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Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents.

OBJECTIVES: To improve tobacco control campaigns, we analyzed tobacco industry strategies that encourage young adults (aged 18 to 24) to smoke. METHODS: Initial searches of tobacco industry documents with keywords (e.g., "young adult") were extended by using names, locations, and dates. RESULTS: Approximately 200 relevant documents were found. Transitions from experimentation to addiction, with adult levels of cigarette consumption, may take years. Tobacco marketing solidifies addiction among young adults. Cigarette advertisements encourage regular smoking and increased consumption by integrating smoking into activities and places where young adults' lives change (e.g., leaving home, college, jobs, the military, bars). CONCLUSIONS: Tobacco control efforts should include both adults and youths. Life changes are also opportunities to stop occasional smokers' progress to addiction. Clean air policies in workplaces, the military, bars, colleges, and homes can combat tobacco marketing.

Adolescent↗

Growth and development of the pediatric cervical spine documented radiographically.

BACKGROUND: The radiographic anatomy of the cervical spine in children is complex and can be difficult to interpret. The present study was undertaken to document radiographically the growth and development of the cervical spine in a prospective, longitudinal manner and to establish standard radiographic measurements on the basis of findings in patients who were followed serially from the age of three months until skeletal maturity. METHODS: The radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush Collection, Cleveland, Ohio) were reviewed. From this large database, we identified fifty boys and forty-six girls who had a sufficient number of radiographs of the cervical spine for inclusion in our study. With use of a computerized image analyzer, the growth and development of the atlantodens interval, the diameter of the spinal canal, the Torg ratio, the height and width of the second through fifth cervical vertebral bodies, the height of the dens, and the ossification of the first cervical vertebra were assessed on serial radiographs made from the age of three months until skeletal maturity. RESULTS: Serial measurements of the atlantodens interval, the anteroposterior diameter of the cervical canal, the height and anteroposterior width of the cervical vertebral bodies, and the height of the dens, made in normal, healthy children from the age of three months to fifteen years, are presented in tabular and graphic forms. The median Torg ratio was 1.47 for both males and females primarily, and it reached values of 1.06 for males and 1.10 for females by maturity. The anterior arch of the first cervical vertebra had ossified in 33% of the children by the age of three months and in 81% of the children by the age of one year. Closure of the synchondroses was completed in all children by the age of three years. CONCLUSIONS: The measurements presented in the current study are important because they are the first, as far as we know, to document the radiographic parameters of the cervical spine in children who were followed longitudinally from before the age of three years through the course of growth and development until skeletal maturity.

Adolescent↗

Use of beryllium-7 to document soil redistribution following forest harvest operations.

Rapid and reliable methods for documenting soil erosion associated with forest harvest operations are needed to support the development of best management practices for soil and water conservation. To address this need, the potential for using 7Be measurements to estimate patterns and amounts of soil redistribution associated with individual post-harvest events was explored. The 7Be technique, which was originally developed for use on agricultural land, was employed to estimate soil redistribution associated with a period of heavy rainfall within a harvested forest area located in the Lake Region of Chile (39 degrees 44'7'' S, 73 degrees 10'39'' W; 22% slope; and mean annual rainfall 2300 mm yr(-1)). The results provided by the 7Be technique were validated against direct measurements of soil gain or loss during the same period obtained using erosion pins. The information produced by the two approaches was similar. The results of this study demonstrate the potential for using 7Be measurements to document event-based erosion in recently harvested forest areas.

Beryllium↗

Osmotic blood-brain barrier modification: clinical documentation by enhanced CT scanning and/or radionuclide brain scanning.

