ll ruolo del medico competente tra nuove funzioni e criticità emergenti: un’analisi qualitativa dei discorsi sulla professione*

«Emerging problems and novel skills: a qualitative analysis on the role of occupational physicians».Introduction:The thorough changes in the world of employment, together with regulatory changes, have made the role of occupational health physicians increasingly complex, with an extension of the prescribing component, linked to the operational aspects of the role, as well as a greater complexity in the discretionary sphere, which also requires a number of “non-technical” skills.Objectives:This work investigates how occupational physicians experience and represent their role, with special attention paid to the person-context relationship, so as to offer reflections and useful tools for supporting this role within the participatory health and safety system in the workplaces.Methods:Using a qualitative approach, the survey has been carried out through semi-structured interviews to a sample of 22 Italian occupational health physicians who were asked to talk about their professional experience with regard to the legislative reforms, critical factors in their work, their relationship with other players in the safety system, and satisfaction with Continuous Medical Training (ECM). The interviews were analyzed using content statistics analysis software.Results:Faced with the various context constraints, occupational physicians often remain confined to their healthcare role and in their relationship with the patient-worker. This causes difficulties in intervening as overall health and safety consultants for workers in a preventive context. Traditional technical expertise, delivered through ECM Training and guidelines, is not enough to make a substantial change in practising the profession, but other types of intervention are necessary to facilitate reflection about problems and one’s own actions.Key words: Occupational physician, role, content analysis, qualitative survey     

A structured community engagement strategy to support uptake of TB active case-finding

BACKGROUND:In Lima, Peru, a mobile TB screening program (“TB Móvil”) was implemented in high TB prevalence districts to increase TB screening. Community engagement activities to promote TB Móvil were simultaneously conducted.OBJECTIVE:To describe a structured, theory-driven community engagement strategy to support the uptake of TB Móvil.METHODS:We adapted Popular Opinion Leader (POL), an evidence-based social networking intervention previously used in Peru to promote HIV testing, for TB Móvil. Community health workers, women who run soup kitchens, and motorcycle taxi drivers served as “popular opinion leaders” who disseminated information about TB Móvil in everyday conversations, aided by a multi-media campaign. Performance indicators of POL included the number/characteristics of persons screened; number of multimedia elements; and proportion of persons with abnormal radiographs hearing about TB Móvil before attending.RESULTS:Between February 2019 and January 2020, 63,899 people attended the TB Móvil program at 210 sites; 60.1% were female. The multimedia campaign included 36 videos, 16 audio vignettes, flyers, posters, community murals and “jingles.” Among attendees receiving an abnormal chest X-ray suggestive of TB, 48% (6,935/14,563) reported hearing about TB Móvil before attending.CONCLUSIONS:POL promotes the uptake of TB Móvil and should be considered as a strategy for increasing TB screening uptake.     

How Do Mothers Take Care of Their Infants with Colic Pain? A Mixed-Method Study

BackgroundColic pain is one of the main reasons for stress and anxiety in infants'' parents, especially mothers, and there is still no specific treatment. Thus, mothers always try their best to relieve their infants'' pain.The researchers attempted to investigate how mothers take care of their infants with colic.MethodsThis study was conducted with a mixed-method approach and a sequential explanatory design. In the quantitative phase, a cross-sectional study was conducted to assess how to control pain. One hundred fifty mothers of infants with colic living in Kerman, Iran, were chosen by convenience sampling. In the qualitative phase, the researchers interviewed 18 mothers using semi-structured in-depth, and face-to-face approaches. These participants were selected by purposive sampling method. The interviews were analyzed by the conventional content analysis method.ResultsIn the quantitative phase, the mothers'' most common methods to relieve colic pain were herbal medicines (3.55±0.51) and the change of position (3.35±0.67). The least methods used were probiotics (1.4±0.2) and acupuncture (0). In the qualitative phase, the main theme was “mothers support needs for care,” which includes the following subcategories: “lack of trust in doctor”; “full-time care”; “feeling of inadequacy,” “persistent anxiety, “care without help,” and “looking for ways to control pain.”ConclusionMothers need support to relieve their infants'' colic. The provision of educational and psychological supportive packages can be helpful for the mothers. In addition, nurses can help mothers improve their quality of care.     

Food insecurity among Canadian youth and young adults: insights from the Canada Food Study

ObjectiveThis study explored associations between socio-demographic characteristics, self-reported health, and household food security among young adults.MethodsNational cohort study participants from Toronto, Montreal, Vancouver, Edmonton, and Halifax, Canada, aged 16–30 years (n = 2149) completed online surveys. Multinomial logistic regression, weighted to reflect age and sex proportions from the 2016 census, was conducted to examine associations between food security status and covariates.ResultsAlmost 30% of respondents lived in food-insecure households, with 19% in “moderately” food-insecure and 10% in “severely” food-insecure households. Respondents identifying as Black or Indigenous were more likely to live in moderately (AOR = 1.96, CI: 1.10, 3.50; AOR = 3.15, CI: 1.60, 6.20) and severely (AOR = 4.25, CI: 2.07, 8.74; AOR = 6.34, CI: 2.81, 14.30) food-insecure households compared with those identifying as mixed/other ethnicity. Respondents who found it “very difficult” to make ends meet were more likely to be moderately (AOR = 20.37, CI: 11.07, 37.46) and severely (AOR = 101.33, CI: 41.11, 249.77) food insecure. Respondents classified as “normal” weight (AOR = 0.64, CI: 0.43, 0.96) or overweight (AOR = 0.53, CI: 0.34, 0.83) were less likely to be moderately food insecure compared with those affected by obesity. Compared with “very good or excellent,” “poor” health, diet quality, and mental health were each positively associated with severe food insecurity (AOR = 7.09, CI: 2.44, 20.61; AOR = 2.63, CI: 1.08, 6.41; AOR = 2.09, CI: 1.03, 4.23, respectively).ConclusionThe high prevalence of correlates of food insecurity among young adults suggests the need for policies that consider the unique challenges (e.g., precarious income) and vulnerability associated with this life stage.     

