Search

Introduction: Exposure to tobacco smoke impacts the onset or exacerbation of most respiratory disorders, and respiratory therapists are well positioned to identify tobacco use and provide cessation assistance. The purpose of this study was to characterize the level of tobacco cessation education provided to students in U.S. respiratory care training programs. Methods: A national survey of 387 respiratory care programs assessed the extent to which tobacco is addressed in required coursework, methods of instruction, perceived importance, and adequacy of current levels of tobacco education in curricula and perceived barriers to enhancing the tobacco-related education. Results: A total of 244 surveys (63.0% response) revealed a median of 165 min (IQR, 88-283) of tobacco education throughout the degree program. Pathophysiology of tobacco-related disease (median, 45 min) is the most extensively covered content area followed by aids for cessation (median, 20 min), assisting patients with quitting (median, 15 min), and nicotine pharmacology and principles of addiction (median, 15 min). More than 40% of respondents believed that latter 3 content areas are inadequately covered in the curriculum. Key barriers to enhancing tobacco training are lack of available curriculum time, lack of faculty expertise, and lack of access to comprehensive evidence-based resources. Nearly three-fourths of the respondents expressed interest in participating in a nationwide effort to enhance tobacco cessation training. Conclusions: Similar to other disciplines, enhanced tobacco cessation education is needed in respiratory care programs to equip graduates with the knowledge and the skills necessary to treat tobacco use and dependence.

La piruvato carboxilasa (PC), una enzima mitocondrial, cataliza la conversión de piruvato, producto final de la glucólisis, en oxaloacetato, un intermediario del ciclo del ácido tricarboxílico. El déficit de piruvato carboxilasa, un trastorno raro, se manifiesta en tres fenotipos clínicos y bioquímicos: tipo de inicio neonatal (tipo A), tipo de inicio infantil (tipo B) y un tipo benigno (tipo C).

Pyruvate carboxylase, a mitochondrial enzyme, catalyses the conversion of glycolytic end-product pyruvate to tricarboxylic acid cycle intermediate, oxaloacetate. Rare pyruvate carboxylase deficiency manifests in three clinical and biochemical phenotypes: neonatal onset type A, infantile onset type B and a benign C type. The objective of this case series is to expand the knowledge of overlapping clinical and biochemical phenotypes of pyruvate carboxylase deficiency.

Background: Tobacco dependence treatment efforts have focused on primary care physicians (PCPs), but evidence suggests that they are insufficient to help most smokers quit. Other health professionals also frequently encounter smokers, but their smoking prevalence, cessation practices, and beliefs are less well known.Methods: The study included 2,804 subjects from seven health professional groups: PCPs, emergency medicine physicians, psychiatrists, registered nurses, dentists, dental hygienists, and pharmacists. Outcomes included self-reported smoking status, smoking cessation practices, and beliefs. Multivariate regression was used to examine factors associated with health professionals (except pharmacists) self-reportedly performing the "5 A's": asking, advising, assessing, assisting, or arranging follow-up about tobacco.Results: Health professionals have a low smoking prevalence (<6%), except nurses (13%). Many health professionals report asking (87.3%-99.5%) and advising (65.6%-94.9%) about smoking but much less assessing smokers' interest (38.7%-84.8%), assisting (16.4%-63.7%), and arranging follow-up (1.3%-23.1%). Controlling for health professional and practice demographics, factors positively associated in the multivariate analyses with self-reportedly performing multiple components of the 5 A's include awareness of the Public Health Service guidelines, having had cessation training, and believing that treatment was an important professional responsibility. Negative associations include the health professional being a current smoker, not being a PCP, being uncomfortable asking patients if they smoke, believing counseling was not an appropriate service, and reporting competing priorities.Conclusion: U.S. health professionals report not fully performing the 5 A's. The common barriers and facilitators identified may help inform strategies for increasing the involvement of all health professionals in conducting tobacco dependence treatments. [ABSTRACT FROM AUTHOR]

