Parental preparation of children for routine physical examinations.

Preparation of the child and parents/caretakers for health care events is expected to decrease a child's anxiety and uncooperative behaviors. The purpose of this study was to ascertain the methods of preparation (discussion, reading, play, other) and levels of discussion used by parents in readying their preschool and school-age children for six selected events during routine physical examinations. A phone survey was conducted to all parents of children, ages 2 to 12 years, who visited an academic nursing center or public school for a routine physical examination (n = 132). The events are "listen to heart," "look in ears," "take temperature," "feel the stomach," "look at the throat," and "give a shot." The most common method of preparation parents used was discussion that consisted largely of procedural information rather than a reciprocal dialogue with the child. Preschool children were told what the health care provider would do and what they should do during the physical examination more often than school-age children.     

Toward a more materialistic medicine: the value of authentic materialism within current and future medical practice

Modern medicine is often accused by diverse critics of being "too materialistic" and therefore insufficiently holistic and effective. Yet, this critique can be misleading, dependent upon the ambiguous meanings of "materialism." The term can refer to the prevalence of financial concerns in driving medical practice. Alternatively, it can refer to "mechanistic materialism," the patient viewed as a body-machine. In each case, this article shows that this represents not authentic "materialism" at play, but a focus upon high-level abstractions. "Bottom-line" financial or diagnostic numbers can distract practitioners from the embodied needs of sick patients. In this sense, medical practice is not materialist enough. Through a series of clinical examples, this article explores how an authentic materialism would look in current and future practice. The article examines the use of prayer/comfort shawls at the bedside; hospitals and nursing homes redesigned as enriched healing environments; and a paradigmatic medical device--the implantable cardioverter defibrillator--as it might be presented to patients, in contrast to current practice.     

Mechanistic explanation for the unique pharmacologic properties of receptor partial agonists.

Simulation data provided in this paper revealed that when a receptor full agonist and a competitive or noncompetitive antagonist for the same type of receptor are covalently linked together in some proper ways, the resulting bifunctional compound would have a reduced efficacy, and their dose-response curve patterns would look exactly like the curve patterns for many known partial agonists. It is also shown that all known pharmacologic characteristics for receptor partial agonists matched precisely the projected properties of the agonist-antagonist bifunctional compounds. The novel mechanistic explanation developed in this paper not only reveals the structural requirements for receptor partial agonists, but it also negates the long-held mechanistic explanation that the reduced efficacy of receptor partial agonists is the result of partial activation of each individual receptor molecule being occupied by the partial agonist because of its "low intrinsic activity".     

Medicare beneficiary decision making about health insurance. Implications for a voucher system

A two-phase study involving focus group interviews and a survey of 2,016 Medicare beneficiaries was conducted to examine beneficiary decision making about health insurance under a hypothetical Medicare voucher program. Some of the major findings were that: beneficiaries lack important information about Medicare and health insurance in general; plans with physician restrictions, no restrictions on hospitals, and benefits for custodial long-term care at home or in nursing homes are most preferred when prices are roughly equal to actuarial costs; plan features often interact rather than combined additively to affect choices; price sensitivity is small in comparison with sensitivity to other plan features; price sensitivity is particularly small for plans with custodial long-term care benefits; Medicare would not experience substantial selection bias in a voluntary system containing a wide range of plans preferred by beneficiaries; physician-restricted plans would experience favorable selection; plans with long-term custodial care benefits would experience some adverse selection which might be handled by modest price adjustments in view of the relatively low price elasticity of preferences.     

