Protecting children and families from tobacco and tobacco-related NCDs in the Western Pacific: good practice examples from Malaysia, Philippines and Singapore.

BACKGROUND: Non-communicable diseases (NCDs) are generally considered diseases of adulthood, but NCD risk factors like tobacco use often are taken up during childhood and adolescence, and second-hand smoke exposure affects child survival and development. METHODS: At a regional meeting of the Asia Pacific Child and Family Health Alliance for Tobacco Control, members reviewed existing good practices of child-focused tobacco control approaches using health promotion strategies. These interventions were implemented nationally in Malaysia, the Philippines and Singapore. RESULTS: Three good practice national examples were identified that focused on creating supportive tobacco-free environments and upgrading cessation skills among paediatricians. These country examples highlight strategic areas to protect children and families from the harms of tobacco, as part of NCD prevention and control. Training paediatricians in brief cessation advice has enabled them to address tobacco-using parents. Fully enforcing smoke-free public areas has led to an increase in smoke-free homes. The Tobacco Free Generation is a tobacco control 'endgame' strategy that taps into a social movement to deglamorize tobacco use and empower youth born in and after year 2000 to reject tobacco and nicotine addiction. CONCLUSION: Tobacco control is pivotal in the fight against NCDs; health promotion strategies to protect children and youth from tobacco have a critical role to play in NCD prevention and control. Frontline health workers, including primary care paediatricians, need to step up and actively advocate for full implementation of the WHO Framework Convention on Tobacco Control, including tobacco tax increases and smoke-free areas, while monitoring patients and their parents for tobacco use and second-hand smoke exposure, preventing adolescent smoking uptake, and offering cessation support. A life-course approach incorporating child-focused efforts to prevent initiation of smoking and second-hand smoke exposure with measures promoting cessation among parents will offer the greatest chance of overcoming future tobacco-related NCD burden.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]. / Internetbasierte Interventionen in der Behandlung psychischer Störungen : Überblick, Qualitätskriterien, Perspektiven.

BACKGROUND: Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available. OBJECTIVE: The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions. METHODS: A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications. RESULTS: Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders. DISCUSSION: When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

Anaesthesia and pre-hospital emergency medicine.

Major trauma is a leading cause of death and disability in the UK, particularly in the young. Pre-hospital emergency medicine (PHEM) involves provision of immediate medical care to critically ill and injured patients, across all age ranges, often in environments that may be remote and are not only physically challenging but also limited in terms of time and resources. PHEM is now a GMC-recognised subspecialty of anaesthesia or emergency medicine and the first recognised training program in the UK commenced in August 2012. This article discusses subspeciality development in PHEM, the competency based framework for training in PHEM, and the provision of pre-hospital emergency anaesthesia.

[Ocular cicatricial pemphigoid - state of the art in clinic and therapy for a problematic disease]. / Das okuläre vernarbende Pemphigoid - aktuelle Aspekte zu Klinik und Therapie einer problematischen Erkrankung.

The ocular cicatricial pemphigoid (OCP) belongs to a family of chronically progressive autoimmune disorders, predominantly affecting mucous membranes (mucous membrane pemphigoids). It is an immunopathologically heterogeneous group of disorders with variable phenotypes that share the unique feature of a subepidermal blistering, through disruption of the adhesion between epidermis and dermis. A key feature is the chronically active inflammation with consecutive fibrosis, leading to a partial or complete loss of function of the affected organ. The ocular disease as a chronic cicatrising conjunctivitis is a common manifestation of the mucous membrane pemphigoid. The identification of the subtle pathology and the prompt initiation of an appropriate therapy are of pivotal importance. One purpose is to prevent further vision loss due to extensive corneal scarring and life-threatening systemic complications, such as the formation of oesophageal or tracheal strictures. So far there are no prospective, randomised studies, regarding the therapy guidelines with an evidence level more than III. The autoimmune nature of the disease implies that systemic immunosuppression is the only effective treatment option, most notably in extended stages. The aim of our study is to give a guideline for a stage adjusted therapy with conventional immunosuppressants and to give a perspective for alternative therapies, especially for recalcitrant disease.

