Can health visitors prevent fractures in elderly people?

OBJECTIVES--To assess whether intervention by a health visitor could reduce the number of fractures, over a four year period, in those aged 70 and over. DESIGN--Randomised, controlled trial; randomisation by household. SETTING--General practice in a market town. SUBJECTS--Of 863 patients aged 70 and over on the practice records, 674 were traced and successfully interviewed; 350 were assigned to the intervention group, 324 as controls. INTERVENTION--The people in the intervention group were allocated to the care of a health visitor. The approach was four pronged: assessment and correction of nutritional deficiencies, including reducing smoking and alcohol intake; assessment and referral of medical conditions such as heart block or inappropriate medication; assessment and correction of environmental hazards in the home such as poor lighting; assessment and improvement of fitness--for example, exercise classes for the moderately fit. The intervention continued for four years. MAIN OUTCOME MEASURE--Fracture rate over four years. RESULTS--The incidence of fractures was 5% (16/350) in the intervention group and 4% (14/324) in the control group (difference not significant). CONCLUSIONS--A health visitor visiting a group of people aged 70 and over and using simple preventive measures had no effect on the incidence of fractures.     

Prevention in practice: what Wessex general practitioners are doing.

A random sample of 214 general practitioners in the Wessex region was invited to complete a postal questionnaire about the practice of preventive medicine and 90% replied. This inquired into their attitude and behaviour towards smoking and accident prevention, promoting exercise, and controlling obesity and hypertension. The results were generally encouraging. Most recognised their key role in health promotion and health education and their shared responsibility with other professionals. Many had made progress in smoking prevention and control of obesity and hypertension. Promoting exercise and accident prevention left room for improvement. The availability of information in patients'' records to identify and monitor problem areas was particularly lacking. We conclude that further progress might be achieved by better training of general practitioners, and developing information systems orientated towards promoting health. The team approach in primary care needs to be strengthened. In particular extending the role of the health visitor and practice nurse may provide the support so vital for the successful outcome of preventive initiatives. Community unit management teams need to consider carefully how they may encourage advances in health promotion in primary care.     

Experimental Restoration of Disturbed Cliff-Edge Forests in Bruce Peninsula National Park, Ontario, Canada

Abstract Restoration of degraded natural vegetation in parks is often complicated by the need to maintain public access. We tested whether the natural canopy species, Thuja occidentalis, can be restored to degraded cliff edges in Bruce Peninsula National Park, Ontario, Canada without reductions in visitor numbers. Eighty 10‐year‐old and 80 4‐year‐old container‐grown saplings and 1,400 seeds were planted and monitored for 4 years. Eight treatments were applied that tested for effects of planting site (distance from cliff edge and pathways) and supportive measures (soil, water, cages, or signs) on survival, growth, and damage. No trees became successfully established from seed. Younger trees showed faster initial establishment and growth, but 4‐year survival was the same for both age groups (39%). Supplemental soil improved the health of planted trees, and both soil and water slightly improved their survival. Cages did not affect survival and growth but decreased damage to 4‐year‐old trees and increased it for 10‐year‐olds. Signs had no effect on any measured variable. Trees planted away from the cliff edge and from pathways had the greatest establishment success, 4‐year survival, and general health. Relative visitor density, as estimated from spot counts of visitors, had the largest effect on restoration success; the results suggest a threshold of visitor density above which restoration may be impossible. Planting location, especially with respect to shade, was also important. The planting of 4‐year‐old trees without supportive measures is suggested as the most cost‐effective restoration technique at this site. The results indicate that restoration of open woodland habitats is possible without total visitor exclusion but that some restrictions on visitor numbers or activities are necessary.     

Domiciliary nebulisers in asthma: a district survey.

Fifty three patients who were found to be using a home nebuliser for asthma completed a questionnaire. The results showed some confusion about the criteria for recommending whether a patient should buy a nebuliser and for its correct use. Twelve patients had not received any instruction on the use of their nebuliser, and only 11 of those old enough used a peak flow meter in conjunction with it. Eight patients aged 7-15 were using inhaled sympathomimetic aerosols only at the time of buying a nebuliser as compared with most of the older patients, who were using regular oral steroids. Forty nine patients assessed their asthma as moderate to severe, but eight of these were not attending a hospital clinic. Several patients were using 20 mg salbutamol or more every day, and on occasion doses of up to 50 mg a day were reported. It is recommended that patients should be assessed before they buy a nebuliser and advice given on correct use by a district nebuliser service, organised either by respiratory function technicians or in physiotherapy departments for adults together with a paediatric health visitor for children.     

