Access to health information and support: a public highway or a private road?

Information and communication technologies may help reduce health disparities through their potential for promoting health, preventing disease, and supporting clinical care for all. Unfortunately, those who have preventable health problems and lack health insurance coverage are the least likely to have access to such technologies. Barriers to access include cost, geographic location, illiteracy, disability, and factors related to the capacity of people to use these technologies appropriately and effectively. A goal of universal access to health information and support is proposed to augment existing initiatives to improve the health of individuals and the public. Both public- and private-sector stakeholders, particularly government agencies and private corporations, will need to collaboratively reduce the gap between the health information "haves" and "have-nots." This will include supporting health information technology access in homes and public places, developing applications for the growing diversity of users, funding research on access-related issues, ensuring the quality of health information and support, enhancing literacy in health and technology, training health information intermediaries, and integrating the concept of universal access to health information and support into health planning processes.     

When is it safe for babies to swim?

What factors are important when health professionals are asked "At what age is it safe to take my baby swimming in a public pool?". In a survey of primary health care doctors, no unified approach was identified but many considered immunisation essential before swimming. There is no evidence to support this view. Careful attention to the infant's body temperature is more important.     

Can we provide reperfusion therapy to all unselected patients admitted with acute myocardial infarction?

OBJECTIVES: This study sought to assess the maximal rate of acute Thrombolysis in Myocardial Infarction (TIMI) grade 3 patency that can be achieved in unselected patients. BACKGROUND: Early and complete (TIMI grade 3 flow) reperfusion is an important therapeutic goal during acute myocardial infarction. However, thrombolysis, although widely used, is often contraindicated or ineffective. The selective use of primary and rescue percutaneous transluminal coronary angioplasty (PTCA) may increase the number of patients receiving reperfusion therapy. METHODS: A cohort of 500 consecutive unselected patients with acute myocardial infarction were prospectively treated using a patency-oriented scheme: Thrombolysis-eligible patients received thrombolysis (n = 257) and underwent 90-min angiography to detect persistent occlusion for treatment with rescue PTCA. Emergency PTCA (n = 193) was attempted in patients with contraindications to thrombolysis, cardiogenic shock or uncertain diagnosis and in a subset of patients admitted under "ideal conditions." A small group of patients (n = 38) underwent acute angiography without PTCA. Conventional medical therapy was used in 12 patients with contraindications to both thrombolysis and PTCA. RESULTS: Ninety-eight percent of patients received reperfusion therapy (thrombolysis, PTCA or acute angiography), and angiographically proven early TIMI grade 3 patency was achieved in 78%. Among patients with TIMI grade 3 patency, thrombolysis alone was the strategy used in 37%, emergency PTCA in 40% and rescue PTCA after failed thrombolysis in 15%; spontaneous patency occurred in 8%. CONCLUSIONS: Reperfusion therapy can be provided to nearly every patient (98%) with acute myocardial infarction. Rescue and direct PTCA provided effective early reperfusion to patients in whom thrombolysis failed or was excluded.     

From balance regulation to body orientation: two goals for muscle proprioceptive information processing?

This study was based on the assumption that the central processing of proprioceptive inputs that arise from numerous muscles contributes to both awareness and control of body posture. The muscle-spindle inputs form a "proprioceptive chain" which functionally links the eye muscles to the foot muscles. Here, we focused on the specific contribution of two links in the control of human erect posture by investigating how proprioceptive messages arising from ankle and neck muscles may be integrated by the central nervous system. Single or combined mechanical vibrations were applied to different muscle tendons at either one (ankle or neck) or both (ankle plus neck) body levels. The amplitude and the specific direction of the resulting oriented body tilts were analyzed by recording the center of foot pressure (CoP) through a force platform with four strain gauges. The results can be summarized as follows: (1) the vibration-induced whole-body tilts were oriented according to the muscles stimulated; furthermore, the tilts were in opposite directions when neck or ankle muscles on the same side of the body were stimulated; (2) except for the ankle antagonist muscles, co-vibrating adjacent or antagonist muscles at the same body level (ankle or neck) resulted in body sways, whose orientation was a combination of those obtained by stimulating these muscles separately; and (3) likewise, co-vibrating ankle and neck muscles induced whole-body postural responses, whose direction and amplitude were a combination of those obtained by separate vibration. We conclude that the multiple proprioceptive inputs originating from either one or both body levels may be co-processed in terms of vector-addition laws. Moreover, we propose that proprioceptive information from ankle and neck muscles may be used for two tasks: balance control and body orientation, with central integration of both tasks.     

