Laparoscopic splenectomy in a community setting.
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Child↗
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Stereotactic breast biopsy: experience in a community setting.
This article reviews the first year experience with stereotactically guided percutaneous breast biopsy at Baptist Health Systems Women's Center. One hundred forty eight procedures were performed on one hundred forty one patients from July 1997 through July 1998. Our biopsy program is a cooperative effort involving surgeons, radiologists, pathologists, and ancillary health care personnel. In accordance with published literature, we have found the procedure to be efficacious, safe, cost effective and well accepted by patients and physicians. The advantages and limitations of minimally invasive breast biopsy are discussed as well as our concept of the role of this technique in management of patients with an abnormal mammogram.
Adult↗
Insurance benefit preferences of the low-income uninsured.
OBJECTIVE: A frequently cited obstacle to universal insurance is the lack of consensus about what benefits to offer in an affordable insurance package. This study was conducted to assess the feasibility of providing uninsured patients the opportunity to define their own benefit package within cost constraints. DESIGN: Structured group exercises. SETTING: Community setting. PARTICIPANTS: Uninsured individuals recruited from clinical and community settings in central North Carolina. MEASUREMENTS: Insurance choices were measured using a simulation exercise, CHAT (Choosing Healthplans All Together). Participants designed managed care plans, individually and as groups, by selecting from 15 service categories having varied levels of restriction (e.g., formulary, copayments) within the constraints of a fixed monthly premium comparable to the typical per member/per month managed care premium paid by U.S. employers. MAIN RESULTS: Two hundred thirty-four individuals who were predominantly male (70%), African American (55%), and socioeconomically disadvantaged (53% earned <$15,000 annually) participated in 22 groups and were able to design health benefit packages individually and in groups. All 22 groups chose to cover hospitalization, pharmacy, dental, and specialty care, and 21 groups chose primary care and mental health. Although individuals' choices differed from their groups' selections, 86% of participants were willing to abide by group choices. CONCLUSIONS: Groups of low-income uninsured individuals are able to identify acceptable benefit packages that are comparable in cost but differ in benefit design from managed care contracts offered to many U.S. employees today.
Adult↗
The use of a videotaped questionnaire for studying asthma prevalence. A pilot study among New Zealand adolescents.
OBJECTIVE: To examine the feasibility of measuring asthma prevalence by means of an audio-visual presentation of asthma symptoms and signs (video questionnaire) and to compare this technique with a standard written questionnaire for predicting bronchial hyperresponsiveness. DESIGN: A cross-sectional study comparing the ability of a video questionnaire and a written, interviewer administered questionnaire to predict bronchial hyperresponsiveness. Bronchial responsiveness was measured with hand held nebulisers. SETTING: Community survey of a New Zealand rural secondary school. SUBJECTS: A total of 456 adolescent school children aged 12-19 years (mean 15.5 years). OUTCOME MEASURES: Comparison of the sensitivity and specificity of a standard questionnaire versus a video questionnaire for bronchial hyperresponsiveness. RESULTS: The technique was easy to administer in the community setting. Overall sensitivity and specificity for the prediction of bronchial hyperresponsiveness were similar for the video and interviewer administered questionnaires. CONCLUSIONS: This new technique is easily used in the community setting, and gives predictions of bronchial hyperresponsiveness similar to those of a standard interviewer administered questionnaire. Further examination of the technique in comparisons of asthma prevalence among different populations is planned.
Adolescent↗
Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients.
