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Objectives. Homeless individuals experience high rates of physical and mental illness, increased mortality, and frequent hospitalizations. Respite care provides homeless individuals with housing and services allowing more complete recovery from illnesses and stabilization of chronic conditions. Methods. We investigated respite care’s impact on 225 hospitalized homeless adults consecutively referred from an urban public hospital during a 26-month period. The cohort was separated into 2 groups: (1) patients referred and accepted into the respite center and (2) patients referred but denied admission because beds were unavailable. All patients met the center’s predefined eligibility criteria. Main outcome measures were inpatient days, emergency department visits, and outpatient clinic visits. Results. The 2 groups had similar demographic characteristics, admitting diagnoses, and patterns of medical care use at baseline. During 12 months of follow-up, the respite care group required fewer hospital days than the usual care group (3.7 vs 8.3 days; P=.002), with no differences in emergency department or outpatient clinic visits. Individuals with HIV/AIDS experienced the greatest reduction in hospital days. Conclusions. Respite care after hospital discharge reduces homeless patients’ future hospitalizations.

The Kennedy Krieger lead paint study stirred controversial questions about whether research designed to develop less expensive interventions that are not as effective as existing treatments can be ethically warranted. Critics questioned the social value of such research and alleged that it sanctions a double standard, exploits participants, and is complicit in perpetuating the social injustice. In response, we demonstrate the propriety of conducting research on interventions that can be extended to the population in need by stipulating the limited conditions in which it is ethically warranted and providing fair terms of participation. We contend that the failure to conduct such research causes greater harm, because it deprives disadvantaged populations of the benefits of imminent incremental improvements in their health conditions.

Bedbug infestations are on the rise in the United States among people of all socioeconomic groups. Bedbug bites typically cause pruritic wheals with central punctum on exposed skin, which are noted upon awakening. The diagnosis is confirmed by identifying fecal smears and blood spots on the bed linens and mattress or by identifying the culprit bug. Extermination of bedbugs using cleaning techniques and pesticides is necessary to prevent recurrence.

This article describes two models for linking theory and practice in nutrition education and traces how concerns about the validity of different types of research drive the choice of models. In the scientific model, theory is defined in terms of statements from which one can deduce hypotheses, which can then be tested in experimental research designs. In the scientific model, practitioners are expected to replicate the methods used by researchers to effect targeted changes in the dependent variable of interest, usually health or eating behaviors. The ethical and epistemological shortcomings of the scientific model are then examined. The report goes on to describe an alternative approach, termed the humanistic model. In the humanistic model, theory is defined in terms of statements that seek to clarify basic social values. In the humanistic model, practitioners use theory as a stimulus for dialogue about the role of eating habits in living the kind of life that community members find most valuable. Examples of humanistic research relevant to nutrition education are presented, and the limitations of establishing the certainty of claims made using humanistic criteria are discussed. The article concludes with a discussion of the implications of the humanistic model for professional preparation.

Objectives: To compare demographic, HIV risk behaviors, and health status characteristics of injection drug users (IDUs) who have injected “crack” cocaine with IDUs who have not. Methods: Nine hundred and eighty-nine IDUs were recruited in New Haven, CT, Hartford, CT and Springfield, MA from January 2000 to May 2002. Participants were administered a modified version of the National Institute on Drug Abuse Risk Behavior Assessment Questionnaire. Results: Nine percent (n = 89) of participants reported “ever” injecting crack cocaine and 4.2% (n = 42) reported injecting crack in the past 30 days. Lifetime and current crack injectors did not differ significantly on any demographic characteristics. Lifetime and current crack injectors did not differ on gender, age or marital status from IDUs who have never injected crack. Significant differences were found on race, education, employment and residence, with crack injectors more likely to be white, employed, better educated and living in New Haven than IDUs who have never injected crack. After adjusting for current (past 30 day) speedball and powder cocaine injection, crack injectors reported higher rates of risky drug use behaviors and female crack injectors reported higher rates of risky sexual behaviors. Crack injectors reported higher rates of abscesses, mental illness and Hepatitis C infection, but not Hepatitis B or HIV infection. Conclusions: The emergence of crack cocaine injection requires urgent attention, as this new drug use behavior is associated with elevated rates of high risk behaviors. © 2005 Elsevier Ireland Ltd. All rights reserved.

