The influence of socio-economic deprivation on tuberculosis treatment delays in England, 2000-2005.

This study investigates the association between socio-economic deprivation and tuberculosis (TB) treatment delays in England, 2000-2005. Patients reported to the Enhanced TB Surveillance system were assigned a deprivation score based on residential postcode, and categorized into deprivation quartiles. Data were analysed using Cox regression. The median interval from symptom onset to treatment initiation was 67 days (inter-quartile range 30-131). The effect of deprivation on this interval was modified by ethnic group and place of birth/time since entry into the United Kingdom. Longer intervals were experienced by the most deprived black Africans, Indians/Pakistanis/Bangladeshis and recent entrants to the United Kingdom, compared to the least deprived. In contrast, among white and UK-born patients, longer intervals were experienced by the least deprived. In conclusion, the effect of deprivation on TB treatment delays varies in different population groups. Efforts are needed to reduce delays including improving awareness of TB and increasing the index of clinical suspicion.

Today's dental student is training for tomorrow's elderly baby boomer.

We are constantly reminded of the exploding elderly population and the increasing demand to meet their needs. But do we fully understand and appreciate the impact that this fastest-growing segment of the population will have upon our profession? Whether we realize it or not, today's dental student is training for tomorrow's elderly baby boomer. The baby boomer generation is 76 million strong, representing 19 years worth of births spanning from 1946-1964. That makes the oldest baby boomer 55 years old and the youngest 37 years old. What does this all mean? That from 2011-2030, the age group of 65 years of age and older will make up approximately 22% of the population, vastly changing our patient population, not to mention a significant increase in patient load. The future holds promise for not only a busy career, but also potentially a financially rewarding one as well. To some extent, we are all going to be geriatric clinicians. There is little doubt that there will be a great demand for services in restorative dentistry, prosthodontic dentistry, endodontics, periodontics, oral surgery, and perhaps orthodontics. As the baby boomers benefited from fluoride and sanitation, more people have been able to maintain their dentition and health into their older years. Dental students graduating today will be only beginning the prime of their careers as the baby boomers make their introduction in full force in the year 2011.

Oral health of ambulatory care patients.

OBJECTIVES: This project assessed the clinical oral health status of Veterans Administration (VA) patients and examined the relationship between oral health and both sociodemographic factors and dental care utilization. METHODS: Data were collected on 538 users of VA ambulatory medical care. Oral health was assessed by clinical examinations, and dental use and sociodemographic information are based on self-report. RESULTS: Younger, more educated VA patients with higher incomes had more teeth, fewer untreated and treated root caries, and were less likely to be edentulous or to have dentures. Dental utilization emerged as the most important aspect of veterans' oral health status, even after sociodemographic factors were controlled. Compared with the general population, veterans have poorer oral health with the exception of coronal caries. CONCLUSION: Compared with national studies, VA patients appear to have worse oral health. The importance of sociodemographic factors and dental utilization that has been found in other studies applies to veterans' oral health as well.

Self-reported and clinical oral health in users of VA health care.

BACKGROUND: This article describes the oral health of users of Veterans Administration (VA) health care using both clinical and self-report measures, and models relationships between these measures and self-perceived oral health. METHODS: We conducted a cross-sectional study of 538 male users of VA outpatient care in the Boston area. Questionnaires assessed self-reported oral health, oral-specific health-related quality of life, health behaviors, and sociodemographic information. Clinical data were collected on oral mucosa status, number of teeth and root tips, dental caries, and periodontal treatment need. We report clinical and self-reported oral health status by age group (era of military service). We regressed models of self-perceived oral health on clinical indices and self-reported measures of the impact of oral health on daily life, adjusting for sociodemographic characteristics and health behavior. RESULTS: Among those participants aged 65 to 91 years old, 2.8%, 18.7%, and 41.5% rated their oral health as excellent, very good, or good, respectively. Among 50- to 64-year-old men, the corresponding values were 1.4%, 18.5%, and 40.4%, while among those aged 22 to 49 years old, the values were 2.3%, 17%, and 34.1%. Tooth loss was common among users of VA care; 34% of those aged 65-90 years, 28% of those aged 50-64 years, and 8% of those aged 25-49 years had no teeth. Periodontal treatment needs were uniformly high among persons with teeth; mild mucosal change was common, and 10% had root tips. Regression models showed self-perceived oral health was better in persons with more teeth and recent dental treatment, and worse with tooth mobility, coronal decay, and more medical problems. Measures of the impact of oral conditions on daily life added significantly to the amount of explained variance in self-perceived oral health. CONCLUSIONS: Clinical conditions and the impact of oral health on daily life are important determinants of self-perceived oral health.