The current dilemmas in primary care stem from 1) the unintended consequences of forces thought to promote primary care and 2) the "disruptive technologies of care" that attack the very function and concept of primary care itself. This paper suggests that these forces, in combination with "tiering" in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche. Evidence already exists in the marketplace for both tiering of health insurance benefits and corresponding practice changes within primary care. In the future, primary care for the top tier will cater to the affluent as "full-service brokers" and will be delivered by a wide variety of clinicians. The middle tier will continue to grapple with tensions created by patient demand and bureaucratic systems but will remain most closely aligned to primary care as a concept. The lower tier will become increasingly concerned with community health and social justice. Each primary care specialty will adapt in a unique way to a tiered world, with general internal medicine facing the most challenges. Given this forecast for the future, those concerned about primary care should focus less on workforce issues and more on macro health care financing and organization issues (such as Medicare reform); appropriate training models; and the development of a conception of primary care that emphasizes values and ethos, not just function. [ABSTRACT FROM AUTHOR]

Commentaries on the ethics of Covid lockdowns nearly all focus on offering substantive guidance to policy-makers. Lockdowns, however, raise many ethical questions that admit of a range of reasonable answers. In such cases, policy-making in a liberal democracy ought to be sensitive to which reasonable views the public actually holds-a topic existing bioethical work on lockdowns has not explored in detail. In this essay, I identify several important questions connected to the kind of influence the public ought to have on lockdown decision-making, including how policy-makers ought to handle misinformed or morally suspect viewpoints, and how policy-makers ought to respond to minority viewpoints. I argue that questions like this, concerning the appropriate influence of the public on decision-making, will be central to the field of bioethics as it increasingly focuses on policy and population-level issues and therefore ought to be priorities for future work., (© 2023 The Hastings Center.)

Scientists have the ability to influence policy in important ways through how they present their results. Surprisingly, existing codes of scientific ethics have little to say about such choices. I propose that we can arrive at a set of ethical guidelines to govern scientists' presentation of information to policymakers by looking to bioethics: roughly, just as a clinician should aim to promote informed decision-making by patients, a scientist should aim to promote informed decision-making by policymakers. Though this may sound like a natural proposal, I show it offers guidance that conflicts with standard scientific practices. I conclude by considering one cost of the proposal: that it would prevent scientists from acting as advocates in a way that is currently common in certain fields. I accept that the proposal would restrict scientists' political advocacy rights, but argue that the benefits of adopting it-promoting democratic governance-justify the restriction.

Up to 40% of neurodevelopmental disorders (NDDs) such as intellectual disability, developmental delay, autism spectrum disorder, and developmental motor abnormalities have a documented underlying monogenic defect, primarily due to de novo variants. Still, the overall burden of de novo variants as well as novel disease genes in NDDs await discovery. We performed parent-offspring trio exome sequencing in 231 individuals with NDDs. Phenotypes were compiled using human phenotype ontology terms. The overall diagnostic yield was 49.8% (n = 115/231) with de novo variants contributing to more than 80% (n = 93/115) of all solved cases. De novo variants affected 72 different-mostly constrained-genes. In addition, we identified putative pathogenic variants in 16 genes not linked to NDDs to date. Reanalysis performed in 80 initially unsolved cases revealed a definitive diagnosis in two additional cases. Our study consolidates the contribution and genetic heterogeneity of de novo variants in NDDs highlighting trio exome sequencing as effective diagnostic tool for NDDs. Besides, we illustrate the potential of a trio-approach for candidate gene discovery and the power of systematic reanalysis of unsolved cases., (© 2021 The Authors. Clinical Genetics published by John Wiley & Sons Ltd.)

