Oral health-related stigma: Describing and defining a ubiquitous phenomenon.

This paper is the fourth of a series of narrative reviews to critically rethink underexplored concepts in oral health research. The series commenced with an initial commissioned framework of Inclusion Oral Health, which spawned further exploration into the social forces that undergird social exclusion and othering. The second review challenged unidimensional interpretations of the causes of inequality by bringing intersectionality theory to oral health. The third exposed how language, specifically labels, can perpetuate and (re)produce vulnerability by eclipsing the agency and power of vulnerabilised populations. In this fourth review, we revisit othering, depicted in the concept of stigma. We specifically define and conceptualize oral health-related stigma, bringing together prior work on stigma to advance the robustness and utility of this theory for oral health research.

Rethinking Oral Health in Aging: Ecosocial Theory and Intersectionality.

Poor oral health affects the health and well-being of older adults in many ways. Despite years of international research investigating poor oral health among older adults, it has remained a largely unresolved problem. The aim of this article is to explore the combination of 2 key frameworks, ecosocial theory and intersectionality, to guide our exploration and understanding of oral health and aging and help inform research, education, policy, and services. Proposed by Krieger, ecosocial theory is concerned with the symbiotic relationship among embodied biological processes and social, historical, and political contexts. Building on the work of Crenshaw, intersectionality explores how social identities such as race, gender, socioeconomic status, and age interconnect in ways that can enhance privilege or compound discrimination and social disadvantage. Intersectionality offers a layered understanding of how power relations reflected in systems of privilege or oppression influence an individual's multiple intersecting social identities. Understanding this complexity and the symbiotic relationships offers an opportunity to reconsider how inequities in oral health for older adults can be addressed in research, education, and practice and increase the focus on equity, prevention, interdisciplinary care, and use of innovative technology.

A Monte Carlo technique to model performance of streak camera-based time-resolving x-ray spectrometers.

A Monte Carlo technique has been developed to simulate the expected signal and the statistical noise of x-ray spectrometers that use streak cameras to achieve the time resolution required for ultrafast diagnostics of laser-generated plasmas. The technique accounts for statistics from both the photons incident on the streak camera's photocathode and the electrons emitted by the photocathode travelling through the camera's electron optics to the sensor. We use the technique to optimize the design of a spectrometer, which deduces the temporal history of electron temperature of the hotspot in an inertial confinement fusion implosion from its hard x-ray continuum emission spectra. The technique is general enough to be applied to any instrument using an x-ray streak camera.

Cancer coverage in newspapers serving large and small communities in Ontario.

Local newspapers are an important source of health news, especially in small communities. We describe the amount and type of cancer information in Ontario daily newspapers dichotomized by circulation size (> 400,000 or < 40,000) and community size (> 250,000 or < 25,000 people) for 1991. All cancer articles (n = 1027) in five newspapers with large circulations, serving large communities, and five newspapers with small circulations, serving small communities, were read and evaluated for focus and newsplay. Although large newspapers had an absolute greater number of cancer articles, there were no significant differences by newspaper size in the number of cancer articles per 1,000 pages. Large newspapers included more cancer articles with a scientific vs. human interest focus than did small newspapers (p < 0.001). Large newspapers tended to use wire services whereas small newspapers tended to use staff reporters. Differences in the type and amount of cancer information varies by newspaper and community size, potentially contributing to differences in community cancer information resources.

Resource allocation in integrated delivery systems and healthcare networks: a proposed framework to guide ethical thinking.

Drawing on a management perspective and the literature, this article suggests an ethical framework to be used at the meso or community level of resource allocation in a Canadian setting. The suggested framework enlarges on the program-level framework developed by Meslin et al primarily by building in stakeholder inclusiveness and public accountability, both of which are essential to resource allocation at the population-based level.

Cost efficacy of duplex surveillance and prophylactic angioplasty of arteriovenous ePTFE grafts.