We assessed the impact of a 2-week required rotation in homeless health care on primary care residents’ attitudes toward homeless people. Attitudes were assessed before and after the course using the Attitudes Toward Homelessness Inventory (ATHI), an instrument previously validated among undergraduate students. Attitude scores on the ATHI improved from 46 to 52 (range of possible scores 11 to 66; P = .001). The ATHI subscales showed, after the course, that residents had a greater belief that homelessness had societal causes and felt more comfortable affiliating with homeless people. After the course, residents also reported an increased interest in volunteering with homeless populations on an anonymous survey.

Patients with persistent pain who lack a detectable underlying disease challenge the theories supporting much of biomedical body-mind discourse. In this context, diagnostic labeling is as inherently vulnerable to the same pitfalls of uncertainty that beset any other interpretative endeavour. The end point is often no more than a name rather than the discovered essence of a pre-existent medical condition. In 1990 a Committee of the American College of Rheumatology (ACR) formulated the construct of Fibromyalgia in an attempt to rectify a situation of diagnostic confusion faced by patients presenting with widespread pain. It was proposed that Fibromyalgia existed as a "specific entity", separable from but curiously able to co-exist with any other painful condition. Epistemological and semiotic analyses of Fibromyalgia have failed to find any sign, clinical or linguistic, which could differentiate it from other diffuse musculoskeletal pain states. The construct of Fibromyalgia sought to define a discernable reality outside the play of language and to pass it off as a natural phenomenon. However, because it has failed both clinically and semiotically, the construct also fails the test of medical utility for the subject in persistent pain.

The article presents results from the Syringe Access, Use, and Discard: Context in AIDS Risk research project comparing two neighborhoods by (1) socioeconomic and demographic characteristics; (2) patterns of syringe access, use, and discard; and (3) encounters with a local human immunodeficiency viruslacquired immunodeficiency syndrome (HIV/AIDS) outreach project targeted to injection drug users (IDUs). The results show that IDUs in more economically advantaged neighborhoods were more likely to acquire syringes from a single source (rather than multiple sources), more likely to inject alone in their own residence (rather than public injection locales), and more likely to dispose of syringes in private garbage cans rather alleys or dumpsters. These results are further associated with the likelihood of encountering street outreach workers, with IDUs in more affluent neighborboods much less likely to have any such contacts. Based on the different patterns of access, use, and discard evident in each neighborhood, the results indicate that different and more carefully tailored local outreach and prevention strategies are urgently needed.

Dear Editor: We welcome the opportunity to respond to Dr. Awerbuch. It seems that he has missed the point of our article, that the withdrawal of empathy may play a role in the stigmatization of the person in pain. His letter itself is an example of the very attitude we wish to highlight. We do not seek an explanatory model for all chronic pain—there is no role for “high priests” in this dialogue—while we do examine the role empathy might play in the clinical encounter between health professional and pain patient. To be fair, Dr. Awerbuch does raise …

The criminalization of behaviors such as the ingestion of certain mood-altering drugs creates ethical dilemmas for researchers studying those behaviors. The Syringe Access, Use, and Discard (SAUD) project is designed to uncover microcontextual factors that influence HIV and hepatitis risk behaviors of injection drug users. The article presents seven ethical dilemmas encountered using ethnographic methods: issues involving syringe replacement at injection locales, risks of participants’ arrest, potential disruptions in participants’ supply routes, risks of research staff arrest, threats to the protection of confidentiality, issues surrounding informed consent in working with addicts, and the confiscation of potentially incriminating information by police. The article concludes with a discussion of the limitations of traditional ethical frameworks, such as utilitarianism, for resolving these dilemmas and recommends instead improving public health professionals’capacity for practical reasoning ( phronesis) through the greater use of case studies in public health curricula.

