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PubMed2006

The principles and processes of inspiring hope in bereavement counselling: a modified grounded theory study--part two.

This second part of a two-part paper attempts to answer the question: do bereavement counsellors inspire hope in their clients and if so, how? Using a modified grounded theory method data were collected by means of semi-structured interviews; undertaken with a theoretical sample of bereavement counsellors and ex-clients who had received bereavement counselling. In keeping with the tenets of grounded theory, the data were coded and analysed using the constant comparison method, and this produced an emerging, substantive theory of the principles and processes of hope inspiration for this client group. This theory is comprised of a core variable: the implicit projection of hope and hopefulness, and three sub-core variables: forging the connection and the relationship; facilitating a cathartic release; and experiencing a healthy (good) ending. Part one of this paper included a review of the literature and focused on stage one. Part two on the other hand, focuses on stages two and three, and highlights the categories therein. The paper concludes by highlighting implications arising from the findings (other discussion points have been published elsewhere).

Attitude of Health Personnel↗

PubMed2026

Access to palliative care in rural settings: A mixed-methods systematic review.

BACKGROUND: Rural populations experience persistent inequities in access to palliative care. Existing evidence often describes individual barriers separately, with less attention to how access breaks down across the care pathway or how different service configurations shape access. OBJECTIVES: To synthesise evidence on access to palliative care in rural settings and examine how access barriers, service models, and implementation conditions interact across the care pathway. METHODS: A mixed-methods systematic review using a convergent integrated approach searched nine databases (PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO, CNKI, WanFang, SinoMed) from inception to 15 March 2026, supplemented by hand-searching. Eligible studies were primary qualitative, quantitative, and mixed-methods studies on access to palliative care for adults in rural or non-urban settings. Two reviewers independently screened studies, extracted data, and assessed quality using the Mixed Methods Appraisal Tool. Findings were mapped to the Levesque access framework, analysed using the updated Consolidated Framework for Implementation Research, and integrated through mixed-methods synthesis, with additional coding of service models. RESULTS: Thirty-four studies were included, of which 26 were conducted in high-income countries and eight in low- and middle-income countries. Service configurations included specialist or hospice-oriented care, generalist or primary-care-oriented care, mixed specialist-generalist models, home-based and caregiver-centred care, nurse-coordinated services, telehealth-supported care, and community or implementation-oriented approaches. Access broke down cumulatively across four interdependent stages: recognition, entry, reach, and use and continuity, with affordability constraining every stage. Recognition was limited by low awareness, poor service visibility, and delayed identification of need. Entry was shaped by stigma, trust, family expectations, and unclear referral processes. Reach was constrained by distance, transport, workforce shortages, limited specialist capacity, and weak infrastructure. Use and continuity were affected by fragmented coordination, weak transitions, unstable follow-up, and reliance on family caregivers. Access problems varied across service configurations. Evidence on service innovations was methodologically less certain, and the overall evidence base remained concentrated in high-income countries. CONCLUSIONS: Access to palliative care in rural settings is best understood as a pathway and service-configuration problem rather than simply a deficit in service availability. Improving access requires earlier recognition, clearer referral routes, stronger specialist-generalist and nursing links, better support for family caregivers, and greater attention to affordability, continuity, and rural settings with limited resources. REGISTRATION: International Prospective Register of Systematic Reviews: CRD420261340783.

Health Services Accessibility↗

PubMed2001

Organization and developmental expression of the mosquito vitellogenin receptor gene.