Poor patency of arteriovenous ePTFE grafts remains a major clinical problem. Prophylactic balloon angioplasty of stenoses has been claimed to prolong graft patency and has been widely introduced into practice. In this manuscript we report the cost incurred in application of such a program involving graft surveillance and prophylactic angioplasty of ePTFE graft stenoses >50% diameter. All patients in a single dialysis unit with ePTFE bridge grafts were subject to a surveillance duplex ultrasound and those with a perigraft stenosis of >50% then underwent angiography. Those patients confirmed to have a stenosis >50% within the graft, were randomized to prophylactic percutaneous transluminal angioplasty (PTA) versus no intervention (observation). Patients were followed every 3 months with ultrasound and those in the treatment group with recurrent stenosis (>50%) were subject to repeat PTA. The outcome was thrombosis. Relevant charges were considered to be: initial duplex screening of the entire ePTFE dialysis group; professional and technical fees for angiography and angioplasty; follow-up duplex scanning; repeat angioplasty; and costs of lytic therapy for an intraprocedure lysis. In the treatment and observation group the 6-month patencies were 69% +/- 7% and 70% +/- 7%, respectively. Twelve-month patencies for the treatment and observation groups were 51% +/- 6% and 47% +/- 4%. There was no significant difference between these two groups (p = 0.97), with an 80% confidence limit for detection of a difference >20%. Cost for duplex screening of all patients in the dialysis unit with ePTFE grafts was $40,440 (@ $337 each x 120 patients). Total charges for initial angiography was $178. Angioplasty charges were $143,040. Cost of the follow-up duplex ultrasound scanning in the treated group was $32,352. Charges for repeat angiograms in those with recurrent stenoses were $83,682 (professional fee $1733 + $229; technical fee + $820; equipment charges x 32 x 0.94). One patient required urokinase therapy for an occlusion following PTA. The overall charge for treating the 32 patients in the treatment arm of this study was $440,834, there was net improvement in patency. A policy of generic graft surveillance and prophylactic is expensive and does not lead to improved patency. Until an effective intervention is defined by prospective randomized trial, surveillance duplex scanning cannot be justified.

Using the balanced scorecard to align strategy and performance in long-term care.

The Sisters of Charity of Ottawa Health Service (SCOHS) is a Canadian health care corporation that has adapted Kaplan and Norton's balanced scorecard to enhance strategic management and measurement in a multisite health care facility comprising long term care, continuing complex care, rehabilitative services, palliative care and ambulatory care. This article discusses how the SCOHS has incorporated the following principles into the balanced scorecard: demonstration of cause and effect; inclusion of outcomes and performance drivers; linkage to fiscal and utilization indicators; and integration of the mission and values of the organization. Examples of corporate level outcomes and performance measures are provided in the form of lead and lag indicators.

A descriptive study of recurrent low back pain claims.

This is the first large-scale study of US workers that describes the demographic and cost differences between recurrent and nonrecurrent low back pain (LBP) disability claimants, using data from a large workers' compensation insurer. Persons with at least one LBP claim in 1990 and one or more additional claims in 1990 to 1996 were defined as recurrent. Persons with at least one LBP claim in 1990 but no subsequent claims were defined as nonrecurrent. Fourteen percent of claimants were recurrent. The percentage of recurrent claimants who were male (77.2%) was higher than the percentage that were female (22.8%). This difference was more pronounced in the younger age groups. The median total cost for recurrent LBP claims in 1990 was 4% greater than for nonrecurrent 1990 LBP claims, whereas the mean cost was 48% less. Most studies of LBP recurrence among US workers have followed single-corporation employees. Our rate of recurrence was lower than these previously reported rates. However, analysis of independent workers' compensation insurance company data may provide a more accurate assessment of LBP claim recurrence among US workers.

Intravenous access in newborn infants: impact of extended umbilical venous catheter use on requirement for peripheral venous lines.

Central venous lines are used to care for critically ill neonates in cases of limited peripheral venous access. This prospective, randomized study evaluated the risks and benefits of the use of single- and double-lumen umbilical venous catheters for up to 14 days. Patients were randomized to one of three treatment arms: (1) single-lumen umbilical catheter, (2) double-lumen umbilical catheter, or (3) no umbilical catheter; peripheral intravenous lines only. Infants in the groups treated with an umbilical venous catheter had significantly fewer venipunctures and peripheral intravenous lines placed during their first 2 weeks of life than those in the peripheral line only group. Less time and money were spent obtaining peripheral line placement in the umbilical venous catheter groups. The incidence rates of sepsis and complications were not higher in treated patients than in control patients. The double-lumen catheter further reduced peripheral venipunctures and lines. We conclude that an umbilical venous catheter used during the first 2 weeks of life is a relatively safe, less stressful, cost-effective means of providing intravenous therapy to neonates.