People's hypercorrection of high-confidence errors: Did they know it all along?

This study investigated the “knew it all along” explanation of the hypercorrection effect. The hypercorrection effect refers to the finding that when people are given corrective feedback, errors that are committed with high confidence are easier to correct than low-confidence errors. Experiment 1 showed that people were more likely to claim that they knew it all along when they were given the answers to high-confidence errors as compared with low-confidence errors. Experiments 2 and 3 investigated whether people really did know the correct answers before being told or whether the claim in Experiment 1 was mere hindsight bias. Experiment 2 showed that (a) participants were more likely to choose the correct answer in a 2nd guess multiple-choice test when they had expressed an error with high rather than low confidence and (b) that they were more likely to generate the correct answers to high-confidence as compared with low-confidence errors after being told they were wrong and to try again. Experiment 3 showed that (c) people were more likely to produce the correct answer when given a 2-letter cue to high- rather than low-confidence errors and that (d) when feedback was scaffolded by presenting the target letters 1 by 1, people needed fewer such letter prompts to reach the correct answers when they had committed high- rather than low-confidence errors. These results converge on the conclusion that when people said that they knew it all along, they were right. This knowledge, no doubt, contributes to why they are able to correct those high-confidence errors so easily. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Pallidal stimulation: an alternative to pallidotomy?

A resurgence of interest in the surgical treatment of Parkinson's disease (PD) came with the rediscovery of posteroventral pallidotomy by Laitinen in 1985. Laitinen's procedure improved most symptoms in drug-resistant PD, which engendered wide interest in the neurosurgical community. Another lesioning procedure, ventrolateral thalamotomy, has become a powerful alternative to stimulate the nucleus ventralis intermedius, producing high long-term success rates and low morbidity rates. Pallidal stimulation has not met with the same success. According to the literature pallidotomy improves the "on" symptoms of PD, such as dyskinesias, as well as the "off" symptoms, such as rigidity, bradykinesia, and on-off fluctuations. Pallidal stimulation improves bradykinesia and rigidity to a minor extent; however, its strength seems to be in improving levodopa-induced dyskinesias. Stimulation often produces an improvement in the hyper- or dyskinetic upper limbs, but increases the "freezing" phenomenon in the lower limbs at the same time. Considering the small increase in the patient's independence, the high costs of bilateral implants, and the difficulty most patients experience in handling the devices, the question arises as to whether bilateral pallidal stimulation is a real alternative to pallidotomy.     

Models for psychiatry: icons or effigies?

Toulmin notes that a good model takes us beyond the phenomena from which we began [67]. It also tempts us. Models demand that we attempt to represent the dynamic relationships between variables. When we use them, we risk insulating our findings from empirical disproof [68]. Self-certifying myths, like articles of faith, need to yield to the demands of science. Psychiatric theory and practice need to yield to the demands of experience. We need to move away from ethereal assumptions to tangible mastery of the understanding of behavior. Freud, in The Interpretation of Dreams [69], writes, "Analogies of this kind are only intended to assist us in our attempt to make the complications of mental functioning intelligible. We are justified, in my view, in giving free rein to our speculations so long as we retain the coolness of our judgment and do not mistake the scaffolding for the building. We have been obliged to build. If we are not wholly in error, other lines of approach are bound to lead us into much the same region and the time may come when we shall find ourselves more at home in it!"     

Doctor in the lab: what is it like for a doctor to work with scientists?