Background: Research in migraine points towards central-peripheral complexity with a widespread pattern of structures involved. Migraine-associated neck and shoulder muscle pain has clinically been conceptualized as myofascial trigger points (mTrPs). However, concepts remain controversial, and the identification of mTrPs is mostly restricted to manual palpation in clinical routine. This study investigates a more objective, quantitative assessment of mTrPs by means of magnetic resonance imaging (MRI) with T2 mapping., Methods: Ten subjects (nine females, 25.6 ± 5.2 years) with a diagnosis of migraine according to ICHD-3 underwent bilateral manual palpation of the upper trapezius muscles to localize mTrPs. Capsules were attached to the skin adjacent to the palpated mTrPs for marking. MRI of the neck and shoulder region was performed at 3 T, including a T2-prepared, three-dimensional (3D) turbo spin echo (TSE) sequence. The T2-prepared 3D TSE sequence was used to generate T2 maps, followed by manual placement of regions of interest (ROIs) covering the trapezius muscles of both sides and signal alterations attributable to mTrPs., Results: The trapezius muscles showed an average T2 value of 27.7 ± 1.4 ms for the right and an average T2 value of 28.7 ± 1.0 ms for the left side (p = 0.1055). Concerning signal alterations in T2 maps attributed to mTrPs, nine values were obtained for the right (32.3 ± 2.5 ms) and left side (33.0 ± 1.5 ms), respectively (p = 0.0781). When comparing the T2 values of the trapezius muscles to the T2 values extracted from the signal alterations attributed to the mTrPs of the ipsilateral side, we observed a statistically significant difference (p = 0.0039). T2 hyperintensities according to visual image inspection were only reported in four subjects for the right and in two subjects for the left side., Conclusions: Our approach enables the identification of mTrPs and their quantification in terms of T2 mapping even in the absence of qualitative signal alterations. Thus, it (1) might potentially challenge the current gold-standard method of physical examination of mTrPs, (2) could allow for more targeted and objectively verifiable interventions, and (3) could add valuable models to understand better central-peripheral mechanisms in migraine.

Resource managers benefit from knowledge of angler support for fisheries management strategies. Factors including angler values (protection, utilitarian, and dominance), involvement (attraction, centrality, social, identity affirmation, and expression), catch-related motivations (catching some, many, and big fish, and keeping fish), satisfaction, agency trust, and demographics may relate to fisheries management preferences. Using results from a mail survey of Minnesota resident anglers, we explored how these factors were related to budget support for fish stocking relative to habitat protection/restoration. Results suggest that values, angler involvement, catch orientation, satisfaction, total and recent years fishing, age, and education influence relative support for stocking versus habitat protection/restoration. Utilitarian values, angling centrality, an orientation to catch many fish, satisfaction with the number of fish caught, number of recent years fishing, and age positively related to support for stocking over habitat management, while protection values, attraction to angling, total years fishing, and education level were negatively related to relative support for stocking.

Smoking is much more common among persons with behavioral health conditions (mental illnesses and/or substance use disorders). Persons with these disorders are more likely to die from smoking-related causes than any other reason. Studies have shown that stopping smoking can improve mental health function, as well as improve outcomes for substance use disorders. Yet, for a variety of reasons, smoking cessation has not been integrated into the treatment of behavioral health conditions, and in many instances tobacco use was not only condoned but encouraged. Beginning in 2007, the Smoking Cessation Leadership Center (SCLC) began engaging relevant agencies in an attempt to stimulate more vigorous smoking cessation activities. Partners included the federal Substance Abuse and Mental Health Services Administration, advocacy organizations such as the National Alliance on Mental Illness and Community Anti-Drug Coalitions of America, and clinical groups such as the American Psychiatric Nurses Association, the American Psychiatric Association, American Psychological Association, National Council on Behavioral Health, and National Association of State Mental Health Program Directors. A signature program featured 16 individual state summits involving agencies and groups from multiple sectors, all aiming to lower smoking rates in behavioral health populations. These activities mark an evolving culture change within behavioral health.

Competing Interests: Competing interests: None declared.