Is paclitaxel and cisplatin a cost-effective first-line therapy for advance ovarian carcinoma?

BACKGROUND: Paclitaxel and cisplatin use for the treatment of advanced ovarian carcinoma (AOC) has been shown to increase median survival duration. An evaluation was performed on the economic consequences of treating AOC patients with combined paclitaxel and cisplatin chemotherapy compared with current usual care, i.e., combined cyclophosphamide and cisplatin chemotherapy. METHODS: Linear modeling techniques combined with retrospective chart analysis were used to predict the clinical progression and treatment of AOC patients until death. Cost-effectiveness analysis comparing paclitaxel and cisplatin and usual care was performed from a simplified Ministry of Health perspective. RESULTS: Assuming a 50% increase in survival for paclitaxel and cisplatin patients, an assumption supported by recent clinical trial data, this treatment showed an average lifetime cost per patient of $50,054 Cdn compared with a cost of $36,837 Cdn for usual care. The incremental cost of the paclitaxel and cisplatin treatment over the usual treatment was $20,355 Cdn per life year gained. These results withstood extensive sensitivity analyses. CONCLUSIONS: Paclitaxel, in combination with cisplatin, appears to be a cost-effective first-line treatment for AOC. A moderate increase in incremental cost compares favorably with other life-saving strategies currently in use. As more data become available for the use of paclitaxel, this pilot study will provide a basis for more extensive economic evaluation of paclitaxel.

Women redrawing the map: the world after the Beijing and Cairo conferences.

PIP: This essay analyzes how the Fourth World Conference on Women (WCW) reinforced and built upon the achievements of previous world conferences, especially the 1994 International Conference on Population and Development's (ICPD) emphasis on women's reproductive health and rights. The introduction describes the WCW, its position in the continuum of world conferences, and its importance in clearly indicating women's centrality in meeting global priorities in the next century and reaffirming women's human rights. Next, the essay focuses on how the WCW was the culminating event in solidifying the shift in global understanding of the role of the international community and of development. The political realities faced by the delegates to the WCW (which opened with 35% of its platform in brackets indicating lack of agreement) are covered in sections that consider 1) the impact of the women's movement and Southern leadership, 2) the importance of the preparatory process, 3) indicators that the tide had turned, and 4) the pattern of diplomacy. The essay then describes how the WCW 1) established the primacy of women's rights, 2) identified action to ensure reproductive and sexual rights, 3) called for a review of restrictive abortion laws, 4) recognized adolescent rights, and 5) established the right of women to control their sexuality. This section also explains why efforts to prevent discrimination on the basis of "sexual orientation" were abandoned. The essay concludes by summarizing the overall messages the WCW sent to the world.^ieng

Who do you serve?: defining clients and stakeholders of long term and continuing care organizations.

Many different groups each have a particular stake in the success of a continuing care or long term care organization. Each of these groups, however, measures success according to its own priorities. Before it can truly measure its accomplishments, an organization must first recognize all of its interested groups and understand their perspectives. Only then will it have a meaningful yardstick with which to measure its success.

Reporting of occupational exposures to blood-borne pathogens in Australian teaching hospitals.

OBJECTIVE: To describe the reporting of occupational exposures to blood and body fluids in Australian teaching hospitals. DESIGN: Survey by questionnaire of the major teaching hospitals in Australia, December 1992. RESULTS: Completed questionnaires were received from 88% of the 69 teaching hospitals in Australia. All responding hospital reported an established procedure for reporting and managing occupational exposures to blood and body fluids and 82% indicated willingness to contribute data to a national monitoring project. Information concerning the actual incident was recorded by all hospitals and two-thirds of hospitals had forms which specifically detailed exposures history. Patient and healthcare worker risk factors for HIV were recorded less frequently. but in 87% of hospitals blood tests were performed on both the staff member and source patient. Among 87 026 equivalent full time staff employed by the responding hospitals, 5803 injuries were reported in 1991. The median number of reported injuries as a percentage of equivalent full time staff was 7%. Estimates of non-reporting ranged from 5% to 70% (median 25%). Prophylactic zidovudine was prescribed for 50 staff from 21 hospitals in 1991. CONCLUSIONS: All Australian teaching hospitals have an established procedure for documenting occupational exposure to blood and body fluids. Although there is limited standardisation at a national level, the information already collected and the willingness to participate indicated by a large number of teaching hospitals are sufficient for a national surveillance mechanism to be established.

