Becoming a competent clinician: basic competencies in intervention

This article summarizes the results from the Intervention Work Group of the Competencies Conference: Future Directions in Education and Credentialing in Professional Psychology. The generic charge presented to the Intervention Work Group was "to address issues related to interventions." The Intervention Work Group identified four competency components of knowledge, skills, and abilities: (a). foundational competencies; (b). intervention planning; (c). intervention implementation; and (d). intervention evaluation competencies. A fifth component that included "practice management" was labeled as "others." Each component is discussed, including competencies that were deemed an essential knowledge, skill, and/or value. A discussion of training for intervention competence and assessing that intervention competence is included. Future directions for the science and practice of psychology in the intervention arena are summarized. This is one of a series of articles published in this issue of the Journal of Clinical Psychology. Several other articles that resulted from the Competencies Conference will appear in Professional Psychology: Research and Practice and The Counseling Psychologist.     

Childhood smoking is an independent risk factor for obstructive airways disease in women

OBJECTIVE: To assess whether starting to smoke in childhood increases the risk of obstructive airways disease (OAD) in adult life. METHODS: A retrospective cohort analysis was undertaken of 12 504 current and ex-smokers in the EPIC-Norfolk cohort. The main exposure was starting to smoke during childhood (age <16 years). Three definitions of OAD were used: doctor diagnosed asthma, doctor diagnosed bronchitis/emphysema, and "any OAD" (doctor diagnosed asthma or bronchitis/emphysema, or taking medication used in the treatment of OAD). RESULTS: Childhood smokers had significantly more pack years of exposure and poorer lung function than subjects who started to smoke in adulthood (>/=16 years). Compared with starting in adulthood, starting to smoke in childhood was associated with a greater risk of bronchitis/emphysema in female smokers (OR 1.79, 95% CI 1.25 to 2.56) and ex-smokers of both sexes (OR 1.29, 95% CI 1.07 to 1.55 in men and OR 1.40, 95% CI 1.05 to 1.85 in women), and of "any OAD" in female smokers (OR 1.72, 95% CI 1.24 to 2.38) and male and female ex-smokers (OR 1.20, 95% CI 1.03 to 1.40 in men and 1.34, 95% CI 1.07 to 1.57 in women). After adjustment for pack years, childhood smoking was associated with poorer lung function (FEV(1) 92.3% predicted in adult smokers and 89.5% in childhood smokers, p = 0.03) and a greater risk of bronchitis/emphysema (adjusted OR 1.55, 95% CI 1.08 to 2.24) and for "any OAD" (OR 1.54, 95% CI 1.10 to 2.13) in female smokers but not in male and female ex-smokers. CONCLUSION: Starting to smoke in childhood is associated with an increased risk of airways disease because of the extra pack years smoked. In women, childhood smoking is itself an independent risk factor for the development of airways disease.     

Blood pressure and urinary sodium in men and women: the Norfolk Cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk)

BACKGROUND: Abundant evidence indicates that a high sodium intake is causally related to high blood pressure, but debate over recommendations to reduce dietary sodium in the general population continues. A key issue is whether differences in usual sodium intake within the range feasible in free-living populations have clinical or public health relevance. OBJECTIVE: We examined the relation between blood pressure and urinary sodium as a marker of dietary intake. DESIGN: This was a study of 23104 community-living adults aged 45-79 y. RESULTS: Mean systolic and diastolic blood pressure increased as the ratio of urinary sodium to creatinine increased (as estimated from a casual urine sample), with differences of 7.2 mm Hg for systolic blood pressure and 3.0 mm Hg for diastolic blood pressure (P < 0.0001) between the top and bottom quintiles. This trend was independent of age, body mass index, urinary potassium:creatinine, and smoking and was consistent by sex and history of hypertension. The prevalence of those with systolic blood pressure >/= 160 mm Hg halved from 12% in the top quintile to 6% in the bottom quintile; the odds ratio for having systolic blood pressure >/= 160 mm Hg was 2.48 (95% CI: 1.90, 3.22) for men and 2.67 (95% CI: 2.08, 3.43) for women in the top compared with the bottom quintile of urinary sodium. Estimated mean sodium intakes in the lowest and highest quintiles were approximately 80 and 220 mmol/d, respectively. CONCLUSIONS: Within the usual range found in a free-living population, differences in urinary sodium, an indicator of dietary sodium intake, are associated with blood pressure differences of clinical and public health relevance. Our findings reinforce recommendations to lower average sodium intakes in the general population.     

The urological care and outcome of pregnancy after urinary tract reconstruction

OBJECTIVE: To assess the obstetric and urological outcomes during and after pregnancy following urinary tract reconstruction, as pregnancies after such surgery can have a significant effect on the function of the reconstructed urinary tract, and the reconstruction can significantly affect the delivery of the fetus. PATIENTS AND METHODS: We retrospectively reviewed the obstetric and urological history of 11 patients (12 pregnancies; 10 singletons and one twin) with previous urinary reconstruction, delivered between 1989 and 2003. Antepartum and postpartum urological function and obstetric outcomes were investigated. RESULTS: All the patients had some difficulty with clean intermittent catheterization (CIC) during pregnancy, and four needed continuous indwelling catheters. During pregnancy 10 women had several bladder infections and all received antibiotic suppression. There were eight Caesarean sections, two vaginal deliveries and one combined delivery. Six Caesareans were elective and three were emergent. The use of CIC returned to normal in all patients after delivery. CONCLUSIONS: Women with a urinary reconstruction can have successful pregnancies. The complexity of the surgery and the concern for possible emergency Caesarean section resulted in most patients having an elective Caesarean delivery before term. Antibiotic prophylaxis is recommended and patients may require indwelling dwelling catheters while pregnant but normal CIC can be resumed after delivery.     

