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PubMed1998

Contribution of smoking to excess mortality in Harlem.

The New York City neighborhood of Harlem has mortality rates that are among the highest in the United States. In absolute numbers, cardiovascular disease and cancer account for the overwhelming majority of deaths, especially among men, and these deaths occur at relatively young ages. The aim of this research was to examine self-reported smoking habits according to measures of socioeconomic status among Harlem men and women, in order to estimate the contribution of tobacco consumption to Harlem's remarkably high excess mortality. During 1992-1994, in-person interviews were conducted among 695 Harlem adults aged 18-65 years who were randomly selected from dwelling unit enumeration lists. The self-reported prevalence of current smoking was strikingly high among both men (48%) and women (41%), even among highly educated men (38%). The 21% of respondents without working telephones reported an even higher prevalence of current smoking (61%), indicating that national and state-based estimates which rely on telephone surveys may seriously underestimate the prevalence of smoking in poor urban communities. Among persons aged 35-64 years, the smoking attributable fractions for selected causes of death were larger in Harlem than in either New York City as a whole or the entire United States for both men and women. Tobacco consumption is likely to be one of several important mediators of the high numbers of premature deaths in Harlem.

Adolescent↗

PubMed1999

Increased reading speed for stories presented during general anesthesia.

BACKGROUND: In the absence of explicit memories such as the recall and recognition of intraoperative events, memory of auditory information played during general anesthesia has been demonstrated with several tests of implicit memory. In contrast to explicit memory, which requires conscious recollection, implicit memory does not require recollection of previous experiences and is evidenced by a priming effect on task performance. The authors evaluated the effect of a standardized anesthetic technique on implicit memory, first using a word stem completion task, and then a reading speed task in a subsequent study. METHODS: While undergoing lumbar disc surgery, 60 patients were exposed to auditory materials via headphones in two successive experiments. A balanced intravenous technique with propofol and alfentanil infusions and a nitrous oxide-oxygen mixture was used to maintain adequate anesthesia. In the first experiment, 30 patients were exposed randomly to one of the two lists of 34 repeated German nouns; in the second experiment, 30 patients were exposed to one of two tapes containing two short stories. Thirty control patients for each experiment heard the tapes without receiving anesthesia. All patients were tested for implicit memory 6-8 h later: A word stem completion task for the words and a reading speed task for the stories were used as measures of implicit memory. RESULTS: The control group completed the word stems significantly more often with the words that they had heard previously, but no such effect was found in the anesthetized group. However, both the control and patient groups showed a decreased reading time of about 40 ms per word for the previously presented stories compared with the new stories. The patients had no explicit memory of intraoperative events. CONCLUSIONS: Implicit memory was demonstrated after anesthesia by the reading speed task but not by the word stem completion task. Some methodologic aspects, such as using low frequency words or varying study and test modalities, may account for the negative results of the word stem completion task. Another explanation is that anesthesia with propofol, alfentanil, and nitrous oxide suppressed the word priming but not the reading speed measure of implicit memory. The reading speed paradigm seems to provide a stable and reliable measurement of implicit memory.

Adult↗

PubMed2004

Prevalence of child and adolescent psychiatric disorders in southeast Brazil.

OBJECTIVE: To describe the prevalence of DSM-IV disorders and the pattern of comorbidity in a population-based sample of 7- to 14-year-old Brazilian schoolchildren. METHOD: Random sampling of schools (stratified into private, public rural, and public urban) was followed by random sampling of pupils from school lists. In 2000-2001, a total of 1,251 children were assessed for DSM-IV diagnoses using the Development and Well-Being Assessment, a structured multiinformant assessment supplemented by verbatim reports reviewed by clinicians. RESULTS: The response rate was 83%. The overall prevalence of DSM-IV disorders was 12.7% (95% confidence interval = 9.8%-15.5%), with 3.5% of children being assigned as not otherwise specified rather than operationalized diagnoses. The overall prevalence of psychiatric disorder was significantly higher than in a British study with the same measures and diagnostic procedures (12.7% versus 9.7%, p =.02). CONCLUSIONS: Approximately one in eight schoolchildren in the study area in the southeast of Brazil have psychiatric disorders involving a level of distress or social impairment likely to warrant treatment. The gulf between need and provision is currently vast.

Adolescent↗

PubMed2005

Unscheduled revisits to a pediatric emergency department: risk factors for children with fever or infection-related complaints.

OBJECTIVE: Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV. METHODS: This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV. RESULTS: Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10). CONCLUSIONS: These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.

