Donation after cardiac death: community views about 'decent' intervals.

Donation after cardiac death (DCD) offers an alternative pathway to donation for some donors. Successful recovery of organs for transplantation following DCD requires that organ recovery surgery commence as soon as possible after death has occurred. This limits the amount of time that family and friends can spend with the donor prior to surgery. The aim of this study was to identify community views about the timing of organ recovery in DCD. Data were collected from two sources in South Australia: 32 members of the public participated in four focus groups, and 2693 adults participated in a representative population survey. Respondents were asked their views about a decent interval to wait after death prior to organ recovery surgery. Focus group participants identified a tension between preserving organ viability and allowing families time with the deceased. Of the survey respondents, 45.2% selected a timeframe compatible with potentially viable donations; 34.1% selected a timeframe incompatible with viable donations; and 20.8% gave an indeterminate answer. These findings provide information about public perceptions of DCD, can be used to inform educational campaigns about DCD and serve as a baseline for evaluating such campaigns, and identify a number of areas for further investigation.

Usability of an adaptive computer assistant that improves self-care and health literacy of older adults.

OBJECTIVES: We developed an adaptive computer assistant for the supervision of diabetics' self-care, to support limiting illness and need for acute treatment, and improve health literacy. This assistant monitors self-care activities logged in the patient's electronic diary. Accordingly, it provides context-aware feedback. The objective was to evaluate whether older adults in general can make use of the computer assistant and to compare an adaptive computer assistant with a fixed one, concerning its usability and contribution to health literacy. METHODS: We conducted a laboratory experiment in the Georgia Tech Aware Home wherein 28 older adults participated in a usability evaluation of the computer assistant, while engaged in scenarios reflecting normal and health-critical situations. We evaluated the assistant on effectiveness, efficiency, satisfaction, and educational value. Finally, we studied the moderating effects of the subjects' personal characteristics. RESULTS: Logging self-care tasks and receiving feedback from the computer assistant enhanced the subjects' knowledge of diabetes. The adaptive assistant was more effective in dealing with normal and health-critical situations, and, generally, it led to more time efficiency. Subjects' personal characteristics had substantial effects on the effectiveness and efficiency of the two computer assistants. CONCLUSIONS: Older adults were able to use the adaptive computer assistant. In addition, it had a positive effect on the development of health literacy. The assistant has the potential to support older diabetics' self care while maintaining quality of life.

Feminism and public health ethics.

This paper sketches an account of public health ethics drawing upon established scholarship in feminist ethics. Health inequities are one of the central problems in public health ethics; a feminist approach leads us to examine not only the connections between gender, disadvantage, and health, but also the distribution of power in the processes of public health, from policy making through to programme delivery. The complexity of public health demands investigation using multiple perspectives and an attention to detail that is capable of identifying the health issues that are important to women, and investigating ways to address these issues. Finally, a feminist account of public health ethics embraces rather than avoids the inescapable political dimensions of public health.

Ethical issues in public health: a qualitative study of public health practice in Scotland.

STUDY OBJECTIVE: To identify ethical issues encountered by staff in the development and implementation of public health activities at two sites in Scotland. DESIGN: Qualitative research study involving face to face semi-structured interviews with participants. SETTING: A public health directorate in a National Health Service Trust, and a public health demonstration project in child health. PARTICIPANTS: Health promotion specialists, managers, nurses, public health consultants and specialists, researchers, trainees, and other public health staff. MAIN RESULTS: Three main categories of ethical issues were identified: paternalism, responsibilities, and ethical decision making. Consulting with the community and sharing information raised issues of paternalism and honesty. Participants identified multiple and sometimes conflicting responsibilities. Barriers to fulfilling responsibilities included meeting targets, working with partners, and political influences. Defining the limits of responsibilities posed challenges. Participants identified values for ideal decision making, but lack of time often led to a more pragmatic approach. CONCLUSION: These empirical findings complement and extend existing discussions of public health ethics, emphasising the complex nature of ethical issues in public health. The implications for public health policy and future research are discussed.

Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups.

