally, might be the motto for the program. Implementing guidelines starts with obtaining national guidelines and literature but needs the use of local data to sharpen the focus on narrow areas to address. Specifically, it is unrealistic to tackle the entire problem at once. Success comes from finding specific opportunities for improvement.

Cesarean Section↗
PubMedDate not supplied

College student bereavement, scholarship, and the university: a call for university engagement.

The prevalence of bereavement among traditional-aged college students should impel universities to assist bereaved students on their campuses. Dealing with bereavement can not only challenge a college student's completing the developmental tasks that our society sets for the later adolescent years, but also imperil the student's remaining in school and graduating. It is in the best interests of the university to develop and implement a variety of effective interventions to assist bereaved students. The author argues that universities are communities devoted to scholarly endeavors and should explicitly incorporate the dimension of compassion and caring. An abbreviated case study is used to illustrate the situations in which one grieving student found herself when she returned to school following the death of her father. A call is made for greater university engagement by forming a university-based bereavement center to coordinate and conduct coherent inquiry that fulfills the scholarly functions of discovery, application, and instruction. Four specific actions for a bereavement center are to train nonbereaved students to provide peer support, to provide structured interventions for college students at risk of bereavement complications, to raise consciousness about bereavement on the university campus, and to conduct research into various bereavement populations and bereavement topics.

Adolescent↗
PubMedDate not supplied

Magnetic resonance imaging studies in early-onset bipolar disorder: a critical review.

BACKGROUND: Neuroimaging studies of early-onset bipolar disorder (BD) are important in order to establish a fuller understanding of the underlying pathophysiology of the illness. The advantages of studying BD in children and adolescents include the relative absence of some confounds present in adult-onset research, such as lengthy duration of illness and exposure to treatments, greater number of mood episodes, and the presence of substance abuse or dependence. Finally, studying youths with the disorder may enhance our knowledge about the neural mechanisms of affective dysregulation and may specifically elucidate whether there are abnormalities that are unique to the early-onset form of the illness. METHODS: PubMed was used to identify peer-reviewed publications from the past 15 years (January 1990 to January 2005) that used brain-imaging techniques (anatomic, functional, and biochemical) to research early-onset BD. RESULTS: Eleven studies using anatomic magnetic resonance imaging (MRI), seven using magnetic resonance spectroscopy (MRS), and two using functional MRI (fMRI) were identified. Structural abnormalities were reported in total cerebral, white matter, superior temporal gyrus, putamen, thalamus, amygdala, and hippocampal volumes. Deficits in cortical gray matter were also reported. Using MRS, abnormalities were reported in the dorsolateral prefrontal cortex, anterior cingulate, and basal ganglia. One fMRI study found increased activation in the putamen and thalamus of BD youths compared to controls, and a second found abnormal prefrontal-subcortical activation in familial pediatric BD. CONCLUSION: Published MRI studies of early-onset BD are few. Nonetheless, extant data implicate abnormalities in brain regions thought to regulate mood and cognition. Synthesis of the findings into an overall model of anatomic and functional disruption is difficult due to the methodological variations among studies and the limitations of individual studies, such as the use of small sample sizes, the heterogeneity of sample characteristics, and the wide range of brain structures selected for analysis. Recommendations are offered to guide future research. It will be important for future studies to reproduce prior findings and determine which findings are unique to early-onset BD, relative to adult-onset illness. In addition, studies will need to establish the extent to which early-onset BD may overlap with comorbid disruptive, mood, anxiety, or psychotic disorders.

Age of Onset↗
PubMed1995

The management of professionals: the preferences of hospital sisters and charge nurses.

This analysis of the preferences of how sisters and charge nurses are managed is the result of a two centre descriptive study using theoretical models of professionalism, developing preferences and exercising situational leadership. It was conducted to determine if the management structure preferred by sisters and charge nurses, in a general acute hospital setting, supported the professionalism of nursing. The outcomes were intended to help develop a strategic plan for the future of nursing and the management of nurses. The research instruments were a self-completed questionnaire (19 were returned, a response rate of 31.1%) and four semi-structured interviews. The findings disclosed some dissatisfaction with the present management arrangements. The sisters and charge nurses felt that their priorities for practice and professional issues were better supported by clinically involved, ward-based senior nurses than by unit-based senior nurses with a general management function. However, sisters' and charge nurses' discussions with ward-based senior nurses were apparently less effective than discussions in peer groups which led to influential collegial autonomy. This preferred management style can be supported by the use of situational leadership theory which would enhance collegial autonomy and professional satisfaction. Recognition of the sisters and charge nurses preferences and adjustment of their management would therefore enable them to participate effectively in organizational decision-making.

Attitude of Health Personnel↗
PubMed2004

Attachment, Friendship, and Psychosocial Functioning in Early Adolescence.

