Scales of geography, time, and population: the study of violence as a public health problem

OBJECTIVES

In this study, data on violent deaths in the Bronx, New York City, from the 1970, 1980, and 1990 censuses were analyzed.

METHODS

The incidence and areal density of intentional deaths were mapped by health area. Simple and stepwise regressions between violent death measures and other factors were performed.

RESULTS

The incidence of deaths at levels of those in the highest 1970 quintile spread so that by 1990 only 2 areas saw incidences at levels of the lowest 1970 quintile. Overcrowding, socioeconomic status, population, population change, and drug deaths in simple regressions and overcrowding, socioeconomic status, and low-weight births in stepwise regressions correlated significantly with violent death incidence or density.

CONCLUSIONS

Understanding the spatiotemporal development of violence can contribute to public policy on violence.

The surgeon and casemix

Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake. Surgery has become a major focus at all large public hospitals, because of its high earning potential, and this pressure to maximise funding could influence surgical practice. Casemix funding's emphasis on length of hospital stay has encouraged forward planning for earlier discharge after surgical procedures. Patients are now assessed in pre-admission clinics, educated about their condition and their hospital stay, and a plan formulated for their discharge and rehabilitation. Funding for major surgical procedures of long duration in patients with complex conditions should reflect the higher level of resource utilisation. Tertiary referral centres, because of their commitment to training and research and their more severely ill patient population, are less cost-effective and require funding to ensure their viability. The improved information that casemix generates should be used to evaluate outcomes and improve patient care; efficiency must not take precedence over quality of care and compassion.

Auditory brainstem responses in a Rhesus Macaque model of neuro-AIDS

Nine rhesus macaques (Macaca mulatta) were inoculated with a combination of two passaged strains of SIVmac (R71 and 17E), both of which are known to be neurovirulent. Auditory brainstem responses (ABRs) were recorded at regular intervals from these animals both before and after inoculation. Increases in ABR peak and interpeak latency were observed corresponding to progression of SIV disease. Post-inoculation increases in latency were observed for all five peaks of the ABR and for interpeak intervals I-V and III-V. The largest increases in latency were associated with end-stage disease. Within 14 weeks of inoculation, all but two animals developed end-stage simian AIDS and were euthanized. Histopathological examination revealed multifocal lesions in the cerebral gray and white matter as well as in the auditory structures of the brainstem. In most animals, ABR changes were accompanied by evidence of underlying neuropathology. However, cases of severe neuropathology with no ABR abnormalities and vice versa were also noted. Though in a much shorter time frame, SIVmac R71/17E produced both physiological and histopathological abnormalities similar to those associated with HIV disease in humans. These results further support the SIVmac R71/17E infected rhesus macaque as an animal model of HIV related neurological disease in humans.

A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke

BACKGROUND AND PURPOSE

Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems; all of these are potentially modifiable with exercise. The purposes of this randomized, controlled pilot study were (1) to develop a home-based balance, strength, and endurance program; (2) to evaluate the ability to recruit and retain stroke subjects; and (3) to assess the effects of the interventions used.

METHODS

Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were randomized to a control group or to an experimental group that received a therapist-supervised, 8-week, 3-times-per-week, home-based exercise program. The control group received usual care as prescribed by the patients' physicians. Baseline and postintervention assessments included the Fugl-Meyer Motor Assessment, the Barthel Index of Activities of Daily Living (ADL), the Lawton Scale of Instrumental ADL, and the Medical Outcomes Study-36 Health Status Measurement. Functional assessments of balance and gait included a 10-m walk, 6-Minute Walk, and the Berg Balance Scale. Upper extremity function was evaluated by the Jebsen Test of Hand Function.

