27.10.06

Lifetime Cumulative Exposure to Secondhand Smoke and Risk of Myocardial Infarction in Never Smokers

Results From the Western New York Health Study, 1995-2001
Saverio Stranges, MD, PhD; Matthew R. Bonner, PhD, MPH; Federica Fucci, MD, MPH; K. Michael Cummings, PhD, MPH; Jo L. Freudenheim, PhD; Joan M. Dorn, PhD; Paola Muti, MD, MS; Gary A. Giovino, PhD; Andrew Hyland, PhD; Maurizio Trevisan, MD, MS

Arch Intern Med. 2006;166:1961-1967.
Background Although many epidemiologic studies have investigated the association between exposure to secondhand smoke (SHS) and risk of coronary heart disease (CHD), few of these studies have assessed exposure measures from different sources over a lifetime. Therefore, we sought to test the association between lifetime cumulative exposure to SHS and risk of myocardial infarction (MI) (as an indication of CHD) among never smokers.
Methods A population-based case-control study in which participants were 1541 never smokers (284 cases and 1257 controls) drawn from 1197 women and men with incident MI and 2850 healthy controls (aged 35-70 years) identified from 2 Western New York counties between 1995 and 2001. Study subjects were asked to report their exposure to SHS at home, at work, and in public settings from childhood to their present age. Exposure histories from each source were combined to form a cumulative lifetime exposure measure. Multiple logistic regression analysis estimated the association between SHS exposure and case status adjusted for age, sex, education, body mass index, race, drinking status, lifetime physical activity, hypertension, diabetes mellitus, and hypercholesterolemia.
Results After adjustment for covariates, exposure to SHS was not significantly associated with an increased risk of MI. Compared with participants in the bottom tertile of SHS exposure, those in the top tertile had an odds ratio of 1.19 [95% confidence interval, 0.78-1.82] for MI. Virtually all subjects reported some exposure to SHS over their lifetime, but self-reported exposures declined over time, especially in the period closest to the interview.
Conclusions Exposure to SHS has declined sharply among nonsmokers in recent years. In the absence of high levels of recent exposure to SHS, cumulative lifetime exposure to SHS may not be as important a risk factor for MI as previously thought.

An Evaluation of Screening Questions for Childhood Abuse in 2 Community Samples

Brett D. Thombs, PhD; David P. Bernstein, PhD; Roy C. Ziegelstein, MD; Christine D. Scher, PhD; David R. Forde, PhD; Edward A. Walker, MD; Murray B. Stein, MD
Arch Intern Med. 2006;166:2020-2026.
Background A number of practice guidelines and recommendations call for the assessment of childhood abuse in adult medical patients, but none specifies how best to do this. The objective of this study was to use evidence from 2 community-based population samples to evaluate abuse-screening questions that are often asked in medical clinics and to identify a small set of questions to improve screening practices.
Methods The Childhood Trauma Questionnaire–Short Form (CTQ-SF) was administered in 2 randomized telephone interview surveys with adults aged 18 to 65 years.
Results A total of 880 (2003 survey) and 998 (1997 survey) respondents completed the CTQ-SF in the 2 surveys. In both surveys, the rates of physical (16% and 15%), emotional (31% and 29%), and sexual (10% and 9%) abuse elicited using 3 behaviorally descriptive items in each abuse category were approximately twice the rates elicited using the explicit labeling terms physically abused (8% and 8%), emotionally abused (15% and 13%), or sexually abused (5% and 5%) (P<.001 for each). Inquiries explicitly using the labeling term abuse successfully identified a low percentage of respondents who reported behaviorally described abusive experiences for each type of abuse (34%-51%). In addition, after adjustment for the number and frequency of abusive experiences in both surveys, women were more likely than men to label themselves as explicitly abused for any abuse (odds ratio [OR], 1.7; P = .11 and OR, 2.8; P<.01), physical abuse (OR, 2.1; P = .14 and OR, 2.9; P<.01), emotional abuse (OR, 2.7; P<.01 and OR, 3.3; P<.01), and sexual abuse (OR, 3.5; P = .08 and OR, 1.5; P = .55).
Conclusion Inquiries about childhood abuse that use broad labeling questions identify a substantially smaller number of patients than behaviorally specific questions and may be less effective in initial screening for a history of abuse.

3.10.06

Rethinking Well-Child Care in the United States: An International Comparison

Kuo, A. A., Inkelas, M., Lotstein, D. S., Samson, K. M., Schor, E. L., Halfon, N.
Pediatrics 2006 118: p. 1692-1702
BACKGROUND. The increasing scope of health supervision recommendations challenges well-child care delivery in the United States. Comparison of the United States with other countries’ delivery systems may highlight different assumptions as well as structural approaches for consideration.
OBJECTIVE. Our goal was to describe the process of well-child care delivery in industrialized nations and compare it to the US model of child health care.
METHODS. Literature reviews and international experts were used to identify 10 countries with unique features of well-child care delivery for comparison to the United States. Key-informant interviews using a structured protocol were held with child health experts in 10 countries to delineate the structural and practice features of their systems. Site visits produced additional key informant data from 5 countries (Netherlands, England, Australia, Sweden, and France).
RESULTS. A primary care framework was adapted to analyze structural and practice features of well-child care in the 10 countries. Although well-child care content is similar, there are marked differences in the definitions of well-child care and the scope of practice of primary care professionals and pediatricians specifically who provide this care across the 10 countries. In contrast to the United States, none of the countries place all well-child care components under the responsibility of a single primary care provider. Well-child care services and care for acute, chronic, and behavioral/developmental problems are often provided by different clinicians and within different service systems.
CONCLUSIONS. Despite some similarities, well-child care models from other countries differ from the United States in key structural features on the basis of broad financing differences as well as specific visions for effective well-child care services. Features of these models can inform child health policy makers and providers in rethinking how desired improvements in US well-child care delivery might be sought.

Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.

MMWR Recomm Rep. 2006 Sep 22;55(RR-14):1-17; quiz CE1-4.
Branson B.M., Handsfield H.H., Lampe M.A., Janssen R.S., Taylor A.W., Lyss S.B., Clark J.E.
These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1-10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1-62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63-85). Major revisions from previously published guidelines are as follows: For patients in all health-care settings HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

2.10.06

The May 2006 revision of the Rourke Baby Record

Rourke Baby Record
Originally developed in 1979 by Drs Leslie Rourke and James Rourke, the Rourke Baby Record (RBR) is an evidence-based health supervision guide for physicians caring for children in the first five years of life. The May 2006 revision of the RBR was written in collaboration with Dr. Denis Leduc of Montréal, PQ, and is endorsed by the College of Family Physicians of Canada and the Canadian Paediatric Society.
Format changes from the previous version of September 2000 are as follows:
- Expansion of visits on 3 guides to 4 to allow more writing space and to add a new optional visit at 15 months to accommodate some immunization preferences/schedules;
- Major emphasis on the 18-month visit as a critical time for assessment of development.
- Use of the CDC full page growth charts rather than small growth charts on the reverse of the RBR;
- Creation of an immunization chart to more easily document immunization rather than trying to record them directly on the RBR;
- Reorganization of the Education & Advice section to avoid omission of issues if a visit is missed.
- Incorporation of selected evidence-based environmental, literacy, and healthy active living issues as well as updating previous items if indicated;
- More detail regarding child development including new evidence-based information on the reverse of Guide 4;
- Incorporation of web-based resources for further information.