The Smoking Cessation Leadership Center (SCLC) was established in 2003 to increase the rate of smoking cessation attempts and the likelihood those efforts would succeed. Although smoking remains the number one cause of preventable death and disability, clinicians underperform in smoking cessation. Furthermore, many clinical organizations, governmental agencies, and advocacy groups put little effort into smoking cessation. Initially targeted at increasing the efforts of primary care physicians, SCLC efforts expanded to include many other medical and non-physician disciplines, ultimately engaging 21 separate specialties. Most clinicians and their organizations are daunted by efforts required to become cessation experts. A compromise solution, Ask, Advise, Refer (to telephone quitlines), was crafted. SCLC also stimulated smoking cessation projects in governmental, not-for-profit, and industry groups, including the Veterans Administration, the Health Resources Services Administration, Los Angeles County, and the Joint Commission. SCLC helped CVS pharmacies to stop selling tobacco products and other pharmacies to increase smoking cessation efforts, provided multiple educational offerings, and distributed $6.4 million in industry-supported smoking cessation grants to 55 organizations plus $4 million in direct SCLC grants. Nevertheless, smoking still causes 540,000 annual deaths in the US. SCLC's work in the field of behavioral health is described in a companion article.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

This paper summarizes The American Journal of Drug and Alcohol Abuse special issue and offers suggestions for future steps. People who use alcohol or other addictive substances are much more likely to use tobacco. Yet, clinicians and scientists have long regarded these addiction categories as separate and unrelated. The resultant benign neglect of tobacco use has had disastrous consequences on patients. This special issue is an important step toward remedying that situation. It has reviewed what is known and what more needs to be discovered regarding the co-occurrence of tobacco use disorder (TUD) and other substance use disorders (SUDs). The timing of this special issue occurs at a moment when smoking rates among both adults and youth are at a modern low. But not all segments of the population have benefited from this improvement. In particular, those with a SUD smoke two to four times the rate of the general population and thus suffer disproportionately from the myriad tobacco-induced diseases. The multi-disciplinary contributors to this special issue have reviewed various aspects of the co-occurring disorders. What emerges is a complex portrait. In some categories, the facts are stark, such as the strong association between SUDs and tobacco use and the toll they both extract. In others, such as the emerging new electronic nicotine delivery devices, there are intriguing associations that warrant further investigation. What is clear is that the historic schism between smoking and other addictions needs to be breached in order to improve the health of the public. This special issue should be viewed as a call to action for breaching that schism.

Introduction: The purpose of the study was to describe changes in smoking intensity among US Latinos and non-Latinos from 1997 to 2014., Methods: National Health Interview Survey data between 1997 and 2014 were used to determine the number of cigarettes smoked per day (CPD) among Latino and non-Latino adults who had smoked at least 100 cigarettes in their lifetime and were currently smoking every day or some days (ie, current smokers)., Results: CPD declined steadily throughout the observation period and were consistently lower for Latino than for non-Latino smokers. However, decreases were not equal across birth cohorts, genders, or among Latino national background groups. CPD declined most among Mexican men and least among younger generations, Cuban women, and acculturated Latina women. Additionally, declines in smoking intensity seemed to slow over time among low CPD consumers., Conclusions: Although smoking intensity has decreased substantially since the late 1990s, CPD data suggest that declines are slowing among younger generations and certain Latina women. Effective tobacco control strategies should be developed to discourage even very light and nondaily smoking., Implications: Few studies have been conducted on how smoking intensity has changed since the late 1990s. Between 2004 and 2011, when the decline in smoking prevalence slowed, it is unknown how smoking intensity (ie, CPD) changed by age. Additionally, no research has assessed differences and changes in smoking intensity over time among Latinos. From this study we learned that smoking intensity declined significantly since the late 1990s, but this decline slowed among younger generations of smokers and certain Latina women. Findings suggest that future patterns of smoking intensity may only marginally decline in the near future., (© The Author 2016. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The gap in health status between the United States and other (OECD) developed countries not only persists but has widened over the past decade. This has occurred despite major declines in smoking prevalence. But as with other health problems, such as obesity, gun violence, and teenage pregnancy, progress against smoking has disproportionately benefitted the better off segments of the American population. Thus smoking, as well as other problems, is now concentrated among the vulnerable members of our society: the poor and less educated, as well as disadvantaged groups such as those with mental illness and substance use disorders, the homeless, those who are incarcerated, and the LGBT community. Although this is a national issue, these problems, as well as overall poverty, are especially concentrated in the Southeastern part of the country. Compared with the other OECD countries, the U.S. has much greater inequality of income and wealth. Furthermore, we are unique in leaving substantial portions of our population not covered by health insurance, again most prominently in the southeastern region. This national health disparity is not simply a factor of the multicultural nature of American society, because it persists when the health of the whites only is compared with the more racially homogeneous OECD nations. The complexity of our poor health performance rules out a single intervention. But it is clear that without focusing on the less fortunate members of our society, especially those in the Southeast, our performance will continue to lag, and possibly deteriorate further., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Despite population-wide efforts to reduce tobacco use, low-income populations in the USA have much higher rates of tobacco use compared with the general population. The principal components of tobacco control policies in the USA include cigarette taxes, clean indoor air laws and comprehensive interventions to increase access to tobacco cessation services. In this review, we describe the effectiveness of these policies and interventions in reducing tobacco use among vulnerable populations, focusing on persons with mental health disorders and substance use disorders, persons who have experienced incarceration or homelessness, and low-income tenants of public housing. We discuss the challenges that evolving tobacco and nicotine products pose to tobacco control efforts. We conclude by highlighting the clinical implications of treating tobacco dependence in healthcare settings that serve vulnerable populations., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

