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PubMed2001

Screening for thyroid disease of 15-17-year-old schoolchildren in an area with normal iodine intake.

OBJECTIVE: The prevalence of thyroid disease in Swedish schoolchildren is today insufficiently known. The aim of the study was therefore to determine the prevalence of abnormal thyroid function and thyroid autoimmunity in teen-age schoolchildren and to compare the findings with a healthy control group of 60-65-year-old inhabitants from the same community. SETTING: A semirural community of approximately 15,000 inhabitants. DESIGN: Cross-sectional study. MAIN OUTCOME MEASURES: Thyroid volume and serum concentrations of serum thyrotropin (TSH), total and free thyroxine (T4), total and free 3,5,3'-triiodothyronine (T3), and antithyroperoxidase antibodies (TPOAb). RESULTS: Four schoolchildren (7%, 59 screened) had elevated TPOAb concentration, three of the subjects being girls (8%). One girl with a goitre was overtly hypothyroid and one girl showed borderline-high serum TSH concentration suggesting subclinical autoimmune thyroid disease. One euthyroid boy had a goitre and high concentration of TPOAb. The serum free T3 concentration was significantly higher in 15-17-year-old than 60-65-year-old (7.4 vs. 6.4 pmol L(-1), P < 0.001). The concentrations of other thyroid hormones and of TSH in 15-17-year-old did not differ from those of the 60-65-year-old. CONCLUSIONS: We found three cases of thyroid disease in need of immediate attention or later follow-up. The prevalence of autoimmune thyroid disease was high as indicated from TPOAb measurements. Thyroid tests including TPOAb measurement should be performed on wide indications when teenagers seek medical advice. The reference intervals for teen-age children for commonly used first line tests (TSH and free T4) do not differ from those for adults.

Adolescent↗

PubMed2001

Comparison of two sites of inflow pressure measurement during retrograde cerebral perfusion.

OBJECTIVE: To determine whether internal jugular venous valves influence inflow pressure during retrograde cerebral perfusion. DESIGN: Prospective study. SETTING: Community hospital, university setting, single institution. PARTICIPANTS: Ten patients undergoing reconstructive aortic arch surgery with profound hypothermic circulatory arrest. INTERVENTIONS: During retrograde cerebral perfusion, inflow pressure was continuously measured at 2 separate sites relative to the left internal jugular venous valve (ie, superior vena cava inflow catheter [infravalvular pressure] and rostral left internal jugular vein [supravalvular pressure]). MEASUREMENTS AND MAIN RESULTS: Infravalvular pressure of 29.8 +/- 3.5 mmHg and supravalvular pressure of 22.7 +/- 0.8 mmHg were significantly different (mean difference, 7.1 +/- 3.6 mmHg; p = 0.041). In 8 patients, the pressure difference was <6 mmHg; whereas in 2 patients, the pressure difference was >20 mmHg. Bland and Altman analysis revealed 95% limits of agreement on mean bias of -12.9 to 27.8 mmHg. CONCLUSION: Internal jugular venous valves can obstruct retrograde cerebral perfusion inflow, manifest by an inflow pressure difference between the superior vena cava and internal jugular vein. In the presence of competent internal jugular venous valves, measurement of inflow pressure in the superior vena cava may be an inaccurate estimate of actual cerebral perfusion pressure. Internal jugular vein pressure should be monitored to avoid inadvertent cerebral hypoperfusion.

Aged↗

PubMed2006

Physician experience with family presence during cardiopulmonary resuscitation in children.

