Local Tobacco Control: Application of the Essential Public Health Services Model in a County Health Department’s Efforts to Put It Out Rockland

In 2000, Rockland County, a small suburban county north of New York City, dedicated $1 million of its Master Settlement Agreement funds to a comprehensive tobacco control program, Put It Out Rockland. Developed and implemented by the county health department, this program used an essential public health services model and an ongoing financial investment, within the context of strong statewide tobacco control efforts, to lower adult smoking rates to 9.7% and to reduce both smoking among youths and exposure to secondhand smoke over the ensuing decade. By combining state funds and local dollars for a total of $6.75 cost per capita, this comprehensive effort yielded 11 000 fewer smokers and translated to a potential savings of more than $24 million for the county.     

Prevalence of pre-diabetes and associated risk factors in an adult Omani population

The Sultanate of Oman has experienced an epidemiological transition over the last 4 decades with rising tide of non-communicable disease such as type-2 diabetes. This study aims to estimate the prevalence of pre-diabetes and explore the associated demographic, clinical and biochemical risk factors among a semi-urban Omani population. A semi-urban satellite town, Bidbid, located about 30 km west of the capital, Muscat, was selected as the study setting. The targeted participants were Omani adults (18 to 60 years old) who had resided in Bidbid municipality for at least 6 months prior to enrollment in the study. Using multistage random sampling, 1,600 Bidbid residents were invited to participate in the study. The study protocol gathered data on the socio-demographic and clinical backgrounds of the participants. Participants’ impaired glucose tolerance (IGT) impaired fasting glucose (IFG) and cholesterol and triglyceride levels were then measured. The study surveyed 1,313 individuals (490 men and 823 women) out of 1,600 who had been invited to participate. The participation rate was higher among women than men (91.5% compared to 54.3%). A total of 459 individuals (35% of participants) were diagnosed as pre-diabetic by either the IGT or IFG test; 121 (9%) were pre-diabetic by virtue of both measurements. Male gender, advanced age and obesity were each independently associated with higher prevalence of pre-diabetes. Increased prevalence of pre-diabetes also correlated with the indices of hypercholesterolemia and dyslipidaemia. Pre-diabetes is a substantial health problem in Oman that may present a significant challenge to the national healthcare system in the near future. Customized interventions targeting groups with high risk of pre-diabetes, especially men, the elderly and the obese, are urgently needed.     

Stress of AIDS caregiving: A preliminary overview of the issues

Abstract

This paper describes the stressors experienced by lovers and friends who were caregivers to AIDS patients and the social supports and coping strategies they drew on in efforts to mediate stress. From exploratory, intensive interviews with San Francisco men who provided care in their homes or those of the patients, three types of stressor were identified. One involves exigencies within the caregiver role itself, such as the demands and burdens encountered in housekeeping and nursing activities and in the management of financial and legal affairs. A second type of stressor involves the uncertainties caregivers experience concerning their own future, uncertainties that arise from the fact that homosexual caregivers are often exposed to the same set of health risk factors as the patients. Third, being a caregiver can create stressful problems in other roles. Thus, the demands of caregivmg can disrupt multiple areas of life-occupational, economic, and social. Once disrupted, these become independent sources of stress.

Formal and informal support systems appear to be important resources in sustaining caregivers and allowing them to continue in this role. In addition to support systems, a variety of coping strategies that may also help caregivers to sustain themselves have been identified. These strategies fall into three classes: those that function to minimize the physical and management demands of caregiving; cognitive and perceptual devices that reduce the level of threat the situation holds for the caregiver; and behaviors and practices that keep tensions and anxieties within manageable bounds.     

Percutaneous endovascular occlusion of symptomatic coronary arteriovenous fistulas with cyanoacrylate

We describe four cases with symptomatic coronary artery fistulas that were treated primarily with endovascular cyanoacrylate embolization. Coils were also used as adjunctive embolic agents in two of these cases. All four cases showed symptomatic improvement after closure of the fistulas. Complications occurred in three cases including transient ST-segment elevation in one, symptomatic pulmonary embolization in a second, and transient pleuritic chest pain, pericarditis and acute renal failure in a third. The technical aspects of all four cases are given together with a review of the use of cyanoacrylate as an embolic material. We conclude that cyanoacrylate embolization could be considered as an alternative technique for the endovascular closure of coronary artery fistulas but must also caution that the use of this embolic agent is hazardous and should be restricted to practitioners experienced in its usage.     

Large iliac arteries: a high-risk group for endovascular aortic aneurysm repair.

