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Over a one-year period of time, five stereotactic biopsies were performed in the Greater-Bridgeport hospitals using a new burr hole-mounted stereotactic device. We discuss our results as well as some general considerations on the applicability of this material to the community neurosurgeon.
BACKGROUND: Children are better served by radiologists and technical personnel trained in the care of pediatric patients. However, a variety of obstacles may limit the access of children to dedicated pediatric imaging facilities. OBJECTIVE: We designed and implemented two models for providing community-based imaging by academic pediatric radiologists. MATERIALS: and methods. The first site was an outpatient clinic staffed by physicians from the university-affiliated children's hospital. Imaging services included radiography, fluoroscopy, and ultrasound. The second site was a full-service community hospital radiology department staffed by a group practice, with pediatric imaging covered by the children's hospital radiologists. Facility, equipment, and protocol modifications were required to maintain quality standards. Success of these models was determined by volume statistics, referring physician/patient satisfaction surveys, and quality-assurance (QA) programs. RESULTS: The outpatient satellite had a 48 % increase in total examinations from the first year to the second year and 87 % the third year. Pediatric examinations in the community hospital increased over 1000 % the first 7 months. Referring physicians reported increased diagnostic information and patient satisfaction compared to previous service. QA efforts revealed improved image quality when pediatric radiologists were present, but some continuing difficulties off-hours. CONCLUSION: We successfully implemented pediatric imaging programs in previously underserved communities. This resulted in increased pediatric radiologist supervision and interpretation of examinations performed on children and improved referring physician and patient satisfaction.
Following the rapid service development brought about by the hospice movement, specialist palliative care services are involved with up to 50% of all patients dying with cancer in the United Kingdom, although the primary health care team remains the main provider of community based palliative care. This paper discusses findings from a survey of palliative care provision in the south west of England, and describes the perceptions of the primary care team (general practitioners and district nurses) about the interface between themselves and voluntary sector specialist palliative care providers (hospice in-patient units, hospice home care nurses and other charitably funded specialist palliative care nurses). The voluntary sector services are run with a mixture of funding from charitable sources (public donations, legacies, charitable trust moneys), and statutory funding (grants and recurrent contracts from central government, district health commissions, and local health care trust). The interview and questionnaire data suggest that the voluntary sector services are perceived variably as substituting, supplementing, complementing and duplicating the services provided by the primary care team. Drawing attention to these dimensions and the ambivalence sometimes felt by general practitioners and district nurses could provide a means of negotiating consensus on appropriate professional tasks and facilitating interprofessional practice in what is increasingly a mixed economy of statutory and voluntary funded health care.
This article presents the results of two studies among participants of two Dutch nutrition education interventions, i.e. a self-help program and a living room group session. Both interventions aim to reduce fat intake in the general population and were developed as part of the Dutch community health project 'Healthy Bergeyk'. The objectives of the studies were to assess number of participants, participant characteristics, use of the self-help program, participant satisfaction and self-reported effects. Telephone interviews and written questionnaires were completed by inhabitants after participating in the interventions. The results are encouraging and the interventions seem to be useful as part of community projects.
During a previous survey, five extended-spectrum beta-lactamase (ESBL)-producing enterobacteria (ESBLE) (two Enterobacter aerogenes isolates expressing TEM-24 b, two Escherichia coli isolates expressing TEM-21 or TEM-24 b, and one Klebsiella pneumoniae isolate expressing SHV-4/TEM-15) responsible for urinary tract infections (UTIs) were found among 1,584 strains collected from community patients. The aim of the present study was to elucidate the route of emergence of these typically nosocomial organisms in the community. Thus, the files of the five patients were analyzed over at least a decade, and potentially related ESBLE from hospitals or clinics were examined. Their enzymes were characterized at a molecular level, and the strains were typed by amplified-primed PCR, enterobacterial repetitive intergenic consensus PCR, and restriction plasmid profile. All patients (C1 to C5) had risk factors for ESBLE acquisition, including past history of hospitalization (2.5 to 23 months before). Four (C1 and C3 to C5) had previously received antibiotics (concomitantly to 35 months earlier), two (C1 and C3) had indwelling urinary catheters and recurrent UTIs, and three (C2, C3, and C5) formerly experienced ESBLE-induced UTIs (2 to 11 months before). The same ESBLE and/or an identical or similar ESBL-encoding plasmid was identified in the hospital ward (C1 to C4) or in a clinic (C5) where the patients had previously resided. Patients C1 and C4, infected with different ESBLE carrying a closely related plasmid, were hospitalized in the same unit. Persistence of ESBLE over at least a 5-year period was demonstrated for patient C3. Thus, community-acquired UTIs in these patients likely resulted from nosocomially acquired ESBLE or an ESBL-encoding plasmid followed by a prolonged digestive carriage.
