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PubMed1995

Comprehensive diabetes care in North Tyneside.

The care of a 25% (n = 559) random sample of all patients with diabetes in a district was assessed to determine whether comprehensive diabetes care was being achieved. Process measures initially assessed were repeated 3 years later after several changes in the programme of diabetes care were instituted. The number of patients with diabetes in structured care increased from 91% to 95% between 1991 and 1994, at the same time as an increase in prevalence from 1.2% to 1.8%. There was a shift in the proportion of patients attending primary care from 27% to 40%. There were significant improvements in the delivery of process measures including education. The majority of process measures were delivered to more than 75% of the district diabetes population (for example HbA1c in 93%, fundoscopy in 86%, urine protein in 81%, education on diabetic control in 84%). Comprehensive diabetes care has not yet been fully achieved in North Tyneside district but the programme of care has shown continuous improvement over a 3-year period. Comprehensive diabetes care should be an aim of every district diabetes programme.

Delivery of Health Care↗

PubMed2004

Phonological memory as a predictor of language comprehension in Down syndrome: a five-year follow-up study.

BACKGROUND: This study reports the language and memory progress over five years of 30 adolescents and young adults with Down syndrome, and investigates the relationship of earlier phonological memory abilities to later language development. METHODS: Tests of nonverbal ability, receptive vocabulary, grammar comprehension, digit span and nonword repetition were administered at two points in time. RESULTS: For the sample as a whole, there were significant gains in nonverbal ability, receptive vocabulary and grammar comprehension, but no increases in phonological memory measured by nonword repetition or digit span. However, there were considerable individual differences in progress which, in part, were related to chronological age. Phonological memory improved in many younger participants but there were signs of decline in some older ones. Partial correlations between earlier nonword repetition scores and later language scores, controlling for nonverbal ability and earlier language scores, indicated a significant role for phonological memory in the acquisition of vocabulary knowledge. There was similar evidence of a role for phonological memory in grammar comprehension, but only for younger participants. Earlier receptive vocabulary also predicted later nonword repetition scores, particularly for participants with higher levels of vocabulary knowledge. CONCLUSION: Relationships among the processes involved in language and memory development in Down syndrome may be similar to those established for typical development.

Adolescent↗

PubMedDate not supplied

A comprehensive strategy for the interpretation of quality-of-life data based on existing methods.

OBJECTIVES: Health-related quality of life (HRQL) instruments generally undergo a rigorous development and validation process. In contrast, methods for interpreting HRQL data are varied, and no comprehensive widely applicable procedure exists. Determining whether differences are statistically significant is the most common method, but this yields conclusions that may be difficult to understand in a clinical context or which may be of no practical value. Consequently, there is a need for a comprehensive interpretation strategy that gives results that are meaningful to a variety of audiences, including patients, clinicians, and decision-makers. METHODS: The review of available interpretation strategies revealed that not all methods are applicable to all questionnaires, and some strategies may be difficult to implement for interpreting trial results. In addition, the issues decision-makers may have when assessing HRQL results have not really been addressed: what is measured and what is the meaning beyond statistical significance? RESULTS: A comprehensive stepwise strategy, based on the most effective methods available, has been developed to address the key interpretation issues of decision-makers. It is structured around several steps: understanding the content of the questionnaire; evaluating the magnitude of changes and their statistical significance; determining whether results are clinically significant, e.g., whether the observed changes crossed ranges of established threshold for meaningful differences; comparing pre- and post-treatment scores distribution with norms of references; and relating score changes to other outcomes end points such as morbidity, death, compliance, resource utilization, or productivity. CONCLUSIONS: The proposed strategy should help to structure and successfully address interpretation issues and thus make HRQL results more convincing.

Data Interpretation, Statistical↗

PubMed1994

Comprehensive geriatric assessment in a day hospital.