HYPOTHESIS: A technique of the laparoscopic Roux-en-Y gastric bypass can be developed that is safe, effective, and practical in the community setting. DESIGN: A case series of 400 morbidly obese and superobese individuals who underwent the laparoscopic Roux-en-Y gastric bypass over a 22-month period. SETTING: Community private practice in Fresno, Calif. PATIENTS: A consecutive sample of 400 patients (70 males and 330 females) who met National Institutes of Health criteria for recommendation of a bariatric procedure. Only patients who had a previous gastric or bariatric procedure were excluded from this sample. INTERVENTION: Laparoscopic Roux-en-Y gastric bypass with a hand-sewn gastrojejunal anastomosis. MAIN OUTCOME MEASURES: Weight loss, complications, length of hospital stay, successful completion of the operation, and operative times were measured. RESULTS: Open conversion was required in 12 patients (6 males and 6 females) and a secondary operation for incomplete division of the stomach was required in 2 patients early in the case series. Alternative exposure and fixation techniques greatly reduced these occurrences. There were 6 staple-line failures owing to a change in the manufacture of the instrument. There were no leaks at the gastrojejunal anastomosis, but 21 patients required endoscopic balloon dilation for significant stenosis. The average hospital stay was 1.6 days for the patients who underwent laparoscopy and 2.7 days for patients requiring open conversion. Average excessive weight loss was 69% at 12 months. Operative times are between 60 and 90 minutes. Other complications are described. CONCLUSION: The Roux-en-Y gastric bypass can be safely and effectively performed in the community setting using advanced laparoscopic techniques.
Adolescent↗
Tai Chi Chuan to improve muscular strength and endurance in elderly individuals: a pilot study.
OBJECTIVE: To evaluate the training effect of a Tai Chi Chuan (TCC) program on knee extensor muscular strength and endurance in elderly individuals. DESIGN: Before-after trial. SETTING: Community setting. PARTICIPANTS: Forty-one community dwelling subjects aged 61.1 +/- 9.8 years undertook a TCC program. Nine dropped out during the study. Pretraining and posttraining measurements were obtained from 15 men and 17 women. INTERVENTION: Subjects participated in a 6-month TCC program. Each session consisted of 20 minutes of warm-up, 24 minutes of structured TCC training, and 10 minutes of cool-down exercises. MAIN OUTCOME MEASURES: Peak torque of dominant and nondominant knee extensors was tested at speeds of 60 degrees , 180 degrees , and 240 degrees/sec concentrically and eccentrically. Muscular endurance of the knee extensor was tested at the speed of 180 degrees /sec. RESULTS: In the group of men, concentric knee extensor peak torque increased by 15.1% to 20.0% and eccentric peak torque increased by 15.1% to 23.7%. The group of women also showed increases, ranging from 13.5% to 21.8% in concentric peak torque, and 18.3% to 23.8% in eccentric peak torque. In addition, the knee extensor endurance ratio increased by 9.6% to 18.8% in the men and 10.1% to 14.6% in the women. CONCLUSION: TCC training may enhance muscular strength and endurance of knee extensors in elderly individuals.
Aged↗
The outcomes of using self-study modules in energy conservation education for people with multiple sclerosis.
OBJECTIVE: To determine whether there were any differences in the outcomes of individuals with multiple sclerosis who attended all six sessions of an energy conservation education programme compared with people who missed a session and received a self-study module. DESIGN: Secondary analysis of data from two naturally occurring groups emerging from a randomized control trial--compliers who received the intervention as intended (group 1) and noncompliers who received a modified intervention with self-study modules (group 2). SETTING: Community settings in Chicago, Illinois and Minneapolis, Minnesota, USA. PARTICIPANTS: Ninety-two community-dwelling people with multiple sclerosis who were participating in an energy conservation education programme. INTERVENTION: Energy conservation education groups based on the 'Managing Fatigue' programme, which were facilitated by an occupational therapist. Self-study modules were sent to participants who missed a session. OUTCOME MEASURES: Fatigue Impact Scale (FIS), Self-Efficacy for Performing Energy Conservation Strategies Assessment, Energy Conservation Strategies Survey (ECSS), six subscales from the Medical Outcomes Study Short-Form Health Survey (SF-36). RESULTS: When comparing individuals who attended all six sessions with individuals who missed one or more sessions and received a self-study module, no significant differences were found after adjusting for multiple comparisons. CONCLUSIONS: Participants who used the self-study modules because they missed sessions of the Managing Fatigue programme experienced benefits from the course similar to those experienced by participants who fully complied with the intervention as intended. A new prospective study to validate the findings of this secondary analysis is required.