Problems of the oncology outpatient: role of the liaison health visitor.

A survey by a liaison health visitor of outpatients attending an oncology department has identified and enumerated the principal problems with which she is confronted, and defined her role. The main medical symptoms of concern to the patient at home and needing attention by the liaison health visitor were anorexia, nausea, vomiting, and constipation: inadequate pain control due to poor drug compliance was also common. Other functions of the liaison health visitor include providing nursing aids and prostheses, support for bereaved relatives, and liaison with the community health care team.     

Visitor Perceptions of Captive,Endangered Barbary Macaques (Macaca sylvanus) Used as Photo Props in Jemaa El Fna Square,Marrakech, Morocco

ABSTRACT

Visitors to Jemaa El Fna Square can pay to have their photograph taken with Barbary macaques. Our aim was to characterize visitors’ perceptions of such photo props, enabling demand-reducing interventions to be targeted appropriately and destination managers to maintain or enhance the visitor experience. Visitors to Jemaa El Fna (n = 513) were surveyed using a 25-item questionnaire including closed and open questions. Most visitors (88%) neither intended to use macaque photo props nor did; 7% either intended to or did use photo props; while 5% both used photo props and had intended to do so. Moroccans were more likely than foreigners to use macaque photo props or intend to do so. Among international visitors, those who had their photo taken or intended to were younger, with a lower level of education and lower income than those who neither had their photo taken nor intended to. Visitors who did not use photo props pitied the animals’ treatment, disapproved of captivity or exploitation, had concerns over hygiene or safety, and disliked trader harassment. Visitors who did use photo props valued novelty and contact with the animal, although half of them also described negative experiences including trader harassment and animal mistreatment. While 16% felt the presence of macaques makes Marrakech lively and interesting, 40% recognized risks to health and safety, and 57% thought Marrakech would be a better place without macaque photo props. Although 66% agreed the practice should be illegal, 80% were unaware that it is illegal. Only 25% correctly identified the Barbary macaque as endangered. Macaque photo props undermine current conservation objectives and legislation, contribute to Disneyfication of macaques, and may threaten the image of the destination; however, their appeal to a minority of visitors indicates a desire to interact with animals, which visitor education might divert toward more responsible tourism.     

游客密度对动物园中黇鹿行为的影响

2006年9月20日-10月10日,以江苏省扬州市茱萸湾公园半散放鲇鹿为研究对象,采用目标动物取样法和全事件记录法,研究了不同游客密度条件下黇鹿日行为时间分配.并探讨了游客密度对鲇鹿日活动的影响.结果表明:在游客高峰期与低峰期,雄性取食、观望行为,雌性观望以及幼鹿取食、观望和修饰行为之间均存在显著差异(P＜0.05).在游客低峰期,雄性与雌性取食、反刍、卧息行为,雄性与幼鹿观望、其它行为,雌性与幼鹿取食、卧息、观望均存在极显著差异(P＜0.01);在游客高峰期,雄性与雌性取食、卧息,雌性与幼鹿取食、卧息、观望及移动行为均差异极显著(P＜0.01),雄性和幼鹿观望行为差异显著(P＜0.05).不同游客密度条件下游客活动对鲇鹿的取食、观望具有显著影响,当游客密度达到6人·min-1以上时,雄性观望行为显著增加,当达到16人·min-1以上时,雄性取食行为差异极显著(P＜0.01),此时雌性和幼鹿观望行为差异亦达到极显著水平(P＜0·01).因此,在旅游管理中,应将游客密度限制在16人·min-1以下,以减少对鲇鹿日活动影响.     

Health surveillance of preschool children.

Discussions with every general practice, health visitor, and clinical medical officer in Northumberland Health Authority led to agreement about the content of preschool health surveillance, the ages at which it should be done, and referral pathways after a failed screening test. Each primary health care team now undertakes to do a basic minimum set of screening tests, and each team decides who in the team will do each test. The screening system agreed on should enable time to become available for the equally important aspects of surveillance--namely, developmental guidance, health education, and assessment and follow up of problems. The discussions also led to agreement about how the health authority should evaluate the effect of the surveillance programme on the health of children.     

