Public health practice is characterized by measuring population health, assessing needs for health care and the provision (directly or indirectly) of services to protect and promote the public's health. It is increasingly explicitly concerned with issues of equity.
Publications discussing ethical issues in public health.
Unlike the duties of clinicians, professional standards for public health practice are not well defined. An ethics framework would help the development and implementation of public health policy.
Public health strategies have been criticized for being paternalistic and restrictive of personal choice behaviours or for being too pragmatic, and appearing to endorse illegal activities.
Historically public health programmes have been delivered at a population level for large groups of people with varying capacity to benefit. Within more autonomy, consumer-orientated political environment, strategy must be more targeted to facilitate healthy choices as defined by the individual.
Debate is needed on the aims of public health, rights and responsibilities of professionals and citizens and mechanisms for developing and implementing policy.
The subject of ‘global health’ can be considered from multiple points of view. While epidemiologists might describe global health problems in categories of pathology groups, social scientists might consider the problem from the stand point of institutional and infrastructural strengths and failings. An over-arching theme, however, is that the distribution of the burden of ill health is disproportionately carried by the poor. This paper aims to defend the idea that inequality should be considered the main priority in global ill health.
Review of the literature, personal communications and the WHO commission on the Social Determinants of Health.
The extent and urgency of global health problems.
The cause of ill health and the appropriate intervention.
We all need a deeper appreciation of the plight of the poor and the extent to which suffering can be mitigated by striving for a more equitable future.
Research into the broader global forces that impact on economic disparity (for the better and the worse) and the extent to which they effect measureable health outcomes is an extremely important area for research in this day and age.
Debate over relationships between economic growth, wealth, health and health inequity is long-standing and ongoing. The main message of this paper is that economic growth, while necessary, is not a sufficient condition in itself for achieving equitable health.
This review surveys and draws on research into principal factors commonly linked with improving health—income, health care, individual behavior—suggesting, using work from the Commission on Social Determinants of Health, that these are better understood in a broader social determinants of health framework.
The paper acknowledges that post-war globalization has seen significant growth, poverty reduction and greater economic resources at individual and household levels all of which can contribute to better health. But it also highlights renewing inequity in global health during the period.
It argues that over-reliance on market-driven growth, which fails to address deep-rooted social inequalities in economic resources key to accessing social determinants of health, and in the key determinants of health themselves have contributed to increasing inequity in health outcomes.
Commitment to market-driven growth remains evident in national policy-making worldwide.
With increasing health inequity, and calamitous global economic events in 2008–09, the centrality of this commitment needs urgently to be reviewed.
Dementia, Alzheimer's disease and vascular dementia being two main causes, is major and growing health problem. Vascular risk factors are thought to be involved in the causation of both dementias.
A review of the literature was conducted using MedLine to identify current evidence for role of vascular risk factors as potential targets in preventing dementia. Cross-references were hand searched.
The evidence from prospective epidemiological studies suggests that optimizing the control of vascular risk factors such as hypertension, high cholesterol, diabetes, smoking and heart disease may prevent dementia. However, this has been proven in randomized placebo-controlled trials (RCT) for only hypertension.
Dementia is a secondary outcome in most RCTs and it is not known if there is a therapeutic time window between mid- and late-life when interventions are most effective. Also, we do not know precise mechanisms by which interventions for vascular risk factors offer brain protection.
Our research suggests that asymptomatic cerebral emboli, which are preventable, may be involved in the causation of dementia.
There is a need for RCT targeting multiple vascular risk factors in patients at high risk of dementia such as those with mild cognitive impairment.
Schizophrenia is a debilitating psychiatric disorder that imposes a considerable burden on sufferers, their families and society. The prominent involvement of genes, combined with the complexity and relative inaccessibility of the brain has led many to suggest that the identification of specific risk loci offers the best chance of understanding pathogenesis.
Recent genome-wide association studies (GWAS) and copy number variation (CNV) publications have been included in this review along with key papers from the fields of schizophrenia, functional psychoses and complex disease mapping.
Recent GWAS have now shown that both common alleles of small effect and rare alleles of moderate to large effect contribute to the high heritability of schizophrenia.
It is well known that many schizophrenic patients suffer symptoms seen in patients with bipolar disease and vice versa. There is now considerable interest in using aetiologically relevant risk factors, including genes, to explore the validity of the contemporary system of classification.
Rare CNVs have been shown to play a role in at least some cases of schizophrenia and it is highly predictable that this figure will rise with the use of technologies with higher resolution or that are better designed to assay common CNVs reliably.
The findings with common alleles thus far point to overlap in the genetic risk for schizophrenia and bipolar disorder, while the specific CNVs implicated in schizophrenia also increase susceptibility to a range of developmental disorders, including autism, mental retardation, attention deficit-hyperactivity disorder (ADHD) and epilepsy.
