Recent Position Paper Research Articles

Ethical, Legal, and Social Issues of Genomics: Implications for Physical Therapist Education

Background and Purpose. The purposes of this paper are to 1) describe common genetic ethical, legal, and social issues that physical therapists may encounter in their professional lives, and 2) to describe the educational implications of genetic ethical, legal, and social issues as they relate to the following questions: Do genetics define a new bioethics or do wellestablished ethical principles and ethical approaches associated with health care professionals apply to genetic problems? What competencies listed by the National Coalition for Health Professional Education in Genetics (NCHPEG) related to ethical, legal, and social issues should be taught? What planning and integration of pedagogical strategies do we recommend to effectively teach this material? Position and Rationale. The completion of the Human Genome Project (HGP) is accelerating the incorporation of genetics into mainstream medical practice. A recent position paper provided the rationale for genomics education for physical therapist students. One premise of that paper is that physical therapists will likely encounter an increasing number of patients with genetic-related conditions in their future practice and should have the knowledge, skill, and attitudes to effectively care for these patients. In this paper, we argue that, at the very least, physical therapists should be positioned to inform their patients about the benefits, risks, and alternatives to genetic testing, as well as help patients deal with the many ethical, legal, and social issues that could be encountered as a result of genetic testing. Discussion and Recommendations. We adopt the following position in this paper: Genetic ethical, legal, and social issues should be integrated into preexisting courses (ie, bioethics and ethics/jurisprudence courses and courses that address the application of genomics to practice) and threaded into existing or new cased-based discussions. Competencies outlined by NCHPEG list certain attitudes, knowledge, and skills that may serve as the basis of learning objectives for ethical, legal, and social issues. Case-based ethics, including narratives and simulated patient cases, would be particularly effective in directly involving students in ethical reflection and consequent emotional responses, as well as problem solving associated with complex genetic ethical, legal, and social issues. Ethical, legal, and social issues should be integrated early and throughout the professional educational curriculum and be taught, if possible, by physical therapist educators.

Unintentional Household Poisoning in Children

Despite the major reduction in fatal paediatric poisonings that has been achieved in industrialised countries over the last few decades, unintentional paediatric poisoning remains a major public health issue worldwide. In this article, we aim to provide clinicians dealing with poisoned children an overview of the problem and specific guidance on the identification and management of significant poisoning. Substances most frequently ingested by children in the developed world include household chemicals, medication, and plants. Although the great majority of such poisonings have no or limited clinical effects, it puts substantial burden on health care systems. Importantly, a few poisons can kill after ingestion of very small amounts. Unintentional poisoning in developing countries can be much more serious, following ingestion of kerosene, caustic agents, herbal remedies, insecticides or herbicides. Management of symptomatic patients involves supportive care, if available the administration of antidotes, and the removal of the offending drug from the body. Recent position papers on gastric decontamination indicate that such interventions are only rarely necessary. To further reduce the number of deaths and disabilities in the industrialised world and to begin to have an effect in the developing world, much more work is required to both identify and implement prevention strategies to reduce the number of cases of paediatric poisoning.

Occupation, Education and Community-Based Rehabilitation

Occupational therapy is rethinking its paradigm of human occupation to take account of the social, political, economic and environmental influences on communities and the effects that these have on opportunities for being and doing. One way of bringing this element into undergraduate curricula may be to develop programmes around community-based rehabilitation (CBR) and human rights. Recent position papers from the World Federation of Occupational Therapists, in combination with occupational justice arguments, may support an orientation of professional thinking towards community needs. Some suggestions are made for the accommodation of CBR perspectives in education, particularly through the development of practice placement opportunities.