Controlled trial of three different antismoking interventions in general practice.

Of 6052 adult patients who consulted their doctors in six Oxfordshire general practices between October 1980 and February 1981, 2110 (35%) were smokers. The smokers were allocated to one of four study groups--a control (non-intervention) group; a group that received verbal and written antismoking advice from the general practitioner; a group that received this advice and also a demonstration of exhaled carbon monoxide; and a group that received the advice plus the offer of further help from a health visitor. After one year 72% of smokers replied to a postal follow up questionnaire: 11% of the control group claimed to have stopped smoking compared with 15% in the group that received advice alone, 17% in the exhaled carbon monoxide group, and 13% in the health visitor group. Validation of these findings by assays of urinary concentrations of cotinine showed that between 24% and 40% of subjects may have misreported their smoking habits, but there was no indication that the rate of misreporting was higher in the intervention groups than in the control group. Giving advice routinely against smoking has a useful effect, and showing an immediate, personal, and potentially harmful consequence of smoking using a CO-oximeter may improve this, particularly in lower socioeconomic groups.     

Audit of terminal care in a general practice.

OBJECTIVE--To determine satisfaction of relatives and general practitioners with care of patients during terminal illness and make recommendations on improving terminal care in general practice. DESIGN--Interviews with available relatives of patients who had had terminal illnesses and died in 1987, supplemented by questionnaires; questionnaire survey of general practitioners after review of case notes of all their patients who had died of terminal illnesses in 1987. SETTING--One urban general practice. SUBJECTS--34 Relatives of patients with terminal illnesses who died in 1987; five general practitioners from one practice. RESULTS--In six cases relatives were dissatisfied, mainly because of lack of communication; in eight cases doctors were dissatisfied because of communication, poor symptom control, and inadequate care. IMPLICATIONS--There is a need for improved communication between relatives and the health professionals involved in terminal care as well as better advice on services and benefits available to both patients and relatives. Bereavement counselling should be better organised.     

Attitudes of Ontario psychiatrists towards health insurance.

In 1979 the opinions of Ontario psychiatrists were sought regarding the influence of the Ontario Health Insurance Plan (OHIP) on the practice of their specialty. Full replies to a 44-item questionnaire were received from more than half the certified psychiatrists in Ontario, half of whom had been in practice before the introduction of OHIP. Both satisfaction and uneasiness were expressed about most aspects of health insurance. Many of the 416 psychiatrists stated that OHIP had improved access to psychiatric care, providing a more socially diverse practice, especially with respect to psychotherapy. Only one quarter believed that OHIP constituted a major intrusion on the doctor-patient relationship, and the majority reported that OHIP had been beneficial to themselves as psychiatrists (70%) and to their patients (86%). Almost half reported having raised their concern about the confidentiality of OHIP records with their patients; the patients less often brought up the issue. Although most psychiatrists in practice before the introduction of OHIP reported no change in their conduct of psychotherapy, a minority reported a decrease in the duration of treatment and an increase in the frequency of missed appointments. Also noted was an increase in the number of referrals for consultation, which led at times to overutilization of these specialists'' services.     

Health checks on patients 75 years and over in Nottinghamshire after the new GP contract.

OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients'' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices'' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.     

CALIFORNIA MEDICAL ASSOCIATION: ARE WE MAKING THE SAME MISTAKES BRITISH DOCTORS MADE?

Almost every doctor who visits England comes back wanting to write an article or give a speech about socialized medicine. Because there has been so much said so many times on the subject, it has lost much of its interest.Yet, the headquarters of the California Academy of General Practice in San Francisco recently had a visitor from England who had some startling, frightening things to say of interest to every American doctor. The visitor was Dr. Alastair J. Marshall, Luton, England, who is visiting in this country under a Ford Foundation Grant. As an area executive in the British Medical Association and on the executive area council (one-third physicians, two-thirds laymen) for the national health system, Dr. Marshall can competently speak on this subject. Here are some of the questions presented to Dr. Marshall by the Academy's Executive Secretary Bill Rogers.     

How good is general practice developmental screening?