OBJECTIVE: Family presence during cardiopulmonary resuscitation in children is an emerging practice. Although many hospitals allow this practice, there is scant research on physician attitudes and opinions and on physician views about training for resident physicians. DESIGN: Survey method. SETTING: University and community settings. PATIENTS: We randomly selected 1,200 pediatric critical care and emergency medicine providers from professional association mailing lists. INTERVENTION: The providers were mailed up to two written surveys and two reminder cards. The survey consisted of 40 multiple-choice and short-answer questions about demographics, past experiences, and opinions on pediatric family presence. MEASUREMENTS AND RESULTS: Of 1,200 surveys mailed, 521 were completed (43.4%) and 73 (6.1%) respondents returned the form declining to participate. More than 99% of respondents were physicians. Four hundred and thirty-three respondents (83%) reported participation in pediatric resuscitation with family members present, with a mean of 15 episodes ever and three episodes within the last year. Of those who had ever participated, more than half thought it was helpful for the family, and two thirds believed that parents wanted the option. Ninety-three percent would allow family presence in some situations. Seventy-four percent believed family presence would be stressful for a resident physician, but nearly 80% believed that residents working with children should be educated in this area. CONCLUSIONS: Family presence during cardiopulmonary resuscitation in children is not an uncommon experience for health care providers. Most respondents had resuscitated a child with family members present. The majority thought that presence was helpful to parents and that residents should be trained in this practice.

Adult↗

PubMed2006

An emergency medical services program to promote the health of older adults.

OBJECTIVES: To evaluate the feasibility and effect of an emergency medical services (EMS) program that screened, educated, and referred older adults with unmet needs. DESIGN: A cluster sample design evaluation of an intervention conducted by EMS in one of two communities. SETTING: Two rural communities in upstate New York. PARTICIPANTS: Two hundred fifty-eight intervention-group and 143 control-group community-dwelling older adults receiving emergency care from participating EMS agencies between February 2004 and June 2005. INTERVENTION: EMS providers screened intervention group patients to identify those at risk for falls, influenza, and pneumococcal infections and provided patients educational materials. Patients' physicians were notified of screening results to provide interventions. Control group patients were provided usual care. MEASUREMENTS: Variables included patient demographic and clinical characteristics, the proportion of eligible patients screened, patient risk during EMS care and 14 days later, and patient recollection of receiving educational materials and conversations with physicians regarding needs. RESULTS: Follow-up was successful in 245 (61%) patients. Approximately 80% of intervention-group patients were successfully screened for each item. No differences were identified for characteristics collected at the time of EMS care, but a notable number of patients were at risk for each item. No differences existed between the control or intervention group for process measures such as recollection of receiving educational materials. For outcome measures, only an improvement in pneumococcal vaccination levels was found. CONCLUSION: EMS screening of older adults during emergency responses is feasible, but a simple intervention of providing educational materials to patients during emergency responses and faxing notifications to physicians appears insufficient to address patients' needs.

Aged↗

PubMed1989

Emotionalism after stroke.

OBJECTIVE: To estimate the prevalence of emotionalism after stroke, to assess its relation with other mood disorders, and to identify clinical variables with which it is associated. DESIGN: Descriptive study of a cohort of patients consecutively entered on a community stroke register. SETTING: Community based research project. PATIENTS: A total of 128 patients who had suffered first ever stroke. INTERVENTIONS AND END POINTS: Patients were interviewed by a psychiatrist at 1, 6, and 12 months after stroke. Mood state was assessed by standardised semistructured interview (present state examination) and self report (Beck depression inventory). Intellectual impairment was assessed by mini mental state examination and Frenchay aphasia screening test. In addition, stroke lesions were localised by computed tomography. MAIN RESULTS: Emotionalism was reported by 13 of 89 patients (15%) at one month, 25 of 119 (21%) at six months, and 12 of 112 (11%) at 12 months after stroke. Patients with emotionalism had higher scores on both measures of mood disorder (at 6 months: mean Beck score 10.5 v 6.4; present state examination score 7.2 v 5.1) and more diagnosable psychiatric disorder (at 6 months: 40% v 14%; odds ratio 4.2, 95% confidence interval 1.5 to 11.9). Almost all episodes were provoked by clearly identified and appropriate emotional experiences. Patients with emotionalism also had more intellectual impairment and larger lesions on computed tomography. Lesions in the left frontal and temporal regions were particularly associated with emotionalism: at 6 months 8 of 14 patients (57%) with such lesions had emotionalism compared with 10 of 52 (19%) of those with lesions elsewhere (odds ratio 5.6, 95% confidence interval 1.4 to 22). CONCLUSIONS: Emotionalism is common after stroke. It is neither emotionally meaningless and inappropriate, nor is it found mostly in patients with bilateral brain damage. Emotionalism is associated with symptoms of a more general mood disturbance and is found especially in patients with left frontal and temporal lesions.

