EBM and Clinical Support Librarians@UCHC

A blog for medical students, faculty and librarians about their use of evidence based medicine, clinical literature, Web 2.0, sources and search strategies

Category Archives: Epidemiology/Public Health

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 4): Causality, Airplanes and GIDEON

As accident re-enactments go, this one is pretty Riveting

Links courtesy of NJ.com and Exosphere3D – All rights reserved – Copyright 2011

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The focus and calm of U.S. Airways Captain Chesley Sullenberger can be appreciated by listening to the audio portion of this re-enactment, as he made critical analyses – over a period of only a few minutes – on how (and where) to land a disabled aircraft sinking earthward over a densely populated area. His decisions saved 100% of the lives on board that day.

Hang out with a bunch of epidemiologists long enough and eventually the conversation while turn to Causality. They will tell you that there are some big differences in semantics between linking causation, etiology and “proof” that X exposure caused Z disease or health condition. When I looked up the terms “causation” and “causality” (on Google) there were major sidetracks, such as WBA (Why-Because-Analysis) as in, Why did the airplane crash? Why did the reactor experience a meltdown?

Why? From the viewpoint of a physician, an engineer or an epidemiologist… because of X-Y-Z.  

X-Y-Z could be bird strikes, human error, engine failure, weather conditions, crazed people bearing guns, lack of fuel or a thousand other accidents waiting to happen. Often the causes can be identified. Sometimes one can only attribute unanticipated events to gauzy, fuzzy concepts such as “it was a one in a million chance” or “this was God’s will”,  “causes unknown” or just plain Karma. The harder (non-fuzzy) data can be applied towards improvements in systems design, development of new vaccines, engineering safety… all targeted towards avoidance of future accidents (or disease outbreaks).

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Epidemiologists save lives.  Sometimes this association accumulates slowly… as in proving associations between Exposure X and development of Disease Y decades later.  In other cases, evidence mounts up as an emergency, such as the identification of a novel virus identified as SARS in 2002.  But linking health effects of exposures over a human life-span is so much more elusive than showing evidence that birds got sucked into a jet engine at 2,500 feet (as above).

Turning to the PubMed database, a screenshot below from Medical Subject Headings List (MeSH) reveals how the term “causation” is mapped in the online thesaurus of medical indexing terms:

Image Source: NLM (http://www.ncbi.nlm.nih.gov/mesh) – All rights reserved – copyright 2011

One way to search a large database such as PubMed is to simply type in some words – for an example, Liver Cancer AND Epidemiology.  This pulls up over 18,000 retrievals…  too many (!), but by then selecting and applying standard Limit Fields such as Language, Journal Subset, Age Group, Gender and others, the retrievals can be filtered down to a more-manageable number.

A more precise way to search a large database like PubMed is to use the Medical Subject Headings list. In the example below, the term Liver Cancer was typed into the MeSH search page, which maps automatically to the preferred MeSH term — Liver Neoplasms. While this search still retrieves thousands of citation, they can be limited by selecting and applying any MeSH Subheading (or clinical qualifiers) that are appropriate to the search. These subheadings include clinical concepts such as Virology, Immunology, Genetics, Epidemiology, Transmission and 80 others.  Following is a screenshot of that type of search:

Image Source: NLM (http://www.ncbi.nlm.nih.gov/mesh) – All rights reserved – copyright 2011

Remember that a librarian’s idea of “causality” could be defined, in part, by the number or types of clinical subqualifiers selected (immunology, virology, epidemiology and those types of “background” concepts) to be combined with the formal MeSH term.

There are many ways to search. It helps a novice medical searcher sometimes to tell them just that: There is no one right way to search. Sounds enigmatic and it is.

Here is an example which I found recently in the medical literature, a 2010 article which discusses application of Bradford Hill criteria (listed here):

  • strength of association
  • consistency
  • specificity
  • temporality
  • biological gradient (dose-response)
  • biological plausibility
  • biological coherence
  • experimental evidence and
  • analogy

 Image: http://www.ncbi.nlm.nih.gov/pubmed/20644061 – All rights reserved – Copyright 2011

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Those searching for practical answers about causality, transmissible agents, disease etiology, global prevalence or current treatments might want to search GIDEON (Global Infectious Disease Epidemiology Online Network), an interesting “niche” information source targeting the research requirements of epidemiologists, clinical & translational researchers, MPH students, toxicologists or anyone interested in tracking or diagnosing infectious diseases on a country- or world-wide scale (subscription required). Updated weekly, the database is produced by Gideon Informatics and hosted on the EBSCO platform.

