Healthcare, Volume 6, Issue 2 (June 2018) – 42 articles

The objective was to examine the prevalence of Borrelia antibodies among symptomatic individuals with recent and past Lyme disease in endemic communities using standard assays and novel assays employing next-generation antigenic substrates. Single- and two-tiered algorithms included different anti-Borrelia ELISAs and immunoblots. Antibody prevalence was examined in sera from 32 individuals with recent erythema migrans (EM), 335 individuals with persistent symptoms following treatment for Lyme disease (PTLS), and 41 community controls without a history of Lyme disease. Among convalescent EM cases, sensitivity was highest using the C6 ELISA (93.8%) compared to other single assays; specificity was 92.7% for the C6 ELISA vs. 85.4–97.6% for other assays. The two-tiered ELISA-EUROLINE IgG immunoblot combinations enhanced case detection substantially compared to the respective ELISA-IgG Western blot combinations (75.0% vs. 34.4%) despite similar specificity (95.1% vs. 97.6%, respectively). For PTLS cohorts, two-tier ELISA-IgG-blot positivity ranged from 10.1% to 47.4%, depending upon assay combination, time from initial infection, and clinical history. For controls, the two-tier positivity rate was 0–14.6% across assays. A two-tier algorithm of two-ELISA assays yielded a high positivity rate of 87.5% among convalescent EM cases with specificity of 92.7%. For convalescent EM, combinations of the C6 ELISA with a second-tier ELISA or line blot may provide useful alternatives to WB-based testing algorithms. Full article

Thoracic outlet syndrome (TOS) describes a group of disorders that are due to a dynamic compression of blood vessels or nerves, between the clavicle and first rib or cervical vertebral nerve roots. Individuals with TOS typically experience upper limb pain, numbness, tingling, or weakness that is exacerbated by shoulder or neck movement. The causes of TOS vary, and can include abrupt movements, hypertrophy of the neck musculature, and anatomical variations in which the brachial plexus roots pass through this musculature, edema, pregnancy, repeated overhead motions, the blockage of an artery or vein, or abnormal posture. To understand the complexity of this condition, an analysis of shoulder anatomy and mechanics are needed to help describe limitations and the subsequent pathophysiology of TOS. Several treatment options are available, including surgery, medications, and exercise. A comprehensive study of shoulder anatomy and biomechanics, and knowledge of the benefits of exercise, may help clinicians and healthcare practitioners determine the most appropriate treatment plan for an individual with TOS. Full article

Little is known about pain and pain treatment among people with intellectual disabilities (IDs). We aimed to describe pain and pain medications among older people with ID compared to the general population. Data on diagnoses and prescriptions were collected from national registers for the period between 2006 and 2012 for 7936 people with an ID and a referent cohort from the general population. IDs were associated with a decreased risk of being diagnosed with headaches, musculoskeletal pain, and pain related to the circulatory and respiratory systems, but they were associated with increased risk of being diagnosed with pain related to the urinary system. Among men, IDs were associated with an increased risk of being diagnosed with visceral pain. People with IDs were more likely to be prescribed paracetamol and fentanyl regardless of the type of pain but were less likely to be prescribed COX(1+2) and COX2 inhibitors and weak opioids. Healthcare staff and caregivers must be made aware of signs of pain among people with IDs who may not be able to communicate it themselves. Further research is needed to investigate whether people with IDs are prescribed paracetamol rather than other pain drugs due to physicians trying to avoid polypharmacy or if there are other reasons not to prescribe a greater range of pain treatments. Full article

The USA is steadily moving towards a health system that emphasizes ‘wellness’ over ‘sickness’ care. An effective wellness program utilizes a ‘population health’ approach that ensures that all patients who seek care from a health system receive the services recommended by evidence and best practice. This means attending not just to patients who are seen for care, but also to patients who have not yet been seen. A key strategy for population health is empanelment and panel management for patients in primary care. This article relates the experience of UW (University of Washington) Medicine in implementing such a program. Full article

