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PubMed2000

Innovations in the nursing care of the chronically ill: a literature review from an international perspective.

This literature review focuses on substitution-related innovations in the nursing care of chronic patients in six western industrialized countries. Differences between primary and secondary care-orientated countries in the kind of innovations implemented are discussed. Health care systems are increasingly being confronted with chronic patients who need complex interventions tailored to their individual needs. However, it seems that today's health care professionals, organizations and budgets are not sufficiently prepared to provide this kind of care. As a result, health care policy in many countries targets innovations which reduce health care costs and, at the same time, improve the quality of care. Frequently, these innovations are related directly to the 'substitution of care' phenomenon, in which care is provided by the most appropriate professional at the lowest cost level, and encompass advanced nursing practice, hospital-at-home care and integrated care. The main conclusion of this paper is that integrated care innovations are implemented in both primary care as well as in secondary care-orientated countries. However, innovations in hospital-at-home care and advanced nursing practice are primarily implemented in primary care-orientated countries. Whether these innovations positively influence the quality of care, costs of care or patients' use of health care facilities remains rather unclear.

Canada↗

PubMed2000

Self-monitoring in Type 2 diabetes mellitus: a meta-analysis.

AIMS: Self-monitoring of blood or urine glucose is widely used by subjects with Type 2 diabetes mellitus. This study evaluated the effectiveness of the technique at improving blood glucose control through a systematic review and meta-analysis. METHODS: Randomized controlled trials were identified that compared the effects of blood or urine glucose monitoring with no self-monitoring, or blood glucose self-monitoring with urine glucose self-monitoring, on glycated haemoglobin as primary outcome in Type 2 diabetes. RESULTS: Eight reports were identified. These were rated for quality and data were abstracted. The mean (SD) quality score was 15.0 (1.69) on a scale ranging from 0 to 28. No study had sufficient power to detect differences in glycated haemoglobin (GHb) of less than 0.5%. One study was excluded because it was a cluster randomized trial of a complex intervention and one because fructosamine was used as the outcome measure. A meta-analysis was performed using data from four studies that compared blood or urine monitoring with no regular monitoring. The estimated reduction in GHb from monitoring was -0.25% (95% confidence interval -0.61 to 0.10%). Three studies that compared blood glucose monitoring with urine glucose monitoring were also combined. The estimated reduction in GHb from monitoring blood glucose rather than urine glucose was -0.03% (-0.52 to 0.47%). CONCLUSIONS: The results do not provide evidence for clinical effectiveness of an item of care with appreciable costs. Further work is needed to evaluate self-monitoring so that resources for diabetes care can be used more efficiently.

Blood Glucose Self-Monitoring↗

PubMed2003

[Locking plate osteosynthesis for fractures of the proximal humerus].

BACKGROUND: Beside non-operative treatment the therapeutic options for proximal fractures of the humerus range from closed reduction and transcutaneous K-wiring to total joint replacement. While the first is regarded as minimally invasive the latter is a rather complex intervention. Plating has been disregarded as combining the disadvantages of an extended approach with too often insufficient primary postoperative stability. The new concept of completely angle stabile plate fixation aims on improving this balance by achieving greater stability even in osteoporotic fractures. STUDY DESIGN: This retrospective analysis compares 51 patients treated with a partially (39) or complete (12) angle stabile humeral plate (Königseeplatte in two modifications) with 32 patients treated according to surgeons preference with conventional plates or K-wires. Both groups were treated at the same department during the same period and did not differ in their age nor sex distribution. RESULTS: Until discharge there were 2 secondary dislocations discovered in group 1 and 7 in group 2. The follow-up rate was 47.1 % (24/51) in group 1 and 46.8 % (15/32) in group 2. The time interval from surgery amounted to 1.2 (0.66-1.75) and 1.0 (0.72-1.32) years respectively. Among the patients available for follow-up in group 1 8 had sustained a two-, 8 a three- and 3 a four-part fracture according to Neer's classification. In group two there were accordingly 2 two-, 8 three- and 1 four part fractures. Clinical assessment using Neer's score revealed an average of 71,8 (63.9-79.8) points in group 1 and 67.6 (47.3-78.7) in group 2. When the results of Neer's scores were expressed in percentage of the unaffected arm a mean of 73.6 (65.6-81.8) in group 1 and 69.3 (51.8-86.9) was obtained. The only statistically significant difference was observed within the sub-group of three-part fractures: treated by angle stabile plates (group 1) these patients (n = 8) achieved a mean Neer-Score of 81 (77-86) compared to 68 (52-84) (n = 8). In group 1 70.8 % of patients followed-up presented an "excellent" or "good" result according to Neer's criteria, in group 2 60 % did so. CONCLUSION: We conclude from our first experience with angle stabile plates for fractures of the proximal humerus that particularly in three part fractures this method might improve functional outcome and is worth further consideration and testing.