Fifth-graders' (N = 162; 93 girls) relationships with parents and friends were examined with respect to their main and interactive effects on psychosocial functioning. Participants reported on parental support, the quality of their best friendships, self-worth, and perceptions of social competence. Peers reported on aggression, shyness and withdrawal, and rejection and victimization. Mothers reported on psychological adjustment. Perceived parental support and friendship quality predicted higher global self-worth and social competence and less internalizing problems. Perceived parental support predicted fewer externalizing problems, and paternal (not maternal) support predicted lower rejection and victimization. Friendship quality predicted lower rejection and victimization for only girls. Having a supportive mother protected boys from the effects of low-quality friendships on their perceived social competence. High friendship quality buffered the effects of low maternal support on girls' internalizing difficulties.

Journal Article↗
PubMed2005

Which young physicians are satisfied with their work? A prospective nationwide study in Norway.

BACKGROUND: Few studies have investigated personality and medical school variables in regard to job satisfaction after graduation. It is of great importance to investigate these factors because this information may be used in the recruitment/admittance process to medical schools, and possibly to improve medical education. METHODS: We conducted a nationwide prospective 10-year follow-up study of medical students at all medical schools in Norway. They were approached three times during their medical training: at very beginning (T1), in the middle (T2), in the last year of medical school (T3), and then four years after graduation (T4). There were 210 participants who responded on all four occasions. Job satisfaction was measured with the Job Satisfaction Scale, which was used as the outcome variable. In addition to conducting multiple regression analysis for the total sample, we also conducted similar analyses separately for men and women. RESULTS: Among the demographic and personality variables, 'having a father who is a physician' and 'interpersonal functioning (being withdrawn)' were significantly associated with job satisfaction at T4. Among the medical school variables, 'well-being with peers', 'identification with the doctor's role at the end of curriculum', 'perceived medical school stress', and 'perceived clinical skills' were significantly associated with job satisfaction. In the multiple regression analysis only 'father as a physician' and 'perceived clinical skills' yielded an independent influence on the outcome variable in separate analyses within sub-groups of male and female students, 'perceived clinical skills' differentiated among woman only, while 'well-being with peers' differentiated only among men. CONCLUSION: The main finding of this study is that the young physicians who are the most satisfied in their work are those whose fathers are physicians and those who have a high level of perceived clinical skills at the end of medical school. There are also differences in regard to predictors of job satisfaction among men and women. These findings indicate that medical schools should invest substantial effort in clinical skills training, and this seems to be especially important among female students.

Adult↗
PubMed2000

Social functioning in children with a chronic illness.

Behavioural, cognitive, and affective aspects of social functioning of 107 children with a chronic illness were studied. The aim of the study was twofold: (1) to describe peer interaction of children with a chronic illness in comparison with normative data of healthy children; (2) to examine whether peer interaction was related to the illness characteristics physical restrictions and pain. Peer interaction was assessed with measures of social activities (CBCL), parent-reported social skills (CABS), child-reported social skills (MESSY), social self-esteem (SPPC), and social anxiety (SASK). Results showed no differences between diagnosis groups, suggesting that the social consequences of chronic illness are not diagnosis specific. Compared with healthy norms, chronically ill children reported less aggressive behaviour. The parent-report measures suggested a similar trend. Children with chronic illness also tended to display more submissive behaviour than healthy norms, as perceived by their parents. With regard to illness characteristics, both physical restrictions and pain were associated with restricted social activities, but not with other measures of social peer interaction. Children who display submissive behaviour and children who are restricted in their social activities should receive extra attention because they are especially vulnerable for problems in their social development.

Adaptation, Psychological↗
PubMed1998

Rejection sensitivity and children's interpersonal difficulties.

Some children respond to social rejection in ways that undermine their relationships, whereas others respond with more equanimity. This article reports 3 studies that test the proposition that rejection sensitivity--the disposition to defensively (i.e., anxiously or angrily) expect, readily perceive, and overreact to social rejection--helps explain individual differences in response to social rejection. Data were from urban, minority (primarily Hispanic and African American) fifth to seventh graders. Study 1 describes the development of a measure of rejection sensitivity for children. Study 2 provides experimental evidence that children who angrily expected rejection showed heightened distress following an ambiguously intentioned rejection by a peer. Study 3 shows that rejection sensitive children behaved more aggressively and experienced increased interpersonal difficulties and declines in academic functioning over time.

Adolescent↗
PubMed1999

Evaluation of orthodontists' perception of treatment need and the peer assessment rating (PAR) index.