Background: For decades, U.S. rural areas have experienced shortages of primary care providers. Nurse practitioners (NPs) are helping to reduce that shortage. However, NP scope of practice regulations vary from state-to-state ranging from autonomous practice to direct physician oversight. The purpose of this study was to determine if clinical outcomes of older rural adult patients vary by the level of practice autonomy that states grant to NPs. Methods: This cross-sectional study analyzed data from a sample of Rural Health Clinics (RHCs) (n = 503) located in eight Southeastern states. Independent t-tests were performed for each of five variables to compare patient outcomes of the experimental RHCs (those in “reduced practice” states) to those of the control RHCs (in “restricted practice” states). Results: After matching, no statistically significant difference was found in patient outcomes for RHCs in reduced practice states compared to those in restricted practice states. Yet, expanded scope of practice may improve provider supply, healthcare access and utilization, and quality of care (Martsolf et al., 2016). Conclusions: Although this study found no significant relationship between Advanced Registered Nurse Practitioner (ARNP) scope of practice and select patient outcome variables, there are strong indications that the quality of patient outcomes is not reduced when the scope of practice is expanded. Full article

Serving in the military leads to mental diseases, such as post-traumatic stress disorder (PTSD), for a percentage of soldiers globally. The number of veterans with PTSD is increasing and, although medication and psychological treatments are offered, treatment results could be improved. Historically, different forms of nature-based therapy have been used for this target group. However, in spite of anecdotally good results, studies measuring the effect of this form of therapy are still lacking. The aim of this study is to explore how veterans with PTSD manage their everyday lives during and after a ten-week nature-based intervention in a therapy garden. Methods: Eight veterans participated in qualitative interviews, which were conducted during a one-year period and were analyzed using interpretative phenomenological analysis (IPA). Results: Five themes emerged from the IPA analysis: Bodily symptoms; relationships; building new identities; the future; and lessons learned. All the participating veterans gained a greater insight into and mastering of their condition, achieved better control of their lives, and developed tools to handle life situations more appropriately and to build a new identity. This improved their ability to participate in social activities and employment. Conclusion: The results should be considered in the future treatment of veterans with PTSD. Full article

Nursing homes are often places where older persons “come to die.” Despite this, death and dying are seldom articulated or talked about. The aim of this study was to explore assistant nurses’ experiences of conversations about death and dying with nursing home residents. This study is part of an implementation project through a knowledge-based educational intervention based on palliative care principles. An ethnographic study design was applied in seven nursing homes, where eight assistant nurses were interviewed and followed in their daily assignments through participant observations. The assistant nurses stated that they had the knowledge and tools to conduct such conversations, even though they lacked the time and felt that emotional strain could be a hinder for conversations about death and dying. The assistant nurses used the strategies of distracting, comforting, and disregarding either when they perceived that residents’ reflections on death and dying were part of their illness and disease or when there was a lack of alignment between the residents’ contemplations and the concept of dying well. They indicated that ambivalence and ambiguity toward conversations about death and dying should be taken into consideration in future implementations of knowledge-based palliative care that take place in nursing homes after this project is finalized. Full article

Background: Living above the poverty line reduces the risk of physical illnesses, including childhood asthma (CA). Minorities’ Diminished Return theory, however, suggests that the protective effects of socioeconomic status (SES) on health are weaker for racial minorities than White families. It is unknown whether the association between SES and CA differs for White and Black families. Aims: Using a national sample, the current study compared Black and White families for the association between living above the poverty line and CA. Methods: Data came from the National Survey of Children’s Health (NSCH), 2003–2004, a national telephone survey. A total of 86,537 Black or White families with children (17 years old or younger) were included in the study. This sample was composed of 76,403 White (88.29%) and 10,134 Black (11.71%) families. Family SES (living above the poverty line) was the independent variable. The outcome was CA, reported by the parent. Age, gender, and childhood obesity were the covariates. Race was conceptualized as the moderator. A number of multivariable logistic regressions were used in the pooled sample and specific to each race for data analysis. Results: In the pooled sample, living above the poverty line was associated with lower odds of CA. An interaction was found between race and living above the poverty line on odds of CA, indicating a smaller association for Black compared to White families. Although race-stratified logistic regressions showed negative associations between living above the poverty line and CA in both White and Black families, the magnitude of this negative association was larger for White than Black families. Conclusions: The health gain from living above the poverty line may be smaller for Black than White families. Due to the existing Minorities’ Diminished Return, policies that merely reduce the racial gap in SES may not be sufficient in eliminating racial health disparities in the United States. Public policies must go beyond reducing poverty to address structural and environmental risk factors that disproportionately impact Blacks’ health. Policies should help Black families gain health as they gain upward social mobility. As they are more likely to face societal and structural barriers, multi-level interventions are needed for the health promotion of Blacks. Full article