A search for causality or epidemiology done in the resources indexed by GIDEON is quite unlike a search done in PubMed about the etiology of Liver Cancer. The producers collect, review and index factual data collected from around the globe; their data encompasses a wide and diverse group of human cultures, agricultural, societal, economic or environmental practices.

Below is a screenshot of one example of the type of data that can be searched on GIDEON: bacterium (causative agent), typhoid (identifiable infectious agent) and United States (location, recorded incidence over time):

.Finally, a screenshot of What’s New at GIDEON (May 11 2011):

Image Source: GIDEON – All rights reserved – copyright 2011


News, Health Disparities, Americans, Politics: The Health Care Safety Net

Image Source: http://www.thesaurus.com/nope –  All rights reserved – copyright 2011

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If you are an American who reads news articles or listens daily to TV, then the budgetary skirmishes being played out between the two governing parties in Washington this month is enough to keep you up at night.

Do our elected government representatives deserve congratulations for haggling for days about and then (at the last minute) passing yet another temporary budget in order to keep the Federal government functioning on a daily basis? No. I say: Skip the drama and get back to governing the country in a cooperative, fair manner that represents the wishes of the people from your home state who voted for you. Sadly, long-term strategical thinking as well as respectful debate seem in short supply in our capital nowadays.

Am I a tea-partier? Nope. Is this blog about politics? Nope. What this blog is about is clinical education, health science research, instruction, trends in searching, public health, epidemiology, health care environments… and the infrastructure supporting these ideas and practices.

This month – from a public health viewpoint – it is troubling to read and hear about challenges to the health care safety net that the 2012 budget proposals being set forth by House Republicans have raised.  If their version of health care reform is enacted, the health care delivery system for children, disabled individuals or senior citizens will be very different by year 2021.

Families USA, a nonprofit policy group, published a report last week that examines the Republicans’ health care reform proposals; it is available online at no cost by clicking here.  It is highly critical of the proposals. Below are two screenshots from this report:

Image Sources: http://tinyurl.com/3bhsjf5 – All rights reserved – copyright 2011

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At this link, the proposed 2012 budget set forth by the current administration can be read online via the Congressional Budget Office (216-page PDF).  Also see a link to the Health Care section for specific numbers and rebuttals to the Republican proposals.


Thanks to Matthew Sturdevant, insurance reporter for The Courant (Hartford, CT newspaper website) for the link to the Families USA report.

News, Public Health, Environmental & Human Catastrophes: The World Watches Japan

Image Source: International Tsunami Information Center –  All rights reserved – copyright 2011

Life-changing events continue hard for the citizens of Japan, as the world watches them cope with multiple environmental disasters after surviving a 9.0 magnitude earthquake (a Big One) that hit near the northeast coast of the island near Honshu on Friday, Mar 11 2011.  An eyewitness filmed this video clip which illustrates with utter clarity the frightening speed and power with which the ocean wave destroyed portions of Miyako City (footage from BBC website, dated Mar 17 2011). The latest death toll shows that 10,000 perished on that day, another 12,000 are still unaccounted for ten days later.

For the estimated 500,000 survivors, the basics of human requirements are being met, but supplies are scarce.  Many are living in shelters.  It will take months to clean up the rubble, and years to restore the damage to the infrastructure. As those who lost loved ones are required to re-define their “new normal”, psychological and counseling services will be in demand.

The challenges facing officials in the Japanese government in the aftermath of the quake and tsunami started out complex and have only grown more so over last ten days. A different public health emergency for these agencies is to contain radioactive materials from being released by quake- and tsunami-damaged nuclear reactors at the Fukushima Daiichi nuclear power station (built in 1979), an event which has been described as one of the most serious civil nuclear accidents in history.  Protection of humans from exposure to radiation is of course the immediate concern; downstream, scientists will have a large amounts of data to collect as they examine health effects from three separate catastrophes.

Below is a map illustrating the 20km exclusion zone (12.4-mile radius) surrounding the Fukushima power facility (from BBC, published Mar 21 2011):

Image Source: BBC http://www.bbc.co.uk/news/world-asia-pacific-12802335 – All rights reserved – copyright 2011

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Following is a brief selection of sources for links to specific medical information and relief efforts taking place in Japan – mainly from websites outside of the country.*

Image Source: Google Crisis Response: Japan 2011 – All rights reserved – copyright 2011

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American Public Health Association (APHA) this month is providing online free access to their 2006 field handbook, Public Health Management of Disasters: The Pocket Guide (55-page PDF).  Below is shown page 42and 43:

Image Source: APHA Disaster Guide – All rights reserved – copyright 2011

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National Library of Medicine (NLM ) produces many information resources for epidemiologists, clinicians and public health officials to use to deal with environmental disasters. Since the monies to fund these agencies is from public tax-dollars, everything on the sites from NLM is on open access, available to anyone in the world to use.  How cool is that!