As clinical academic medical departments strive to improve the quality of their research, clinicians and scientists are forced into closer liaison. In many cases, clinical departments now have research laboratories directed by "basic scientists" but often staffed, in part at least, by doctors. To someone who has not worked in one, these laboratories may seem uncompromising and forbidding work environments. This article presents a "case report" written from the viewpoints of the doctor, the scientist, and the professor.     

Provider profiling: What works for medicine works for mental health?

Provider profiling is a growing practice in organizations that supply or pay for health care, and escalating health care costs are likely to accelerate this trend. First developed for general medical settings, profiling systems now challenge practicing psychologists to meet ostensibly objective, scientific standards of care. The most advanced approaches compare providers on a "level playing field" statistically adjusted for variations in the "illness burden" of their patients. Profiling psychological practice, however, requires specialized new tools and more sophisticated analytical methods than have typically been used. This article provides a practical overview of provider profiling, emphasizing related developments in health care policy that are perhaps less familiar to practicing psychologists. Potential pitfalls confronting professional psychology are discussed, and points for advocacy are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Arterial graft patency in coronary artery bypass grafting: what do we really know?

BACKGROUND: With increasing use of beating heart techniques for bypass of the left anterior descending coronary artery with the left internal mammary artery (LIMA), appropriate concerns have been raised of whether graft patency by these techniques compares favorably with conventional, arrested heart techniques. METHODS: All published articles that examine outcome efficacy of the LIMA graft to the left anterior descending coronary artery were reviewed. Because angiography has been considered the "gold standard," only those studies that included angiographic follow-up were analyzed. RESULTS: From 1972 through 1998, there have been 37 peer-reviewed publications that examined outcomes of LIMA grafting in conventional coronary bypass grafting, of which 27 contained angiographic follow-up data. The completeness of angiographic follow-up was variable, but early graft patency (< or =1 month) in studied patients ranged between 94% and 99%. Late graft patency (up to 15 years) ranged from 51% to 98%. Five recent series of minimally invasive direct coronary artery bypass grafting that contained LIMA graft patency data show early graft patency rates between 91% and 99%. CONCLUSIONS: Meaningful comparison of LIMA graft patency between arrested heart, conventional coronary artery bypass grafting, and minimally invasive direct coronary artery bypass grafting is difficult; however, early graft patency by both techniques can confidently be stated as being 90% or greater.     

Fear of contagion: a response to stress?

Alterations of neutrophil functions by tobacco products may play a central role in the pathogenesis of periodontal diseases and several smoking-related systemic diseases. In the present study, we examined the in vitro effects of cigarette smoke on neutrophils at times and concentrations that may be encountered during smoke exposure. We measured the level of smoke exposure in the in vitro system by measuring the levels of nicotine and comparing these to levels in the oral cavity in smokers before and after smoking. We examined both the unstimulated and stimulated release of 2 oxidative burst products: superoxide (O-2) and hydrogen peroxide (H2O2). Salivary washings were collected from 7 smokers (> 1 pack/day) before smoking a cigarette. Immediately after they smoked a cigarette, a second set of washings was collected. In vitro exposure to smoke involved incubating aliquots of neutrophils in phosphate-buffered saline for 1 to 5 minutes. Nicotine and cotinine levels were quantitated using gas chromatography, with detection by electron impact mass spectrometry. Peripheral neutrophils were isolated from medically healthy non-smoking volunteers via a double-density gradient technique and incubated in vitro with whole cigarette smoke for 0 to 5 minutes. Phorbol myristate acetate (PMA; 10(-7) M) was used to stimulate half of the cell aliquots. Superoxide generation was assessed through the superoxide dismutase (SOD) inhibitable reduction of ferricytochrome c. H2O2 production was assessed through the H2O2-dependent breakdown of dichlorofluorescin diacetate to its fluorophore and measured by flow cytometry. There was a marked elevation in salivary nicotine concentration from before smoking (mean: 80.8 ng) to after smoking (mean 1,685 ng/mL). In the in vitro smoke box system, there was a time-related elevation in nicotine from 1 to 5 minutes (50-->136 ng/mL). In PMA-stimulated cells exposed to smoke, there was a time-related inhibition of both superoxide and H2O2 production. However, in unstimulated cells exposed to smoke, there was a time-related increase in the release of superoxide and H2O2. A novel finding in unstimulated cells exposed to smoke was that there appeared to be 2 distinct populations of cells--one of "high" H2O2 producers and one of "low" H2O2 producers. The proportion of high H2O2 producers increased relative to smoke exposure. The relative production of H2O2 in the unstimulated high producers was comparable to PMA-stimulated cells at 5 minutes. This release of superoxide and H2O2 in unstimulated cells exposed to smoke may alter the pathogenic processes both in periodontal diseases and other systemic diseases.     