Prevalence and interpretation of Xpert® Ultra trace results among presumptive TB patients

BACKGROUND:The “trace call” results on Xpert® Ultra indicates extremely low TB levels and may be difficult to interpret. The prevalence of trace results among presumptive TB patients in high TB-HIV infection settings is unknown, as is the significance of divergent “trace call” result interpretations.METHODS:Presumptive TB patients attending a public health facility in Lusaka, Zambia, were prospectively enrolled. Participants underwent several TB investigations, including sputum smear microscopy, Ultra testing, and culture. The diagnostic accuracy of Ultra (culture-based reference) and the number of patients recommended for TB treatment was assessed according to several different interpretation criteria for “trace call” results.RESULTS:Among the 740 participants, 78 (10.5%) were Ultra-positive and an additional 37 (5.0%) had a “trace call” result. The prevalence of trace results did not differ according to HIV status (5.3% vs. 4.8%) or prior TB status (5.6% vs. 4.9%). Differing interpretations of trace results had modest effects on Ultra’s sensitivity (range 79.3–82.6%) and specificity (range 94.3–99.2%), but increased the number of patients recommended for treatment by up to 44.9%.CONCLUSIONS:Ultra trace results were common in this setting. The interpretation of trace results may substantially impact TB case yield.     

Secondhand Tobacco Smoke Exposure in Open and Semi-Open Settings: A Systematic Review

Background: Some countries have recently extended smoke-free policies to particular outdoor settings; however, there is controversy regarding whether this is scientifically and ethically justifiable.Objectives: The objective of the present study was to review research on secondhand smoke (SHS) exposure in outdoor settings.Data sources: We conducted different searches in PubMed for the period prior to September 2012. We checked the references of the identified papers, and conducted a similar search in Google Scholar.Study selection: Our search terms included combinations of “secondhand smoke,” “environmental tobacco smoke,” “passive smoking” OR “tobacco smoke pollution” AND “outdoors” AND “PM” (particulate matter), “PM_2.5” (PM with diameter ≤ 2.5 µm), “respirable suspended particles,” “particulate matter,” “nicotine,” “CO” (carbon monoxide), “cotinine,” “marker,” “biomarker” OR “airborne marker.” In total, 18 articles and reports met the inclusion criteria.Results: Almost all studies used PM_2.5 concentration as an SHS marker. Mean PM_2.5 concentrations reported for outdoor smoking areas when smokers were present ranged from 8.32 to 124 µg/m³ at hospitality venues, and 4.60 to 17.80 µg/m³ at other locations. Mean PM_2.5 concentrations in smoke-free indoor settings near outdoor smoking areas ranged from 4 to 120.51 µg/m³. SHS levels increased when smokers were present, and outdoor and indoor SHS levels were related. Most studies reported a positive association between SHS measures and smoker density, enclosure of outdoor locations, wind conditions, and proximity to smokers.Conclusions: The available evidence indicates high SHS levels at some outdoor smoking areas and at adjacent smoke-free indoor areas. Further research and standardization of methodology is needed to determine whether smoke-free legislation should be extended to outdoor settings.     

Educational Intervention of Healthy Life Promotion for Children with a Migrant Background or at Socioeconomic Disadvantage in the North of Italy: Efficacy of Telematic Tools in Improving Nutritional and Physical Activity Knowledge

The aim of the “Smuovi La Salute” (“Shake Your Health”) project was to implement an integrated and comprehensive model to prevent and treat overweight and obesity in low socioeconomic status (SES) and minority groups living in three different districts in the north of Italy. An app and a cookbook promoting transcultural nutrition and a healthy lifestyle were developed, and no-cost physical activities were organized. Healthy lifestyle teaching was implemented in 30 primary school classrooms. Learning was assessed through pre- and post-intervention questionnaires. At the Obesity Pediatric Clinic, overweight and obese children of migrant background or low SES were trained on transcultural nutrition and invited to participate in the project. Primary school students increased their knowledge about healthy nutrition and the importance of physical activity (p-value < 0.001). At the Obesity Pediatric Clinic, after 6 months, pre–post-intervention variation in their consumption of vegetables and fruit was +14% (p < 0.0001) and no variation in physical activity habits occurred (p = 0.34). In this group, the BMI z-score was not significantly decreased (−0.17 ± 0.63, p= 0.15). This study demonstrates the feasibility and efficacy of telematic tools and targeted community approaches in improving students’ knowledge with regard to healthy lifestyle, particularly in schools in suburbs with a high density of migrants and SES families. Comprehensive and integrated approaches provided to the obese patients remain mostly ineffective.     