First, Toxicology Data Network (TOXNET), is a gateway site from which groups of individual database can be searched.  Below is a sample search on the term “radiation“:

Image Source: NLM Toxnet – All rights reserved – copyright 2011

Another resource from NLM:  Disaster Medicine & Public Health Literature, a practical and multi-purpose website.  One example of what can be found here: A schematic describing Public Health Preparedness and Response Competency Map (Dec 2010), produced by Association of Schools of Public Health, one of the accrediting bodies for institutions offering MPH/DoctorPH degrees. Worth a look, at:

Image Source: ASPH –  All rights reserved – copyright 2011

Environmental Health & Toxicology is a wide-ranging portal from NLM. After clicking on the “health professionals” link… I found access to IUPAC (International Union of Pure & Applied Chemistry and Human Health Division) Glossary of Terms Used in Toxicology and went to a random letter (I) to take a look (below):

Image Source: NLM: IUPAC Glossary –  All rights reserved – copyright 2011

Many other quality information resources are available from the NLM Specialized Information Services Division... too many to describe, free access for anyone.

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Lastly: This 6-minute instructional video called Tsunami Teacher describes how tsunamis form, how to recognize if one is likely to take place, and testimonials from those who have survived them.  It is a basic tutorial.

An iconical, enduring image about a terrible subject: “Great Wave off Kanagawa“, a colored woodblock print by Japanese artist Katsushika Hokusai (1760-1849) is one print in a series produced between 1829 and 1833.

Image source: Wikipedia – All rights reserved – copyright 2011

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* Thanks to librarians at the National Library of Medicine, who earlier this month posted some of these websites on the MED-LIB listserv, which started the idea for this post.

Oncology, Statistics, Summary Reports: Treating Cancer, Living with Cancer

Ask almost anyone you know about cancer, and they will have stories to relate about parents or family, close friends or co-workers (or themselves) who have received a diagnosis of cancer, or are going through treatments, or who have been declared cancer-free.  Living as a cancer survivor has become more common, thankfully, than in previous decades, and represents one of the health success stories of our era.

This post presents a short, eclectic sample of recent cancer-related news, statistics, research or summary reports.  The final portion of the post links to video presentations given by two UCHC research faculty as they discuss clinical and translational cancer research (filmed in November 2009).

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First: The National Conference of State Legislatures (NCSL) website provides an assortment of statistics or background pieces on state-based social or economic indicators, health initiatives, legislation or other current issues.  This site is a valuable resource for reference librarians, epidemiologists, policy-makers or anyone seeking current statistics about state-sponsored programs.

NCSL provides a collection of documents about Cancer Data, Trends and Policy 2009 reports, free and open to anyone to access (although registration is required to view some of the tables).  That page is where the table describing U.S. Cancer Incidence, 2009 shown below. According to statistics from the American Cancer Association, lung, prostate or breast cancers represent the most common diagnoses in the United States in 2009:

Image Source: http://www.ncsl.org/Portals/1/Documents/magazine/articles/2009/SL0110_Statestats.pdf – All rights reserved – Copyright 2009

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Next:  Several paragraphs from a December 2009 article written by Harmon J. Eyre, formerly chief medical officer of the American Cancer Society, entitled “Winning the Cancer Fight: Looking at the Future“:

” The medical management of cancer for the past 100 years has grouped cancers by the organ in which they originate and used standard interventions such as surgery, radiation, and chemotherapy.  With the development of the cancer genome anatomy of various cancer sites, individualized cancer therapy will quickly follow.

Specific genetic profiles are being introduced to project the risk of breast cancer recurrence and to shape the choice of treatment agents. We have decades of data on outcomes using estrogen receptor, progesterone receptor, and human growth factor receptor 2 testing which dictates treatment in breast cancer. Tests such as these are needed for lung, colon, prostate, lymphoma, leukemia, and other cancers. They are beginning to be developed and disseminated, with encouraging early results.

Despite keeping records in cancer registries for many decades, widespread evaluation of the level of quality care in cancer is lacking. We know that large variations in the delivery of care occur by hospital, city, state, and region. There are a number of groups working to develop indicators of quality cancer care, but there is a lack of agreement on these indicators and they are not being widely collected. For optimal outcomes, quality care has to be delivered nationwide to all cancer patients. ”

Text Source: Page 863 – Primary Care, Vol. 36:859-865 (December 2009) – All rights reserved – Copyright 2010

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An 18-page annual report from American Society of Clinical Oncology entitled “Clinical Cancer Advances 2009: Major Research Advances in Cancer Treatment, Prevention, and Screening—A Report
From the American Society of Clinical Oncology
” was published in December, 2009.  Following is an excerpt from this report:

This report [from ASCO] now it its fifth year, was developed under the guidance of a 18-person editorial board made up of leading oncologists and other cancer specialists… The editors reviewed research published in peer-reviewed scientific journals and the results of research presented at major scientific meetings over a 1-year period (October 2008 to September 2009).

