Ecosystemic Theory, Practice, and Policy: Training Recommendations for Environmental Public Health.

The readiness of the public health workforce to deliver the essential public health services is benchmarked against training competencies. Consequently, it is expected that the establishment of the Council on Education in Public Health competencies will continue to drive the agenda of the learning continuum, from education to practice. However, the absence of environmental health as a listed competency in the Council on Education in Public Health accreditation criteria weakens the core public health program structure originally outlined by the National Academy of Medicine (formerly known as the Institute of Medicine) and could further dissolve environmental health content from schools and programs of public health. The authors have examined the literature on environmental health and public health education, and propose 3 overarching perspectives to employ from a theory, practice, and policy viewpoint to address this disconnect as follows: The current environmental health competency gap weakens the public health workforce infrastructure by creating graduates without the necessary science-based skills to protect communities from environmental threats. This departure from environmental health devalues the profession of public health and prohibits populations from reaching their full health potential. Practitioners, educators, and the public need to play a role in transforming siloes in environmental public health theory, practice, and policy into coherent learning ecosystems on which current and future populations can confidently depend.

Population Health Rounds: A Novel Vehicle for Training in Population Medicine and Clinical Preventive Medicine.

CONTEXT: Preventive medicine residents must train in population medicine (including analytics and population health) and clinical preventive medicine (including screening, behavioral counseling, and chemoprophylaxis). Yet, opportunities to perform both functions concurrently for the same population are scarce. Residents must also master the art of preventive medicine, but they often lack an established community of practice that provides a continuous forum to do so. This project explored Population Health Rounds as a novel vehicle to optimize preventive medicine residency training. PROGRAM DESCRIPTION: Modeled after traditional medical rounds, Population Health Rounds consist of a 1-hour weekly meeting engaging preventive medicine residents and supervising attendings at Stony Brook Medicine in both population medicine and clinical preventive medicine concurrently, including patient case discussions and targeted population health analytics. EVALUATION AND RESULTS: Because of the pandemic, the rounds have predominantly focused on COVID-19 and its effects on the hospital employee population. In addition to providing direct patient care to COVID-19-positive and exposed employees, residents have analyzed data on this population and made recommendations to hospital leadership based on COVID-19's institutional epidemiology, including incidence, prevalence, and predictive factors. A formative qualitative survey of resident perceptions offers insights on the value and learning outcomes of this new model. DISCUSSION AND CONCLUSION: Factors that may impact the implementation, sustainability, and feasibility of this model are discussed. The preventive medicine residency program is commissioned to address gaps in clinical preventive services for the patient-centered medical home tied to the sponsoring institution's family medicine practice. Additional plans are underway to expand the rounds to other clinical contexts, such as lifestyle medicine in the occupational setting, and for targeted populations, such as the underserved. Replication of the Population Health Rounds model is recommended to determine its effectiveness.

Risk factors for hypertensive crisis in adult patients: a systematic review.