Vitellogenin is a precursor of the major yolk protein, vitellin. It is internalized by developing oocytes via receptor-mediated endocytosis. Previously, we characterized the vitellogenin receptor (VgR) from oocytes of the mosquito Aedes aegypti [Sappington, T.W., Kokoza,V.A., Cho,W.L. and Raikhel,A.S. (1996) Molecular characterization of the mosquito vitellogenin receptor reveals unexpected high homology to the Drosophila yolk protein receptor. Proc Natl Acad Sci USA 93: 8934-8939]. The VgR receptor has a unique structure with two putative ligand-binding domains. In order to understand the regulation of this important molecule, we characterized the VgR gene structure and its expression during vitellogenesis in the mosquito A. aegypti. We report here that the VgR gene was separated by five introns that have an average length of 60 bp, except for the second intron which was more than 20 kb long. Most introns were located within the coding regions of the first protein domain. We isolated two allelic variations of the VgR gene, VgR1 and VgR2, the nucleotide sequences of which differing only in their 5'-flanking regions. Considering their frequency in the mosquito genome, VgR2 appeared to be a major allele. The expression of VgR mRNA was studied by the Northern blot analysis and in situ hybridization. The level of the VgR transcript started to rise in the ovary one day post-eclosion. It continued its dramatic rise during the vitellogenic period, reaching its peak at 24 h PBM. The VgR transcript was present exclusively in ovaries where it was seen in oocytes and nurse cells of primary follicles and germ-line cells of the germarium.

Aedes↗

PubMed2002

Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons.

OBJECTIVE: To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height. METHODS: A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March 2001. Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians. RESULTS: Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twenty-one primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture. CONCLUSIONS: Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture.

Aged↗

PubMed2001

Forced externalization of control in people with diabetes: a qualitative exploratory study.

AIM: The purpose of this study was to explore and describe the patients' perceptions of the Diabetic Disease State and its complications using an ethnographic method. BACKGROUND: Diabetes mellitus is an extensively researched and studied disease, however, relatively little attention has been given to the lived experience of chronic illness. METHODS: A purposive sample of 18 people with diabetes was derived from a diabetes register database. Data were collected by semistructured interviews, which were tape-recorded and transcribed. The transcripts were analysed together with the researchers' observational notes, using open coding procedures to identify main categories. Discussion of the results is made in the theoretical context of the locus of control (LOC) framework. FINDINGS: Three main categories emerged from the data: information-knowledge of illness; the psychological burden of diabetes; rationalizing. A further subcategory, reality avoidance, was identified. The findings showed that these people with diabetes experience and describe complex psychological effects and coping mechanisms in having a chronic illness. CONCLUSIONS: The findings also suggested that participants in this study might have felt that the control of their chronic condition had been externalized to the health care professionals responsible for their care.

Adaptation, Psychological↗

PubMed1994

Provisional practice: the nature of psychosocial bone marrow transplant nursing.

PURPOSE/OBJECTIVE: To develop an empirically based description of the key concepts guiding psychosocial nursing practice for the patient undergoing bone marrow transplantation (BMT). DESIGN: Retrospective, descriptive. SETTING: National Cancer Institute-designated comprehensive cancer center. SAMPLE: Medical records of 23 adults (11 males, 12 females; X age = 33 years) who have undergone BMT. METHODS: All psychosocial-related charting was extracted manually from the subjects' medical records and nursing care plans. Text was analyzed for content, coded, and sorted into 42 categories. The investigators wrote category definitions. MAIN RESEARCH VARIABLES: All present and past psychosocial problems that had been identified; psychosocial assessment; psychosocial-related admission and discharge teaching; and references to pain and sleep disturbances that included or implied psychosocial overlay. FINDINGS: Thematic categories were present in each of five core concepts: discovering the lived reality, managing the flow, emerging awareness, keeping watch, and behind closed doors. Synthesis of these concepts led to one encompassing concept--the provisional nature of psychosocial BMT nursing practice. CONCLUSIONS: The results provide empirical evidence that five key concepts exist within psychosocial BMT nursing and can be applied to a new paradigm of nursing care. IMPLICATIONS FOR NURSING PRACTICE: Provisional practice, as a new paradigm, requires further development. The five concepts derived from this study provide a useful framework for delineating significant psychosocial needs of patients and families and for designing tailored nursing therapeutics. The study suggests that preparation for practicing BMT nursing should include education in specific psychosocial strategies, documentation, and coping with the personal implications of practice in this setting. The study raises important issues in psychosocial care requiring further clarification and elucidation. These center around the nature of uncertainty, caring, and social support in BMT.

