Self-verification and bulimic symptoms: do bulimic women play a role in perpetuating their own dissatisfaction and symptoms?

OBJECTIVE: It is suggested that self-verification theory may provide insight as to why bulimic symptoms often persist for years, sometimes even despite intervention. In an effort to meet basic needs for self-confirmation, bulimic women may invite the very responses they fear (e.g., negative feedback about appearance), and thus propagate their symptoms. It was thus predicted that interest in negative feedback would be correlated with body dissatisfaction and bulimic symptoms, and that interest in negative feedback would serve as a risk factor for development of later symptoms, via the mediating effects of increased body dissatisfaction. METHOD: Seventy-nine undergraduate women completed self-report assessments of interest in negative feedback, bulimic symptoms, and body dissatisfaction. RESULTS AND DISCUSSION: Results supported the prediction that, despite serious concerns about body appearance, bulimic women were interested in the very feedback that would aggravate these concerns. Moreover, interest in negative feedback appeared to serve as a risk factor for development of later symptoms, via the mediating effects of increased body dissatisfaction. The clinical implications of these findings are discussed.     

Shan women and girls and the sex industry in Southeast Asia; political causes and human rights implications.

The human rights abuses which occur during civil conflicts pose special threats to the health and lives of women. These can include rape, sexual violence, increased vulnerability to trafficking into prostitution, and exposure to HIV infection. The long-standing civil conflict in the Shan States of Burma is investigated as a contributing cause to the trafficking of ethnic Shan women and girls into the Southeast Asian sex industry, and to the subsequent high rates of HIV infection found among these women. The context of chronic human rights abuses in the Shan states is explored, as well as the effects of recent forced population transfers on the part of the Burmese Military Regime. Rights abuses specific to trafficked women may further increase their vulnerability to HIV and other STD. The need for a political resolution to the crisis in Burma is discussed, as are approaches aimed at preventing trafficking, empowering women already in the sex industry, and reducing the risks of HIV and other STD among these women and girls.     

701名女大学生儿童期性虐待回顾性调查

目的探讨成年女生儿童期性虐待危险因素及施虐者特征。方法用自编性虐待问题及家庭环境问卷，对某学院701名成年女生就有关儿童期受性虐待经历、家庭情况及施虐者特征进行不记名的回顾性调查。结果701名女生中有155人（22．1l％）回答18岁以前曾经历过非身体接触和／或身体接触的性虐待，其中26人（3．71％）经历被试图性交或肛交，8人（1．14％）经历被强行性交或肛交。有117人（16．69％）16岁以前曾经历过性虐待。施虐者大多数为男性（99．4％）；只有少数（3．2％）的施虐者采用了暴力手段；非身体接触性虐待主要由陌生人所为（78．7％），而71．3％的身体接触性虐待是由熟人所为，其中老师占12．5％，邻居占17．5％，亲戚占21．3％。父、母亲经常在家庭中使用暴力、有不良嗜好、体弱多病、家庭成员之间关系紧张及生活在重组家庭是儿童性虐待发生的危险因素，而父亲文化程度高是保护因素。结论儿童期性虐待问题在被调查的女生中并非少见，且家庭环境在儿童性虐待发生中起重要作用。     

The relationship between competence and performance: implications for assessing practice performance

OBJECTIVE: This paper aims to describe current views of the relationship between competence and performance and to delineate some of the implications of the distinctions between the two areas for the purpose of assessing doctors in practice. METHODS: During a 2-day closed session, the authors, using their wide experiences in this domain, defined the problem and the context, discussed the content and set up a new model. This was developed further by e-mail correspondence over a 6-month period. RESULTS: Competency-based assessments were defined as measures of what doctors do in testing situations, while performance-based assessments were defined as measures of what doctors do in practice. The distinction between competency-based and performance-based methods leads to a three-stage model for assessing doctors in practice. The first component of the model proposed is a screening test that would identify doctors at risk. Practitioners who 'pass' the screen would move on to a continuous quality improvement process aimed at raising the general level of performance. Practitioners deemed to be at risk would undergo a more detailed assessment process focused on rigorous testing, with poor performers targeted for remediation or removal from practice. CONCLUSION: We propose a new model, designated the Cambridge Model, which extends and refines Miller's pyramid. It inverts his pyramid, focuses exclusively on the top two tiers, and identifies performance as a product of competence, the influences of the individual (e.g. health, relationships), and the influences of the system (e.g. facilities, practice time). The model provides a basis for understanding and designing assessments of practice performance.     