Case-Control Studies↗

PubMed2006

Preferences for aspects of a dermatology consultation.

BACKGROUND: General practitioners with special interests (GPSIs) are increasingly being used to provide dermatology services in the U.K. Little is known about U.K. dermatology patient attitudes to proposed variations in secondary care service delivery or the values they attach to aspects of the care they receive. OBJECTIVES: To quantify preferences for different attributes of care within dermatology secondary care services. METHODS: Attributes of care that are important to dermatology patients were derived using in-depth qualitative interviews with 19 patients at different points in the care pathway. A discrete choice experiment using 'best-worst scaling' was sent by post to 119 patients referred to secondary care dermatology services and suitable for GPSI care who had agreed to participate in research. RESULTS: Four attributes were derived from the qualitative work: waiting, expertise, thorough care and convenience. For the discrete choice experiment, 99 patients returned questionnaires, 93 of which contained sufficient data for analysis. All attributes were found to be quantitatively important. The attribute of greatest importance was expertise of the doctor, while waiting time was of least importance. Respondents were willing to wait longer than the current 3 months maximum to receive care that was thorough, 2.1 months to see a team led by an expert and 1.3 months to attend a consultation that is easy to get to. CONCLUSIONS: Although the need to reduce outpatient waiting times is a key policy driver behind the expansion of GPSI services, this does not appear to be the most important issue for patients. The thoroughness with which the consultation is provided and the expertise of the clinician seen are higher priorities.

Attitude to Health↗

PubMed2005

Double-blind randomized controlled study of coblation tonsillotomy versus coblation tonsillectomy on postoperative pain in children.

OBJECTIVES: The purpose of this study was to establish if children experienced any difference in pain, between coblation tonsillectomy and coblation tonsillotomy. DESIGN: A double-blind randomized controlled trial was performed. SETTING: District general hospital department of Otolaryngology. PARTICIPANTS: Eighteen children listed for tonsillectomy were recruited into the study. Each was randomly assigned either tonsillotomy or tonsillectomy in the right tonsil. The contralateral tonsil was removed by the other method. In the first 24-h period (while in hospital) the children were interviewed at 2, 5, 10 and 24 h to quantify the pain they perceived in right and left sides. There was a four point visual analogue scoring system for monitoring pain. The power of the study was 80%. In this study the patients were their own controls. MAIN OUTCOME MEASURES: Visual analogue pain scores were plotted against time and the area under the curves was calculated (AUC). RESULTS: The AUC mean difference was 0.47. A t-test for the difference gives a P-value of 0.85 and a 95% confidence interval for difference is -0.79 to 5.73, which clearly contains zero. Using AUC as a combined pain score there is no statistically significant difference between tonsillotomy and tonsillectomy (power value of 80%). CONCLUSIONS: There is no demonstrable statistical difference between techniques when measuring pain experienced by children in the 24-h postoperative period.

Acute Disease↗

PubMed2006

Reports of birthweight by adolescents and their mothers: comparing accuracy and identifying correlates.

Birthweight is associated with health outcomes throughout the lifespan. Official birthweight records are not always available, and researchers must rely on self-reports for birthweight information. This study evaluates the accuracy of adolescent self-reports of birthweight, using medical records as a standard, and compares it with maternal reports. It also examines potential correlates of accuracy. Respondents are 17-year-old adolescents and their mothers, who participated in a follow-up study of randomly selected samples from newborn discharge lists (1983-85) of two major hospitals in south-east Michigan. Nearly one-quarter of the adolescents stated that they did not know their own birthweight, with males twice as likely as females to respond 'don't know'. In addition, self-reports of birthweight among the remaining adolescents were inaccurate, and accuracy was inversely related to birthweight. While maternal reports of offspring's birthweight are highly accurate across diverse subgroups of the population, adolescent self-reports of birthweight are unlikely to be useful in medical research.

Adolescent↗

PubMed1995

Prevalence of asthma and asthma symptoms in a general population sample from northern Italy. European Community Respiratory Health Survey--Italy.