OBJECTIVE: The objective of this review was to examine the best available evidence on the risk factors for hypertensive crisis in adult patients with hypertension. INTRODUCTION: Hypertensive crisis is an acute severe elevation in blood pressure, which can present as hypertensive urgency or emergency. In contrast to hypertensive urgency, which is a markedly elevated blood pressure without acute target organ damage, hypertensive emergency is associated with equally high blood pressure in the presence of potentially life-threatening target organ damage, such as myocardial infarction, stroke, pulmonary edema, or acute kidney injury. Hypertensive crisis results in adverse clinical outcomes and high utilization of health care. INCLUSION CRITERIA: This review considered studies of non-modifiable factors (age, sex, ethnicity) and modifiable factors such as socioeconomic factors (lack of medical insurance, lack of access to medical care), adherence to medical therapies, presence of comorbidities (diabetes, hyperlipidemia, coronary artery disease, history of stroke, chronic kidney disease, congestive heart failure), and substance abuse in persons of either sex, older than 18 years with a diagnosis of hypertension. METHODS: A search of four databases, seven gray literature sites, and relevant organizational websites revealed 11,387 titles. After duplicates were removed, 9183 studies were screened by the title and abstract for eligibility. Forty full-text articles were retrieved, and each was assessed for eligibility. Twenty-one articles were excluded. The remaining 19 full-text studies were critically appraised and included in this review. RESULTS: The risk of hypertensive crisis was higher in patients with a history of comorbid cardiovascular conditions, such as chronic kidney disease (odds ratio [OR] 2.899, 95% confidence interval [CI] 1.32, 6.364), coronary artery disease (OR 1.654, 95% CI 1.232, 2.222), or stroke (OR 1.769, 95% CI 1.218, 2.571). Patients with hypertensive emergency had higher mean systolic blood pressure (mean difference [MD] 2.413, 95% CI 0.477, 4.350) and diastolic blood pressure (MD 2.043, 95% CI 0.624, 3.461). Hypertensive emergency was more common in men (OR 1.390, 95% CI 1.207,1.601), older patients (MD 5.282, 95% CI 3.229, 7.335), and those with diabetes (OR 1.723, 95% CI 1.485, 2.000) and hyperlipidemia (OR 2.028, 95% CI 1.642, 2.505). Non-adherence to antihypertensive medications (OR 0.939, 95% CI 0.647,1.363) and hypertensive diagnosis unawareness (OR 0.807, 95% CI 0.564, 1.154) did not increase the risk of hypertensive emergency. CONCLUSIONS: Comorbid cardiac, renal, and cerebral comorbidities (coronary artery disease, congestive heart failure, cerebrovascular disease, and chronic kidney disease) increase the risk of hypertensive crisis. The risk of hypertensive crisis is higher in patients with unhealthy alcohol and recreational drug use. Systolic and diastolic blood pressure are marginally higher in patients with hypertensive emergency compared to patients with hypertensive urgency. Since these differences are small and not clinically significant, clinicians should rely on other symptoms and signs to differentiate between hypertensive urgency and hypertensive emergency. The risk of hypertensive emergency is higher in older adults. The coexistence of diabetes, hyperlipidemia, and chronic kidney disease increases the risk of hypertensive emergency. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42019140093).

Core functions, knowledge bases and essential services: A proposed prescription for the evolution of the preventive medicine specialty.

The pandemonium from the 2020 pandemic calls for a greater emphasis on prevention, public health and population health. Yet the role of preventive medicine specialists, ideally qualified to lead this charge, remains difficult to situate within the houses of medicine and public health. To overcome this challenge to its identity and evolve to better tackle novel and on-going public health and population health problems, the authors propose that the specialty of preventive medicine should assert 3 core functions within preventive care; expand and modernize its knowledge base; and enhance its residency training accordingly. The authors also propose 10 essential services, not otherwise systematically provided by other specialties, that the preventive medicine specialty can optimally fulfill as its unique contributions within medicine and public health.

Organic food consumption and the incidence of cancer: a systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the association between organic food consumption and the incidence of cancer among adults. INTRODUCTION: Organic foods differ from traditional food in the methods in which they are produced. There is literature to suggest that they are associated with better health outcomes, including a lower incidence of some cancers. The association between organic food consumption and the incidence of cancer has not yet been synthesized. INCLUSION CRITERIA: Studies that compared organic food consumption to conventional food consumption, measured the incidence of cancer among adults, and captured disease incidence, such as prospective and retrospective cohort methodologies, will be included. METHODS: A comprehensive search strategy will be implemented to retrieve relevant studies from PubMed, CINAHL, LILACS, Embase, PsycINFO, Science.gov, Web of Science/Web of Knowledge, and Academic Search Premiere, as well as gray literature sources such as Google Scholar, DARE and Dissertation Abstracts International. The search parameters will include studies for which the full text in English is available, and studies dated 2009 or later, as this was the date of a previous systematic review on the association between organic food consumption and health outcomes that did not find any studies with cancer-related outcomes. Study screening, critical appraisal, and data extraction will be performed independently by pairs of reviewers among the authorship team. Data synthesis will include narrative review and meta-analysis if appropriate. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019126224.

Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.