Endoscopic surgery and telemedicine in microgravity: developing contingency procedures for exploratory class spaceflight.

OBJECTIVES: The risk of a urinary calculus during an extended duration mission into the reduced gravity environment of space is significant. For medical operations to develop a comprehensive strategy for the spaceflight stone risk, both preventive countermeasures and contingency management (CM) plans must be included. METHODS: A feasibility study was conducted to demonstrate the potential CM technique of endoscopic ureteral stenting with ultrasound guidance for the possible in-flight urinary calculus contingency. The procedure employed the International Space Station/Human Research Facility ultrasound unit for guide wire and stent localization, a flexible cystoscope for visual guidance, and banded, biocompatible soft ureteral stents to successfully stent porcine ureters bilaterally in zero gravity (0g). RESULTS: The study demonstrated that downlinked endoscopic surgical and ultrasound images obtained in 0g are comparable in quality to 1g images, and therefore are useful for diagnostic clinical utility via telemedicine transmission. CONCLUSIONS: In order to be successful, surgical procedures in 0g require excellent positional stability of the operating surgeon, assistant, and patient, relative to one another. The technological development of medical procedures for long-duration spaceflight contingencies may lead to improved terrestrial patient care methodology and subsequently reduced morbidity.

Using the GOHAI to assess oral health status of frail homebound elders: reliability, sensitivity, and specificity.

A pilot study assessed the clinically determined and self-reported oral health status of 50 randomly selected homebound patients served by Boston's Home Medical Service. The sample was largely female, low-income, and edentulous. The median age of the patients was 81 years (range, 64-101). While 76% deemed themselves to be in good to excellent oral health, 80% of the patients had not seen a dentist within the last two years, and 80% were found to be in need of routine dental care. To assess whether the Geriatric Oral Health Assessment Index (Atchison and Dolan, 1990) could be used by non-dental health professionals to determine the need for requesting dental consultation, the study physician repeated the administration of the GOHAI for 23 of the 50 subjects within eight weeks of the initial examination. For the 23 subjects having both dentist- and physician-administered GOHAI scores, the intraclass correlation coefficient was r = 0.61 (p = 0.002), indicating good agreement between the dentist's and physician's administrations of the GOHAI. However, given the high prevalence of need for care, the GOHAI appears to be of less value than an examination for identifying persons who need dental care in this population. Future research is needed to examine the GOHAI's sensitivity and specificity in populations with low to moderate prevalence of treatment need.

University of Miami/Jackson Memorial Medical Center restructures its health care system for the 21st century.

Change, challenge, and commitment motivate staff at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, to prepare its health care system for the 21st century. Doctors, nurses, environmental workers, pharmacists, cashiers, nursing assistants, laboratory technologists, and many others are participating on a variety of teams to bring about the changes needed for our delivery system to be competitive.

Structural and dynamical properties of a denatured protein. Heteronuclear 3D NMR experiments and theoretical simulations of lysozyme in 8 M urea.

Oxidized and reduced hen lysozyme denatured in 8 M urea at low pH have been studied in detail by NMR methods. 15N correlated NOESY and TOCSY experiments have provided near complete sequential assignment for both 1H and 15N resonances. Over 900 NOEs, including 130 (i, i + 2) and 23 (i, i + 3) NOEs, could be identified by analysis of the NOESY spectra of the denatured states, and 3J(HN, Halpha) coupling constants and 15N relaxation rates have been measured. The coupling constant and NOE data were analyzed by comparisons with theoretical predictions from a random coil polypeptide model based on amino acid specific phi,psi distributions extracted from the protein data bank. There is significant agreement between predicted and experimental NMR parameters suggesting that local conformations of the denatured states are largely determined by short-range interactions within the polypeptide chain. This result is supported by the observation that the chemical shift, coupling constant, and NOE data are little affected by whether or not the four disulfide bridge cross-links are formed in the denatured protein. The relaxation data, however, show significant differences between the oxidized and reduced protein. Analysis of the relaxation data in terms of simple dynamics models provides evidence for weak clustering of hydrophobic groups near tryptophan residues and increased barriers to motion in the more compact conformers formed when the polypeptide chain is cross-linked by the disulfide bridges. Using this information, a structural description of these denatured states is given in terms of an ensemble of conformers, which have a complex relationship between their local and global characteristics.