The European Community Respiratory Health Survey is an international survey of the general population which aims to establish whether there are significant variations in the prevalence of asthma among European countries. The present paper reports the prevalence of asthma and asthma-like symptoms in a sample of subjects living in three areas of northern Italy: Turin, Pavia, and Verona. Samples of residents 20-44 years old (3000 subjects in Turin and Verona and 1000 in Pavia) stratified by sex (M:F = 1/1) were randomly selected from local health authority lists in the three participating areas. To correct the observed prevalence estimate for nonresponse bias, a method proposed by Drane was applied. Of the sampled subjects, 86% (6031) participated in the survey. Two different definitions of asthma were adopted: 1) prevalence of asthma attack in the last 12 months; 2) prevalence of asthma attack or treatment with antiasthmatic drugs, or both wheezing apart from the common cold and wheezing with shortness of breath. This combination of symptoms has been called current asthma. According to these definitions, the prevalence of asthma attack was 3.47% (3.74% in men and 3.14% in women), and the prevalence of current asthma was 5.01% (5.07% in men and 4.90% in women). The lowest prevalence was found in Pavia; the highest in Turin. Our findings support the hypothesis that the difference in prevalence reflects the difference in mortality.

Adult↗

PubMed1996

Important components of antenatal care: midwives' and obstetricians views.

This study sought the views of midwives and obstetricians about what they considered to be important aspects of routine antenatal care. Midwives and obstetricians were randomly selected from the NSW membership lists of the Australian College of Midwives and the The Royal Australian College of Obstetricians and Gynaecologists, respectively. Seventy-eight percent of midwives (n = 196) and 52% of obstetricians (n = 114) completed a questionnaire which itemised components of routine care derived from the National Health and Medical Research Council's Guidelines for Antenatal Care. Participants were asked to rate each of the 77 components on a 4-point scale as either: very important; desirable but not essential; not necessary; or, don't know. Twenty-four (31%) of the components were rated as very important by at least 90% of midwives and 19 (22%) were rated as very important by at least 90% of obstetricians. 'Recording details of previous pregnancy complications' was the component most commonly rated as being very important by both groups. On 37 (48%) of the components there was a significant difference between midwives and obstetricians in terms of whether or not they rated the component as very important (p < 0.01). There were considerable differences between midwives' and obstetricians' views about the important components of routine antenatal care and a substantial proportion of both groups did not consider many of the components listed in the guidelines to be essential in routine care. The findings suggest that a revision of the current antenatal care guidelines is necessary.

Attitude of Health Personnel↗

PubMed1993

Oral disease and physical disability in community-dwelling older persons.

OBJECTIVE: The aim of this epidemiologic investigation was to determine whether poor oral health in older persons was associated with physical disability. DESIGN: The study was a cross-sectional survey involving in-home interviews and dental examinations of older persons. SETTING: A random sample of 68 cities and towns was selected from the six New England states, with stratification according to population size. PARTICIPANTS: The study sample consisted of 1,156 community-dwelling (non-institutionalized) individuals aged 70 and over, randomly selected from the Medicare beneficiary lists for each city and town. MEASUREMENTS: Oral health was assessed by three dichotomous indices: edentulism (no teeth); current caries, including either coronal or root decay; and periodontal disease, as measured by gingival pocket depth. Physical disability was indicated by the subject's self-report of difficulty in the areas of personal care (eating, bathing, dressing, and using the toilet) and mobility (walking, bed transfer, getting outside). Additional independent variables included age, sex, number of teeth, education, living alone, oral hygiene practices, and time since last dental visit. RESULTS: We found a direct association between specific areas of physical disability and current caries and edentulism. The risk of poor oral health did not increase with advancing age once the related risk factors were controlled for. Those subjects with mobility disabilities were at increased risk of tooth loss; those with personal care limitations were at increased risk of current caries. CONCLUSIONS: Physical disability should be added to the list of known risk factors for oral disease among the older population. Our findings call attention to the need for health care providers to screen for oral health problems among disabled older persons. Further gerontologic research is needed to identify the mechanisms linking physical disability with oral disease in older persons.

Activities of Daily Living↗

PubMed2006

Knowledge and practices of Ohio nurse practitioners regarding food access of patients.

PURPOSES: To assess the self-identified food security knowledge and practices of nurse practitioners (NPs) in Ohio and the relationships of food security knowledge and practices to NP characteristics. DATA SOURCES: This study utilized a survey approach for data collection. Participants were licensed NPs with prescriptive authority in Ohio who were randomly selected from the Ohio licensure list and responded to a questionnaire (n= 288) with demographic and food security-related questions. CONCLUSIONS: Less than one third of respondents agreed or strongly agreed that they were knowledgeable about the topic of food security. Education of NPs about food insecurity and about incorporation of food security principles into the healthcare process is needed. IMPLICATIONS FOR PRACTICE: Food insecurity can negatively impact compliance to prescribed treatments. NPs should address food security issues in order to provide specialized, individualized care to patients in order to achieve positive outcomes. Through evaluation of patients' food access, and factors that are related to food insecurity, this can be achieved.