Conceptualization and evaluation of an optimal healing environment for chronic low-back pain in primary care

This paper describes what a primary care-based optimal healing environment (OHE) might look like for chronic low-back pain, and presents a research protocol to evaluate the effect of such an environment on a variety of important patient and clinician outcomes. Such an environment may be conceived of as having three major components: (1) the health care environment in which the primary care team works; (2) the cognitive, technical, clinical and organizational skills of the team, and; (3) the "healing" skills of the team members, particularly the primary care physician. A variety of study designs available for evaluating the effects of an OHE on patient and clinical outcomes are described. Decisions about study site and population, appropriate outcome measures, required sample sizes, methods of patient recruitment, treatment protocol and analytic issues would need to be tailored to the specific requirements of the study. Because many elements of an OHE designed for chronic back pain seen in primary care settings would also be relevant for the other 98% of primary care visits, it is preferable to design, implement and evaluate an OHE for primary care practice in general than for only a specific condition.     

Families as caregivers: the limits of morality

There is a developing trend to look to families to provide care and support of those in need of rehabilitation. A widespread assumption is that family care is superior care and, with modest degrees of support, families can provide that care. Yet we may question the ethical limits of the obligation of a family or family member to provide care when the demands are severe. Psychologic and moral problems that confront caregivers are examined. In some cases caregivers must sacrifice their present and future welfare. That the moral claim made upon them may seem a justifiable one in many respects does not mean that it will be endurable; that it is endurable does not mean that it is justifiable. The problem is exacerbated by lack of a supportive culture, one that rewards and honors those who take on heroic duties. Caregivers may be socially isolated. If heroic demands are to be made on family members, a richer moral culture is required, not just the provision of improved social services.     

Screening Adults for Pre-Diabetes and Diabetes May Be Cost-Saving

OBJECTIVE

The economic costs of hyperglycemia are substantial. Early detection would allow management to prevent or delay development of diabetes and diabetes-related complications. We investigated the economic justification for screening for pre-diabetes/diabetes.

RESEARCH DESIGN AND METHODS

We projected health system and societal costs over 3 years for 1,259 adults, comparing costs associated with five opportunistic screening tests. All subjects had measurements taken of random plasma and capillary glucose (RPG and RCG), A1C, and plasma and capillary glucose 1 h after a 50 g oral glucose challenge test without prior fasting (GCT-pl and GCT-cap), and a subsequent diagnostic 75 g oral glucose tolerance test (OGTT).

RESULTS

Assuming 70% specificity screening cutoffs, Medicare costs for testing, retail costs for generic metformin, and costs for false negatives as 10% of reported costs associated with pre-diabetes/diabetes, health system costs over 3 years for the different screening tests would be GCT-pl $180,635; GCT-cap $182,980; RPG $182,780; RCG $186,090; and A1C $192,261; all lower than costs for no screening, which would be $205,966. Under varying assumptions, projected health system costs for screening and treatment with metformin or lifestyle modification would be less than costs for no screening as long as disease prevalence is at least 70% of that of our population and false-negative costs are at least 10% of disease costs. Societal costs would equal or exceed costs of no screening depending on treatment type.

CONCLUSIONS

Screening appears to be cost-saving compared to no screening from a health system perspective, and potentially cost-neutral from a societal perspective. These data suggest that strong consideration should be given to screening—with preventive management—and that use of GCTs may be cost-effective.The prevalence and costs associated with diabetes and pre-diabetes challenge the financial integrity of our healthcare systems. However, screening would allow management aimed at preventing or delaying development of diabetes and complications and could possibly reduce costs. Recommendations regarding screening for pre-diabetes and diabetes have been made by the American Diabetes Association (ADA) (1), but formal screening is infrequent (2). Screening options include fasting plasma glucose (FPG) and oral glucose tolerance tests (OGTTs), but both require fasting samples that patients find inconvenient (3), and it is not clear what the best screening strategy is—another reason screening is under-performed (4). There is also controversy as to whether screening for diabetes is cost-effective (5). Previous analyses of the costs of screening have often focused only on diabetes, have not compared different screening strategies, or have examined screening in only limited ways, e.g., have not included the downstream implications of detecting diabetes as well as pre-diabetes or have ignored the costs of false-negative and false-positive screening results (6–12).We evaluated the economic justification for screening for diabetes and pre-diabetes. We estimated the costs of screening with random plasma or capillary glucose (RPG or RCG) and A1C tests, informal screening tests frequently used in routine practice, and a glucose challenge test (GCT) approach similar to that used to screen for gestational diabetes, along with the costs of management. Our objectives were to determine whether screening coupled with 3 years of preventive management is likely to be cost-effective compared with no screening, and if there is an optimal screening strategy from an economic perspective.     