Adaptation, Psychological↗

PubMed2006

Cost of cardiovascular diseases in the United Kingdom.

OBJECTIVE: To estimate the economic burden of cardiovascular disease (CVD) in the United Kingdom, including health and non-healthcare costs, and the proportion of total CVD cost due to coronary heart disease (CHD) and cerebrovascular disease. DESIGN AND SETTING: Prevalence-based approach to assess CVD-related costs from a societal perspective. PATIENTS: All UK residents in 2004 with CVD (International classification of diseases, 10th revision (ICD-10) codes I00-I99) and subgroups with CHD (ICD-10 codes I20-I25) or cerebrovascular disease (ICD-10 codes I60-I69). MAIN OUTCOME MEASURES: Healthcare costs were estimated from expenditure on community health and social services, accident and emergency care, hospital care, rehabilitation and drugs. Non-healthcare costs were estimated from data on informal care and from productivity losses arising from morbidity and premature death. RESULTS: CVD cost the UK economy 29.1 billion pound in 2004, with CHD and cerebrovascular disease accounting for 29% (8.5 billion pound) and 27% (8.0 billion pound) of the total, respectively. The major cost component of CVD was health care, which accounted for 60% of the cost, followed by productivity losses due to mortality and morbidity, accounting for 23%, with the remaining 17% due to informal care-related costs. CONCLUSIONS: CVD is a leading public health problem in the UK measured by the economic burden of disease. This study identified the size and main components of that burden, and will help to inform decisions about research priorities and to monitor the impact of policy initiatives.

Absenteeism↗

PubMedDate not supplied

Dimensions of women's long-term postabortion experience.

PURPOSE: To explore and describe the long-term postabortion experience as lived by women, at least 5 years after a first-trimester-induced abortion. METHODS: This phenomenological study used semistructured interviews and constant-comparison analysis. Stories of 17 women were recorded on audio tape, transcribed verbatim, coded, and analyzed. RESULTS: Women who had induced abortions represented several ethnic groups, religions, and occupations, and were single, married, or divorced. The average number of years from abortion to interview was 18.9 (range 6-31 years). The age range at first abortion was 14 to 43, and at interview was 23 to 60 years of age. Five themes emerged within the women's stories: Making the Decision, Coping With the Memories, Gaining Perspective, Seeking Help, and Recognizing Its Worth. Most women who participated in this study were able to integrate the abortion experience into their lives, and had found meaning in the abortion experience. CLINICAL IMPLICATIONS: This study provides yet more reasons why nursing should encourage women to prevent unplanned pregnancies through fertility control. Women in this study described many life-changing experiences, both positive and negative, because of an abortion. Therefore, preabortion counseling should be sensitive and include information about possible long-term effects. Postabortion support should acknowledge spiritual issues, and include steps women can take to help heal themselves, such as grief counseling and mourning rituals when appropriate.

Abortion, Induced↗

PubMed2003

Managers see the problems associated with coding clinical data as a technical issue whilst clinicians also see cultural barriers.

OBJECTIVE: In UK general practice, the coding of clinical data (Read Coding) is far from universal. This study set out to examine the barriers to recording structured information in computerised medical records; and to explore whether managers and clinicians had different perspectives in how these barriers should be overcome. METHOD: A qualitative study, using semi-structured interviews of general practitioners, primary care nurses and practice managers. The interviews were recorded verbatim, and then underwent thematic analysis; additional interviews were conducted until thematic saturation was achieved. RESULTS: For clinicians the recording of structured data within a consultation is not a neutral activity, they are highly aware of diagnostic uncertainty and sensitive to the potential impact of both a correct and incorrect diagnostic label on their relationship with their patient. Clinicians accept that data has to be coded if they are to demonstrate that appropriate evidence based care has been provided to populations; but alongside this they require free-text as a more powerful reminder of the individual human encounter. Managers felt that they could encourage clinicians to code data for re-use as part of population data or as quality target indicators rather than as an enabler of the next consultation. CONCLUSIONS: The primary care consultation is a complex social interaction, and coding of the medical diagnosis in itself imposes the bio-medical model, carries assumptions about certainty, and is perceived by clinicians to potentially jeopardise their relationships with their patient. Further research to elicit patients' views may help clarify the magnitude of this barrier.