BACKGROUND: Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence. OBJECTIVES: To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings. SEARCH METHODS: We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers. SELECTION CRITERIA: Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence. MAIN RESULTS: We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave-on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath. In five studies, treatment duration ranged from five days to six months; only one study had post-treatment follow-up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel. Three studies each had high risk of attrition, detection, and performance bias. Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice-daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed-days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin-moisturising regimen) (P = 0.004), but this is based on very low-quality evidence, so we are uncertain of this result. Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave-on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water-in-oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low-quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid-volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low. One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low-quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable. Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow-up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low. Outcomes of erythema and clinical score of itch were not assessed in any included studies. AUTHORS' CONCLUSIONS: Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low-quality evidence. Low-quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care. Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient-reported outcomes, such as comfort and acceptability.

Risk factors for hypertensive crisis in adult patients: a systematic review protocol.

OBJECTIVE: The objective of this review is to conduct comprehensive appraisal and synthesis of evidence on risk factors for hypertensive crisis and, specifically, hypertensive emergencies among adult patients with hypertension. INTRODUCTION: Hypertensive crisis is the most extreme form of poorly controlled hypertension that may lead to acute target organ damage (hypertensive emergency). Hypertensive crisis is associated with increased mortality, high utilization of health care and escalated healthcare costs. INCLUSION CRITERIA: This review will include epidemiological studies with participants over 18 years old with diagnosis of hypertension. The review will exclude pediatric, pregnant and postpartum patients. The review will consider studies that explore risk factors for hypertensive crisis, defined as an acute elevation of blood pressure equal or above 180/110 mmHg. METHODS: The search strategy aims to find both published and unpublished studies. The databases to be searched will include MEDLINE (Ovid), Embase, Cochrane Database of Systematic Reviews and Web of Science. Following the search, all identified studies will be screened against the inclusion criteria. Selected studies will be critically appraised for methodological quality. Data on exposures and outcomes will be extracted from papers included in the review. Quantitative data, where possible, will be pooled in meta-analysis. Effect sizes expressed as odds ratio and their 95% confidence intervals will be calculated. Heterogeneity of studies will be assessed statistically. Subgroup analysis to determine the association of risk factors with hypertensive emergencies will be conducted, if possible. Where statistical pooling is not possible, the findings will be presented in a narrative form. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019140093.

Effectiveness of Mohs micrographic surgery for nonmelanoma skin cancer: a systematic review protocol.

REVIEW OBJECTIVES/QUESTIONS: The objective of the review is to evaluate the effectiveness of Mohs micrographic surgery on the mortality, recurrence and quality of life of patients with nonmelanoma skin cancers when compared with other treatment modalities.Specifically, it aims to examine the effectiveness of Mohs micrographic surgery compared with other treatment modalities such as excisional surgery, curettage and electrodessication and radiation therapy, as well as nonsurgical/chemotherapeutic interventions such as topical 5-fluorouracil and imiquimod immunotherapy in the management of nonmelanoma skin cancers.

Disparities in Cardiac Rehabilitation Participation in the United States: A SYSTEMATIC REVIEW AND META-ANALYSIS.

PURPOSE: Phase 2 cardiac rehabilitation (CR) is a class I recommendation for all patients following an acute cardiac event or cardiac surgery according to the The American Heart Association and the American College of Cardiology Foundation. Studies have shown that there are differences in cardiac rehabilitation participation rates between sociodemographic groups. The purpose of this systematic review and meta-analyses was to synthesize quantitative data on the relationship between outpatient cardiac rehabilitation (OCR) attendance and various sociodemographic factors. METHODS: We conducted a search of PubMed, PsycINFO, CINAHL, Google Scholar, Dissertations & Theses A&I, and conference abstracts for observational studies conducted in the United States that fit our inclusion criteria. A total of 21 studies were included in our final review and meta-analyses. RESULTS: Our meta-analyses showed that overall, attenders were younger than nonattenders (mean difference=-3.74 years, 95% CI =-5.87 to -1.61) and the odds of participation were lower among females (OR = 0.59; 95% CI = 0.51-0.69), individuals with a high school degree or less (OR = 0.67; 95% CI = 0.50-0.91), and the uninsured or self-payers (OR = 0.32; 95% CI = 0.14-0.71). Full- or part-time employees were more likely to participate than those not employed (OR = 1.45; 95% CI = 1.08-1.95). CONCLUSIONS: Our systematic review and meta-analyses showed that there are significant sociodemographic disparities in CR participation. On the basis of this knowledge, clinicians and policy makers should focus on identifying and eliminating barriers to participation.