This article examines the implicit promises of fairness in evidence based medicine (EBM), namely to avoid discrimination through objective processes, and to distribute effective treatments fairly. The relationship between EBM and vulnerable groups (such as those disadvantaged by virtue of poverty, ethnicity, age, gender, mental health problems or similar) is examined. Several aspects of EBM are explored: the way evidence is created (commissioning and design of, and participation in research), and the way evidence is applied in clinical care and health policy. This analysis suggests that EBM turns our attention away from social and cultural factors that influence health and focuses on a narrow biomedical and individualistic model of health. Those with the greatest burden of ill health are left disenfranchised, as there is little research that is relevant to them, there is poor access to treatments, and attention is diverted away from activities that might have a much greater impact on their health.

Confidentiality and the ethics of medical ethics.

In this paper we consider the use of cases in medical ethics research and teaching. To date, there has been little discussion about the consent or confidentiality requirements that ought to govern the use of cases in these areas. This is in marked contrast to the requirements for consent to publish cases in clinical journals, or to use personal information in research. There are a number of reasons why it might be difficult to obtain consent to use cases in ethics. Many cases concern people who are incompetent, and thus unable to give consent. Often the material is of a sensitive nature, it is not clear who should give consent, or the ethicist has no access to those involved. We argue that the use of cases in ethics research and teaching can be justified by appeal to the public interest argument, and suggest a number of areas for discussion and clarification.

Is there a moral duty for doctors to trust patients?

In this paper I argue that it is morally important for doctors to trust patients. Doctors' trust of patients lays the foundation for medical relationships which support the exercise of patient autonomy, and which lead to an enriched understanding of patients' interests. Despite the moral and practical desirability of trust, distrust may occur for reasons relating to the nature of medicine, and the social and cultural context within which medical care is provided. Whilst it may not be possible to trust at will, the conscious adoption of a trusting stance is both possible and warranted as the burdens of misplaced trust fall more heavily upon patients than doctors.

An ethics core curriculum for Australasian medical Schools.

Teaching ethics incorporates teaching of knowledge as well as skills and attitudes. Each of these requires different teaching and assessment methods. A core curriculum of ethics knowledge must address both the foundations of ethics and specific ethical topics. Ethical skills teaching focuses on the development of ethical awareness, moral reasoning, communication and collaborative action skills. Attitudes that are important for medical students to develop include honesty, integrity and trustworthiness, empathy and compassion, respect, and responsibility, as well as critical self-appraisal and commitment to lifelong education.

An evaluation of warning habits and beliefs across the adult life span.

Beliefs about warnings and habits associated with reading them were assessed for 863 individuals of various ages. Information gathered for various common household products included (a) how frequently people attend to warning information, (b) the degree of risk they believe is involved during product usage, and (c) how important they believe warnings are for different product types. Also assessed were perceived helpfulness and comprehension for symbols commonly found on product labels or on signs in the environment. Respondents 55 years and older reported reading product warnings more frequently than did younger adults, although they generally perceived warnings as less important. However, no overall age-related differences were found for perceived level of risk involved in using different product types. Although older adults generally perceived symbols to be very helpful when using a particular product, their comprehension levels were poorer than those of younger adults for half of the symbols. Overall, these data suggest that adults of all ages do read warnings on a variety of product types and that they believe warning information is important. This research illustrates the importance of including older adults in usability studies during the development of warning systems, given age-related effects may be associated with some aspects of the warning processing but not others.

Age-related effects of blocked and random practice schedules on learning a new technology.

Computer technology is pervasive in today's society. Issues of training must be investigated to ensure that older individuals are capable of interacting with such technology. In the present research a simulated automatic teller machine (ATM) served as a prototypical technology for which issues of training and transfer could be investigated. The focus of the study was on the potential benefits of a random practice schedule (wherein trial types are intermixed) relative to a blocked practice schedule (wherein trial types are grouped together). Both younger and older adults benefited from random practice for the acquisition of the ability to perform transactions on an ATM. Moreover, random practice was beneficial for both age groups in the transfer of learning to novel tasks on a novel ATM. These data have general implications for theories of training and specific implications for the development of training protocols for older adults and new technologies.