RESULTS

Of 22 patients who met study criteria, 20 completed the study and 2 refused to participate. The experimental group tended to improve more than the control group in motor function (Fugl-Meyer Upper Extremity: mean change in score, 8. 4 versus 2.2; Fugl-Meyer Lower Extremity: 4.7 versus -0.9; gait velocity: median change, 0.25 versus .09 m/s; 6-Minute Walk: 195 versus 114 ft; Berg Balance Score: 7.8 versus 5; and Medical Outcomes Study-36 Health Status Measurement of Physical Function: 15. 5 versus 9). There were no trends in differences in change scores by the Jebsen Test of Hand Function, Barthel Index, and Lawton Instrumental ADL Scale.

CONCLUSIONS

This study demonstrated that a randomized, controlled clinical trial of a poststroke exercise program is feasible. Measures of neurological impairments and lower extremity function showed the most benefit. Effects of the intervention on upper extremity dexterity and functional health status were equivocal. The lasting effects of the intervention were not assessed.

Determinants of self-efficacy among persons with spinal cord injuries

The purpose of this study was to determine the factors affecting self-efficacy among persons with spinal cord injury (SCI). The study population consisted of 105 persons with SCI who were discharged from one of eight hospitals in north central Alabama between October 1989 and September 1992. Data were derived from a retrospective acute-care medical record review and 12-month annual follow-up telephone interviews. The findings indicate that high self-efficacy is significantly associated with less severe neurological impairment, being white, employed at injury, having a high-school education or beyond, and having an unintentional injury. In terms of marital status our data indicate the odds of divorced persons having high self-efficacy are 8.2 (CL = 0.919, 74.1) times those of married persons. In addition, 64% of those who were divorced during the 12 months after injury had high self-efficacy compared to 50% of those who were divorced prior to injury.

Psychometric evaluation of the Organizational Job Satisfaction Scale

Findings are reported from a replicated evaluation of the psychometric properties of the Organizational Job Satisfaction Scale. Data lend strong support for the scale which assesses four dimensions of organizational job satisfaction. Principal component factor analysis of data from two independent samples of urban staff registered nurses (RNs) (n = 496; n = 532) confirmed four dimensions of pay, interaction, administration, and status. Cronbach's alpha for subscales ranged from .76 to .88. Pearson correlation coefficients for the interrelationships among subscales and an estimate of theta verified internal consistency. The Organizational Job Satisfaction Scale scores correlated significantly with a criterion measure of job enjoyment. Hypothesis testing of theoretically predictable relationships supported construct validity. Scores on the organizational job satisfaction subscales correlated significantly with automony, stress, and commitment. Item revisions and recommendations for future use of the instrument are discussed.

An in vivo comparison between a visible light-cured bonding system and a chemically cured bonding system

Direct bonding of brackets has become a routine procedure in clinical orthodontics. Many techniques and materials are currently advocated and used, the most recent being light-cured composites. Advantages of the light-cured systems are their relative ease of use, improved bracket placement, and more rapid set of the composite. For a new system to be clinically viable, it must possess properties that are at least as reliable as existing systems. The purpose of this longitudinal clinical study was to evaluate and compare the rate of success and/or failure between a visible light-cured bonding material (Sequence) and a chemically cured bonding material (System 1+), using both systems in every patient. Contralateral quadrants were bonded with each system respectively. A total of 32 patients were followed for a mean period of 11 months (range of 3 to 21 months), with a total of 531 brackets bonded, 265 with visible light-cured and 266 with chemically cured resins. Failures for each system were recorded and failure rates calculated. The failure rate of the visible light-cured composite was 11.3% and that of the chemically cured composite was 12%. A Chi-squared (chi2) test did not reveal any statistically significant differences between the failure rates of the two systems, (chi2 = 0.014, df-1, P > 0.9).

Cardiovascular reactivity to video game predicts subsequent blood pressure increases in young men: The CARDIA study

OBJECTIVE

This study was undertaken to determine the relationship between heightened reactivity of blood pressure (BP) during stress and 5-year changes in blood pressure and hypertensive status, using the CARDIA study.