Improving the linkages between air pollution epidemiology and quantitative risk assessment

Background: Air pollution epidemiology plays an integral role in both identifying the hazards of air pollution as well as supplying the risk coefficients that are used in quantitative risk assessments. Evidence from both epidemiology and risk assessments has historically supported critical environmental policy decisions. The extent to which risk assessors can properly specify a quantitative risk assessment and characterize key sources of uncertainty depends in part on the availability, and clarity, of data and assumptions in the epidemiological studies.Objectives: We discuss the interests shared by air pollution epidemiology and risk assessment communities in ensuring that the findings of epidemiological studies are appropriately characterized and applied correctly in risk assessments. We highlight the key input parameters for risk assessments and consider how modest changes in the characterization of these data might enable more accurate risk assessments that better represent the findings of epidemiological studies.Discussion: We argue that more complete information regarding the methodological choices and input data used in epidemiological studies would support more accurate risk assessments—to the benefit of both disciplines. In particular, we suggest including additional details regarding air quality, demographic, and health data, as well as certain types of data-rich graphics.Conclusions: Relatively modest changes to the data reported in epidemiological studies will improve the quality of risk assessments and help prevent the misinterpretation and mischaracterization of the results of epidemiological studies. Such changes may also benefit epidemiologists undertaking meta-analyses. We suggest workshops as a way to improve the dialogue between the two communities.     

Dr Thomas Percival and the Beginnings of Industrial Legislation

The great expansion of the textile industry in England at theend of the eighteenth century was associated with numerous medicaland social problems. Dr Thomas Percival of Manchester becamepersonally involved in these problems through his studies onpopulation structure and his attempts to eliminate typhus inthe Lancashire mills. His views and plans greatly influencedRobert Peel who introduced the first legislation designed tocombat the abuses and improve the health and welfare of factoryemployees. Dr J. K. Howard, University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT     

Displacement and disease: The Shan exodus and infectious disease implications for Thailand

Decades of neglect and abuses by the Burmese government have decimated the health of the peoples of Burma, particularly along her eastern frontiers, overwhelmingly populated by ethnic minorities such as the Shan. Vast areas of traditional Shan homelands have been systematically depopulated by the Burmese military regime as part of its counter-insurgency policy, which also employs widespread abuses of civilians by Burmese soldiers, including rape, torture, and extrajudicial executions. These abuses, coupled with Burmese government economic mismanagement which has further entrenched already pervasive poverty in rural Burma, have spawned a humanitarian catastrophe, forcing hundreds of thousands of ethnic Shan villagers to flee their homes for Thailand. In Thailand, they are denied refugee status and its legal protections, living at constant risk for arrest and deportation. Classified as "economic migrants," many are forced to work in exploitative conditions, including in the Thai sex industry, and Shan migrants often lack access to basic health services in Thailand. Available health data on Shan migrants in Thailand already indicates that this population bears a disproportionately high burden of infectious diseases, particularly HIV, tuberculosis, lymphatic filariasis, and some vaccine-preventable illnesses, undermining progress made by Thailand's public health system in controlling such entities. The ongoing failure to address the root political causes of migration and poor health in eastern Burma, coupled with the many barriers to accessing health programs in Thailand by undocumented migrants, particularly the Shan, virtually guarantees Thailand's inability to sustainably control many infectious disease entities, especially along her borders with Burma.     