Level of physical activity and barriers to exercise in adults with type 2 diabetes

IntroductionPhysical activity (PA) is an important element in type 2 diabetes mellitus (T2DM) management. The aims of this study were to assess the percentage of adults with T2DM who perform PA, according to the intensity level and to describe barriers to exercise and the association between metabolic control and other clinical variables.MethodsMulticenter, observational, cross-sectional study. Data were collected through the International PA Questionnaire (IPAQ) and the PA Barrier Questionnaire. Adults (18–65 years old) with T2DM from 17 Argentine diabetes centers were included, from May to July 2018.ResultsA total of 270 men (54.9 ± 9.8 years) and 225 women (55.3 ± 9.6 years) were included. Duration of diabetes: 8.2 ± 6.3 years. The BMI in men was 32 ± 10.6 kg/m², whereas that in women was 32.5 ± 7.2 kg/m². The last two HbA1c values were 7.6 ± 1.7% and 7.5 ± 1.6. Results also showed that 12.7% had clinical heart disease, 13.7% had nephropathy, 20.8% had neuropathy, 6.1% had diabetic foot and 14.1% had retinopathy. The level of PA was low in 52.3% of the patients studied and moderate in 30.5%. The most frequent barriers were: “lack of will” (59.6%) and “lack of energy” (37.2%). The low level of PA was associated with age (OR: 1.05 per year of age; p < 0.001), HbA1c (OR: 1.16 per 1%; p < 0.05), BMI (OR: 1.06 per kg/m²; p < 0.001) and sex (OR: 1.69 for women; p < 0.01).ConclusionsPA in a cornerstone in management T2DM. Nevertheless, in this study, 52.3% of T2DM adults showed low level of PA. The main barriers reported were related to low personal motivation. These factors should be taken into account to implement programs to promote physical activity.     

Predicting the Number of Suicides in Japan Using Internet Search Queries: Vector Autoregression Time Series Model

BackgroundThe number of suicides in Japan increased during the COVID-19 pandemic. Predicting the number of suicides is important to take timely preventive measures.ObjectiveThis study aims to clarify whether the number of suicides can be predicted by suicide-related search queries used before searching for the keyword “suicide.”MethodsThis study uses the infoveillance approach for suicide in Japan by search trends in search engines. The monthly number of suicides by gender, collected and published by the National Police Agency, was used as an outcome variable. The number of searches by gender with queries associated with “suicide” on “Yahoo! JAPAN Search” from January 2016 to December 2020 was used as a predictive variable. The following five phrases highly relevant to suicide were used as search terms before searching for the keyword “suicide” and extracted and used for analyses: “abuse”; “work, don’t want to go”; “company, want to quit”; “divorce”; and “no money.” The augmented Dickey-Fuller and Johansen tests were performed for the original series and to verify the existence of unit roots and cointegration for each variable, respectively. The vector autoregression model was applied to predict the number of suicides. The Breusch-Godfrey Lagrangian multiplier (BG-LM) test, autoregressive conditional heteroskedasticity Lagrangian multiplier (ARCH-LM) test, and Jarque-Bera (JB) test were used to confirm model convergence. In addition, a Granger causality test was performed for each predictive variable.ResultsIn the original series, unit roots were found in the trend model, whereas in the first-order difference series, both men (minimum tau 3: −9.24; max tau 3: −5.38) and women (minimum tau 3: −9.24; max tau 3: −5.38) had no unit roots for all variables. In the Johansen test, a cointegration relationship was observed among several variables. The queries used in the converged models were “divorce” for men (BG-LM test: P=.55; ARCH-LM test: P=.63; JB test: P=.66) and “no money” for women (BG-LM test: P=.17; ARCH-LM test: P=.15; JB test: P=.10). In the Granger causality test for each variable, “divorce” was significant for both men (F₁₀₄=3.29; P=.04) and women (F₁₀₄=3.23; P=.04).ConclusionsThe number of suicides can be predicted by search queries related to the keyword “suicide.” Previous studies have reported that financial poverty and divorce are associated with suicide. The results of this study, in which search queries on “no money” and “divorce” predicted suicide, support the findings of previous studies. Further research on the economic poverty of women and those with complex problems is necessary.     

The “Foresty Way”: My Mother’s Brave Choice of Medical Aid in Dying

I miss my mom, who died last year, and I want to tell the happy story of her death, or perhaps the story of her happy death through her choosing and accomplishing medical aid in dying. My mom was 85 when she died, had atypical presentation of lymphoma which took time to diagnose, and went through 3 painful months of surgery, radiation, and a single horrific round of chemotherapy. She suffered a lot. When she was in the hospital recovering from chemo, I witnessed 3 amazing doctors being true to core values of their profession. But the most profound aspect and gift of the events surrounding her death was the way in which making an informed choice gave my mom back her presence—allowing her both peace and power in the end of her life.Key words: end of life, informed decision making, physician-assisted dying, medical aid in dying