Aged↗

PubMed1996

Skull base allergic fungal sinusitis with abducens palsy in the third trimester.

Allergic fungal sinusitis (AFS) usually follows a slow course, but bone erosion including that of the skull base can be seen. Patients may present with intracranial extension mimicking a cranial base neoplasm. We describe a 21-year-old pregnant female initially seen at 27 weeks gestation with a complete right sixth nerve paralysis. MR imaging showed an apparent nasopharyngeal neoplasm invading both temporal lobes. Further evaluation revealed typical findings of fungal sinusitis on both CT and MR images. Biopsy results fulfilled the diagnostic criteria of AFS, and after endoscopic treatment the sixth nerve palsy quickly resolved. Although abducens palsy has been reported with acute bacterial sinusitis and with mucocele, and limitation of eye motility has been described with orbital involvement by AFS, we are unaware of any prior reports of true cranial nerve palsy associated with proven AFS. Our patient had no evidence of mucocele or of bacterial infection. The palsy in this case was presumably the result of compression of the cavernous sinus. The patient's pregnancy made decision making regarding imaging and surgical intervention complex. Mother and child are alive and well 31 months after surgery.

Case Reports↗

PubMed2006

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review.

REVIEW DATE: Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. SEARCH STRATEGY: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. CRITERIA DEFINITIONS EXPERIENCE: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. EXCLUSIONS: Not empirical; not early; post-basic; simulated rather than 'authentic' experience. DATA COLLECTION: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. HEADLINE RESULTS: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. CONCLUSIONS: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Attitude of Health Personnel↗

PubMed2004

Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden.

This study investigates attitudes toward androgenic anabolic steroids among male adolescents who have used anabolics compared with those who have not. A cross-sectional survey was performed in the year 2000 in all secondary schools in the county of Halland on the west coast of Sweden. An anonymous multiple-choice questionnaire was distributed to all classes with 14-, 16-, and 18-year-old male adolescents. The response rate was 92.7% (n=4049). Those who admitted having used androgenic anabolic steroids differed in several ways from those who had not. Fewer believed androgenic anabolic steroids to be harmful (OR=0.15, 95% CI 0.08-0.30) and more believed that girls preferred boys with large muscles (OR=6.1, 95% CI 3.4-11.0). They trained more often at gyms (OR=5.6, 95% CI 3.0-10.6), drank more alcohol (OR=4.2, 95% CI 2.0-9.1), and had used narcotic drugs more often (OR=15.3, 95% CI 8.5-27.5) than the other male adolescents. More immigrants than native-born adolescents had used anabolics (OR=4.2, 95% CI 2.2-7.9). Attitudes toward anabolics differ between users and nonusers. These aspects may be beneficial to focus on as one part of a more complex intervention program in order to change these attitudes and decrease the misuse of androgenic anabolic steroids.

Adolescent↗

PubMed2005

Attitudes and behaviors with regards to androgenic anabolic steroids among male adolescents in a county of Sweden.

AIMS: The aim of this study was to investigate attitudes towards androgenic anabolic steroids among male adolescents who have used anabolics compared to those who have not. DESIGN AND SETTING: A cross-sectional survey was performed in the year 2000 in all secondary schools in the county of Halland on the west coast of Sweden. PARTICIPANTS AND MEASUREMENTS: An anonymous multiple-choice questionnaire was distributed to all classes with 14-, 16-, and 18-year-old male adolescents. The response rate was 92.7% (n=4049). FINDINGS: Those who admitted having used androgenic anabolic steroids differed in several ways from those who had not. Fewer believed androgenic anabolic steroids to be harmful [odds ratio (OR) = 0.15, 95% CI 0.08-0.30] and more believed that girls preferred boys with large muscles (OR = 6.1, 95% CI 3.4-11.0). They trained more often at gyms (OR = 5.6, 95% CI 3.0-10.6), drank more alcohol (OR = 4.2, 95% CI 2.0-9.1), and had used narcotic drugs more often (OR = 15.3, 95% CI 8.5-27.5) than the other male adolescents. More immigrants than native-born adolescents had used anabolics (OR = 4.2, 95% CI 2.2-7.9). CONCLUSION: Attitudes towards anabolics differ between users and nonusers. These aspects may be beneficial to focus on as one part of a more complex intervention program in order to change these attitudes and decrease the misuse of androgenic anabolic steroids.