Energy Metabolism↗
Simulated patients in the community pharmacy setting. Using simulated patients to measure practice in the community pharmacy setting.
BACKGROUND: Performance measurement and quality of care in community pharmacy settings is problematic because of the lack of formal patient registration and the resultant risk of selection bias. Although simulated patients have been used for teaching and education purposes, particularly in medical settings, their use as a research tool requires exploration in other health settings. The purpose of this paper is to describe how we used simulated patients to measure professional performance of community pharmacy staff. METHOD: Sixty pharmacies participated in a randomised controlled trial (RCT) to evaluate the effectiveness and efficiency of two guideline implementation strategies in the community pharmacy setting. The primary outcome measure for the study was derived from assessment forms completed by simulated patients following covert visits to participating pharmacies. RESULTS: Of the 420 simulated patient visits scheduled, 384 (91%) were completed. Nine visits were reported by pharmacy staff using reply-paid postcards, four of which concurred with known SP visits. Each detected visit was made by a different SP. In a post-intervention survey, 26 (52%) pharmacists stated they had been apprehensive about the use of simulated patients as part of the study, however, 41 (82%) pharmacists agreed that SP visits were an acceptable research method to use in a community pharmacy setting. DISCUSSION: Simulated patients are a feasible method of assessing professional performance in community pharmacy settings and overcome the methodological problems of other measurement methods. Further research is needed to assess the reliability and validity of simulated patients.
Adult↗
Exploring the content of physiotherapeutic home-based stroke rehabilitation in New Zealand.
OBJECTIVE: To address the paucity of information on the content of home interventions for people with stroke by reporting on the practice of physiotherapeutic home-based stroke rehabilitation in New Zealand. DESIGN: Qualitative research methodology comprising a series of semi-structured interviews. SETTING: Community setting in 6 cities in New Zealand. PARTICIPANTS: A purposeful sampling strategy recruited 20 physiotherapists working in home-based stroke rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Participants described patients as being fatigued, frustrated, depressed, and scared once discharged home and said that the primary aim of rehabilitation in the home environment is preparation for life after stroke. Physiotherapists aimed at optimal independent functioning by building patients' confidence, self-responsibility, and problem-solving skills while ensuring patient safety. Participants, illustrating the complexities of stroke rehabilitation, described a wide range of interventions. We identified a number of factors that influenced the practice decisions made by participants. The success of intervention was measured more by the successful attainment of carefully set patient-centered goals than by the use of validated outcome measures. CONCLUSIONS: This study presents a conceptual model or framework for physiotherapy practice for people with stroke living in the community.
Activities of Daily Living↗
Experience in the development of a postmarketing surveillance network: the pharmacy medication monitoring program.
OBJECTIVE: To describe the pilot and early implementation phase of a system for assembling and recruiting cohorts of patients taking selected prescription medications and prospectively monitoring them for new health events. DESIGN: Prospective observational study, based on telephone interviews, of 1475 patients filling prescriptions for a nonsteroidal antiinflammatory drug (NSAID). Patients were interviewed by telephone using trained interviewers at a central site. Hospitalizations and deaths were followed up and reviewed by an independently physician. SETTING: Community setting in a region of Hamilton, Ontario, Canada. PARTICIPANTS: All consenting patients filling new or repeat prescriptions for NSAIDs at participating pharmacies. MAIN OUTCOME MEASURES: The authors report on the development and assessment of systems for: (1) ongoing recruitment of patients through community pharmacies; (2) data transfer from pharmacies to the coordinating center; (3) surveying patients; (4) classifying, coding, and evaluating new health events; and (5) following up on new serious adverse events. RESULTS: Fifty-one percent of patients approached were recruited, and 83% of these provided completed interviews. For patients picking up their own medications, pharmacy workload varied from 4 to 10 minutes per patient approached. Nineteen percent of patients reported having a new health problem or unusual symptom at the initial telephone interview. Reported health-related events were similar to those described in other studies of NSAIDs. CONCLUSIONS: Most aspects of the monitoring system performed well. One limitation was the low recruitment rate for patients who did not directly drop off or pick up their own prescriptions. Even so, this method of patient accrual may complement alternative monitoring programs.
