Are more options always better? The attraction effect in physicians' decisions about medications.

Consumer choice research has shown that, contrary to normative theory, the introduction of an inferior alternative to an existing choice set can increase the likelihood that one of the original alternatives will be chosen. This phenomenon, the attraction effect, is relevant to physician decision making, particularly when the physician is in the role of a consumer who must make decisions about prescribing medications when a number of alternatives are available. To investigate the attraction effect in physician decision making, 40 internal medicine residents reviewed three patient cases (concerning depression, sinusitis, and vaginitis) and then chose the most appropriate medication for each patient. In some versions of the cases, two medication options were available. Other versions included a third medication (the decoy) that was inferior in every way to one of the original options (the target) but not to the other (the competitor). The results showed that addition of the "decoy" medication increased the likelihood of choosing the target medication. That is, the attraction effect does occur in physicians' decisions about medications. Physicians should be aware of this bias when evaluating or suggesting several similarly attractive medications or treatment options for the same medical condition.     

A randomized trial of 72- versus 24-hour intravenous tubing set changes in newborns receiving lipid therapy.

OBJECTIVE: To compare the microbial contamination rate of infusate in the intravenous tubing of newborns receiving lipid therapy, replacing the intravenous delivery system at 72-hour versus 24-hour intervals. DESIGN: Infants requiring intravenous lipid therapy were randomly assigned to have intravenous sets changed on a 72- or a 24-hour schedule, in a 3:1 ratio, in order to compare the infusate contamination rates in an equivalent number of tubing sets. SETTING: A 35-bed, teaching, referral, neonatal intensive-care unit (NICU). PARTICIPANTS: All neonates admitted to the NICU for whom intravenous lipid was ordered. METHODS: Patients were randomized in pharmacy, on receipt of the order for intravenous lipid therapy, to either 72- or 24-hour administration set changes, and followed until 1 week after discontinuation of lipids or discharge from the NICU. Microbial contamination of the infusate was assessed in both groups at the time of administration set changes. Contamination rates were analyzed separately for the lipid and amino acid-glucose tubing sets. Patient charts were reviewed for clinical and epidemiological data, including birth weight, gestational age, gender, age at start of lipid therapy, duration of parenteral nutrition, and type of intravenous access. RESULTS: During the study period, 1,101 and 1,112 sets were sampled in the 72- and 24-hour groups, respectively. Microbial contamination rates were higher in the 72-hour group than the 24-hour group for lipid infusions (39/1,101 [3.54%] vs 15/1,112 [1.35%]; P=.001) and for amino acid infusions (12/1,093 [1.10%] vs 4/1,103 [0.36%]; P=.076). Logistic regression analysis controlling for birth weight, gestational age, and type of venous access showed that only the tubing change interval was significantly associated with lipid set contaminations (odds ratio, 2.69; P=.0013). The rate of blood cultures ordered was higher in the 72- versus the 24-hour group (6.11 vs 4.99 per 100 patient days of total parenteral nutrition; P=.017), and a higher proportion of infants randomized to the 72-hour group died (8% vs 4%; P=.05), although the excess deaths could not clearly be attributed to bacteremia. CONCLUSION: Microbial contamination of infusion sets is significantly more frequent with 72- than with 24-hour set changes in neonates receiving lipid solutions. This may be associated with an increased mortality rate.     

Crisis management during anaesthesia: hypertension

Background: Hypertension occurs commonly during anaesthesia and is usually promptly and appropriately treated by anaesthetists. However, its recognition is dependent on correctly functioning and calibrated monitors. If it is not diagnosed and/or promptly corrected, it has the potential to cause significant morbidity and even mortality.

Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK" supplemented by a specific sub-algorithm for the management of hypertension occurring in association with anaesthesia.

Methods: The potential performance of this approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

Results: There were 70 reports of intraoperative hypertension among the first 4000 incidents reported to AIMS. Drug related causes accounted for 59% of all incidents. It was considered that, properly applied, this structured approach would have led to a quicker and/or better resolution of the problem in 21% of the cases.

Conclusion: Once hypertension is identified and confirmed, its rapid control by the careful use of a volatile anaesthetic agent, intravenous opioids, or rapidly acting antihypertensives will usually avoid serious morbidity. If hypertension is unresponsive to the treatment recommended in the relevant sub-algorithm, an unusual cause such as phaeochromocytoma, carcinoid syndrome, or thyroid storm should be considered.

     

Crisis management during anaesthesia: pulmonary oedema

Background: Pulmonary oedema may complicate the perioperative period and the aetiology may be different from non-operative patients. Diagnosis may be difficult during anaesthesia and consequently management may be delayed.

Objectives: To examine the role of a previously described core algorithm "COVER ABCD–A SWIFT CHECK", supplemented by a specific sub-algorithm for pulmonary oedema, in its management occurring in association with anaesthesia.

