Understanding barriers to preventive health actions for occupational noise-induced hearing loss.

A theoretically based formative evaluation was conducted with coal miners in the Appalachian Mountains who were at high risk for noise-induced hearing loss (NIHL). The results of four focus groups indicate that despite high levels of knowledge, strong perceived severity of negative consequences, and strong perceived susceptibility to hearing loss, two main categories of barriers (environmental and individual) keep coal miners from using their hearing protection devices (HPD). Further analysis suggests that the environmental factors, rather than individual variables, more strongly influence decisions against protective actions. Recommendations and practical implications are offered.

Protocol for detection of biofilms on needleless connectors attached to central venous catheters.

Central venous catheter needleless connectors (NCs) have been shown to develop microbial contamination. A protocol was developed for the collection, processing, and examination of NCs to detect and measure biofilms on these devices. Sixty-three percent of 24 NCs collected from a bone marrow transplant center contained biofilms comprised primarily of coagulase-negative staphylococci.

Hands on/hands off: why health care professionals depend on families but keep them at arm's length.

The authors assert that a system that requires ever greater direct and indirect participation from families must change the negative presumption that families equal trouble to one that acknowledges legitimate family interests in decision making and care delivery and treats families as partners in caregiving.

The trouble with families: toward an ethic of accommodation.

Although some clinicians are extraordinarily sensitive to the legitimate roles of patients' families in medical crises, a persistent tendency to equate families with trouble is evident in both the literature and the practice of medicine. Some negative presumptions about families derive from western medicine's almost exclusive focus on the individual patient in codes of ethics, training, and practice. Modern bioethics has reinforced this individualistic approach. Physicians' primary responsibilities are unequivocally to their patients, but a complete understanding of the patient's personhood must include consideration of the significant persons who help define the patient's core identity. One source of tension between professionals and families lies in differing perceptions of the roles that family members should play and how they should play them. Members of a family may act as advocates, provide or manage care, serve as trusted companions on the journey through illness and death, and make decisions on behalf of an incompetent patient. Each role presents potential conflicts. Other sources of conflict include disagreement within a family; challenges to physician authority; fear of litigation; and differing religious, ethnic, or cultural traditions. An ethic of accommodation emphasizes the need to negotiate care plans that do not compromise patients' basic interests but that recognize the capacities and limitations of family members. Family caregivers want understandable and timely information, better training, compassionate recognition of their anxiety, guidance in defining their roles and responsibilities, and support for the setting of fair limits on their sacrifices. Health care professionals can better meet these needs through education and skills acquisition, the establishment of partnerships with families, and regular dialogue and communication.

End of life care and decision making: how far we have come, how far we have to go.

While enormous progress has been made in improving the quality of care and the decision-making process for patients at the end of life, as a society we still have far to go to ensure that dying patients and their families have a comfortable and dignified death. In particular, reexamination and reconfiguration of our current decision framework is essential as our elderly population with chronic disease and slowly fatal conditions expands. With less certain disease paths and more complex and ambiguous choices, the growth of this geriatric population challenges us to develop a broader conceptualization of end of life care planning, so that end of life considerations are integrated into a larger anticipatory framework addressing options and needs as patients gradually decline. Within this framework hospice becomes a natural, integrated option along a continuum of care planning, rather than an abrupt alternative at a late stage of illness. End of life care planning must positively anticipate a robust array of needs and concerns well beyond the dramatic decisions to withhold or withdraw life-prolonging technologies usually found in advance directives. To embrace this broader framework it is critical that primary care physicians as well as disease specialists receive training in fundamental aspects of both geriatric and palliative care. Professionals from both of these disciplines must share expertise with each other, and should collaborate in advocacy efforts to effectuate changes in the clinical, policy and legislative arenas.

HIV seroprevalence in a chronically mentally ill population.

This article describes a study undertaken to determine the prevalence of human immunodeficiency virus (HIV) infection and risk factors associated with HIV infection in a chronically mentally ill population. Patients were eligible for inclusion in the survey at their first outpatient or inpatient admission to a Maryland state psychiatric hospital between August 1990 and July 1991. Demographic and risk behavior information was collected, and unlinked HIV antibody testing was performed on blood specimens drawn for routine clinical purposes. Of 533 patients surveyed, 31 patients (5.8%) were infected with HIV. The prevalence of HIV infection was 36.4% among female patients reporting intravenous drug use and 14.5% among their male counterparts. The prevalence of HIV infection among homeless patients was 10.1%; 88.9% of those HIV infected also reported intravenous drug use. On admission, 90% of patients reported no knowledge of their HIV antibody status; 4.1% of these patients were HIV infected. The data confirmed the risk of HIV infection in this population of chronically mentally ill individuals. Risk reduction programs designed specifically for individuals with chronic mental illness need to be developed.

Prevalence of human immunodeficiency virus-1 infection in a Baltimore acute care hospital.

In conjunction with the Centers for Disease Control and Prevention's (CDC's) national Sentinel Hospital Surveillance System for HIV (human immunodeficiency virus) Infection, we conducted unlinked (anonymous) testing of a systematically selected sample of blood specimens for HIV-1 antibodies to assess the HIV-1 infection level in an urban hospital's catchment population. We excluded specimens from patients with admitting diagnoses often associated with HIV infection. Of the 5,350 specimens tested between April 1988 and October 1989, 106 (2%) were HIV-1 seropositive. HIV-1 seroprevalence in female patients was 1%, and in male patients, 3%. Those 25-44 years of age showed the highest seroprevalence (3.7% in all patients: 6.6% in male patients, 1.1% in female patients). These results demonstrate a high HIV-1 infection level in this patient population and suggest Baltimore hospitals should evaluate the impact and costs of developing routine HIV counseling and testing programs for their patients.

Regulation of type II iodothyronine 5'-deiodinase by thyroid hormone. Inhibition of actin polymerization blocks enzyme inactivation in cAMP-stimulated glial cells.

The cellular events mediating the rapid, thyroid hormone-dependent modulation of membrane-bound, type II iodothyronine 5'-deiodinase were studied in dibutyryl cyclic AMP(bt2cAMP)-treated brain astrocytes. Unstimulated cells had undetectable type II 5'-deiodinating activity. Treating the cells with bt2cAMP and hydrocortisone induced enzyme expression by increasing transcription of the enzyme or an essential enzyme related protein(s), with steady-state levels of type II 5'-deiodinase attained after 8 h of bt2cAMP treatment. Glial cells grown in the absence of thyroid hormone had 10-15-fold higher levels of 5'-deiodinating activity than cells grown in the presence of serum. The increased type II 5'-deiodinating activity observed in serum-free cultures was due to a prolonged enzyme half-life with no change in the rate of enzyme synthesis. Addition of thyroxine or 3,3',5'-triiodothyronine to the serum-free culture medium resulted in a concentration-dependent fall in steady-state enzyme levels, with EC50 values of approximately 0.4 nM. 3,5,3'-Triiodothyronine was at least 100-fold less effective. Chloroquine, NH4Cl, tunicamycin, colchicine, and monodansylcadavarine had no effect on the t1/2 of the enzyme, while both carbonyl cynanide m-chlorophenylhydrazone and cytochalasins completely blocked the inactivation of the type II 5'-deiodinase. These data indicate that in glial cells, an intact actin-cytoskeleton is required for thyroid hormone to modulate the energy-dependent regulation of the half-life of the short-lived, membrane-bound enzyme, type II 5'-deiodinase.