Warning research: an integrative perspective.

We developed an integrative perspective on the empirical evidence supporting the influence of particular variables on the warning process based on a broad review of the warning literature. The warning process is described in terms of the following four components: notice, encode, comprehend, and comply. Relevant variables are classified as person variables (characteristics of the individual interacting with the warning) and warning variables (characteristics of the warning itself or the context in which the warning appears). This integrative perspective yields general principles about the variables that influence the warning process and serves as a resource for warning developers and as a guide to facilitate effective analysis of warnings. We also identify aspects of the warning process that are not well understood, directions for effective methods of intervention, and a research agenda for future efforts. Actual or potential applications of this research include improving the design of warnings.

An individual differences analysis of ability and strategy influences: age-related differences in associative learning.

The relationships among abilities, strategies, and performance on an associative learning task were investigated for young (aged 17 to 34) and older adults (aged 60 to 82). Participants received extensive practice on a noun-pair task in which they could use a visual-scanning strategy or a memory-retrieval strategy. Older adults were more likely to use the scanning strategy. Age differences were reduced when comparisons were made only for participants using a retrieval strategy. Associative memory was predictive of learning on the task, and semantic memory access speed was predictive of practiced performance. Practiced performance on a memory-search task that also required associative learning was predictive of practiced noun-pair performance. Models of ability-performance relationships for skill acquisition are discussed.

Beneficence in general practice: an empirical investigation.

OBJECTIVES: To study and report the attitudes of patients and general practitioners (GPs) concerning the obligation of doctors to act for the good of their patients, and to provide a practical account of beneficence in general practice. DESIGN: Semi-structured interviews administered to GPs and patients. SETTING AND SAMPLE: Participants randomly recruited from an age and gender stratified list of GPs in a geographically defined region of South Australia. The sample comprised twenty-one general practitioners and seventeen patients recruited by participating GPs. RESULTS: In practice, acting for the good of the patient not only accommodates the views of patients and GPs on expertise and knowing best, but also responds to the particular details of the clinical situation. Patients had a complex understanding of the expertise necessary for medical practice, describing a contextual domain in which they were expert, and which complemented the scientific expertise of their GPs. General practitioners identified multiple sources for their expertise, of which experience was the most significant. The role of the GP included responding to individual patients and particular clinical problems and ranged from the assumption of responsibility through to the proffering of medical advice. CONCLUSION: This study found that GPs acting for the good of their patients covered a variety of GP actions and patient preferences. Beneficence was not justified by presumed patient vulnerability or the inability of patients to understand medical problems, but furthered through a recognition of the different areas of expertise contributed by both parties to the consultation.

Age-related differences in the acquisition, utilization, and extension of a spatial mental model.

The acquisition, utilization, and extension of a spatial mental model were assessed for young and older adults. The model consisted of a map with nine buildings. In acquisition, 91% of the young adults and 62% of the older adults were able to acquire the mental model as determined by a strict criterion. There were age differences in trials required to reach criterion. However, once acquired, the older adults were able to utilize their mental model as well as the young adults, with the exception of questions that were taxing on working memory. Both age groups were also able to extend their mental model to 16 buildings, and then utilize this extended model. Individual differences in working memory and fluid intelligence were related to successful acquisition of the mental model.

An alternative technique for mandibular advancement prosthesis fabrication.

One of the conservative and successful modalities of treatment for obstructive sleep apnea is the mandibular advancement prosthesis. This prosthesis engages teeth on both dental arches for retention and stability. This article describes a technique that allows the fabrication of such a prosthesis in one piece and in a single laboratory step. This may be beneficial in reducing the laboratory time required for fabrication of such a prosthesis.

Written language comprehension in younger and older adults.