My feet crunch on the rocky soil as I take the shortcut through a mini forest of about 30 pine trees that makes up the incongruous view outside my office window in high-tech San Francisco. The juxtaposition of pine trees with urban space always reminds me of my mom, who would often drive me to the supermarket in our urban community on a side street, known always between us as “the foresty way.” It was a dark, mysterious avenue of mature pines that one could imagine led to some otherworldly realm. When I got to my desk, which looks out over endless construction and these pines, I wanted to call her to tell her about today’s foresty way reminder. I miss my mom, who died last year, and I want to tell the happy story of her death, or perhaps the story of her happy death through her choosing and accomplishing physician-assisted dying.My mom was 85 when she died. She had been extremely healthy, and happily living independently in the mountains a couple of hours away from me. She had atypical presentation of lymphoma which took a while to diagnose. To treat the cancer, she went through 3 painful months of surgery, radiation, and a single horrific round of chemotherapy, and she suffered a lot through it. When she was in the hospital recovering from the chemo, I witnessed 3 amazing doctors being true to core values of their profession. Although I am surrounded by talented physician colleagues at work and I see my husband who is a family practice–trained hospitalist take good care of people, I was nonetheless impressed at their excellent care.First, a wonderful palliative care doctor with a strong spiritual energy came in and discussed my mom’s pain, the wishes she had in her life, and the ways that hospice might help her. She took her time in the visit, a noticeable shift from the hectic pace we had become accustomed to in the previous few months of diagnosis and treatment. What was most remarkable was how deeply connected my mom felt toward her and how this connection also made my mom believe this doctor understood her life—the trajectory of her life. At my mother’s prompting, their conversations led to a discussion of the End of Life Act, which became law in 2015 in California and has been in effect since 2016. The End of Life Option Act allows an adult diagnosed with a terminal disease, who meets qualifications, to request aid in dying drugs from their attending physician. My mom practically hopped out of her bed when she heard the details and that she qualified; she was so excited. She told me right away after the doctor left, “That’s what I’m going to do—physician-assisted dying. I don’t want to compete with this disease—that’s not what I want to do with the rest of my life.” I sat with her and my sadness and then, over the next few days, we set upon the logistics to put her right to choose into motion—the who, how, when, where of finding a local group to provide the medical evaluation, signing of documents, payment, etc. By law she had to wait 15 days from the time she had her first medical assessment, establishing that she had a less than 6-month prognosis and was of sound mind in the decision to choose and then actualize the dying.One afternoon during this waiting period, we were packing up her things, preparing to leave the hospital and return to her home in the Sierras. Suddenly, her oncologist knocked on the door, whooshed in, and looked her straight in the eye. “This cancer could go into remission, maybe for the rest of your life.” He took her hand and said, “It’s rare that I get to say this to my patients, but you have a very good chance of being cured.” He was clear and direct, but not at all pushy. I could see, however, that she did not return his enthusiasm. They spoke more about treatment options, what she was feeling about the next few months of being in remission, and her next steps. “I’ll give it some thought,” she demurred but her eyes had no brightness. I was not surprised. I had already felt her shift, from coping to preparing, to focusing within—it was that simple. His good intentions, openness, and clear summarizing of his viewpoint regarding her options were meaningful and deeply appreciated.Moments later, the doctor from the physician assisted–dying group we had contacted arrived. The 2 doctors literally passed each other in the hall. I marveled at how this third doctor, an emergency physician by training, gave an amazing “non-pitch.” He described the details of how the medical aid in dying process works in California—the mandatory waiting period, the 2 required medical authorizers of her status as terminal, how she would have to self-administer the “cocktail,” and that many people were reassured to have the medicines prescribed “just in case” but that only a much smaller proportion went through with it, and that was perfectly okay. All of this was easy mannered, clearly phrased—while also being kind and comforting to her. She beamed. “Yes, thank you, and how soon?” Switching to countdown mode was incredibly hard for me, but not awful. I could see she was invigorated in spirit, alternating between peaceful energy and her familiar attentive, detailed “conquering” of lists, of things to do before she was gone. I wanted her to have her own foresty way at the end of her life, so we were on the same page. Her resolve was reassuring too, as was recalling our past conversations about advanced care planning, which fully aligned with her decision. She needed my support to get through it; her dying was not going to be easy for either of us. So, we watched some cat videos and nature shows, visited with my 3 kids and husband, and we talked about the plants I would bring home from her garden. Three weeks later, she died at her house with her beloved cat, my brother, and myself. It happened very fast—I had not finished reading her the poem we had chosen, Evening by Rainer Maria Rilke, before she lost consciousness and slipped away.There is not much medical literature about how informed decision making might look at the end of life in the context of physician-assisted dying. What I have read seems to draw attention to the things that are to be avoided, like the medicalization of dying or a culture of “prolongivism,”—a perspective that the prolonging of life can create end-of-life meaning. I feel that such an avoidance-oriented view misses an important part of what was so wonderful for my mom—what was gained. In looking at the situation, one might be tempted to focus solely on the palliative care and assisted-dying doctors’ behaviors and actions, as they are the “managers” of the experience in the medical-legal context. To me, though, what was vital for my mom’s decision to feel right for her, to actually comfort her, was the oncologist’s engagement with her, even as much as she valued the other 2 clinicians’ wonderful ways of being with her suffering. The clarity the oncologist gave her through his honesty and explanation was essential to her peace of mind in her decision making, and as a result she gained her life back. She was able to “die well,” feeling content in her resolve, because she could see that she had the option to live, but it was one she could reject, because she believed her suffering would be too great. Being able to reject her treatment options because they were options, not defaults or platitudes, made it clear to my mom and to me that she was choosing her path based on her desired quality of life, not on her expected health outcomes. Because of that clarity in knowing her choices, she felt free. She could “just” prepare, enjoy her world a bit longer, and feel proud to be so brave. This is what she gained and what I gained too.     