In recent years, there has been an increasing focus on the need to integrate formal knowledge with clinical experience in the pre-clinical years since the initial years of medical education play an important role in shaping the attitudes of medical students towards medicine and support the development of clinical reasoning. In this study, we describe approaches that involve real patients and patient-simulation-based methodologies to teach gastroenterology to second year medical students. Our goals were to (i) demonstrate bio-psychosocial aspects of clinical practice, (ii) demonstrate commonality of gastrointestinal ailments, and (iii) help understand complex gastroenterology concepts. We used two main approaches including brief, pre-prepared questions and answers discussing with the patients in various sessions throughout the course and a two-hour session that included patient participation, patient simulation modalities with high fidelity mannequins, a lightening round of interactive cases, and a Patient Oriented Problem Solving (POPS) session. The approaches improved the effectiveness of the delivery of the content-heavy, fast-paced GI course and provided opportunities for the students to think about gastroenterology from both basic and clinical points of view. The approaches involved peer teaching, which supports knowledge acquisition and comprehension. Very positive feedback and overall engagement of students suggested that these approaches were well-received. Full article

In low-and-middle-income countries (LMICs), traditional birth attendant (TBA) training programs are increasing, yet reports are limited on how those programs affect the prenatal clinical abilities of trained TBAs. This study aims to assess the impact of clinical training on TBAs before and after a maternal health-training program. A prospective observational study was conducted in rural Guatemala from March to December 2017. Thirteen participants conducted 116 prenatal home visits. Data acquisition occurred before any prenatal clinical training had occurred, at the completion of the 14-week training program, and at six months post program completion. The paired t-test and McNemar’s test was used and statistical analyses were performed with R Version 3.3.1. There was a statistically significant improvement in prenatal clinical skills before and after the completion of the training program. The mean percentage of prenatal skills done correctly before any training occurred was 25.8%, 62.3% at the completion of the training program (p-value = 0.0001), and 71.0% after six months of continued training (p-value = 0.034). This study highlights the feasibility of prenatal skill improvement through a standardized and continuous clinical training program for TBAs. The improvement of TBA prenatal clinical skills could benefit indigenous women in rural Guatemala and other LMICs. Full article

Person-centered care (PCC) is fundamental for providing high-quality care in long-term care homes. This study aimed to evaluate the psychometric properties of an 11-item Team Member Perspectives of Person-Centered Care (TM-PCC) survey, adapted from White and colleagues (2008). In a cross-sectional study, 461 staff from four long-term care homes in Ontario, Canada, completed the TM-PCC. Construct validity and internal consistency of the TM-PCC were examined with a principal component analysis and Cronbach’s alpha coefficient. Findings revealed a three-component structure with factor 1, Supporting Social Relationships; factor 2, Familiarity with Residents’ Preferences; and factor 3, Meaningful Resident–Staff Relationships. The TM-PCC, as compared to the original survey, presented with less components (i.e., did not address Resident Autonomy, Personhood, Comfort, Work with Residents, Personal Environment, and Management Structure), yet included one new component (Meaningful Resident–Staff Relationships). The TM-PCC has a similar internal consistency (Cronbach’s alpha coefficient 0.82 vs. White et al. 0.74–0.91). The TM-PCC can be used to assess PCC from the staff’s perspective in long-term care homes. Full article

