Negotiating palliative care expertise in the medical world

This paper explores the relationship between palliative medicine and the wider medical world. It draws on data from a focus group study in which doctors from a range of specialties talked about developing palliative care for patients with heart failure. In outlining views of the organisation of care, participants engaged in a process of negotiation about the roles and expertise of their own, and other, specialties. Our analysis considers the expertise of palliative medicine with reference to its technical and indeterminate components. It shows how these are used to promote and challenge boundaries between medical specialties and with nursing. The boundaries constructed on palliative medicine's technical contribution to care are regarded as particularly coherent within orthodox medicine. In contrast, its indeterminate expertise, represented by the 'holistic' and 'psychosocial' agendas, is potentially compromising in a medical world that prizes science and rationality. We show how the coherence of both kinds of expertise is contested by moves to extend palliative care beyond its traditional temporal (end-of-life) and pathological (cancer) fields of practice.     

Occupational injury and illness among migrant and seasonal farmworkers in New York State and Pennsylvania, 1997-1999: pilot study of a new surveillance method

BACKGROUND: Traditional worksite injury surveillance methods are often ineffective for Northeastern farms employing seasonal harvest labor. Many are small farms, exempt from mandatory injury reporting. The high proportion of foreign workers and the temporary nature of the work further discourages reporting. Therefore, an alternative migrant health center-based occupational injury and illness surveillance system was piloted during 1997-1999. METHODS: Anonymous medical chart data from nine migrant health centers and four regional hospital emergency rooms was collected during 1997-1999. RESULTS: There were 516 injury/illness cases over two seasons. Joint/muscle straining (31%), falling (18%), poison ivy contact (10%), and object strikes (8%) were most common injurious events. The participation rate of health care was 75%; 130 cases were reported by hospital emergency rooms; and optimal health center participation was associated with: being a farmworker-dedicated program, and including the chart reviewer in the health center's decision to participate. CONCLUSIONS: Further development of a medical records-based surveillance system should include hospital emergency rooms and focus on identified health center performance factors.     

Normative models of health technology assessment and the social production of evidence about telehealth care

Telehealthcare is a rapidly growing field of clinical activity and technical development. These new technologies have caught the attention of clinicians and policy makers because they seem to offer more rapid access to specialist care, and the potential to solve structural problems around inequalities of service provision and distribution. However, as a field of clinical practice, telehealthcare has consistently been criticised because of the poor quality of the clinical and technical evidence that its proponents have marshalled. The problem of "evidence" is not a local one. In this paper, we undertake two tasks: first, we critically contrast the normative expectations of the wider field of Health Technology Assessment (HTA) with those configured within debates about Telehealthcare Evaluation; and second, we critically review models that provide structures within which the production of evidence about telehealthcare can take place. Our analysis focuses on the political projects configured within a literature aimed at stabilising evaluative knowledge production about telehealthcare in the face of substantial political and methodological problems.     

Promoting better use of the PSA test in general practice: randomized controlled trial of educational strategies based on outreach visits and mailout

BACKGROUND: Prostate-specific antigen (PSA) testing for prostate cancer is controversial. Demand for PSA testing is likely to rise in the UK, Australia and other western countries. Primary care needs to develop appropriate strategies to respond to this demand. OBJECTIVES: Our aim was to compare the effectiveness of educational outreach visits (EOVs) and mailout strategies targeting PSA testing in Australian primary care. METHODS: A randomized controlled trial was conducted in general practices in southern Adelaide. The main outcome measures at baseline, 6 months and 12 months post-intervention were PSA testing rates and GP knowledge in key areas relating to prostate cancer and PSA testing. RESULTS: The interventions were able to demonstrate a change in clinical practice. In the 6 months post-intervention, median PSA testing rate in the EOV group was significantly lower than in the postal group, which in turn was significantly lower than the control group (P < 0.001). Statistically significant differences were not, however, maintained in the 6-12 month post-intervention period. The EOV group, at 6 months follow-up, had a significantly greater proportion of "correct" responses than the control group to questions about prostate cancer treatment effectiveness (P = 0.004) and endorsement of PSA screening by professional bodies (P = 0.041). CONCLUSIONS: Primary care has a central role in PSA testing for prostate cancer. Clinical practice in this area is receptive to evidence-based interventions.     

Transforming general practice: the redistribution of medical work in primary care

The paper focuses on the redistribution of medical work within primary health care teams. It reports the results of the analysis of interviews with general practitioners, practice nurses and managers, undertaken as part of an ethnographic study of primary care organisation and practice during a period of rapid organisational change. By examining the ways in which the respondents account for how work is being redefined and redistributed, we explore how current government policy and professional discourses combine to reconfigure both the identities of those who work in primary care and the nature of patienthood. In particular, we show how general practitioners are being reconfigured as medical specialists or consultants in ways that seem to depart radically from earlier claims that general practice is a distinctive field of social or biographical medicine. Within this new discourse medical work is distributed between doctors, nurses and unqualified staff in ways which make explicit the reduction of general practice work to sets of biomedical problems or tasks. At the same time, the devolution of much general practice work to less qualified and cheaper personnel is justified by drawing on a discourse of person-centred medicine.     