Diagnostic test accuracy: methods for systematic review and meta-analysis.

Systematic reviews are carried out to provide an answer to a clinical question based on all available evidence (published and unpublished), to critically appraise the quality of studies, and account for and explain variations between the results of studies. The Joanna Briggs Institute specializes in providing methodological guidance for the conduct of systematic reviews and has developed methods and guidance for reviewers conducting systematic reviews of studies of diagnostic test accuracy. Diagnostic tests are used to identify the presence or absence of a condition for the purpose of developing an appropriate treatment plan. Owing to demands for improvements in speed, cost, ease of performance, patient safety, and accuracy, new diagnostic tests are continuously developed, and there are often several tests available for the diagnosis of a particular condition. In order to provide the evidence necessary for clinicians and other healthcare professionals to make informed decisions regarding the optimum test to use, primary studies need to be carried out on the accuracy of diagnostic tests and the results of these studies synthesized through systematic review. The Joanna Briggs Institute and its international collaboration have updated, revised, and developed new guidance for systematic reviews, including systematic reviews of diagnostic test accuracy. This methodological article summarizes that guidance and provides detailed advice on the effective conduct of systematic reviews of diagnostic test accuracy.

Indoor Tanning Practices of Colorado High School Students.

For the first time, the 2013 Colorado Youth Risk Behavior Survey assessed indoor tanning practices of Colorado high school students. The survey revealed that girls are more likely to use indoor tanning devices than boys and that the majority of students who tan do so once or twice annually. Health care professionals and policymakers should focus on these groups in efforts to curtail indoor tanning and the associated risk of skin cancer in youth.

Solar cheilosis: an ominous precursor: part I. Diagnostic insights.

Squamous cell carcinoma (SCC) of the lower lip is a deadly nonmelanoma skin cancer. Its precursor, a distinctive cutaneous neoplasia analogous to cervical dysplasia, is known by the confusing term actinic cheilitis. Solar cheilosis (SC) is a more appropriate designation. It represents incipient SCC in situ. SC is widely recognized as an ultraviolet light-induced precancer of the lower lip that is typically seen in light-skinned individuals and others with poorly pigmented lower lips. Lip SCC is one of the most common malignancies of the oral cavity. SCC is much more likely to metastasize from the lip than cutaneous surfaces, with a 5-year overall survival rate of less than 75%. SC results from long-term exposure to ultraviolet radiation. The occurrence of SC is dose-dependent and is influenced by the patient's solar exposure, age, genetic predisposition, geographic latitude of residence, occupation, leisure activities, and use of lip protective agents. Molecular abnormalities of SC are similar to those of actinic keratosis and facilitate the evolution to SCC. A high degree of clinical suspicion should be maintained, given the malignant nature of this condition. Ulceration and nodularity often indicate progression to SCC. We performed a Medline and Google Scholar search for all articles related to actinic cheilitis, actinic cheilosis, SC, actinic keratosis, solar keratosis, premalignant oral disease, and lip SCC, and have also evaluated many other articles and book chapters. One hundred forty-two peer-reviewed articles were identified as being of particular value. Pertinent facts were selected and analyzed.

Solar cheilosis: an ominous precursor part II. Therapeutic perspectives.

The differential diagnosis of SC includes malignant, premalignant, metastatic, inflammatory, and eczematoid disorders, along with photodermatoses and a few rare but important disorders of the lower lip. Current treatment options include topical, ablative, and surgical therapies. Several clinical challenges are also addressed, including the issue of obtaining a high-yield diagnostic biopsy specimen while minimizing patient morbidity, field-directed treatment for SC, and strategies for combination therapy.