[Processing of medical products in the urological practice]. / Aufbereitung von Medizinprodukten in der urologischen Praxis.

The reprocessing of medical products is an important topic both in urological practices and in hospitals. The complexity is caused by the increasing variety of medical instruments and also by the increasing demands on the legally required quality of the reprocessing. The Robert Koch Institute (RKI) and the Federal Institute for Drugs and Medical Devices (BfArM) have published recommendations for the processing of MD and last updated them in 2012. This article summarizes the legal framework for the reprocessing of medical devices, how medical devices are categorized before the appropriate procedure for reprocessing can be selected and the various steps in the reprocessing. A special focus is placed on medical products that are typically found in urological practices or outpatient departments and are processed there. Furthermore, the necessity of validating the processing method and the required training (expertise) of the personnel are discussed.

Perioperative care of the older patient.

Nearly 60% of the Dutch population undergoing surgery is aged 65 years and over. Older patients are at increased risk of developing perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital stay or death. Preoperative risk stratification calculates a patient's risk by evaluating the presence and extent of frailty, pathophysiological risk factors, type of surgery, and the results of (additional) testing. Type of anesthesia, fluid management, and pain management affect outcome of surgery. Recent developments focus on multimodal perioperative care of the older patient, using minimally invasive surgery, postoperative anesthesiology rounds, and early geriatric consultation.

Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve patient psychomotor skills.

BACKGROUND: Early recovery of patients following sedation/analgesia and anesthesia is important in ambulatory practice. The aim of this study was to assess whether modafinil, used for the treatment of narcolepsy, improves recovery following sedation/analgesia. METHODS: Patients scheduled for extracorporeal shock wave lithotripsy were randomly assigned to one of four groups. Two groups received a combination of fentanyl/midazolam with either modafinil or placebo. The remaining groups received remifentanil/propofol with either modafinil or placebo. Modafinil 200 mg was administered to the treatment group patients 1 h before sedation/analgesia. Groups were compared using the digital symbol substitution test (DSST), trail making test (TMT), observer scale of sedation and analgesia (OAA/S) and Aldrete score. Verbal rating scale (VRS) scores for secondary outcome variables e.g. energy, tiredness and dizziness were also recorded before and after treatment. RESULTS: Sixty-seven patients successfully completed the study. Groups received similar doses of sedation and analgesic drugs. No statistically significant difference was found for DSST between groups. No significant adverse effects occurred in relation to modafinil. No statistically significant difference between groups was identified for TMT, OAA/S and Aldrete scores. The mean VRS score for tiredness was lesser in the modafinil/fentanyl/midazolam group [1.3 (2.0)] compared with the placebo group [3.8 (2.5)], P=0.02. Such a difference was not found between the remifentanil/propofol groups [placebo 2.6 (2.2) vs. modafinil 3.1(2.7)], p>0.05. Dizziness was greater in the modafinil/remifentanil/propofol group 1.7 (2.0) vs. placebo 0.0 (0.5), p<0.05. CONCLUSION: Modafinil reduces patient-reported tiredness after sedation/analgesia but does not improve recovery in terms of objective measures of patient psychomotor skills.

Best practice recommendations: ENT consultations during the COVID-19 pandemic.

These best practice recommendations for ENT consultations during the COVID-19 pandemic have been drawn up because ENT examinations and treatments are at risk of contamination by the SARS-Cov-2 virus in certain instances. Thus, ENT specialists are among the professionals who are most exposed to this infection. During the pandemic, insofar as an asymptomatic patient may be infected and contagious, the same precautions must be employed whether the patient is ill with, suspected of having, or without any clinical evidence of COVID-19 infection. According to the scientific data available, the examinations and procedures potentially exposing to projections/aerosolizations of organic material of human origin are considered to be at risk of staff contamination. For ENT examinations and procedures without exposure to such projections/aerosolizations, the professional is advised to a long sleeve clean outfit, a surgical mask and gloves in case of contact with the patient's mucosa. ENT examinations and procedures with exposure to these projections/aerosolizations require the so-called "airborne", "contact", and "droplets" additional precautions: FFP2/N95 respiratory protection device, eye protection, disposable headwear and long sleeve overgown.

