Role dilemmas among health-workers in cross-cultural patient encounters around dietary advice

AIM: The aim of this paper is to explore Norwegian health workers' experiences from cross-cultural patient encounters, and how they understand and enact their role when meeting patients with Pakistani background to whom they give dietary advice related to type 2 diabetes. METHODS: Qualitative in-depth interviews have been performed with six hospital dietitians and six general practitioners in Oslo. RESULTS: The health workers consider themselves to be patient-centred and stress the importance of the two dimensions, empathy and equality. However, they often experience that patients want them to be more authoritarian, a way of acting that would be totally in disagreement with their convictions, although some occasionally do adopt an authoritarian style. More striking is that some health workers' moral engagement to involve and empower patients actually leads them to be authoritarian. For others, a fear of insulting the patient results in their advice being too diffuse. CONCLUSIONS: A possible explanation for such ways of responding to the patient may be that the health workers, in their articulation of patient-centredness, draw on a repertoire of social conduct that involves an effort to level out, or tacitly deny, hierarchic structures, and that this becomes more pronounced in cross-cultural encounters. Patient-centredness and empowerment are results of long ongoing processes in Western countries, based on ideals of equality and individual freedom. The results from this study indicate that these approaches may pose intricate dilemmas for the health workers in their cross-cultural encounters, and need further attention.     

Children with early refusal to eat: follow-up in adolescence

Aim: To describe the adolescent outcome of infant refusal to eat (RTE) and to investigate early predictors of adolescent outcomes. Methods: 19 of 25 children with RTE and 35 of 42 controls were assessed at age 16. The participants rated eating attitudes and self-perceptions with a Swedish version of the Children's Eating Attitudes Test (ChEAT) and a Swedish self-perception measure. Weight and height were assessed through self-reports, and body mass index (BMI) was computed. Child and family variables measured from infancy through age 4 were used as predictors. Results: RTE and controls did not differ with regard to disturbed eating attitudes, BMI or self-perceptions. There were no relations between early predictors and adolescent disturbed eating for the whole sample, but breastfeeding problems and social adversity in the early years predicted negative self-perceptions, and weight at 4 y predicted adolescent BMI. For the RTE group, low birthweight predicted higher levels of disturbed eating attitudes and less positive self-perceptions. For the control group, social adversity predicted high BMI.

Conclusion: RTE does not seem to constitute a risk factor for adolescent disturbed eating. Further, there may be different risk factors for adolescent disturbed eating for children with and without RTE.     

Efficient growth inhibition of Bacillus anthracis by knocking out the ribonucleotide reductase tyrosyl radical

Bacillus anthracis, the causative agent of anthrax, is a worldwide problem because of the need for effective treatment of respiratory infections shortly after exposure. One potential key enzyme of B. anthracis to be targeted by antiproliferative drugs is ribonucleotide reductase. It provides deoxyribonucleotides for DNA synthesis needed for spore germination and growth of the pathogen. We have cloned, purified, and characterized the tyrosyl radical-carrying NrdF component of B. anthracis class Ib ribonucleotide reductase. Its EPR spectrum points to a hitherto unknown three-dimensional geometry of the radical side chain with a 60 degrees rotational angle of C(alpha)-(C(beta)-C(1))-plane of the aromatic ring. The unusual relaxation behavior of the radical signal and its apparent lack of line broadening at room temperature suggest a weak interaction with the nearby diiron site and the presence of a water molecule plausibly bridging the phenolic oxygen of the radical to a ligand of the diiron site. We show that B. anthracis cells are surprisingly resistant to the radical scavenger hydroxyurea in current use as an antiproliferative drug, even though its NrdF radical is efficiently scavenged in vitro. Importantly, the antioxidants hydroxylamine and N-methyl hydroxylamine scavenge the radical several orders of magnitude faster and prevent B. anthracis growth at several hundred-fold lower concentrations compared with hydroxyurea. Phylogenetically, the B. anthracis NrdF protein clusters together with NrdFs from the pathogens Bacillus cereus, Bacillus thuringiensis, Staphylococcus aureus, and Staphylococcus epidermidis. We suggest the potential use of N-hydroxylamines in combination therapies against infections by B. anthracis and closely related pathogens.     