A recurring conference theme was the essential place of social justice within family medicine, especially the need to focus on denominator populations, exalt the personal and caring qualities of doctoring, and address social determinants of health. Many expressed solidarity with "community," but it is not always easy to define community in our large and diverse nation. Exhortations for health advocacy were frequently voiced, but putting these into meaningful action agendas is a challenge. There was general agreement that medicine is in flux and that the many expressions of "commodity-centered consumerism" have altered organization and financing. The increasing demands by "consumers", who want low cost, instant availability, and shared decision-making, and yet change doctors when health plans alter coverage also differentially impact high-volume, low-margin specialties such as family medicine. Additional challenges were the electronic health record and calibrating an appropriate work/life balance. Five action steps are recommended: 1) speak out on the important social and moral issues; 2) be the experts on personal care; 3) make common cause with potential allies; 4) help institutions perceive the value of generalism; and 5) help find ways to enrich generalist disciplines to increase the joy of medicine and decrease the threat of burn out., (© Copyright 2016 by the American Board of Family Medicine.)

Over the past 30 years, Israel has made great progress in attitudes and practices about smoking; probably nothing else has contributed more to the health of its population. Yet, a recent survey about a non-smoking ban at an Israeli health sciences campus found incomplete enforcement. In addition, smoking rates among health sciences students, though lower than the general population, were higher than might be expected based on rates in other developed countries. Whether the ban is-as the authors speculate-"an intrusive life style intervention" or a justifiable public health intervention, cuts to the heart of the history of tobacco control efforts and their opposition by the tobacco industry. Despite concerns that the Israeli population is not ready to accept smoke-free bans, experience in other countries suggests otherwise.

Purpose: To assess reproducibility in measuring left ventricular (LV) myocardial stiffness in volunteers throughout the cardiac cycle using MR elastography (MRE) and to determine its correlation with age., Methods: Cardiac MRE (CMRE) was performed on 29 normal volunteers, with ages ranging from 21 to 73 years. For assessing reproducibility of CMRE-derived stiffness measurements, scans were repeated per volunteer. Wave images were acquired throughout the LV myocardium, and were analyzed to obtain mean stiffness during the cardiac cycle. CMRE-derived stiffness values were correlated to age., Results: Concordance correlation coefficient revealed good interscan agreement with rc of 0.77, with P-value < 0.0001. Significantly higher myocardial stiffness was observed during end-systole (ES) compared with end-diastole (ED) across all subjects. Additionally, increased deviation between ES and ED stiffness was observed with increased age., Conclusion: CMRE-derived stiffness is reproducible, with myocardial stiffness changing cyclically across the cardiac cycle. Stiffness is significantly higher during ES compared with ED. With age, ES myocardial stiffness increases more than ED, giving rise to an increased deviation between the two., (© 2015 Wiley Periodicals, Inc.)