[Urological infections and antibiotic management in geriatric patients]. / Urologische Infektionen und Antibiotikamanagement bei geriatrischen Patienten.

Both the demographic shift and progress in medicine are resulting in an increasingly longer life expectancy. It is presumed that a mean age of 90 years will be achieved within the next decade in many countries. Thus, geriatric medicine, which is committed to the specific needs of older, often frail and frequently comorbid patients, is becoming increasingly more important. The prevalence of infections of the genitourinary tract increases with age, simultaneously, a critical and conscious use of antibiotics is required in terms of antimicrobial treatment. The intention of the present review is to make the reader aware of the specific characteristics of urinary tract infections and asymptomatic bacteriuria in the older patient population in terms of epidemiology, spectrum of pathogens and resistance as well as the indications for and performance of antimicrobial treatment.

[Ureterorenoscopy]. / Ureterorenoskopie.

Ureterorenoscopy (URS) is a minimally invasive treatment option for removal of kidney stones, which has gained importance in this field over the past two decades. This technique has replaced extracorporeal shock wave lithotripsy (ESWL) stone surgery for many indications. It is also particularly important in the diagnostics and treatment for tumors of the upper urinary tract. This article describes the indications, surgical technique and management of complications of URS.

[Operative technique for percutaneous nephrolithotomy]. / Operative Technik der perkutanen Steintherapie.

Percutaneous nephrolithotomy (PCNL) is a well-established minimally invasive treatment option for removal of kidney stones. This technique has now replaced open stone surgery for virtually all indications. This article describes the indications, the surgical technique and the complication management of PCNL.

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

[Atypical genesis of anterior ischemic optic neuropathy]. / Atypische Genese einer anterioren ischämischen Optikusneuropathie.

BACKGROUND: This article presents a case of arteritic anterior ischemic optic neuropathy as a manifestation of granulomatosis with polyangiitis (GPA). CASE REPORT: A 52-year-old woman suffered acute unilateral vision loss. Besides a unilateral papillary edema, serological investigations revealed elevated inflammation parameters with a positive (cytoplasmic) anti-neutrophil cytoplasmic autoantibodies (c-ANCA) titer. In addition to the occurrence of pulmonary nodules and cavitary lesions this is indicative for the diagnosis of GPA. RESULTS: Treatment with cyclophosphamide and prednisolone led to a rapid regression of inflammation parameters but no visual improvement occurred.

Emerging perspectives in management and prevention of infections of the respiratory tract in infants and children.

New products, new procedures, new information, and new legislation will have a significant impact on management and prevention of respiratory infections in children. Current areas of investigation include the changing epidemiology (increased number of children in day care), concern about morbidity of common infections (hearing impairment and effect on development of speech and language due to otitis media), and new modes of microbiologic diagnosis (antigen detection). New antimicrobial agents have wider spectrums of activity, increased concentrations in body fluids, and lesser toxicity than available drugs. New uses of old drugs are identified (value of erythromycin for Legionella pneumophila, Chlamydia trachomatis, and Mycoplasma pneumoniae). Increased usage of chemoprophylaxis for prevention of recurrences of acute otitis media follows publication of impressive results of recent studies. New conjugate polysaccharide vaccines are immunogenic in young infants. Finally, and of major importance to children, physicians, and manufacturers, is vaccine liability legislation, now in congressional committee.

Candy cigarettes: do they encourage children's smoking?