Risk-taking amongst veterans has severe consequences, yet few studies have examined factors that may predict risk-taking in help-seeking veteran populations. This paper presents a cross-sectional study involving a random sample of 667 UK help-seeking veterans, investigating the role of demographics, mental health and physical health presentations on the propensity for risk-taking. Out of 403 (73.4%) veterans, 350 (86.8%) reported risk-taking in the past month. We found that younger age, being in a relationship, probable PTSD, common mental health difficulties and traumatic brain injury were significantly associated with risk-taking. Additionally, a direct association was found between increased risk-taking and PTSD symptom clusters, including higher hyperarousal, elevated negative alterations in mood and cognition. Our findings provide initial evidence for demographic and mental health presentations as predictors of risk-taking in help-seeking veterans. Further research and longitudinal studies are needed to facilitate valid risk assessments, and early intervention for veteran services. Full article

Background: Transient Ischaemic Attacks (TIA) should be treated as a medical emergency. While high-risk TIAs have higher stroke risks than low-risk patients, there is an inherent limitation to this risk stratification, as some low-risk patients may have undiagnosed high-risk conditions. Inequity of care for TIA patients was observed, such that high-risk patients received urgent assessment through acute admission, while low-risk patients faced long waits for clinical consultation. A redesign of the TIA service was planned to offer timely assessment for all patients and avoid acute admission for high-risk patients. Methods: Service reconfiguration was undertaken to set up a daily weekday rapid access TIA clinic where patients would be assessed, investigated, and treated. Results: A re-audit of clinic performance showed a significant increase in the number of patients seen in the ages of 18 to 52. The median time from referral to clinical consultation improved from 10 days to 1. There were similar significant improvements seen in median time to brain imaging (from 10.5 days to 1), and carotid ultrasound (from 10 days to all scans being performed on the same day). Conclusions: The redesigned service achieved the objective of offering urgent assessment and investigations for all TIA patients, including low-risk patients, while avoiding the acute admission for high-risk patients. We share our experience of establishing a successful rapid access ambulatory service without any additional resources. Full article

Chief Nursing Officers (CNOs) have a demanding, complex role that commands accountability in leading the nursing profession and achieving quality patient outcomes. The purpose of this study was to understand the CNO’s view of meeting the needs of the Registered Nurse (RN) at point of care and how this could affect quality patient outcomes. In two qualitative studies twenty-five CNOs were individually interviewed in eight states including: Florida, Tennessee, Kentucky, Maine, New Hampshire, Vermont, Massachusetts, and New Jersey. The majority of these CNOs interviewed believed they were doing the best for their nurses and their healthcare facility. After analyzing their responses, it was apparent that some CNOs actually encouraged peer pressure among nurses to achieve compliance and felt patient acuity is being addressed adequately, since most patients were discharged within three to four days and those that were more critical were admitted to the critical care units. The average length of stay, which is the number of paid days a patient remained in the hospital, was an important metric. A large amount of nurses felt they were unable to deliver the care needed for their patients due to patient load, lack of collaboration among the health care team, higher patient acuity and absence of decision-making and autonomy. Many of the CNOs trusted that patient care outcomes, meaning relatively short hospital stays, demonstrated that the nursing practice was successful; rather than first having the nurse being set up for success to provide the best care possible to their patients. Full article

Nurses encounter difficulties evaluating constipation in elderly people with physical and cognitive impairment. Transabdominal ultrasonography (US) has been used to evaluate fecal impaction or fecal quality. However, it is unclear whether colorectal US can evaluate constipation symptoms in older people. Using colorectal US, we continuously observed the elderly and clarified the relationship between patterns of fecal distribution changes and constipation symptoms in older people with physical and cognitive impairment at long-term care facilities. This study included patients aged ≥65 years with oral intake. US was performed once a day until the next defecation, and fecal hardness was assessed. US images were extracted and categorized. Then, patterns of fecal distribution changes in the colorectum were classified. Multiple logistic regression analysis was performed to examine related factors associated with a constipation pattern. Among 101 patients, US images of 95 patients were analyzed. In 74.4% of the patients, US showed continuation of reflection with acoustic shadow in the rectum, which was significantly associated with defecation on the bed. Of the patients with a continuous crescent-shaped reflection pattern (R3), 92.9% had hard stool. R3 was found to be significantly associated with a Mini-Mental State Examination score of ≤10. In most of the patients, US detected a continuation of reflection with acoustic shadow in rectal patterns, indicating fecal retention in the rectum. Point-of-care US can be used by nurses to visualize rectal fecal retention as constipation patterns in the older people with physical and cognitive impairment at long-term care facilities. Full article

