Sharing vs. caring--the relative impact of sharing decisions versus managing emotions on patient outcomes

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.

Effects of a comprehensive rehabilitation program on quality of life in patients with chronic heart failure

This evaluation was performed to assess the effects of a new, comprehensive outpatient rehabilitation program on generic and disease-specific quality of life related to exercise tolerance in stable chronic heart failure patients. Fifty-one patients (aged 59+/-11 years; 84% men) were treated for 12 weeks. Patients underwent optimized drug treatment, exercise training, and counseling and education. At baseline and at the end of the program, functional status, exercise capacity, and quality of life were assessed using the Medical Outcomes Study 36-item Short-Form Health Survey and the Minnesota Living with Heart Failure Questionnaire. Left ventricular ejection fraction and New York Heart Association functional class, as well as measures of physical fitness and walking distance covered in 6 minutes, improved significantly (by 11%-20% and by 58% on average, respectively). Physical functioning (effect size, 0.38; p<0.0001), role functioning (effect size, 0.17; p<0.05), and mental component score (effect size, 0.47; p<0.0001) on the questionnaire improved significantly. Disease-specific quality of life improved in sum score (effect size, 0.24; p<0.0001) and physical component score (effect size, 0.35; p<0.0001). The latter was inversely correlated to improvement in peak power output (r= -0.31; p<0.05). In patients with stable chronic heart failure, significant improvements in both generic and disease-specific quality of life related to improved exercise tolerance can be achieved within 12 weeks of comprehensive rehabilitation.

TERPENE AND TERPENOID EMISSIONS AND SECONDARY ORGANIC AEROSOL PRODUCTION

Approximately 90% of fine aerosol in the Midwestern United States has a regional component with a sizable fraction attributed to secondary production of organic aerosol (SOA). The Ozark Forest is an important source of biogenic SOA precursors like isoprene (> 150 mg m-2 d-1), monoterpenes (10-40 mg m-2 d-1), and sesquiterpenes (10-40 mg m-2d-1). Anthropogenic sources include secondary sulfate and nitrate and biomass burning (51-60%), vehicle emissions (17-26%), and industrial emissions (16-18%). Vehicle emissions are an important source of volatile and vapor-phase, semivolatile aliphatic and aromatic hydrocarbons that are important anthropogenic sources of SOA precursors. The short lifetime of SOA precursors and the complex mixture of functionalized oxidation products make rapid sampling, quantitative processing methods, and comprehensive organic molecular analysis essential elements of a comprehensive strategy to advance understanding of SOA formation pathways. Uncertainties in forecasting SOA production on regional scales are large and related to uncertainties in biogenic emission inventories and measurement of SOA yields under ambient conditions. This work presents a bottom-up approach to develop a conifer emission inventory based on foliar and cortical oleoresin composition, development of a model to estimate terpene and terpenoid signatures of foliar and bole emissions from conifers, development of processing and analytic techniques for comprehensive organic molecular characterization of SOA precursors and oxidation products, implementation of the high-volume sampling technique to measure OA and vapor-phase organic matter, and results from a 5 day field experiment conducted to evaluate temporal and diurnal trends in SOA precursors and oxidation products. A total of 98, 115, and 87 terpene and terpenoid species were identified and quantified in commercially available essential oils of Pinus sylvestris, Picea mariana, and Thuja occidentalis, respectively, by comprehensive, two-dimensional gas chromatography with time-of-flight mass spectrometric detection (GC × GC-ToF-MS). Analysis of the literature showed that cortical oleoresin composition was similar to foliar composition of the oldest branches. Our proposed conceptual model for estimation of signatures of terpene and terpenoid emissions from foliar and cortical oleoresin showed that emission potentials of the foliar and bole release pathways are dissimilar and should be considered for conifer species that develop resin blisters or are infested with herbivores or pathogens. Average derivatization efficiencies for Methods 1 and 2 were 87.9 and 114%, respectively. Despite the lower average derivatization efficiency of Method 1, distinct advantages included a greater certainty of derivatization yield for the entire suite of multi- and poly-functional species and fewer processing steps for sequential derivatization. Detection limits for Method 1 using GC × GC- ToF-MS were 0.09-1.89 ng μL-1. A theoretical retention index diagram was developed for a hypothetical GC × 2GC analysis of the complex mixture of SOA precursors and derivatized oxidation products. In general, species eluted (relative to the alkyl diester reference compounds) from the primary column (DB-210) in bands according to n and from the secondary columns (BPX90, SolGel-WAX) according to functionality, essentially making the GC × 2GC retention diagram a Carbon number-functionality grid. The species clustered into 35 groups by functionality and species within each group exhibited good separation by n. Average recoveries of n-alkanes and polyaromatic hydrocarbons (PAHs) by Soxhlet extraction of XAD-2 resin with dichloromethane were 80.1 ± 16.1 and 76.1 ± 17.5%, respectively. Vehicle emissions were the common source for HSVOCs [i.e., resolved alkanes, the unresolved complex mixture (UCM), alkylbenzenes, and 2- and 3-ring PAHs]. An absence of monoterpenes at 0600-1000 and high concentrations of monoterpenoids during the same period was indicative of substantial losses of monoterpenes overnight and the early morning hours. Post-collection, comprehensive organic molecular characterization of SOA precursors and products by GC × GC-ToFMS in ambient air collected with ~2 hr resolution is a promising method for determining biogenic and anthropogenic SOA yields that can be used to evaluate SOA formation models.