PURPOSE: To examine if the presence of large iliac arteries is a potential risk factor for the development of a type Ib endoleak (iliac sealing zone) or need for iliac artery-related secondary intervention in patients undergoing endovascular abdominal aortic aneurysm repair. METHODS: The medical notes and all preoperative and postoperative plain abdominal radiographs and computer tomographic scans were reviewed for a consecutive series of 100 patients (89 men; mean age 75 years, range 56-91) with large iliac arteries (mean 19.7 mm, range 16-22) who had Zenith endovascular stent-grafts inserted for management of aortoiliac aneurysmal disease from January 1999 until September 2002. Endpoints were all-cause mortality, aneurysm-related death, endoleak, secondary intervention, secondary interventions, and stent-graft migration. RESULTS: Mean follow-up was 30.1+/-8.3 months; at the last follow-up, 30% of patients were dead, 3% were aneurysm-related. Seven (7%) patients developed a type Ib endoleak, with the remainder being type II (29%), type Ia (2%), type III (1%), and type V (endotension, 1%). Eight (27.5%) type II endoleaks persisted, with the remainder closing spontaneously with sac shrinkage. The iliac artery-related secondary intervention rate was 10%, and the overall secondary intervention rate was 16%. CONCLUSION: Iliac arteries between 16 and 22 mm in diameter may be treated with a cuff to the iliac limb with an expectation of 90% efficacy. Surveillance is required, with a high index of suspicion for type 1b endoleaks. Early secondary iliac intervention with extension to the external iliac artery is recommended if there is an increase in sac size after 6 months.     

Hemorrhagic complications in patients treated with anticoagulant doses of a low molecular weight heparin (enoxaparin) in routine hospital practice.

Low molecular weight heparins (LMWHs) are a rapidly growing class of anticoagulant drug. Their efficacy has been demonstrated in several clinical settings where they are rapidly becoming the anticoagulant of choice. Controlled clinical studies in patients with deep vein thrombosis, pulmonary embolism, and unstable angina have documented that the frequency of major hemorrhage is 0.5-4%. The purpose of the study was to determine the frequency of minor and major hemorrhage occurring in patients receiving anticoagulant doses of an LMWH (enoxaparin) during routine clinical practice. A prospective, observational study of consecutive patients receiving enoxaparin 1 mg/kg twice daily for at least 24 hours in five internal medicine wards of a university teaching hospital was performed. Five hundred forty-nine patients were studied. The mean age was 67.5+/-15.5 years and the mean duration of enoxaparin therapy was 3.8+/-1.5 days. Hemorrhage was documented in a total of 94 patients (17.3%). Major hemorrhage occurred in 14 patients (2.6%), injection-site hemorrhage occurred in 55 patients (10%), and minor hemorrhage (noninjection site) was documented in 25 patients (4.7%). There were two deaths attributed to hemorrhage. Patients with major hemorrhage were older than patients with minor or no hemorrhage (75.5+/-10.4 versus 66.8+/-15.2 years; p=0.03) and occurred in patients receiving enoxaparin for a longer period (5.14+/-3.8 days) than those with minor (4+/-2.5 days) or no hemorrhage (2.9+/-2.1 days). Major hemorrhage was significantly associated with impaired renal function, chronic liver disease, and concomitant treatment with warfarin or a proton pump inhibitor. Enoxaparin used in anticoagulant doses in unselected medical patients is not associated with more major hemorrhagic complications than observed in controlled clinical trials. Major hemorrhage may be more likely in older patients, in patients with chronic liver disease and impaired renal function, in patients receiving prolonged enoxaparin therapy, and in patients receiving warfarin or proton pump inhibitors.     

A common founder mutation in FANCA underlies the world's highest prevalence of Fanconi anemia in Gypsy families from Spain

Fanconi anemia (FA) is a genetic disease characterized by bone marrow failure and cancer predisposition. Here we have identified Spanish Gypsies as the ethnic group with the world's highest prevalence of FA (carrier frequency of 1/64-1/70). DNA sequencing of the FANCA gene in 8 unrelated Spanish Gypsy FA families after retroviral subtyping revealed a homozygous FANCA mutation (295C>T) leading to FANCA truncation and FA pathway disruption. This mutation appeared specific for Spanish Gypsies as it is not found in other Gypsy patients with FA from Hungary, Germany, Slovakia, and Ireland. Haplotype analysis showed that Spanish Gypsy patients all share the same haplotype. Our data thus suggest that the high incidence of FA among Spanish Gypsies is due to an ancestral founder mutation in FANCA that originated in Spain less than 600 years ago. The high carrier frequency makes the Spanish Gypsies a population model to study FA heterozygote mutations in cancer.