The growing healthcare industry is generating a large volume of useful data on patient demographics, treatment plans, payment, and insurance coverage—attracting the attention of clinicians and scientists alike. In recent years, a number of peer-reviewed articles have addressed different dimensions of data mining application in healthcare. However, the lack of a comprehensive and systematic narrative motivated us to construct a literature review on this topic. In this paper, we present a review of the literature on healthcare analytics using data mining and big data. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a database search between 2005 and 2016. Critical elements of the selected studies—healthcare sub-areas, data mining techniques, types of analytics, data, and data sources—were extracted to provide a systematic view of development in this field and possible future directions. We found that the existing literature mostly examines analytics in clinical and administrative decision-making. Use of human-generated data is predominant considering the wide adoption of Electronic Medical Record in clinical care. However, analytics based on website and social media data has been increasing in recent years. Lack of prescriptive analytics in practice and integration of domain expert knowledge in the decision-making process emphasizes the necessity of future research. Full article

This study investigated ethnic and nativity differences in the chronicity and treatment of psychiatric disorders of African American and Caribbean Black men in the U.S. Data were analyzed from the National Survey of American Life, a population-based study which included 1859 self-identified Black men (1222 African American, 176 Caribbean Black men born within the U.S., and 461 Caribbean Black men born outside the U.S.). Lifetime and twelve-month prevalence of DSM-IV mood, anxiety, and substance use disorders (including Bipolar I and Dysthmia), disorder chronicity, and rate of mental health services use among those meeting criteria for a lifetime psychiatric disorder were examined. Logistic regression models were employed to determine ethnic differences in chronicity, and treatment utilization for disorders. While rates of DSM-IV disorders were generally low in this community sample of Black men, their disorders were chronic and remained untreated. Caribbean Black men born in the U.S. had higher prevalence of Post-Traumatic Stress Disorder, Major Depressive Disorder, and Alcohol Abuse Disorder compared with African American men. Foreign born Caribbean Black men experienced greater chronicity in Social Phobia and Generalized Anxiety Disorder compared to other Black Men. Utilization of mental health service was low for all groups of Black Men, but lowest for the foreign born Caribbean Black men. Results underscore the large unmet needs of both African American and Caribbean Black men in the United States. Results also highlight the role of ethnicity and nativity in mental disorder chronicity and mental health service utilization patterns of Black men. Full article

Background: The number of international students enrolled in universities in Japan is increasing. To provide better oral care services for international students, we have to understand their oral environment and dental health behaviors. However, few studies have investigated the oral health status of international university students. The object of the present study was to clarify the current oral status of international university students. Methods: The subjects were students who visited the dental department at the University of Tokyo’s Health Services Center between April 2012 and March 2013. Our medical records were reviewed with regard to the following items: attributes (nationality, gender, and age); chief complaint (reason for visit); history of dental treatment; mean number of decayed (D), missing (M) or filled (F) teeth as a single (DMFT) index; degree of calculus deposition; gingival condition; and oral hygiene status. Results: The records of 554 university students (138 international and 416 non-international students) were analyzed; 88.4% of the 138 international students were from Asian countries (n = 122), of which 47.1% were from China and 10.9% from Korea, followed by North America (5.8%), Europe (4.3%), and Africa (1.5%). Although no significant differences were found regarding the history of dental treatment between international and non-international students (49.3% and 48.8%, respectively), international students had a significantly higher dental caries morbidity rate (60.1%) than non-international students (49.0%). The international students showed a significantly higher DMFT value compared with the non-international students: 5.0 and 4.0 per individual, respectively. Severe calculus deposition was observed in international students compared with non-international students (51.9% and 31.7%, respectively). Conclusions: The international university students had poorer oral health status than the non-international students, even though the result might include many uncertainties and possible biases. Full article