Do patients respect the line? Transgression of boundaries reported by Swiss general practitioners

OBJECTIVE: Transgression of boundaries in the relationship between physician and patient is commonly studied with patient as victim and physician as transgressor. A recent survey in the U.S. reported that almost 90% of physicians face transgression by patients over one year. Incidents happened mainly through verbal abuse, disregarding privacy, and overly affectionate behavior. Since this incidence seems to be alarmingly high, we were interested to analyze how often general practitioners in Switzerland experience transgression by patients. METHODS: 24% of the members of the Swiss Society of Internal Medicine (SGIM) and of the Swiss Society of General Medicine (SGAM) (n=675/2781) responded to an internet-based survey which asked for experiences of transgression by patients and for physicians' responses to transgression in the last 12 months. RESULTS: 81% of responding physicians experienced transgression over the period of one year. Analyzing the frequency of incidents per physician per year, the most common forms of transgression were 'use of physician's first name' (7.7/y), 'asking personal questions' (1.8/y), 'being verbally abusive' (1.5/y), and 'being overly affectionate' (1.4/y). Calculated incidence of transgression was 3 per 1000 patient contacts. 39% of physicians decided to ignore the incident, 37% discussed the event openly. Transgression led to dismissal of patients in 13% of events. CONCLUSION: Transgression even in mild and modest form is a rare phenomenon in Swiss practices. PRACTICE IMPLICATION: The Swiss data do not suggest that there is a specific risk for Swiss practitioners to be exposed to major transgression for which they should specifically be prepared for example in communication skills trainings.

Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic burden both in western and developing countries, in which this burden is increasing in close correlation to economic growth. Health authorities and the general population have started to recognize that the fight against these diseases can only be won if their burden is faced by increasing our investment on interventions in lifestyle changes and prevention. There is an overwhelming evidence of the efficacy of secondary prevention initiatives including cardiac rehabilitation in terms of reduction in morbidity and mortality. However, secondary prevention is still too poorly implemented in clinical practice, often only on selected populations and over a limited period of time. The development of systematic and full comprehensive preventive programmes is warranted, integrated in the organization of national health systems. Furthermore, systematic monitoring of the process of delivery and outcomes is a necessity. Cardiology and secondary prevention, including cardiac rehabilitation, have evolved almost independently of each other and although each makes a unique contribution it is now time to join forces under the banner of preventive cardiology and create a comprehensive model that optimizes long term outcomes for patients and reduces the future burden on health care services. These are the aims that the Cardiac Rehabilitation Section of the European Association for Cardiovascular Prevention & Rehabilitation has foreseen to promote secondary preventive cardiology in clinical practice.

