Factors that influence clinicians' assessment and management of family violence.

OBJECTIVES. High rates of family violence and low rates of detection, report, and therapeutic intervention by health professionals are well documented. This study was undertaken to determine what factors influence clinicians' decision making about identifying abuse and intervening with victims. METHODS. Survey data about clinicians' experiences with and attitudes toward family violence were gathered by mailed questionnaire from a random sample of practicing clinicians in six disciplines (n = 1521). RESULTS. Data showed similarities within and wide differences among three groups of subjects: dentists/dental hygienists, nurses/physicians, and psychologists/social workers. Overall, a third of subjects reported having received no educational content on child, spouse, or elder abuse in their professional training programs. Subjects with education on the topic more commonly suspected abuse in their patients than those without; among all subjects, spouse abuse was suspected more often than child abuse while elder abuse was suspected infrequently. Significant numbers of subjects did not view themselves as responsible for dealing with problems of family violence. Subjects indicated low confidence in and low compliance with mandatory reporting laws. CONCLUSIONS. There is a need for educators to expand curricula on family violence and for legislators to reexamine mandatory reporting laws.     

Nurses' Reasoning in the Assessment of Family Violence

This is a report of the reasoning related to family violence by health professionals but specifically by 247 surveyed and 9 interviewed nurses. Using survey and interviewing techniques, this study explored factors that influence clinicians' choice to intervene in family violence and compared the differences in reasoning of health professionals. Findings from both the survey and interviews are discussed. It is recommended that content about family violence be integrated in curricula and that different approaches to clinical reasoning emphasized.     

Polychlorinated biphenyl contamination of nursing mothers' milk in Michigan.

The problem of environmental contamination by toxic substances and human exposure to these substances has attracted increased attention in recent years. Particular concern has centered on polychlorinated biphenyls (PCBs), which have become widespread environmental pollutants as well as contaminants of the human population. This paper reports data from a study of PCB contamination of nursing mothers' breast milk in Michigan. During 1977 and 1978, breast milk samples of 1,057 nursing mothers residing in Michigan were tested for PCB residues. All of the 1,057 samples collected from 68 of the state's 83 counties contained PCB residues ranging from trace amounts to 5,100 parts per million (fat weight basis). The mean level was 1,496 parts per million (ppm), with 49.5 per cent of the samples having PCB levels of 1-2 ppm, 17.4 per cent had 2-3 ppm, and 6.14 per cent had more than 3 ppm. There was no consistent trend in the level of PCB contamination over the 24 months of monitoring. The mean PCB level for the eighth quarter of monitoring was slightly higher than for the first quarter. The public health significance of PCB contamination in human populations and its effects on breast-fed for eight months by a woman with the average PCB level in this sample would have an estimated body burden of approximately 0.89 ppm of PCBs. The implications of PCB contamination of human milk with regard to current breast-feeding practices are discussed and several precautionary measures are recommended.     

Immune modulatory effects of indomethacin in melanoma patients are not related to prostaglandin E2-mediated suppression

Indomethacin significantly enhances the depressed levels of lymphocyte proliferation to the mitogens phytohemagglutinin and concanavalin A in melanoma patients. We postulated that these results were related to an abnormality in prostaglandin E2 (PGE2)-mediated suppression, since this mechanism has previously has previously been demonstrated in patients with Hodgkin's lymphoma and with head and neck carcinoma. However, the results of three experimental approaches did not support this hypothesis. First, in vitro PGE2 production by cultured blood mononuclear cells was the same in 16 melanoma patients as in 45 normal controls (4.9 versus 4.7 ng/ml). Second, lymphocyte sensitivity to PGE2 for melanoma patients was essentially the same as that for normal controls, since exogenous doses of PGE2 inhibited the mitogen responses to the same degree. Third, another prostaglandin synthetase inhibitor (RO-205720), which is structurally unrelated to indomethacin, did not augment the mitogen response in these patients. Thus PGE2 cannot be implicated as a mediator of immunosuppression in melanoma patients. To further examine the immunomodulatory mechanism of indomethacin, we preincubated the drug with purified populations of either lymphocytes or monocytes, which were then recombined and tested for mitogen response. The results suggested that indomethacin had a direct effect on the responding T lymphocytes rather than an indirect effect on monocytes. These are the first studies demonstrating that indomethacin can act directly as a modulator of cellular immune function, independent of PGE2-mediated suppression.     

