Can natural and virtual environments be used to promote improved human health and wellbeing?

Exposure of individuals to natural environments, such as forests and coastlines, can promote stress reduction and assist in mental recovery following intensive cognitive activities. Settings as simple as hospital window views onto garden-like scenes can also be influential in reducing patients' postoperative recovery periods and analgesic requirements. This paper reviews the evidence supporting the exploitation of these restorative natural environments in future healthcare strategies. The paper also describes early research addressing the development of multisensory, computer-generated restorative environments for the benefit of patients with a variety of psychologically related conditions (including depression, attention deficit disorder, pain, and sleep deficit), who may be unable to access and experience real natural environments, such as those in hospices, military rehabilitation centers, and long-term care facilities. The Table of Contents art is a virtual reconstruction of Wembury Bay, in the southwest of the UK, based on imported Digital Terrain Elevation Data (DTED) to provide the topography and a high-resolution aerial image to provide a template for the location of 3D building and vegetation models, rock features, and pathways. The 3D environment is rendered using the Unity 3 Game Development Tool and includes spatial sound effects (waves, wind, birdsong, etc.), physics-based features (such as early morning sea mist), time-of-day cycles, and real-time weather changes. The Village Church of St. Werburgh can also be seen in this image.

Stratification of COPD patients by previous admission for targeting of preventative care.

BACKGROUND: Hospital admissions for exacerbations of chronic obstructive pulmonary disease (COPD) impact considerably on disease evolution and healthcare provision. Building on previous studies, this study postulated that COPD patients could be stratified by risk of admission to determine which groups provide the greatest burden on resources, and how interventions should be targeted to prevent admissions. METHODS: COPD admissions during 1997-2003 in three Strategic Health Authorities in England were analysed (n=80,291). Patients admitted during winter (1 November-31 March) were stratified into three groups according to the number of admissions during the previous year: 0 (NIL), 1-2 (MOD) or >or=3 (FRQ). Winter weeks were classified as "average", "above average", "high", or "very high" risk, compared with the long-term mean. RESULTS: The risk of admission during winter for FRQ and MOD patients was 40% and 12% respectively. NIL patients contributed to 70% of winter admissions, and 90% of the variation between "average" and "very high" weeks, versus 9% and 1% for MOD and FRQ. CONCLUSIONS: Patients with no previous admissions have lower individual risk, but contribute to a high overall utilisation of health care resources and should be targeted to prevent admissions. Focusing upon high-risk patients (frequent attenders or more severe) may only reduce a small proportion of admissions, and therefore clinicians should ensure that all COPD patients receive appropriate therapy to reduce risk of exacerbations.

Associations between meteorological variables and acute stroke hospital admissions in the west of Scotland.

BACKGROUND: We combined a large clinical stroke registry with the UK Met Office database to assess the association between meteorological variables and specific clinical subtypes of acute stroke. METHODS: We used negative binomial regression and Poisson regression techniques to explore the effect of meteorological values to hospital with acute stroke. Differential effects of atmospheric conditions upon stroke subtypes were also investigated. RESULTS: Data from 6389 patients with acute stroke were examined. The mean age (SD) was 71.2 (13.0) years. About 5723 (90%) patients suffered ischaemic stroke of which 1943 (34%) were lacunar. Six hundred and sixty-six patients (10%) had haemorrhagic stroke. Every 1 degrees C increase in mean temperature during the preceding 24 h was associated with a 2.1% increase in ischaemic stroke admissions (P = 0.004). A fall in atmospheric pressure over the preceding 48 h was associated with increased rate of haemorrhagic stroke admissions (P = 0.045). Higher maximum daily temperature gave a greater increase in lacunar stroke admissions than in other ischaemic strokes (P = 0.035). CONCLUSION: We report a measurable effect of atmospheric conditions upon stroke incidence in a temperate climate.

Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial.

STUDY OBJECTIVE: To compare health walks, a community based lay-led walking scheme versus advice only on physical activity and cardiovascular health status in middle aged adults. DESIGN: Randomised controlled trial with one year follow up. Physical activity was measured by questionnaire. Other measures included attitudes to exercise, body mass index, cholesterol, aerobic capacity, and blood pressure. SETTING: Primary care and community. PARTICIPANTS: 260 men and women aged 40-70 years, taking less than 120 minutes of moderate intensity activity per week. MAIN RESULTS: Seventy three per cent of people completed the trial. Of these, the proportion increasing their activity above 120 minutes of moderate intensity activity per week was 22.6% in the advice only and 35.7% in the health walks group at 12 months (between group difference =13% (95% CI 0.003% to 25.9%) p=0.05). Intention to treat analysis, using the last known value for missing cases, demonstrated smaller differences between the groups (between group difference =6% (95% CI -5% to 16.4%)) with the trend in favour of health walks. There were improvements in the total time spent and number of occasions of moderate intensity activity, and aerobic capacity, but no statistically significant differences between the groups. Other cardiovascular risk factors remained unchanged. CONCLUSIONS: There were no significant between group differences in self reported physical activity at 12 month follow up when the analysis was by intention to treat. In people who completed the trial, health walks was more effective than giving advice only in increasing moderate intensity activity above 120 minutes per week.