Is the disease risk associated with good self-reported health constant across the socio-economic spectrum?

BACKGROUND: Self-reported health is likely to be dependent on two key assessments: that of one's own health and that of the best health that could be expected. As many health outcomes are known to vary according to socio-economic position (SEP), it is possible that assessments of the best health that could be expected will vary with SEP. It is, therefore, possible that the disease risk associated with different levels of self-reported health varies according to SEP. We investigated this using data from the 1998 Health Survey for England. METHODS: Disease risk was measured as systolic blood pressure and body mass index (BMI), and SEP was measured as occupational social class. Associations between social class and the markers of disease risk were investigated in those reporting different levels of self-reported health using linear regression in order to control for age. RESULTS: There were statistically significant socio-economic variations in systolic blood pressure and BMI (in women only) in those who reported their health as good or very good. No such socio-economic variations in disease risk were seen amongst those reporting their health as less than good. CONCLUSIONS: The meaning of self-reported health, in terms of disease risk, may not be comparable across the socio-economic spectrum.     

Vitamin D metabolism, functions and needs: from science to health claims

Background

Vitamin D is a nutrient long considered as essential for skeletal health but is now attracting interest from medical and nutritional communities as knowledge emerges of its biological function and its association with decreased risk of many chronic diseases.

Results

A question emerges: How much more vitamin D do we need for these new functions of vitamin D? This review discusses vitamin D physiology and hypovitaminosis D and presents two vitamin D dietary policies: that according to regulatory authorities and that of nutrition scientists. Scientific evidence suggests that 25(OH)D serum levels should be over 75 nmol/L; otherwise, there is no beneficial effect of vitamin D on long-latency diseases. Current regulatory authority recommendations are insufficient to reach this level of adequacy. Observational and some prospective data show that vitamin D has a role in the prevention of cancer as well as immunity, diabetes and cardiovascular and muscle disorders, which supports the actions of 1α,25(OH)2D at cellular and molecular levels. The recent assessments done by the European Food Safety Authority should lead to new health claims.

Conclusions

Vitamin D, through food fortification and supplementation, is a promising new health strategy and thus provides opportunities for food industry and nutrition researchers to work together towards determining how to achieve this potential health benefit.     

Of mugs, meals and more: the intricate relations between physicians and the medical industry

Empirical research has proven the influence exerted by the medical industry on physicians’ decision-making. Physicians are the gatekeepers who determine how money is spent within the healthcare system. Hence, they are the target group of powerful lobbies in the field, i.e. the manufacturers of medical devices and the pharmaceutical industry. As clinical research lies in the hands of physicians, they play an exclusive and central role in launching new medical products. There are many ethical problems involved here: physicians may develop a mindset of entitlement; biased decisions may put patients at risk; academic interests and research activities will no longer be free if they are influenced considerably by financial incentives; fair resource allocation may be restricted. An aspect that has been neglected so far is the administrators’ involvement as they not rarely expect physicians to acquire external financial resources from industry as benefits often lie with the institutions. To “protect” physicians from undue sway may be in the best interest of patients in order to guarantee a fair allocation of resources and to prevent the application of technologies (and medications) that would not have been used according to current standards of care. The latter may and obviously does put patients at risk. On the other hand, medico–industrial relations are of great importance. A considerable part of medical progress is driven by private industry. Yet, any co-operation between those who care for patients and industry ultimately has to serve the patient. Hence, strong policies to guide conduct are sorely needed. The following points are held to be pivotal in order to secure ethical conduct: (1) professional codes of ethics; (2) a stronger academic attitude amongst medical staff, (3) rules of transparency for medico?industrial relations including online disclosure and limiting scale of payments, (4) establishing rules (and laws) that ban unethical conduct and mandate vigorous surveillance of adherence to guidelines.     