Candy and bubble gum cigarettes are packaged to resemble cigarette brands, and so they may encourage young children to smoke. Two studies of the role of these products in the development of children's attitudes and behaviors toward smoking were conducted. In the first study, six focus group interviews were conducted with 25 children in three age groups (4 through 5, 6 through 8, and 9 through 11 years old). Children in each group were shown five candy and snack foods and asked about their opinions and experiences with each item. In the second study, 195 seventh-grade students in a southeastern city school system were surveyed about their cigarette smoking and candy cigarette use. In the focus groups, candy cigarettes were recognized by most children. Young children played with the candy cigarettes more than with other candy or snack items and made general references to smoking behaviors. Older children made favorable references to smoking behavior; most knew which stores sold candy cigarettes, and many had chosen to buy and use these items, despite parental disapproval. Candy cigarettes may play a role in the development of children's attitudes toward smoking as an acceptable, favorable, or normative behavior. Elimination of these products should be part of efforts to prevent initiation of smoking by children.

Adolescents' risky behavior and mass media use.

OBJECTIVE: To understand better the relationship between adolescents' use of the mass media (including television, radio, and magazines) and their risky or unhealthy behaviors. DESIGN: Secondary data analysis of a 1987 in-home survey of 2760 randomly selected 14- to 16-year-old adolescents in 10 urban areas in the southeastern United States. MEASUREMENT: The extent of participation in eight potentially risky behaviors (sexual intercourse, drinking, smoking cigarettes, smoking marijuana, cheating, stealing, cutting class, and driving a car without permission) and the use of a variety of mass media. RESULTS: Adolescents who had engaged in more risky behaviors listened to radio and watched music videos and movies on television more frequently than those who had engaged in fewer risky behaviors, regardless of race, gender, or parents' education. White male adolescents who reported engaging in five or more risky behaviors were most likely to name a heavy metal music group as their favorite. Adolescents reported reading a wide diversity of magazines, and most reported reading at least one of a few selected magazines. Sports and music magazines were most likely to be read by adolescents who had engaged in many risky behaviors. CONCLUSIONS: Mass media health promotion efforts could more specifically target adolescents who are engaging in multiple risky behaviors.

Management of otitis media: 2000 and beyond.

BACKGROUND: In the next few years what will alter our modes of diagnosis, choice of therapies and strategies for prevention of acute otitis media (AOM)? These issues, as well as whether antibiotic resistance will continue to threaten the efficacy of currently available antimicrobial agents, whether industry and academia will be able to respond to bacterial resistance with effective new antimicrobial drugs and whether the pneumococcal conjugate vaccine will substantially reduce the incidence of AOM provide a basis for discussing the problems and possible solutions related to AOM. ANTIMICROBIAL DRUGS: Bacteria and viruses will continue to find ways to survive the activity of currently available antimicrobial drugs. Among the new antibacterial drugs under consideration are ketolides, oxazolodinones and quinolones. Guidelines stress limiting usage of antimicrobial agents to diseases that are likely caused by bacterial pathogens. Antiviral drugs are now available against influenza virus and respiratory syncytial virus infections. DIAGNOSIS: Tympanometry and/or acoustic reflectometry are adjunctive techniques for assisting in the diagnosis of middle ear effusion in children whose otoscopic examination is ambiguous. Laser myringotomy has been used in several hundred children; however, there are no published studies of randomized trials. NEW VACCINES: Investigators have evaluated the safety and efficacy of a heptavalent pneumococcal polysaccharide vaccine conjugated with CRM197 (a diphtheria toxin mutant). The results showed a reduction in the overall burden of severe and recurrent AOM. Respiratory syncytial virus is the viral pathogen most frequently associated with AOM. For this reason safe and effective viral vaccines are needed to complement the efficacy of bacterial vaccines for prevention of AOM. CONCLUSIONS: Parents influence decisions by pediatricians to use antimicrobial agents and should be informed about the appropriate usage of antibiotics. Educators and public health officials must find techniques to distinguish WebSites that provide information of value from those that are not credible. Of paramount importance is the development of techniques to increase the accuracy of clinical and microbiologic diagnosis. Finally there is a need for studies of appropriate scientific design that can assess the efficacy and safety of alternative therapies.

Adolescents who use the emergency department as their usual source of care.