Public health has historically viewed health and disease as the product of three interacting factors: the host, the agent, and the environment. As classically captured in Hippocrates’ Airs, Waters, Places, the major emphasis of public health interventions until modern times was focused on changing the environment to prevent illness: building sewage systems, assuring clean water supplies, draining swamps. In one of the best-known legends of public health, a medical practitioner and anesthetist named John Snow plotted the locations of an outbreak of cholera cases in London in the year 1854 (Rosen, 1958). On the basis of his scatterplot, he deduced that one well, the Broad Street pump, was responsible for the outbreak. He then marched down and removed the handle from the pump, thus interrupting further spread of the epidemic—an effective environmental intervention enacted 30 years before the discovery of bacterial agents.

Background Colorectal cancer (CRC) is common and leads to significant morbidity and mortality. Although screening with fecal occult blood testing (FOBT) or endoscopy has been shown to decrease CRC mortality, screening rates remain suboptimal. Screening rates are particularly low for people with low incomes and members of underrepresented minority groups. FOBT should be done annually to detect CRC early and to reduce CRC mortality, but this often does not occur. This paper describes the design of a multifaceted intervention to increase long-term adherence to FOBT among poor, predominantly Latino patients, and the design of a randomized controlled trial (RCT) to test the efficacy of this intervention compared to usual care. Methods In this RCT, patients who are due for repeat FOBT are identified in the electronic health record (EHR) and randomized to receive either usual care or a multifaceted intervention. The usual care group includes multiple point-of-care interventions (e.g., standing orders, EHR reminders), performance measurement, and financial incentives to improve CRC screening rates. The intervention augments usual care through mailed CRC screening test kits, low literacy patient education materials, automated phone and text message reminders, in-person follow up calls from a CRC Screening Coordinator, and communication of results to patients along with a reminder card highlighting when the patient is next due for screening. The primary outcome is completion of FOBT within 6 months of becoming due. Discussion The main goal of the study is to determine the comparative effectiveness of the intervention compared to usual care. Additionally, we want to assess whether or not it is possible to achieve high rates of adherence to CRC screening with annual FOBT, which is necessary for reducing CRC mortality. The intervention relies on technology that is increasingly widespread and declining in cost, including EHR systems, automated phone and text messaging, and FOBTs for CRC screening. We took this approach to ensure generalizability and allow us to rapidly disseminate the intervention through networks of community health centers (CHCs) if the RCT shows the intervention to be superior to usual care. Trial registration ClinicalTrials.gov NCT01453894

To interpret electrical surveys used to monitor subsurface steam-injection projects, one needs to know whether steam zones are resistive or conductive relative to initial conditions. This can be determined through laboratory measurements of the effects of steam injection on the electrical conductivity of sand. Experiments presented in chapter 2 measured the combined effects of the salinity of the boiler feedwaters and the steam quality - the fraction of the injected flux that is vapour. The injection of low quality steam, boiled from a saline solution, into clean sand saturated with the same solution, resulted in a net decrease in conductivity, and a constant equilibrium conductivity in the steam zone. The injection of high-quality steam, using the same solutions, resulted in conductivity dropping first to a minimum, and then increasing to an equilibrium value similar to that seen in the low quality injection. This localized conductivity minimum became progressively less conductive with time, and travelled with the steam front. The appearance of the conductivity minimum at the steam front can be attributed to the formation of a dilution bank, which temporarily decreases the local salinity. This suggests that many steam injections will create steam zones with electrically resistive fronts, which can be used to track the steam. The effects of clay on the electrical conductivity of steam zones is further investigated in chapter 3. Experimental and numerical results indicate that clay-bearing steam zones can be electrically conductive relative to initial conditions, in part due to water saturations in the steam zones that are higher than those in comparably steam-flooded clean sands. However, it is still likely that high quality steam injections will result in resistive leading edges of the steam zones. In low quality steam injections, where dilution banks do not form around the front, it is more likely that steam zones are entirely conductive relative to initial conditions, particularly in fresh water environments.