This study examined the effects of text genre and repeated reading on written language comprehension in younger (M = 21 years) and older (M = 72 years) healthy adults (N = 54). Participants verified four text-based statements (i.e., explicit, implicit, contradictory, and elaborated) after reading expository, narrative, and procedural texts. Verification accuracy was comparable for both age groups; however, text genre, statement-type, and repeated reading produced significant effects. Expository passages, explicit and implicit statements, and repeated reading yielded superior results. Procedural passages and contradictory and elaborated statements yielded less accurate results. Statement-types invoked multiple levels of cognitive representation across text genres and age groups. Overall, reading time was significantly faster for younger adults, and reading times were significantly faster for both age groups during the repeated reading trial. Text genre also influenced reading time, with expository passages read faster than narrative and procedural passages. These findings suggest the appreciable influences of text genre and repeated reading on measures of text processing and comprehension in healthy adults, irrespective of age.

Functional limitations to daily living tasks in the aged: a focus group analysis.

We assessed constraints on daily living of 59 healthy, active adults 65-88 years of age in focus group interviews. Individual comments about specific problems were coded along the dimensions of (a) the locus of the problem (motor, visual, auditory, cognitive, external, or health limitations); (b) the activity involved (e.g., transportation, leisure, housekeeping); (c) whether the problem was attributable to task difficulty or the perception of risk; and (d) response to limitations (perseverance, cessation, compensation, or self-improvement). The data provide information about the types of difficulties encountered in everyday activities as well as the way in which individuals respond to such difficulties. Each comment was also coded in terms of whether it was remediable via training, design changes, or some combination of the two. More than half of the problems that were reported had the potential to be improved in some way, thus providing direction for future research in human factors and aging. Actual or potential applications of this research include identifying problems and difficulties that older adults encounter in daily activities such as transportation and leisure; more specifically, determining the degree to which such problems are potentially remediable by human factors solutions. Applications of this research also include understanding the types of systems, products, and technologies that older adults interact with currently, or are interested in learning to use.

Memory for activities for young, young-old, and old adults.

Adult age differences in memory for activities have frequently been reported. However, the age range of the older sample has varied from as young as 56 to as old as 89. The present memory for activities study distinguished between the performance of young-old adults (60 to 70) and old adults (71 to 82) in comparison to young adults (18 to 34). Nineteen tasks were administered over a 2-day period, and individuals were asked to recall them immediately or after a 24-h delay. Young-old adults' memory for activities was comparable to the young adults' for both immediate and delayed recall. Both the young and the young-old groups outperformed the old adults. The results suggest that researchers must consider the age of the individuals in the "old" group before drawing conclusions about adult age differences in memory for activities.

Neoergasilus japonicus (Poecilostomatoida: Ergasilidae), a parasitic copepod new to North America.

Adult, gravid female Neoergasilus japonicus Harada, 1930 are described from several species of fish from Lee County, Alabama. Samples of bluegill Lepomis macrochirus Rafinesque (n = 25), largemouth bass Micropterus salmoides Lacépéde (n = 6), redear sunfish Lepomis microlophus Gunther (n = 5), and channel catfish Ictalurus punctatus Rafinesque (n = 1) were collected between November 1993 and May 1995. Prevalence of infection was 100% in all fish collected. The dorsal fin was the site of infection containing the highest number of parasites and the anal fin showed the highest frequency of infection. Morphological comparisons are made between this report and previous descriptions, and disparities among them are indicated. New hosts for N. japonicus include largemouth bass, channel catfish, and redear sunfish. This report is the first North American record for the genus Neoergasilus.

Electroforming technique.

Electroforming technology is used to form substructures for porcelain inlays and crowns. This technique may be used as an alternative to the currently available porcelain-fused-to-metal and all-ceramic systems. Composed of pure 24 K gold deposited directly onto a duplicate die, electroformed copings are relatively thin (0.2 mm), highly biocompatible, and present a marginal accuracy of 20 microns on average. The equipment is relatively easy to use and therefore makes this technique attractive to small ceramics laboratories. The esthetic advantages of a gold colored substructure, the reduced thickness of the coping, and the improved fit of the gold collar when it is used, present a restorative alternative to the dentist, to the ceramist, and to the patient.