Ambulatory Care Information Systems↗

PubMedDate not supplied

Supraventricular tachycardia after coronary artery bypass grafting surgery and fluid and electrolyte variables.

OBJECTIVE: To explore the relationship between fluid and electrolyte variables and the development of supraventricular tachycardia (SVT) after coronary artery bypass grafting (CABG) surgery. DESIGN: Retrospective chart review. Random selection from a list obtained from the medical records department and with use of the International Classification of Diseases code to identify patients undergoing their initial CABG. SETTING: Medical records department of a southeastern 600-bed urban referral hospital with a large cardiovascular surgical program. PATIENTS: Forty patients experiencing SVT and 40 patients not experiencing SVT during their stay in an intensive care unit after CABG. OUTCOME MEASURES: Fluid and electrolyte variables and the development of SVT in the intensive care unit after CABG. VARIABLES: Data collected included preoperative demographic variables such as age and gender; previous history of SVT, congestive heart failure, cardiac arrest, previous surgery, diabetes, hypertension, valve disease, tobacco use, obesity; preoperative and postoperative medications; postoperative laboratory values of potassium, calcium, and magnesium; intravenous intake; hourly urine output; and chest tube drainage. RESULTS: Demographic variables revealed that patients with SVT were older (p = 0.001) and had a higher incidence of preoperative SVT (p = 0.04). Although groups did not differ by numbers of patients with high or low potassium, calcium, or magnesium, patients receiving additional intravenous potassium by bolus after surgery had a higher incidence of SVT (p = 0.02). Patients who lost blood via the chest tube at a rate greater than 100 ml per hour for at least 1 hour after surgery had a higher incidence of SVT (p = 0.02). Patients with a urine output greater than 300 ml per hour for longer than 9 hours had an increased incidence of SVT (p = 0.02). In the patients experiencing SVT, 62% had it occur 24 to 48 hours after surgery. CONCLUSIONS: These data suggest that shifts in fluid and electrolytes may be important characteristics of patients in whom SVT will develop, which could lead to better identification and nursing management of SVT and improve hemodynamic status, patient recovery, and cost after CABG.

Coronary Artery Bypass↗

PubMed2001

Understanding women's anger: a description of relational patterns.

Sixty women's narratives about their anger were coded for elements of anger expression. Their decisions regarding how and where to express anger are most strongly influenced by the anticipated reactions of others. Six patterns of bringing anger into relationships or keeping it out were identified. Women bring anger into relationship: (1) positively and directly, with the goal of removing barriers to relationship; (2) aggressively, with the goal of hurting another; and (3) indirectly, through disguising anger with the goal of remaining safe from interpersonal consequences, using strategies of (a) quiet sabotage, (b) hostile distance, (c) deflection, and (d) loss of control. Women keep anger out of relationship (1) consciously and constructively, choosing to express it in positive ways; (2) explosively expressing anger, but not in the presence of another; and (3) through self-silencing, which ranges from conscious to less-conscious awareness of anger and its suppression. Implications of differing patterns for women's health are discussed.

Adaptation, Psychological↗

PubMed2003

Emergency department blood or body fluid exposure evaluations and HIV postexposure prophylaxis usage.