Affective Symptoms↗

PubMed2002

Assessing community child passenger safety efforts in three Northwest Tribes.

OBJECTIVE: To identify strengths and weaknesses in community based child passenger safety programs by developing a scoring instrument and conducting observations of child restraint use in three Native American communities. SETTING: The three communities are autonomous Tribal reservations in the Pacific Northwest. Their per capita incomes and rates of unemployment are comparable. METHODS: In each community, 100 children under 5 years old were observed for car seat use. A six item community assessment tool (100 points maximum) awarded points for such items as the type (primary or secondary) and enforcement of child restraint laws; availability of car seats from distribution programs; extent of educational programs; and access to data on vehicle injuries. RESULTS: For children from birth to 4 years, the car seat use rate ranged from 12%-21%. Rates for infants (71%-80%) far exceeded rates for 1-4 year old children (5%-14%). Community scores ranged from 0 to 31.5 points. There was no correlation between scores and observed car seat use. One reason was the total lack of enforcement of restraint laws. CONCLUSIONS: A community assessment tool can highlight weaknesses in child passenger efforts. Linking such a tool with an objective measure of impact can be applied to other injury problems, such as fire safety or domestic violence. The very process of creating and implementing a community assessment can enhance agency collaboration and publicize evidence based "best practices" for injury prevention. Further study is needed to address methodologic issues and to examine crash and medical data in relation to community child passenger safety scores.

Accidents, Traffic↗

PubMed2006

What happens to women who sell sex? Report of a unique occupational cohort.

BACKGROUND/OBJECTIVES: Sex work has been seen as both a health and a social problem. However, there is a paucity of evidence on the longer term impact on health. We explored the health and career paths over a period of 15 years among women who have worked in the sex industry. DESIGN: A longitudinal study of sex workers recruited between 1986 and 1993 and followed for 15 years. Outcome data were obtained through interview, clinic records, or third parties. SETTING: Clinic and community settings in London. PARTICIPANTS: We obtained outcome data on 130 (37%) of the original cohort of 354 women, with a combined follow up of 1247 years. MAIN OUTCOME MEASURES: Vital status, most recent occupation, duration of sex work, sexually transmitted infections (STI), major health problems. RESULTS: The majority (73/124, 59%) were still in the sex industry and had sold sex for a mean of 13.6 years. There were six deaths, a mortality of 4.8 per 1000 person years. Surviving women had a high cumulative risk (110 of 118, 93%) of STI. Past gonorrhoea was associated with pelvic inflammatory disease (RR 2.28, 95% CI 1.12 to 4.66) and infertility (RR 10.9, 95% CI 1.5 to 77.3). Other outcomes included mental health problems (38 of 97, 40%) and addiction (46 of 72, 64%). There were no significant differences in health outcomes between women who were still in the sex industry and those who had stopped. There was a high level of occupational mobility, and 31 women (of 84, 37%) had completed vocational or higher education, including eight to postgraduate level. CONCLUSIONS: Sex work is associated with excess mortality and morbidity including the sequelae of STI, mental health problems, and substance misuse. The relation between these health problems and sex work is complex.

Adolescent↗

PubMedDate not supplied

The impact of asthma management guideline dissemination on the control of asthma in the community.

OBJECTIVE: To measure the impact of asthma management education on the control of asthma in the community. DESIGN: A cross-sectional study comparing three communities. SETTING: Three rural communities in southern Alberta. PATIENTS AND METHODS: A population sample of patients with asthma attending a pharmacy to fill a prescription for asthma medication were selected from three communities. Patients were asked to complete a questionnaire relating to their asthma management and control. INTERVENTION: Three levels of asthma management education were provided in the three communities with populations of 6000 to 10,000. The levels of education ranged from standard continuing medical education programs relating to the national asthma guidelines and a visiting asthma nurse educator to the establishment of an asthma clinic and a multiple-target, intensive education program for health professionals, town leaders, local media, schools and the public. The survey of the population with asthma was conducted approximately one year after the education program had been completed. RESULTS: A total of 327 completed questionnaires were submitted. Analysis showed that there was no significant difference that could be attributed to the intervention in the management of asthma or in the level of asthma control among the patients from the three communities. CONCLUSION: The more intense levels of education used to disseminate the content of the national asthma management guidelines did not translate into improved asthma control in the community.

