A captive audience: bringing the WISEWOMAN program to South Dakota prisoners.

PURPOSE: This analysis compares the baseline heart disease risk profile of WISEWOMAN participants screened in the South Dakota Women's Prison with the general WISEWOMAN population in South Dakota and explores the potential benefits of lifestyle intervention programs to reduce heart disease risk factors among women during incarceration. METHODS: Using baseline data for WISEWOMAN participants in South Dakota, we compared participants who were enrolled in prison (n = 261) with nonincarcerated participants enrolled throughout the state (n = 1,427). Using regression analysis and adjusting for demographics, we assessed differences in baseline prevalence of risk factors (hypertension, high cholesterol, smoking, and obesity), awareness and treatment of hypertension and high cholesterol, and attendance at lifestyle intervention sessions. RESULTS: Incarcerated participants had significantly lower (p < .01) total cholesterol (183 mg/dL) than nonincarcerated participants (199 mg/dL). However, a significantly higher (p < .03) percentage of incarcerated women (85%) than nonincarcerated women (54%) with high cholesterol were unaware of their condition. Despite the smoke-free status of the prison, 24% of incarcerated participants reported smoking. Attendance at lifestyle intervention sessions was significantly higher among incarcerated participants than among nonincarcerated participants with intervention take-up rates of 53% among incarcerated versus 23% among nonincarcerated women (p < .01) and intervention completion rates of 43% and 4% (p < .01). CONCLUSIONS: The results illustrate the need for screening and education programs in prisons. WISEWOMAN screenings helped identify undiagnosed cases of abnormal blood pressure and cholesterol, and educational interventions provided women with opportunities to improve their health. Such programs may also improve discharge planning and linkages between released women and community health providers.     

Arguing about the evidence: readers, writers and inscription devices in coronary heart disease risk assessment

This paper examines the history of tools developed to assess an individual's risk of coronary heart disease. A close reading of the tools themselves is combined with an analysis of debates published in medical journals such as the British Medical Journal (BMJ) and The Lancet. These literary conversations between scientists and doctors reveal complex negotiations about the form and meaning of medical technologies that have yet to become fully 'stable'. Early tools were promoted as a response to the high cost of cholesterol-lowering drugs (statins), but came to embody broader attempts to shape medical practice. These include the promotion of what has been understood as evidence-based medicine and regulation by political and professional actors, as well as the spread of 'risk thinking' more generally. Despite having a central place in recent British guidelines and policy, there is a surprising variety of tools in circulation, and ongoing uncertainty about their use and value.     

Clinical exposure during clinical method attachments in general practice

BACKGROUND: There has been a significant decline in medical students' clinical experience in hospitals. Hospital-based teaching is struggling to provide medical students with sufficient experience of the common health problems of our industrialized ageing society. Hence, general practice has become an important locus for medical education. Published evidence, however, that students can access appropriate clinical experience in general practice is sparse. OBJECTIVE: To determine students' clinical exposure during clinical and method attachments based in general practice at two medical schools. EDUCATIONAL INITIATIVE: Students were attached to general practice tutors to learn clinical method in internal medicine. METHOD: General practice tutors from two medical schools collected data on age, gender, diagnoses, symptoms and signs of the patients they invited to teaching sessions. RESULTS: The frequency of diagnoses, symptoms and signs seen by medical students are recorded. Students mostly saw patients with chronic illnesses; the commonest diagnoses were ischaemic heart disease and angina. DISCUSSION: Our study has recorded the largest published database of clinical diagnoses, symptoms and signs encountered by students learning clinical method in general practice. It shows that students obtained a wealth of experience with patients with common chronic diseases. Students must also learn in the hospital setting, to experience the presentation of acute illness. The combination of teaching in these two settings is likely to provide the most effective technique to ensure that students encounter the common, acute and chronic conditions that affect patients in the 21st century.     

