Kitty K. Corbett

Information needs in terminal illness

Despite evidence that doctor-patient communication affects important patient outcomes, patient expectations are often not met. Communication is especially important in terminal illness, when the appropriate course of action may depend more on patient values than on medical dogma. We sought to describe the issues important to terminally ill patients receiving palliative care and to determine whether patient characteristics influence the needs of these patients. We utilized a multimethod approach, first conducting interviews with 22 terminally ill individuals, then using these data to develop a more structured instrument which was administered to a second population of 56 terminally ill patients. Patient needs and concerns were described and associations between patient characteristics and issues of importance were evaluated. Seven key issues were identified in the initial interviews: change in functional status or activity level; role change; symptoms, especially pain; stress of the illness on family members; loss of control; financial burden and conflict between wanting to know what is going on and fearing bad news. Overall, respondent needs were both disease- and illness-oriented. Few easily identifiable patient characteristics were associated with expressed concerns or needs, suggesting that physicians need to individually assess patient needs. Terminally ill patients receiving palliative care had needs that were broad in scope. Given that few patient characteristics predicted responses, and that the majority opinion may not accurately reflect that of an individual patient, health care providers must be aware of the diverse concerns among this population and individualize assessment of each patients needs and expectations.

Gender, social pressure, and smoking cessations: The Community Intervention Trial for Smoking Cessation (COMMIT) at baseline

This study was undertaken to examine gender differences in the perception of social constraints against smoking and to explore the role of other sociodemographic and smoking factors that influence the perception of social pressure. Baseline data from the 20 U.S. sites in the National Cancer Institutes Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed. We found that women were less likely than men to be heavy smokers and to report that smoking had affected their health, but more likely to report behavior indicating physiological addiction (timing of first cigarette). At all smoking levels, women were about twice as likely as men to report feeling pressure to quit, after adjusting for education, income, ethnic group, age, and other factors. The source of pressure, however, was different: more women report pressure from their children, whereas more men report pressure from friends and coworkers. Women were equally likely as men to make quit attempts, after adjusting for other factors, but were less likely to remain abstinent for at least 10 days. Women, regardless of education, ethnicity, and age, reported a greater tendency to ask permission before smoking in non-restricted public places. College-educated men were less likely than men without college education to smoke without asking in non-restricted places, but education did not influence whether women asked permission. For both sexes, smoking level and nicotine dependence were significant predictors of lighting up without asking in public places, after adjustment for other variables. We discuss these findings and their implications for the gender gap in smoking cessation and womens conflicting pressures to stop/continue smoking. Tobacco control efforts are discussed within the context of gender differences in social norms, roles, socialization, and communication cultures.

Get smart Colorado: impact of a mass media campaign to improve community antibiotic use.

Context: Large-scale strategies are needed to reduce overuse of antibiotics in US communities. Objectives: To evaluate the impact of a mass media campaign—“Get Smart Colorado”—on public exposure to campaign, antibiotic use, and office visit rates. Design: Nonrandomized controlled trial. Setting: Two metropolitan communities in Colorado, United States. Subjects: The general public, managed care enrollees, and physicians residing in the mass media (2.2 million persons) and comparison (0.53 million persons) communities. Intervention: The campaign consisting of paid outdoor advertising, earned media and physician advocacy ran between November 2002 and February 2003. Principal Measures: Antibiotics dispensed per 1000 persons or managed care enrollees, and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign. Results: After the mass media campaign, there was a 3.8% net decrease in retail pharmacy antibiotic dispenses per 1000 persons (P = 0.30) and an 8.8% net decrease in managed care-associated antibiotic dispenses per 1000 members (P = 0.03) in the mass media community. Most of the decline occurred among pediatric members, and corresponded with a decline in pediatric office visit rates. There was no change in the office visit prescription rates among pediatric or adult managed care members, nor in visit rates for complications of acute respiratory tract infections. Conclusions: A low-cost mass media campaign was associated with a reduction in antibiotic use in the community, and seems to be mediated through decreases in office visits rates among children. The campaign seems to be cost-saving.