Variable-ratio pushrim-activated power-assist wheelchair eases wheeling over a variety of terrains for elders

OBJECTIVES: To test (1) whether a prototype variable-ratio pushrim-activated power-assist wheelchair would decrease effort and perceived exertion associated with wheeling and (2) whether the prototype would be acceptable to elders. DESIGN: Repeated-measures design. SETTING: Biomechanics laboratory. PARTICIPANTS: Eleven elderly wheelers (mean age +/- standard deviation, 70.7+/-7.8 y). INTERVENTIONS: Wheelers propelled their own wheelchairs and the prototype on a level surface, a carpet, and an incline. MAIN OUTCOME MEASURES: Surface electromyographic activity from upper limb and torso, heart rate, number of pushes, category-ratio scale of perceived exertion, and Consumer Assessment of Power Assist Wheelchairs. RESULTS: Compared with subjects' own manual wheelchairs, the prototype was associated with lower heart rate elevation (P<.0125), lower perceived exertion (P<.0125), and reduced electromyographic activity in 5 of 8 muscles. Of the 11 participants, 10 found the prototype to be "very easy" or "easy" to push on level and inclined surfaces; 9 gave that assessment on carpeted and inclined surfaces. Seven would "definitely" or "probably" trade their manual chairs for the power-assist chair if given the opportunity. Nine thought they would venture to new and different places in a power-assist wheelchair. Time and number of pushes to complete tasks did not differ significantly between chairs. CONCLUSIONS: The prototype reduced the effort associated with wheeling and was an acceptable alternative to manual wheelchairs. Further testing outside the laboratory is warranted.     

"The Golden Rule": Only a starting point for quality care

The Golden Rule guides people to choose for others what they would choose for themselves. The Golden Rule is often described as 'putting yourself in someone else's shoes', or 'Do unto others as you would have them do unto you'(Baumrin 2004). The viewpoint held in the Golden Rule is noted in all the major world religions and cultures, suggesting that this may be an important moral truth (Cunningham 1998). The Golden Rule underlies acts of kindness, caring, and altruism that go above and beyond "business as usual" or "usual care" (Huang, 2005). As such, this heuristic or 'rule of thumb' has universal appeal and helps guide our behaviors toward the welfare of others. So why question the Golden Rule? Unless used mindfully, any heuristic can be overly-simplistic and lead to unintended, negative consequences.A heuristic is a rule of thumb that people use to simplify potentially overwhelming or complex events. These rules of thumb are largely unconscious, and occur irrespective of training and educational level (Gilovich, Griffin & Kahneman 2002). Rules of thumb, such as the Golden Rule, allow a person to reduce a complex situation to something manageable-e.g., 'when in doubt, do what I would want done'. Because it is a simplifying tool, however, the Golden Rule may lead to inappropriate actions because important factors may be overlooked.In this article we describe "The Golden Rule" as used by administrators, supervisors, charge nurses, and CNAs in case studies of four nursing homes. By describing use of this rule-of-thumb, we aim to challenge nurses in nursing homes to: 1) be mindful of their use of "The Golden Rule" and its impact on staff and residents; and 2) help staff members think through how and why "The Golden Rule" may impact their relationships with staff and residents.     