Adult↗

PubMed2005

Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease.

BACKGROUND: Black subjects with a family history of premature coronary heart disease (CHD) have a marked excess risk, yet barriers prevent effective risk reduction. We tested a community-based multiple risk factor intervention (community-based care [CBC]) and compared it with "enhanced" primary care (EPC) to reduce CHD risk in high-risk black families. METHODS AND RESULTS: Black 30- to 59-year-old siblings of a proband with CHD aged <60 years were randomized for care of BP > or =140/90 mm Hg, LDL cholesterol > or =3.37 mmol/L, or current smoking to EPC (n=168) or CBC (n=196) and monitored for 1 year. EPC and CBC were designed to eliminate barriers to care. The CBC group received care by a nurse practitioner and a community health worker in a community setting. The CBC group was 2 times more likely to achieve goal levels of LDL cholesterol and blood pressure compared with the EPC group (95% CI, 1.11 to 4.20 and 1.39 to 3.88, respectively) with adjustment for baseline levels of age, sex, education, and baseline use of medications. The CBC group demonstrated a significant reduction in global CHD risk, whereas no reduction was seen in the EPC group (P<0.0001). CONCLUSIONS: Eliminating known barriers may not be sufficient to reduce CHD risk in primary care settings. An alternative community care model that addresses barriers may be a more effective way to ameliorate CHD risk in high-risk black families.

Adult↗

PubMed1996

Effects of substance abuse on housing stability of homeless mentally Ill persons in supported housing.

OBJECTIVE: The study examined two-year housing outcomes of homeless mentally ill clients who took part in an experimental investigation of supported housing. The relationships between housing outcomes and client characteristics, such as gender, psychiatric diagnosis, and substance use, were of primary interest. METHODS: A two-factor, longitudinal design was used. Homeless clients in San Diego County who were diagnosed as having chronic and severe mental illness were randomly assigned to four experimental conditions. Half of the clients were given better access to independent housing through Section 8 rent subsidy certificates. All clients received flexible case management, but half were provided more comprehensive case management services. The housing of each individual over a two-year period was classified in one of three categories: stable independent housing, stable housing in another setting in the community, or unstable housing. RESULTS: Clients with access to Section 8 housing certificates were much more likely to achieve independent housing than clients without access to Section 8 certificates, but no differences emerged across the two different levels of case management. Housing stability was strongly mediated by several covariates, especially the presence of problems with drugs or alcohol. CONCLUSIONS: Supported housing interventions can be very successful tools for stabilizing homeless mentally ill individuals in independent community settings. Advantages include the low level of restrictiveness of these settings and the preference of many clients for independent housing. However, the success of supported housing projects is likely to depend strongly on the specific characteristics of the population being served.

Adolescent↗

PubMed2006

Evaluation of the decision support computer program for cancer pain management.

PURPOSE/OBJECTIVES: To evaluate a decision support computer program (DSCP) for cancer pain management. DESIGN: An Internet intervention study to evaluate the usage profile, accuracy, and acceptance of the DSCP. SETTING: Internet and community settings. SAMPLE: 122 nurses working with patients with cancer were recruited through the Internet through a convenience sampling method. METHODS: The instruments included tools for registration and for evaluation of the DSCP. To evaluate the DSCP, the usage profile was measured by counting the total number of cases in which the participants used the DSCP; accuracy was measured by determining whether the decision support from the DSCP was appropriate and accurate; and acceptance was measured using the Questionnaire for User Interaction Satisfaction. MAIN RESEARCH VARIABLES: Usage profile, accuracy, and acceptance of the DSCP. FINDINGS: Participants used the DSCP an average of 1.49 times per person (SD = 1.16). Eighty-eight percent of the participants evaluated the DSCP as appropriate and accurate. The mean scores of overall satisfaction in four major areas of the computer program ranged from 7.46-9.69. CONCLUSIONS: The DSCP could provide accurate and acceptable computerized evidence-based practice guidelines for cancer pain management. IMPLICATIONS FOR NURSING: The findings suggest that researchers should develop decision support systems in multiple aspects and dimensions of cancer pain experience and that hand-held devices would increase the usability of the DSCP.