Microalbuminuria independently predicts all-cause and cardiovascular mortality in a British population: The European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) population study

BACKGROUND: In patients with diabetes or hypertension, raised albuminuria is independently associated with an increased risk of all mortality, cardiovascular morbidity and mortality, and renal insufficiency. The role of albuminuria in the general population is still controversial. We therefore undertook this study to examine the relationship between albuminuria and all-cause, cardiovascular disease (CVD) and non-CVD mortality in the general population. METHODS: Prospective population-based cohort study of 20 911 individuals aged 40-79 years recruited in 1993-1997 for the EPIC-Norfolk Study (UK) and followed-up for an average of 6.3 years. Random spot urine specimens were collected at baseline and the albumin-to-creatinine ratio measured. Participants were categorized into normoalbuminuria, microalbuminuria, and macroalbuminuria ordered groups. At follow-up, vital status and cause of death were obtained from the UK Office for National Statistics. RESULTS: During follow-up, 934 deaths were registered. Age-adjusted all-cause mortality rate increased significantly across categories of baseline albuminuria (5.3, 5.2, and 6.3/1000 person years (pyrs) across tertiles of normoalbuminuria, 8.7/1000 pyrs for microalbuminuria, and 18.4/1000 pyrs for macroalbuminuria, P < 0.001 for trend); CVD, 1.6, 1.7, 2.1, 4.3, 12.6/1000 pyrs (P < 0.001); and non-CVD, 3.7, 3.5, 4.2, 4.4, 5.8/1000 pyrs (P = 0.052) respectively. The multivariate hazard ratio for all-cause mortality associated with microalbuminuria was 1.48 (95% CI: 1.20, 1.79), and CVD 2.03 (95% CI: 1.55, 2.67). The association with non-CVD mortality was only significant in men. CONCLUSIONS: The significant increased risk of all-cause mortality especially from CVD associated with microalbuminuria, suggest that this may be a useful indicator in identifying those in the population at greatest absolute risk of fatal CVD events alongside conventional CVD risk factors.     

Change in cardiovascular risk factors in France, 1985–1997

The change in the main cardiovascular risk factors in France was assessed using the MONICA population surveys conducted in the Urban Community of Lille, Bas-Rhin and Haute-Garonne. Trends in obesity, tobacco smoking, hypertension, hypercholesterolaemia and self-reported diabetes were established for the first (1985-1988) and the last (1995-1997) survey. The results indicate that the prevalence of overweight and obesity remained stable in both genders; tobacco smoking decreased in men but increased in women. Prevalence of hypertension decreased, and preventive measures improved in both genders. Prevalence of hypercholesterolaemia remained stable, and preventive measures improved only in men. Prevalence of self-reported diabetes increased solely in women, and preventive measures improved in both genders. However, in 1995-1997 still 40% of the treated hypertensive and 30% of the treated hypercholesterolaemic subjects were not adequately controlled. We conclude that prevalence and prevention of the main cardiovascular risk factors have evolved favourably in France, but the management of hypercholesterolaemia and hypertension can still be improved.     

A pilot study of milk odor effect on nonnutritive sucking by premature newborns

OBJECTIVE: To study the effect of milk odor on nonnutritive sucking by premature newborns. DESIGN: Blinded, crossover study of the effects of milk vs sham odor on nonnutritive sucking. SETTING: Urban neonatal intensive care unit. PATIENTS: Twenty-nine premature newborns with gestational age of 29 to 36 weeks. INTERVENTION: Fourteen subjects were tested with fortified breast milk odor (group 1) and 15 were tested with formula odor (group 2). For the test observation, milk odor was directed to the nose (orthonasal exposure) using a specially modified pacifier. For the control observation, water was used as a sham odor. Observations were made concurrently with tube feeding of the newborn with either fortified breast milk (group 1) or formula (group 2). MAIN OUTCOME MEASURES: Total number of sucks and sucking bursts, measured from a digital record of pressure changes within the pacifier. RESULTS: Nutrient odor increased suck bursts in group 1 subjects, with borderline statistical significance (46.6 bursts/10 min with odor [95% confidence interval (CI), 39-54] vs 35.4 bursts/10 min without odor [95% CI, 28-43]). Unexpectedly, when test and control observations were combined, subjects in group 1 showed an overall increase in number of sucks (260.4 [95% CI, 206-315]) and suck bursts (41.0 [95% CI, 36-46]) compared with group 2 subjects (144.8 [95% CI, 87-203] vs 27.4 [95% CI, 21-34]). CONCLUSIONS: Nutrient odor exposure via pacifier may stimulate nonnutritive sucking during gavage feeding of premature newborns. Further studies on the effects of nutrient odor on nonnutritive sucking by premature newborns must take into account the effects of nutrients given via gavage.     

The literature of neonatal nursing: stories from the turning points column

The stories of neonatal care are a rich source of information, going beyond the typical clinical article to convey the meaning of nursing in this special environment. During its run, the Turning Points column in Neonatal Network gave nurses, doctors, and family members affected by the NICU an outlet to share their stories with others. The brief overview of the columns' contents provided in this article displays the wide variety of patient cases, workplace issues, and family situations encountered by neonatal nurses.