Perspective transformation: Women in long-term recovery from alcohol abuse

Objective. The purpose of this study was to determine the meaning of personal transformation for twenty women in long term, stable recovery from alcohol abuse; to identify themes or patterns of this recovery, and; to determine the extent to which they experienced the phenomenon of perspective transformation. ^ Method. Volunteers were recruited by advertisement, word of mouth, and through a closed circuit web based broadcast. A descriptive, exploratory study, which analyzed perspective transformation from the standpoint of five action phases, was conducted. Data was collected using in-depth personal interviews and questionnaires. Subjects' responses were analyzed by qualitative methods. Triangulation was performed on the grouped data comparing the interviews to the data produced by the questionnaires. Quantitative analysis of questionnaire items explored behavioral changes experienced before and after alcoholism recovery. ^ Results. Five phases of recovery were identified. Phase I which involved recognition that alcohol was a problem and change might be possible took several years during which 3 major transitions occurred: (1) from often being alienated to having relationships with family and friends; (2) from daily upheavals to eventually a more peaceful existence, and; (3) from denial that alcohol was a problem to acceptance and willingness to change. Recovery was often seen in a spiritual context, which also required ongoing support. During Phase II there was an assessment of self, others, and the environment which revealed a pattern of intense unhappiness and negative feelings toward self and others with a disregard for cultural norms. Phase III revealed a period of desperation as life became unmanageable, but gradual willingness to accept support and guidance and a desire to improve self and help others. This led to improvement of existing role performance and the willingness to try out new roles. In Phase IV there was a pattern of personal growth which included: the establishment of boundaries, setting priorities, a willingness to place others' needs above their own, acceptance of responsibility, and learning to cope without alcohol, often with the use of tools learned in AA. During Phase V, many experienced knowledge of frailties but growing respect for self and others, with an improved ability to function in giving relationships. Implications for Prevention and Recovery: Early education concerning addiction and recovery may play a crucial role in prevention and early recovery, as it did for children of women in this study. Recovery requires persistent effort and organized support. ^

Locus of control as a predictor of students dropping out of high school

Education is related to health. In cross-sectional data, education level has been associated with physical functioning. Also, lower levels of education have been associated with health behaviors including smoking, alcohol use, and greater body weight. In school, students may benefit from greater exposed to health-related messages, while students who have dropped out may be more susceptible to influences regarding negative health behaviors such as smoking. ^ Improved school retention might improve long-term health outcomes. However, there is limited evidence regarding modifiable factors that predict likelihood of dropping out. Two likely psychosocial measures are locus of control and parent-child academic conversations. In the current study, data from two waves of a population-based longitudinal survey, the National Education Longitudinal Survey, were utilized to evaluate whether these two psychosocial measures could predict likelihood of dropping out, for students (n = 16,749) in tenth grade at 1990, with dropout status determined at 1992, while controlling for recognized sociodemographic predictors including parental income, parental education level, race/ethnicity, and sex. Locus of control was measured with the Pearlin Mastery Scale, and parent-child academic conversations were measured by three questions concerning course selection at school, school activities and events, and things the student studied in class. ^ In a logistic regression model, with the sociodemographic control measures entered in a first step before entry of the psychosocial measures in a second step, this study determined that lower levels of locus of control were associated with greater likelihood of dropping out after two years (odds ratio (OR) = 1.11, 95% confidence interval (CI) 108 to 1.15, p < .001), and two of the three parent-child academic discussion items were associated with greater likelihood of dropping out after two years (OR = 1.69, CI 1.48-1.93, p < .001; OR = 1.22, CI 1.05-1.41, p = .01; OR = 1.01, CI .88-1.15, p = .94). ^ It is possible that interventions aimed at improving locus of control, and aimed at building parent-child academic conversations, could lower the likelihood of students dropping out, and this in turn could yield improved heath behaviors and health status in the child's future. ^

A systematic review of community-based colorectal cancer screening randomized controlled trials with multi-ethnic groups