Would They Follow What has been Laid Down? Cancer Patients' and Healthy Controls' Views on Adherence to Advance Directives Compared to Medical Staff

Advance directives are propagated as instruments to maintain patients’ autonomy in case they can no longer decide for themselves. It has been never been examined whether patients’ and healthy persons themselves are inclined to adhere to these documents. Patients’ and healthy persons’ views on whether instructions laid down in advance directives should be followed because that is (or is not) “the right thing to do”, not because one is legally obliged to do so, were studied and compared with that of medical staff. Method: Vignette study presenting five cases. Cancer patients, healthy persons, nursing staff and physicians (n = 100 in each group) were interviewed. An adherence score was calculated (maximum value 5). The adherence score is found to be low in all groups, yet lowest in patients (1.55; standard deviation 1.13) and healthy controls (1.60; 1.37). The scores are significantly different between nursing staff on the one hand and patients and healthy controls on the other (p < 0.005 and p < 0.05, respectively), and between doctors and patients (p < 0.05). Interviewees who want these documents to be followed tend to live alone and to have already written an advance directive. Conclusions: Cancer patients and healthy persons widely disregard instructions laid down in advance directives and consider them less binding than physicians and nursing staff do. Only a minority tends to adhere more to advance directives. To improve decision-making at the end of life when patients are no longer able to decide for themselves alternative concepts, such as advanced care planning, should be considered.     

Comparative health assessment among migrants and Germans: combined results of a school health examination and a health survey among parents

Objectives  

Previous studies on the health of migrants in Germany focus either on the health of children or on that of adults of ethnic minorities in comparison to the German population. In our study the health status of preschool-aged children and their parents among Germans and ethnic minorities was studied and interlinked.     

A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver's safer injection facility

BackgroundConventional drug overdose prevention strategies have been criticised for failing to address the macro- and micro-environmental factors that shape drug injecting practices and compromise individual ability to reduce the risks associated with drug-related overdose. This in turn has led to calls for interventions that address overdose risks by modifying the drug-using environment, including the social dynamics within them. Safer injection facilities (SIFs) constitute one such intervention, although little is known about the impact of such facilities on factors that mediate risk for overdose.MethodsSemi-structured qualitative interviews were conducted with fifty individuals recruited from a cohort of SIF users in Vancouver, the Scientific Evaluation Of Supervised Injecting (SEOSI). Audio recorded interviews elicited injection drug users’ (IDU) accounts of overdoses as well as perspectives regarding the impact of SIF use on overdose risk and experiences of overdose. Interviews were transcribed verbatim and a thematic analysis was conducted.ResultsFifty IDU, including 21 women, participated in this study. The perspectives of participants suggest that the Vancouver SIF plays an important role in mediating various risks associated with overdose. In particular, the SIF addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest. Further, SIF use appears to enable overdose prevention by simultaneously offsetting potential social risks associated with injecting alone and injecting in the presence of strangers. The immediate emergency response offered by nurses at the SIF was also valued highly, especially when injecting adulterated drugs and drugs of unknown purity and composition.ConclusionThe perspectives of IDU participating in this study suggest that SIFs can address many of the micro-environmental factors that drive overdose risk and limit individual ability to employ overdose prevention practices. Although challenges related to coverage remain in many settings, SIFs may play a unique role in managing overdoses, particularly those occurring within street-based drug scenes.     

Implantable Electrical Bone Stimulation for Arthrodeses of the Foot and Ankle in High-Risk Patients: A Multicenter Study

This study assessed arthrodesis procedures performed in the foot and ankle of high-risk patients following implantation of an internal electrical bone stimulator. Criteria defining patients as "high risk" included diabetes, obesity, habitual tobacco and/or alcohol use, immunosuppressive therapy, and previous history of nonunion. Standard arthrodesis protocol of bone graft and internal fixation was supplemented with the implantable electrical bone stimulator. A retrospective, multicenter review was conducted of 26 patients (28 cases) who underwent 28 forefoot and hindfoot arthrodeses from 1998 to 2002. Complete fusion was defined as bony trabeculation across the joint, lack of motion across the joint, maintenance of hardware/fixation, and absence of radiographic signs of nonunion or pseudoarthrosis. Radiographic consolidation was achieved in 24 of the 28 cases at an average 10.3+/-4.0 weeks. Followup averaged 27.2 months. Complications included 2 patients who sustained breakage of the cables to the bone stimulator. Five patients underwent additional surgery. Four of the 5 patients had additional surgery in order to achieve arthrodesis. All 4 went on to subsequent arthrodesis. This study demonstrates how arthrodesis of the foot and ankle may be enhanced by the use of implantable electrical bone stimulation.     