Contextual influences on reproductive wellness in northern India

OBJECTIVES: There has been a growing recognition of the importance of contextual influences on health outcomes. This article examines community-level influences on 5 reproductive wellness outcomes in Uttar Pradesh, India. METHODS: Multilevel modeling is used to estimate household and community-level effects on wellness, with hierarchically organized data from a statewide survey of villages, urban blocks, households, women, health providers, and staff. RESULTS: The household and community have a strong contextual influence on wellness, although the models explain more of the variation in outcomes between households than between communities. CONCLUSIONS: Communities influence wellness outcomes through the socioeconomic environment and the characteristics of the health infrastructure. The specific dimensions of the community and health infrastructure varied between the outcomes.     

Height, leg length, and cancer: the Caerphilly Study

The incidence of several cancers increases with height. Some studies report that leg length, a marker of prepubertal growth, is the component of height underlying these associations, but few prospective studies have investigated this issue. We examined height-cancer associations in a 21-yr follow-up of a cohort based on 2,512 men aged 45-59 living in the town of Caerphilly, South Wales, U.K., between 1979 and 1983. The men underwent a detailed examination, and 2,393 (95.3%) had measures of height and sitting height (from which leg length and trunk length were derived) recorded and were cancer-free at baseline. Cox proportional hazards models were used to investigate associations of height, leg length, and trunk length with overall and site-specific cancer incidence; 328 men developed cancer over the follow-up period. Associations with height were weak and did not reach conventional levels of statistical significance. In models controlling for age, socioeconomic position, smoking, and body mass index, cancer incidence was weakly positively associated with increases in height; hazard ratio (HR, 95% confidence interval) per standard deviation (6 cm) increase in height was 1.09 (0.97, 1.21; P = 0.14). Associations were somewhat stronger in relation to leg length (HR 1.09; (0.97-1.22) than trunk length (HR 1.05; 0.94-1.18). Height-cancer associations were strongest for lung cancer (HR 1.21; 0.96-1.51). This analysis provides limited support for the suggestion that leg length is the component of height underlying height-cancer associations     

A comparative study of three warming interventions to determine the most effective in maintaining perioperative normothermia

Perioperative hypothermia poses a challenge because of its deleterious effects on patient recovery. The current practice of applying two cotton blankets on patients during surgery is thought to be less ideal than using reflective insulation or forced-air warming. We studied 300 patients who underwent unilateral total knee replacement and were randomized equally to three groups: (a) the two-cotton-blanket group, (b) the one-reflective-blanket with one-cotton-blanket group, and (c) the forced-air-warming with one-cotton-blanket group. Tympanic temperature readings were taken before surgery in the induction room, on arrival at the recovery room, and at 10-min intervals until discharge from the recovery room. On arrival at the recovery room, the forced-air-warming group had significantly higher temperatures (adjusted for sex, age, and patient's induction room temperature) of 0.577 degrees C +/- 0.079 degrees C (95% confidence interval [CI], 0.427-0.726; P < 0.001) and 0.510 degrees C +/- 0.08 degrees C (95% CI, 0.349-0.672; P < 0.001) more than the reflective-blanket and two-cot-ton-blanket groups, respectively. The forced-air-warming group took a significantly (P < 0.001) shorter time of 18.75 min (95% CI, 13.88-23.62) to achieve a temperature of 36.5 degrees C in the recovery room as compared with 41.78 min (95% CI, 36.86-46.58) and 36.43 min (95% CI, 31.23-41.62) for the reflective-blanket and two-cotton-blanket groups, respectively. The reflective technology was less effective than using two cotton blankets, and the forced-air warming was most efficient in maintaining perioperative normothermia. IMPLICATIONS: Perioperative hypothermia has deleterious effects on patient recovery. We found in patients having knee surgery that reflective technology was less effective than using two cotton blankets, whereas active surface warming with the forced-air method was most effective in maintaining normothermia.     

Management of obliterated urinary segments using a laser fiber for access

PURPOSE: We describe a modification of the cut to the light and core-through procedures using a laser fiber to gain through and through access for treatment of complete occlusion of the ureter or urethra. MATERIALS AND METHODS: Three patients presented with complete obliteration of the ureter (2) and vesicourethral anastomosis (1). In each case the laser fiber was advanced through the obliterated segment under direct vision and then exchanged for a standard guide wire using an open ended catheter. RESULTS: Through and through access was obtained in all 3 cases and allowed subsequent incision for repair. In all 3 patients the area of incision was stented and urinary continuity was restored. CONCLUSIONS: Loss of access can lead to complications and termination of any endoscopic procedure. Use of the laser fiber to incise through the obliterated segment and subsequently act as a guide wire in our experience minimized the possibility for loss of access. The disadvantage is the cost of the laser fiber, which cannot be reused. Use of a laser fiber as a guide wire can be a viable and effective option for gaining access across strictures when alternative methods fail.     

Anxiety in children with epilepsy

Although the prevalence is unknown, affective disorders are more common in children with epilepsy than in healthy controls. The purpose of the present study was to examine the occurrence of anxiety in children and adolescents with epilepsy and to determine factors associated with elevation of these symptoms. Children and adolescents (n=101) between the ages of 6 and 16 years were given the Revised Children's Manifest Anxiety Scale (RCMAS). Mild to moderate symptoms of anxiety were reported by 23% of the patients. Based on regression analysis, factors significantly associated with increased anxiety included the presence of comorbid learning or behavioral difficulties, ethnicity, and polytherapy. Results suggest the need to monitor children and adolescents with epilepsy for affective symptoms in order to provide appropriate interventions.