Methods: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

Results: Pulmonary oedema was identified in 35 (<1%) of the first 4000 reports to AIMS. The most frequent presenting sign was hypoxia (46%) and the most specific sign was the presence of frothy sputum (23%). The core algorithm, although successful in the management of the initial physiological upset, was found to be inadequate for the ongoing management of pulmonary oedema. A specific sub-algorithm for the management of perioperative pulmonary oedema was devised, tested against the reports and would have been effective, if properly applied, in the management of all but one of the reported cases.

Conclusion: Successful recognition and management of perioperative pulmonary oedema is likely with the application of the structured algorithm and specific sub-algorithm approach outlined in this study.

     

The West Virginia Health Education Assessment Project

Well-designed school health education should provide students with the knowledge and skills to prevent the health risk behaviors most responsible for the major causes of morbidity and mortality. This paper reports the methodology and findings of a West Virginia statewide health education assessment initiative and describes how the findings are used to design professional development training for school health educators. Selected response items from the State Collaborative on Assessment and Student Standards, Health Education Assessment Project were used to develop a 40-item assessment instrument for 6 health education content areas. In West Virginia, 51 counties and 242 schools were recruited (county response rate = 93%; school response rate = 53%); 17,549 students were tested in grades 6, 8, and high school health education classes. Mean total scores by grade were 30.61 (grade 6), 26.55 (grade 8), and 26.53 (high school), indicating a slight decline in scores as grade level increased. Females in each grade level scored higher on total Health Education Assessment Project (HEAP) scores and subtest scores than males. The results suggest notable differences across grade levels. High school students failed to meet the standard on any health education content areas, indicating the need for enhanced knowledge and skill development. During professional development training, HEAP scores were examined in the context of results from the West Virginia Youth Risk Behavior Survey to underscore the importance of providing quality skills-based health education in West Virginia schools.     

Occupational magnetic field exposure, cardiovascular disease mortality, and potential confounding by smoking

PURPOSE: To assess the relationship between occupational magnetic field (MF) exposure and cardiovascular disease (CVD) mortality and to determine whether smoking could confound this relationship. METHODS: Death certificate and proxy respondent information from the US 1986 and 1993 National Mortality Followback Surveys (NMFS) were used to determine whether job titles with potential occupational MF exposure were risk factors for CVD mortality and whether smoking behavior may confound the observed relationship. A qualitative MF exposure matrix was developed based on job titles and published exposure measurements. In a case-control analysis, logistic regression models, adjusting for age, sex, race, working status, level of education, and survey year, were used to examine the associations between estimated MF exposure and death from CVD. To assess the effect of adjustment for smoking, we conducted our analyses with and without including smoking-related variables in the models, and evaluated the change in CVD risk estimates. RESULTS: There was no consistent dose-response relationship between occupational MF exposure estimates and CVD mortality. Adjustment for smoking behavior did not appreciably change the observed MF exposure-CVD mortality relationship. CONCLUSIONS: Although limited by self-reported information on exposure and smoking, our results suggest that CVD mortality was not associated with MF exposure in this study, and smoking behavior was not an apparent confounder of the MF-CVD association.     

A one year study of Escherichia coli O157 in raw beef and lamb products

Between April 1996 and March 1997 we examined 5093 samples of raw beef and lamb products for the presence of E. coli O157. Samples were purchased from 81 small butchers' shops in south Yorkshire. In March 1997 we also examined five samples of dried mint for the presence of E. coli O157. Strains of E. coli O157 were isolated by enrichment culture in modified buffered peptone water followed by immunomagnetic separation and culture of magnetic beads onto cefixime tellurite sorbitol MacConkey agar. Strains were characterized by phage typing, toxin genotyping and plasmid analysis. Strains of E. coli O157 were isolated from 72 (1.4%) of 5093 samples; it was isolated from 36 (1.1%) of 3216 samples of beef products and from 29 (2.9%) samples of lamb products. The highest prevalence was found in lamb sausages and lamb burgers where E. coli O157 was isolated from 3 (4.1%) of 73 and 18 (3.7%) of 484 samples respectively. Strains of E. coli O157 were isolated most frequently during early summer. Strains of E. coli O157 were also isolated from 2 of 5 samples of dried mint although we did not determine how the mint had become contaminated. All isolates of E. coli O157 were Verocytotoxin-producing as determined by both Vero cell assay and DNA hybridization for the genes encoding Verocytotoxin and all were positive for the eaeA gene. A combination of phage typing, toxin genotyping and plasmid profile subdivided the 72 strains of E. coli isolated into 20 different subtypes, of which 18 were indistinguishable from strains isolated previously from cattle and sheep; of these 18 strains, 8 were indistinguishable from strains isolated from human cases of infection during the study period.     