All developmental screening in Somerset is performed by general practitioners and health visitors. A retrospective review of a cohort of 1504 7 year old children living in semirural Somerset found that the development assessment by a health visitor at age 3 1/2 years had a sensitivity of 45% for identifying the 103 children with special educational needs, whereas the sensitivity of the preschool examination by a general practitioner was 56%. There was no relation between results of preschool developmental assessment and later reading ability. Of the 23 children in special schools, 22 had been identified independently of the developmental screening programme before starting school. Intervention was started at a mean age of 1 year 5 months (range 2 months to 3 years) for children with severe learning difficulties, and 3 years 9 months (2 years 3 months to 6 years 6 months) for children with moderate learning difficulties. The preschool medical examination revealed fairly minor medical problems: 29 of 81 children referred for specialist opinions were shown to be medically normal, and for only seven of the medically abnormal children was information about their conditions given to their teachers. In Somerset screening the development of all children at predetermined ages has not been very useful.     

Old people not known to the general practitioner: low risk group.

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner''s knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.     

Newly registered elderly patients: who are they and why such delay in the transfer of their medical records?

The time taken to transfer the records of elderly patients registering with a new general practice was investigated. Thirty five (5%) of a total of 671 patients aged 75 and over were entered as new patients on to the age-sex register of an urban group practice during one year. Twenty nine had moved into the area and six had changed their general practitioner for personal and other reasons. An average of 141 (range 71-296) days elapsed before dispatch of their medical records to the new practice. During this period an average of 3·5 (range 0-15) consultations with a general practitioner were recorded, indicating the need of such patients for medical care. The long delays were caused by the processing of medical records at the central register and the transfer of records between family practitioner committees and general practitioners. Delays were most apparent in the time taken for general practitioners to dispatch the necessary documents to the family practitioner committees, and these should be minimised.The use of a summary card written and updated by the general practitioner and retained by the patient would facilitate continuing care should patients change to a new practice. Meanwhile, assessment of elderly patients after registration with a new practice by a member of the primary health care team may identify problems before the records have been transferred and may help the resettlement of these high risk elderly patients.     

The practice brochure: a patient's guide to team care.

A practice brochure describing the primary health care team was given to 262 new and established patients in a group practice. Most liked it, and thought it helpful, and improved their knowledge of team care. When asked how they would respond to certain hypothetical health problems and clinical situations, there was a significantly greater use of non-doctor members of the team than by a matched sample who had not read the brochure. Inappropriate use of members of the team was not engendered.     

The effects of visitor density and intensity on the behavior of two captive jaguars (Panthera onca)

Several researchers have reported significant effects of visitor density and intensity on captive animal behavior. This study determined whether this was the case for 2 captive jaguars housed at the Woodland Park Zoo, Seattle, WA. Subjects were monitored for changes in behavior as a function of visitor density and intensity. The jaguars were observed for 8 hr per week for 29 weeks—March 31 until October 11, 1998—for a total of 230 hr. Continuous frequency sampling was used, and visitor density and intensity were recorded every minute. Parametric statistics were used to test for correlations between behavior and density, intensity, or a combination of the two. Both density and intensity were significant for time spent non-visible for both cats, and intensity showed a significant effect on the female's pacing behavior. In addition, the male cat exhibited a trend for increased aggression based on both visitor density and intensity and a trend of intensity affecting his social behavior. In conclusion, both density and intensity had a significant effect on behavior, with intensity showing a larger effect.     

The Effects of Visitor Density and Intensity on the Behavior of Two Captive Jaguars (Panthera onca)

Several researchers have reported significant effects of visitor density and intensity on captive animal behavior. This study determined whether this was the case for 2 captive jaguars housed at the Woodland Park Zoo, Seattle, WA. Subjects were monitored for changes in behavior as a function of visitor density and intensity. The jaguars were observed for 8 hr per week for 29 weeks—March 31 until October 11, 1998—for a total of 230 hr. Continuous frequency sampling was used, and visitor density and intensity were recorded every minute. Parametric statistics were used to test for correlations between behavior and density, intensity, or a combination of the two. Both density and intensity were significant for time spent non-visible for both cats, and intensity showed a significant effect on the female's pacing behavior. In addition, the male cat exhibited a trend for increased aggression based on both visitor density and intensity and a trend of intensity affecting his social behavior. In conclusion, both density and intensity had a significant effect on behavior, with intensity showing a larger effect.