Emergency contraceptive pills in Sweden: evaluation of an information campaign

OBJECTIVE: To evaluate a community-based intervention regarding emergency contraceptive pills, including a mass media campaign and information to women visiting family planning clinics. DESIGN: Quasi-experimental. SETTING: Two counties in Sweden. POPULATION: Eight hundred randomly selected women aged 16-30 years, 400 women in the intervention group and 400 in a comparison group. METHODS: Postal questionnaires before (2002) and after (2003) the intervention. MAIN OUTCOME MEASURES: Exposure to the intervention, knowledge, attitudes, practices and intention to use emergency contraceptive pills. RESULTS: Before the intervention, the response rate was 71% (n= 564); after the intervention, the corresponding figure was 83% (n= 467); overall response rate 58%. Two-thirds (64%) of the targeted women had noticed the information campaign. One out of six who had visited a family planning clinic during the intervention year recalled being given information about emergency contraceptive pills. Specific knowledge and attitudes improved over time in both groups, but there was no difference in change between the groups. The proportion of women who had used emergency contraceptive pills increased from 27% to 31% over time. Intention to use emergency contraceptive pills in case of need was reported by 74% of the women and remained stable over time, but logistic regression showed that information during the previous year contributed to willingness to use the method in the intervention group. CONCLUSIONS: Knowledge, attitudes and practices about emergency contraceptive pills increased in both groups. Emergency contraceptive pills is gradually becoming a more widely known, accepted and used contraceptive method in Sweden, a trend that may have limited the impact of the intervention.     

Endotracheal colonization at birth is associated with a pathogen-dependent pro- and antiinflammatory cytokine response in ventilated preterm infants: a prospective cohort study

The possible association between mediators of inflammation such as cytokines and perinatal colonization of the respiratory tract remains unclear. This prospective cohort study evaluated endotracheal colonization in 141 ventilated preterm infants at birth. The relation with cytokine response in the airways and C-reactive protein (CRP) in umbilical blood was investigated. Of the 141 preterm infants enrolled in this study, 37 (26%) were colonized. In addition to traditional pathogens (61%), commensal species (26%) and Mycoplasmataceae (13%) were isolated. Both the pro-inflammatory cytokines IL-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha as well as the antiinflammatory IL-10 are increased in colonized patients in a dose-dependent manner, with the strongest response in neonates colonized with Gram-negative organisms. There was no antimicrobial IL-12p70 response in colonized infants. Commensal flora is associated with the same inflammatory response as traditional pathogens. Although the umbilical cord blood CRP level was significantly higher in neonates with endotracheal colonization, it was highest in those colonized with Gram-negative organisms but still close to normal limits. Microorganisms in the endotracheal fluid of ventilated preterm infants are associated with a pathogen-specific and dose-dependent cytokine response in the airways and systemic CRP response.     

To what extent is the American Society for Reproductive Medicine addressing the needs of the membership?

The American Society for Reproductive Medicine (ASRM) conducted a survey of its domestic members to develop a strategic plan and policies for the Society. This survey was very valuable in assessing the needs of its members and demonstrated that the ASRM is addressing their needs.     

Variations in quality of frozen-thawed semen from Swedish Red and White AI sires at 1 and 4 years of age

The predictability of semen quality of mature sires from measurements at an early age is not well established. The aim of the present study was to determine age-dependent changes in the quality of bull semen for artificial insemination (AI). Semen was collected and frozen from each of six Swedish Red and White (SRB) dairy AI bulls when they were 1 and 4 years old. Three batches were randomly selected from each bull and age group. From each batch, semen was analysed immediately after thawing [post-thaw (PT), control] as well as after washing/resuspension (W) and after a swim-up procedure (SU). The analyses comprised subjective and computerized (computer-aided sperm analysis, CASA) measurements of motility as well as sperm concentration, morphology and membrane integrity. When semen was analysed, PT, overall sperm motility (CASA), concentration of motile spermatozoa and membrane integrity improved when sires were older. After SU, there was a similar improvement in membrane integrity and concentration of motile spermatozoa, but linear motility decreased. No significant differences between ages were recorded after W-treatment. The above findings indicate that SU is not only superior to W-treatment in differentiating semen quality among bulls but also reveals age-dependent changes. Improved motility and membrane integrity suggest increased viability of spermatozoa at 4 years of age in the SRB sires examined here.     