Adverse Drug Reaction Reporting Systems↗
Risk of active tuberculosis among schoolchildren in Hong Kong.
OBJECTIVE: To estimate the risk of active tuberculosis (TB) and its implication on preventive treatment among BCG-vaccinated schoolchildren. DESIGN: Cohort and case-control designs. SETTING: Community settings in a high-prevalence area. PARTICIPANTS: Children in primary school. The main exposure was their tuberculin response. MAIN OUTCOME MEASURES: Of 94,928 primary schoolchildren tuberculin tested during a routine school revaccination program in 1999, 656 with a tuberculin response at 20 mm or more were followed up prospectively through the territory-wide TB registry up to December 31, 2003, for the development of TB. In a separate case-control analysis, the tuberculin responses of children who subsequently had active TB (at the age of 10-15 years) were compared with those of their sex- and age-matched classmates to ascertain the relative risks of TB for different tuberculin reaction categories. The absolute and relative risks were applied to the 1999 cohort for estimating the incidence of TB among different tuberculin reactors. RESULTS: The annual incidence (95% confidence interval) of active TB was estimated to be 13.4 (5.6-40.6) per 100,000 for the entire cohort and 7.5 (2.4-24.5), 7.5 (1.7-32.0), 16.0 (4.4-57.2), 92.6 (26.6-320.2), and 340.6 (163.3-626.4) per 100,000 for children with a tuberculin reaction at 0 to 4, 5 to 9, 10 to 14, 15 to 19, and 20 mm or more, respectively. By using 10 mm as the cutoff, 482 (95% confidence interval, 163-1391) children have to be treated to prevent a single case of active TB within 5 years. Treatment will cover 17.5% of the cohort, but prevent only 54.1% of all active TB cases. CONCLUSION: It is desirable to reexamine the existing screening method for BCG-vaccinated children from high-prevalence countries.
Adolescent↗
Behaviour changes in dementia. 2: Are there behavioural syndromes?
OBJECTIVE: To establish whether robust behavioural 'syndromes' can be identified from among the widely heterogeneous behavioural changes which occur in dementia. DESIGN: Longitudinal, prospective study with follow-up at 4 and 8 months. SETTING: Community settings in Oxfordshire, UK. PARTICIPANTS: 97 elderly people with a diagnosis of Alzheimer's disease or vascular dementia (in many cases confirmed by postmortem examination) and who were living at home with a carer. MEASURES: Each subject's behaviour was assessed in detail at each interview using the Present Behavioural Examination to assess subject's behaviour over the preceding 4 weeks. Seventeen key behaviour items which were both common and clinically important were selected for further analysis. RESULTS: Three syndromes were identified: (a) overactivity (walking more, walking aimlessly, trailing the carer or checking where the carer was); (b) aggressive behaviour (physical aggression, aggressive resistance, verbal aggression); (c) psychosis (anxiety, persecutory ideas and hallucinations). The same syndromes were found using data collected at three different time points and by using a variety of statistical techniques, confirming their robustness. CONCLUSIONS: Overactivity, aggressive behaviour and psychosis form three distinct behavioural syndromes in dementia.
Aged↗
A feminist exploration of Traveller women's experiences of maternity care in the Republic of Ireland.
OBJECTIVE: to explore Traveller women's experiences of maternity care so that their needs might be identified and perceptions of helpful responses elicited. DESIGN: feminist research methodology using unstructured non-directive interviews. SETTING: community setting in the Republic of Ireland. PARTICIPANTS: snowball sample of 13 Traveller women aged 19-42 years. Each had experienced between two and eight pregnancies. FINDINGS: a fluid concept of culture affected Traveller women's expectations and negotiation of maternity care. The essential nature of familism, socialisation and religious beliefs, and the particular emphasis placed upon peer support, reflected cohesive and supportive aspects of culture. The concept of 'possessive individualism' was portrayed as conflicting with contraceptive use, the uptake of preventive care and women's reporting of mental-health problems. Majority norm expectations of breast feeding, husband participation and 'rooming in' were culturally unacceptable. Political and structural factors, such as the direct discriminatory barriers created by general practitioner services, indirect discrimination arising from dysfunctional communication and control of information, poor housing and lack of public transport were the basic causes of inequity of access to care. IMPLICATIONS FOR PRACTICE: midwives are challenged to respond sensitively to cultural preferences, meet informational needs and act as political advocates in efforts to improve maternity care experiences for Traveller women.