Only studies that significantly altered the way a cancer is understood or had an important impact on patient care were included. Research in each section is divided into “major advances” and “notable advances,” depending on the impact of the advance on patient care and survival. “

Excerpt from ” Clinical Cancer Advances 2009: Major Research Advances in Cancer Treatment, Prevention, and Screening—A Report“, published Dec 10 2009 in Journal of Clinical Oncology – Vol. 27, No. 35:6052-606

ASCO provides links to reference information about current cancer treatments for physicians or other clinical staff, called Cancer Portal, which can be accessed at this link.

The society also provides free cancer information targeted for people living with cancer on their website, Cancer.net.

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Next: Two segments from a lecture series given in 2009 by UCHC faculty.  Oncologist Susan Tannenbaum is Medical Director of the Clinical & Translational ResearchProgram at UCHC, is shown in a 54-minute presentation on trends and improvements in the treatment of metastatic breast cancer.

The second video is a presentation on translational research given by Kevin P. Claffey, PhD, who is co-director of the UConn Health Center Breast Cancer Translational Research Group and an associate professor in Cell Biology, Center for Vascular Biology.

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Video Credits: http://mediasite.uchc.edu/Mediasite41/Viewer/?peid=22f078e3c075411380af60acdab8da83 – All rights reserved – Copyright UCHC 2010

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Next: Regarding a May 6 2010 New York Times editorial written by Nicholas D. Kristof:

In “New Alarm Bells About Chemicals and Cancer” (column, May 5 2010) writer Nicholas D. Kristof drew attention to a document being released by the President’s Cancer Panel that warns that – in Mr. Kristof’s words – “our lackadaisical approach to regulation may have far-reaching consequences for our health. ”

Text Source: The New York Times – All rights reserved – Copyright 2010

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I found readers’ comments as (or more) interesting to read as the original editorial.  There are 200+  comments which can be read at this link:  http://www.nytimes.com/2010/05/08/opinion/l08kristof.html

Teaching & Learning in Medicine, Research Methodology, Biostatistics: Show Me the Evidence (Part 1)

Question everything… especially what you read.

A 2009 quote from Dr. P,  PBL facilitator

.One of the many tasks for first-year graduate students in clinical or research areas is building a healthy skepticism about what one reads in the medical literature.

Ideally, as they progress through four years of medical education, students find that they must change their approach to searching as well as exploring what new resources will answer their questions of increasing complexity.  What answered their learning issues in their first year often doesn’t carry over to their third-year clerkship, when they are faced with finding solutions to the care of actual living patients.

This evolution (both practical and intellectual) asks that they grow a set of appraisal techniques for examining, embracing or rejecting what they find in the ever-increasing assortment of health science, pharmacology or social science databases available to them. (Note that I’m not referring to what can be found by simply plugging a few words into a search engine.)

And very likely, they jettison the use of a few previously well-used resources  as their clinical questions and experience become more complex.

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.Separate what is of statistical importance from what is clinically significant.

Another 2009 quote from Dr. P

As a facilitator for PBL, many first-year students have stated in class that they rely most on the library’s subscription to the Access Medicine* collection – including Harrisons’ Online – as a “first place” to go to do research.

It is what the librarians consider as a sort of a “package product”.  This subscription resource has developed in major ways over the years which UCHC Library has been providing it for our users.

As examples: there are now 60 core medical textbooks on the site, lists of DDx criteria, audio cases, calculators and clinical videos, podcasts, study guides for USMLE.  The library added subscriptions to Access Surgery and Access Emergency Medicine when they became available from the company.

Residents especially appreciate having 24×7 access to these resources.

And truly, we librarians were thrilled back in 1999 when the subscription to a digital version of Harrisons’ Principals of Internal Medicine was rolled out.  LOL.  (Link here to an academic paper from 1999 reviewing the resource.)  Back then, the medical and dental students were excited about this 16th digital edition too, although most of them elected to purchase their own hardbound copy of the textbook.  These memories seem a little quaint from eleven years on.

In 2010, here’s a screenshot of the newly-redesigned Access Medicine front page:

Photo/Text source: http://www.accessmedicine.com/features.aspx – All rights reserved – Copyright 2010
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What are other examples of what librarians consider garden-variety “packaged databases” that are frequently mentioned by first year students as essential to their research?

MD-Consult*, Up to Date* and for locating primary studies (or for “just shopping around” as one student said), PubMed.