Addressing arsenic bioaccessibility in ecological risk assessment: a novel approach to avoid overestimating risk

The risk of arsenic exposure to deer mice (Peromyscus maniculatus) living in areas of naturally and anthropogenically elevated arsenic levels was determined using three separate calculations of arsenic daily intake: Estimated daily intake (EDI), bioaccessible EDI (BEDI), and actual daily intake (ADI). The present work is of particular interest, because the risk assessments were determined for animals naturally exposed to arsenic. Gastric fluid extraction was used to obtain bioaccessibility data for soil and plant samples collected from three study sites (background, mine forest, and tailings) in Yellowknife (NT, Canada). Calculations using the EDI indicated that deer mice living in tailings habitat (average soil arsenic concentration, 1,740 +/- 2,240 microg/g) should have been experiencing serious health effects as a result of their exposure to arsenic. Using BEDI and ADI in the risk assessment calculation, however, resulted in an order-of-magnitude decrease in calculated risk. In addition, results calculated using the BEDI and ADI were not significantly different, suggesting that using bioaccessibility provides a more realistic estimate of potential risk. The present results provide evidence that the use of EDI in traditional risk assessments may seriously overestimate the actual risk, which in some instances may result in expensive and unnecessary clean-up measures.     

Substituting proxy ratings for patient ratings in cancer clinical trials: An analysis based on a Southwest Oncology Group trial in patients with brain metastases

In studies of the effect of cancer treatment in the advanced disease setting, researchers have attempted to avoid missing data for quality of life (QOL) assessments by either substituting proxy for patient assessments from the outset or by interspersing proxy measures when patients are unable to respond. Although poor agreement between patient and proxy assessments has been amply demonstrated in the literature, interest in using proxy measures persists. Completion of the Spitzer QL-Index by a small sample of patients with brain metastases and family member proxies provided data for evaluating the ability to substitute proxy for patient QOL assessments. These data cannot address treatment efficacy due to the modest sample size. Rather, the analyses serve to alert researchers to the important distinction (in a clinical trial setting) between agreement and the use of the proxy as a surrogate. We present several methods for evaluating the accuracy of proxy measures and for identifying other sources of error and bias that may vary with time or with treatment arm. Lin's concordance correlation coefficient suggests that proxies are generally a poor substitute for capturing a patient's perspective of his/her QOL. A longitudinal analysis suggests that the use of proxy rather than patient responses could lead to different conclusions concerning radiation therapy's effect on QOL.     

From radio-astronomy to medical imaging.

A common thread in much of the medical imaging that has developed over the past 20 years has been the Fourier transform. It was Richard Bates' interest in radio-interferometry, as well as his fascination with problems of medical imaging that prompted an initial interest in applying Fourier techniques to medical imaging in general and to Computed Tomography in particular. This resulted 20 years ago in one of the earliest technical papers advocating Fourier techniques for reconstructing cross-sections from radiographic projections (Bates and Peters, NZ J Science 14:883-896, 1971). Since those early days, medical imaging has explored into a multi-billion dollar industry. The CT scanner has become the workhorse imaging modality in the radiology department, while its more recent relative, the MR scanner, is rapidly gaining ground as a technique of even greater importance. Richard Bates, with his team of "Medical Imagers" was a very significant force in the development of the field of Medical Imaging as we know it today. This paper attempts to chronicle the genesis of this process from the personal perspective of the author.     

Reliability: on the reproducibility of assessment data

CONTEXT: All assessment data, like other scientific experimental data, must be reproducible in order to be meaningfully interpreted. PURPOSE: The purpose of this paper is to discuss applications of reliability to the most common assessment methods in medical education. Typical methods of estimating reliability are discussed intuitively and non-mathematically. SUMMARY: Reliability refers to the consistency of assessment outcomes. The exact type of consistency of greatest interest depends on the type of assessment, its purpose and the consequential use of the data. Written tests of cognitive achievement look to internal test consistency, using estimation methods derived from the test-retest design. Rater-based assessment data, such as ratings of clinical performance on the wards, require interrater consistency or agreement. Objective structured clinical examinations, simulated patient examinations and other performance-type assessments generally require generalisability theory analysis to account for various sources of measurement error in complex designs and to estimate the consistency of the generalisations to a universe or domain of skills. CONCLUSIONS: Reliability is a major source of validity evidence for assessments. Low reliability indicates that large variations in scores can be expected upon retesting. Inconsistent assessment scores are difficult or impossible to interpret meaningfully and thus reduce validity evidence. Reliability coefficients allow the quantification and estimation of the random errors of measurement in assessments, such that overall assessment can be improved.     