Dentists' attitudes and behaviors regarding domestic violence. The need for an effective response.

BACKGROUND: The authors examined the attitudes and behaviors of a national sample of dentists regarding domestic violence and the barriers dentists face in intervening to help victims. METHODS: The authors surveyed a national random sample of 321 dentists by mail from November 1997 to March 1998 about their attitudes and clinical practice behaviors related to domestic violence. Survey items were developed based on the domestic violence and health care literature. The authors used the Total Design Method to maximize the response rate and analyzed data to determine differences between dentists who had received domestic violence education and those who had not. RESULTS: Eighty-seven percent of responding dentists never screened for domestic violence; 18 percent never screened even when patients had visible signs of trauma on their heads or necks. Overall, respondents intervened only minimally to help patients whom they had identified as victims. Respondents reported that the major barriers to screening were the presence of a partner or children (77 percent), lack of training (68 percent), concern about offending patients (66 percent) and their own embarrassment about bringing up the topic of abuse (51 percent). Respondents who had received domestic violence education were significantly more likely to screen for domestic violence and to intervene. CONCLUSIONS: Dentists face many barriers to identifying and helping patients who are abuse victims, yet these data suggest that education about domestic violence could help them overcome some of these barriers. CLINICAL IMPLICATIONS: We suggest that dentists follow the AVDR model when approaching abused patients in their practice: Ask about abuse, provide Validating messages, Document presenting signs and Refer victims to domestic violence specialists.

A prospective study of the use of liquid oral dietary supplements in nursing homes.

OBJECTIVE: To investigate the use of liquid oral dietary supplements among nursing home residents who were eating poorly and losing weight. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds. PARTICIPANTS: Purposive sampling was used to select 40 residents from among the 100 residents who were not eating well. Dietary data were collected on this sub-sample of 40 residents. MEASUREMENTS: Participant observation, in-depth interviews, event analysis, bedside dysphagia screenings, oral health examinations, body weight, body mass index (BMI), and chart review were used to collect data. Dietary data were collected over a 3-day period, and data were gathered on how supplements were ordered, served, and consumed. RESULTS: Supplements had been ordered for 29 of the subsample of 40 residents. Only nine of 29 residents were served the correct number and type of supplements as ordered by their physicians, and only two residents consumed the full amount of supplement as ordered. The overall mean percentage of supplement consumed compared with that ordered was 55.1%. Although supplements were ordered primarily to prevent weight loss and to facilitate weight gain, nearly half (n = 14) of the residents continued to lose weight. Supplements were ordered without investigating the underlying factors contributing to weight loss, such as inadequate staffing and lack of supervision at mealtime, undiagnosed dysphagia, and poor oral health. Without evaluation of these factors, it is unknown which residents might benefit from oral supplements. CONCLUSION: Findings indicate that supplements were used nonspecifically as an intervention for weight loss in nursing home residents without regard to dose, diagnosis and management of underlying problem(s), amount of supplement consumed, and outcome. Further research is needed to establish when supplements should be ordered, how to ensure that they will be taken, and whether they are effective.

Accidental exposures to blood and body fluids among health care workers in dental teaching clinics: a prospective study.

The authors evaluated accidental exposures to blood and body fluids reported to a hotline or to health officials at four dental teaching clinics. The authors used a standard questionnaire to solicit and record data regarding each exposure. During a 63-month period, 428 parenteral exposures to blood or body fluids were documented. Dental students and dental assistants had the highest rates of exposure. Syringe needle injuries were the most common type of exposure, while giving injections, cleaning instruments after procedures and drilling were the activities most frequently associated with exposures.

Detecting alcohol abuse: the value of carbohydrate deficient transferrin.

The author, an advocate of CDT testing for insurance applicants, senses considerable uncertainty among medical directors concerning the value of the test. This review of CDT literature and the history of CDT testing in insurance laboratories is an attempt to mitigate that confusion. Two principle problems are identified: 1) the expected sensitivity of the CDT test in insurance applicants will be 50% at most, usually considerably less. 2) adapting CDT testing to commercial laboratories has been, and still is, an unsolved problem for there remains an important disparity between the method used at Clinical Reference Laboratories and LabOne. Other important issues are also reviewed: gender differences, ethnicity, LFT's and CDT, and technical facts.