Assessment of Bone Acquisition in Childhood and Adolescence

Availability, ease of use, relative low cost, and minimal radiation exposure have made dual-energy x-ray absorptiometry the most widely used technique worldwide to obtain bone measurements for both research and clinical purposes in pediatric populations. However, errors related to growth and maturity significantly diminish the accuracy of dual-energy x-ray absorptiometry bone measurements. Several investigators have found that dual-energy x-ray absorptiometry in children frequently leads to a misdiagnosis of osteoporosis and an underestimation of the amount of bone. In this regard, a recent official position paper by the International Society for Clinical Densitometry states that subjects <20 years of age should not be given a diagnosis of osteoporosis on the basis of dual-energy x-ray absorptiometry criteria. Nevertheless, the increased awareness that osteoporosis has its antecedents in childhood and the demand for examinations of bone acquisition and response to therapy stress the urgent need to improve the value of dual-energy x-ray absorptiometry measurements for children.

Doctors and drug companies: the beauty and the beast?

Doctors and drug companies: the beauty and the beast?

Diffusion‐Weighted MRI in Creutzfeldt‐Jakob Disease: A Better Diagnostic Marker Than CSF Protein 14‐3‐3?

Two middle-aged patients presented with rapidly progressive dementia and ataxia, nonspecific electroencephalography findings, and negative cerebrospinal fluid (CSF) protein 14-3-3. Both patients underwent brain magnetic resonance imaging (MRI) scans that demonstrated abnormalities on diffusion-weighted imaging (DWI) sequences, and both were later confirmed to have Creutzfeldt-Jakob disease. (CJD) by tissue examination. Because a recent position paper from the American Academy of Neurology characterized CSF protein 14-3-3 as a gold standard for clinically diagnosing CJD, the authors reviewed studies of CJD in which DWI-MRI imaging and CSF protein 14-3-3 studies were both performed. Among 19 reported cases of CJD with DWI-MRI lesions, CSF protein 14-3-3 was negative in 6 cases and positive in 2 others. The authors' findings suggest that multifocal cortical and subcortical hyperintensities confined to gray matter regions in DWI-MRI may be a more useful noninvasive diagnostic marker for CJD than CSF protein 14-3-3. These observations provide a compelling rationale for a prospective comparative study.

Appropriate use of antibiotics for respiratory infections: review of recent statements and position papers

Appropriate use of antibiotics for respiratory infections: review of recent statements and position papers

Appropriate use of antibiotics for respiratory infections: review of recent statements and position papers.

Respiratory infections are among the most common reasons for prescribing antibiotics. The excessive use of antibiotics in ambulatory practice has contributed to the emergence and spread of antibiotic resistance. The appropriate use of antimicrobial agents for respiratory infections could potentially reduce the emergence of antibiotic resistance. This article reviews recent guidelines and position papers on the appropriate antibiotic treatment for respiratory infections. There is a wide consensus that antibiotics are not appropriate for the treatment of most cases of acute bronchitis, pharyngitis, and rhinosinusitis. The recently published community-acquired pneumonia guidelines emphasized the importance of selecting antibiotic regimens active against both typical and atypical pathogens. However, there is disagreement regarding the routine use of the new quinolones.

Standardization of Bone Marker Nomenclature

A recent position paper (1) proposed standardization of the nomenclature of bone markers as outlined in …

Interpreting the discourse of HG Widdowson: a corpus-based critical discourse analysis

The discourse of a recent position paper by H.G. Widdowson is subjected to analysis by three methods criticised in that very paper. The paper was converted into a miniature data corpus and analysed with the concepts of systemic functional linguistics, corpus linguistics, and critical discourse analysis. These methods may well harbour a potential for more rigorous and disciplined intellectual debate thematising the rhetorical strategies that serve to construct or deconstruct academic ideas and positions.

Allergen-specific sublingual immunotherapy for respiratory allergy.

