Tobacco sales in pharmacies: time to quit

OBJECTIVE

To assess the pharmacy profession's perceptions of tobacco sales in US pharmacies and explore whether a policy prohibiting sales of tobacco in pharmacies would alter adult consumer shopping behaviour.

SUBJECTS AND DESIGN

In California, surveys were administered to 1168 licensed pharmacists and 1518 pharmacy students, and telephone interviews were conducted with 988 adult consumers.

RESULTS

Most (58.1%) licensed pharmacists were strongly against sales of tobacco in pharmacies, 23.6% were against it, 16.7% were neutral, 1.2% were in favour of it, and 0.4% were strongly in favour of it. Pharmacists who were current tobacco users were more likely to be in favour of tobacco sales in pharmacies than were pharmacists who were current non-users (p < 0.005). Similar statistics were observed for pharmacy students. Most consumers (72.3%) disagreed with the statement, "I am in favour of tobacco products being sold in drugstores"; 82.6% stated that if the drugstore where they most commonly shopped were to stop selling tobacco products, they would shop there just as often, 14.2% would shop there more often, and 3.2% would shop there less often.

CONCLUSION

Little professional or public support exists for tobacco sales in pharmacies.

Merchandising of cigarettes in San Francisco pharmacies: 27 years later

OBJECTIVE

To estimate changes since 1976 in the proportion of San Francisco pharmacies that sell cigarettes and to characterise the advertising of cigarettes and the merchandising of non-prescription nicotine replacement therapy (NRT) products in these retail establishments.

METHODS AND SETTING

100 randomly selected San Francisco pharmacies were visited in 2003. Pharmacies were characterised based on the sale of cigarettes, advertising for cigarettes, and the merchandising of non-prescription NRT products.

RESULTS

In 2003, 61% of pharmacies sold cigarettes, a significant decrease compared to 89% of pharmacies selling cigarettes in 1976 (p < 0.001); 84% of pharmacies selling cigarettes also displayed cigarette advertising. Non-prescription NRT products were stocked by 78% of pharmacies, and in 55% of pharmacies selling cigarettes, the NRT products were stocked immediately adjacent to the cigarettes.

CONCLUSIONS

Since 1976, there has been a decline in the overall proportion of pharmacies in San Francisco that sell cigarettes yet most pharmacies, particularly traditional chain pharmacies, continue to merchandise the primary known risk factor for death in the USA.

Structure, dynamics, and stability of beta-cyclodextrin inclusion complexes of aspartame and neotame

Studies of the high-intensity sweetener aspartame show that its stability is significantly enhanced in the presence of beta-cyclodextrin (beta-CyD). At a 5:1 beta-CyD/aspartame molar ratio, the stability of aspartame is 42% greater in 4 mM phosphate buffer (pH 3.1) compared to solutions prepared without beta-CyD. Solution-state (1)H NMR experiments demonstrate the formation of 1:1 beta-CyD/aspartame complexes, stabilized by the interaction of the phenyl-ring protons of aspartame with the H3 and H5 protons of beta-CyD. Inclusion complex formation clearly accounts for the observed stability enhancement of aspartame in solution. The formation of inclusion complexes in solution is also demonstrated for beta-CyD and neotame, a structural derivative of aspartame containing an N-substituted 3,3-dimethylbutyl group. These complexes are stabilized by the interaction of beta-CyD with both phenyl-ring and dimethylbutyl protons. Solid-state NMR experiments provide additional characterization, clearly demonstrating the formation of inclusion complexes in lyophilized solids prepared from solutions of beta-CyD and either aspartame or neotame.

Person of the year. Steven A. Schroeder, MD

The mission of the Robert Wood Johnson Foundation is to improve the health and health care of all Americans. An ambitious goal, but the Foundation has the financial resources to do just that. The Foundation also has another resource: President and Chief Executive Officer Steven A. Schroeder, MD, who has led the philanthropic organization since 1990. For his work with the Robert Wood Johnson Foundation, Dr. Schroeder is New Jersey Medicine's 1999 Person of the Year.

Understanding health behavior and speaking out on the uninsured: two leadership opportunities

The author reviews the growth of managed care and its transforming effect on academic medical centers. He then maintains that in this time of fundamental changes and stress, academic medical centers should not only attend to the organization and financing of the clinical enterprise and the enhancement of biomedical research capacity, but also ask how academic medicine can live up to the unique opportunities and responsibilities it has been entrusted with to improve the health of the public, particularly in two neglected areas. First, if the nation does not expand the research agenda to include social and behavioral factors involved in preventable causes of morbidity and mortality, it will fail to maximize the dividends from the generous public investment in research and fail to learn how to promote healthy personal behavior. Academic medicine can promote such behavior by increasing the science base of prevention and translating into action what is already known, including how to market that knowledge so the public will respond. Second, the number of the medically uninsured is increasing; the largest percentage are the working poor. It is becoming more difficult for teaching hospitals to continue providing a third of the nation's uncompensated care. The author shares a variety of statistics about the uninsured and their care, and maintains that academic medicine, which has been entrusted with the health of the public, can declare that the high number of the uninsured is not acceptable and is a dangerous side effect of the U.S. health care system that must be treated. Doing so will also set an example to medical students and trainees that medicine's responsibility is to all Americans.