BACKGROUND: The one third middle cerebral artery territory ((1/3) MCA) method and the Alberta Stroke Program Early CT Score (ASPECTS) were used to detect significant early ischemic changes (EIC) on CT brain of acute stroke patients. We sought to compare the reliability of the 2 methods in routine clinical practice. METHODS: Eighty consecutive patients admitted to a community hospital in Hong Kong with suspected acute ischemic stroke and a CT brain scan performed within 6 hours of symptom onset were included. Five blinded observers (1 neurologist, 2 general radiologists, and 2 neuroradiologists) independently evaluated the scans, using the ATLANTIS/CT Summit criteria for >(1/3) MCA involvement, and ASPECTS (1/3) MCA involvement, all observers agreed in 57 cases (71%), with moderate interobserver agreement (kappa=0.49). For ASPECTS <or=7, all observers agreed in 34 cases (42%), with fair interobserver agreement (kappa=0.34). After prevalence and bias adjustments, substantial (prevalence-adjusted bias-adjusted kappa [PABAK]=0.74) and moderate (PABAK=0.44) agreements were found for the (1/3) MCA method and ASPECTS respectively. CONCLUSIONS: The (1/3) MCA method was more reliable in detecting significant EIC on CT brain within 6 hours of stroke onset in routine clinical practice, whereas ASPECTS was able to detect significant EIC in a higher proportion of these early scans.
To assess the degree to which mothers, nurses and pediatricians share common concerns regarding infants' health and well-being a cross-sectional survey with stratified demographic sampling was conducted. A 12-item questionnaire pertaining to health concerns was administered to 22 mothers of infants between 1 and 18 months of age, treated at six Well Baby community clinics with 36 nurses and 25 pediatricians. Mothers and health care professionals expressed significantly different concerns. Pediatricians and nurses shared a more similar order of concerns. However, they too differed on the degree of concern related to some of the health issues, i.e. nurses perceived the issues related to feeding, behaviour, skin, sleep and daily routines as significantly more important than did pediatricians. Additional efforts should be devoted to improve and clarify communication between mothers and health care professionals.
Failure to thrive, the direct result of inadequate nutrition and in particular energy intake, is commonly encountered. This paper considers how to identify the nature of this inadequacy using specific nutritional assessment methodology and how the information can be used to enable appropriate and effective intervention to take place. It discusses the observations and findings of 7 years of community dietetic practice and the potential impact on other health professionals working with children who are failing to thrive.
Attempts to improve instrumental role performance among mentally ill persons have traditionally focused on the modification of individual level variables. Recent interest in environmental-behavioral linkages, however, has led to attempt to isolate environmental variables which are both readily manipulable and significantly related to improved instrumental role performance. The present study examines the impact of a variety of individual, residential, and community variables on instrumental role performance using multiple regression analysis. The 10 variables in the equation had a multiple r of .77 with total score on the Residential portion of the Adaptive Functioning Index, indicating that they account for 60% of the variance in scores. Individual level variables account for 3% of the variance, while environmental variables, primarily those related to normalization account for 57% of the variance. The data suggest that environmental normalization may be an effective technology as well as an ideology.
Constipation is a distressing symptom, common in many patient groups and traditionally treated by nurses. Ambiguity concerning limits of the nurse's role in treating constipation exists and guidelines are scarce. Theoretically constipation is largely preventable, but acute episodes arise for a number of reasons and often need prompt treatment. This article describes the development of a local protocol which empowers appropriately trained community nurses to treat adult patients with acute constipation. A flow chart was used to define the guidelines. Implementation of the protocol is briefly discussed in relation to other current local initiatives.
PURPOSE: Although use of colony-stimulating factor (CSF) is widespread and guidelines for use have been disseminated, actual practice patterns of medical oncologists are unknown. The purpose of this study was to collect these data using an office-based computerized clinical information system. PATIENTS AND METHODS: Data were collected on patients at 10 community-based oncology practices. Information regarding CSF use was captured at the time of prescribing through a computerized clinical support tool and stored in a data warehouse, and an analysis was carried out retrospectively. RESULTS: A total of 6,813 cancer regimens administered to 5,034 patients were evaluated for growth factor use. Overall, CSFs were used in 14% of regimens, with breast, lymphoma, lung, and ovarian being the most common cancers for which CSFs were used. In 49.4% of regimens, CSF was initiated during cycle 1, with an average duration of 1 week, and was used in two or three cycles per regimen. Afebrile neutropenia is rarely followed by CSF initiation. Granulocyte colony-stimulating factor (G-CSF) is associated with fewer dose adjustments, delays, and hospitalizations when compared with granulocyte-macrophage colony stimulating factor (GM-CSF). There is wide variation among oncologists in CSF use, and several substantial differences were noted between the prescribing behavior of American Society of Clinical Oncology (ASCO) survey-reported oncologists and actual clinical practice, as captured by the computerized clinical information system. CONCLUSION: Computerized clinical information systems can collect detailed information regarding practice patterns of medical oncologists. ASCO physician practice survey data do not accurately reflect actual practice patterns and must be interpreted with caution. Substantial deviations from ASCO growth factor guidelines remain, and oncologists' use of CSFs demonstrates wide variation. There may be important clinical differences between G-CSF and GM-CSF, but definitive phase III trials are needed for confirmation.
