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PubMed1997

Immunization for prevention and treatment of cocaine abuse: legal and ethical implications.

A cocaine vaccine, currently under investigation by several laboratories, would be an innovative and exciting means of treating and preventing cocaine addiction. However, an approved vaccine will raise at least two major areas of concern. (1) Loss of privacy: cocaine antibodies might be used as a marker to identify, penalize, and stigmatize vaccinated individuals. (2) Selection for vaccination: should immunization be voluntary or compelled: should immunization be restricted to addicts, to those at risk of addiction, or should it be universal; should immunization be used in children? I propose to analogize cocaine addiction to an infectious disease which poses a major public health problem. This approach can provide an ethical and legal foundation on which we may begin to formulate a societal approach to the use of the cocaine vaccine.

Adult↗
PubMed1998

Research in radiology residency programs: a survey.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether there are characteristics that typify research undertaken in diagnostic radiology residency programs, to determine how the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee's scholarly activity requirement is met by those programs not requiring research, and to ascertain whether differences in research requirements exist between university-based residency programs and those in private facilities. MATERIALS AND METHODS: A one-page survey regarding research requirements during residency was mailed to the 203 program directors of accredited diagnostic radiology residency programs. Chief residents from programs that had not responded to the survey were interviewed at the Armed Forces Institute of Pathology. Data collected were analyzed by using Pearson's chi 2 test. RESULTS: Ninety-two residency programs responded to the survey. Residents were required to assist a faculty member with research in 33% of programs and perform independent research in 20%. There was no statistically significant difference between private practice-based and university-based training programs. A total of 53% of residency programs required some type of resident research. Defined rotations in research were less common (14%). Time off for research activity was granted on request in 23% of the programs. Programs that did not require research used voluntary research activity (25%) and teaching opportunities (17%) to meet the scholarly activity requirement. CONCLUSION: While there is no specific ACGME requirement for research by residents, data indicate that the majority of programs consider research activity, either independent or by assisting faculty, to fulfill the ACGME scholarly activity requirement. However, no single method was selected by more than 33% of those responding.

Data Collection↗
PubMed2002

Improvement of voluntary quadriceps muscle activation after total knee arthroplasty.

OBJECTIVE: To evaluate the maximal voluntary contraction (MVC) force and the voluntary activation of the quadriceps femoris muscle in patients with knee osteoarthritis (OA) before and after total knee arthroplasty (TKA). DESIGN: A prospective intervention study. SETTING: University hospital clinic in Germany. PATIENTS: Fifty patients (32 women, 18 men; mean age +/- standard deviation, 65.8+/-5.6 y) with knee OA and 23 healthy age- and gender-matched control subjects. INTERVENTION: Unilateral TKA without patella resurfacing. MAIN OUTCOME MEASURES: Voluntary activation, MVC, and true maximal contraction forces of the bilateral quadriceps femoris muscles, using the twitch interpolation technique before and 33+/-8 months after TKA. Assessment of postoperative knee pain by the Lewis score. RESULTS: Voluntary activation increased bilaterally after surgery (P<.01 operated side, P=.02 nonoperated side) but remained lower than the voluntary activation of the controls. MVC (P<.001) and true maximal contraction forces (P=.01) increased significantly on the operated side. MVC remained unchanged (P=.45), and true maximal contraction forces decreased significantly (P=.04) on the nonoperated side. CONCLUSION: Patients with knee OA have significant bilateral voluntary activation deficits that are, at least in part, reversible within 3 years after TKA. Rehabilitation programs immediately after TKA should focus on reduction of voluntary activation deficits. After voluntary activation improves, physical therapy should target the augmentation of quadriceps femoris muscle strength.

Aged↗
PubMed1991

Incorporating HIV education and counseling into routine prenatal care: a program model.

This article reports how a prenatal clinic in a major urban teaching hospital has developed and integrated an HIV education and counseling program into routine prenatal care. The patient population served are predominantly minority women living in an inner-city community that has been disproportionately affected by the AIDS epidemic. Implementation of the patient program has required training and support for all professional staff. Staff training served as a foundation for this comprehensive patient program, which has reached all prenatal patients regardless of risk behavior. The program has succeeded in involving a large population of women in an educational program, has identified HIV-1 seropositive pregnant women through voluntary testing, and has provided them with the necessary medical and social work services. Principles of program development are identified for use in other settings.

Ambulatory Care↗
PubMed1996

A program for eradication of hepatitis B from Taiwan by a 10-year, four-dose vaccination program.