Cancer care in the 1980s

Even when all available preventive strategies are strongly encouraged, the diagnosis of cancer will often be encountered in the primary care setting. Patients will look to their personal physician for advice in dealing with their illness and commonly ask, "What would you do?" Knowing the patient well, whether he or she desires to fight for every possible day of life or apparently welcomes an earlier death with freedom from life prolongation therapies, is the basis for helping the patient to choose alternatives. Informed decisions by the physician are facilitated by appropriate classification and staging of the tumor. Entrusted to the primary physician are numerous responsibilities that include team management, aiding the patient and family to cope with the illness, and maintaining a quality life with the best possible functional status. Both patient and physician must fully understand and share what is known about the cancer in order to individualize treatment with the proper level of care. Modern cancer care is highly sophisticated and changeable; to do it well requires a special interest and attention from the physician.     

Impact of the new US health-care-reform legislation on the pharmaceutical industry: who are the real winners?

Over the past two years, the US pharmaceutical and biotechnology industries were preparing themselves for passage of some type of health-reform legislation with a clear appreciation-and concern-about the enormous impact any law would be likely to have on the structure and viability of the research-based industry. Now, with final passage in March 2010 of the Patient Protection and Affordable Care Act and its companion "quick-fix" and budget bill, the Health Care and Education Reconciliation Act, it is a good time to take a look at how the industry fared and assess how the various provisions of the health-care reform bill might affect the industry's long-term prosperity and growth.     

What women wish they knew before prophylactic mastectomy

Although prophylactic mastectomy significantly reduces the incidence and recurrence of breast cancer, little is known about women's information needs before the procedure. We surveyed 967 women, from 6 healthcare systems, with bilateral or contralateral prophylactic mastectomy performed between 1979 and 1999. There were 2 open-ended questions: "What one thing do you wish you had known before your prophylactic mastectomy" and "Is there anything else you would like to share with us?" Three researchers categorized responses, and informational needs were ascertained. Seventy-one percent (684 women) responded, of which 81% answered one or both open-ended questions. There were 386 comments (made by 293 women) that related to information needs; 79% of women had bilateral prophylactic mastectomy and 58% had contralateral prophylactic mastectomy. Most concerns (69%) were related to reconstruction: the longevity; look and feel of implants, pain, numbness, scarring, and reconstruction options. Many women wished they had seen photographs to better prepare them for the final result. Our findings suggest that information needs of many women undergoing prophylactic mastectomy, particularly those selecting bilateral prophylactic mastectomy, have not been sufficiently addressed. Clinicians and health educators should be aware of patient needs and must counsel women accordingly.     

Comparison of cytomegalovirus polymerase chain reaction and serology for screening umbilical cord blood components

BACKGROUND: Recipients of umbilical cord blood (UCB) transplants are susceptible to opportunistic infections, including cytomegalovirus (CMV). To prevent CMV transmission from UCB donors, most laboratories perform serology on corresponding maternal samples and quarantine units when the mother has immunoglobulin M (IgM) anti-CMV. STUDY DESIGN AND METHODS: UCB units and associated samples (UCB plasma and red cell pellet; maternal whole blood and serum) from two cord blood banks were tested with two validated CMV polymerase chain reaction assays (UL54 and UL93 targets). Results were compared with maternal CMV serology (IgG and IgM). RESULTS: Only 4 of 48 (8.3%) quarantined CMV IgM-positive units were also CMV nucleic acid testing (NAT)-positive (651-68,600 copies/mL). In contrast, 1 of 200 "CMV-safe" UCB units (CMV IgM-equivocal or -negative) had CMV DNA (0.5%). The corresponding maternal samples were CMV NAT-negative. Positive maternal IgM serology demonstrates only modest sensitivity (80%) and specificity (82%) and poor positive predictive value (8%), when correlated with the presence of CMV DNA in UCB units. CONCLUSION: CMV NAT may be a useful adjunct to serologic screening, potentially reducing wastage of IgM-positive and NAT-negative units while also detecting potentially infectious units that would pass serologic screening. A prospective clinical trial to further evaluate the role of CMV NAT in UCB transplantation appears warranted.     