1. Psychiatric home care is a cost-effective, feasible alternative to hospitalization. 2. Psychiatric home care nurses must possess psychiatric and physical assessment skills, genuine caring, and the ability to develop trust. 3. The role of the psychiatric home care nurse involves assessment of psychopathology and development of interventions that include educating patients regarding medications, psychopathology, and coping skills that assist them to remain in the community. 4. Autonomy, working collaboratively with psychiatrists, and learning from patients are rewards that psychiatric home care nurses experience.
BACKGROUND: The United States Preventive Services Task Force recommends that women who are at both high risk for breast carcinoma and low risk for adverse events should receive counseling regarding tamoxifen for chemoprevention. Estimates of the risks and benefits of tamoxifen based on results from clinical trials may not reflect the real-world experience. The authors determined the prevalence of women in a community-based cohort who would meet the definition of high risk for breast carcinoma and calculated the number of women needed to screen to determine one for whom the benefits of tamoxifen would outweigh the risks. Baseline incidence also was examined for adverse health events in this community-based cohort compared with participants in the Breast Cancer Prevention Trial. METHODS: The study participants were women ages 40-70 years (n = 6048 women) who were members of the CLUE II cohort, which started in 1989, and who responded to questionnaire surveys in 1996 and 2000. RESULTS: Eighteen percent of all women had a 5-year risk of invasive breast carcinoma > or = 1.66%. The number of women needed to screen to find 1 woman for whom the benefits outweighed the risks of tamoxifen ranged from 26 women ages 40-49 years to 142 women ages 60-70 years. For women who had undergone a hysterectomy, the numbers needed to screen were lower. Baseline incidence rates of fracture and thromboembolic disease were higher in the community-based cohort compared with the rates observed among prevention trial participants; thus, fewer women had to be treated with tamoxifen to prevent one fracture. However, fewer women in the community also had to be treated to observe harm with a thromboembolic event. CONCLUSIONS: Clinicians who counsel women about tamoxifen should take into consideration community-level risks and benefits.
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BACKGROUND AND OBJECTIVE: Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists' Home Medicines Review (HMR) findings and recommendations for people with mental illnesses. METHODS: This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruited and referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient- and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences. MAIN OUTCOME MEASURES: Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists' findings and recommendations were classified using the Clinical Pharmacy Activity Classification System. RESULTS: The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 +/- 4.4 (mean +/- SD) drugs each (range 1-18). Following home interviews, pharmacists determined people to be taking 9.1 +/- 4.8 drugs (range 1-20). This difference was statistically significant (p < 0.001). CONCLUSIONS: Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.
Providers and their treatment programs are the focus of efforts to translate research into practice. In the best of partnerships, they are more than the recipients of research efforts, because they are actively involved in developing and evaluating healthy links between practice and research . This article reports on experiences in a multisite methamphetamine treatment trial funded in October of 1998 by the Center for Substance Abuse Treatment. The goal of the trial is to generate knowledge about how a comprehensive treatment protocol developed by the Matrix Center in Los Angeles can be effectively transferred to the community drug treatment system. The Matrix model provides a three-times-per-week outpatient treatment experience that combines behavioral, educational, and 12-Step counseling techniques. When complete, the study will compare outcomes of the 16-week Matrix program with the usual treatment offered by the programs at the eight participating sites. The UCLA Drug Abuse Research Center and the Matrix Institute on Addictions coordinate the trial. This article describes factors that have fostered or hindered the development of this partnership. These factors can be divided into three temporal phases, although the circumstances presented may occur at any time during the research process. The first set of factors affecting the development of a healthy research-to-practice relationship exists prior to the establishment of that relationship. A second set of circumstances occurs at the initiation of the collaborative enterprise, and the third set of factors is more involved in the development and maintenance of ongoing productive collaboration between researchers and providers.
A series of twenty-six interviews, fourteen with district nursing sisters and twelve with students they supervised, was conducted in 1992 in one Project 2000 demonstration district in England. The data were collected as part of an English National Board funded research study; data were reinterpreted in 1994 and formed one element in the author's PhD thesis. Participants described the ways in which a supervisor might enable a student to learn during a community placement. One of the most important means by which supervisors could provide assistance was by creating an environment in which the students felt supported. Students described how supervisors demonstrated concern, acceptance and understanding, attributes which bore striking resemblance to the qualities of congruence, unconditional positive regard and empathic understanding identified by Carl Rogers as enabling learning.
BACKGROUND: Based on the technologies of applied behavior analysis and person-centered planning, positive behavior support is a process for designing and implementing proactive behavioral interventions with the goal of positive lifestyle changes. PARTICIPANTS: The two adolescents who received the intensive, longitudinal, multicomponent intervention had experienced escalating behavior challenges over several years after brain injury in early childhood. MAIN OUTCOME MEASURES: Quantitative data included episodes of aggression and property destruction. Qualitative data included intensity of supports, family involvement, peer relationships, medication regime, vocational status, educational status, community access, and self-help skills. RESEARCH DESIGN: A long-term, natural-environment, case-study method was used. RESULTS: The targeted challenging behaviors were reduced to zero. In addition, the participants' domains of activity increased and self-management improved even as supports were systematically withdrawn. CONCLUSIONS: These results illustrate the potential for successfully treating extreme chronic behavior disorders after childhood brain injury.