Results of initial clinical trials of brain tumor chemotherapy after osmotic blood-brain barrier disruption are promising. In general, the procedure is well tolerated. The major complication has been seizures. In this report, data are presented which indicate that the etiology of these seizures is related to the use of contrast agent (meglumine iothalamate) to monitor barrier modification. A series of 19 patients underwent a total of 85 barrier modification procedures. Documentation of barrier disruption was monitored by contrast-enhanced computed tomographic (CT) scanning, radionuclide brain scanning, or a combination of both techniques. In 56 procedures (19 patients) monitored by enhanced CT, seizures occurred a total of 10 times in eight patients. Twenty-three barrier modification procedures (in nine of these 19 patients) documented by nuclear brain scans alone, however, resulted in only one focal motor seizure in each of two patients. In eight of the 19 patients who had seizures after barrier disruption and enhanced CT scan, four subsequently had repeat procedures monitored by radionuclide scan alone. In only one of these patients was further seizure activity noted; a single focal motor seizure was observed. Clearly, the radionuclide brain scan does not have the sensitivity and spatial resolution of enhanced CT, but at present it appears safer to monitor barrier modification by this method and to follow tumor growth between barrier modifications by enhanced CT. Four illustrative cases showing methods, problems, and promising results are presented.

Adult↗

[Cardiopulmonary resuscitation: discrepancy between the actual cardiopulmonary resuscitation and the documentation in the medical record]

OBJECTIVES: To describe the characteristics of the patients not resuscitated in a university affiliated pediatric hospital. To characterize the data registered in the chart regarding the resuscitation and evaluate ethical and legal aspects of CPR (cardiopulmonary resuscitation). METHODS: Retrospective study of 176 deaths that occurred in a one year time period. The chart was reviewed and compared to information received directly from the physician that participated in the patientacute;s resuscitation. Ethical and legal aspects involved in resuscitation efforts were discussed. RESULTS: During the study period 176 deaths occurred. 47 (26.7%) patients did not receive CPR as reported directly by the physician in charge of the patient when the dead occurred. Two patients were excluded, because the chart could not be found. Prior to their death, 64.4% (29/45) received mechanical ventilatory support and 48.5% (33/45) received inotropic support. 60% (27/45) of the deaths occurred in the intensive care unit. The most common diagnoses at admission were sepsis in 28% (13/45) and pneumonia with respiratory failure in 27% (12/45). The most common underlying medical conditions were malignancies in 28.8% (13/45). Of these 45 patients, the medical record about CPR was available in 40 charts. It was documented that 11/40 (27.5%) were declared dead without resuscitation efforts and in 29/40 (72.5%) the medical record stated that CPR was performed without improvement in vital signs. CONCLUSION: There was a discrepancy between the actual cardiopulmonary resuscitation efforts and the documentation of cardiopulmonary resuscitation in the medical record. This behavior may be due to fear of possible legal consequences of not performing cardiopulmonary resuscitation. However, in patients with very poor prognosis it may be ethically justified to withhold CPR.

Journal Article↗

Is the number of documented diabetes process-of-care indicators associated with cardiometabolic risk factor levels, patient satisfaction, or self-rated quality of diabetes care? The Translating Research into Action for Diabetes (TRIAD) study.

OBJECTIVE: Simple process-of-care indicators are commonly recommended to assess and compare quality of diabetes care across health plans. We sought to determine whether variation in the number of simple diabetes processes of care across provider groups is associated with variation in other quality indicators, including cardiometabolic risk factor levels, patient satisfaction with care, or patient-rated quality of care. RESEARCH DESIGN AND METHODS: We used cross-sectional survey and chart audit data for 8,733 patients with diabetes who received care from 68 provider groups nested in 10 health plans that participated in the Translating Research Into Action for Diabetes study. Analyses using hierarchical regression models assessed associations of the mean number of seven simple process measures with each of the following: HbA(1c) (A1C), systolic blood pressure (SBP), HDL and LDL cholesterol levels, patient satisfaction with care, and patient-rated quality of care. RESULTS: After adjusting for case-mix differences across groups and plans, an average of one additional documented process of care for each patient in a group or plan was associated with significantly lower mean LDL cholesterol levels (-4.51 mg/dl [95% CI 1.46-7.58]) but not with A1C, SBP, or HDL cholesterol levels. The number of care processes documented was associated with patient satisfaction measures and self-rated quality of diabetes care. CONCLUSIONS: Variation in the number of simple process-of-care indicators across provider groups or health plans is associated with differences in patient-centered measures of quality, but assessment of the quality of cardiometabolic risk factor control will require more advanced clinical performance indicators.