Erythrocyte folate analysis: a cause for concern?

Neural tube defects can be prevented by adequate intake of periconceptional folate, and inverse associations between folate status and cardiovascular disease and various cancers have been noted. Thus, there is renewed interest in the analysis of red cell folate (RCF) as an indicator of folate deficiency risk. Assessment of the assumptions that underpin RCF assays indicates that many are false. Published literature suggests that increased deoxy-hemoglobin (which can bind RCF electrostatically) yields more assayable folate, and increased oxy-hemoglobin (which cannot bind RCF) yields less assayable folate. It is argued that as deoxy-hemoglobin picks up oxygen and switches quaternary structure, any bound folate must, on purely theoretical grounds, become physically "trapped". Venous blood taken for analysis is 65% to 75% saturated with oxygen, and pro-rata "trapping" will lead to serious underestimation of RCF. Hence, doubt is cast over the validity of all previous RCF values. Some strategies for accurately assessing RCF are suggested.     

Is there a role for induction androgen deprivation prior to radical prostatectomy?

The potential advantages of neoadjuvant androgen deprivation include decreased prostatic size, reduced vasculature, and reduced incidence of positive margins. The potential disadvantages are the side effects of hormonal medication, cost, tissue reaction, treatment "delay," and progression of androgen-independent clones. Many theories have been postulated to explain the observed reduction in the incidence of positive margins with neoadjuvant hormonal treatment. It is possible that the reduced prostate size and the frequently found periprostatic tissue reaction facilitate dissection, allowing better cancer clearance. It is possible, however, that the fibrosis may also increase the surgical difficulty, which critics argue may increase the risk of a positive margin. It is difficult to conceive of a research methodology that could resolve this issue. The occurrence of tumor cell death is likely a more significant explanation for the improved results. Whether tumor cells beyond the prostatic capsule are consistently affected to pathologically downstage the disease is unknown. The careful pathologic assessment in the randomized trials discussed previously suggests that pathologic downstaging is not as common as earlier reports have suggested. Difficulty in interpreting pathologic specimens after neoadjuvant treatment must be considered. At this point, neoadjuvant hormonal treatment prior to surgery would appear appropriate for those patients at high risk of having a positive surgical margin. Specifically, this includes clinical stage T2b, PSA elevation greater than 10 to 20 ng/mL, and a high Gleason score on the prostatic biopsy. Research to date suggests that neoadjuvant hormonal therapy prior to radical prostatectomy has a significant effect in reducing the incidence of positive surgical margins. The treatment is well tolerated with minimal side effects. Whether this will translate into improved disease-free survival remains to be determined. Fortunately, the randomized trials have been completed and follow-up data will be forthcoming.     

Routine antibiotic cover for newborns intubated for aspirating meconium: is it necessary?

A retrospective analysis was performed on 215 babies to evaluate the incidence of septicemia in babies intubated at birth for aspirating meconium from the trachea. Only term, appropriate for gestational age babies were included. Babies with any known perinatal risk factor for infection were excluded from the study and none of the babies had been put on "prophylactic antibiotics." There were 88 babies in the intubated group in a one year period from January 1991 to December 1991. One hundred and twenty seven babies were taken as controls. There was no significant difference in the incidence of early septicemia in the two groups. There were no deaths in either group. It is concluded that well term babies who are intubated for aspirating meconium need not be put on routine antibiotic cover.     