Present knowledge regarding the clinical efficacy and safety of sublingual immunotherapy (SLIT) for the treatment of respiratory allergy is reviewed. Allergen-specific immunotherapy is presently considered a 'biological response modifier' for the treatment of respiratory allergy, to be used in association with drug therapy and allergen avoidance. Its value in the treatment of these conditions has been established in position papers from the World Health Organization and the European Academy of Allergology and Clinical Immunology. Immunotherapy is usually administered subcutaneously (SCIT), and with this route several severe adverse events and fatalities have been described. Therefore, in the last 15 years, novel and safer routes of administration (local routes) have been developed. SLIT, in particular, has been investigated in 18 randomised controlled clinical trials. SLIT's clinical efficacy (improvement in symptoms and reduction in drug intake) in both asthma and rhinitis has been clearly assessed in 16 of these studies and for the most common allergens. SLIT's safety profile, derived from the clinical trials and from post-marketing surveillance studies, was shown to be satisfactory in both adults and children. The most frequently reported adverse events are gastrointestinal complaints, which can be avoided through appropriate dosage adjustment. For these reasons, SLIT has been accepted as a viable alternative to SCIT in recent position papers. The main advantages of SLIT are its safety (no severe systemic adverse event has ever been described) and good patient acceptance, especially in children; in addition, SLIT is a self-administered treatment that can be carried out at home by the patient. In contrast to injection immunotherapy, knowledge of the mechanisms of action of SLIT is still developing, albeit rapidly, although interesting data about its pharmacokinetics in humans are available. Data are also required concerning the possible preventive and long-lasting effects. SLIT is a viable alternative to SCIT, with the same rationale and indications. It is intended to be used in association with proper pharmacological treatment, at the earliest stages of the disease, for optimal management of respiratory allergy.

Local reactions during allergen immunotherapy do not require dose adjustment

Background: The recent World Health Organization position paper on allergen immunotherapy states that local reactions to immunotherapy are not predictive of subsequent systemic reactions. Nevertheless, in clinical practice dose adjustment after local reactions continues to be recommended, presumably in an effort to prevent future systemic reactions. Objective: We sought to determine whether dose adjustment versus no adjustment for local reactions during allergen immunotherapy influences the occurrence of subsequent systemic reactions. Methods: In a single-site allergy clinic before October 1, 1997, local reactions after allergen vaccine injection resulted in adjustment of the subsequent dose. After October 1, 1997, no dose adjustments were made for immediate and late local reactions. For the same 9-month period before and after the change in local reaction dose-adjustment policy, systemic reaction rates were compared retrospectively. For individuals experiencing a systemic reaction, local reaction rates and local reactions immediately preceding a systemic reaction were also compared before and after the policy change. Results: Comparing the 9-month period (October 1996-June 1997) preceding the policy change and the 9 months (October 1997-June 1998) after the change in policy, the systemic reaction rates (0.80% and 1.01%, respectively) were not statistically different (P = .24). Among those experiencing a systemic reaction, the rate of local reactions was unchanged (7.3% and 4.7%, respectively; P = .07), and the rate of local reactions immediately preceding a systemic reaction did not increase (18.8% and 10.5%, respectively; P = .37). The sensitivity of a local reaction predicting a systemic reaction at the next immunotherapy dose was 15%. Conclusions: A local reaction is a very insensitive predictor for a subsequent systemic reaction at the next allergen vaccine dose. Dose adjustment for most local reactions is unnecessary and may delay therapy, increase costs, and put the patient at increased risk of dose administration errors. (J Allergy Clin Immunol 2000;106:840-3.)

Nutritional implications of dietary phytochemicals.

Although increasing the levels of phytochemicals in foods via traditional breeding or genetic engineering would appear to pose less of a risk, there is still the possibility of over consumption given the ease with which phytochemical content can be increased. According to the recent position paper by the American Dietetic Association on phytochemicals, "the dietetics professional ... is the specialist who should make recommendations concerning appropriate dietary intake to optimize the potential benefits of phytochemical-rich or functional foods in overall health." For dietitians to make these recommendations, it will be necessary for the nutrition community to make a concerted effort to incorporate information on phytochemicals into nutrition manuals and professional resources. As it is, most of the research and discussion of phytochemicals is conducted by professionals not related or only peripherally related to the field of nutrition. This is truly an exciting time to be involved in the nutrition field. We have moved a head from thinking that only a relatively small number of dietary factors possess biological activity to recognizing that there are hundreds and perhaps thousands of such factors. It will be many years before our understanding of phytochemicals approaches our knowledge of vitamins and minerals- and it is worth nothing that our knowledge of vitamins and minerals is still incomplete. But it does appear that the phytochemicals help explain why plant-based diets, in general, are associated with a reduced risk of many chronic diseases. And in fact, his may be the most important outcome from use of phytochemicals. The nutrition community now has more reasons for encouraging consumers to eat plant-based diets.