Aged↗

Relationship of field dependence-independence to documentation of nursing-process components by registered nurses in a clinical setting.

Scores on the Group Embedded Figures Test of 56 registered staff nurses were correlated with percentage of components of nursing process documented on care plans and progress notes. Education, age, and work experience were control variables. The mean embedded figures scores for associate degree, diploma, and baccalaureate nurses were 11.47, 9.47, and 12.83, respectively. Baccalaureate nurses had the most success in documenting components and diploma nurses had the least. A significant correlation was observed between test scores and percentage of nursing process chains completed by diploma nurses. For associate-degree nurses, a significant inverse correlation was observed between test scores and percentage of components used and percentage of chains with a nursing diagnosis.

Adult↗

Some practical notes on documentation of superficial hyperthermia treatment.

A detailed and accurate documentation of the treatment setup of each individual hyperthermia session is extremely important for retrospective data analysis as well as treatment quality control. In this paper the relatively simple and cheap documentation system developed by the Hyperthermia Department of the Dr Daniel den Hoed Cancer Center, is presented.

Humans↗

Sources of variance in the objective documentation of human cataractous change with Topcon SL-45 and Neitz-CTR retroillumination photography and computerized image analysis.

In the application of Topcon SL-45 Scheimpflug slit and Neitz CTR retroillumination photography to in vivo documentation of cataractous change, several sources of variance affect the results of each technique. We have measured the between-person, between-photographer, between-focal plane (Neitz), between-photo session, replicate photograph (Topcon), between-image analyst and replicate image analysis variances encountered in in vivo documentation of human cataracts with the Topcon SL-45 and Neitz-CTR cameras and our system of computerized image analysis.

Adult↗

Ultradian, circadian and circannual rhythms of blood glucose and injected insulins documented in six self-controlled adult diabetics.

The aim of the study was to document during one to two years individual rhythmic patterns in blood glucose and injected insulin in self-controlled insulin dependent (C-peptide negative) diabetics with home blood glucose monitoring. Two females and four males with diurnal activity from 0700 to 2300 self-determined their blood glucose three to six times a day over a period of 12-27 months. Circadian and ultradian rhythms were analysed for each subject on a monthly basis to document annual rhythms. Blood glucose (BG) estimated circadian acrophases were located between 2200 and 0300 for all patients and months with few exceptions. A correlation was found between circadian mesors and amplitudes of BG in four subjects. Annual changes in BG were validated for each subject with large interindividual differences in peak times. The individual mean of injected insulin (II) varied from 40 to 80 iU with annual changes validated for each subject. A group pattern was observed with a peak time either in the autumn (four patients) or in the summer (two patients). A circadian rhythm of II was detected in almost all monthly means and for all patients. Locations of computed peak time phi of II exhibited a great stability for a given individual but large interindividual differences. Thus the rather constant phi location of BG for all subjects contrasted with interindividual differences in phi locations of II. These results suggest that rhythmic changes in BG and II should be recognized when forming a realistic strategy for timing and dosing time(s) of insulin.

Activity Cycles↗

Comparison of amphotericin B lipid complex (ABLC) vs. ambisome in the treatment of suspected or documented fungal infections in patients with leukemia.