Access to psychiatric care; the results of the Pathways to Care study in Preston.

BACKGROUND: The aim of the present research was to study factors that might determine speed of access to psychiatric care, including the effect of the introduction of a community psychiatric service. METHODS: A Pathways to Care analysis was used to detail new referrals to mental health professionals (MHPs) during two one-month intervals one year apart, before and after the introduction of a community service (n = 279). Univariate analysis of possible factors that might affect access was undertaken, including socio-demographic factors, clinical factors and style of service. Significant associations were then investigated using stepwise logistic regression. RESULTS: The inception rate for treatment was similar to that reported for other services (0.10 per cent). After the establishment of community teams, there was an overall 22 per cent increase in the number of patients seen, with the greatest increase being for neurotic disorders and patients seen by non-medical staff. Of patient-based factors, younger age and suicidal ideation were associated with shorter pathways. Older age, married status, somatic symptoms, anxiety and depression were associated with slower pathways. Patients with suicidal ideation were seen within three days. The introduction of a community pathways team was associated with a lengthening of time to specialist care. CONCLUSIONS: Following a non-experimental change in service delivery, an increase in referrals for less severe mental illness was demonstrated. Continued comprehensive data collection of this type can be used by purchasers to monitor referral patterns and can provide a basis for determining priorities in service delivery.

Tobacco use prevalence and correlates among adolescents in a clinician initiated tobacco prevention trial in California, USA.

OBJECTIVES: Baseline data for the clinician initiated, tobacco prevention trial, the first non-school based clinician mediated tobacco prevention study, were used to explore the degree to which young people receiving orthodontic treatment use tobacco and the differences in use rates between national, California, and patient samples. Correlates of tobacco use were identified and these correlates were contrasted with findings from the published reports. DESIGN AND SETTING: A 26 item telephone survey assessed demographic information, tobacco use, selected health related behaviours, and variables based on social learning theory. The study was conducted among 11 to 18 year old orthodontic patients from San Diego, Orange, Riverside, San Bernardino, and Los Angeles Counties, California, USA. PARTICIPANTS: Of the 17925 patients who were eligible, 16915 (> 94%) completed the survey. MEASUREMENTS AND MAIN RESULTS: Multivariate analyses were conducted using a logistic mixed effects model. Although the 30 day prevalence rate of tobacco use (6%, n = 1010) proved lower than California and national samples, the rates for the age, gender, and race ethnicity subgroups showed trends similar to those seen in California and national samples. Ten variables were significantly associated with tobacco use (p < 0.05), including 30 day alcohol use (OR = 7.88), age (OR = 1.32), and living with a tobacco user (OR = 1.72). CONCLUSIONS: Because 6% of orthodontic patients use tobacco, interventions are warranted to reach the health "Objectives for the Nation". Patterns of correlates of tobacco use were essentially the same for orthodontic patients, California, and national samples, suggesting that these associations are generalisable.

Exposure to bloodborne pathogens in the academic setting: prevention, reporting, and management issues.

Management of nursing students exposed to bloodborne pathogens in the academic setting continues to challenge nurse educators. Management issues include nonreporting by students, lack of established policies and procedures, and inconsistent application of postexposure policies. The authors confirmed previously identified 50% nonreporting rates by students. Development of a postexposure management plan is discussed, emphasizing the need for psychological and medical interventions.

The department of Veterans Affairs oral health services and eligibility.

The Department of Veterans Affairs (VA) operates one of the largest health care systems in the nation; more than 2.5 million veterans receive care annually. Among the special foci of care within VA is the Dental Service. The Department of Veterans Affairs Dental Service is the largest dental care system in the nation and the largest hospital-based dental care system in the world, receiving more than 1.2 million visits annually. The authors describe the VA dental care system and the larger health care system in which it is embedded. How the system is organized, who is eligible for services, who uses care, and what types of services are used are detailed. Compared with medical care, eligibility for VA dental care is more complex and differs for inpatients and outpatients. Outpatients account for 65% of patient visits and 76% of treatment provided in VA dental clinics. The two largest groups of users are inpatients with compelling medical needs (17%) and outpatients who are totally disabled (24%). A wide variety of services is provided, ranging from diagnostic and preventive care to insertion of crowns, bridges, and removable prostheses. Changes in the nation's health care system mandate introspection by all health agencies. The goal of the VA Dental Service is to become veterans' first choice for dental care. Information needed by VA to best respond to the needs of veterans include the following: (1) reasons for why eligible veterans do not use VA dental care; (2) veterans' oral health needs; (3) definition of optimum care and whether it varies as a person moves from functional independence to dependence; (4) whether VA is providing the most cost-efficient care possible and is best utilizing allied health professions; and (5) whether this care is best provided in a hospital setting. Modifications of data gathering systems are required as a first step to providing the needed information.

Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs.

OBJECTIVE: To examine changes in the rate of falling of an experimental group of restrained subjects who underwent restraint reduction, and to compare their rate of falling with a group of subjects who did not have restraint orders during the study period. DESIGN: A quasi-experimental, multiple time-series study utilizing the principles of single-subject design. Each subject was followed for 25 weeks before and 25 weeks after initiation of the intervention. SETTING: Seven nursing homes. INTERVENTION: Formal programs aimed at reducing all bed and chair restraints were initiated in all sites after staff received education and training. Multidisciplinary teams implemented the restraint reduction process on a case-by-case basis, beginning with 1 unit/floor at a time in each site. Most experimental subjects reached their optimum restraint-elimination/reduced status within 2 weeks of intervention initiation. The implementation periods ranged from 4 months to more than a year. PARTICIPANTS: Subjects with chart orders for restraints at the start of the study comprised the experimental group and participated in the restraint reduction program (184 subjects). Subjects with no orders for restraints during the study period comprised the nonequivalent control group (111 subjects) and, therefore, did not undergo the intervention. MEASUREMENTS: Incident reports documenting all falls during the study period were examined. Falls, the dependent variable, were classified as serious or nonserious. The independent variable (intervention) was the restraint reduction program offered to experimental subjects. Based on the principles of single subject design, the impact of the intervention on falls was calculated before and after the date the restraint reduction process was initiated for an individual (experimental group) subject. For the control group, the pre- and posttest period was calculated from the start date of the restraint reduction program on the unit on which each subject resided. RESULT: Serious falls did not increase, but nonserious falls increased significantly after restraints were removed or reduced in experimental subjects. The total mean weekly fall rate for this group increased from 1.87% of residents falling per week during preintervention to 3.01% during postintervention. The mean weekly fall rate of the control group was 3.18% at pretest and did not change statistically over time. CONCLUSIONS: The increase in nonserious falls among the experimental group may be attributed to restraint reduction. The mean weekly fall rate in the experimental group postintervention (25 weeks) became comparable to the mean weekly fall rate for the control group during the entire study period (50 weeks). In light of such findings, policy makers have to confront the ethical choice between tying some frail, elderly subjects to beds and chairs versus exposing them to the risks of freedom in their old age.

Gains in dental care use not shared by minority elders.

Americans have steadily increased their reported use of dental services over the past 30 years. Persons aged 65 years and older have made the greatest gains, from 16 percent in 1957-58 to 43 percent in 1989. This article reviews national data on reported use of dental care over the past three decades, focusing on differences in rates of utilization on the basis of age, race, and national origin. In addition, differences in sample selection, definitions of race and national origin, and data collection methodology were reviewed to identify systematic sources of bias in comparing the data. Findings indicate that reported dental care use among minority elders has not increased parallel with elders of all races and national origins. In 1957-59, 17 percent of white elders versus 9 percent of nonwhite elders had seen a dentist within the past year. By 1989 percentages had improved to 45 percent of whites, but only 22 percent of blacks and 40 percent of Hispanics. In addition, reporting and recording race and national origin varied considerably during the three decades, hampering comparisons over time. Finally, published national data on usual correlates of dental care use (dentition status, insurance, age, income, and education) are inadequate to explain the causes of these discrepancies. More research is needed to identify barriers to use of dental care by all Americans, particularly those of African and Hispanic descent.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral health status of a long-term-care, veteran population.

The Department of Veterans Affairs (VA) operates the largest, integrated health care system in the United States of America. The projected need for long-term-care in the VA health care system parallels an expected increase in need for care in the United States, but precedes the need for care in the general population by 25-30 yr. The VA's Office of Dentistry, in an effort to estimate the resource requirements of this swelling group of veterans, initiated in 1986-7 an oral health survey of long-term care patients. The overall goals were to describe the oral health status of VA nursing home care units (NHCU) residents and to develop a methodology for estimating future dental health services utilization. This study describes the oral health status of the study population. Demographic and oral health data were collected for 650 long-term care residents of six VA NHCUs between October 1986 and July 1987. Data were collected on sociodemographic status, medical history, dental caries, periodontal diseases, oral soft tissue pathology, and the presence of dental prostheses. Caries and periodontal disease were evaluated using the United States National Institute of Dental Research Survey of Employed Adults and Seniors protocols. The oral health status of the population is described using DMF and ESI indices, the prevalence of oral lesions, levels of tooth loss, oral hygiene scores, and the status of existing dentures. Findings show moderate levels of untreated dental caries and periodontal disease and significant tooth loss which increased with age. A need for preventive therapy, restorative dentistry, conservative periodontal therapy, and prosthodontic care was evident.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a worksite mammography program.