The hospitalist: new boon for internal medicine or retreat from primary care?

The growing reliance on hospitalists in the United States has implications for several areas of internal medicine, including patient care, administration, clinical practice, and medical education. This paper discusses some of the potential advantages and disadvantages of the use of hospitalists in each of these areas. The new hospitalist practice mode highlights long-standing tensions about the role and direction of internal medicine, tensions that affect generalist and specialty care in both outpatient and hospital settings. The career trajectory of hospitalists will depend on whether burnout is a problem and on whether hospitalists will be able to compete effectively with sub-specialists, such as cardiologists and physicians specializing in AIDS. Clearly, hospitalism meets a clinical need and expands opportunities for internists, but it is important that it not overreach, forfeiting primary care turf and distorting medical education. This new field warrants close monitoring because of its potential effects and because-unlike related fields, such as emergency medicine and intensive care--its birth was strongly influenced by system-wide financial considerations.

Scientific evidence and research in primary care

The key areas of scientific research in general internal medicine are (1) prevention; (2) the natural history of common illnesses; (3) improving the outcomes and efficiency of the health care system and (4) orphan diseases. Disease prevention is at the top of the list because of the enormous role preventable causes play in morbidity and mortality, above all tobacco. Research in this field is difficult because it touches such questions as individual behaviour and personal choice. Research in the natural history of common illnesses is critical to informed patient decision making. Recent studies show that procedures thought to be safe bear a high percentage of complications, when viewed from the generalist's point of view: high incidence of strokes after elective coronary bypass surgery; higher mortality rates among patients having had pulmonary catheterization; high incidence of incontinence and impotence after transurethral resection of the prostate. A third area for research in primary care is how to improve outcome and efficiency through improvements in the health care delivery system. This field touches the problem of unnecessary surgical interventions and inappropriate prescription of antibiotics. Orphan diseases in this context are conditions no speciality wants to study, such as dementia and low back pain. The most important obstacle for research in the field of general internal medicine is funding. It is much easier to be funded for research in high profile conditions, like heart disease, cancer and AIDS. A second barrier to research relates to the role of special interest groups in influencing not only funding but also policy. Important examples were the pressure on consensus conference decisions on the role of spinal fusion surgery for low back pain and on the question whether women between 40 and 50 should have annual mammography. For generalist research to be fruitful it is of outmost importance to have an adequate intellectual infrastructure, i.e. support by epidemiologists, biostatisticians, economists and research methodologists.

Cost containment in U.S. health care

The author explains why supply factors, particularly the overdevelopment of the nation's medical capacity, are more important than demand factors in explaining the high use and cost of U.S. health care. Yet such costly care often does not translate into better health for Americans. While market forces, especially the efficiencies fostered by managed care, may clear some of the excess acute-care capacity and foster the use of less-costly generalist physicians, such forces favor the strong over the weak. This makes vulnerable those persons without health insurance or on Medicaid only, inner-city and rural hospitals, and academic medical centers. And when health care is treated as a market product, the relationship between doctors and patients is endangered. The author urges that the effects of managed care be watched, particularly for possible neglect of the underserved and for diminished employment opportunities for all health professionals, especially nurses and certain specialists. He thinks it is likely that much of the savings that market forces will create will not stay in the health care sector (where they could be used to expand services for the uninsured, for example) but will go into the business side of health care (e.g., to pay shareholders' dividends). And he stresses that issues of adverse selection, risk adjustment, and outcomes measurement will have increasing importance to persons with chronic illnesses, who may be neglected.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous pneumothorax in children with AIDS

The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.

Protection against bronchial asthma by CFTR delta F508 mutation: a heterozygote advantage in cystic fibrosis

Cystic fibrosis (CF) is a multisystem autosomal recessive disorder caused by mutations of the cystic fibrosis transmembrane regulator (CFTR), a protein that regulates cyclic-AMP-mediated chloride conductance at the apical membrane of secretory epithelia. Mutations in the CFTR gene are common in many populations. In North America, 4-5% of the general population are heterozygous for a CFTR mutation. Although there are over 400 known CFTR mutations, a single mutation, a deletion of the phenylalanine at position 508 (delta F508) in exon 10, accounts for about 70% of all CF chromosomes worldwide. The reasons for the high frequency of the delta F508 CFTR allele--the selective advantage associated with CF heterozygosity--are unknown. Many physiological abnormalities have been observed in CF heterozygotes, although the clinical significance of these observations is unknown. Preliminary unpublished data and anecdotal information from CF families suggested that, remarkably, the delta F508 allele might protect heterozygotes against bronchial asthma prompted us to further investigate this possibility. Here we present evidence that the delta F508 CF allele protects against asthma in childhood and early adult life.