Beneficios de un programa de ejercicio físico comunitario prescrito desde Atención Primaria en la salud de mujeres perimenopáusicas/menopaúsicas

ObjetivoMedir los beneficios de un programa comunitario de ejercicio físico, a través de las modificaciones que se producen en calidad de vida, y condición física de mujeres perimenopáusicas-menopáusicas.EmplazamientoLas participantes fueron reclutadas en consultas de Atención Primaria (AP) de dos centros de Salud de Molina de Segura (Murcia).ParticipantesMujeres de entre 40 y 70 años o menores de 40 diagnosticadas de menopausia precoz.DiseñoEstudio cuasiexperimental, no aleatorizado, controlado, abierto y unicéntrico con dos ramas paralelas a estudio.IntervenciónGrupo experimental: programa de ejercicio ACTIVA-Salud Ósea durante seis meses. Control: Inactivos.Mediciones principalesCalidad de vida mediante cuestionario SF36.Condición físicaCondición aeróbica, flexibilidad, equilibrio y fuerza, medida con los test de la milla, flamenco y el cajón, así como lanzamiento del balón medicinal, respectivamente. Nivel de actividad física a través del General practice physical activity questionnaire (GPPAQ). Se recogieron variables sociodemográficas y se midió la adherencia al programa.ResultadosLa calidad de vida mejoró en el grupo intervención vs. control, salvo la dimensión «dolor corporal» (p = 0,412). A nivel intragrupo, presentan mejoría significativa todas las dimensiones, a excepción de «función física» (p = 0,263) y «dolor corporal» (p = 0,136). Las capacidades físicas que más se beneficiaron fueron la condición aeróbica, fuerza y equilibrio.ConclusionesEl pilotaje del Programa de ejercicio físico Activa Salud Ósea demostró beneficios sobre la calidad de vida física y mental de las participantes. Además, se constata que la realización de un ejercicio específico para mujeres premenopáusicas-menopáusicas mejora su condición física.Palabras clave: Mujer, Ejercicio físico, Menopausia, Calidad de vida     