Challenges and opportunities in occupational medicine

Recent position papers of the American College of Physicians and the Institute of Medicine have emphasized the role of primary care physicians in occupational medicine. Although opportunities for physicians to become certified in occupational medicine have expanded, shortages in the specialty are likely to persist throughout the 1990s. To help acquaint osteopathic physicians with some of the challenges facing the specialty of occupational medicine, this article addresses the extent of occupational illnesses, health-related policies in the workplace, the delivery of occupational medical services, and graduate medical education.

From Research to Practice

The Individuals with Disabilities Education Act introduces a new discretionary category of preschool eligibility: “developmental delay.” A recent DEC position paper supports the use of this new category but raises concerns about the transition from the broad category of developmental delay instead of eligibility categories commonly used in elementary school. Investigators at UCLA have been following two cohorts of young children with developmental delays and their families since 1979. Findings from these longitudinal studies relate directly to the concerns raised in the DEC document and support the introduction of the new category of eligibility.

Career-Related Information

The provision of comprehensive, well-organised information on educational courses, jobs and career opportunities has been recognised as a key component of careers services in schools since the inception of such services. Recent position papers on desirable career education programs and training programs for careers teachers/coordinators in Australia have reinforced the important role of adequate information resources. Some of the recommendations of these papers are summarised and recent Australian research on adolescents' life concerns and the perceived value of a range of potential sources of career-related information is reviewed. Findings related to information seeking by over 5000 high school students in some new research are described and discussed.

Occupational Medicine: Too Much Expected?

To the Editors: The recent position paper (1) represents a valuable advance toward defining a role that has so far eluded any comfortable categorization or implementation. However, as a practitione...

In Reply: Rape and AIDS

Drs Mascola and Gellert are correct to alert pediatricians to the need to consider the issue of the possible transmission of human immunodeficiency virus (HIV) at the time of a sexual assault. The failure to address this issue within the recent position paper on Rape and the Adolescent represents an omission by the Committee on Adolescence which we hope will be in part corrected by their letter. However, the Committee would add the following points of clarification.

The Setting of Tuition in Public Higher Education

The need to develop a better understanding of how tuition prices are established has become increasingly important as governmental policies have come to encourage greater reliance upon this source of income as a means of financing higher education. That is, as will be seen below, institutions of higher education are having to rely more and more upon tuition income to balance operating budgets. One of the reasons is that at the federal level, the principal method of providing assistance to higher education has shifted from direct institutional support (largely categorical) to indirect aid through student financial assistance. Now, many state governments have adopted the federal example, with the implication that institutions may have to raise their prices in order to capture the restructured public subsidy. The purpose of this paper is to identify the determinants of tuition levels among major state universities. Such information should be useful in evaluating possible effects on tuition of some of the current higher education financing proposals, such as greater reliance upon state student aid programs, the introduction of educational tax credits, and the expansion of eligibility for federal need-based student aid programs. Also, some of the assumptions of recent and future financing policies and policy position papers can be examined. An important assumption of the major new financing policy of the 1970s was that need-based student aid programs would raise tuition prices in public colleges and universities [2,7]. The reasoning was that at least

Investment Income: The Legal Part

This attitude, however, did not prevent industry spokesmen from repeating, perhapis for purposes of self-assurance if nothing else, the standard anti-consideration arguments, often including references to the few court decisions that both dealt with the subject and concurred with the industry position.2 Recent industry position papers on the topic have been more sophisticated,3 and the strict question of legality of consideration under the rate-making statutes has not generally been raised in print. The question is, however, not irrelevant-since insurance regulators are still occasionally