The treatment of lymphedema related to breast cancer: a systematic review and evidence summary

Goals of work

To provide an evidence summary report on the question: What are the treatment options for women with lymphedema following treatment for breast cancer?

Methods

Cancer Care Ontario’s Supportive Care Guidelines Group (SCGG) employed systematic review methodology to produce an evidence summary on this topic. Evidence-based opinions were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners.

Results

The systematic review search strategy identified ten randomized controlled trials which form the basis of this evidence summary report. Four key opinions offered by the SCGG are outlined below. Responses from the practitioner feedback process supported the validity of these opinions in Ontario. (1) There is some evidence to suggest that compression therapy and manual lymphatic drainage may improve established lymphedema, but further studies are needed. Compression garments should be worn from morning to night and be removed at bedtime. Patients should be advised that lymphedema is a lifelong condition and that compression garments must be worn on a daily basis. Patients can expect stabilization and/or modest improvement of edema with the use of the garment in the prescribed fashion. (2) There is no current evidence to support the use of medical therapies, including diuretics. (3) Additional efforts to define relevant clinical outcomes for the assessment of patients with lymphedema would be valuable. (4) These opinions are appropriate for patients with more than mild lymphedema, where the signs and symptoms are considered significant from the patients’ perspective.

     

PCR methodology and applications for the detection of human fungal pathogens

Introduction: Polymerase chain reaction (PCR) has emerged as a promising technology for the rapid and reliable detection and identification of medical mycoses. Recent technological advancements – including microarray, multiplex PCR with magnetic resonance, and beacon probes – have mitigated the technical difficulties of performing nucleic amplification in fungi, thereby improving the sensitivity and specificity of PCR-based assays. In this paper, we examine current applications of PCR in the diagnosis of human fungal infections and look ahead to emerging techniques that may play a larger role in molecular diagnostics in the future.

Areas covered: This review includes a brief overview of the advantages and disadvantages of PCR using various clinical specimens, manual versus automated DNA extraction procedures, panfungal versus specific targets, and spectrum of pathogens detected. This is followed by a brief synopsis of species-specific PCR approaches and a more in-depth look at the obstacles to widespread implementation.

Expert commentary: The review concludes with a short perspective for the next five years, including the hurdles to standardization and validation, as well as the role of PCR coupled with electrospray-ionization mass spectrometry (PCR/ESI-MS) or nuclear magnetic resonance for the diagnosis of medical mycoses.     

High yield criteria for emergency cranial computed tomography in adult patients with no history of head injury

OBJECTIVES: A recent American study identified clinical factors which effectively predicted those patients who would have significant findings on cranial computed tomography. It was proposed to apply these criteria in a UK setting and to determine whether modifications could be made to improve their efficiency. METHODS: A prospective observational study was conducted over a four month period including all non-trauma adult patients referred from the accident and emergency (A&E) department for urgent cranial computed tomography. Presenting symptoms and signs were analysed for ability to predict clinically significant computed tomography findings, namely: acute infarct, malignancy, acute hydrocephalus, intracranial haemorrhage, or intracranial infection. RESULTS: Sixty two patients were included; 22 (35%) had significant findings on computed tomography. Applying the original criteria (any of: age 60 years or older, focal neurology, headache with nausea or vomiting, altered mental status) to the study population showed that no clinically significant tomograms would have been omitted but only 11% fewer performed. Modifying the criteria by removing "age 60 years or older" and replacing "altered mental status" with a Glasgow coma score <14, still ensured 100% sensitivity and would have resulted in 19% fewer scans being performed. CONCLUSION: Simple clinical criteria can be usefully applied to patients presenting to an A&E department in this country to target patients most likely to have clinically significant findings on urgent cranial computed tomography.     