OBJECTIVE: To assess the effectiveness of comprehensive geriatric assessment conducted in day hospitals. DESIGN: Retrospective cohort comparison study with restricted inclusionary criteria and adjustment for baseline characteristics. SETTING: A hospital-based geriatric day hospital and geriatric clinic sites (both in the university and in the community). PATIENTS: Four hundred sixty-eight patients referred for comprehensive geriatric assessment during a 12-month period. INTERVENTION: Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital. MAIN OUTCOME MEASURES: Services received in the first 2 weeks; hospitalization, emergency room visits, placement, death, and change in selected health status measures. Follow-up data was obtained from medical records, a telephone survey, and death certificates. RESULTS: Except in the case of rehabilitative services, day hospital patients were more likely to receive interdisciplinary services. The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression. After adjusting for subjects' baseline characteristics and limiting the analyses to subjects meeting specific inclusionary criteria, the day hospital had no significant effect on mortality, use of emergency or hospital services, placement, or change on selected measures of health status. For example, compared with the clinic patients, receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 (95% confidence interval: 0.53, 1.91) of being at a higher level of care at 6 months. The results were not sensitive to the choice of inclusionary criteria. CONCLUSION: Given their cost and uncertain effectiveness, day hospitals need additional evaluation before their further diffusion occurs.

Activities of Daily Living↗

PubMed1998

The association between chronic illness and functional change among participants in a comprehensive geriatric assessment program.

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.

Activities of Daily Living↗

PubMed1989

Correlation of manual dexterity and comprehension with oral hygiene and periodontal status in mentally handicapped adults.

Although there is relatively little information concerning the oral health of handicapped adults there is increasing evidence to suggest that their oral condition, particularly periodontal health, is poor. The present investigation involved assessment of 382 handicapped patients attending four different Adult Training Centres in Birmingham. The caries status, oral hygiene, and periodontal conditions were evaluated and the Community Periodontal Index of Treatment Need (CPITN) was calculated. In order to assess the manual dexterity and the comprehension of the trainees a standard test was devised. This consisted of timing each participant in carrying out simple instructions to pick up and position certain common objects. The results indicated high levels of plaque, calculus, and bleeding with a mean CPITN of 7.43. The mean time taken for the manual dexterity and comprehension test was 23.9 seconds with a range from 10 to 80 seconds, S.E.+/- 1.33. This compares with results from 34 "normal" adults of a mean time of 8.2 seconds +/- 1.8 with a range of 6 to 12 seconds. There was no significant correlation between the Manual Dexterity and Comprehension scores and the periodontal indices in the handicapped adults.

Adult↗

PubMed1991

Comprehensive school health programs in Texas public schools.

One goal of the Texas Comprehensive School Health Initiative (TCSHI) involves assessing the status of comprehensive school health (CSH) programs in Texas public schools. This project used a case study approach to establish baseline information regarding CSH programs in selected school districts across the state. Eight researchers were trained to use a case study instrument and procedures for conducting interviews. Seven school districts participated in the survey during fall 1990. Results indicated considerable concern and support for CSH programs but little coordination of programs was evident. Six districts were not organized to address health comprehensively. Generally, school districts were overwhelmed with other responsibilities, so CSH programming was not a priority. Results will be used to revise the survey instrument and further expand the data base.

Adolescent↗

PubMed1993

Health policy reform and comprehensive school health education: the need for an effective partnership.

This article offers a framework for considering how health care reform issues will impact the success of any national movement to implement Comprehensive School Health Education and the potential role that CSHE proponents can play in advocating reforms congruent with CSHE goals. The effectiveness of the CSHE movement within this arena will depend largely on its ability to critically self-diagnose its potential contributions to short-term and long-term positive health outcomes, and on its ability to join forces in ensuring that a variety of health, educational, and social services are made available in nontraditional sites--particularly schools--that are able to reach children and their families. An important step will be to expand the availability of Comprehensive School Health Education throughout the country: only one-half of all states currently mandate Comprehensive School Health Education programs, and implementation is spotty in some of these states. Another boost for the potential role of CSHE proponents can be found in the Year 2000 health objectives, of which more than one-third of 300 objectives geared to promoting health and disease prevention are devoted to the health behavior of school-age children and youth. Many of these objectives can be achieved directly or indirectly in schools, contingent upon appropriate financing and the establishment of CSHE goals as priorities at the policymaking level. An important factor will be the ability of the CSHE movement to provide its programs in the most cost-effective and cost-efficient manner, possibly including redeployment of staff and relocating resources as needed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1999

Partnerships for comprehensive school health: collaboration among colleges/universities, state-level organizations, and local school districts.