Adult↗

PubMed1985

Mechanical output and iEMG of isokinetic plantar flexion in 40-64-year-old subjects.

Peak torque (PT), contractional work (CW) and mean power of isokinetic plantar flexions were measured in unselected, clinically healthy subjects, randomly chosen from the official census lists of Umeå, in three age groups: 40-44, 50-54 and 60-64 years. Simultaneous recordings of integrated electromyograms (iEMG) were obtained by surface electrodes from all three heads of the m. triceps surae. PT and CW decreased exponentially with increasing velocity of angular motion and at 60 degrees X s-1 (r2 = 0.79 and 0.63, respectively) were adequately determined by crural circumference, age and sex. The muscular output declined with increasing age. Both output and iEMG showed an approximate 3:2 male:female ratio. Therefore, the ratio CW/iEMG was age, but not sex-dependent at any given velocity of angular motion. Independently of this age, the iEMGs were inversely proportional to velocity of angular motion, while iEMG/manoeuvre time was constant indicating that torque/velocity and work/velocity exponential relationships are mainly determined by muscular properties. Based on the literature it is suggested that the dependence of the measured parameters on age and sex is determined by muscular properties, rather than by the central nervous system. Moreover, the CW/iEMG ratio appears to provide a comprehensive picture of excitation and mechanical output of the muscle group studied and may therefore be a useful measure.

Adult↗

PubMed2004

Risk factors of acute endophthalmitis after cataract extraction: a case-control study in Asian eyes.

AIM: To describe risk factors of acute endophthalmitis after cataract extraction in an Asian population. METHODS: A retrospective, case-control study. Cases (n = 34) were patients with acute endophthalmitis presenting within 6 weeks after cataract surgery. Three controls per case (n = 102) were randomly selected from the cataract surgery list matched on the date of operation of cases. RESULTS: Few risk factors were identified. In multivariable analysis, endophthalmitis was associated with silicone intraocular lens (odds ratio 5.1, 95% confidence intervals, 1.2 to 21.6, compared to poly(methylmethacrylate) lens) and posterior capsular rupture during surgery (odds ratio 20.9, 95% confidence intervals 2.3 to 187.9). CONCLUSION: Silicone intraocular lens and rupture of the posterior capsule are risk factors of acute endophthalmitis after cataract surgery.

Acute Disease↗

PubMed1991

Penicillin prophylaxis in children with sickle cell disease in Brent.

OBJECTIVE: To assess compliance with oral penicillin prophylaxis in children with sickle cell disease and identify possible reasons for poor compliance. DESIGN: Closed questionnaires given to parents of children with sickle cell disease and general practitioners in Brent. Urine samples from 23 children were tested for penicillin. SETTING: Paediatric haematology clinic, Central Middlesex Hospital, and general practices in Brent. SUBJECTS: 50 children (aged less than or equal to 16) attending clinic with sickle cell disease over six months (33 HbSS, 12 HbSC, five HbS beta thalassaemia). 30 general practitioners: 15 with the greatest number of patients with sickle cell disease on the Brent register; 15 selected randomly from family practitioner committee's list. MAIN OUTCOME MEASURES: Reported compliance with and awareness of importance of penicillin prophylaxis. Results of urine tests for penicillin. RESULTS: 31 parents claimed that their children received penicillin every day and 19 that they received it most days (greater than or equal to 5 days a week). Penicillin was detected in only 10 of 23 urine samples tested. Parents and doctors seemed not to appreciate the importance of treatment: only eight parents were aware of the risk of death if penicillin were discontinued, and 16 doctors were unaware that regular penicillin prophylaxis prevents pneumococcal septicaemia and death in these children. CONCLUSIONS: Education for families with children with sickle cell disease must be improved. Specialised information and training are needed for doctors working in areas with a high prevalence of the disorder.

Administration, Oral↗

PubMed1992

Job stress, satisfaction, and mental health among general practitioners before and after introduction of new contract.