METHOD

A total of 3364 participants (910 white men, 909 white women, 678 black men, and 867 black women), initially 20 to 32 years old and normotensive, were included. Cardiovascular reactivity to psychological stressors (video game and star-tracing tasks for 3 minutes, cold pressor test for 1 minute) was measured in 1987-1988. We then examined reactivity as a predictor of significant BP change (> or = 8 mm Hg, thought to represent a clinically significant increase) over the next 5 years. Logistic regression models were used to control for potential covariates. Significant BP change and the development of hypertension (BP greater than 140/90 or taking medication for hypertension) over the 5-year follow-up were examined in separate analyses.

RESULTS

Increased systolic blood pressure (SBP) reactivity to the video game was associated with a significant 5-year SBP increase among the entire cohort, independent of resting SBP (p < .0001). Subsequent analyses showed that this relationship held for men but not for women. Reactivity to the star-tracing task or the cold pressor test did not predict significant BP change. Among black men only, new hypertensives (N = 36) had greater diastolic blood pressure (DBP) reactivity to the video game (p = .01).

CONCLUSIONS

Although BP reactivity to all physical and mental stressors used in this study did not consistently predict 5-year change in BP in this young cohort, the results indicate that reactivity to a video game stressor predicts 5-year change in BP and early hypertension among young adult men. These findings are consistent with other studies showing the usefulness of stressors producing a primarily beta-adrenergic response in predicting BP change and hypertension. The results may be limited by the shortened initial rest and recovery periods used in the CARDIA protocol.

Aqueous solubilization of transmembrane peptide sequences with retention of membrane insertion and function

We recently reported that the peptide C-K4-M2GlyR mimics the action of chloride channels when incorporated into the apical membrane of cultured renal epithelial monolayers. C-K4-M2GlyR is one of a series of peptides that were prepared by the addition of lysine residues to the N- or C-terminus of the M2 transmembrane sequence of the brain glycine receptor. This study addresses how such modifications affect physical properties such as aqueous solubility, aggregation, and secondary structure, as well as the ability of the modified peptides to form channels in epithelial monolayers. A graded improvement in solubility with a concomitant decrease in aggregation in aqueous media was observed for the M2GlyR transmembrane sequences. Increases in short-circuit current (I(SC)) of epithelial monolayers were observed after treatment with some but not all of the peptides. The bioactivity was higher for the more soluble, less aggregated M2GlyR peptides. As described in our previous communication, sensitivity of channel activity to diphenylamine-2-carboxylate, a chloride channel blocker, and bumetanide, an inhibitor of the Na/K/2Cl cotransporter, was used to assess changes in chloride selectivity for the different assembled channel-forming peptides. The unmodified M2GlyR sequence and the modified peptides with less positive charge are more sensitive to these agents than are the more highly charged forms. This study shows that relatively insoluble transmembrane sequences can be modified such that they are easier to purify and deliver in the absence of organic solvents with retention of membrane association, insertion, and assembly.

Factors associated with awareness of vocational rehabilitation services after traumatic brain injury

OBJECTIVES

To determine the characteristics of persons with traumatic brain injury (TBI) who were aware of vocational rehabilitation (VR) services 1 year after hospital discharge.

DESIGN

Medical record and longitudinal survey data on persons with TBI were analyzed using logistic regression and bivariate analyses.

SETTING

The study sample was drawn from a population-based sample of persons hospitalized in 1 of 8 hospitals in north-central Alabama.

PARTICIPANTS

Criteria for inclusion were: (1) being at least 18 years of age or older when injured; (2) having sustained a TBI; (3) being discharged alive after a hospital stay of at least 3 days; (4) residing and having been injured in the state of Alabama; (5) participation in a 12-month follow-up interview.

MAIN OUTCOME MEASURE

Patients' awareness of VR service programs and benefits.

RESULTS

Awareness of VR service programs was associated with: (1) being Caucasian; (2) being more often employed at the time of injury; (3) being more often severely injured; and (4) more frequently receiving outpatient rehabilitation.

CONCLUSION

Interventions should target non-Caucasians, those who were unemployed when injured, those less severely injured, and those not receiving outpatient rehabilitation services after hospital discharge. Periodic review of VR benefits with patients and their families should be undertaken by health care and VR professionals.