A qualitative survey on the collaborative experiences of colleges and universities, state-level organizations, and school districts related to comprehensive school health programs in 12 states found four primary collaborative outcomes: training, consultation, research, and networking. Five common dimensions of collaboration also were identified: interpersonal and organizational interactions, level of awareness and understanding of comprehensive school health programs, organizational priorities and reward systems, political forces, and availability and sharing of resources. The potential for such linkages to advance comprehensive school health programs remains largely untapped. Recommendations for developing such collaborations are presented.

Data Collection↗

PubMed1994

Pictorial support for discourse comprehension.

Discourse comprehension often involves the construction of a mental model of a situation and its updating as the discourse progresses. Theory suggests that a picture which depicts the initial physical situation in a story could help young children construct a functional mental model which they might maintain as the story progresses, thereby supporting comprehension. This was tested with young children, 4 to 6 years of age. The ability of those who saw the picture to model the final story event was enhanced and, even though the picture did not depict the main character's goal directly, recall of the goal was increased. This could be explained in terms of the creation of a functional mental model and the increased opportunity that it provides for linking goal-directed events with the goal as the model is updated. Mental representation theory was found useful here for predicting how to support comprehension in ways which could translate readily into practice in the classroom. Some potential applications of the findings in teaching young children are described.

Child Development↗

PubMed2002

Comprehensive analysis of CD8(+)-T-cell responses against hepatitis C virus reveals multiple unpredicted specificities.

The hepatitis C virus (HCV)-specific CD8(+)-T-cell response is thought to play a critical role in HCV infection. Studies of these responses have largely relied on the analysis of a small number of previously described or predicted HCV epitopes, mostly restricted by HLA A2. In order to determine the actual breadth and magnitude of CD8(+)-T-cell responses in the context of diverse HLA class I alleles, we performed a comprehensive analysis of responses to all expressed HCV proteins. By using a panel of 301 overlapping peptides, we analyzed peripheral blood mononuclear cells (PBMC) from a cohort of 14 anti-HCV-positive, HLA A2-positive individuals in an enzyme-linked immunospot assay. Only four subjects had detectable HLA A2-restricted responses in PBMC, and only 3 of 19 predicted A2 epitopes were targeted, all of which were confirmed by tetramer analysis. In contrast, 9 of 14 persons showed responses with more comprehensive analyses, with many responses directed against previously unreported epitopes. These results indicate that circulating HCV-specific CD8(+)-T-cell responses can be detected in PBMC in the majority of infected persons and that these responses are heterogeneous with no immunodominant epitopes consistently recognized. Since responses to epitopes restricted by single HLA alleles such as HLA A2 do not predict the overall response in an individual, more comprehensive approaches, as shown here, should facilitate definition of the role of the CD8(+)-T-cell response in HCV infection. Moreover, the low level or absence of responses to many predicted epitopes provides a rationale for immunotherapeutic interventions to broaden cytotoxic-T-lymphocyte recognition.

CD8-Positive T-Lymphocytes↗

PubMed2003

Comprehensive drug screening in decision making of patients attending the emergency department for suspected drug overdose.

OBJECTIVES: This study aimed to evaluate the usefulness of a comprehensive drug screening method as a first line diagnostic tool on clinical decision making in patients attending an emergency department for suspected drug overdose in terms of agreement between physicians on patients' disposal. METHODS: Five emergency physicians retrospectively evaluated the records of 142 adult patients, admitted to the emergency department of a community hospital for suspected drug overdose. They were asked for an expert opinion on patients' disposal at the end of the observation period, based on paired records, with/without the results of a comprehensive drug screening. RESULTS: In the absence of the drug screening, a very poor agreement (kappa statistics) was observed between physicians. When the drug screening was available, the interobserver agreement for decision on patients' disposal increased to the fair to good range (global agreement: from 0.238 (0.019) to 0.461 (0.020) (mean(SE)); p<0.001). The agreement also increased when admission to an intensive care unit, to a general ward, and discharge from hospital were separately analysed. The availability of drug screening would have saved 21.7% of hospital admissions and 53.3% of high dependency and/or intensive care unit admissions. CONCLUSION: Comprehensive drug screening adds to decision making for patients attending an emergency department for suspected drug overdose, improving agreement among physicians on patients' disposal and potentially saving hospital resources.