Adolescent↗

PubMed1999

Methicillin-resistant Staphylococcus aureus and antimicrobial use in Belgian hospitals.

OBJECTIVE: To investigate relationships between the incidence of methicillin-resistant Staphylococcus aureus (MRSA) and the use of different classes of antimicrobials in Belgian hospitals. DESIGN: Using Pearson correlation coefficients, the number of new nosocomial MRSA-colonized or -infected patients in the second half of 1994 and the first half of 1995 reported by the national MRSA surveillance program was compared with use of various antimicrobial classes as reported by the National Institute for Sickness and Disability Insurance. Relationships between different classes of antimicrobials were evaluated in a correlation matrix. MRSA incidence, antimicrobial use, and potential confounding factors were included in a multiple linear regression analysis. SETTING: 50 hospitals in Belgium. RESULTS: The use of a number of different classes of antimicrobials was interrelated. In the multivariate analysis, the incidence of nosocomial MRSA increased with increasing use of ceftazidime and cefsulodin (P=.0003), amoxicillin with clavulanic acid (P=.02), and quinolones (P=.005). No association was found between MRSA incidence and total antimicrobial use. CONCLUSIONS: The relationships between antimicrobial use and MRSA are complex. Interventions aimed at promoting more rational prescribing patterns should be supported by adequate experimental and epidemiological evidence. Advice for preventing and controlling MRSA has focused mainly on hygienic measures and precautions to avoid cross-transmission; the role of relieving antimicrobial pressure needs to be clarified.

Anti-Bacterial Agents↗

PubMed2006

Beyond needling--therapeutic processes in acupuncture care: a qualitative study nested within a low-back pain trial.

BACKGROUND: In the medical and scientific literature, there is a dearth of reports about how acupuncturists work and deliver care in practice. An informed characterization of the treatment process is needed to support the appropriate design of evaluative studies in acupuncture. METHODS: The design was that of a nested qualitative study within a pragmatic clinical trial. Six acupuncturists who treated up to 25 patients each were interviewed after the treatment phase of the trial to obtain an account of their experiences of providing acupuncture care to patients with low back pain referred by their GP. Using semistructured interviews and a topic guide, data were collected and analyzed for both a priori and emergent themes. This paper focuses on practitioners' accounts of the goals and processes of care, and describes the strategies employed in addition to needling and other hands-on treatments. RESULTS: From the interview data, it is clear that a coherent body of theoretical knowledge informed clinical decisions and practice, and that the goals of treatment went beyond the alleviation of immediate pain-related symptoms. Acupuncturists in this study all described a pattern of patient-centered care based on a therapeutic partnership. Study participants confirmed the importance of three processes that characterized acupuncture care in this trial, each contributing to the goal of a positive long-term outcome; building a therapeutic relationship; individualizing care; and facilitating the active engagement of patients in their own recovery. Acupuncturists described elements of care that characterized these processes including establishing rapport, facilitating communication throughout the period of care, using an interactive diagnostic process, matching treatment to the individual patient, and the use of explanatory models from Chinese medicine to aid the development of a shared understanding of the patient's condition and to motivate lifestyle changes that reinforce the potential for a recovery of health. Acupuncturists did not view these therapeutic goals, processes, and strategies as a departure from their usual practice. CONCLUSIONS: This study suggests that acupuncture care for patients with chronic conditions such as low back pain is likely to be a complex intervention that utilizes a number of patient-centered strategies to elicit longterm therapeutic benefits. Research designed to evaluate the effectiveness of acupuncture as it is practiced in the UK needs to accommodate the full range of therapeutic goals and related treatment processes.

Acupuncture↗

PubMed2004

The North Dublin randomized controlled trial of structured diabetes shared care.