Cost-utility analyses of clinical preventive services: published ratios, 1976-1997

BACKGROUND: Cost-effectiveness analyses of clinical preventive services are a potential means to aid public health resource allocation. Cost-utility analysis (CUA) is a specific form of cost-effectiveness analysis where results are expressed in terms of cost per quality-adjusted life year (QALY) gained. To increase the transparency and comparability of CUAs, standardization of methods has been recommended. OBJECTIVES: The purposes of this study were as follows: (1) identify published articles with original CUAs of primary and secondary clinical preventive services, (2) summarize the ratios found in these analyses, (3) identify articles employing comparable methods, and (4) explore analytic methods employed over time. METHODS: As part of a larger study we conducted a comprehensive search of published CUAs in the area of clinical preventive services and systematically collected data on the results of the analyses and analytic methods employed. Cost-effectiveness ratios were standardized and organized into a table.Results: We found 50 CUAs pertaining to clinical preventive services (primary, n=22, 44%; and secondary, n=28, 56%) and 174 cost-effectiveness ratios. These ratios ranged from cost-savings up to $27,000,000/QALY, with a median of $14,000/QALY. Only three (6%) of the CUAs met minimum reference case requirements. There was no apparent improvement of methods over time. CONCLUSIONS: Immunizations and chemoprophylaxis have the most favorable cost-effectiveness ratios, and preventive services are more cost-effective when targeted at high-risk populations. However, there is wide variation in the methods used in these analyses. This study allows us to define where improvements in methodologic rigor need to occur, provides a base-line for future audits, and highlights disease areas in clinical preventive services that have been omitted or underevaluated.     

Athletes’ and Coaches’ Perceptions of Nutritional Advice: Eating More Food for Health and Performance

Background: Low energy availability results in physiological adaptations which contribute to unfavourable health outcomes. Little information exists on perceptions of nutritional advice to eat more food to maintain health and enhance performance. The aim of this study was to explore athletes’ and coaches’ perceptions towards advice to athletes to eat larger than their current quantities of food and to explore how nutritionists could deliver this advice. Methods: Semi-structured interviews (~20 min in length) were conducted using online communication technology, audio-recorded, and transcribed verbatim. The interview explored perceptions of the nutritional advice provided, its role in health and performance, and the challenges to eating larger amounts of food. Data were analysed using NVIVO 1.2 using an inductive thematic approach. Results: Nine elite athletes (female = 6; males = 3) and nine high-performance coaches (female = 3; male = 6) completed the semi-structured interviews. Athletes reported improved training consistency, fewer injuries and illnesses, and improved resilience when consuming adequate energy and nutrients to meet their needs. Lack of time and meal preparation difficulties were the main challenges faced to fuelling. Conclusions: Although education about under-fuelling is important, motivating, enabling, and supporting athletes to change behaviour is pivotal to increasing athlete self-awareness and to make long-term nutritional changes.     

A Prospective Study of Marine Phytoplankton and Reported Illness Among Recreational Beachgoers in Puerto Rico, 2009

Background:

Blooms of marine phytoplankton may adversely affect human health. The potential public health impact of low-level exposures is not well established, and few prospective cohort studies of recreational exposures to marine phytoplankton have been conducted.

Objective:

We evaluated the association between phytoplankton cell counts and subsequent illness among recreational beachgoers.

Methods:

We recruited beachgoers at Boquerón Beach, Puerto Rico, during the summer of 2009. We conducted interviews at three time points to assess baseline health, water activities, and subsequent illness. Daily water samples were quantitatively assayed for phytoplankton cell count. Logistic regression models, adjusted for age and sex, were used to assess the association between exposure to three categories of phytoplankton concentration and subsequent illness.

Results:

During 26 study days, 15,726 individuals successfully completed all three interviews. Daily total phytoplankton cell counts ranged from 346 to 2,012 cells/mL (median, 712 cells/mL). The category with the highest (≥ 75th percentile) total phytoplankton cell count was associated with eye irritation [adjusted odds ratio (OR) = 1.30; 95% confidence interval (CI): 1.01, 1.66], rash (OR = 1.27; 95% CI: 1.02, 1.57), and earache (OR = 1.25; 95% CI: 0.88, 1.77). In phytoplankton group-specific analyses, the category with the highest Cyanobacteria counts was associated with respiratory illness (OR = 1.37; 95% CI: 1.12, 1.67), rash (OR = 1.32; 95% CI: 1.05, 1.66), eye irritation (OR = 1.25; 95% CI: 0.97, 1.62), and earache (OR = 1.35; 95% CI: 0.95, 1.93).

Conclusions:

We found associations between recreational exposure to marine phytoplankton and reports of eye irritation, respiratory illness, and rash. We also found that associations varied by phytoplankton group, with Cyanobacteria having the strongest and most consistent associations.

Citation:

Lin CJ, Wade TJ, Sams EA, Dufour AP, Chapman AD, Hilborn ED. 2016. A prospective study of marine phytoplankton and reported illness among recreational beachgoers in Puerto Rico, 2009. Environ Health Perspect 124:477–483; http://dx.doi.org/10.1289/ehp.1409558