Research considerations: the link between housing and health in the elderly.

1. Elderly tenants of housing projects are "aging in place" and increasingly need more supportive services. 2. The link between housing and health for the elderly is not recognized. 3. Elders differ on how declining health and disability should be managed in housing projects. 4. Fostering participation in decision making is health promoting.

The relationship of health-promoting behaviour to health locus of control: analysis of one baccalaureate nursing class.

This study established a health-promoting lifestyle profile in one first year baccalaureate nursing class using the Health-Promoting Lifestyle Profile (HPLP) scale (Walker, Sechrist, & Pender, 1987). Students also completed the Multidimensional Health Locus of Control Scale. Pearson correlation coefficients were run to determine the relationship between perceived health locus of control and each of the categories in the HPLP scale. The only significant, albeit low, correlations were between: stress management and internal health locus of control (r = .39, p = .01); and, interpersonal support and powerful others locus of control (r = .33, p = .03). Although low statistical power (n = 34) may have contributed to these findings, the value of health locus of control as an antecedent to health promoting behaviour is questioned. The students in the current study did engage in health-promoting behaviours as measured by the HPLP scale, with behaviours in the categories self-actualization and interpersonal support receiving the highest scores. As a group, the students displayed a high perceived internal locus of control. There was virtually no relationship between perceived health locus of control and the health-promoting lifestyle profile categories. However, the significant relationship between internal locus of control and the dimension, stress management, and the powerful others locus of control and the dimension, interpersonal support, may indicate that people with a differing locus of control have different coping strategies.

Quality, innovation and cost containment.

Quality, innovation, cost containment--these three criteria for change within the business world can be applied just as usefully within the realm of health care. Each of these criteria must be met by projects for change. By considering these aspects from the outset and by incorporating a means to measure all three, planners can ensure that change is beneficial. These three criteria also make it easier to monitor the change at regular intervals. Eventually, the project comes full circle, with the criteria used to establish the project's viability being used to report on its final results.

Comparison of four methods for rapid detection of Pneumocystis carinii in respiratory specimens.

Four stains for the detection of Pneumocystis carinii in respiratory specimens were compared for sensitivity, specificity, preparation time, and ease of interpretation. One hundred specimens were collected. Of these, 50 were induced sputum specimens and 50 were bronchoalveolar lavage fluid. All specimens were stained with Diff-Quik (DQ) (a modified Giemsa stain), a quick silver stain, and direct and indirect immunofluorescence stains. A positive specimen was defined as any smear positive by two or more of the methods. Fifty-eight percent of specimens were positive. Seventy-four percent of the sputum specimens and 42% of the bronchoalveolar lavages were positive. The sensitivities for detection of P. carinii in sputum were 92% with silver stain, 97% with direct immunofluorescence assay (DFA), 97% with indirect immunofluorescence assay (IFA), and 92% with DQ. The sensitivities for detection in bronchoalveolar lavage were 86% with silver stain, 90% with DFA, 86% with IFA, and 81% with DQ. Preparation times varied from 90 min for the silver stain and IFA to 3 min for DQ. Costs of the tests varied from $1.50 per slide for DQ to $10.00 per slide for the silver stain and DFA. Reading times varied from 10 to 30 min for the silver stain and DQ to less than 5 min for the immunofluorescence assays. We conclude that all of these tests are viable options for the clinical laboratory, and the choice will be influenced by factors such as clinical volume, ability to batch specimens, and expertise of technological support. A reasonable option may be to use the quick and inexpensive DQ as a screening test and to confirm negative smears with a more sensitive assay.