Decision Support Systems, Clinical↗

PubMed2006

Dynamic interactions between impairment and activity after stroke: examining the utility of decision analysis methods.

OBJECTIVE: To examine the utility of decision analysis methods for examining the dynamic nature of impairment-activity interactions following stroke. DESIGN: Decision analyses (Chi-squared Automatic Interaction Detector) of a prospective cohort study. SETTING: Community and institutional settings based on the location of participants three months after stroke. PARTICIPANTS: Individuals were recruited from consecutive admissions to a regional academic health center and were assessed three months after stroke (N= 67). MAIN OUTCOME MEASURES: Neurological impairment was measured with the National Institutes of Health Stroke Scale (NIHSS). Mobility, self-care and instrumental activities of daily living (instrumental ADL) performance were assessed with a performance observation measure, the Performance Assessment of Self-care Skills (PASS). Decision analysis methods were used to examine interactions between neurological impairments and activity outcomes. RESULTS: Unique neurological impairments were associated with each activity outcome (bowel and bladder urgency interacted with mobility; hand function interacted with self-care; mental functions interacted with instrumental ADL), and these findings are supported by previous studies. The predictive validity of mobility and self-care analyses was stronger than the instrumental ADL analyses. CONCLUSIONS: Decision analysis methods show promise for understanding dynamic impairment--activity interactions. This understanding may enhance methods for informing rehabilitation decisions.

Activities of Daily Living↗

PubMedDate not supplied

Emerging trends in mental health policy and practice.

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.

Comprehensive Health Care↗

PubMed1993

Use of the brief psychiatric rating scale by nurses.

1. Nurses are intimately involved in the assessment of patients in inpatient clinical settings and in community settings--and nurses have a role to play in the systematic rating of severe psychopathology. 2. The Brief Psychiatric Rating Scale (BPRS) provides a means of assessing mental health status from an interview using 16 rating concepts. Analysis of BPRS rating profiles obtained from a variety of patients and settings have consistently revealed four syndromes: withdrawal-retardation, anxious depression, hostile-suspiciousness, and thinking disturbance. 3. Once properly trained regarding the BPRS, nurses can use the scale effectively in the assessment and ongoing monitoring of patient conditions. The scale is an added tool for nurses to use in monitoring the effectiveness and outcome of both medical and nursing interventions.

Clinical Competence↗

PubMed1992

Breast cancer screening among women from 65 to 74 years of age in 1987-88 and 1991. NCI Breast Cancer Screening Consortium.

OBJECTIVE: To compare breast cancer screening rates from the 1991 survey with data from 1987-88 for women aged 65 to 74. DESIGN: Surveys of women from five communities. SETTINGS: Five control communities of the National Cancer Institute's Breast Cancer Screening Consortium. PARTICIPANTS: White, non-Hispanic women, ages 65 to 74; 499 in 1987-88 and 2156 in 1991. Response rates for the first survey wave ranged by area from 65% to 77% and for the second survey wave, from 62% to 85%. MAIN OUTCOME MEASURE: Mammogram and clinical breast examination during the past year and performance of monthly breast self examination, with the screening rates in wave 2 directly standardized to the income and education distribution of wave 1 in each area. RESULTS: Mammography use between waves increased significantly (P < 0.05 after adjusting for education, income, and age) in all but one area (from 19% to 33% in wave 1 to 35% to 59% in wave 2). Among women who had a mammogram, the percent who also had a clinical breast examination decreased between waves from 95% to 85% (P = 0.001). CONCLUSIONS: Mammography in older women increased dramatically over 3 years, although the use of clinical breast examination may be decreasing.

Aged↗

PubMed2001

The incidence of unrecognized myocardial infarction in women with coronary heart disease.