Approximately 15 percent of the Taiwanese population are chronic carriers of hepatitis B virus (HBV), among the highest rates in Asia. In July 1984, the Taiwanese government initiated a nationwide HBV-vaccination program. The program began with educational efforts and voluntary prenatal screening for HBsAg. Infants of HBsAg-carrier mothers received a four-dose regimen of hepatitis B vaccine. Those born to highly infectious mothers also received a dose of hepatitis-B immune globulin within 24 hours after birth. Seroepidemiologic studies were conducted using a random sample of infants. Serum samples were collected at 18, 24, 36, and 48 months and analyzed via radioimmunoassay for HBsAg, anti-HBs, and anti-HBc. Infants of highly infectious mothers had HBsAg positivity rates of 14.2 percent (vaccine plus HBIG) and 19.7 percent (vaccine only) when on schedule, and 17.0 percent when off schedule. Infants of moderately infectious mothers had an HBsAg positivity rate of 3.0 percent when on schedule and 6.4 percent when off schedule. These low positivity rates persisted throughout the 48-month follow-up period. This represents a dramatic improvement upon the 40 to 96 percent vertical transmission rate seen before the program implementation. This program demonstrates that mass immunoprophylaxis for HBV is feasible, and provides practical strategies for other Asian countries.

Adolescent↗
PubMed1996

The adolescent's right to confidential care when considering abortion. American Academy of Pediatrics. Committee on Adolescence.

In this statement, the American Academy of Pediatrics (AAP) reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. The AAP supports the recommendations presented in the report on mandatory parental consent to abortion by the Council on Ethical and Judicial Affairs of the American Medical Association. Adolescents should be strongly encouraged to involve their parents and other trusted adults in decisions regarding pregnancy termination, and the majority of them voluntarily do so. Legislation mandating parental involvement does not achieve the intended benefit of promoting family communication, but it does increase the risk of harm to the adolescent by delaying access to appropriate medical care. The statement presents a summary of pertinent current information related to the benefits and risks of legislation requiring mandatory parental involvement in an adolescent's decision to obtain an abortion. The AAP acknowledges and respects the diversity of beliefs about abortion and affirms the value of voluntary parental involvement in decision making by adolescents.

Abortion, Induced↗
PubMed1975

National health planning in the United States: prospects and portents.

The National Health Planning and Resources Development Act of 1974 in the United States demonstrates a growing determination in Congress to motivate the system of health services toward greater efficiency in utilization of resources. The Act was designed to overcome some of the weaknesses in earlier planning legislation. More complete coverage and more functional local jurisdictions for planning should result. The Act provides better financial support, and more effective incentives and inducements to assure adherence to plans. Concern is expressed about aspects of the legislation which the authors feel may deserve consideration. The principle of delegating responsibility to voluntary agencies for disbursement of public funds is questioned, and the authors suggest that local public health authorities apply for designation as planning agencies. Reservation is expressed about the adequacy of regional organization as provided by the Act to accomplish its purposes, and the authors recommend demonstrations of regional administrative agencies to implement plans developed by Health Systems Agencies. Failure to incorporate the provision of the House planning bill to set up a national health policy council in the Act is considered unfortunate. Persistence in pursuing the course outlined in the Act is urged.

Financing, Government↗
PubMed2004

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland.

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.

Community Networks↗
PubMed2001

Primary care physicians' experience with disease management programs.

OBJECTIVE: To examine primary care physicians' perceptions of how disease management programs affect their practices, their relationships with their patients, and overall patient care. DESIGN: Cross-sectional mailed survey. SETTING: The 13 largest urban counties in California. PARTICIPANTS: General internists, general pediatricians, and family physicians. MEASUREMENTS AND MAIN RESULTS: Physicians' self-report of the effects of disease management programs on quality of patient care and their own practices. Respondents included 538 (76%) of 708 physicians: 183 (34%) internists, 199 (38%) family practitioners, and 156 (29%) pediatricians. Disease management programs were available 285 to (53%) physicians; 178 had direct experience with the programs. Three quarters of the 178 physicians believed that disease management programs increased the overall quality of patient care and the quality of care for the targeted disease. Eighty-seven percent continued to provide primary care for their patients in these programs, and 70% reported participating in major patient care decisions. Ninety-one percent reported that the programs had no effect on their income, decreased (38%) or had no effect (48%) on their workload, and increased (48%)) their practice satisfaction. CONCLUSIONS: Practicing primary care physicians have generally favorable perceptions of the effect of voluntary, primary care-inclusive, disease management programs on their patients and on their own practice satisfaction.

Chi-Square Distribution↗
PubMed2006

A national survey of tobacco cessation programs for youths.

OBJECTIVES: We collected data on a national sample of existing community-based tobacco cessation programs for youths to understand their prevalence and overall characteristics. METHODS: We employed a 2-stage sampling design with US counties as the first-stage probability sampling units. We then used snowball sampling in selected counties to identify administrators of tobacco cessation programs for youths. We collected data on cessation programs when programs were identified. RESULTS: We profiled 591 programs in 408 counties. Programs were more numerous in urban counties; fewer programs were found in low-income counties. State-level measures of smoking prevalence and tobacco control expenditures were not associated with program availability. Most programs were multisession, school-based group programs serving 50 or fewer youths per year. Program content included cognitive-behavioral components found in adult programs along with content specific to adolescence. The median annual budget was 2000 dollars. Few programs (9%) reported only mandatory enrollment, 35% reported mixed mandatory and voluntary enrollment, and 56% reported only voluntary enrollment. CONCLUSIONS: There is considerable homogeneity among community-based tobacco cessation programs for youths. Programs are least prevalent in the types of communities for which national data show increases in youths' smoking prevalence.