Operation for pelvic organ prolapse: a follow-up study

OBJECTIVE: Long-term results of surgery for pelvic organ prolapse in terms of objective and subjective cure rates, postoperative complications and side-effects were studied retrospectively. METHODS: Two hundred and sixty-nine women underwent surgery between 1986 and 1988 and were invited to a follow-up visit in 1998-99. One hundred and twenty-eight (47%) women attended the follow-up. In the time between surgery and follow-up, 67 (25%) women had died. The medical records were reviewed for women not attending follow-up (n = 131), revealing a higher age and a more severe prolapse in the lost to follow-up group. RESULTS: The subjective cure rate, with cure of all symptoms of pelvic organ prolapse, was 46% (n = 59). The objective cure rate, with satisfactory anatomic outcome, was 56% (n = 72). If perfect results had been attained in the women who did not undergo follow-up examination, the subjective and objective cure rates would be 73% and 79%, respectively. Previous prolapse surgery, a traumatic delivery, urinary incontinence and a prolapse stage III or more seemed to be risk factors for an adverse outcome. CONCLUSIONS: In evaluating the cure rate of pelvic floor surgery not only the anatomic outcome should be studied but also the outcome in terms of side-effects and/or symptoms as resolved, persistent or new onset. An unsatisfactory anatomic outcome was not necessarily associated with symptoms. The modest cure rate after surgery may be due to the aggravation with time of pelvic floor disorder, this confounding the results of surgery.     

Effects of acupuncture on skin and muscle blood flow in healthy subjects

In 14 healthy female subjects, the effects of needle stimulation (acupuncture) on skin and muscle blood flow were investigated using a non-invasive custom-designed probe and photoplethysmography (PPG). In randomised order, 2–7 days apart, three modes of needle stimulation were performed on the anterior aspect of the tibia: superficial insertion (SF), insertion into the anterior tibial muscle (Mu), and insertion into the muscle including manipulation of the needle in order to elicit a distinct sensation of distension, heaviness or numbness (DeQi). Before intervention, the subjects rested for 30 min. After the intervention, the needle was left in situ for 20 min. Blood flow recordings were performed intermittently from 10 min prior to the intervention to the end of the trial. In a fourth session, serving as control, corresponding measurements were performed without any needle stimulation. Area under curve was calculated for 5-min periods prior to and after stimulation, respectively, and for the remaining 15-min period after stimulation. Compared to the control situation, muscle blood flow increased following both Mu and DeQi for 20 min, with the latter being more pronounced for the initial 5 min. Skin blood flow increased for 5 min following DeQi. However, no increase was found following SF. The DeQi stimulation was preceded by higher visual analogue scale ratings of anxiety prior to stimulation, which might have influenced skin blood flow to some extent. The results indicate that the intensity of the needling is of importance, the DeQi stimulation resulting in the most pronounced increase in both skin and muscle blood flow.     

Risk Management: Konzepte und Chancen für das Gesundheitswesen

Zusammenfassung Hintergrund: Fehler sind in der Medizin allgegenwärtig und stellen ein komplexes, multifaktorielles Geschen dar. Sie bedeuten ein erhebliches Risiko für den Patienten und haben enorme wirtschaftliche Konsequenzen für die Leistungserbringer. Systembezogener Ansatz: Unerwünschte Ereignisse haben ihre Ursache in der Regel nicht in einem einzelnen vorausgehenden Fehler. Ein effizientes Risk-Management-Konzept, das Bestandteil eines umfassenden Qualitätsmanagements, muss daher einen systembezogenen Ansatz verfolgen, der sich auf die Entdeckung und Analyse von Beinahe-Fehlern stützt und auf die Entwicklung von Abwehrmechanismen für die unerwünschten Folgen von Fehlern zielt. Die Frage "Wer ist schuld?" muss in den Hintergrund treten. Beinahe-Fehler (Near Misses) gehorchen den gleichen theoretischen und praktischen Bedingungen wir Indikatoren und bieten hierbei gegenüber der Messung von Fehlern und unerwünschten Ereignissen erhebliche methodische Vorteile. Abstract Background: Errors are a common problem in medicine and occur as a result of a complex process involving many contributing factors. Medical errors significantly reduce the safety margin for the patient and contribute additional costs in health care delivery. System Approach: In most cases adverse events cannot be attributed to a single underlying cause. Therefore an effective risk management strategy must follow a system approach, which is based on counting and analysis of near misses. The development of defenses against the undesired effects of errors should be the main focus rather than asking the question "Who blundered?". Analysis of near misses (which in this context can be compared to indicators) offers several methodological advantages as compared to the analysis of errors and adverse events. Risk management is an integral element of quality management.