Strategies for conducting dental examinations among cognitively impaired nursing home residents.

Many nursing home residents have poor oral health and are in need of treatment. A major barrier to providing care is the difficulty of examining cognitively impaired elders. In two research studies, 625 exams were conducted on 181 nursing home residents, the majority of whom suffered severe cognitive impairment. Qualitative data collected during the course of these two studies revealed strategies that permitted examiners to conduct the examinations successfully, including developing rapport with the residents, providing a quiet environment, and enlisting the help of the primary caregiver. The importance of interdisciplinary collaboration among health professionals, especially dentists and nurses, is discussed.

An instrument to assess the oral health status of nursing home residents.

This article presents data from the development and testing of an instrument to evaluate the oral health of nursing home residents by nursing personnel (RNs, LVNs, and CNAs). After the instrument was developed, nursing staff were taught to do a brief oral health status examination (BOHSE). Using the instrument, a dentist examined 100 residents; the examination was repeated on the same residents by each category of nurse examiners. Correlation coefficients indicate that statistically significant interrater reliability between the three categories of nursing personnel and the dentist was established, suggesting that nursing staff can be taught to evaluate the oral health of residents. Replication of the study in multiple sites is recommended.

A longitudinal evaluation of varying widths of attached gingiva.

32 patients with bilateral areas of inadequate attached gingiva on the facial surface of homologous contralateral teeth have been followed for 6 years. Treatment consisted of scaling, root planing, oral hygiene and maintenance at 3- to 6-month intervals or as needed to control inflammation. A free gingival graft was placed on one side (experimental), while the other side served as the unoperated control. Areas of inadequate attached gingiva on control sides, to include those with recession and no attached gingiva, did not demonstrate additional recession or further loss of attachment. Gingival inflammation and plaque were significantly reduced. On experimental sides, the dimension of keratinized and attached gingiva increased and was stable over 6 years. Areas which began with recession and no attached gingiva exhibited a reduction in recession and gain in clinical attachment following the placement of a gingival graft. Examination of patients who had discontinued participation in the study for a period of 5 years revealed a re-establishment of gingival inflammation on the control sides associated with additional recession. Similar changes were not observed in areas treated by a free graft. The findings demonstrate that it is possible to maintain periodontal health and attachment through control of gingival inflammation despite the absence of attached gingiva.

Longitudinal evaluation of free autogenous gingival grafts. A four year report.

This ongoing study was designed to determine the necessity for and effectiveness of the free autogenous graft in maintaining periodontal attachment. Four-year data are presented for 42 patients who initially had bilateral surfaces with inadequate attached keratinized gingiva including 22 patients who began with bilateral areas of recession and no attached gingiva. In both populations a free autogenous gingival graft was placed on one side and the contralateral side was treated by scaling and root planing to serve as the control. The results indicate that plaque and gingival indices significantly decreased over 4 years on both experimental (grafted) and control (nongrafted) sides. Neither side had further attachment loss but the grafted side showed "creeping" attachment with a concomitant decrease in recession. This study would indicate that facial gingival units with minimal or no attached keratinized gingiva can maintain attachment levels when inflammation is controlled.

Longitudinal evaluation of free autogenous gingival grafts.

This study was designed to determine the necessity for and effectiveness of the free autogenous gingival graft in maintaining the periodontal attachment to teeth. Ninety-two patients with bilateral facial surfaces of inadequate keratinized gingiva had a free autogenous gingival graft placed on one of the facial surfaces (experimental side) while the contralateral side served as the control. Measurements were recorded from the CEJ to the 1) free gingival margin, 2) base of the gingival sulcus, and 3) mucogingival junction on the mid-facial of selected teeth. The Gingival Index and Plaque Index (Löe 1967) were also evaluated. A total of 107 grafts were performed and followed from 6 months to 2 years post grafting. Patients were recalled (scaling, root planing, plaque control instruction) and clinical parameters such as pocket depth, recession and attachment level were measured at 3- and 6-month intervals. Both experimental (grafted) and control (unoperated) sides showed marked reduction in the Gingival Index and Plaque Index. Neither side demonstrated further attachment loss. it would appear that minimizing inflammation is sufficient to maintain attachment levels despite the width of keratinized attached gingiva.

TWX and interlibrary loans.

Libraries now have available to them a variety of ways of speeding the flow of information among widely scattered locations. One of the means for the improvement of interlibrary loan service is the use of the teletypewriter, and the use of Teletypewriter Exchange Service (TWX) by medical libraries during the past three years is described. The background of library applications of teletypewriter systems is outlined, and the advantages, types of use, cost factors, and experiences of some groups are discussed, as well as the impact of the "network concept" on library service.