> Why then 'tis none to you; for there is nothing either good or bad, but thinking makes it so. To me it is a prison. Hamlet Act 2, scene 2, 239–251. We are dismayed to learn that “maldynia” has now entered Pain Medicine's lexicon [1] due in large part to the efforts of the American Academy of Pain Medicine to categorize pain “on a neurobiologic basis as eudynia (nociceptive pain) … or maldynia (maladaptive pain)”[2,3]. These concepts, which were first suggested in 1998 by Lippe [4], are worthy …

Context Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. Objective To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. Design, Setting, and Participants Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker–referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat. Intervention Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered on-site at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers. Main Outcome Measures Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. Results The analytic sample (n = 405 [n = 201 for the intervention group, n = 204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the intervention group had unadjusted annualized mean reductions of 0.5 hospitalizations (95% confidence interval [CI], −1.2 to 0.2), 2.7 fewer hospital days (95% CI, −5.6 to 0.2), and 1.2 fewer emergency department visits (95% CI, −2.4 to 0.03). Adjusting for baseline covariates, compared with the usual care group, the intervention group had a relative reduction of 29% in hospitalizations (95% CI, 10% to 44%), 29% in hospital days (95% CI, 8% to 45%), and 24% in emergency department visits (95% CI, 3% to 40%). Conclusion After adjustment, offering housing and case management to a population of homeless adults with chronic medical illnesses resulted in fewer hospital days and emergency department visits, compared with usual care. Trial Registration clinicaltrials.gov Identifier: NCT00490581

Geomagnetically Induced Currents (GIC's) in B. C. Hydro's 500 kV transmission system have in the past been responsible for the generation of harmonics of 60 Hz, system voltage drops, and misoperation of relay units. Characterization of the associated magnetic storms' spatial scales would further the understanding of GIC generation in the area, and allow advanced warning of potential problems in future power transmission projects. Data collected in 1984 at four substations were analysed to determine lateral variations in geomagnetically induced earth surface electric fields. Inversion techniques were employed to find a variety of solutions that would reproduce the data. Results suggested that the magnetic storms were larger than the area monitored, and that resultant electric fields seen by a large portion of the transmission grid were uniform. Departures from this uniformity in other portions of the electric field models were felt either to be due to earth induction effects, or in some cases, to be artifacts of the data analysis techniques. An experiment designed to determine the controlling factors behind GIC's is outlined. Considerable effort would be required to explicitly determine all electric fields affecting the transmission system

Purpose of the study: To identify problems in the biopsychosocial model when applied to people in pain and to explore a resolution. Methods: Critical analysis of the literature concerning the theory and application of biopsychosocial models to the practice of pain medicine Results: The biopsychosocial model for understanding illness has generated the IASP definition of pain, two simpler conceptual frameworks, and three explanatory schemata for pain. However, in the absence of a theory of living systems that seeks to understand how the different domains of these schemata interact with each other, these attempts have been caught in circular argument and have been unable to transcend either biomedical reductionism or the perpetuation of body-mind dualism. In particular, the implication that pain is a “thing” separate and distinct from the body not only bears little relationship to the lived experience of pain but also emphasises the inherent problem that arises when an observer attempts to reduce the experience of the pain of “the other” to predictable parameters. Conclusions: The self-referentiality of living systems (through their qualities of autopoiesis, non-centrality and negentropy) sees pain “emerge” in unpredictable ways that defy any reduction of the lived experience to any particular “thing.” Pain therefore constitutes an aporia,a space and presence that deny us access to its secrets. We suggest a project in which pain may be approached in the clinical encounter through the engagement of two autonomous self-referential beings from which new therapeutic possibilities can arise. We see three challenges to be met in this project: to accept that the pain of another person is irreducible to its neuronal correlates; to acknowledge all the principles which characterise autonomous biological systems; and to allow a rapprochement between the world of the clinician and the world of the person in pain.