Annals Journal Club: One Cold Autumn Day

Behavioral change is at the heart of effective primary care, but when patients don’t change, how do we account for our days? In this personal essay, I relate an encounter with a patient who wants to quit smoking, lose weight, and control her diabetes. I am discouraged when she deflects my recommendations, but a colleague’s comment encourages a deeper inquiry. Knowing the patient’s story and deepening the conversation, however, do not guarantee change. The experience reminds me why patience, humility, and faith are core values of the primary care physician.Sometimes I feel angry with the patient. She’s a 44-year old, morbidly obese, diabetic who flies in from the Alaskan bush to be seen for “medication renewal” and “wound care” at the tribal urgent care. After a brief review, I level with her: “You know if you lost weight, you could probably get off all 10 of these medicines.” I don’t say it meanly, though, because frustration is not all I feel. I care. But sometimes, when my embers have grown dim, the caring looks a bit more like cold, biomedical efficiency.“What kinds of foods do you eat?” I ask.“Just regular food,” she replies.“Uh huh. Like what?”The more I learn about her body and behaviors, the more “to the point” I become. It’s not only impatience that drives me. It’s fear. Images of cracking, yellow plaque, a fatty hardening of the arteries, sharpen my pursuit.“Do you drink?”“No.”“You smoke, though.”“Yeah.”“Have you tried to quit?”“Yeah. I’ve tried everything.”“What have you tried?”“The patches, the gum…”“Have you tried pills, like Wellbutrin or Zyban?”“I tried that. They made me really on edge.”“How about Chantix?”“I tried that twice, but they told me I couldn’t get any more.”“Yeah, they won’t give you that for more than 3 or 4 months,” I explain. “It’s really expensive.”I have the feeling it won’t matter, though, if the pharmacy cuts her a break.“Do you want to quit?”“Yeah.”“It’s just hard,” I say. My weak attempt at empathy doesn’t pass through her skin.She says she wants to change everything—the diet, the smoking, and the sugar control. If I’m a machine, she’s a baseball mitt straight from the factory. Until you oil the palm and play a season of catch, the leather is thick and unyielding. If only she’d check her blood glucoses and cut out the soda pop…“I’ve tried that,” she says. No doubt she has.I stand and take a step toward the door. “You take aspirin?” I say.“Yeah.”Maybe if I were a better doctor, or no, a better human, I’d have more luck. For now, perhaps the little white aspirin is her best hope.It was the love of patient stories that tipped my scales toward family medicine. Right now, however, I don’t see a person with a name and personality. I see a ticking time bomb, an embolic stroke or myocardial infarction waiting to happen.Brushing my badge against the scanner, I listen for the beep and enter the hidden quarters of the clinic. In my first job in northern Maine, I had an office to myself. In that quiet space, I dictated, meditated, and contemplated. Here in Alaska, we have what might be called an “open office.” Head-high dividers cordon the several dozen employees into teams. There are doctors, medical assistants, nurses, nurse practitioners, physician assistants, clerks, case managers, care coordinators, and behavioral health clinicians. There’s a trade-off: proximity facilitates collaboration; solitude favors contemplation.After notifying the wound care nurse about my patient, I approach the physician’s assistant, Stephanie, who, at the moment, seems to be everything my patient is not. A tall, confident woman with a bright smile, she has just returned from the summit of Kilimanjaro.“Ugh,” I say, as she swivels in her chair. “Everything I suggest to this patient ‘doesn’t work.’ It’s so frustrating. She’s huge and she smokes and she’s on like 10 medications.”Fifteen years my younger, Stephanie is neither jaded nor ignorant.I continue to vent: “She could get off all of them—her anti-hypertensives, her diabetes medicines, her cholesterol medicine—if she would just lose weight.”It’s not that I’m culturally ignorant. I know the traumatic history of this land: the microbial plagues, the famine, the cultural genocide. I’ve spent many weeks in the villages, and convened community meetings to dialog about cancer, substance abuse, diet, and suicide. Today, however, this knowledge is lost to me, buried beneath a thick crust of frustration.“Some people…” I say, “everything you propose, they have an answer.”Stephanie doesn’t judge me. “Those patients,” she says, “are depressed.”“Yeah,” I say. Whether or not the patient is clinically depressed is not really the question, but sometimes a friend’s advice works, not because of diagnostic accuracy, but because it slips the heart into a more productive channel of thought.After the wound care nurse leaves the room, I start back in with my patient. “Some patients who have a hard time quitting smoking have trauma in their past,” I say. “Do you have any unresolved trauma—physical or sexual?”My inquiry is too abrupt, and probably too presumptuous, but my patient levels with me, anyway. “When I was 14 years old, I was raped by someone in the village.”Statistically speaking, one-half of my female and one-quarter of my male patients have experienced sexual trauma. “Did you get care?” I say.“My Mom took me to get seen and we put the man behind bars.”The sexual trauma is not surprising. The imprisonment is. Few sexual trauma survivors or their families want to disturb the social fabric of the village. The perpetrator may be an important provider or leader, and the survivor may even fear that she’ll be the cause of his or her suicide.“Did you ever get counseling?”“I went a couple times.”“Hmm.”“I started drinking after that. They sent me to rehab in Arizona.”“Uh-huh.”“How was it?”“It was okay.”“Did it work?”“Not really. I drank for the next decade.”“Do you think the trauma is still affecting you?” I say.Though I learn a bit more about her life—that she smokes against the stress of living with her new boyfriend, occasionally has panic attacks, and frequently can’t sleep—I leave unsatisfied. And I think she does too. She doesn’t commit to quitting tobacco, dismisses the idea of a dietician with, “I’ve seen them before,” and refuses counseling, even if the counselor is waiting in the wings.Sometimes I leave a room with words of encouragement, something like, “You can do it, I know you can,” or, simply, “Take care.” It can be a bit paternalistic, I know, and today, in particular, such words would seem false. “My nurse will come in to take you to the lab,” I say. We don’t leave as friends, but we are polite.At the end of the day, a surgeon knows she’s changed the world. She commands the surgical field. “Scalpel,” she says. She cauterizes bleeders, hands off the appendix, and closes the case. What do I command beyond a steady income?Sometimes at dusk when I travel by foot down the dirt road overlooking the great flat valley where most of my patients live, I feel regret. I think that I should have spent my life creating something concrete, like bridges or movies. Maybe even now I should rekindle my dream of becoming a bigwig at the World Health Organization. As I descend from the crest line toward a grove of birch trees, I pull out my smart phone and take a sip of social media. “Chena!” I call, when a car rumbles up the slope. My golden retriever comes bounding up the road to sit by my feet until the danger is passed. I snap her picture and post it on the web.On these days, when I’m retracing my steps back up the hill between the birch, the dog again sniffing around in the alder, my phone now zipped away in my cargo pocket, I recognize my failures. I should have explored my patient’s successes, not only her deficits. I should have communed more and checked off boxes less. Cultural insight gleaned from past experience doesn’t substitute for a quiet mind, a refreshed body, and a curious heart. “Tell me about how you were able to quit alcohol,” I should have said. “Tell me about your hopes and dreams.” Maybe that simple reaching would have opened us into each other.But I also remind myself of the good I’ve done. I remember the elderly gold miner with the history of stroke who got his diabetes under control and the woman I diagnosed with primary biliary cirrhosis. I doubt any of the babies I’ve delivered would have died without my care. Even the new mother whose eyes dimmed with hemorrhage would likely have survived without me in specific. Someone else—any family doctor, midwife, or obstetrician—would have dug the clots out of her womb and cried, “Hemabate!” Maybe I’ve even made mistakes, both big and small, which have endangered human life. I know I have. But I hope that, for the most part, I have confirmed in my patients a sense of their own strength and value as human beings.And the other thing I say to myself now as I write within a hilltop of fallen leaves is this: I am that someone else. We’re all that someone else, aren’t we, whether we ascend to lofty positions or dig quietly in the valley? In primary care, most of our interventions are not determinate. We can only hope to shift the odds in the patient’s favor. Someday my little piece will make a difference, we say. We walk by faith, even while grounded in the scientific evidence. Maybe my moon-faced patient will knit socks for an uncle dying of lung cancer. He’ll pat her hand, and on her walk home, the heavens will conspire. Blue-green ribbons, the northern lights, will snake across the sky and, stopping by the river, she’ll look up. Something will shift, won’t it?She’ll fly into town and check in at the front desk. Probably I won’t be working the urgent care that day. She wouldn’t remember me, anyway. But perhaps a moment the two of us shared will join hands with other moments life brings, and those other moments will give meaning to ours. My faith is not blind: I’ve seen people heal. Some other doctor will enter the room, set her laptop down on the counter, and continue the journey.Some days we don’t feel it, do we—that lively pulse that called us to medicine? We don’t sense that fleshy compassion that inspired us. For whatever reason, we go home without a “story” to tell. But maybe it’s true that we together, imperfect doctor and impassive patient, laid down one plank on the bridge of trust. Can I be that someone else, that faceless doctor that asked the questions and listened, if not with welling heart, at least with the integrity of honest intent? Can I be that nameless man that played his part one cold autumn day? I pray that I am.     