BACKGROUND: A new diabetes shared care service was introduced in North Dublin. It was designed as a randomized controlled trial with a complex intervention comprising education of participating practitioners, the introduction of a community-based diabetes nurse specialist, local agreement on clinical protocols and structured communication across the primary-secondary care interface. OBJECTIVES: Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care. METHODS: A Cluster randomized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practices in North Dublin. Biophysical outcomes (HbA1c, blood pressure, body mass index), psychosocial measures (smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores) and process outcomes were collected. RESULTS: There were significant improvements in diabetes care delivery and in psychosocial outcomes, but no significant improvements in biomedical outcomes. Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual reviews and fewer patients defaulting from care. There were also significant improvements in information exchange between primary and secondary care. CONCLUSION: Structured diabetes shared care, in a mixed health care system, can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients, with improved information exchange across the primary-secondary care interface.

Adult↗

PubMed1998

A randomized controlled trial of the effect of naproxen on delayed onset muscle soreness and muscle strength.

OBJECTIVE: To determine the effect of naproxen in attenuating the symptoms (muscle soreness level) and signs (plasma creatine kinase [CK] activity and muscular strength decrement) of delayed onset muscle soreness (DOMS) induced by repeated bouts of eccentric exercise. DESIGN: The design was a randomized, double-blind, placebo-controlled, crossover trial with two testing phases of 8 days' duration that were separated by a "washout" period of 7 days. SETTING: University-based sports science center. PARTICIPANTS: Twenty healthy male volunteers who responded to a notice in the university's athletic complex. INTERVENTIONS: Eccentric single-leg exercises were performed on days 1, 3, and 4 to induce DOMS in the quadriceps muscles. Naproxen or placebo tablets (500 mg) were taken orally twice per day beginning on day 2 and continuing until the end of the testing phase. MAIN OUTCOME MEASURES: Perception of muscle soreness and knee extensor torque were evaluated daily throughout each phase. Plasma CK levels were evaluated on days 1, 3, 6, and 8 of each phase. RESULTS: After the eccentric exercise, plasma CK levels were similarly elevated in both naproxen and placebo conditions (F=1.42; p=0.25). After DOMS developed, naproxen reduced the perception of soreness on day 3, when muscle soreness was highest (F=2.20; p=0.04). After treatments with naproxen, peak quadriceps torque during leg extension at 60 degrees/s was higher than that after treatment with the placebo (F=4.77; p=0.04). There were no significant differences between the naproxen and placebo conditions for leg extension at 180 degrees/s (F= 1.66; p=0.21) and 300 degrees/s (F=0.71; p=0.41). CONCLUSION: The data indicate that therapeutic doses of naproxen do not prevent CK release into the plasma but decrease the perception of muscle soreness and positively influence quadriceps peak torque.

Adult↗

PubMed2004

Sustainability and effectiveness of comprehensive diabetes care to a district population.

AIMS: To evaluate whether diabetes care in a district population can be sustained over time and intensive management of multiple risk factors can be achieved against a background of rising prevalence of known diabetes and shift of responsibility towards primary care. METHODS: Assessment of process and outcome measures achieved by a comprehensive diabetes service. Routine data were collected from patients registered with diabetes in a district population by repeated cross-sectional survey in 1991 (n = 2284 patients) and 2001 (n = 5809 patients). RESULTS: Between 1991 and 2001 the recording of body mass index (76.8 vs. 71.3%, P = 0.01) and HbA(1c) measurement (92.2 vs. 86.4%, P < 0.001) decreased, whereas recording of smoking status (72.4 vs. 82%, P < 0.001), cholesterol level (54.7 vs. 82.5%, P < 0.001) and eye screening result (86.1 vs. 91.3%, P < 0.001) improved. Surviving patients with Type 2 diabetes had significant improvements in systolic blood pressure, diastolic blood pressure and cholesterol, significant deterioration in HbA(1c) and creatinine, and no change in body mass index. Changes in blood pressure and HbA(1c) over time were similar to those reported in the UKPDS. CONCLUSIONS: The delivery of processes and outcomes of care to a district population can be sustained at a high level over a 10-year period within a comprehensive diabetes service. We would suggest that a multifaceted complex intervention is required to achieve these results.

Adult↗

PubMed2005

Acute obstetric emergency drill in England and Wales: a survey of practice.

Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.

Clinical Competence↗

PubMed2006

A systematic review of the effects of home blood pressure monitoring on medication adherence.