3-Hydroxyflavone derivatives: promising scaffolds for fluorescent imaging in cells

As a typical class of excited-state intramolecular proton transfer (ESIPT) molecules, 3-hydroxyflavone derivatives (3HF, also known as flavonols) have received much attention recently. Thereinto, the role of hydrophobic microenvironment is significant importance in promoting the process and effects of ESIPT, which can be regulated by the solvents, the existence of metal ions and proteins rich with α-helix structures or the advanced DNA structures. Considering that plenty of biological macromolecules offer cellular hydrophobic microenvironment, enhancing the ESIPT effects and resulting in dual emission, 3HF could be a promising scaffold for the development of fluorescent imaging in cells. Furthermore, as the widespread occurance of compounds with biological activity in plants, 3HF derivatives are much more secure to be cellular diagnosis and treatment integrated fluorescent probes. In this review, multiple regulatory strategies for the fluorescence emission of 3HF derivatives have been collectively and comprehensively analyzed, including the solvent effects, metal chelation, interaction with proteins or DNAs, which would be beneficial for ESIPT-promoting or ESIPT-blocking processes and then enhance or control the fluorescence emission of 3HF effectively. We expect that this review would provide a new perspective to develop novel 3HF-based fluorescent sensors for imaging in cells and plants.

Considering that biological macromolecules offer hydrophobic microenvironment, 3HF is a promising scaffold for the development of fluorescent imaging in cells.     

Towards circular fashion – transforming pulp mills into hubs for textile recycling

Most waste textiles are currently incinerated or landfilled, which is becoming an increasing environmental problem due to the ever-increasing consumption of textiles in the world. New recycling processes are required to address this problem and, although textile-to-textile recycling would be preferable, many researchers have suggested implementing processes based on the depolymerization of the textile fibers. We suggest integrating textile recycling with pulp mills, which would reduce the cost of depolymerizing the textile fibers and, at the same time, would diversify the product portfolio of the pulp mill, transforming the facility into a true biorefinery. This integration would be based on using green liquor as the pretreatment agent in the textile recycling process, as well as energy integration between the two processes. Na₂CO₃ was used to identify the conditions under which this pretreatment should be performed. Temperature and residence time proved to be critical in the efficacy of the pretreatment, as suitable values were required to ensure partial solubilization of the waste textiles. The conditioning of the pretreated material also had an important effect on the process, as it ensured a suitable environment for the enzymatic depolymerization while maintaining the changes in the material caused by pretreatment. Pretreatment was then performed with industrial green liquor, showing that the efficiency of textile recycling was about 70% when integrated in a pulp mill.

Textile recycling can be integrated in pulp mills through the use of green liquor in the pretreatment of the textiles.     

Health Promotion Practices in Two Chiropractic Teaching Clinics: Does a Review of Patient Files Reflect Advice on Health Promotion?

Purpose:

To retrospectively review patient files in two teaching clinics in the United States and to assess the documented attempts to deliver health promotion messages when a chart indicated a need for health promotion or a red-flag condition that could be helped with positive behavioral changes.

Methods:

Approximately 100 patient files were randomly selected from each of two separate chiropractic teaching clinics, for patients seen after January 2007. Files were assessed for pertinent family history of diseases, personal medical history, and red-flag conditions of patients that would warrant intervention with health promotion.

Results:

Health promotion advice on at least one occasion was noted in 108 (53.7%) patient charts. Only 7 of 98 overweight or obese patients and none of those with family history of obesity were advised on weight management. Among 23 hypertensive patients, only 5 were advised and 17 of the 97 patients with risk of cardiovascular disease were advised.

Conclusion:

Chiropractic teaching clinics should assess what they are doing to help Americans reach their health goals. There is an opportunity to shape future practitioners so they include primary prevention as a part of what they do if the profession cares to move in that direction. Future research should look at mechanisms of delivery for health promotion, including better tracking of patients who need it and how staff doctors are trained to deliver oversight to interns in the area of primary prevention.Key Indexing Terms: Cardiovascular System, Chiropractic, Health Promotion, Hypertension, Obesity