Fungal infections remain a major cause of treatment failure and death in acute leukemia. New liposomal preparations of amphotericin B are now available. While less toxic, their comparative efficacy and toxicity profiles are unknown. In this study the comparative efficacy and safety of ABLC vs. AmBisome was evaluated in seventy-five patients with leukemia who developed 82 episodes of suspected or documented mycosis, and were treated (1:1) with either ABLC (n=43) or AmBisome (n=39). Both drugs were dosed accordingly from 3 to 5 mg/kg/day. Using an intent-to-treat analysis, the overall response to therapy was 27/43 (63%) for ABLC and 15/39 (39%) for AmBisome (p=0.03). Median dose and duration of treatment was 10 days at 3 mg/kg for ABLC and 15 days at 4 mg/kg for AmBisome. Acute, not dose-limiting infusion side effects were seen in 70% vs. 36% (p=0.002), ABLC vs. AmBisome. Increase of bilirubin > 1.5 times from baseline was 38% vs. 59%, ABLC vs. AmBisome (p=0.05). ABLC and AmBisome were equally effective for the treatment of suspected or documented fungal infections. While, acute infusion-toxicity was greater with ABLC, infusion toxicity requiring discontinuation was similar for both drugs. AmBisome was better tolerated than ABLC but was associated with mild abnormalities in liver function tests at the end of therapy.

Acute Disease↗

Documenting rotation at the glenohumeral joint. A technical note.

Present methods of documenting internal rotation of the shoulder joint are based on the point reached over the back by the tip of the fully extended thumb. Disease or stiffness of the joints distal to the shoulder gives a false measure of internal rotation. Using the interepicondylar line of the humerus in the coronal plane as the neutral position, internal rotation can be documented accurately as the angle formed by this line with the coronal plane when the shoulder is rotated inwards.

Biomechanical Phenomena↗

Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation.

The coexistence of traumatic locked facets of the cervical spine and a herniated disc is not well described. The authors present a series of patients with traumatic locked facets who demonstrated a high incidence of associated disc herniation documented on magnetic resonance (MR) imaging. Thirteen patients with either unilateral (four cases) of bilateral (nine cases) locked facets of the cervical spine were analyzed retrospectively. Immediate closed reduction using traction and/or manipulation was attempted in the first nine cases treated and was successful in only three; however, the procedure was abandoned in three cases due to deterioration in the patient's clinical status. In the subsequent four patients, an MR image was obtained prior to attempts at closed reduction. All patients underwent MR imaging of the cervical spine. Of eight consecutive cases treated at the University of Michigan, frank disc herniation with fragmented disc in the canal was found in five while pathological disc bulging was found in the other three. All five cases contributed by other institutions had concurrent disc herniation. This series illustrates the importance of using MR imaging to document the presence of a herniated disc during the initial evaluation of a patient with traumatic locked facets of the cervical spine and prior to attempted reduction of the locked facets. Experience indicates that closed reduction of facet dislocation associated with disc rupture may result in increased spinal cord compression and neurological deficit. If a herniated disc is discovered, anterior discectomy and fusion would be favored as the initial therapy over attempts at closed reduction or operative posterior reduction.

Adolescent↗

Magnetic resonance imaging-documented extravasation as an indicator of acute hypertensive intracerebral hemorrhage.

OBJECT: The aim of this study was to determine the usefulness of magnetic resonance (MR) imaging-documented extravasation as an indicator of continued hemorrhage in patients with acute hypertensive intracerebral hemorrhage (ICH). METHODS: The authors studied 108 patients with acute hyperintensive ICH. Imaging modalities included noncontrast-enhanced computerized tomography (CT) scanning, gadolinium-enhanced MR imaging, and conventional cerebral angiography obtained within 6 hours after the onset of hemorrhage. A repeated CT scan was obtained within 48 hours to evaluate enlargement of the hematoma. Findings on MR imaging indicating extravasation, including any high-intensity signals on T1-weighted postcontrast images, were observed in 39 patients, and 17 of these also showed evidence of extravasation on cerebral angiography. The presence of extravasation on MR imaging was closely correlated with evidence of hematoma enlargement on follow-up CT scans (p < 0.001). CONCLUSIONS: Evidence of extravasation documented on MR imaging indicates persistent hemorrhage and correlates with enlargement of the hematoma.