iCook 4-H is a lifestyle intervention to improve diet, physical activity and mealtime behavior. Control and treatment dyads (adult primary meal preparer and a 9–10-year-old youth) completed surveys at baseline and 4, 12, and 24 months. A Health Disparity (HD) score composite was developed utilizing a series of 12 questions (maximum score = 12 with a higher score indicating a more severe health disparity). Questions came from the USDA short form U.S. Household Food Security Survey (5), participation in food assistance programs (1), food behavior (2), level of adult education completed (1), marital status (1), and race (1 adult and 1 child). There were 228 dyads (control n = 77; treatment n = 151) enrolled in the iCook 4-H study. Baseline HD scores were 3.00 ± 2.56 among control dyads and 2.97 ± 2.91 among treatment dyads, p = 0.6632. There was a significant decline in the HD score of the treatment group from baseline to 12 months (p = 0.0047) and baseline to 24 months (p = 0.0354). A treatment by 12-month time interaction was found (baseline mean 2.97 ± 2.91 vs. 12-month mean 1.78 ± 2.31; p = 0.0406). This study shows that behavioral change interventions for youth and adults can help improve factors that impact health equity; although, further research is needed to validate this HD score as a measure of health disparities across time. Full article

The recruitment and retention of health professionals in rural, remote, and northern regions is an ongoing challenge. The Northern Nursing Education Network brought together nursing students working in rural and remote regions of the circumpolar north in Innovative Learning Institute on Circumpolar Health (ILICH) events to create opportunities for shared learning and expose both students and faculty to local and traditional knowledge that informs health behaviors specific to regions with Indigenous populations. Using participant experience data extracted from program discussions, evaluations, and reflective notes conducted after ILICH events held in 2015–2017, this paper explores how these two-week institutes can contribute to knowledge that is locally relevant yet transferable to rural areas across the circumpolar north. The findings clustered around experiences related to (1) Language as a barrier and an enabler; (2) shared values and traditions across borders; (3) differences and similarities in nursing practice; (4) new perspectives in nursing; and (5) building sustainable partnerships. Students learned more about their own culture as well as others by exploring the importance of language, cultures, and health inequity on different continents. Shared values and traditional knowledge impacted student perspectives of social determinants of health that are highly relevant for nurses working in the circumpolar north. Full article

Human babesiosis caused by Babesia duncani is an emerging infectious disease in Canada. This malaria-like illness is brought about by a protozoan parasite infecting red blood cells. Currently, controversy surrounds which tick species are vectors of B. duncani. Since the availability of a serological or molecular test in Canada for B. duncani has been limited, we conducted a seven-year surveillance study (2011–2017) to ascertain the occurrence and geographic distribution of B. duncani infection country-wide. Surveillance case data for human B. duncani infections were collected by contacting physicians and naturopathic physicians in the United States and Canada who specialize in tick-borne diseases. During the seven-year period, 1119 cases were identified. The presence of B. duncani infections was widespread across Canada, with the highest occurrence in the Pacific coast region. Patients with human babesiosis may be asymptomatic, but as this parasitemia progresses, symptoms range from mild to fatal. Donors of blood, plasma, living tissues, and organs may unknowingly be infected with this piroplasm and are contributing to the spread of this zoonosis. Our data show that greater awareness of human babesiosis is needed in Canada, and the imminent threat to the security of the Canadian blood supply warrants further investigation. Based on our epidemiological findings, human babesiosis should be a nationally notifiable disease in Canada. Whenever a patient has a tick bite, health practitioners must watch for B. duncani infections, and include human babesiosis in their differential diagnosis. Full article