As librarians (and instructors) a major teaching role for us is to encourage their exploration… and also to model the effective use of these information resources.  Feedback from students or faculty on the nature of their experiences as they  “consume” these products is very important.

And (dare I mention!) the librarians are there in the classrooms to also reinforce that using sources such as Google or Google Scholar to do credible clinical research represent truly two of the least satisfactory choices but also the ones most easily or readily available.   (Sigh.)

There are many free information sites in the world… the librarians don’t use or teach (or endorse) many of them. Why? Not because we are close-minded, too traditional, or old and cranky. This is a conversation thread that will be continued in Part 2 of this post.

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Seeing a dozen patients with XYZ syndrome will significantly increase their practical assessment skills.  So will participating in the care of a patient that even the seasoned clinicians and experts haven’t yet figured out a diagnosis for. A common short-hand for diagnostic skills is Horses versus Zebras.

Learning to comb the literature for clinically-sound research studies – and weighing what has been found for validity or predictive value – are skills not easily learned.  Is four years sufficient time for practice in this pick-and-choose process?

Many students in their third and fourth year of study come back to meet with the reference librarians for a “refresher course” on how to search more efficiently, as they begin their required fourth year individual research project (called their “selective“).

I consider these reference training sessions with students as excellent indicators that they are growing quite sophisticated about what they consider to be “good” evidence.  Getting choosy is a wonderful thing.

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* Please note: Resources mentioned are subscriptions and limited to UCHC students, staff and faculty only.  If off-site, use the Library’s proxy access to connect to them.

Public Health, Medically Underserved in Connecticut, UCHC Students, News: Migrant Health Workers Clinic

It’s a measure of how behind at work I am, that I missed posting the following article during Public Health Week (April 5-11 2010) and – yikes – also forgot that last week was officially National Library Week as declared by the American Library Association Sorry!

This post describes a unique public service and community outreach effort provided by individuals who volunteer their clinical services to staff the Migrant Health Workers Clinic (MHWC), a medical-dental clinic for seasonal farm-workers in Connecticut.

This traveling health clinic was founded in 1997 by UCHC professor Dr. Bruce Gould (shown in the photo below with two patients at a clinic in 2008):

Photo Credit:  http://publichealth.uconn.edu/aboutus_mfwc.php – All rights reserved – Copyright 2010

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Here is are some facts and background about the mission of the Migrant Health Workers Clinic:

Migrant farm workers are among the most economically disadvantaged and most medically vulnerable groups in the United States having little, if any, access to health care or medication. In addition to barriers to access to health care that many citizens meet like affordable health insurance, language barriers, and lack of transportation, migrant workers also experience additional barriers such as fear of deportation, loss or garnished wages, and being dismissed or not invited back to work by the employer due to missed work or health issues.  A coalition of local organizations, along with the University of Connecticut, has formed a network to overcome these barriers and attend to the health care needs of migrant and seasonal farm workers. “

The UConn Migrant Farm Worker Clinic opened its doors in 1997, with the aid of the Connecticut Area Health Education Program (CT-AHEC).… the clinic operates annually from June to October offering diagnostic and treatment options [to workers] for a variety of conditions, both acute and chronic, including primary care screenings, oral health screenings, distribution of medications for mild and self-limiting conditions, as well as preventive health education“.

Text Source: http://publichealth.uconn.edu/aboutus_mfwc.php – All right reserved – Copyright 2010

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Click here to view a list of health or social services agencies and non-profit organizations from throughout Connecticut that contribute funding, advisory services and personnel to staff the rotating schedule.

Many students from the University who are enrolled in professional programs in medicine, dentistry, pharmacology or nursing volunteer at the MHWC; some have chosen to participate in the Urban Service Track.

There is a special need for volunteers who are native Spanish speakers.  For those graduate students interested in primary care – as well as developing their (medical) Spanish language skills – it is an excellent opportunity to practice hands-on health care, advising and counseling.

Next, a 2-minute video filmed in 2008, narrated by a UCHC medical student which shows a typical visit with patients at the end of their workday, held at a local farm:  click here to watch.

Image Source: http://publichealth.uconn.edu/images/MFWC_video/index.html – All rights reserved – Copyright 2010

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Open a schedule showing 2009 locations in Connecticut where the medical and dental Migrant Health Worker Clinics were held (PDF file).

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This week on the Public Health @ UConn Facebook page, the following announcement was posted (Apr 15 2010):  “The 11th Annual UConn Migrant Farm Worker Clinic Symposium will be held on Tuesday, June 29th from 8:30-2:30 at the UConn Health Center in Massey Auditorium…  Students – Mark Your Calendars!