La ricostruzione dell’esposizione ad amianto in un’azienda tessile di produzione filati cucirini attraverso l’utilizzo di un’insolita fonte informativa

«Reconstruction of the asbestos exposure in a textile company producing sewing threads through the use of an unusual information source».Background:The Tuscan Regional Operating Center (ROC) of Malignant Mesotheliomas has identified a cluster of 11 cases of malignant mesothelioma occurred in a textile plant manufacturing sewing thread. Using the common research method, the ROC had not previously been able to identify the specific sources of asbestos exposure causing such a large cluster.Objectives:The ROC’s objective was to review all cases of the cluster and to better identify their occupational asbestos exposures.Methods:The cases’ occupational histories of asbestos exposure have been reviewed, using information deriving from the annual reports sent to the Tuscany Region since 1988 by all the asbestos removal companies according to the Law no. 257/1992, article 9, and from interviews to former employees of the plant.Results:The work cycle has been reconstructed and enriched with the new information about the asbestos presence and its uses in the plant. The eleven cases were all reclassified as “certainly occupational exposed” given that the new collected information depicted a widespread asbestos pollution of the workplace during the period of employment of all cases.Conclusions:Using different sources of information, in addition to those traditionally collected through questionnaires, to reconstruct past asbestos exposuresallowed us to clarify the existence of the cluster of mesothelioma cases and the highest level of occupational asbestos exposure was attributed to all cases with consequent activation of the medico-legal procedure.Key words: Asbestos, malignant mesothelioma, occupational exposure, textile, sewing threads     

Emergency Medical Technicians' Experiences of the Challenges of Prehospital Care Delivery During the COVID-19 Pandemic: A Qualitative Study

BackgroundExploring emergency medical technicians'' (EMTs) experiences of COVID-19 epidemic, help to identify the challenges they face in their daily work and develop strategies that address these challenges. This study aimed to explore EMTs'' experiences of the challenges of prehospital care delivery during the COVID-19 pandemic.MethodsThis qualitative study was conducted in March-July 2020 using conventional content analysis approach. Fifteen EMTs were purposively selected from the Emergency Medical Services (EMS) Center in Qom, Iran. For data collection, semi-structured interviews were conducted until data saturation was reached.ResultsEMTs'' experiences of the challenges of prehospital care delivery during the COVID-19 pandemic were classified into three main categories including “restless society”, “difficult care delivery conditions”, and “unprepared organization”. The emergent subcategories were “need for information”, “limited perception of the COVID-19 risk”, “obsessive use of disinfectants”, “fear over the transmission of COVID-19 to self and others”, “burnout due to heavy workload”, “altered communication with hospital staff”, “ethical conflicts”, “lack of a definite treatment plan”, “lack of protective equipment”, “staff shortage due to the affliction of EMTs by COVID-19”, and “inadequate support by authorities”.ConclusionDuring COVID-19 pandemics, EMTs face many challenges including emotional and occupational stress, social strains, risk of affliction by infections, heavy workload, and ethical conflicts and hence, experience difficulties in quality care delivery. Developing appropriate strategies, guidelines, and policies are needed to effectively manage these challenges and improve the quality of prehospital care delivery in COVID-19 epidemic.     

Data-Driven Dietary Patterns,Nutrient Intake and Body Weight Status in a Cross-Section of Singaporean Children Aged 6–12 Years

Pattern analysis of children’s diet may provide insights into chronic disease risk in adolescence and adulthood. This study aimed to assess dietary patterns of young Singaporean children using cluster analysis. An existing dataset included 15,820 items consumed by 561 participants (aged 6–12 years) over 2 days of dietary recall. Thirty-seven food groups were defined and expressed as a percentage contribution of total energy. Dietary patterns were identified using k-means cluster analysis. Three clusters were identified, “Western”, “Convenience” and “Local/hawker”, none of which were defined by more prudent dietary choices. The “Convenience” cluster group had the lowest total energy intake (mean 85.8 ± SD 25.3% of Average Requirement for Energy) compared to the other groups (95.4 ± 25.9% for “Western” and 93.4 ± 25.3% for “Local/hawker”, p < 0.001) but also had the lowest calcium intake (66.3 ± 34.7% of Recommended Dietary Allowance), similar to intake in the “Local/hawker” group (69.5 ± 38.9%) but less than the “Western” group (82.8 ± 36.1%, p < 0.001). These findings highlight the need for longitudinal analysis of dietary habit in younger Singaporeans in order to better define public health messaging targeted at reducing risk of major noncommunicable disease.     