Background. The CDC estimates that 40% of adults 50 years of age or older do not receive time-appropriate colorectal cancer screening. Sixty percent of colorectal cancer deaths could be prevented by regular screening of adults 50 years of age and older. Yet, in 2000 only 42.5% of adults age 50 or older in the U.S. had received recommended screening. Disparities by health care, nativity status, socioeconomic status, and race/ethnicity are evident. Disparities in minority, underserved populations prevent us from attaining Goal 2 of Healthy People 2010 to “eliminate health disparities.” This review focuses on community-based screening research among underserved populations that includes multiple ethnic groups for appropriate disparities analysis. There is a gap in the colorectal cancer screening literature describing the effectiveness of community-based randomized controlled trials. ^ Objective. To critically review the literature describing community-based colorectal cancer screening strategies that are randomized controlled trials, and that include multiple racial/ethnic groups. ^ Methods. The review includes a preliminary disparities analysis to assess whether interventions were appropriately targeted in communities to those groups experiencing the greatest health disparities. Review articles are from an original search using Ovid Medline and a cross-matching search in Pubmed, both from January 2001 to June 2009. The Ovid Medline literature review is divided into eight exclusionary stages, seven electronic, and the last stage consisting of final manual review. ^ Results. The final studies (n=15) are categorized into four categories: Patient mailings (n=3), Telephone outreach (n=3), Electronic/multimedia (n=4), and Counseling/community education (n=5). Of 15 studies, 11 (73%) demonstrated that screening rates increased for the intervention group compared to controls, including all studies (100%) from the Patient mailings and Telephone outreach groups, 4 of 5 (80%) Counseling/community education studies, and 1 of 4 (25%) Electronic/multimedia interventions. ^ Conclusions. Patient choice and tailoring education and/or messages to individuals have proven to be two important factors in improving colorectal cancer screening adherence rates. Technological strategies have not been overly successful with underserved populations in community-based trials. Based on limited findings to date, future community-based colorectal cancer screening trials should include diverse populations who are experiencing incidence, survival, mortality and screening disparities. ^

Using service-learning to encourage community health advocacy among high school students

The project outlined throughout this program management plan aims to develop a health-focused student advocacy group in the San Antonio Independent School District (SAISD). At its core, this project will be an opportunity for SAISD students to engage in service-learning, through which they will learn and develop by designing, organizing and participating in meaningful public health service experiences. ^ This program management plan addresses the genuine need for public health community education by using the service-learning model as a framework to engage students to effect change. The plan delineates the process by which the student advocacy group is to be assembled, selection of service-learning project, project objectives, technical objectives, and communication requirements. Ideally, the plan should help to facilitate project coordination, communication, and planning, and to support the direction of resources. The appendices that follow also provide useful tools with which to follow through with project implementation. ^ The plan is about more than providing a tool to educate students about the health issues in their community. It is about providing a way to teach health advocacy and self-interest and encourage civic engagement via public health. Students have the potential to positively effect lasting change among their peers, in their schools and in the community.^

An evaluation of a behavioral change intervention for smokeless tobacco use

During the last three decades considerable attention has been placed on the reduction of tobacco use due to cigarette smoking. During this time, studies have been funded and programs have been developed that focus on both prevention and cessation of cigarette smoking. This intense focus has led to a significant decline in cigarette smoking. But now, use of another form of tobacco--smokeless tobacco--is gaining in popularity.^ In 1989, the National Cancer Institute funded a research study at The University of Texas M. D. Anderson Cancer Center, called Working Well, to develop, implement, and evaluate worksite health promotion programs aimed at reducing cancer risks. As part of this program, a behavioral intervention for smokeless tobacco use was developed. This dissertation evaluates the impact of that behavioral change intervention for smokeless tobacco use.^ Data collected during the Working Well program were analyzed to determine the effect of the intervention. The primary outcomes analyzed were smokeless tobacco cessation, stages of change movement, and prevalence. The secondary outcomes analyzed included the prediction of smokeless tobacco use, stage movement, and cessation. Primary outcome analyses were conducted using the worksite as the unit of analysis, while the secondary analyses were conducted using the individual as the unit of analysis.^ Approximately 20% of the male population used smokeless tobacco. Results of intervention analyses indicate that the Working Well program produced no intervention effect on any of the primary outcomes. At the final observation, the experimental worksites achieved a quit rate of 27%, while the control worksites achieved a quit rate of 26% (P = 0.78). Stage movement for the experimental worksites was 49%, while the control worksites experienced stage movement of 43% (P = 0.20). The results of the analyses on smokeless tobacco prevalence followed the same pattern. Predictors of smokeless tobacco use, cessation, and stage movement were also identified.^ Based on the results found in this study, smokeless tobacco should remain a research priority. Future research should focus on smokeless tobacco use, including the identification of the determinants of smokeless tobacco use and the development of measures and effective intervention strategies. ^