Home blood pressure monitoring (HBPM) improves blood pressure control, but little is known about its effects on medication adherence. The authors conducted a systematic review of the published literature on the effects of HBPM on medication adherence. Of 440 abstracts and citations reviewed, 11 randomized control trials met predefined criteria. Six of the 11 randomized controlled trials reported statistically significant improvement in medication adherence; 84% of these were complex interventions involving the use of HBPM in combination with other adherence-enhancing strategies such as patient counseling by nurses, pharmacists, or a telephone-linked system; patient education; and the use of timed medication reminders. Interventions conducted in primary care settings were not effective compared with those that occurred in hospital-based clinics or nonclinical settings. The data on the effects of HBPM on patients' medication-taking behavior are mixed. Future studies should investigate the independent effects of HBPM in primary care practices where the majority of hypertensive patients receive their care.

Antihypertensive Agents↗

PubMed1995

A comparative study of selected patient variables as risk factors in hospitalization for chronic headache.

Patients seeking relief for chronic headache at specialized headache treatment centers are offered a multidisciplinary approach to treating their disorder. Neurologists, who specialize in headache, offer both inhospital and outpatient treatment programs. Clinicians and researchers experienced in headache disorders have advocated inpatient treatment for certain patients. Hospital programs address such issues as elevated anxiety and depression levels, overuse of analgesics, and related factors. This study was undertaken to investigate those differences, long observed by clinicians, between patients assigned to inpatient or outpatient care or to both. In view of the ever-tightening purse strings of third-party payers, the results may aid in delineating some of the forthcoming practice guidelines for dealing with headache sufferers. This study suggests: (a) significant differences do exist between the groups, (b) hospitalized patients may indeed require more complex interventions than those managed with outpatient care, and (c) documenting some of the etiologic factors that predict hospitalization may help alert providers at the front end and preclude some of the current need for hospital care.

Adolescent↗

PubMed1992

Prevalence of hepatitis B surface antigen, hepatitis C antibody, and HIV-1 antibody among residents of a long-term-care facility.

OBJECTIVE: To determine the prevalence of hepatitis B antigen (HBsAg), antibody to hepatitis C virus (anti-HCV), and antibody to human immunodeficiency virus (anti-HIV) among residents of a long-term care facility. DESIGN: Anonymous unlinked serosurvey. SETTING: Accredited university-affiliated long-term-care facility in Toronto with 300 chronic-care hospital patients, 350 nursing home residents, and 200 residents of a senior citizens' apartment complex. INTERVENTIONS: Sera from left-over blood samples obtained from residents in November 1990 were tested for HBsAg, anti-HCV, and anti-HIV using standard methods. RESULTS: A total of 508 sera were tested. The number (%) positive for HBsAg, anti-HCV, and anti-HIV, respectively were: 3(0.6%), 7(1.4%), and 0(0%). CONCLUSIONS: This is the first report defining rates of infection with bloodborne infective agents among residents of a long-term care facility. These results support the use of hepatitis B vaccine for medical and nursing staff and the implementation of universal precautions in long-term care facilities.

Aged↗

PubMed1994

Management of the arterial puncture site.

With more complex interventional procedures, such as intracoronary stent placement, there is a higher incidence of procedural related peripheral vascular complications including pseudoaneurysm and hemorrhage. In these procedures, the amount of anticoagulation as well as the use of thrombolytic agents intraprocedurally increases the risk of complication. Meticulous care during vascular access, careful use and monitoring of anticoagulation, and patient selection are helpful in reducing the risk. Newer vascular hemostatic devices utilizing biodegradable collagen plugs might be of advantage since they allow early sheath removal without interrupting anticoagulation and, therefore, early ambulation. However, it remains to be determined, whether these devices are effective in reducing complications, duration of bed rest and hospitalization, or improvement of stent patency. Newer designs, e.g., coated or biodegradable stents, or different deployment strategies might reduce the need of anticoagulation and lower the risk of peripheral vascular complications.

Anticoagulants↗

PubMed2000

The effective use of enactments in family therapy: a discovery-oriented process study.

In this investigation we examine the elements of enactments--in-session dialogues used to observe and modify family interactions in structural family therapy. Twenty-one videotaped segments of 18 therapy sessions with different families were used to compile detailed descriptions of therapist techniques and client responses. Enactments were analyzed as consisting of three distinct phases--initiation, facilitation, and closing--each of which required more numerous and complex interventions than are usually described in the clinical literature. Judges were able to reliably describe therapist interventions that led to successful enactments as well as what therapists did or failed to do that led to unproductive outcomes. Clinical implications of these findings are discussed.

Conflict, Psychological↗