Adult↗

PubMed2004

A combined HPLC-immunoenzymatic comprehensive screening for suspected drug poisoning in the emergency department.

OBJECTIVE: To review the results of a comprehensive drug screening as first line diagnostic tool in patients attending an emergency department for suspected drug poisoning. METHODS: A comprehensive drug screening was carried out in plasma or urine, or both, of 310 patients combining an HPLC multidrug profiling system and a fluorescence polarisation immunoassay. RESULTS: In 64.2% of cases the screening confirmed the diagnosis of drug poisoning, in 13.9% suspected drugs were measurable at non-toxic concentrations, and in 21.9% no drugs were found. The suspected drugs were fully confirmed in a minority of cases, (symptomatic patients: 28.2% compared with asymptomatic: 16.5%). Symptomatic patients were less likely to have at least one suspected drug (29.6% compared with 57.7%; p<0.001), and more likely to have at least one unsuspected drug found at analysis (17.4% compared with 3.1%; p = 0.005). In 5% of patients, asymptomatic when first observed, one or more unsuspected drugs were found. In 6 of 29 patients, with suspected poisoning of an unspecified drug, the screening identified the specific drug and excluded acute intoxication in the remaining cases. CONCLUSION: A rapid comprehensive drug screening adds to the diagnosis of patients with suspected drug poisoning, identifying unsuspected drugs in symptomatic patients and excluding drugs in asymptomatic subjects.

Acute Disease↗

PubMed1990

Comprehension of prosody in Huntington's disease.

Patients with Huntington's Disease (HD) who were without dementia were compared to unilateral stroke patients and controls as previously reported in 1983, to discover if they had a prosodic defect. Subjects were presented tape-recorded speech filtered sentences and asked to indicate the tone of voice as happy, sad or angry (affective prosody), or as a question, command or statement (propositional prosody). HD patients were impaired in comprehension of both types of prosody compared to controls but were not different from stroke patients. A second study compared early HD patients with at-risk siblings and spouse controls on comprehension of affective and propositional prosody, discrimination of both types of prosody, rhythm discrimination and tonal memory (Seashore tests). HD patients were impaired in both comprehension and discrimination of all types of prosody. HD patients were less accurate than at-risk patients on the tonal memory task but not on the rhythm discrimination task. These findings suggest compromise in ability to understand the more subtle prosodic aspects of communication which may contribute to social impairment of HD patients very early in the course of the disease.

Attention↗

PubMed2000

Effectiveness of comprehensive tobacco control programmes in reducing teenage smoking in the USA.

OBJECTIVE: To describe the extent to which comprehensive statewide tobacco control programmes in the USA have made progress toward reducing teenage smoking. DATA SOURCES: Literature search of Medline for reviews of effectiveness of programme and policy elements, plus journal articles and personal request for copies of publicly released reports and working papers from evaluation staff in each of the state programmes of California, Massachusetts, Arizona, Oregon, and Florida. STUDY SELECTION: All studies, reports, and commentaries that provided information on aspects of programme implementation and evaluation. DATA SYNTHESIS: Statewide comprehensive programmes show high levels of advertising recall and generally positive improvement in smoking related beliefs and attitudes among teenagers. More fully funded programmes lead to increased mass media campaign advertising and community initiatives; a greater capacity to implement school based smoking prevention programmes; and an increase in the passage of local ordinances that create smoke free indoor environments and reduce cigarette sales to youth. The combination of programme activity and increased tobacco tax reduce cigarette consumption more than expected as a result of price increases alone, and these effects seem to apply to adolescents as well as adults. Programmes are associated with a decline in adult smoking prevalence, with these effects observed to date in California, Massachusetts, and Oregon. Arizona and Florida have yet to examine change in adult prevalence associated with programme exposure. California and Massachusetts have demonstrated relative beneficial effects in teenage smoking prevalence, and Florida has reported promising indications of reduced prevalence. Arizona has yet to report follow up data, and Oregon has found no change in teenage smoking, but has only two years of follow up available. One of the most critical factors in programme success is the extent of programme funding, and consequent level of programme implementation, and the degree to which this is undermined by the tobacco industry and other competitors for funding. CONCLUSIONS: Despite the different strengths and combinations of programme messages and strategies used in these comprehensive programmes, there is evidence that they lead to change in factors that influence teenage smoking, and to reductions in teenage smoking.