What Factors Affect the Evolution of the Wife’s Mental Health After the Husband’s Retirement? Evidence From a Population-Based Nationwide Survey in Japan

BackgroundThe “retired husband syndrome” refers to the negative impact of the husband’s retirement on the wife’s health. This study provided new insights by examining whether and to what extent the wife’s social participation, interactions with her husband, and job status prior to her husband’s retirement affected the evolution of her mental health after her husband’s retirement.MethodsWe collected data from a 12-wave nationwide panel survey conducted from 2005 to 2016, starting with individuals aged 50–59 years. Focusing on 3,794 female respondents whose husbands retired during the survey period, we applied random-effects linear regression models to investigate the evolution of their mental health as measured by the Kessler 6 (K6) score (range, 0–24; Mean, 3.41; standard deviation, 4.11) during the 5 years after their husbands’ retirement.ResultsOn average, the wife’s K6 score rose by 0.18 (95% confidence interval [CI], 0.08–0.28), 0.18 (95% CI, 0.03–0.34), and 0.19 (95% CI, −0.02 to 0.43) in the first 3 years, respectively, after the husband’s retirement, before declining toward the baseline level. However, the wife’s active social participation, intense interactions with her husband, and absence of paid employment before her husband’s retirement prevented her mental health from deteriorating.ConclusionThe results suggest the limited relevance of the “retired husband syndrome” among middle-aged Japanese couples. The effects of a husband’s retirement on the wife’s mental health depended heavily on her prior behavior.Key words: marital quality, mental health, random-effects model, retired husband syndrome, social participation     

Caregiver Status and Diet Quality in Community-Dwelling Adults

Objective: We investigated cross-sectional and longitudinal associations of diet quality with middle-aged caregiver status. Methods: Caregiving in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study (57.7% women, 62% African American (AA)) was measured at waves 3 (2009–2013) and 4 (2013–2017) (mean follow-up time 4.1 years). Diet quality was assessed by the Healthy Eating Index 2010 (HEI-2010) derived from two separate 24 h diet recalls. Multivariable ordinary least square regression was performed for cross-sectional analyses of the association of wave 4 caregiving with wave 4 HEI-2010. Wave 3 caregiving was examined both cross-sectionally and with annual rate of change in HEI using mixed-effects linear regression Models. Multivariable models were adjusted for age, sex, and poverty status. Results: Cross-sectional analyses at wave 4 demonstrate an inverse association of frequent caregiving (“Daily or Weekly” vs. “Never”) for grandchildren with HEI-2010 total score (i.e., lower diet quality) among Whites (β = −2.83 ± 1.19, p = 0.03, Model 2) and AAs (β = −1.84 ± 0.79, p = 0.02,). The “cross-sectional” analysis pertaining to grandchildren caregiving frequency suggested that frequent caregiving (i.e., “Daily or Weekly” vs. “Never” (β = −2.90 ± 1.17, p = 0.04)) only among Whites was inversely related to HEI-2010 total score. Total HEI-2010 score was also related to caring (Model 1), for the elderly over “5 years vs. Never” among Whites (−7.31 ± 3.54, p = 0.04, Model 2). Longitudinally, we found slight potential improvement in diet quality over time (“Daily or Weekly” vs. Never by TIME interaction: +0.88 ± 0.38, p = 0.02) with frequent caregiving among Whites, but not so among AAs. Conclusions: Frequent caring for grandchildren had an inverse relationship with the diet quality of White and AA urban middle-aged caregivers, while caring for elderly was inversely linked to diet quality among Whites only. Longitudinal studies should address the paucity of research on caregivers’ nutritional quality.     

COVID-19 Vaccine Perception in South Korea: Web Crawling Approach

BackgroundThe US Centers for Disease Control and Prevention and the World Health Organization emphasized vaccination against COVID-19 because physical distancing proved inadequate to mitigate death, illness, and massive economic loss.ObjectiveThis study aimed to investigate Korean citizens’ perceptions of vaccines by examining their views on COVID-19 vaccines, their positive and negative perceptions of each vaccine, and ways to enhance policies to increase vaccine acceptance.MethodsThis cross-sectional study analyzed posts on NAVER and Instagram to examine Korean citizens’ perception of COVID-19 vaccines. The keywords searched were “vaccine,” “AstraZeneca,” and “Pfizer.” In total 8100 posts in NAVER and 5291 posts in Instagram were sampled through web crawling. Morphology analysis was performed, overlapping or meaningless words were removed, sentiment analysis was implemented, and 3 public health professionals reviewed the results.ResultsThe findings revealed a negative perception of COVID-19 vaccines; of the words crawled, the proportion of negative words for AstraZeneca was 71.0% (476/670) and for Pfizer was 56.3% (498/885). Among words crawled with “vaccine,” “good” ranked first, with a frequency of 13.43% (312/2323). Meanwhile, “side effect” ranked highest, with a frequency of 29.2% (163/559) for “AstraZeneca,” but 0.6% (4/673) for “Pfizer.” With “vaccine,” positive words were more frequently used, whereas with “AstraZeneca” and “Pfizer” negative words were prevalent.ConclusionsThere is a negative perception of AstraZeneca and Pfizer vaccines in Korea, with 1 in 4 people refusing vaccination. To address this, accurate information needs to be shared about vaccines including AstraZeneca, and the experiences of those vaccinated. Furthermore, government communication about risk management is required to increase the AstraZeneca vaccination rate for herd immunity before the vaccine expires.