We implemented a one-year program to promote mammography for employees at one campus of a state university system; a second campus served as a comparison site. Measurement cohorts, who were surveyed immediately before and after the intervention, had been randomly selected at each site; all of the subjects had insurance coverage that included mammographic screening. The intervention consisted of print media, on-site workshops, and incentive drawings. Results indicated that mammography rates increased significantly at both sites, for both those 40-49 years of age and for those > or = 50 years of age. The rate increases for the 40- to 49-year-old age group at the intervention and control sites were 17.6% and 13.6%, respectively, and, for the > or = 50-year-old age group, 11.9% and 6.3%. However, the differential changes in rates between the sites were not significant for either age category. The intervention was perceived positively by the intervention site cohort, and participation in the various components was encouraging. We present suggestions for future research on this topic.

Osteoporosis risk assessment of mature working women: primary and secondary prevention strategies.

1. Occupational health nurses have a prime opportunity to promote a healthy and stable population of working women through teaching osteoporosis risk reduction behaviors and conducting periodic osteoporosis risk assessments. 2. Health teaching about osteoporosis prevention is needed to foster health promotion and risk reduction behaviors among pre-, peri-, and postmenopausal women to lessen the incidence of fractures and secondary consequences. 3. By incorporating primary and secondary prevention strategies into occupational health nursing practice, great strides can be made in guiding women to initiate osteoporosis prevention behaviors to promote a more healthy and less restrictive lifestyle in later years.

Mammography knowledge and intentions among insured women.

UNLABELLED: METHOD. A survey was conducted among 1,113 randomly selected insured state university employees to evaluate knowledge of the American Cancer Society mammography guidelines, awareness of insurance coverage for screening mammograms, previous guideline adherence, and future mammography intentions. RESULTS: The survey, which included two mailings with follow-up phone cells of nonresponders, had a refusal rate of 6%. Respondents were relatively more likely to know the guideline for older age groups; 77% knew the guidelines for women 50+. Over one-third of the responders were not aware that their insurance policy covered screening mammograms. For women who had never had a mammogram, insurance knowledge was significantly related to intentions to have a mammogram in the future. Previous screening adherence, as well as future intentions, was positively related to the age of the respondent. The results are contrasted with those of previous studies, and the implications for the content of future breast cancer screening campaigns are discussed.

Determination of hepatic blood flow in the rat using sequential infusions of indocyanine green or galactose.

A method was developed for the estimation of hepatic blood flow in the rat using sequential infusions of one of two model substrates, indocyanine green or galactose. Either substrate was infused to steady state (achieved within 6 min of the start of indocyanine green infusion and within 40 min of the start of galactose infusion) through either the femoral or portal vein, and three steady state blood samples were obtained. Following a 30-min washout period, the same substrate was infused a second time through the alternate blood vessel. Using a pharmacokinetic approach, hepatic blood flow was estimated from the mean steady state concentrations during the two infusions and the infusion rate. The present method yielded hepatic blood flow estimates of 2.03 +/- 0.13 ml/min/g of liver (indocyanine green) and 2.28 +/- 0.49 ml/min/g of liver (galactose) in two groups of four adult male rats. A Monte-Carlo simulation experiment was conducted to assess the potential error introduced into the blood flow calculation by the moderate transhepatic extraction ratio of the two model substrates (0.386 +/- 0.049 for indocyanine green; 0.439 +/- 0.139 for galactose). The simulation experiment predicted calculational errors between 7.4% (indocyanine green) and 19.5% (galactose), based on the hepatic extraction ratio and the precision of the analytical method for the two compounds. The predicted errors were in good agreement with the variability in blood flow estimates observed experimentally (6.5% for indocyanine green; 21.4% for galactose). The steady state approach employed appears to be associated with superior reproducibility as compared to previously reported methods utilizing bolus dose administration of marker compounds and calculations based upon AUC estimates.