Adolescent↗

PubMedDate not supplied

Comprehension of emotional information in patients with aphasia.

Comprehension of emotional information has traditionally been attributed to right hemispheric processing. Especially nonverbal emotional communication seems to be much better than verbal competence in aphasics. Yet evidence stressing the importance of the left hemisphere for an adequate interpretation of emotional information has been reported. This article reports data on two experiments primarily aimed at emotional inferences in text comprehension. Patients with cortical lesions in their left vs. right hemisphere showed similar deficits in perceiving both verbal and nonverbal emotion tasks. The question arises, which underlying deficits may result in these similar comprehension patterns. Best predictors in regression analyses differed for patients with left hemisphere and right hemisphere lesions.

Affect↗

PubMed2005

Rehabilitation of left brain-damaged ischemic stroke patients: the role of comprehension language deficits. A matched comparison.

BACKGROUND: Aphasia is considered a risk factor for disability after stroke. The aim of this study was to assess the specific influence of aphasia on rehabilitation results. METHOD: A case-control study in consecutive left brain-damaged stroke inpatients, enrolled in three homogeneous subgroups [nonaphasic (NA) patients, aphasic with comprehension deficit (CD), and without comprehension deficit (NCD)] matched for age and onset-admission interval. Rehabilitation results (gain, efficiency, effectiveness of treatment, percentage and odds ratio of dropouts and of each degree of therapeutic response, assessed by Barthel Index and Rivermead Mobility Index) were compared among the subgroups. RESULTS: Two hundred and forty patients with sequelae of a first stroke were enrolled. CD patients, as compared with NCD and NA ones, had a significantly more severe basal neurological and functional status at admission, minor effectiveness on ADL and mobility, a higher percentage of low responders on ADL and urinary incontinence at discharge, and a risk of low therapeutic response on ADL nearly 4 times higher than the other patients (OR = 4.22, 95% CI = 1.90-9.38). The rehabilitative behavior between NCD and NA was similar. However, all subgroups (NA, CD and NCD) showed a significant improvement (p < 0.001) between their basal and discharge score, both on BI and RMI. CONCLUSIONS: Comprehension language deficit was confirmed to be a strong negative rehabilitation prognostic factor despite the speech therapy done by all CD patients.

Aged↗

PubMed2004

Rasch analysis of combining two indices to assess comprehensive ADL function in stroke patients.

BACKGROUND AND PURPOSE: To justify the summation of scores representing comprehensive activities of daily living (ADL) function, a Rasch analysis was performed to examine whether items of the Barthel Index (BI), assessing ADL, and items of the Frenchay Activities Index (FAI), assessing instrumental ADL, contribute jointly to a single, unidimensional construct in stroke patients living in the community. The number of scoring points of both indices was examined for their usefulness in discerning the various ability levels of ADL in these patients. METHODS: A total of 245 patients at 1 year after stroke participated in this study. The BI and FAI were administered to the patient and/or the patient's main caregiver by interview. RESULTS: The initial Rasch analysis indicated that the middle scoring points for many items of the BI and FAI could be collapsed to allow only dichotomous response categories. All but 2 items of the FAI, social occasions and walking outside, fitted the model's expectations rather well. These 2 items were excluded from further analysis. A factor analysis performed on the residuals of the Rasch-transformed scores recovered no dominant component. These results indicate that the combined 23 dichotomous items of the BI and FAI assess a single unidimensional ADL function. CONCLUSIONS: A clinically useful assessment of the comprehensive ADL function of patients at or later than 1 year after stroke can be obtained by combining the items of the BI and FAI (excluding 2 FAI items) and simplifying the responses into dichotomous categories. It is also demonstrated that the items of the new scale measure comprehensive ADL function as a single unidimensional construct when assessed at 1 year after stroke.

Activities of Daily Living↗