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Background Injection drug use is on the rise in the USA, and skin and soft tissue infections (SSTI) are a common complication, resulting in significant morbidity and mortality. Due to structural barriers to care-seeking, many people who inject drugs avoid formal care and resort to self-care techniques, but little is known about the nature of these techniques, or more generally about the accuracy or breadth of this population’s knowledge of SSTIs. Methods Semi-structured qualitative interviews were conducted with 12 people who inject heroin in two metropolitan areas: Sacramento and Boston, USA. Results These interviews reveal a robust and accurate knowledge base regarding skin infections, including the progression from simple cellulitis to an abscess, and acknowledgment of the possibility of serious infections. Nonetheless, there remains a reticence to seek care secondary to past traumatic experiences. A step-wise approach to self-care of SSTI infections was identified, which included themes of whole-body health, topical applications, use of non-prescribed antibiotics, and incision and drainage by non-medical providers. Conclusions The reported SSTI self-care strategies demonstrate resilience and ingenuity, but also raise serious concerns about inappropriate antibiotic consumption and complications of invasive surgical procedures performed without proper training, technique, or materials. Harm reduction agencies and health care providers should work to obviate the need for these potentially dangerous practices by improving healthcare access for this population. In the absence of robust solutions to meet the needs of this population, education materials should be developed to optimize the efficacy and minimize the harms of these practices, while empowering and supporting the autonomy of people who use drugs and providing clear guidance on when self-care should be abandoned in favor of formal medical care.

(2022) overturned (1973), thus returning abortion policy decisions to state governments, abortion access across the United States became fragmented, with some states enacting near-total bans and other states strengthening protection. As a parallel, the Republic of Ireland's (ROI) 2018 repeal of the Eighth Amendment and the United Kingdom's (UK) longstanding framework of care offer informative historical examples. This qualitative study explores the perspectives and experiences of abortion-trained physicians in California (CA), Texas (TX), ROI, and the UK, focusing on how legislation shapes physicians' ability to deliver comprehensive abortion care. In accordance with Consolidated Criteria for Reporting Qualitative Research (COREQ), nineteen abortion-trained physicians practicing in Family Medicine, Obstetrics & Gynecology, and General Practice (CA = 6; TX = 4; UK = 4; ROI = 5) participated in 1-hour semi-structured interviews from August 2022 to November 2023 relating to their abortion care training and practice. Interviews were audio-recorded, transcribed, anonymized, and coded using Braun and Clarke's six-step approach to thematic analysis and conducted until thematic saturation was reached. Analysis revealed several interconnected themes. Across all geographical practices, physicians highlighted the importance of centering care on patients' needs, but variations in legislation largely shaped clinical care. Training experience varied widely with many shaping their own education in the context of available resources. Changing policies functioned as a clinical variable, often shifting with cultural and political attitudes. Geographic, financial, facility-related, and healthcare infrastructure barriers compounded legislative obstacles, highlighting that legality does not guarantee accessibility. Participants additionally emphasized cross-specialty advocacy, reported experiences with stigma, and dispelled common misconceptions on abortion. These findings highlight that policy functions as a major determinant of health and that centering on patient experiences, standardizing education, addressing healthcare infrastructure barriers, strengthening peer support systems, continued physician advocacy, and systemic reforms are necessary to reduce preventable delays, patient distress, and disparities in care. This study highlights the importance of incorporating physicians' perspectives into legislative discussions to ensure accurate representation of patient needs and challenges in accessing abortion care.

Background Screening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions. Methods One hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information. Results PCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients. Conclusion While our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

We provide an overview of what is known about the impact of direct-to-consumer (DTC) advertising of prescription drugs. Specifically, we explore the historical trends that led to the industry's increasing use of this form of promotion. Then, using the published literature to date, we review the impact of DTC advertising on the consumer, the medical profession, and the health care system. We conclude by offering policy suggestions for how the pharmaceutical industry can promote its products more responsibly, how the Food and Drug Administration (FDA) can regulate DTC advertising more effectively, and how the medical and public health communities can educate the public about drug therapies more constructively.

ABSTRACT INTRODUCTION The information provided by pharmaceutical sales representatives has been shown to influence prescribing. To enable safe prescribing, medicines information must include harm as well as benefits. Regulation supports this aim, but relative effectiveness of different approaches is not known. The United States (US) and France directly regulate drug promotion; Canada relies on industry self-regulation. France has the strictest information standards. METHODS This is a prospective cohort study in Montreal, Vancouver, Sacramento and Toulouse. We recruited random samples of primary care physicians from May 2009 to June 2010 to report on consecutive sales visits. The primary outcome measure was “minimally adequate safety information” (mention of at least one indication, serious adverse event, common adverse event, and contraindication, and no unqualified safety claims or unapproved indications). RESULTS Two hundred and fifty-five physicians reported on 1,692 drug-specific promotions. “Minimally adequate safety information” did not differ: 1.7 % of promotions; range 0.9–3.0 % per site. Sales representatives provided some vs. no information on harm more often in Toulouse than in Montreal and Vancouver: 61 % vs. 34 %, OR = 4.0; 95 % CI 2.8–5.6, or Sacramento (39 %), OR = 2.4; 95 % CI 1.7–3.6. Serious adverse events were rarely mentioned (5–6 % of promotions in all four sites), although 45 % of promotions were for drugs with US Food and Drug Administration (FDA) “black box” warnings of serious risks. Nevertheless, physicians judged the quality of scientific information to be good or excellent in 901 (54 %) of promotions, and indicated readiness to prescribe 64 % of the time. DISCUSSION “Minimally adequate safety information” did not differ in the US and Canadian sites, despite regulatory differences. In Toulouse, consistent with stricter standards, more harm information was provided. However, in all sites, physicians were rarely informed about serious adverse events, raising questions about whether current approaches to regulation of sales representatives adequately protect patient health.