Adult↗
[The prevalence of diabetes mellitus and its association with other cardiovascular risk factors in the province of Albacete. The Vascular Disease Group of Albacete (GEVA)].
OBJECTIVE: To find the prevalence of DM in the population of Albacete, and their relationship with other risk factors. DESIGN: A descriptive cross-sectional population study. SETTING: Community setting in the province of Albacete. PARTICIPANTS: A sample of 2121 people+ over 18 (843 from the capital and 1278 from the rest of the province) was selected through stratified random sampling. MEASUREMENTS AND MAIN RESULTS: Appointments were made by mail. All those attending underwent anamnesis, a physical examination, EKG and basic analytic test. 1263 people older than 18 years were studied. The prevalence of DM observed with WHO criteria was 6.7% (95% CI, 5.9%-7.4%), of which 6.5% corresponded to known DM and only 0.2% to unknown. If ADA criteria were used, the prevalence was 9.8%. We found association between DM and age, obesity, hypertension, hyperlipaemia, low HDL-c, high levels of fibrinogen, left ventricular hypertrophy, arrhythmias and personal history of ischemic cardiopathy and peripheric arteriopathy. CONCLUSIONS: DM is a highly prevalent pathology in Albacete. We consider necessary to standard epidemiological methods that allow us to know the real situation of DM in our country. Other cardiovascular risk factors are more prevalent in diabetic patients, increasing their coronary risk. The control of modifiable factors is fundamental to avoid as possible the chronic complications of the disease.
Adult↗
Experience of non-fatal overdose among heroin users in Adelaide, Australia: circumstances and risk perceptions.
AIMS: To ascertain the prevalence and risk factors for non-fatal overdose among heroin users to assist in the development of an effective intervention. DESIGN: Cross-sectional design. SETTING: Community setting, principally metropolitan Adelaide. PARTICIPANTS: Current heroin users (used heroin in the previous six months). MEASUREMENTS: A structured questionnaire including the Severity of Dependence Scale. FINDING: Of 218 current South Australian heroin users interviewed in 1996, 48% had experienced at least one non-fatal overdose their life-time (median: two overdoses), and 11% had overdosed in the previous 6 months. At some time, 70% had been present at someone else's overdose (median: three overdoses). At the time of their own most recent overdose, 52% had been using central nervous system depressants in addition to heroin, principally benzodiazepines (33%) and/or alcohol (22%). The majority of overdoses occurred in a private home (81%) and in the presence of other people (88%). Unrealistic optimism regarding the risk of overdose was evident across the sample. Despite almost half the sample reporting having had an overdose, and the belief expressed by respondents that on average about 50% of regular heroin users would overdose during their life-time 73% had, during the previous 6 months, "rarely" or "never" worried about possibly overdosing. Optimism regarding the possibility of future overdose was reduced in those with recent experience of overdose in comparison to the rest of the sample. A targeted intervention aimed at the reduction of overdose among heroin users is outlined.
Adolescent↗
Gender differences in the psychological determinants of cigarette smoking.