This paper examines the relationship between orthodontists' subjective assessment of treatment need and objective measurements obtained during standardized intra- and extraoral examinations. Logistic regression modeling was used to develop predictive models of treatment need. Data were obtained from 1155 eighth-grade students by four orthodontists who used standardized examination forms to assess demographics, trauma, skeletal relationships, morphologic malocclusion traits, and mandibular function. At the conclusion of the examination, the orthodontist rated the subjective treatment need as none, elective, recommended, soon, or immediate. For some analyses, the categories were collapsed to represent no need and need. The peer assessment rating (PAR) index (American validated version) was computed from the clinical exam findings and scoring of dental models; PAR scores were used to document malocclusion severity and treatment difficulty. Spearman rank correlation coefficients quantified the relationship between PAR scores and need categories. Logistic regression analysis modeled treatment need using components of the PAR index as well as other variables. The components of these models, as well as sensitivity and specificity, were compared with malocclusion severity/treatment difficulty scores obtained from malocclusion assessments using the PAR index. The five subjective treatment need categories and the PAR index scores were significantly correlated (rho = 0.62, p<0.001). Significant differences were detected between the need and no need groups for all PAR components (p<0.001). PAR index scores and predicted probabilities from logistic regression models performed equally well for classification purposes (no need, need). The data suggest that the PAR index is highly correlated with orthodontists' subjective assessment of treatment need when that assessment is made in the absence of financial considerations and patient desires.

Adolescent↗
PubMed2005

Poor premorbid social functioning and theory of mind deficit in schizophrenia: evidence of reduced context processing?

Investigations have demonstrated deficits in theory of mind (ToM) ability in schizophrenia. Yet, the development of, and mechanisms associated with these deficits are not well understood. The present investigation examined the hypothesis that, among chronic schizophrenia patients, impaired ToM is associated with failures in context processing, greater disorganized symptoms, and poor premorbid functioning. Forty-two inpatients with schizophrenia spectrum disorders were assessed on tests of ToM, visual and linguistic context processing, executive functioning, and verbal IQ. Symptomatology and premorbid functioning were also assessed. Results revealed that more impaired ToM was associated with poorer performance on both visual and linguistic context processing measures and higher ratings of disorganization on the BRRS. ToM was also associated with poorer childhood social functioning and an earlier age of illness onset. ToM was not associated with verbal processing speed, verbal fluency, response inhibition, sequence learning, or estimated verbal IQ. A significant regression model including measures of childhood peer problems and visual and language context processing significantly predicted ToM performance and accounted for 43% of the variance. These findings suggest that, among chronic schizophrenia patients, deficits in ToM ability may be the result of context processing impairments. These impairments may be a factor in both poor social functioning during childhood and greater disorganized symptoms after illness onset.

Adult↗
PubMed2005

When adolescents disagree with others about their symptoms: differences in attachment organization as an explanation of discrepancies between adolescent, parent, and peer reports of behavior problems.

This study examined whether attachment theory could be used to shed light on the often high degree of discordance between self- and observer ratings of behavioral functioning and symptomatology. Interview-based assessments of attachment organization, using the Adult Attachment Interview, were examined as predictors of the lack of agreement between self- and other reports of behavioral and emotional problems among 176 moderately at-risk adolescents. Lack of agreement was measured in terms of concordance of adolescent and parent or close friend report on equivalent measures of behavioral and emotional adjustment. Insecure-dismissing attachment was linked to less agreement in absolute terms between self- and mother reports of externalizing symptoms, and between adolescent and close friend reports of behavioral conduct. Insecure-preoccupied attachment was associated with higher levels of adolescent reporting of internalizing and externalizing symptoms relative to parent reports of adolescent symptomatology. The findings suggest that attachment organization may be one factor that accounts for individual differences in the degree of discordance between self- and other reports of symptoms in adolescence.

Adolescent↗
PubMed1999

Numerical and arithmetical cognition: patterns of functions and deficits in children at risk for a mathematical disability.

Based on performance on standard achievement tests, first-grade children (mean age = 82 months) with IQ scores in the low-average to high-average range were classified as at risk for a learning disability (LD) in mathematics, reading, or both. These at-risk children (n = 55) and a control group of academically normal peers (n = 35) were administered experimental tasks that assessed number comprehension and production skills, counting knowledge, arithmetic skills, working memory, and ease of retrieving information from long-term memory. Different patterns of intact cognitive functions and deficits were found for children in the different at-risk groups. As a set, performance on the experimental tasks accounted for roughly 50% and 10% of the group differences in mathematics and reading achievement, respectively, above and beyond the influence of IQ. Performance on the experimental tasks thus provides insights into the cognitive deficits underlying different forms of LD, as well as into the sources of individual differences in academic achievement.

Case-Control Studies↗
PubMedDate not supplied

Parent and peer contexts for children's moral reasoning development.

This study addressed the polarization among theoretical perspectives in moral psychology regarding the relative significance of parents and peers in children's developing moral maturity. The sample was composed of 60 target children from late childhood and midadolescence, 60 parents, and 60 friends who participated in parent/child and friend/child dyadic discussions of a series of moral conflicts. The quality of parents' and friends' verbal interactions, ego functioning, and level of moral reasoning in these discussions was used to predict the rate of children's moral reasoning development over a 4-year longitudinal interval. Results revealed that interactions with both parents and peers were predictive of children's development but that these two types of relationships influence development in rather different ways. Implications of the findings for the understanding of these socialization agents' roles in moral development are discussed.

Adolescent↗