Traditionally, there has been a widely accepted notion that the transition from acute to chronic pain follows a linear trajectory, where an injury leads to acute episodes, subacute stages, and progresses to a chronic pain condition. However, it appears that pain progression is much more complicated and individualized than this original unsupported assumption. It is now becoming apparent that, while this linear progression may occur, it is not the only path that pain, specifically low-back pain, follows. It is clear there is a definite need to evaluate how low-back pain trajectories are classified and, subsequently, how we can more effectively intervene during these progression stages. In order to better understand and manage pain conditions, we must examine the different pain trajectories, and develop a standard by which to use these classifications, so that clinicians can better identify and predict patient-needs and customize treatments for maximum efficacy. The present article examines the most recent trajectory research, and highlights the importance of developing a broader model for patient evaluation. Full article

Philip Morris International (PMI) has developed the Population Health Impact Model (PHIM) to quantify, in the absence of epidemiological data, the effects of marketing a candidate modified risk tobacco product (cMRTP) on the public health of a whole population. Various simulations were performed to understand the harm reduction impact on the U.S. population over a 20-year period under various scenarios. The overall reduction in smoking attributable deaths (SAD) over the 20-year period was estimated as 934,947 if smoking completely went away and between 516,944 and 780,433 if cMRTP use completely replaces smoking. The reduction in SADs was estimated as 172,458 for the World Health Organization (WHO) 2025 Target and between 70,274 and 90,155 for the gradual cMRTP uptake. Combining the scenarios (WHO 2025 Target and cMRTP uptake), the reductions were between 256,453 and 268,796, depending on the cMRTP relative exposure. These results show how a cMRTP can reduce overall population harm additionally to existing tobacco control efforts. Full article

Most of the care in nursing homes is palliative in nature, as it is the oldest and the frailest people who live in nursing homes. The aim of this study was to explore next of kin’s experiences of participating in the care of older persons at nursing homes. A qualitative design was used, based on semi-structured interviews with 40 next of kin, and analyzed using qualitative content analysis. An overarching theme emerged, a balancing act consisting of three categories: (1) visiting the nursing home; (2) building and maintaining relationships; and (3) gathering and conveying information. The next of kin have to balance their own responsibility for the older person’s wellbeing by taking part in their care and their need to leave the responsibility to the staff due to critical health conditions. The next of kin wanted to participate in care meetings and conversations, not only in practical issues. The findings indicate the need to improve the next of kin’s participation in the care as an equal partner. Increased knowledge about palliative care and decision-making of limiting life-prolonging treatment may lead to a higher quality of care. Full article

Hong Kong, as a special administrative region of the People’s Republic of China, is a metropolitan city in Asia with a population of approximately 7.4 million. This paper reflects the oral health care situation in Hong Kong. Water fluoridation was introduced in 1961 as the primary strategy for the prevention of dental caries. The fluoride level is currently 0.5 parts per million. Dental care is mainly provided by private dentists. The government’s dentists primarily serve civil servants and their dependents, with limited emergency dental service for pain relief offered to the general public. Nevertheless, the government runs the school dental care service, which provides dental treatments to primary school children through dental therapists. They also set up an oral health education unit to promote oral health in the community. Hong Kong had 2280 registered dentists in 2017, and the dentist-to-population ratio was about 1:3200. The Faculty of Dentistry at the University of Hong Kong is the only institution to provide basic and advanced dentistry training programs in Hong Kong. Dental hygienists, dental surgery assistants, dental therapists, and dental technicians receive training as paradental staff through the university or the government. Full article

Background: Quality improvement initiatives can help nursing homes strengthen psychosocial work environments. The aim of the present study was to examine the association between supportive psychosocial work environment, and professional and organizational characteristics regarding quality improvement initiatives in dementia care. Methods: A paper questionnaire survey was administered to a convenience sample of 365 professional caregivers in 12 special nursing homes in Japan. Psychosocial work environment was assessed using the Social Capital and Ethical Climate at the Workplace Scale to calculate a score of social capital in the workplace, ethical leadership, and exclusive workplace climate. Variables for quality improvement initiatives included type of home (unit-type or traditional), presence of additional benefit for dementia care, and professionalism in dementia care among caregivers evaluated using the Japanese version of the Sense of Competence in Dementia Care Staff Scale. Results: Elevated professionalism and unit-type home were significantly associated with high social capital, strong ethical leadership, and low exclusive workplace climate. The presence of dementia care benefit was not associated with any subscale of psychosocial work environment. Conclusions: Quality improvement initiatives to foster supportive psychosocial work environment should enhance professionalism in dementia care with unit-based team building of professional caregivers in special nursing homes. Full article