If you’re interested in keeping up-to-date with public health/service program announcements about activities at UConn Storrs or UConn Health Center, become a friend of Public Health@ UConn.

There is also a Learning Community in Public Health for undergraduates at Storrs campus. A recent newsletter from that group can be opened here

News, Healthy Communities: This is Public Health

Today – April 7 – is World Health Day

in addition to

National Public Health Week 2010

Image credit:  http://www.nphw.org/nphw10/home1.htm – All rights reserved – Copyright 2010

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First, two items about international community health projects:

The Comprehensive Rural Health Project (CRHP) has been working among the rural poor and marginalized [in rural Jamkhed, India] for over 37 years. By partnering with village communities and expanding upon local knowledge and resources, the project aims to effectively meet the immediate and long-term needs of these groups, especially women. With values of compassion, justice, respect and trust, CRHP works to empower people, families and communities, regardless of caste, race or religion, through integrated efforts in health and development. ”

Text Excerpt from http://www.jamkhed.org – All rights reserved – Copyright 2010

These videos (filmed in 2007) briefly describe two of the CRHP projects:

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Video credit: http://www.youtube.com – All rights reserved – Copyright 2010

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The CRHP in Jamkhed operates a 40-bed low-cost secondary care hospital providing quality emergency, medical, surgical, and outpatient care for the 1.5 million people residing in the surrounding 8 block catchment area. Each year about 20,000 outpatients receive treatment, 250 deliveries take place (high-risk referrals), and 400 surgical procedures are performed. Most deliveries take place in the village and because we provide extensive training for VHWs (village health workers) and birth attendants these deliveries are very safe. “

Text Excerpt from http://www.jamkhed.org – All rights reserved – Copyright 2010

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Video credit: http://www.youtube.com – All rights reserved – Copyright 2010

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Next:  A novel community mental health outreach program.

Data collected by staff at the U.S. Department of Veterans Affairs (VA) agency show that approximately 20% of American veterans returning from Iraq or Afghanistan are diagnosed with mental health disorders.

Dr. Karen H. Seal was lead author on a recent research study published in the Journal of Traumatic Stress (Vol. 23-1  Feb 2010) which examined how former combat veterans are being diagnosed and treated for mental health disorders within the Veteran Affairs health system including post traumatic stress disorder (for years 2002 through 2008).

The authors’ conclusions?  Only about 30% of the population studied received the recommended treatments for PTSD through the VA healthcare system.

Janie Lorber wrote an article in The New York Times (Apr 2 2010) entitled “For the Battle-Scarred, Comfort at Leash’s End”  which describes the mission and work of a non-profit foundation called Puppies Behind Bars (PBB) that selects and trains volunteer prisoners to provide 24×7 care and training for puppies chosen to become companion-service animals for disabled veterans whose mental or physical disabilities have prevented them from easing back into the practical daily challenges of civilian life.

View this video link from the New York Times website for interviews with prisoners who are now actively caring for and training service puppies. 

PBB has established canine training programs for inmates housed in six prisons in New York, New Jersey or Connecticut;  there are currently 90 animals in the program.  PBB also trains dogs to serve a very different aspect of public health and safety: detection of explosive devices.

This therapeutic community effort extends benefits to both disabled veterans and the groups of incarcerated men and women training the dogs.  The dogs look like they are enjoying themselves too.

Photo credit: http://www.newyorktimes.com – All rights reserved – Copyright 2010

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Finally: Here’s a link and calendar to special events at UConn this week that celebrate National Public Health Week 2010.

News, Health Care, Public Health, Statistics, Demographics: A Healthcare Bill and County Health Rankings

An important change in the health of current and future generations of Americans is shaping up today – March 23 2010 – as President Barack Obama signed into law the H.R. Bill #4872Health Care and Education Affordability Reconciliation 4 Act of 2010“.

A copy of the 153-page PDF version of the bill as written 3-18-2010 can be viewed here; note that this copy is only a working version.  There will likely be modifications made by legislators to the Act in the coming days and weeks. 

Link here to view a 3-page PDF document outlining the details of the “Patient Protection and Affordable Care Act“.  Many of the benefits described in this document will become effective in calendar year 2010.

Rivers of bandwidth and digital ink have been used up over this piece of legislation.  My (non-0fficial and personal) view of the events of this day is that it will be seen as a landmark day for future generations, very much like the passage of the Civil Rights Act of 1964 or the 1973 Supreme Court decision for Roe-v-Wade.  But as this isn’t a political blog, let’s move on to the topic of statistical resources about the health of Americans.

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Recently mentioned on Twitter* was County Health Rankings which offers up a valuable collection of current statistical data on the health of Americans or their access to health care, organized at a county-level by state.  This is exactly the type of local, microcosmic health measurement/outcome data that our MPH students and faculty often ask for.  Nice.