Objective The primary purpose of the study was to assess the prevalence of adverse childhood experiences (ACEs) in a cohort of third-year medical students and characterize their childhood protective factors. Methods The authors developed a web-based anonymous survey distributed to all third-year medical students in one school ( N  = 98). The survey included the 10-item ACE Study questionnaire, a list of childhood protective factors (CPF) and questions to assess students’ perception of the impact of ACEs on their physical and mental health. The medical school’s IRB approved the student survey as an exempt study. The authors computed descriptive and comparative statistical analyses. Results Eighty-six of 98 students responded (88% response rate). Forty-four students (51%) reported at least one ACE exposure and 10 (12%) reported ≥ 4 exposures. The latter were all female. The average difference in the ACE score between male and female medical students was − 1.1 (independent t test with unequal variances t (57.7) = − 2.82, P  = .007). Students with an ACE score of ≥ 4 were significantly more likely to report a moderate or significant effect on their mental health, compared with students with scores ≤ 3 (chi-square test, P  = < .0001). Most students reported high levels of CPF (median score = 13 of a maximum score = 14). ACEs and CPF were inversely associated (Pearson correlation = − 0.32, P  = .003). Conclusions A sizeable minority of medical students reported exposure to multiple ACEs. If replicated, findings suggest a significant vulnerability of these medical students to health risk behaviors and physical and mental health problems during training and future medical practice.

Two decades ago, the genocide against the Tutsis in Rwanda led to the deaths of 1 million people, and the displacement of millions more. Injury and trauma were followed by the effects of a devastated health system and economy. In the years that followed, a new course set by a new government set into motion equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality rates have fallen precipitously in recent years, and life expectancy has doubled since the mid-1990s. Here we reflect on the lessons learned in rebuilding Rwanda's health sector during the past two decades, as the country now prepares itself to take on new challenges in health-care delivery.

The authors outline a new visual tool that can help patients assess the benefits and risks of different treatments.

ABSTRACT BACKGROUND Many primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer. OBJECTIVE To evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians. DESIGN Randomized two-group design. PARTICIPANTS 121 California and Pennsylvania community physicians. INTERVENTION Web-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer. MAIN MEASURES Transcripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer. KEY RESULTS Across all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6 %), and fewer (43.8 %) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3 % versus 60.7 %, P  = 0.048), encourage genetic counseling before testing (38.3 % versus 21.3 %, P  = 0.048), ask about a family history of prostate cancer (25.0 % versus 6.6 %, P  = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0 % versus 1.6 %, P  = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3 % versus 34.4 %, P  = 0.01) or to reply that they would get tested when asked, “What would you do?” (33.3 % versus 54.1 %, P  = 0.03). CONCLUSIONS Physicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.

OBJECTIVE: We undertook this investigation to characterize conflict of interest (COI) policies of biomedical journals with respect to authors, peer‐reviewers, and editors, and to ascertain what information about COI disclosures is publicly available. METHODS: We performed a cross‐sectional survey of a convenience sample of 135 editors of peer‐reviewed biomedical journals that publish original research. We chose an international selection of general and specialty medical journals that publish in English. Selection was based on journal impact factor, and the recommendations of experts in the field. We developed and pilot tested a 3‐part web‐based survey. The survey included questions about the presence of specific policies for authors, peer‐reviewers, and editors, specific restrictions on authors, peer‐reviewers, and editors based on COI, and the public availability of these disclosures. Editors were contacted a minimum of 3 times. RESULTS: The response rate for the survey was 91 (67%) of 135, and 85 (93%) of 91 journals reported having an author COI policy. Ten (11%) journals reported that they restrict author submissions based on COI (e.g., drug company authors' papers on their products are not accepted). While 77% report collecting COI information on all author submissions, only 57% publish all author disclosures. A minority of journals report having a specific policy on peer‐reviewer 46% (42/91) or editor COI 40% (36/91); among these, 25% and 31% of journals state that they require recusal of peer‐reviewers and editors if they report a COI. Only 3% of respondents publish COI disclosures of peer‐reviewers, and 12% publish editor COI disclosures, while 11% and 24%, respectively, reported that this information is available upon request. CONCLUSION: Many more journals have a policy regarding COI for authors than they do for peer‐reviewers or editors. Even author COI policies are variable, depending on the type of manuscript submitted. The COI information that is collected by journals is often not published; the extent to which such “secret disclosure” may impact the integrity of the journal or the published work is not known.