A Systematic Review of Family Witnessed Resuscitation and Family Witnessed Invasive Procedures in Adults in Hospital Settings Internationally - Part I: Perspectives of Patients and Families.

BACKGROUND: Medicalization of care has removed family members from loved ones during critical events. Family Witnessed Resuscitation and Family Witnessed Invasive Procedures represent patient / family centered care options that can assist with having the family at the bedside during this perilous time. OBJECTIVES: The objective was to examine the evidence on FWR and FWIP in adults from the perspective of patients and relatives. INCLUSION CRITERIA: This review considered studies involving adult patients and their relatives, in intensive care units, emergency departments, trauma rooms and general nursing wards.This review examined interventions used for the adoption/implementation of FWR and FWIP including but not limited to: formal policy and guidelines; family facilitator/chaperone role; educational programming; communication approaches; and debriefing.This review considered studies that included the following outcome measures for patients and family members: level of support; stress and anxiety; grief and bereavement; coping; psychological sequelae; and impact of family facilitator/chaperone role, formal family presence policy or protocols, educational programming, communication approaches, and debriefing.Any randomised controlled trials, controlled trials, cohort studies, case-control studies, before and after studies, case series studies, and survey studies were considered for inclusion. SEARCH STRATEGY: A comprehensive multistep search was undertaken for English language published and unpublished studies from 1985-2010. METHODOLOGICAL QUALITY: Retrieved papers were assessed for methodological quality independently by two reviewers, using appropriate JBI critical appraisal assessment tools. DATA COLLECTION: Findings were extracted using researcher-developed de novo tools, utilizing a framework of experiential, participant, and environmental factors influencing FWR/FWIP. The de novo tools best addressed the data collected. DATA SYNTHESIS: Meta-analysis was not possible due to heterogeneity; all the results of this review are presented in narrative form. RESULTS: 38 studies were retrieved and after critical appraisal a total of 15 studies were included. Of the seven patient studies, one was a match-control "actual witness" study representing JBI Level IIIA evidence and the remaining "perception of witness" studies were descriptive cross-sectional survey designs representing JBI Level IIIC evidence. Ten family member studies included four with "actual witness" and six with "perception of witness." All family member studies were descriptive cross-sectional survey designs representing JBI Level IIIC evidence. Two studies surveyed both patients and relatives, reducing the number of unique studies to 15. CONCLUSIONS: From the focus of family members with actual resuscitation experience and those with "perception" of witness, there exists strong support/preference for FWR across all countries in the included studies, and the belief that it is a right. IMPLICATIONS FOR PRACTICE: Health care organisations should provide family members the option to witness. There is insufficient evidence on FWIP to make policy recommendations. IMPLICATIONS FOR RESEARCH: There is a need for well-designed randomised controlled designs that test the effectiveness of different approaches to FWR with outcomes that go beyond the level of support for the procedure. NOTE:: This is Part I of the systematic review report. Part I of the review report will explicate the perceptions of patients and family members on family witnessed resuscitation (FWR) and family witnessed invasive procedures (FWIP) in the adult population in emergency departments, intensive care units and general hospital wards internationally. Part II of the review report will explicate the perceptions of physicians, nurses and other healthcare providers regarding this phenomenon.Both review reports (part I and part II) are based on the same a priori approved review protocol. The decision to provide two review reports for one review protocol was justified for the sake of improved organization of the results. The volume of information from part I and part II, if combined, would make the review excessively long and difficult to read. Furthermore, some studies analysed the perspectives of both patients/families and healthcare providers. Thus, to minimize the risk of study selection bias, the reviewers decided that a separate round of critical appraisal and data extraction of studies was prudent in order to fully and independently explicate the perspectives of patients/families and healthcare providers.Furthermore, the textual component initially proposed in the approved review protocol was not included namely because the majority of FWR and FWIP protocols from the included studies could not be located for further analysis. Also, the reviewers determined that a separate systematic review that searches specifically for studies rich in textual information would be needed to truly capture the breadth of expert opinions and consensus statements on the issues of FWR and FWIP.