Following is an excerpt from their About page:

This web site provides access to 50 state reports, ranking each county within the 50 states according to its health outcomes and the multiple health factors that determine a county’s health.  Each county receives a summary rank for its health outcomes and health factors and also for the four different types of health  factors: health behaviors, clinical care, social and economic factors, and the physical environment. Each county can also [be]  drilled down to see specific data (as well as state bench-marks) for the measures upon which the rankings are based. “

Text Source: http://www.countyhealthrankings.org/about-project – All rights reserved – Copyright 2010


County Health Rankings is a joint project of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

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Today, starting from the main page (shown below), I clicked on the state of Pennsylvania:

Image Source: http://www.countyhealthrankings.org/ – All rights reserved – Copyright 2010

Then I used the pull-down menu to select a county in the state:  Philadelphia County (PA).  The “snapshot” of ranked data for this highly urbanized county in the south-east corner of Pennsylvania is displayed below; the numbers do not reflect favorably for the health of those residents:

Image Source: http://www.countyhealthrankings.org/ – All rights reserved – Copyright 2010

According to the health indicators ranked by County Health Rankings, Philadelphia County holds the (undesirable) distinction of the lowest score (or 67th) for the criteria measured – including “Health Factors” and “Health Behaviors”.

The data assembled on the site is not an exhaustive list of health behaviors or exposures – such as you would find on the NCHS site – but the data collected (incidence of Premature Death, Smoking Habits, Infections with Chlamydia, Births to Adolescents, Infant Mortality, etc.) serve as an approximate measure of the overall health and evidence of access to health care for that local population.

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Current statistical or demographic data as provided by County Health Rankings complements information previously made available from non-profit American foundations or organizations.

Below are only a few of the available websites that are open-access and searchable for health-related outcome measures in US populations.  If you have other great sites, please send a comment!

Image Source: http://www.statehealthfacts.org/ – All rights reserved – Copyright 2010
  • Staff from the Agency for Healthcare Research and Quality manages HCUP-NET (Healthcare Cost & Utilization Project), described as “ a free, on-line query system based on data from HCUP [which]… provides access to health statistics and information on hospital inpatient and emergency department utilization“. This page has been invaluable for answering those in-depth reference questions about hospital administration and/or patient statistics.

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Finally: Here is a link to a post I wrote in November 2009 which includes other related links to healthcare data or statistics about Americans such as Healthcare Rankings.

* And I thank the person who mentioned it on Twitter because I don’t know who did.

News, Public Health, Disease Prevention: World Cancer Day – Feb 4 2010 and a Very Special Cat

Today is World Cancer Day 2010 – Feb 4 2010

International Union Against Cancer (UICC) is the principal sponsor for World Cancer Day and is responsible for organizing the annual World Cancer Campaign and World Cancer Summit (held every two years).

The theme for the 2010 campaign is “Cancer can be prevented too”.  The public health message promotes practical lifestyle choices or modifications to lower the risk of  developing cancer, such as avoiding tobacco use, limiting alcohol consumption or exposure to the sun’s rays (or tanning booths), maintaining a healthy weight and take preventative measures against cancer-causing infections.

World Cancer Day began in 2006, and is held every year on Feb 4th.

Here are some additional facts about the International Union Against Cancer (UICC), from their “About” page:

In 1933, cancer researchers recognized the need to share knowledge and expertise globally and so founded the International Union Against Cancer (UICC). Since then, UICC has grown to embrace organizations engaged in all aspects of cancer prevention and control: voluntary cancer societies, research and treatment centres, public health authorities, patient support networks andadvocacy groups, and ministries of health “.

UICC works closely with the World Health Organization (WHO), the International Agency for Research on Cancer (IARC), and the Programme of Action for Cancer Therapy (PACT), and has consultative status with the UN Economic and Social Council. It offers corporate partners a unique opportunity to demonstrate social responsibility on a global scale. Every two years, UICC brings together key stakeholders in a World Cancer Summit. ”

Text Source: http://www.uicc.org/ – All rights reserved – Copyright 2010

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It probably isn’t correct to say that any cat has a “mission” in life… other than eating, looking for tuna, seeking out sunny spots, sleeping, batting balls around or searching for insects to chew on.  But anyone who has ever lived with a feline knows how comforting a warm, purring cat can be in times of trouble or stress.

This month, the press has picked up on the story of one spotted cat from Providence, RI  that does seem to have a purpose and meaning in his behaviors, as documented by David Dosa, MD.