The risks posed by the importation of animals vaccinated against foot and mouth disease and products derived from vaccinated animals: a review

The Terrestrial Animal Health Code of the OIE (World organisation for animal health) (the Terrestrial Code) makes recommendations for international movements of live animals and animal products because of a possible generic risk of foot and mouth disease (FMD) for these different commodities. For instance, international movement of vaccinated live animals or products of such animals is restricted due to the possible masking of clinical disease as a result of vaccination and to the perceived risk of persistently infected animals among vaccinated livestock. In addition, bilateral agreements between exporting and importing countries on the importation of animal products can be based on the 'equivalence' of the animal health conditions in both countries, or on formal or informal risk assessments in accordance with the norms and recommendations of the Terrestrial Code. In this regard, an exporting country may be required to prepare a complete and transparent document describing the animal health situation, including the factors required to assess the risk involved. Furthermore, expert committees of importing countries regularly evaluate and verify these conditions in exporting countries. The level of confidence in the information obtained by the expert committee can then be entered into the risk analysis equation. An important FMD risk reduction factor for the importation of animals and animal products is early recognition of the disease at the source of the commodity by alert stakeholders, such as official and private veterinarians and the chain of the livestock industry. This is true for all countries irrespective of their vaccination status. The risk posed by the importation of vaccinated animals becomes negligible when an adequate protocol--in compliance with the norms and recommendations of the Terrestrial Code--is applied. However, recently, export of live animals from countries that do not practise vaccination has also proven to pose a significant risk and the rules governing such transport may have to be reviewed. Disease surveillance, biosecurity at the farm level, traceability and control of the source cattle and slaughterhouse inspections are the main risk reduction measures for meat and meat products from vaccinated cattle. If these animals are slaughtered and processed under good management practice--in accordance with the norms and recommendations of the Terrestrial Code--these products present a negligible risk for the introduction of FMD. Risk reduction by maturation and deboning is an important procedure, but is probably overemphasised. Mechanical contamination of cattle carcasses with 'carrier virus' from the pharyngeal area during slaughter and processing is very unlikely. Risk assessments showed that the importation of milk products from countries or zones that practise vaccination of dairy herds poses a negligible risk. Risk assessments also demonstrated that the importation of bovine embryos from vaccinated cows--in accordance with the norms and recommendations of the Terrestrial Code--poses a negligible risk. Likewise, the risk from the importation of semen from vaccinated bulls is also negligible when an adequate test protocol is applied in accordance with the Terrestrial Code.     

Evaluation of occupational and leisure time exposure assessment in a population-based case control study on leukaemia

OBJECTIVES: To increase the credibility of retrospective exposure assessments. documentation of the procedures and presentation of measures on quality control is recommended. The aim of this study was to present and evaluate the procedures used in a case-control study on leukaemia. METHODS: A series of 1,087 cases and matched controls were interviewed. Exposure assessments were performed for 13 occupational agents and ten leisure-time activities and the confidence of the assessments was coded. The exposure assessments were performed blind by three occupational hygienists. Ten percent of the interviews were reassessed by two of the three occupational hygienists. RESULTS: The leisure-time activities contributed to a large extent to the overall prevalence of exposure. For organic solvents approximately 25% of the controls classified as exposed would be misclassified if leisure-time exposure were not considered. The proportions of subject assessments with low confidence were higher for next-of-kin than for in-person interviews. A negative correlation was seen between the proportions of assessments with low confidence and the reliability. A significant difference was seen in the inter-rater comparison between cases and controls when the reliability was calculated for each assessed period; no difference was seen for the subject assessments used for relative risk estimation. CONCLUSION: When low-dose exposure in epidemiological studies are being assessed there is an obvious risk of misclassification if leisure-time activities are not included. Furthermore, the reliability of the assessments may suffer if next-of-kin interviews are used to a large extent. For cancers with poor prognoses, prospective studies are preferable to minimise possible information bias.     