OBJECTIVE: To examine the factors associated with use of the emergency department (ED) as the only source of health care among adolescents. DESIGN: Analyses of the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of 6748 in-school male and female adolescents in 5th through 12th grade. The X2 statistics and logistic regression analyses were computed with the use of SUDAAN. RESULTS: Overall, 4.6% of the adolescents in the survey, or 1.5 million adolescents in the United States, reported that the ED was their usual source of health care. In multivariate models, factors associated with the use of the ED included male sex, African American ethnicity, fewer financial resources, and living in a rural area. Adolescents with higher levels of risky behaviors, a history of physical or sexual abuse, and higher depression scores were all more likely to use the ED as their usual source of care. Adolescents who reported using the ED as their usual care source were also less likely to have had regular well visits and were more likely to report having missed needed care than those with other sources of primary care. CONCLUSIONS: Adolescents who use the ED as their usual source of care are often from vulnerable populations. Many have special mental or physical needs that are unlikely to be met with ED visits only, and they are likely to have missed care they needed. Creating linkages between EDs and other services could help at-risk adolescents identify and use more appropriate sources of primary care.

Effect of intraabdominal pressure elevation and positioning on hemodynamic responses during carbon dioxide pneumoperitoneum for laparoscopic donor nephrectomy: a prospective controlled clinical study.

BACKGROUND: Carbon dioxide (CO2) pneumoperitoneum (PP) increases mean arterial blood pressure (MAP) and systemic vascular resistance (SVR) but decreases stroke volume (SV) and cardiac output (CO). This study evaluated the hemodynamic effects of elevated intraabdominal pressure (IAP) occurring during laparoscopic donor nephrectomy (LDN). METHODS: Twenty-two patients undergoing LDN were investigated and hemodynamic parameters, P(v)CO2) (carbon dioxide partial pressure), and VCO2 (carbon dioxide production) were monitored during the procedure. Before and after PP, IAP was raised from 12 to 20 mmHg and the hemodynamic effects were measured every 30 s. RESULTS: During IAP of 12 mmHg and stable serum CO2, there was no change in SV compared to preinsufflation levels. When IAP was elevated from 12 to 20 mmHg, SV initially decreased (p < 05), followed by an increase in MAP and SVR (p < 0.05). CONCLUSION: This study shows that with the fluid and ventilation protocol used, PP has no significant effect on SV at an IAP of 12 mmHg, whereas increasing IAP to 20 mmHg does. In this study, the hemodynamic effects induced by CO2 PP of 12 mmHg are not due to changes in serum CO2. Compression of the venous system during a PP of 20 mmHg reduces preload, with an subsequent increase in SVR.

Intervention to reduce environmental tobacco smoke exposure in Latino children: null effects on hair biomarkers and parent reports.

OBJECTIVE: To evaluate the effectiveness of a lay delivered intervention to reduce Latino children's exposure to environmental tobacco smoke (ETS). The a priori hypothesis was that children living in households that were in the intervention group would have lower exposure over time than measurement only controls. DESIGN: A two group, randomised control trial was conducted. SETTING: Areas of San Diego county with a large Latino population. PARTICIPANTS: 143 Latino parent-child pairs. INTERVENTION: Trained bicultural and bilingual Latina lay community health advisors, or promotoras, conducted problem solving aimed at lowering the target child's exposure to ETS in the household. Six home and telephone sessions were delivered by the promotoras over a four month period. MAIN OUTCOME MEASURES: Outcome measures were collected at baseline, immediately post-intervention, three months post-intervention, and 12 months post-intervention. Four outcomes were considered: (1) parent's paper-and-pencil reports of the child's past month exposure; (2) hair samples from the child analysed for past month nicotine; (3) hair samples from the child analysed for past month cotinine; and (4) per cent confirmed reducers. RESULTS: There were no significant condition-by-time interactions, the term indicative of a differential intervention effect. Significant or near significant time main effects were seen for children's hair cotinine, per cent confirmed reducers, and, in particular, parent reports of exposure. CONCLUSIONS: Applying a lay promotora model to deliver the behavioural problem solving intervention unfortunately was not effective. A likely explanation relates to the difficulty of delivering a relatively complex intervention by lay women untrained in behaviour change theory and research methods.