How should nuclear cardiologists prepare for the next 5 to 10 years?

We developed a simple and easy nonsurgical percutaneous method for autografting parathyroid tissue into the forearm muscles. This method was applied to 30 patients suffering from secondary hyperparathyroidism who were then refractory to medical treatment. The operative results were then compared with 16 patients who underwent treatment using Wells' method. The graft "take," judged by a significant intact parathyroid hormone (PTH) ratio (> 1.5) between grafted and nongrafted arm vein blood, was 82% for the percutaneous method group and 75% for the Wells' method group, respectively. The percentage of recurrent hyperparathyroidism necessitating a subtotal removal of the autograft was equal in the two groups. No complications were noted for either method. Wells' method can thus be replaced by this simple and easy nonoperative method.     

Radiation therapy: are we getting value for money?

Intra-osseous ganglia are among the more frequent causes of cystic lesions of the carpus and may be responsible for diffuse pain, possibly be related to biological activity of the lesions, or when the ganglia opens into the adjacent joint. A CT-scan is useful to determine their exact location and the presence of a cortical defect. Although not this feature is completely established, they seem to arise de "novo" from the bone although their fluid content is reminiscent of those of soft-tissue ganglia. Surgical curettage with bone grafting is only indicated when pain persists despite a period of rest.     

Telomeric DNA: marker for human prostate cancer development?

OBJECTIVES: To establish consensus case definitions for several common work related upper limb pain syndromes for use in surveillance or studies of the aetiology of these conditions. METHODS: A group of healthcare professionals from the disciplines interested in the prevention and management of upper limb disorders were recruited for a Delphi exercise. A questionnaire was used to establish case definitions from the participants, followed by a consensus conference involving the core group of 29 people. The draft conclusions were recirculated for review. RESULTS: Consensus case definitions were agreed for carpal tunnel syndrome, tenosynovitis of the wrist, de Quervain's disease of the wrist, epicondylitis, shoulder capsulitis (frozen shoulder), and shoulder tendonitis. The consensus group also identified a condition defined as "non-specific diffuse forearm pain" although this is essentially a diagnosis made by exclusion. The group did not have enough experience of the thoracic outlet syndrome to make recommendations. CONCLUSIONS: There was enough consensus between several health professionals from different disciplines to establish case definitions suitable for use in the studies of several work related upper limb pain syndromes. The use of these criteria should allow comparability between studies and centres and facilitate research in this field. The criteria may also be useful in surveillance programmes and as aids to case management.     

Consulting psychology: A vision for the new millennium?

Consultants at all levels must be visionary as they approach the new millennium. In this article, the author examines the forces of change in consulting, the recognition of essential leadership styles, the use of algorithms and pathways for delivering consulting services, and the paradigm shifts that are likely to occur for professional psychology. A number of visionary projections are offered as consultants view with clarity and prepare for new directions in the 21st century. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

To Be or Not to Be—That Is the Question: Is a DRB Right for Your Project?

Dispute review boards (DRBs) have been used on a wide variety of projects both in the United States and abroad. However, this alternative dispute resolution1 methodology has been around for over 3 decades and as of 2006 has been used on over 1,434 projects according to the Dispute Resolution Board Foundation; therefore, now is the time to consider whether the benefits of a DRB outweigh its potential downside. Some DRBs are successful in that all issues have been resolved prior to the close of the project, while others have failed and caused the issues to travel the continuum to litigation and/or arbitration. The writer’s first experience with a DRB was one that failed and the issues continued to both arbitration and litigation at great expense to both the owner and the contractor. The purpose of this paper is to explore the questions that need to be asked to determine whether or not a DRB is right for your project. It will outline the history and development of a DRB as well as its use in the United States and abroad. It will evaluate the advantages and disadvantages of using a DRB to permit a deliberate decision on whether or not a DRB is right for your project.