Addressing teenage pregnancy in rural areas: A case study from Liberty County, Texas

This study explores the issue of teenage pregnancy in a case study of Liberty County, a rural area in Texas with no public health department. It also describes the decision-making process and barriers faced in the beginning phases of adopting a sexual education program, and sets forth an implementation plan for two school districts on disseminating an evidence-based, comprehensive curriculum. Methods include a review of epidemiological data surrounding teenage pregnancy on the national, state, and county level; a literature review of factors related to teenage pregnancy and past interventions implemented in a rural community; a policy review of past and current bills in Legislature; and an analysis of barriers and decision making in implementing an evidence based program through qualitative observations, discussions with community members during meetings, presentations, and discussions. Results of this study indicate that there is a lack of research conducted in rural areas in the field of teenage pregnancy prevention and sexual education programs. Barriers experienced in Liberty County are shown to be consistent in scientific literature such as funding, logistical issues, and problems approaching the School Board in adopting a comprehensive sexual education program. This study fills a large gap in the literature on rural adolescents and attempts to analyze the process of decision-making in a rural area related to adoption of sexual education programming. In order to relieve this health disparity, further research should focus on rural areas to gain insight on the attitudes and behaviors of rural adolescents and beliefs among community stakeholders.^

Work instability versus mental health

This contribution is part of a research on guidance and employment in La Plata , province of Buenos Aires (Argentina) undertaken jointly by the Chairs of Preventive Psychology and Vocational Guidance, both pertaining to the course of studies for Psychology at the National University of La Plata. This research is based on four axes, namely, education-work-social policies-health. This paper shall focus around the health axis, which is not provided with placement and employment services. Some unsystematical guidance experiences from the services of Adolescence and Mental Health are currently under way in the area. Research points to the existence of new demands of psychological treatment from a population ("the new poor") afraid of losing their jobs -or even unemployed- who was not in the habit of going to the public hospital. In the casuistry explored here, people afraid of losing their jobs present more psychosomatic complexities. Local population is also analysed and the said analysis is linked with several national and international research projects.

Work instability versus mental health

This contribution is part of a research on guidance and employment in La Plata , province of Buenos Aires (Argentina) undertaken jointly by the Chairs of Preventive Psychology and Vocational Guidance, both pertaining to the course of studies for Psychology at the National University of La Plata. This research is based on four axes, namely, education-work-social policies-health. This paper shall focus around the health axis, which is not provided with placement and employment services. Some unsystematical guidance experiences from the services of Adolescence and Mental Health are currently under way in the area. Research points to the existence of new demands of psychological treatment from a population ("the new poor") afraid of losing their jobs -or even unemployed- who was not in the habit of going to the public hospital. In the casuistry explored here, people afraid of losing their jobs present more psychosomatic complexities. Local population is also analysed and the said analysis is linked with several national and international research projects.

Work instability versus mental health

This contribution is part of a research on guidance and employment in La Plata , province of Buenos Aires (Argentina) undertaken jointly by the Chairs of Preventive Psychology and Vocational Guidance, both pertaining to the course of studies for Psychology at the National University of La Plata. This research is based on four axes, namely, education-work-social policies-health. This paper shall focus around the health axis, which is not provided with placement and employment services. Some unsystematical guidance experiences from the services of Adolescence and Mental Health are currently under way in the area. Research points to the existence of new demands of psychological treatment from a population ("the new poor") afraid of losing their jobs -or even unemployed- who was not in the habit of going to the public hospital. In the casuistry explored here, people afraid of losing their jobs present more psychosomatic complexities. Local population is also analysed and the said analysis is linked with several national and international research projects.