Women Gain Weight 1 Year After Smoking Cessation While Dietary Intake Temporarily Increases

OBJECTIVE To examine the relationship of dietary change to weight change in women who quit smoking and remained abstinent for 1 year. METHODS For 1 year, 582 women participating in smoking cessation classes were studied. Weight, diet, and physical activity were measured at baseline and at 1, 6, and 12 months after smoking cessation. Multivariate regression models were used to predict 1-year weight change for the 139 women who remained abstinent. RESULTS Women gained, on average, 9.9 lb over a 1-year period while increasing their intake of energy for 1 and 6 months but returning to baseline levels by 1 year. Sucrose, total carbohydrate, and fat intake increased significantly for the first month; fat and total carbohydrate intake remained at an increased level for 6 months. In unadjusted analyses, older women and those who smoked more cigarettes gained more weight than younger women and lighter smokers; lighter and heavier women gained more weight than women of intermediate weight. In adjusted analyses, age remained a significant factor and number of cigarettes remained of borderline significance. Change in energy intake was predictive of weight change only in women with the highest energy intake at baseline. APPLICATIONS Dietitians should acknowledge that most women who quit smoking gain weight in the short term. Although many women increase their energy intake, change in energy level is only one factor in weight change. Over the long term, women with high baseline intakes appear to be able to affect their weight change by reducing their energy intake.

Optimizing antibiotic prescribing for acute respiratory tract infections in an urban urgent care clinic.

AbstractOBJECTIVE: To decrease unnecessary antibiotic use for acute respiratory tract infections in adults in a point-of-service health care setting. DESIGN: Prospective, nonrandomized controlled trial. SETTING: An urban urgent care clinic associated with the major indigent care hospital in Denver, Colorado between October 2000 and April 2001. PATIENTS/PARTICIPANTS: Adults diagnosed with acute respiratory tract infections (bronchitis, sinusitis, pharyngitis, and nonspecific upper respiratory infection). A total of 554 adults were included in the baseline period (October to December 2000) and 964 adults were included in the study period (January to April 2001). INTERVENTIONS: A provider educational session on recommendations for appropriate antibiotic use recently published by the Centers for Disease Control and Prevention, and placement of examination room posters were performed during the last week of December 2000. Study period patients who completed a brief, interactive computerized education (ICE) module were classified as being exposed to the full intervention, whereas study period patients who did not complete the ICE module were classified as being exposed to the limited intervention. MEASUREMENTS AND MAIN RESULTS: The proportion of patients diagnosed with acute bronchitis who received antibiotics decreased from 58% during the baseline period to 30% and 24% among patients exposed to the limited and full intervention, respectively (P<.001 for intervention groups vs baseline). Antibiotic prescriptions for nonspecific upper respiratory tract infections decreased from 14% to 3% and 1% in the limited- and full-intervention groups, respectively (P<.001 for intervention groups vs baseline). CONCLUSION: Antibiotic use for adults diagnosed with acute respiratory tract infections can be reduced in a point-of-service health care setting using a combination of patient and provider educational interventions.

Susceptibility of youth to tobacco: a social ecological framework for prevention

For most smokers, tobacco dependence begins in childhood or adolescence. This review summarizes the state of social science with respect to the prevention of tobacco use. Social ecology is introduced as a theoretical framework useful for organizing prevention approaches. In recent years, the field has shifted from approaches directed at individuals, towards appreciation of additional, more comprehensive social and environmental influences on initiation. These range from intra-individual factors (including physiological responses to nicotine and the psychology of use) to individual, interpersonal, organizational, community, and population factors affecting access and demand. This review highlights prevention approaches that address social and societal influences, from school programs that attempt to change susceptibility of individual youth to tobacco, to community projects, media campaigns, restrictive policies, and tobacco pricing. The most promising approaches are those designed with input based on extensive formative research including studies with youth, directed at multiple levels of the social ecology, and sustained over time with significant resources and ongoing, multi-sector inputs.