OBJECTIVES: To determine the frequency and type of patient visits for blood or body fluid exposures to a large, urban emergency department (ED); to ascertain the frequency that human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) was prescribed for these exposures; and to compare HIV PEP usage by patient group, occupation, and exposure type. METHODS: Retrospective medical record review of ED patient visits (January 1, 1995, through June 30, 2001) extracted from two separate billing record computerized databases using 14 ICD-9 codes that defined blood or body fluid exposures. RESULTS: Of the 1,436 visits, 22% were by health care workers (HCWs) and 78% by non-HCW adults, adolescents, or children. Sixty percent of the HCWs sustained needlestick or sharp injuries, 73% of non-HCW adults had human bites, and 81% of adolescents and children had sexual exposures. Nurses were the largest group of HCWs, whereas police, correction officers, and security guards were the largest group of non-HCWs exposed at work. HCWs and non-HCW adults who sustained nonsexual exposures were much more likely to present for an evaluation within 24 hours than adolescents or children who suffered sexual assault (p<0.001). HIV PEP was prescribed 143 times: 92 to HCWs and 51 to all other patients. HIV PEP was most often prescribed to HCWs sustaining needlestick injuries. CONCLUSIONS: The majority of patients were not HCWs, which attests to the need for national, nonoccupational blood or body fluid management guidelines. There may be particular groups who would benefit from educational campaigns informing them of the need for early-intervention, postexposure measures to prevent an HIV infection.

Adolescent↗

PubMed2003

Promoting the dignity of the child in hospital.

This article aims to deconstruct the concept of dignity in a way that is meaningful, in particular to nurses and other health workers who seek to promote the dignity of children in their care. Despite the emphasis in a variety of codes and policies to promote dignity, there is a lack of a clear definition of dignity in the literature. In particular there is little reference to dignity, theoretically or empirically, as it relates to children. Without clarity it is not possible to act in an ethical way on behalf of children whose dignity could otherwise be compromised. The theoretical position taken has evolved from the medico-nursing and philosophical discourse concerning the nature of human dignity and more recent sociological texts that discuss the social construction of the child and childhood. The article is further influenced by additional insights derived from an ethnographic pilot study at a large district general hospital. This study was undertaken in an attempt to appreciate the subjective experience of dignity by children, and to begin to address the empirical gap in the literature and promote discussion. The concept of a macro and a micro dignity is discussed, together with the role of the nurse in articulating the relationship between the two. The importance of control and witnesses in the experience of dignity is discussed and, finally, also the ethical implications when seeking to promote the dignity of children.

Anthropology, Cultural↗

PubMed2000

Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database.

BACKGROUND: The management of heart failure (HF) by cardiologists may be better than that of other physicians in that cardiologists' treatment choices more frequently conform with published guidelines and the results of clinical trials. Whether cardiologists' management of HF is more or less cost-effective is up for debate. METHODS: Information on all 1995 New York state hospital discharges assigned ICD-9-CM codes indicative of HF in the principal diagnosis position was obtained. Demographic and clinical characteristics, process of care, resource utilization, and short-term HF-related outcomes were compared between patients of cardiologists and patients of other physicians. RESULTS: A total of 44,926 patients were identified, with 10,506 (23%) receiving care from cardiologists, 28,300 (63%) from internists, 4812 (11%) from family practitioners, and 1308 (3%) from other physicians. Patients of cardiologists were younger, more frequently male, and less frequently residents of nursing homes. They were more likely to have associated cardiovascular diagnoses but less likely to have comorbid general medical conditions. Patients of cardiologists were more likely to undergo cardiac catheterization (9%) than those of internists (3%) and family practice (2%) physicians but had similar adjusted hospital length of stay and charges. Mortality and hospital readmission rates for HF were similar among the groups. Patients in the "other" group (managed mostly by surgeons) were the youngest, underwent more invasive and cardiac surgical procedures, and had the longest length of stay and highest hospital charges. CONCLUSIONS: Cardiologists' management of HF is not economically disadvantageous. The relations among physician specialty, process of care, resource utilization, and clinical outcomes require further study before rational and evidence-based health care staffing recommendations can be formulated.