OBJECTIVE: To compare measures of job stress, job satisfaction, and mental health among general practitioners before and after the introduction of the new contract in April 1990. DESIGN: Cross sectional postal questionnaire survey in July 1990. Comparison of results with those obtained in previous survey in November 1987. SETTING: General practice in United Kingdom. SUBJECTS: 1500 general practitioners randomly selected from general medical services lists, 917 of whom (61%) returned questionnaires usable for statistical analysis. MAIN OUTCOME MEASURES: Aspects of job causing stress, job satisfaction (Warr, Cook, and Wall scale), and mental health (Crown-Crisp experiential index). RESULTS: Compared with 1987, in 1990 doctors experienced more stress from night calls (mean score 3.83 in 1990 v 3.45 in 1987), emergencies during surgery hours (3.72 v 3.48), and interruption of family life by telephone (3.58 v 2.73; p less than 0.001 for all three variables). Scores for somatic anxiety and depression were higher in both men and women in 1990 (men: somatic anxiety 3.12 v 2.36; depression 3.80 v 2.94; women: somatic anxiety 3.56 v 2.65; depression 4.02 v 3.37; p less than 0.001). Job satisfaction had also decreased in 1990 (5.23 v 4.26; p less than 0.001). CONCLUSIONS: Doctors experienced more stress, less job satisfaction, and poorer mental health in 1990 than in 1987. These changes may have resulted from the introduction of the new contract.

Adult↗

PubMed1992

Validating the SF-36 health survey questionnaire: new outcome measure for primary care.

OBJECTIVES: To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile. DESIGN: Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two weeks after the first mailing. SETTING: Two general practices in Sheffield. PATIENTS: 1980 patients aged 16-74 years randomly selected from the two practice lists. MAIN OUTCOME MEASURES: Scores for each health dimension on the SF-36 questionnaire and the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics. RESULTS: The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile. CONCLUSIONS: The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.

Adolescent↗

PubMed1993

Microalbuminuria: associations with height and sex in non-diabetic subjects.

OBJECTIVES: To study the association(s) between microalbuminuria and cardiovascular risk factors in non-diabetic subjects. DESIGN: Patients aged 40-75 years were randomly selected from a general practice list and invited to participate. SETTING: Health centre in inner city London. SUBJECTS: Of those invited, 1046 out of 1671 (62.6%) attended. Subjects were excluded for the following reasons: not being white (44); urinary albumin excretion rate > 200 micrograms/min (3); having a urinary infection (5); taking penicillamine or angiotensin converting enzyme inhibitors (7); older than 75 (2); having diabetes (25); missing data on glucose concentration (1). MAIN OUTCOME MEASURES: Glucose tolerance test results, albumin excretion rate from overnight and timed morning collections of urine; blood pressure; height. RESULTS: Mean albumin excretion rate was significantly lower in women than men (mean ratio 0.8, 95% confidence interval (0.69 to 0.91)). Mean albumin excretion rate was significantly associated with age, blood pressure, and blood glucose concentration (fasting, 1 hour, and 2 hour) in men and inversely with height. Men who had microalbuminuria in both samples were significantly shorter (by 5 cm (1.3 to 9.3 cm)) than those who had no microalbuminuria in either sample when age was taken into account. In the case of women only systolic pressure was significantly associated with albumin excretion rate. CONCLUSIONS: Microalbuminuria and short stature in men are associated. Cardiovascular risk has been associated with both of these factors and with lower birth weight. The inverse association of microalbuminuria with height is compatible with the suggestion that factors operating in utero or early childhood are implicated in cardiovascular disease. The higher prevalence of microalbuminuria in men compared with women may indicate that sex differences in cardiovascular risk are reflected in differences in albumin excretion rate.

Adult↗

PubMed2003

Effectiveness of out-of-home day care for disadvantaged families: randomised controlled trial.

OBJECTIVE: To assess the effects of providing daycare facilities for young children on the health and welfare of disadvantaged families. DESIGN: Randomised controlled trial. Eligible children from the application list to a daycare facility were randomly allocated to receive a daycare place or not. SETTING: Early Years daycare centre in Borough of Hackney, London. PARTICIPANTS: 120 mothers and 143 eligible children (aged between 6 months and 3.5 years). INTERVENTION: A place at the centre, which provided high quality day care. Control families used other child care that they secured for themselves. MAIN OUTCOME MEASURES: Maternal paid employment, household income, child health and development. RESULTS: At 18 months' follow up, 67% of intervention group mothers and 60% of control group mothers were in paid employment (adjusted risk ratio 1.23 (95% confidence interval 0.99 to 1.52)), but were no more likely to have a weekly household income of above pound 200 (risk ratio 0.88 (0.70 to 1.09)). Intervention group children had more otitis media with effusion (risk ratio 1.74 (1.02 to 2.96)) and used more health services (1.58 (1.05 to 2.38)), but both estimates were imprecise. CONCLUSION: The provision of child day care may have increased maternal employment, but it did not seem to increase household income. The results suggest that providing day care may be insufficient as a strategy to reduce poverty. The study shows how random allocation can be used to ration and evaluate interventions where demand exceeds supply.

Child Day Care Centers↗