Differential regulation of genes encoding synaptic proteins by the Oct-2 transcription factor

In order to investigate the effect of the Oct-2 POU family transcription factor on the regulation of genes encoding synaptic proteins, we have used cell lines in which the level of Oct-2 has been greatly reduced using an antisense approach. The reduced Oct-2 level results in enhanced expression of SNAP-25 and synapsin I, indicating that the genes encoding these proteins are normally repressed by Oct-2 in neuronal cells. In contrast, no alteration was observed in the levels of the synaptic proteins, synaptophysin and synaptotagmin. Although the neuronal forms of Oct-2 can repress the synapsin I promoter in co-transfection experiments, indicating that they have a direct effect on the expression of this gene, they have no effect on the activity of the SNAP-25 promoter, indicating that the effect of Oct-2 on this gene is likely to be indirect. These effects are discussed in terms of the differential effect of Oct-2 and the related POU family transcription factor Brn-3a, on the promoters of genes encoding different synaptic proteins.

Socioeconomic determinants of health: community marginalisation and the diffusion of disease and disorder in the United States

This article describes the cascading diffusion of "inner city problems" of disease and disorder in the United States--from the huge marginalised inner city communities of the largest municipalities, first along national travel routes to smaller cities, and then from central cities into surrounding more affluent suburbs-following the pattern of the daily journey to work. Public policies and economic practices which increase marginalisation act to damage the "weak ties" of the community social networks which bind central city neighbourhoods into functioning units. Spreading disease and disorder can be interpreted as indices of the resulting social disintegration, which is driven by policy. This "failure of containment" in the United States should serve as a warning for cities in Europe against reducing the municipal and other services that they provide to "unpopular" subpopulations.

The hierarchical diffusion of AIDS and violent crime among U.S. metropolitan regions: inner-city decay, stochastic resonance and reversal of the mortality transition

Census data on migration within and between the 25 largest U.S. metropolitan areas-containing more than 113 million people-permit construction of a probability-of-contact matrix corresponding to a particular Markov process dominated by the nation's largest cities, a hierarchical structure. Regression models based on vectors associated with that process find the large-scale diffusion of AIDS in the U.S.A. depends strongly on national patterns of contact with the original AIDS outbreaks in New York City and San Francisco as modulated by the violent crime rate, a local index of social disintegration resulting from the marginalization of minority ethnic urban communities. Violent crime is itself undergoing a recognizably similar hierarchical diffusion from the largest U.S. cities into smaller metropolitan regions. Further analysis suggests that continuation of public policies of "benign neglect" and "planned shrinkage" directed against marginalized urban populations may trigger a strong stochastic resonance which can significantly degrade public health and public order for much of the three-quarters of the U.S. population living in or near cities, in effect reversing the mortality transition of the last century.

Differential regulation of the two neuronal nitric-oxide synthase gene promoters by the Oct-2 transcription factor

The Oct-2 transcription factor has been shown previously to repress both the cellular tyrosine hydroxylase and the herpes simplex virus immediate-early genes in neuronal cells. Here we identify the gene encoding the neuronal nitric-oxide synthase (nNOS) as the first example of a gene activated in neuronal cells by Oct-2. The levels of the nNOS mRNA and protein are greatly reduced in neuronal cell lines in which Oct-2 levels have been reduced by an antisense method, although these cells have enhanced levels of tyrosine hydroxylase. Moreover, the nNOS gene regulatory region is activated by Oct-2 expression vectors upon cotransfection into both neuronal and non-neuronal cells, and this response is dependent upon a 20-amino acid region within the COOH-terminal activation domain of Oct-2. Of the two closely linked promoters that drive nNOS gene expression, only the downstream 5.1 promoter is activated by Oct-2, whereas the 5.2 promoter is unaffected. These effects are discussed in terms of the potential role of Oct-2 in regulating nNOS expression in the nervous system.