Open tibial fractures have been studied extensively in adults, and detailed treatment strategies have been developed: wound irrigation and debridement, fracture stabilization and delayed primary wound closure or early flap coverage are basic principles of management. No clear guidelines regarding the management of open tibial fractures in children exist.
We searched Medline, Embase, Cochrane, CINAHL and Google Scholar databases using the keywords: ‘open’, ‘tibia’, ‘fracture’, ‘children’, ‘paediatric’, ‘pediatric’, ‘external fixation’, ‘nailing’. Fourteen clinical studies were included. Quality of the studies was assessed using the Coleman Methodology Score.
Age above 10 years and grade III (severe) open fractures are associated with complications and outcomes similar to those in adults.
It is unclear whether open fractures of the tibia in children should be managed according to the principles followed in adults. Many authors support primary skin closure and non-operative management for grade I open fractures. There is no clear effect of fracture fixation method on time to union.
The quality of the studies was relatively poor. Patients' age affects outcome; adolescents should probably be managed as adults.
Carefully designed prospective cohort studies including a large number of children would be of value. Adequate follow-up is necessary to assess the long-term effects in the growing skeleton. The efficacy of flexible intramedullary nailing for open fractures needs further evaluation. Outcome studies based on general health measures are needed.
Clostridium difficile is the commonest cause of nosocomial diarrhoea. The epidemiology and clinical phenotype of the disease has dramatically changed with the global emergence of a virulent strain of C. difficile.
This review was compiled using data from individual studies and review articles identified from PubMed. The retrieved articles were also examined for additional references.
Appropriate and timely infection control measures are required to control C. difficile infection (CDI) in the hospital environment, and either oral metronidazole or vancomycin remains the mainstay of treatment depending on the severity of infection.
The optimal method for diagnosing CDI remains unclear, as does the best therapeutic strategy for the management of multiple relapses.
Studies of new antimicrobial agents with activity against C. difficile are required to improve the management of multiply relapsing disease. The use of novel therapeutic approaches that do not require antimicrobials requires urgent research, including the use of immunological or vaccine-based regimen, bacteriotherapy or C. difficile-specific bacteriophages.
Active sports participation can be important in some patients with degenerative joint disease in the lower limb. We investigated whether this is possible after an osteotomy for osteoarthritis of the hip, knee and ankle joints.
We performed a literature search using Medline, Cochrane, CINAHL and Google Scholar with no restriction to time period or language using the keywords: ‘osteotomy and sports’. Eleven studies (all level IV evidence) satisfied our inclusion and exclusion criteria. Nine reported on high tibial osteotomies, one on periacetabular osteotomies and one on distal tibial osteotomies. The Coleman Methodology Score to assess the quality of studies showed much heterogeneity in terms of study design, patient characteristics, management methods and outcome assessment.
Participation in recreational sports is possible in most patients who were active in sports before lower limb osteotomy. In no study were patients able to participate in competitive sports.
Intensive participation in sports after osteotomy may adversely affect outcome and lead to failures requiring re-operation.
Patients may be able to remain active in selected sports activities after a lower limb osteotomy for osteoarthritis. More rapid progression of arthritis is however a possibility.
Prospective comparative studies investigating activities and sports participation in age-matched patients undergoing osteotomy or joint replacement could lead to useful conclusions. Increased activity and active sports participation may lead to progression of arthritis and earlier failure requiring additional surgery.
Functional gastrointestinal disorders (FGIDs) are a highly prevalent group of heterogeneous disorders whose diagnostic criteria are symptom based in the absence of a demonstrable structural or biochemical abnormality. Chronic abdominal pain or discomfort is a defining characteristic of these disorders and a proportion of patients may display heightened pain sensitivity to experimental visceral stimulation, termed visceral pain hypersensitivity (VPH).
We examined the most recent literature in order to concisely review the evidence for some of the most important recent advances in the putative mechanisms concerned in the pathophysiology of VPH.
VPH may occur due to anomalies at any level of the visceral nociceptive neuraxis. Important peripheral and central mechanisms of sensitization that have been postulated include a wide range of ion channels, neurotransmitter receptors and trophic factors. Data from functional brain imaging studies have also provided evidence for aberrant central pain processing in cortical and subcortical regions. In addition, descending modulation of visceral nociceptive pathways by the autonomic nervous system, hypothalamo–pituitary–adrenal axis and psychological factors have all been implicated in the generation of VPH.
Particular areas of controversy have included the development of efficacious treatment of VPH. Therapies have been slow to emerge, mainly due to concerns regarding safety.
The burgeoning field of genome wide association studies may provide further evidence for the pleiotropic genetic basis of VPH development.
Tangible progress will only be made in the treatment of VPH when we begin to individually characterize patients with FGIDs based on their clinical phenotype, genetics and visceral nociceptive physiology.