Aged↗

PubMedDate not supplied

Struggling with paradoxes: the process of spiritual development in women with cancer.

PURPOSE/OBJECTIVES: To examine the process of spiritual development in women diagnosed with cancer within five years of initial treatment. DESIGN: Exploratory, qualitative. SETTING: Outpatients in the mid-central and southwestern United States. SAMPLE: 10 Caucasian women, ages 45-70, who completed initial treatment, were not undergoing treatment for recurrence, and were within five years of diagnosis for breast or ovarian cancer or non-Hodgkin's lymphoma. METHODS: Data collected during two semistructured interviews, coded and analyzed using grounded theory techniques. Frame of reference--symbolic interactionism. MAIN RESEARCH VARIABLES: Developmental processes of spirituality; responses to diagnosis, treatment, and survival of cancer. FINDINGS: Diagnosis of cancer threatened the meaning of the women's lives, resulting in a sense of disintegration. This problem was resolved through the basic social psychological process of Struggling With Paradoxes, a three-phase process of Deciphering the Meaning of Cancer for Me, Recognizing Human Limitations, and Learning to Live with Uncertainty. In phase I, the paradoxes focused on the possibility of death, distress, vulnerability, and maintaining connection. In phase II, the paradoxes involved confronting death, asking difficult questions, and letting go of ultimate control of their lives. In phase III, the paradoxes centered on uncertainty, redefining meaning, and identifying spiritual growth. Reintegration occurred over time, although when threatened by the possibility of recurrence, disintegration resurfaced for a time. CONCLUSIONS: Findings emphasize not only the importance of spirituality, but also that spiritual experience is individualized and developmental in nature. Spiritual growth occurs over time following the diagnosis of cancer and is not necessarily related to age. IMPLICATIONS FOR NURSING PRACTICE: Spiritual concerns may be painful for patients to address; spiritual caregiving requires an acknowledgment of need by the woman with cancer and a caring, sensitive caregiver. Nurses should be aware of the phases of spiritual development so that interventions can be designed to address individual needs that may vary over time.

Adaptation, Psychological↗

PubMed2006

Spontaneous reporting of hepatotoxicity associated with antiandrogens: data from the Spanish pharmacovigilance system.

PURPOSE: To analyse the type and main features of the hepatotoxicity induced by steroidal and non-steroidal antiandrogens spontaneously reported by physicians, pharmacists and nurses. This analysis could increase the information related to these adverse reactions mainly available from the published isolated cases. METHODS: Using the Spanish Pharmacovigilance database we searched for spontaneous reports recorded since the date of approval of each antiandrogen up to the present time. We analysed the frequency of liver disorders, the preferred terms coded, the presence of other hepatotoxic drugs, and the characteristics of cases of hepatitis. RESULTS: Liver disorders were the most common adverse reactions associated with flutamide and bicalutamide, but not with cyproterone acetate. 'Hepatitis' and 'cholestatic hepatitis' were the most frequent terms coded. In 38% of the reports related to cyproterone acetate, 18% of those related to flutamide and 33% of those related to bicalutamide the patient had simultaneously received other hepatotoxic drugs. The disproportionality analysis of hepatitis showed a strong association with flutamide and a weak association with bicalutamide and cyproterone acetate. Mean doses of flutamide and bicalutamide were very close to their defined daily dose (DDD) to treat prostate cancer, although in the case of cyproterone acetate it was slightly higher. The latency period of hepatitis was between 3 and 10 months for the three antiandrogens, and the recovery period was shorter (0.5-3 months). The majority of the reported cases of hepatitis evolved favourably. CONCLUSION: Our results highlight the hepatotoxic potential of flutamide compared to cyproterone acetate. The data related to bicalutamide should be cautiously considered due to the smaller number of reports.

Adverse Drug Reaction Reporting Systems↗

PubMedDate not supplied

A 360 degrees evaluation of a night-float system for general surgery: a response to mandated work-hours reduction.