BACKGROUND: Several cohort studies in populations without coronary heart disease have demonstrated that up to 40% of incident myocardial infarctions are clinically unrecognized. OBJECTIVE: To determine the incidence of unrecognized myocardial infarction in women with coronary heart disease in the Heart and Estrogen/progestin Replacement Study (HERS). DESIGN: Randomized, double-blind, placebo-controlled trial of conjugated estrogens plus medroxyprogesterone or identical placebo with 4.1 years of follow-up. SETTINGS: Outpatient and community settings at 20 U.S. clinical centers. PATIENTS: 2763 postmenopausal women younger than 80 years of age with coronary heart disease and an intact uterus. MEASUREMENTS: Annual electrocardiograms were obtained for all participants during follow-up (mean, 4.1 years) and were evaluated by using the NOVACODE computer algorithm and visual confirmation. A total of 13 715 electrocardiograms were obtained. Suspected unrecognized myocardial infarctions were investigated by comparing a participant's previous surveillance electrocardiograms with the electrocardiograms obtained from all of her intervening hospitalizations. Characteristics of patients with recognized and unrecognized myocardial infarction were compared. RESULTS: Among the 256 nonfatal myocardial infarctions, 11 were unrecognized (4.3% [95% CI, 2.2% to 7.6%]). Seven occurred in women assigned to placebo and 4 occurred in women assigned to hormone therapy (P > 0.2). Women with unrecognized myocardial infarction were less likely to have diabetes mellitus or previous angina and were more likely to have had previous bypass surgery compared with women who had clinically recognized myocardial infarction. CONCLUSION: The incidence of unrecognized myocardial infarction in women with coronary disease was far lower than that observed in previous studies of populations without coronary heart disease.

Aged↗

PubMed1995

Les Nouveaux Miserables: modern victims of social asphyxia.

During the past 30 years, social and economic barriers to health care services have increased for many Americans, especially for the nation's most vulnerable populations. Health status actually has declined for certain populations during this time. Meanwhile, national attention has been focused primarily on containing health care costs and on devising strategies for reforming the financing of health care rather than strategies for achieving improvements in the health status of the population. Existing methods of financing health care services, health research priorities, the increasing centralization and compartmentalization of health care services, and the recent failure of national health reform all serve to hinder this nation's progress towards developing a comprehensive and accountable health care system focused on promoting and achieving improved health as well as treating sickness. Recent changes in the health care marketplace, however, including a growing movement toward measuring the outcomes of medical treatments and an emphasis on improving the quality of services, have increased interest among payers and providers of health care services in investing in preventive services. Health maintenance organizations and other integrated health care delivery systems are beginning to devise incentives for increasing preventive care as well as for containing costs. The transformation of the nation's current medical care system into a true health care system will require innovative strategies designed to merge the existing fragmented array of services into coordinated and comprehensive systems for delivering primary and preventive health care services in community settings. The Community-Oriented Primary Care concept successfully blends these functions and has achieved measurable results in reducing health care costs and improving access to preventive services for identified populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Care Costs↗

PubMed2002

Feasibility and effectiveness of a pulmonary rehabilitation programme in a community hospital setting.

BACKGROUND: Pulmonary rehabilitation programmes run in secondary care have proved to be one of the most effective interventions for patients with chronic obstructive pulmonary disease (COPD). AIM: To assess whether a pulmonary rehabilitation programme, similar to that run in secondary care, could be established in a primary care-run community hospital and whether it could achieve similar benefits in patents with moderately severe COPD. DESIGN OF STUDY: Uncontrolled prospective intervention study SETTING: A primary care-run community hospital. METHOD: Thirty-four patients with COPD aged between 5 and 80 years of age (mean = 70years) with a forced expiratory volume (FEV1) of 30 to 50% (mean = 40%) predicted were enrolled in a programme established in the activities room at Honiton Community Hospital. Patients were assessed at the start, on completion of the programme, and six months after completion, using spirometry, shuttle-walking distance, and short form-36 (SF-36) and chronic respiratory questionnaire (CRQ) scores. RESULTS: All but one patient completed the programme. There were significant improvements in the walking distance (by a mean of 100 m), in the SF-36, and in all domains of the CRQ. There was no significant change in the FEV1 or forced vital capacity. CONCLUSION: Pulmonary rehabilitation programmes can be run in community hospitals. They appear to be as effective as those run in secondary care and patients may find them easier to access.

Aged↗