Dr. Dosa is an associate professor of medicine at Brown University and a gerontologist at Steere House Nursing & Rehabilitation Center in Providence. Oscar is a therapy cat and lives at the facility on the third floor where there is a 41-bed unit for patients with dementia. The staff has noticed that, over time, Oscar has purposely chosen to enter rooms  of patients who are near death and will stay with them until they’ve passed on.

The doctor has written a book about the cat, entitled “Making Rounds with Oscar: The Extraordinary Gift of An Ordinary Cat” which was published by Hyperion Books on Feb 2 2010.  Earlier, an essay he wrote about the cat was published the New England Journal of Medicine in July 2007.

In the Medical Subject Headings List (MeSH) I found that the term “animal assisted therapy” was added to PubMed only recently (in 2010).  Link here to a group of recent citations found on Medline about therapeutic human-animal relationships.

Reporters from The Providence Journal visited with Dr. Dosa and Oscar recently, and the video link is here (Jan 31 2010). Some of the other news videos about this story are regrettably sensationalistic, even calling him the furry “angel of death” or other silly stuff.

And today, I learned that Oscar now has a Facebook page!


Public Health, Health Infrastructure, Humanitarian Aid: Health Crisis in Haiti

The recent major earthquake in the capital city of Port-au-Prince, Haiti on Jan 12 2010 has been a catastrophic and life-altering event for those living there.  The death toll climbed this week to an estimated 200,000 people.  For world leaders (and regular citizens), viewing the news reporting and photos from afar, the downtown area resembles a post-nuclear landscape.  Thankfully, many millions of people worldwide have donated monies toward the relief effort currently gearing up for their aid.

Watching the grim news from this poor Caribbean country unfold,  it seems unfortunately predictable as a sober demonstration of what happens when a government does (next to) nothing for a few days after a major catastrophe.  “No one” was in charge of managing the after-effects of this disaster.  Bodies piled up in the streets, people trapped under rubble – and whom might have lived had they been pulled away from the buildings which collapsed around them – were not rescued, roads are not cleared, the government was not visible. The infrastructure failed.

Injured people waited in pain and fear for help which only began to arrive on Friday, Jan 15th.   Those folks lucky enough to walk out of fallen buildings with non life-threatening injuries – an estimated 1.1 million people survived the Jan 12th quake in Port-Au-Prince – are now homeless.  Growing civil unrest is gaining hold.

This is the second wave of their public health emergency.

The public health infrastructure in Haiti was thin to begin with, but now with the city’s port severely damaged, roads blocked by fallen debris, scant fuel supplies, no functional communication networks and a lack of coordination among international aid agencies, newly-arrived emergency health personnel* and security forces ready to distribute aid are hard-pressed to get it quickly to those most in need.

An NPR reporter on the ground on Sunday Jan 17 was quoted as saying: “Money means little here right now.  People are dying from exposure, lack of drinking water and from injuries which are now infected… the stench of death and raw sewage is everywhere“.  Age-old scourges – communicable diseases (measles, meningitis, tetanus or malaria),  secondary infections (such as gangrene) from untreated traumatic injuries, dehydration, psychological shock, lack of food or medicine and rising criminal activities by a few – will be working against those survivors who have been literally camped out, sleeping on the ground for six nights. Click here to read an article dated Jan 17 2010 about a field hospital in Port-au-Prince, where Sanjay Gupta, physician and medical correspondent for CNN, stayed to treat patients after Belgian health personnel left due to security threats.

In most places, the infrastructure works (until it does not). So much about public health is essential yet unglamorous, addressing basic human needs: adequate and safe food, clean water, shelter from the elements, a means of earning a living, sewage and waste management, knowledge of basic healthcare practices, and the means to implement them, a chance for an education, safety from danger or interpersonal violence, peace of mind if possible.

There will be little of that (peace of mind, that is) on the island of Haiti in the near-term, but as one of of the many Haitian politicians interviewed on a news programs stated last week: “Maybe now we can rebuild a new Haiti”.

That would be a great public health opportunity for the citizens of this devastated country.

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* One charitable international volunteer agency, Medicins sans Frontiere, filed this report on Jan 19 2010 regarding the work of their medical staff(s) in Port-au-Prince.

** Link here to an assortment of non-profit international agencies coordinating aid to the population in Haiti, collected by Google.

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Addendum #1: On the morning of Jan 20 2010, a second earthquake of 6.1 magnitude struck near Port-au-Prince.  Read a brief report about this new quake from the U.S. Geological Survey.

Addendum #2: On Thurs Jan 21, this entry was added:  Dr. Robert Fuller, director of Emergency Medicine at UCHC, is currently in Haiti as a volunteer physician for International Medical Corps. Dr. Fuller spoke with with CNN reporter Wolf Blitzen on Jan 19 2010 about the medical rescue efforts in Port au Prince (link here for video).