Adolescent↗
PubMed1995

Early interactions between drug-involved mothers and infants. Within-group differences.

OBJECTIVE: To explore differences in maternal characteristics, mother-infant interaction, and infant development within a group of women who used cocaine, alcohol, and tobacco during pregnancy and their infants. DESIGN: Prospective survey. SETTING: Countywide, voluntary, home-based clinical intervention program. PARTICIPANTS: Thirty-two mother-infant pairs identified through a risk-assessment screen who participated in the program for 1 year. VARIABLES: Maternal characteristics, neonatal characteristics, interactional measures (Nursing Child Assessment Feeding Scale and Home Observation for Measurement of the Environment scale), and developmental assessment (Bayley Scales of Infant Development at 1 year). RESULTS: The majority of women were black, single, and unemployed. Fifteen (47%) of the infants were born prematurely; four (13%) were small for gestational age. Mean Bayley Scales of Infant Development scores were as follows: the mental development index was 99.8, and the psychomotor development index was 102.4. Older mothers (r = .41, P = .04), mothers of higher parity (r = .42, P = .02), and mothers who were more actively involved in the program (r = .41, P = .04) had higher scores on the Nursing Child Assessment Satellite Training Feeding Scale. Mothers who were better educated (r = .49, P = .009) and mothers who were more active in the program (r = .44, P = .02) had higher scores on the Home Observation for Measurement of the Environment scale. Several of the subscales of the Home Observation for Measurement of the Environment scale were significantly associated with scores on the Bayley Scales of Infant Development. CONCLUSIONS: For this group of substance-exposed infants whose mothers were receiving support services, developmental skills at 1 year were age appropriate. Despite drug abuse and poverty, there was some variability in the ability of mothers to provide a developmentally supportive environment for their infants. Those who were better organized to support infant development had infants who performed better on global developmental assessments.

Child Development↗
PubMed1985

National survey of patterns of care for Hodgkin's disease.

Patterns of care for Hodgkin's disease were surveyed through voluntary audits of hospitals with cancer programs approved by the Cancer Commission of the American College of Surgeons. Four hundred seventy-three hospitals reported 6314 patients in the long-term survey (patients diagnosed immediately preceding December 31, 1975), and 611 hospitals identified 3168 new patients in the short-term study (patients diagnosed immediately following January 1, 1981). The latter represent 45% of the estimated annual incidence in the United States. Comparison of the two studies showed changes in the procedures employed in staging, including an increased use of lung and abdominal computed tomography and bilateral bone marrow biopsies. Use of upper mantle plus periaortic node radiotherapy increased, whereas the inverted-Y field decreased. The use of single-agent chemotherapy decreased, and MOPP (nitrogen mustard, vincristine, procarbazine, and prednisone) chemotherapy increased. The survival rates varied with age, being better at younger ages and worse in the elderly.

Adolescent↗
PubMed1992

Survival in Hodgkin's disease by stage and age.

Patterns of care for Hodgkin's disease in the United States were surveyed through voluntary audits of hospitals with cancer programs nonapproved and approved by the Cancer Commission of the American College of Surgeons. Four hundred and seventy-three hospitals reported 6,345 patients diagnosed immediately preceding December 31, 1975. The survival rates varied with age, being better at younger ages and worse in the elderly. By pathologic stage, the younger patients faired better than the elderly in each stage grouping. Histologic type was not a factor in this poor prognosis. Hodgkin's disease in elderly patients has a different biologic behavior than in younger patients.

Adolescent↗
PubMed1993

Consumer-operated drop-in centers: evaluation of operations and impact.

Research on self-help for consumers of psychiatric services has focused on the operation of voluntary groups and largely ignored service programs operated by consumers. This evaluation study focused on six consumer-operated drop-in centers, each established for at least two years. These centers served a combined total of 1,445 consumers and were funded as demonstration projects by the Michigan Department of Mental Health. Structured interviews of consumer-users of these centers indicated that the program was meeting its funding intents of serving people with serious mental illness and of creating an environment promoting social support and shared problem solving. Levels of satisfaction were uniformly high; there were few differences across centers. Issues that emerged for future policy and research considerations included funding constraints, enhancing accessibility (particularly for women and people needing frequent hospitalization), variable levels of support from catchment area community mental health agencies, and determining the long-term benefits of drop-in center participation.

Community Mental Health Centers↗