Improving Scotland's health: time for a fresh approach?

Scotland's health remains the worst in the UK. There are several probable reasons for this. Of those that are amenable to change, health improvement policy has been excessively preoccupied with targeting individuals perceived to be 'at risk' rather than adopting a whole population perspective. Environmental as opposed to behavioural approaches to health improvement have been relatively neglected. To meet the challenge of Scotland's poor health more effectively in the future, new strategic thinking is necessary. Three initial steps are required: recognize that current approaches are inadequate and that fresh ideas are needed; identify the principles that should underlie future strategy development; translate these principles into achievable operational objectives. Five principles of a revitalized strategy to improve the health of Scotland in the future are proposed. These are start early and sustain effort; create a healthy and safe environment; reduce geographical as well as social inequalities in health; adopt an evidence-based approach to public health interventions; use epidemiology to assess need, plan interventions and monitor progress. These principles may then be translated into achievable operational policy and practice objectives.     

Carvedilol for heart failure: more than just a beta-blocker?

Carvedilol is a non-selective beta-blocker, and the only one, in recent clinical trials, to have shown a clear reduction in mortality. It is suggested that, compared with other beta-blockers, carvedilol has additional advantageous effects in heart failure, and should be considered as part of the routine treatment of heart failure.     

Clogbusting: time for a concerted approach to catheter occlusions?

PURPOSE OF REVIEW: Occlusions of central venous catheters in service are frequent, but the random nature of the problem has resulted in a piecemeal approach to solving it. The purpose of this review is to examine what is known from past and recent publications and to recommend strategies for future investigations. RECENT FINDINGS: Long-term central venous access is a critical part of nutritional support for many patients with intestinal failure. The technique also has wide applicability in oncology, the management of certain types of infections and in organ failure. The causes of occlusion have been found to be multifactorial, including a combination of mechanical obstruction, chemical precipitation, lipid deposition and thrombus formation. Most unblocking strategies have been aimed at cure rather than prevention, and targeted at individual causes of obstruction. The British Pharmaceutical Nutrition Group and home parenteral nutrition patients group (Patients on Intravenous and Nasogastric Nutrition Therapy), member organizations of the British Association for Parenteral and Enteral Nutrition, have recently charged a subcommittee with targeting future research into a more concerted practical and pharmaceutical approach to the phenomenon. SUMMARY: Catheter occlusion is a common problem costing considerable time and money for patients and healthcare professionals, requiring pro-action rather than reaction. None of the existing approaches is a complete answer, and further, coordinated research effort is needed. Endoluminal brushing is gradually gaining acceptance as a 'catch-all' solution once the catheter malfunctions, but understanding how and why catheters become blocked, and developing strategies to prevent occlusion would be a more scientific approach.     

Are some lives more valuable? An ethical preferences approach

We develop a theoretical model of the ethical preferences of individuals, combining individual social welfare functions and random utility theory. The model is applied by conducting a choice experiment regarding safety-enhancing road investments that target different age groups and road user types. The relative value of a saved life is found to decrease with age, such that the present value of a saved life-year is almost independent of age at a pure rate of time preference of a few percent. Moreover, a saved pedestrian is consistently valued higher than a saved car driver of the same age.     

What more do we need to know for a world without violence?

Violence, a universal health issue, presents serious implications for general health and interpersonal relations. Roots of violence appear in early childhood and instances of extreme violence may become apparent in adolescence. Serious antisocial behavior in adolescence is a predictor of violence in later age. Risk factors for violent behavior could be categorized as individual and environmental. Environmental risk factors can be familial, social, and chemical environmental. Maltreatment in childhood is an important predictor of violent behavior in later age. The presence of mental illness is another important predictor of violence. Contemporary television has a visual and auditory power to promote violence with all its elements. Computers are another field where children confront violence. For identification of individuals who have an increased propensity or susceptibility, for violent behavior, research has suggested that polymorphisms related to certain genes might be important. However, we should emphasize that the expression of such behavior would always depend on interactions between various genes, environmental factors, and genetic-environmental interactions. Experiments in rhesus monkeys have shown that optimal early social experiences might overcome the deleterious effects of susceptible alleles. The effective prevention of violence should consist of interventions that aim to reduce the number of risk factors during early childhood, such as home visitation programs and giving individuals the skills and opportunities for engaging in positive behaviors during school years and adolescence, coupled with the identification of new barriers and reassessment of needs.     