The increasing numbers of people with dementia places considerable stress on health and aged care services and has resulted in the development of community adult day services. Aim: The aim of this integrative review is to determine the extent to which these services support the occupational participation of people with dementia, and how they impact their primary carers. Method: The mixed-methods appraisal tool (MMAT) was used to identify relevant studies in the period 2011–2016. Results: Nine databases were searched and yielded 16 articles with a variety of research designs for inclusion in the review. Conclusions: Findings indicate that adult day services use a range of approaches to support attendees and their carers. In spite of these efforts, there appears to be a lack of interest in utilizing these services while a person is in the early stages of dementia. This suggests that policies in aged care, such as aging-in-place, need to consider the pressure and stress they exert on carer’s quality of life. Another consideration is to better promote the benefits of participating in adult day services in the early stages of dementia for both the attendees and their carers, thereby delaying the tendency towards early institutionalization. Full article

The WHO Regional Office for Europe developed a set of public health functions resulting in the ten Essential Public Health Operations (EPHO). Public health or primary care settings seem to be favorable to embrace all actions included into EPHOs. The presented paper aims to guide readers on how to assign individual health promotion and environmental health services to public health or primary care settings. Survey tools were developed based on EPHO 2, 3 and 4; there were six key informant surveys out of 18 contacted completed via e-mails by informants working in Denmark on health promotion and five face-to-face interviews were conducted in Australia (Melbourne and Victoria state) with experts from environmental health, public health and a physician. Based on interviews, we developed a set of indicators to support the assignment process. Population or individual focus, a system approach or one-to-one approach, dealing with hazards or dealing with effects, being proactive or reactive were identified as main element of the decision tool. Assignment of public health services to one of two settings proved to be possible in some cases, whereas in many there is no clear distinction between the two settings. National context might be the one which guides delivery of public health services. Full article

Background: Successful aging is best determined by active management and self-determination of one’s aging roadmap. Some individuals are ready to respond to these challenges, others may benefit from assistance that might be offered through an evidence-based intervention. The Aging Mastery Program^® (AMP) has been developed to meet these needs. Method: In a cross over design the intervention was tested in ten senior centers and aging network agencies looking at impacts upon general health and quality of life, patient activation, physical activity and advanced care planning. Results: There was a statistically significant (tested at a 0.05 level) level of improvement found in physical activity and advanced care planning. Conclusion: Findings support the program’s effectiveness and its value as an evidence-based intervention for older adult programming. Full article

Nutraceuticals are important for healthy skin maintenance. Probiotics, phenolics, and vitamins are just a few of the nutraceuticals meant to potentially prevent and assist medical management of dermatologic conditions. Among these, probiotics, vitamin E, and green tea catechins may offer the broadest array of skin protective mechanisms with probiotics having the greatest clinical range. Probiotics’ amelioration of atopic dermatitis and opportunistic infections of skin burns has been targeted in recent research efforts. This includes the improvement of Scoring Atopic Dermatitis index scores, p = 0.02, with intact Lactobacillus rhamnosus Goldin and Gorbach (LGG) in comparison to heat inactivated LGG or placebo. Lactobacillus reuteri used prior to or concurrently with Staphylococcus aureus infection can increase epidermal keratinocyte survival, p < 0.01. Phenolics may not have been extensively studied for atopic dermatitis or skin burns. However, phenolics do have a role in photoprotection. The phenolic rutin increases ultraviolet B radiation filter reactive oxygen species scavenging at 75%, p < 0.002, and peak wavelength absorption, p < 0.001. While oral and topical probiotics have untapped potential for atopic dermatitis amelioration and skin infection prevention, phenolics will be increasingly used for photoprotection. With optimized bioavailability, dosage, and formulation, nutraceuticals will become crucial for healthy skin maintenance. Full article