Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem?

Excessive and inappropriate use of medications, or 'polypharmacy', has been recognized as a public health problem. In addition, there is growing use of dietary supplements in the United States; however, little is known about the patterns of supplement use. Recent reports in the literature of cases of excessive or inappropriate use of herbal dietary supplements leading to the term 'polyherbacy'. The clinical vignettes described in this article highlight the need for further research on the nature and extent of multiple and inappropriate dietary supplement use or 'dietary supplement polypharmacy'. Clinical interviewing and population surveys both address this issue in complementary ways, and provide a further understanding of dietary supplement use patterns.     

Does Advanced Community/Public Health Nursing Practice Have a Future?

Societal trends and predicted needs of the health care system indicate that there will be increasing demands for health care professionals who can effectively manage the health needs of populations and communities. Nurses who have master's degrees in community/public health nursing have the educational background to provide this expertise. Although the Association of Community Health Nursing Educators and many nursing leaders maintain that these nurses are advanced practice nurses, most leading nursing organizations and state nurse practice acts do not include population and community health management skills in their definitions of advanced practice nursing. These exclusions have produced a serious status problem for master's programs in community/public health nursing. This article examines issues affecting the current and future status of master's-level community/public health nursing. Solutions are suggested for ensuring the viability of this specialty area.     

Does Public Health Nurse Home Visitation Make a Difference in the Health Outcomes of Pregnant Clients and Their Offspring?

Abstract Public health nurses (PHNs) at Lincoln‐Lancaster County Health Department have used the Care Pathway tool to track client progress. Conceptually similar to critical pathways used in hospital settings, the Care Pathway is used by the PHN to document milestones of progress by trimester of pregnancy. Data for this research was gathered from chart review of 55 prenatal clients. Study results demonstrate that subjects who had from five to nine home visits by a PHN during pregnancy showed a higher average hemoglobin for the mothers and a higher average birthweight for the babies than those visited four or fewer times. None of the low birthweight babies was born to mothers in the “more visits” category. Furthermore, more breastfeeding was recorded for those who had received more PHN visits. This documentation enabled us to describe better the referent population and to begin to estimate the effect of PHN home visitation on the health outcomes of clients. In essence, we addressed the questions: (1) “Does PHN home visitation make a difference in health outcomes of clients and their families?” and (2) “If so, how can effects be measured?”     

How to Anticipate the Assessment of the Public Health Benefit of New Medicines?