On markets and morals—(re-)establishing independent decision making in healthcare: a reply to Joao Calinas-Correia

Medical practitioners owe much of the significant progress made in the diagnosis and treatment of disease to industrial research. Hence, co-operation between providers of medical services, most notably medical practitioners, and the pharmaceutical industry is in the best interest of patients. Yet, empirical evidence shows how well-directed influence exerted by the pharmaceutical industry impacts physicians’ decision-making. Profit-motivated inducement by the pharmaceutical industry may expose patients to considerable risks. Against what many think to be based on overwhelming evidence, Joao Calinas-Correia takes the view that the criticism levelled at the pharmaceutical industry as well as the call for transparency in the relationships between physicians and the industry are exaggerated. In his polemic he praises “Big Pharma” as a success and espouses the view that the undesired consequences of its activities are allegedly inherent in the underlying market environment shaped by politics. Moreover, he believes that the proposals made to control and eliminate such undesired effects will lead to mediocrity. Astonishingly, his polemic reaches out to contest the appropriateness of setting rules at all—even if being set by a democratic process. Calinas-Correia’s assertions are based on the wrong premises. They fail to recognize that today individual civil rights and liberties often enough do not have to be defended against encroachments by governmental authorities. Rather, it is incumbent on the state to create rules designed to defend the individual against infringements by overly powerful non-governmental institutions, in our case the medical-industrial complex. Given the power exercised by physicians and the special nature of their role in public health, clear-cut rules have to be enacted and implemented with respect to their relationship to Big Pharma.     

Criteria and methods used for the assessment of fitness for work: a systematic review

The main findings from reports published in scientific journals on the criteria and methods used to assess fitness for work were reviewed. Systematic searches were made using internet engine searches (1966-2005) with related keywords. 39 reports were identified, mostly from the US and western Europe. Assessment of fitness for work is defined by most as the evaluation of a worker's capacity to work without risk to their own or others' health and safety. It is mainly assessed at recruitment (pre-offer or post-offer), and when changes of work or health conditions occur. Five main criteria used by occupational doctors to evaluate fitness for work were identified: the determination of worker's capacity and worker's risk in relation to his or her workplace, as well as ethical, economic and legal criteria. Most authors agreed that assessment tools used need to be specific and cost-effective, and probably none gives unequivocal answers. Outcomes from fitness for work assessments range from "fit" to "unfit", with other possible intermediate categories such as "fit subject to work modifications", "fit with restrictions" or "conditionally fit (temporarily, permanently)". Workplace modifications to improve or adjust working conditions must always be considered. There is confusion about the decision-making process to be used to judge about fitness for work. There is very scarce scientific evidence based on empirical data, probably because there are no standard or valid methodologies for all professions and circumstances.     

Competing interests in healthcare: a conflict of quality. Part II: regulations, transparency, and policy implications

This research explores the association of physician conflicts of interest with quality of care. Specifically, we discuss the role of some government regulations as policy alternatives. The need for further regulation has become more apparent as improprieties in the healthcare industry have come to light. The dominating theme in current and proposed legislation, as well as institutional policies, is the idea of ensuring that conflicts of interest are transparent, thereby increasing the likelihood that appropriate relationships will be maintained between healthcare providers and industry representatives. Much of the difficulty that organizations are going to have in implementing effective policies is the resistance that will be initiated by physicians. In order to decrease the frequency of negative effects from conflicts of interest, we suggest that each organization establish a committee to create and oversee strict policies governing expectations regarding conflicts of interest.