The influence of age on clinical and patient-reported outcomes after cholecystectomy

OBJECTIVE

To examine the relationship between the age of cholecystectomy patients and surgical complications, length of stay, symptom relief, and postdischarge functional status.

DESIGN

Patients' medical records were reviewed and patients were sent a questionnaire three months after hospital discharge.

SETTING

Four university-affiliated teaching hospitals.

PATIENTS

372 patients who had a primary operation of total cholecystectomy.

OUTCOME MEASURES

In-hospital complications, length of stay, patient satisfaction, symptom relief, and functional status after discharge.

RESULTS

Patients over the age of 60 years experienced a higher major postoperative complication rate than did younger patients (p < 0.01), although the overall major complication rate was too low to determine whether factors other than age were important predictors. There was no age-related difference in minor postoperative complication rates. The older patients had a longer mean length of stay, even after statistical adjustment for covariates (p < 0.05). The older patients reported similar levels of patient satisfaction, but reported recurrence of preoperative abdominal pain less often than did the younger patients (OR = 0.4, 95% CI = 0.2, 0.7). There was no statistically significant difference between the older and younger patients in postoperative functioning, except for work performance. The younger patients reported improvement in postoperative work performance, while the older patients reported a decline (p < 0.01).

CONCLUSIONS

Older cholecystectomy patients may experience more postoperative complications but report less recurrence of preoperative abdominal pain than do younger patients. The decline in work performance in older patients may indicate the need for a longer recuperation period.

Training an appropriate mix of physicians to meet the nation's needs

Although the lack of a national policy on medical manpower has served U.S. medicine well in some ways, it also has created problems, the most important of which is the maldistribution of physicians in the various specialties, with too many specialists and not nearly enough generalists. The author explains why this imbalance is a problem and why it is receiving so much attention, describes three types of forces--economic, practice-related, and scientific--that favor the practice of specialty medicine, and demonstrates that the medical school experience itself may be a critical influence on students' career decisions. He then outlines possible ways to correct the imbalance, both outside and inside academic medicine; for the latter sphere, he proposes five detailed alternative scenarios of how corrective change might come about, which range from doing nothing to making a number of fundamental changes within academic medicine's institutions to having external financial pressures for change brought to bear by the states and the federal government. In conclusion, the author notes that some combination of these scenarios will occur, because spending for medical care in the United States is out of control and cannot be reduced unless the distribution of physicians by specialty is rebalanced to have a much greater percentage of generalists. His hope is that academic medicine will accept this challenge and bring about the best mix of physicians to meet the nation's needs.

The importance of relating medicine and public health

The historical division between medicine and public health is arbitrary and not in the best interest of the health of the American public. Combating the major causes of death and disability requires integration of medicine and public health by government and academia.

Cellular interstitial pneumonitis in infants. A clinicopathologic study

Five infants had interstitial pneumonitis with constant histologic findings, which was different from that previously described in children. All the infants presented with tachypnea at birth and persistent disease, both clinically and radiographically, despite treatment. Open-lung biopsy in each case showed a diffuse interstitial thickening due to pale oval and spindle-shaped histiocytes without scarring. This neonatal cellular interstitial pneumonitis differs both clinically and histologically from the usual interstitial pneumonitis, lymphocytic interstitial pneumonitis and desquamative interstitial pneumonitis observed in adults and children. The etiology of this cellular interstitial pneumonitis in neonates is unknown.

The troubled profession: is medicine's glass half full or half empty?

Abundant evidence that medicine is in trouble includes serious career dissatisfaction among practicing and would-be physicians as well as steeply declining interest in generalist careers, especially internal medicine. Medicine is threatened by ever-rising health care expenditures and ineffectual but vexing administrative efforts to contain them. Additional problems challenge internal medicine in particular: the clinical complexity of practice, lower income potential, and incomplete clinical experiences for medical students. Yet, in the past 25 years, spectacular advances in science and technology enabled improved patient care and outcomes; more women and minorities entering the profession brought it into better demographic balance; relative physician incomes rose; and access to physician services improved with Medicare and Medicaid and the desegregation of southern hospitals. Despite an unfinished agenda, never before has medicine held so much promise for improving the health of the public. Despite various professional problems, no other career offers the unique blend of state-of-the-art science and humanism that epitomizes internal medicine--medicine's integrating specialty.

An interview with Steven A. Schroeder

In 1972, with a ! billion endowment from the immense personal fortune left by the late Robert Wood Johnson, the Robert Wood Johnson Foundation became the world's largest health care philanthropic organization. Now, with a new chairman of the board, Sidney F. Wentz, and president, Steven A. Schroeder, MD, the foundation has revised its overall grant-making prospectus. In this interview, Dr. Schroeder discusses the foundation's grant-making strategies and health manpower projects, forces affecting the U.S. health care system, and his vision for health care over the next decade.