The paper presents an analysis of the policy advocacy strategies used by both proponents and opponents of needle exchange programs in the US, drawing on the analytic framework developed by Stone. Based on a case study of the politics of needle exchange in Massachusetts, we argue that proponents of needle exchange have relied almost exclusively on empirical scientific arguments to build their case, while opponents have generally resorted to normative ethical arguments. Since the frames of argument are unrelated, the two sides talk past one another, bypassing progress towards resolution or consensus. By failing to address the ethical concerns raised by opponents, public health advocates of needle exchange are losing the larger public debate. The paper concludes with specific recommendations for how public health advocates should respond to the normative dimensions of this public policy issue.

Electrolyte leakage was used to measure direct heat injury to roots of Illicium anisatum L., Ilex cornuta L. cv. Burfordii and Juniperus chinensis L. cv. Parsonii. A sigmoidal relationship was found between percent electrolyte leakage and temperature treatment. About 50% electrolyte leakage was realized from a 20 minute exposure of roots to 50.5 ± 0.5°, 48.5 ± 0.5° and 46.5 ± 0.5°C for I. anisatum, J. chinensis, and I. cornuta, respectively.

The female of Spalangia drosophilae, Ashm, attack the puparia of Drosophila melanogaster, laying eggs between the puparial case and the pupa. The procedure is as follows: the parasite makes a careful examination of the puparia, tapping it with its antennae; then it stings the pupa to immobility and lays an egg. In a series of observations carried at the Imperial Institute of Entomology, Canada, using Spalangia as parasite and Drosophila as host, it was noted that the ovipositing female seemed to avoid superparasitism -- that is, laying eggs in already parasitized puparia. Naturally, if the number of non-parasitized insects still available was relatively small, the restraint exercised by the female tended to break down, and several eggs would be laid in some of the hosts. In order to determine the number of times the female Spalangia could exercise restraint before she was compelled to lay an egg, a series of three hundred and sixty separate experiments were performed. These involved the exposure of groups of five, ten and twenty-five Drosophila puparia to different numbers of parasites for various lengths of time, so that considerable variation in the number of eggs laid occurred. The observational results were expressed in terms of the number of puparia containing zero, one, two, etc., eggs. As the probability theory involved in this type of situation does not seem to be available, it is proposed to develop it in such a manner that experimental results may be analyzed to estimate the number of times the parasite could withhold an egg. The aspect of the experimental data which is of primary interest is the number of cases of superparasitism occurring for any given number of eggs laid and hosts exposed. Master of Science

Background Breast cancer is the most frequent cause of cancer death in women worldwide, but global disparities in breast cancer control persist, due to a lack of a comprehensive breast cancer control strategy in many countries. Objectives To identify and compare the need for breast cancer control strategies in Asia, Latin America and the Middle East/North Africa and to develop a common framework to guide the development of national breast cancer control strategies. Methods Data were derived from open-ended, semi-structured interviews conducted in 2007 with 221 clinicians, policy makers, and patient advocates; stratified across Asia (n = 97), Latin America (n = 46), the Middle East/North Africa (ME/NA) (n = 39) and Australia and Canada (n = 39). Respondents were identified using purposive and snowballing sampling. Interpretation of the data utilized interpretive phenomenological analysis where transcripts and field notes were coded and analyzed and common themes were identified. Analysis of regional variation was conducted based on the frequency of discussion and the writing of the manuscript followed the RATS guidelines. Results Analysis revealed four major themes that form the foundation for developing national breast cancer control strategies: 1) building capacity; 2) developing evidence; 3) removing barriers; and 4) promoting advocacy - each specified across five sub-ordinate dimensions. The propensity to discuss most dimensions was similar across regions, but managing advocacy was discussed more frequently (p = 0.004) and organized advocacy was discussed less frequently (p < 0.001) in Australia and Canada. Conclusions This unique research identified common themes for the development of breast cancer control strategies, grounded in the experience of local practitioners, policy makers and advocacy leaders across diverse regions. Future research should be aimed at gathering a wider array of experiences, including those of patients.