The Public Health Benefit (PHB) of new medicines is a recent and French-specific criterion (October 1999 decree) which is often only partially documented in the transparency files due to a lack of timely information. At the time of the first reimbursement application for a new medicine to the "Transparency Committee", the file is exclusively based on data from randomised clinical trials. These data are generated from a global clinical development plan which was designed a long time before the new medicine's submission for reimbursement. And this plan does not systematically provide the data needed to assess the PHB. Thus, one easily understands the difficulty to anticipate and document this recent French criterion. In France, the PHB is both one of the necessary criteria for the reimbursement submission and an indicator for the national health policy management. Its assessment also helps to identify the needs and objectives of the post-registration studies (nowadays in the scope of responsibilities of the "Drug Economics Committee"). The assessment of the PHB criterion is carried through after the marketing authorization process and is an addition to it. To understand how to anticipate the assessment of the new medicines' PHB, one needs to consider how it differs from the preliminary step of the marketing authorization process. Whereas the evaluation for marketing authorization seeks to determine if the new medicine could be useful in a specific indication, the PHB assessment aims at quantifying the therapeutic benefit in a population, taking into account the reference treatments in this population. A new medicine receives a marketing authorization based on the data of the registration file which provides information on the clinical benefit of the new medicine in the populations of the trials and in the context of the trials. On the other side, the PHB looks at the effects of the new medicine at the scale of the general population, in real practice. The PHB components of a new medicine at first submission are the expected response of this new medicine to a public health need, the expected benefit on the health status of the population and ultimately the expected impact on the health care system. The benefit of a new medicine on the health status of a population is based on public health criteria which can be morbi-mortality or quality of life criteria. However, few registration files contain these public health criteria from the beginning and the predictive value of the surrogate criteria used in the trials is not always precisely assessed. It is, thus, difficult to quantify the expected benefit on these public health criteria. Moreover, the data that enable to quantify the new medicine's effects according to the various characteristics of the target population, are rarely available. Similarly, the French population epidemiological data related to the indication of the new medicine are often not available at the time of the assessment. Therefore it is difficult to evaluate the expected number of events that could be avoided if the new medicine reached the market. The authors suggest to adapt the clinical development plan for a better documentation of the PHB. They specifically recommend to integrate to the judgment criteria (endpoints) of the trials, criteria that are relevant in terms of public health, and to check for a good heterogeneity of the trial populations. They also suggest to start early enough collecting reliable national epidemiological data and the necessary elements for the assessment of the transposability of the trial results to the French population (ability to target the patients to be treated, adaptation of the healthcare system...). About the epidemiological data, the authors consider that the needs are covered in various ways depending on the diseases. To meet the needs of evaluation of the new medicines' target populations in specific indications, they recommend to use ad hoc studies as much as needed. In addition, epidemiological studies designed for market purpose with an acceptable methodology should not be systematically rejected but deserve to be presented.To be able to assess the importance of the expected theoretical benefit of a new medicine in a population, the authors underline the necessity to have access to study results with criteria related to this objective. They suggest to first define and list the criteria by disease. Regarding the representativity of the populations, it comes out that it would be advisable, but unrealistic to include in trials a population 100% representative of the population to be treated. Therefore the effect of the new medicine must be modelised (the "effect model") to be evaluated in the general population. Yet to obtain a reliable effect model, the study population must be sufficiently heterogeneous, which legitimates the demand to ensure a good population heterogeneity at the time of decision-making about trials methodology. When the criteria assessed during the development plan does not correspond to the PHB criteria, the only way to evaluate the number of events related to the PHB criterion is, again, to use modelisation. However, modelisation is only possible when the scientific literature has established a reliable correlation between the two types of criteria. In this case, the new model should be applied to a French target population to assess the expected benefit.As a conclusion, the possibilities to estimate the expected benefit of a new medicine on the health status of a specific population are currently limited. These limitations are regrettable because such an estimate is feasible without disrupting the development plans. The authors' general recommendations to update the development plans seem especially appropriate as the additions should not only be beneficial to France but to all the health authorities who would wish to assess the expected benefit of a new medicine on their territories. Anticipating the lack of clinical and epidemiological data and the lack of data that enable to evaluate the transposability of the trials results to real clinical practice is a sine qua none condition to improve the PHB assessment. The anticipation of these needs should be planned early enough by the pharmaceutical companies which could in this purpose meet the health authorities and the heads of the French public health policy in a consultation.Finally, because of the PHB's universal dimension, it is suggested that the necessary actions and publications be initiated so that the PHB can be acknowledged at the European level.     

Public Health and School Nurses’ Perceptions of Barriers to HPV Vaccination in Missouri

Human Papilloma Virus (HPV) is associated with various forms of cancer and is preventable with vaccination. Nurses are in a unique position to directly influence a person’s decision to receive the HPV vaccine. A statewide sample of both school and public health nurses was used to assess knowledge and attitudes related to the HPV vaccine as well as nurse’s behaviors and behavioral intentions toward educating parents and recommending the vaccine. Positive attitudes and adequate knowledge levels were found, however, the majority of school nurses did not provide information and resources to parents. Targeted health promotion programs for school nurses are recommended.     

Combat‐Related Blast‐Induced Neurotrauma: A Public Health Problem?

The purpose of this article is to raise nurses' awareness of the significance and potential public health impact of combat-related blast-induced neurotrauma (BINT) in U.S. troops returning from Afghanistan and Iraq. A comprehensive review of the current literature on BINT was completed by the author, based primarily on combat-related blast exposure in the military population. She found that it is necessary to theorize about potential etiologies for mild traumatic brain injury in the military population since the literature suggests that neurological and psychological trauma resulting from military duty may be linked to exposure to blasts. Identification of potential risk factors for BINT in the military population provides direction for scientific inquiry into this emerging phenomenon. Gaps in current knowledge and its health implications for future scientific study in nursing are presented.     

Social Justice or Market Justice? The Paradoxes of Public Health Partnerships with Managed Care

Public health is increasingly joining forces with managed care, yet the effect of this partnership on public health nursing (PHN) has received little scrutiny. The feasibility and consequences of a public-private alliance raise questions about whether the mission of public health can be sustained in a managed care system and whether managed care's approaches to health care are conducive to providing population-oriented care. Expanding the links between PHN and private organizations is both problematic and promising. Managed care organizations have much to offer, including coordination of services and comprehensive care. However, they may also restrict coverage and create bureaucratic obstacles to obtaining services. The growth of for-profit health care corporations evokes questions about ways in which concern for communities and populations collide with stockholder interests. The task for PHN is to recognize and to dialogue about these complexities so that nursing's voice can be heard as solutions to these dilemmas are created.     