PURPOSE: New York State Code 405 and societal/political pressure have led the RRC and ACGME to mandate strict limitations on resident work hours. In an attempt to meet these limitations, we have switched from the previous Q3 call schedule to a specialized night float (NF) system, the continuity-care system (CCS). The purpose of this CCS is to maximize resident duty time spent on direct patient care, operative experience, and outpatient clinics, while reducing duty hours spent on performing routine tasks and call coverage. The implementation of the CCS is the fundamental step in the restructuring of our residency program. In addition to a change in the call system, we added physician assistants to aid in performing some service tasks. We performed a 360 degrees evaluation of this work in progress. METHODS: In May 2002, the standard Q3 call system was abolished on the general surgery services at the New York Presbyterian Hospital, Columbia campus. Two dedicated teams were created to provide day and night coverage, a day continuity-care team (DCT) and a night continuity-care team (NCT). The DCTs, consisting of PGY1-5 residents, provide daily in-house coverage from 6 AM to 5 PM with no regular weekday night-call responsibilities. The DCT residents provide Friday night, Saturday, and daytime Sunday call coverage 3 to 4 days per month. The NCT, consisting of 5 PGY1-5 residents, provides nightly continuous care, 5 PM to 6 AM, Sunday through Thursday, with no other weekend call responsibilities. This system creates a schedule with less than 80 duty hours per week, on average, with one 24-hour period off a week, one complete weekend off per month, and no more than 24 hours of consecutive duty time. After 1 year of use, the system was evaluated by a 360 degrees method in which residents, residents' spouses, nurses, and faculty were surveyed using a Likert-type scale. Statistical significance was calculated using the Student t-test. Patient satisfaction was measured both by internal review of a patient complaint database as well as by the Press Ganey patient satisfaction surveys. RESULTS: Twenty-one residents, 10 residents' spouses, 11 general surgery faculty, and 16 nurses were surveyed. Statistically significant findings included reduced resident fatigue noted by all groups (residents, p = 0.01; resident spouses, p = 0.05; faculty, p < 0.0001; nurses, p < 0.0001). Further, residents reported more time for sleep at home (p = 0.0005) and more time for independent reading (p = 0.01). Residents' spouses reported increased availability for family events (p = 0.01). Nurses reported increased availability of residents (p = 0.0002), shorter times to physician identification of patient problems (p = 0.0086), improved resident-nursing communications (p = 0.0096), and increased ease of nursing duties (p < 0.0001). Faculty were the only responders who felt that continuity of patient care suffered with the new system (p = 0.02). The Press Ganey review showed improvement in the quality of care rendered as perceived by patients. CONCLUSIONS: The institution of a specialized NF or CCS for in-house coverage of general surgical services in a large metropolitan university hospital has had initial success in meeting the mandated changes in resident work hours. The CCS reduced resident fatigue, improved quality of resident life, and improved patient care as judged by patients and nurse.

Appointments and Schedules↗

PubMed1993

Managing the early discharge experience: taking control.

The purpose of this study was to understand women's experiences in an early discharge programme. Using grounded theory, the investigator collected, coded, compared and contrasted data gathered in unstructured interviews with eight women. The women managed their early discharge experience, first, by taking control of their antenatal and intrapartal care once they were accepted into the programme and, later, by taking control of their postpartum recovery and their infants' care. Taking control was influenced by the women's beliefs about family and home; their personalities, e.g. their ability to accept help; and their available support. Their beliefs, personalities and available support were central to their motivation to participate in the early discharge programme and to their perception of a successful experience. The women used a number of strategies to take control. These strategies emerged during organizing antepartal requirements, meeting their own expectations during labour and birth, and learning to trust their abilities to manage self-care and parenting postpartum. The women anticipated their increased family involvement, family integration and participation in decision-making. They did not, however, anticipate their increased feelings of confidence and competence. Taking control has implications for health professionals who are working with childbearing women experiencing early discharge.

Adaptation, Psychological↗