AIMS: To compare the distributions of smoking-related variables and the size of associations between these variables in men and women. DESIGN AND PARTICIPANTS: Mail survey in 2934 daily smokers (1533 women and 1401 men) who volunteered for a smoking cessation trial. Follow-up after 7 months in 2456 people (84%). SETTING: Community setting (French-speaking part of Switzerland, 1998). FINDINGS: Women smoked less than men (18 versus 22 cigarettes per day, p < 0.001), had lower confidence in their ability to refrain from smoking, used more frequently the strategy defined as 'coping with the temptation to smoke' and reported more drawbacks of smoking (gender differences ranged between 0.1 and 0.3 standard deviation units on these scales). There was no gender difference in the distribution of smokers by stage of change. At follow-up, smoking cessation rates were similar in men and women (6% versus 5%, p=0.3). Intention to quit, quit attempts in the previous year and a more frequent use of self-change strategies predicted smoking cessation and were associated with tobacco dependence in both sexes. A more frequent use by women of coping strategies suggests that some women are 'self-restrained' smokers who control their smoking permanently. This could explain lower smoking rates in women. The size of associations between smoking-related variables was similar in men and women. CONCLUSIONS: Even though there were gender differences in the distributions of some smoking-related variables, associations between these variables were similar in men and women. This suggests that smoking behaviour is regulated by similar psychological mechanisms in men and women.
Adaptation, Psychological↗
Prevalence and correlates of intravenous methadone syrup administration in Adelaide, Australia.
AIMS: The aims of this study were to determine the prevalence of methadone syrup injecting in Adelaide, South Australia and to characterize methadone injectors, including their heroin use and risk behaviours associated with heroin overdose. DESIGN: Cross-sectional design. SETTING: Community setting, principally metropolitan Adelaide. PARTICIPANTS: Current heroin users (used heroin in the last 6 months), recruited through snowballing. MEASUREMENTS: Structured questionnaire. FINDINGS: Of 365 participants, 18.4% reported having ever injected methadone syrup and 11.0% had injected methadone in the last 6 months. Those that had injected methadone were more likely to be male, and were more likely to be receiving methadone maintenance. They were also maintained on higher doses of methadone than subjects not injecting methadone. A history of methadone injection was associated with more heroin overdose experiences and greater dependence on heroin. Methadone injectors were also more likely to engage in risky behaviours associated with heroin overdose, including using heroin when no other people were present, not trial-tasting new batches of heroin and polydrug use. CONCLUSIONS: Methadone syrup injectors appear to be at greater risk of a series of harms than subjects not injecting methadone. The prevalence of methadone syrup injecting in Adelaide, South Australia was 11%, which was lower than prevalence in Sydney, New South Wales, but higher than in Melbourne, Victoria. Jurisdictional differences concerning the prevalence of methadone syrup injecting may reflect differing policies by each state to methadone dispensing.
Adolescent↗
Donepezil is associated with delayed nursing home placement in patients with Alzheimer's disease.
OBJECTIVES: To assess the relationship between donepezil treatment and time to nursing home placement (NHP) for patients with Alzheimer's disease (AD). DESIGN: Observational follow-up of patient NHP and vital status. SETTING: Community. PARTICIPANTS: Patients previously enrolled in one of three randomized, double-blind, placebo-controlled clinical trials of donepezil and two subsequent open-label studies (total N = 1,115); 671 patients provided complete data for analysis. MEASUREMENTS: Data were obtained through follow-up interviews with caregivers and chart reviews of patients with AD. Comparison groups were defined by whether patients received an effective dose of donepezil (>/=5 mg/d; >/=80% compliance) for specific numbers of weeks during the double-blind or open-label trial phase, in both phases, or in neither. Cox proportional hazards models were used to estimate risk ratios for NHP and survival curves from which median times to NHP were estimated for first dementia-related placement of longer than 2 weeks and permanent placement. The models were adjusted for age, sex, baseline Mini-Mental State Examination score, whether the caregiver was a spouse, caregiver continuity, and use of other cholinesterase inhibitors after the clinical trials. RESULTS: Use of donepezil of 5 mg/d or more was associated with significant delays in NHP. A cumulative dose-response relationship was observed between longer-term sustained donepezil use and delay of NHP. When donepezil was taken at an effective dose for at least 9 to 12 months, conservative estimates of the time gained before NHP were 21.4 months for first dementia-related NHP and 17.5 months for permanent NHP. CONCLUSION: Use of donepezil by AD patients resulted in significant delays in NHP. Long-term use of donepezil may help AD patients live longer in community settings, with consequent personal, social, and economic benefits.
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