Acute Disease↗

Flushing in relation to a possible rise in intracranial pressure: documentation of an unusual clinical sign. Report of five cases.

This report documents clinical features in five children who developed transient reddening of the skin (epidermal flushing) in association with acute elevations in intracranial pressure (ICP). Four boys and one girl (ages 9-15 years) deteriorated acutely secondary to intracranial hypertension ranging from 30 to 80 mm Hg in the four documented cases. Two patients suffered from ventriculoperitoneal shunt malfunctions, one had diffuse cerebral edema secondary to traumatic brain injury, one was found to have pneumococcal meningitis and hydrocephalus, and one suffered an intraventricular hemorrhage and hydrocephalus intraoperatively. All patients were noted to have developed epidermal flushing involving either the upper chest, face, or arms during their period of neurological deterioration. The response was transient, typically lasting 5 to 15 minutes, and dissipated quickly. The flushing reaction is postulated to be a centrally mediated response to sudden elevations in ICP. Several potential mechanisms are discussed. Flushing has clinical importance because it may indicate significant elevations in ICP when it is associated with neurological deterioration. Because of its transient nature, the importance of epidermal flushing is often unrecognized; its presence confirms the need for urgent treatment.

Adolescent↗

Empirical antibiotic treatment with piperacillin-tazobactam in patients with microbiologically-documented biliary tract infections.

AIM: To report our experience with empiric antimicrobial monotherapy (piperacillin/tazobactam, of which no data are available in such specific circumstances) in microbiologically-documented infections in patients with benign and malignant conditions of the biliary tract. METHODS: Twenty-three patients, 10 with benign and 13 with malignant conditions affecting the biliary tree and microbiologically-documented infections were recruited and the efficacy of empirical antibiotic therapy was assessed. RESULTS: The two groups featured similar demographic and clinical data. Overall, the infective episodes were most due to Gram negative agents, more than 60% of such episodes (mostly in malignant conditions) were preceded by invasive instrumental maneuvers. Empirical antibiotic therapy with a single agent (piperacillin/tazobactam) was effective in more than 80% of cases. No deaths were reported following infections. CONCLUSION: An empiric therapeutic approach with piperacillin/tazobactam is highly effective in biliary tract infections due to benign or malignant conditions.

Adult↗

The nursing shortage: the legal impact on documentation.

In 1985, two significant events occurred in the health care industry. These events ultimately proved to have a deleterious effect on the nursing profession. In an effort to contain spiraling health care costs, the federal government implemented a reimbursement system based on diagnosis related groups (DRGs). One of the major foci of this system was the length of stay, i.e., the shorter the stay, the greater the monetary profit for the institution. Therefore, patients were being admitted and discharged "sicker." These two events resulted in nurses being torn between the need for adequate documentation and the delivery of patient care. When one adds to this mix the legal environment in health care, with its focus on the adage "if it is not documented, it was not done," nurses were becoming increasingly frustrated and frightened. In light of current legal trends, this article reexamines this adage and discusses implications for the nurse educator.

Education, Nursing, Continuing↗

Legal aspects of nursing documentation for the Alzheimer's patient.

1. Bergerson (1988) developed a set of charting rules called the FACT system (charting that is Factual, Accurate, Complete, and Timely). Nurses' notes are viewed as legal sources of documentation. 2. Nurse's notes made regarding the patient's cognitive status, ability to communicate and participate in treatment decisions, and safety needs may be carefully reviewed by the court system for a variety of reasons. 3. Nurses caring for patients with Alzheimer's disease must recognize that the primary function of any charting or documentation is optimal care for the individual patient. Nurses should not chart in anticipation of a legal review of the charting. However, nurses also must be aware that a legal challenge may prompt a review of the record and require the nurse to explain or clarify entries that have been made.

Adult↗