Where's the pump? Associating sporadic enteric disease with drinking water using a geographic information system, in British Columbia, Canada, 1996-2005

We investigated whether risk of sporadic enteric disease differs by drinking water source and type using surveillance data and a geographic information system. We performed a cross-sectional analysis, at the individual level, that compared reported cases of enteric disease with drinking water source (surface or ground water) and type (municipal or private). We mapped 814 cases of campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis and verotoxigenic Escherichia coli infection, in a region of British Columbia, Canada, from 1996 to 2005, and determined the water source and type for each cases residence. Over the 10-year period, the risk of disease was 5.2 times higher for individuals living on land parcels serviced by private wells and 2.3 times higher for individuals living on land parcels serviced by the municipal surface/ground water mixed system, than the municipal ground water system. Rates of sporadic enteric disease potentially differ by drinking water source and type. Geographic information system technology and surveillance data are accessible to local public health authorities and used together are an efficient and affordable way to assess the role of drinking water in sporadic enteric disease.

Emerging infectious diseases: the role of social sciences

1884 www.thelancet.com Vol 380 December 1, 2012 Popular and scientifi c representations of research into emerging infectious disease often focus on the pathogen itself—its molecular machinery, processes of reassortment and mutation, and how these factors indicate risk for human-to-human transmission. How ever, social and ecological processes that facilitate infection also deserve close attention, as emphasised in the Lancet Series on zoonoses. Present models of pathogen emergence and spread do not identify underlying drivers with suffi cient clarity to allow eff ective prevention of disease. More robust models that encompass the complex interface between pathogen biology and human, Emerging infectious diseases: the role of social sciences are known to harbour pathogens that have previously emerged and focus eff orts on the regions where most contact between wildlife and humans occurs. A microbe in a primate population is more likely to become zoonotic than is a microbe from a rodent, because we are more likely to have similar cell surface receptors to the primate owing to our shared evolutionary history. But at what point does contact override phylogeny? If a hunter catches a primate once a year, but the staple diet in his village is bush rats, which of these is the high-risk species? These are the questions that disease ecologists can answer, and that are being applied to the new science of pandemic prediction. How ever, the prediction and prevention of a pandemic is not straightforward. Although molecular techniques exist that can identify novel microbes carried by these high-value wildlife targets, our predictive ability can be overwhelmed by the many novel microbial sequences discovered. For example, how can we identify, from the genetic sequences of ten new paramyxoviruses from bats, which one is most likely to be a virulent pathogen of human beings, capable of spillover and sustained human-to-human transmission? This is the biggest of the grand challenges for pandemic prevention, and one that I believe we are not strategically addressing. Morse and colleagues describe a strategy for the so-called known unknowns—novel microbes closely related to known agents. But what of the unknown unknowns—novel microbes that have no known close relative? This challenge, of prediction of viral virulence from a sequence, for example, should be a major focus of basic virology research in every developed country. A global programme for pandemic prevention based on improved risk forecasting, surveillance, and pathogen discovery will be expensive. Who should pay and how would it work? The answer might lie in the underlying socio economic drivers of disease emergence. Pandemics are a product of our economic development—they emerge when we domesticate new species, open up new trade routes, build roads into forests, or expand air travel networks. Perhaps these industries should insure themselves against the rare but devastating pandemics their activities can sometimes cause. Additionally, health-impact assess ments, already used in many large development projects, could calculate and assess the pandemic risk of a project. The ultimate public health programme would work with, and be funded by, high-risk development projects to develop better clinics, pathogen discovery, and surveillance programmes that prevent pandemics at their source.

A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home

OBJECTIVES: To assess the feasibility of a multifaceted strategy to translate evidence‐based guidelines for treating nursing home–acquired pneumonia (NHAP) into practice using a small intervention trial.

Antibiotic treatment of acute respiratory tract infections in the elderly: effect of a multidimensional educational intervention

Objectives: To measure and improve antibiotic use for acute respiratory tract infections (ARIs) in the elderly.