Role of interleukin 2 and a serum suppressive factor on the induction of activated killer cells cytotoxic for autologous human melanoma cells

Activated killer (AK) cells cytotoxic for freshly prepared autologous melanoma cells were generated in vitro when recombinant interleukin 2 (rIL2) was incubated with peripheral blood mononuclear cells from 11 of 12 patients with metastatic melanoma. The cytotoxic response first appeared significant after 3 days of culture with rIL2; it peaked after 6 days and then declined after 9 days of incubation. Peripheral blood mononuclear cells cultured with medium alone (control) or with recombinant gamma-interferon alone (200 units/ml) failed to acquire AK cytotoxicity at any time in any of the 12 patients. Autologous tumor cells also could not induce AK activity in mixed-lymphocyte tumor cell cultures. The level of AK activity generated was significantly reduced (P less than 0.001) when 10% autologous human serum was used instead of 10% fetal calf serum in the rIL2 cultures. This suppression was specific for the inductive phase of AK activity, because autologous human serum could not suppress the cytotoxic capability of AK cells once they were activated by rIL2. The serum suppressive effect on the induction of AK cytotoxicity could be overcome by increasing the dose of rIL2 or by adding recombinant gamma-interferon to the cultures. Lymphocytes from melanoma patients thus have the latent ability to kill autologous melanoma tumor cells. However, this cytotoxic capability requires an interleukin 2-induced differentiation step that could be amplified by gamma-interferon and inhibited by a serum suppressive factor.     

Retrospective cost analysis of gemcitabine in combination with cisplatin in non-small cell lung cancer compared to other combination therapies in Europe

In two recent randomised trials, gemcitabine plus cisplatin (Gem/Cis) was found to be at least as effective as vinorelbine plus cisplatin (Vin/Cis), paclitaxel plus cisplatin (Pac/Cis), paclitaxel plus carboplatin (Pac/Carbo), or docetaxel plus cisplatin (Doc/Cis) in patients with advanced non-small cell lung cancer (NSCLC). In cost-minimisation analyses of these studies from the perspectives of the national health services of five European countries (France, Germany, Italy, Spain, UK), Gem/Cis was associated with lower average treatment-related costs than Vin/Cis, Pac/Cis, and Pac/Carbo, and similar or lower costs than Doc/Cis. The incremental cost savings per patient of Gem/Cis compared to Vin/Cis ranged from 827 Euro to 2055 Euro per patient and from 1616 Euro to 5342 Euro compared to the paclitaxel-containing regimens. Overall, results were generally similar between countries, and were robust to univariate sensitivity analyses. Although differences in healthcare systems mean that the results may not be generalisable to all countries/settings, these results provide an economic rationale for the use of Gem/Cis as a first-line treatment option in Europe for patients with NSCLC.     

Changing end-of-life planning: the Oregon experience

Large state-by-state variations exist in location of dying and level of aggressive treatment during the final phase of life. This paper describes Oregon's incremental gains toward improving advance planning for end-of-life care in a state with the lowest rate of in-hospital deaths. Action strategies have required data gathering and reporting, and coalition building with a focus on systems change. Also, public education through the news media has proved to be a vital component of Oregon's process of change. The impact of media coverage is complemented by continuing education for health professionals. Special efforts are still needed to improve access to the Physician's Orders for Life-Sustaining Treatment program (POLST) for some rural, minority, and pediatric populations and for persons living at home with a diagnosis other than cancer. However, with enough time, a sustained effort, and a broad coalition of partners, profound change is possible.