Fatal work-related injuries in the U.S. chemical industry 1984-89

Several mortality studies of the chemical industry have examined fatal injuries, but most of these studies have been of employees of large chemical firms and have not separated work-related from non-work-related injuries. We examined all U.S. Occupational Safety and Health Administration (OSHA) investigation files in 1984-89 in 47 U.S. states of fatal injuries in the chemical industry, Standard Industrial Classification (SIC) 2800-2899. OSHA investigates all reported deaths over which it has jurisdiction; this includes most causes of work-related death except for homicide and motor vehicle crashes. For the 6 year period, there were 234 fatalities in the chemical industry, for a work-related fatality rate of 0.55 per 10,000 workers/year. The largest category of deaths was from explosions, with 99 (42%), followed by fire & burns, with 32 (14%), poisoning, with 31 (13%), and falls, with 18 (8%). Of the 99 deaths from explosions, 45 (45%) involved manufacture or handling of fireworks or other explosives. The fatality rate at firms with fewer than 50 employees was more than twice that of larger firms (P < 0.05) and employees at small firms were less likely to have been covered by a union contract (P < 0.05). OSHA issued citations for safety violations in 73% of the deaths. While regulatory authorities and the media often focus attention on large, multinational chemical corporations, the highest worker fatality rates are found at the smallest chemical firms.

Prenatal diagnosis of a chest wall hamartoma and sternal cleft

We present the prenatal evaluation and diagnosis of a disorganized chest wall hamartoma with underlying sternal cleft in a family with a prior offspring with the VATER association. The possibility that these conditions are linked to mesodermal defects with a common pathogenic etiology is suggested.

Using reflective diaries to assess students

This article looks at the problems of using reflective diaries to conduct formative assessments of students' performance. The author highlights the importance of the proper definition of terms, and suggests there are strengths and limitations associated with attaching significance to retrospective, reflective self-assessment.

Changes in the intracellular free amino acid pool in human saphenous vein tissue culture

The aim of this work was to investigate the effect of tissue culture on the intracellular amino acid pool in both freshly isolated and surgically prepared saphenous vein segments taken from patients undergoing coronary artery bypass surgery (number of patients, n = 8). Viability of freshly isolated vein rings, indicated by ATP concentration, was maintained in culture (321 +/- 41 vs. 277 +/- 31 nmol (g wet wt)-1, 0 vs. 14 days). The initial decrease in ATP concentration in surgically prepared rings was significantly reversed following 14 days in culture from 135 +/- 26 to 201 +/- 18 nmol (g wet wt)-1 (P < 0.05). Freshly isolated vein rings maintained their intracellular free amino acid pool during the 14 days in culture (from 166 +/- 25 to 166 +/- 23 mumol (g protein)-1). Surgical preparation of vein rings induced a decrease in the intracellular free amino acid pool (from 166 +/- 25 to 87 +/- 15 mumol (g protein)-1, P < 0.05). This decrease was partially reversed after 14 days in culture (140 +/- 19 mumol (g protein)-1). Although the total amino acid pool in both types of vein rings after 14 days in culture was similar, there were variations in individual amino acid concentrations. Freshly isolated rings showed an increase in glutamine concentration and a decrease in alanine and aspartate concentrations after 14 days in culture. Surgically prepared vein rings showed a decrease in aspartate concentration and an increase in concentrations of glutamine, asparagine, glutamate and glycine. The changes in individual intracellular free amino acid concentrations, which were largely determined by the corresponding concentrations in the medium, indicates that culture media should be supplemented with taurine, aspartate and alanine.

Experiential learning and critical thinking in nursing

This article describes a continuing ethnographic study of critical thinking, reflection and experiential learning in nursing. The author examines the related theory and explains the terms of reference which underpin the study. Date analysis so far emphasises the importance of recognising positive and negative feelings associated with experiences, when engaging in reflection. She also outlines the precursors to effective and non-effective reflection implied by the data. It is suggested that there is no correct model for critical thinking and the author highlights the need for further research into effective and non-effective outcomes of reflection.