Does empirical research make bioethics more relevant? “The embedded researcher” as a methodological approach

Medicine, Health Care and Philosophy - What is the status of empirical contributions to bioethics, especially to clinical bioethics? Where is the empirical approach discussed in bioethics related...     

Is price a barrier to eating more fruits and vegetables for low-income families?

OBJECTIVE: To determine if price is a barrier to fruit and vegetable consumption for low-income families by comparing the average cost of a market basket of fruits and vegetables from the Thrifty Food Plan and the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines), investigating variations in price by neighborhood income and by type of supermarket, and estimating the influence of a 2005 Dietary Guidelines fruit and vegetable basket on the food budget of a low-income family. DESIGN: A market basket survey was conducted at 25 supermarkets across three time periods to allow for seasonal variation in produce prices. SETTING: Stores were selected from census tracts with a variety of income levels in Sacramento, CA, and Los Angeles, CA. MAIN OUTCOME MEASURES: The average cost of a Thrifty Food Plan and 2005 Dietary Guidelines market basket for fruits and vegetables. STATISTICAL ANALYSES PERFORMED: Student t tests were used to compare the mean cost of market baskets. RESULTS: The 2005 Dietary Guidelines market basket cost 4% less than the Thrifty Food Plan (P<0.001), and was significantly less expensive in low-income areas at 65 dollars (P<0.05), and in bulk supermarkets at 59 dollars (P<0.05). The 2005 Dietary Guidelines market basket would require a low-income family to devote 43% to 70% of their food budget to fruits and vegetables. CONCLUSIONS: Public policies should examine ways to make fruits and vegetables more affordable to low-income families.     

Do the research goal and databases match? A checklist for a systematic approach

To test the appropriateness of a given database for specific research questions, we designed a checklist starting with the definition of an ideal database. This ideal database contains all relevant data on patients, providers and services. It is safe and accessible, input is always accurate, continuity is guaranteed and linkage with other information is easy. Of course no such database exists. Still these features are often taken for granted, but highly influenced by organizational processes in healthcare and prioritization. Starting with the characteristics of an ideal database, one can systematically list the required aspects for research goals and compare these with the available systems. This checklist is used to address important aspects of administrative database research and ethical issues. The increasing possibility to misuse sensitive data needs to be discussed by researchers, administrators, individuals and society. This checklist can also be valuable to others to design or interpret studies based on claims databases.     

Measuring blood pressure at the wrist: more comfortable for patients and more convenient for doctors?

OBJECTIVES: To compare the agreement between conventional measurement of blood pressure and measurements obtained using two automated devices; and to compare how comfortable each of the three methods of measurement were for patients. METHODS: Blood pressure measurements and patient comfort scores were recorded using three different devices in 125-surgery and 40-community patients. The devices used were a conventional aneroid sphygmomanometer, an automated device that measured blood pressure on the upper arm and an automated device that measured blood pressure at the wrist. In each patient, the difference between the conventional and automatic measurement was calculated. The limits of agreement of each device were then calculated as the mean difference +/-1.96 standard deviations. RESULTS: In surgery patients, the width of limits of agreement of wrist measurement were 20.0 mm Hg and 12.1 mm Hg for systolic and diastolic blood pressure respectively, compared with 26. 4 mm Hg and 27.7 mm Hg for automatic arm measurement. In community patients, the width of limits of agreement of wrist measurement were 11.6 mm Hg and 11.0 mm Hg for systolic and diastolic blood pressure respectively, compared with 19.5 mm Hg and 12.1 mm Hg for automatic arm measurement. Surgery patients also reported that wrist measurement of blood pressure was significantly more comfortable than either manual or automatic arm measurement (mean comfort scores 4.03 for automatic wrist and 2.13 for automatic arm measurement, Friedman's Test, P<0.001). CONCLUSIONS: Blood pressure measurements taken using the wrist device agreed more closely with those obtained using a conventional aneroid sphygmomanometer than the arm device. The wrist device was also more comfortable for patients than two other methods of blood pressure measurement. Public Health (2000) 114, 165-168