Postsalmonella reactive phenomena in 2 patients with ankylosing spondylitis: no modification of the underlying disease

HLA-B27 related disease occurs in 2 main forms, ankylosing spondylitis (AS) or reactive arthropathy/Reiter's syndrome. These entities often "breed true" within families or distinct ethnic groups. Reactive arthropathy/Reiter's syndrome may be complicated by AS, but little is known about the impact on AS of a de novo reactive arthropathy occurring at a later date. We describe 2 patients with AS who developed postsalmonella reactive phenomena several years after the onset of their primary disease. In both patients the intestinal salmonella infection did not modify the course of the AS.     

Alterations in thyroid status modulate apolipoprotein, hepatic triglyceride lipase, and low density lipoprotein receptor in rats

The influence of altered thyroid state is investigated on plasma apolipoprotein-A-I (apo-A-I), apo-B, and apo-E levels and on apo-A-I, apo-A-II, apo-B, apo-E, hepatic triglyceride lipase (HTGL), and low density lipoprotein (LDL) receptor mRNA levels in rat liver and intestine. Plasma total cholesterol and triglycerides are unchanged in hyperthyroid rats. Liver apo-A-I mRNA levels increase 3-fold, whereas intestinal apo-A-I mRNA levels remain constant. Plasma apo-A-I levels almost double after L-T4. Liver apo-B and apo-E and intestinal apo-B mRNA levels are not influenced by L-T4, but plasma apo-B and apo-E decrease significantly. In the liver, apo-A-II mRNA levels decrease, whereas LDL receptor mRNA levels increase more than 50%. HTGL mRNA is not influenced by L-T4. N-Propyl-thiouracil-induced hypothyroidism does not influence plasma triglycerides, but plasma cholesterol levels nearly double. Liver and intestinal apo-A-I mRNA levels and plasma apo-A-I concentrations remain constant after propylthiouracil treatment. Accompanying the increase in plasma apo-B, liver and intestinal apo-B mRNA concentrations rise by approximately 100% and 40%, respectively. Plasma apo-E increases nearly 2-fold, but liver, apo-A-II mRNA rises, whereas HTGL and LDL receptor mRNA levels decrease 20% and nearly 50%, respectively. In conclusion, thyroid hormones regulate rat apo-A-I and apo-A-II gene expression in opposite directions. Furthermore, the LDL receptor is regulated at the mRNA level, whereas HTGL gene expression is relatively resistant to alterations in thyroid status.     

A new hepatitis B virus strain in patients with severe anti-HBe positive chronic hepatitis B

In hepatitis B virus carriers who are anti-HBe positive despite ongoing viral replication (HBcAg in liver and HBV-DNA in serum) the natural course of hepatitis is severe and the response to interferon is low. We investigated whether a new hepatitis B virus (HBV) strain could be involved. A translational termination codon at the carboxyterminal end of the pre-C region responsible for the lack of HBeAg secretion was found in 18 of 19 HBV clones isolated from seven pedigreed patients with this clinical syndrome. The same findings were confirmed by direct sequencing. One of these patients underwent a liver transplant and HBV infection of the new liver resulted in high titered viremia and intrahepatic expression of HBcAg, without detectable HBeAg in serum. Another patient was superinfected by hepatitis delta virus (HDV) and developed high titres of total and IgM anti-HD. In spite of this, chronic hepatitis remained unchanged during 7 years of follow-up. These data strongly suggest that a viable precore minus mutant of hepatitis B virus is responsible for the lack of HBeAg in the serum of these patients. The HBV variant may explain the peculiar geographic distribution of anti-HBe positive hepatitis. The variations in the virus genome sequence may cause the more severe form of liver disease and modify the pathogenicity in the case of HDV superinfection.