International Classification of Public Health Nursing Practices - CIPESC®: a pedagogical tool for epidemiological studies

The CIPESC? is a tool that informs the work of nurses in Public Health and assists in prioritizing their care in practice, management and research. It is also a powerful pedagogical instrument for the qualification of nurses within the Brazilian healthcare system. In the teaching of infectious diseases, using the CIPESC? assists in analyzing the interventions by encouraging clinical and epidemiological thinking regarding the health-illness process. With the purpose in mind of developing resources for teaching undergraduate nursing students and encouraging reflection regarding the process of nursing work, this article presents an experimental application of CIPESC?, using meningococcal meningitis as an example.     

Integration of Clinical Medicine and Public Health: Necessity and Urgency, a View from SARS Crisis

Inearly 2 0 0 3,theoutbreakofsevereacuterespiratorysyndrome (SARS)inChinacausedagreatnegativeimpacton publichealth ,nationaleconomyandsocialstability ,withatotalof 80 98infectedand 774deadin 32countriesandareas.Therearequiteafewreflectionpointsthroughoutthecrisis.Basedontheauthor’sownexperienceandthe principleofevidence basedmedicine(EBM ) ,the perspectiveontheintegrationofclinicalmedicineandpublichealthwasdiscussedinthisarticle.CommonMisunderstandingDevelopmentofeconomy ,progressofsociet…     

Meeting the Public Health Challenge of Pain in Later Life: What Role Can Senior Centers Play?

Interest in nonpharmacologic approaches for managing pain continues to grow. The aim of this study was to determine the types of pain-relevant programs offered by senior centers and whether the programs varied by clients’ race/ethnicity status and center size. A telephone survey was conducted. Respondents were presented with a list of 15 programs and the option to choose “other” and asked (1) whether the activity was offered and, if so, how often; (2) if they believed the programs had value for seniors with pain; and (3) whether the classes were advertised as a means of achieving pain relief. Of 204 center staff contacted, 195 (95.6%) participated. The most common programs offered were movement-based, including exercise (by 91.8% of the centers), dance (72.3%), walking clubs (71.8%), yoga (65.6%), and Tai Chi (53.3%) classes. Creative arts programs were also frequently offered, including music (58.5%) and fine arts (47.7%). Programs such as stress management (27%) and relaxation (26%) classes were less commonly offered. Most respondents identified movement-based programs as helpful for seniors with pain, but few identified creative arts classes as potentially beneficial. The programs/classes offered were infrequently advertised as a means of helping seniors manage pain and varied by clients’ race/ethnicity status and center size. Programs that have potential utility for older adults with pain are commonly offered by senior centers. Future research should determine optimal strategies for engaging older adults in these programs in the senior center setting.     

Community Health

What are definitions of a community? A community is a collection of people who share some attribute of their lives. It may be that they live in the same locale, attend a particular church, or even share a particular interest, such as skiing. Groups that constitute a community because of common     

Curriculum Reform in a Public Health Course at a Chiropractic College: Are We Making Progress Toward Improving Clinical Relevance?

Improving education in health promotion and prevention has been identified as a priority for all accredited professional health care training programs, an issue recently addressed by a collaboration of stakeholders in chiropractic education who developed a model course outline for public health education. Using a course evaluation questionnaire, the authors surveyed students in the public health course at the Canadian Memorial Chiropractic College (CMCC) before and after the implementation of new course content based on the model course outline. Following the new course, there were significant improvements in perceived relevance to chiropractic practice and motivation to learn the material as a foundation for clinical practice. Changes made to the content and delivery of the course based on the model course outline were well received in the short term.     

Can Regenerative Medicine Help Close the Gap Between the Medicine Pipeline and Public Health Burden of Cardiovascular and Musculoskeletal Diseases?

Purpose

This commentary discusses the therapeutic and economic potentials of regenerative medicine (RM) by addressing how the reprioritization of resources in drug development may alleviate unmet medical need across many diseases, but especially cardiovascular diseases (CVDs) and musculoskeletal diseases (MSDs), the leading causes of mortality and morbidity, respectively, in the United States.