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PubMedDate not supplied

Epidemiology in community psychiatric research: common uses and methodological issues.

OBJECTIVE: Epidemiological principles underpin much medical research particularly that concerned with the planning and evaluation of health services, including research in community and social psychiatry. The aim of this paper is to review some of the common uses of epidemiology in community psychiatric research and to discuss some methodological issues that arise frequently in epidemiological research in community settings. METHODS: This is a review of the relevant literature and of the work currently in progress in the department of psychological medicine of the university of Wales College of Medicine. RESULTS: Among the many uses of epidemiology in health care, four are especially relevant in community psychiatric settings: the assessment of the mental health needs of the population (four approaches are described: the collection of routine data, surveys of existing patients, surveys of the general population and statistical modelling), the identification of risk factors of disease, the contribution to prevention and the assessment of the clinical effectiveness of health care interventions. The most important methodological issues include causal inference which in epidemiology takes the form of explaining the association between an exposure and disease (chance, bias, confounding, reverse causality and causality), the issue of confounding and how to adjust for it and issues arising in the context of specific study designs. CONCLUSION: Epidemiology has become a set of methods used to investigate a wide range of clinical questions. Population based research is an essential part of clinical research but epidemiological knowledge is also needed by clinicians in order to critically appraise and interpret the scientific literature.

Bias↗

PubMedDate not supplied

Development of a nurse-managed, school-based health center.

As the healthcare environment continues to change, nurses are developing models for interdisciplinary care in a variety of community settings. The high school is an ideal treatment setting for the delivery of health services to adolescents. This article describes the development of a nurse-managed, school-based health center. The steps in planning and implementing this interdisciplinary service and training site are outlined to provide a guide for nurses wishing to develop autonomous community practice settings.

Adolescent↗

PubMed1996

The virtual clinical campus.

The increased use of community sites for the clinical training of medical students creates many challenges for educators. Among them is the need to provide students in community settings with access to the same range of educational resources-the medical literature, student colleagues, feedback, and faculty-that are customarily available at academic medical centers. One way to make this access possible is to use information technology to create a "virtual clinical campus," which would allow students to enjoy the best of both worlds: the immersion in primary care offered by the community-based setting and the knowledge-rich resources of the academic medical center, including the all-important library. With a virtual campus in place, students would be able to access most library resources, interact with their peers, ensure that they were meeting the goals of their community rotations, and participate with their colleagues in didactic sessions without having to travel. The virtual campus is technologically feasible and economically within reach. It is possible that the movement of clinical training into the community will make it imperative for all medical students to own their own computers and for medical centers to provide the infrastructure that would enable community sites to have access to a range of educational resources.

Clinical Clerkship↗

PubMed2001

Living with support in a home in the community: predictors of behavioral development and household and community activity.

The purpose of this article was to review studies of behavioral development and household and community activity among adults with mental retardation living in community residential services and to distill knowledge about the factors that influence outcome. Research points to behavioral development occurring across the full spectrum of disability but influenced by mental retardation syndrome and the acquisition of pivotal skills. However, engagement in household and community activities has been found to be strongly related to individual adaptive behavior. People with more severe mental retardation are vulnerable to leading lives characterized by underoccupation and lack of community involvement. Moving from institutional to community-based residential services may be accompanied by significant increases in adaptive behavior, but a plateau effect on subsequent development has also been reported. There is substantial evidence to suggest that key aspects of effective teaching technology may be absent in community-based residential environments. Community settings support greater engagement in household and community activities than institutions. Ordinary housing stock and normative architecture and standards of material enrichment are to be preferred. The use of normative housing constrains group living to relatively small scale, but there is little evidence that smaller size within this range is to be preferred to larger size. There is little evidence to suggest that higher staff-to-resident ratios lead to uniformly better outcomes, but staff orientation, working methods, and performance are important influences. Little is known about what precise characteristics of community location give rise to greater community integration. MRDD Research Reviews 7:75-83, 2001.

Adaptation, Psychological↗

PubMed2001

Violence against women and the assaulted staff action program.

Women have been subjected to high rates of victimization at home, in the community, and at work. An earlier study found female inpatient staff to be at risk for same-gender patient assaults in psychiatric hospitals and female community residential staff to be at increased risk for assaults from male patients in residences. This study sought to revisit the original 2-year findings during a subsequent 6-year period. Inpatient and community assault data were gathered within the context of the Assaulted Staff Action Program (ASAP), a post-incident crisis response approach. Female inpatient staff were again found to be at increased risk in both inpatient and community settings. However, in this second study, female community residential staff were found to be at increased risk for assault from both male and female patients. The findings and their implications are discussed.

Adult↗

PubMed2003

The nurse-community health advocate team for urban immigrant primary health care.

PURPOSE: To describe: (a) development and implementation of an urban outreach health program for Latino immigrants; (b) nurse-community-health advocate (CHA) partnership roles in primary health care delivery, and (c) lessons learned from these activities over 7 years in urban community settings. METHODS: Descriptive study of a community-based health project in a large Midwestern American city. Information was gathered from participants and staff, from observing staff, and from a variety of sources to describe the program and its individual, family, and community effects. FINDINGS: Major findings pertain to the project team's ability to address the health promotion needs of Latino immigrant families and to successfully incorporate CHAs in planning and implementing the program. CHAs were a "bridge" between health programs and the community, promoting cultural sensitivity. CHAs and nurses provided a range of services including health education and promotion, outreach through home visits, assessment of family needs for referrals to appropriate resources, and follow-up support. CONCLUSIONS: The nurse-CHA team was an effective strategy for promoting Latino immigrant families' access to needed health care. This framework allowed for flexibility in assisting clients of different cultural backgrounds to obtain appropriate health care.

Attitude of Health Personnel↗

PubMed2001

Is the standard compliance check protocol a valid measure of the accessibility of tobacco to underage smokers?

OBJECTIVE: To determine if the standard compliance check protocol is a valid measure of the experience of underage smokers when purchasing tobacco in unfamiliar communities. SETTING: 160 tobacco outlets in eight Massachusetts communities where underage tobacco sales laws are vigorously enforced. PROCEDURE: Completed purchase rates were compared between underage smokers who behaved normally and inexperienced non-smoking youths who were not allowed to lie or present proof of age (ID). RESULTS: The "smoker protocol" increased the likelihood of a sale nearly sixfold over that for the non-smokers (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.5 to 22). When the youths presented an ID with an underage birth date, the odds of a completed sale increased dramatically (OR 27, 95% CI 3.4 to 212). Clerks judged to be under 21 years of age were seven times more likely to make an illegal sale (OR 7.6, 95% CI 2.4 to 24.0). CONCLUSIONS: Commonly used compliance check protocols are too artificial to reflect accurately the experience of underage smokers. The validity of compliance checks might be improved by having youths present ID, and by employing either tobacco users, or non-tobacco users who are sufficiently experienced to mimic the self confidence exhibited by tobacco users in this situation. Consideration should be given to prohibiting the sale of tobacco by individuals under 21 years of age.

Adolescent↗

PubMed2004

Strengthening community-based programming for juvenile sexual offenders: key concepts and paradigm shifts.

The past decade has been witness to a sharp increase in residential placement of adjudicated delinquent youth, including juvenile sexual offenders. It is argued that this trend has fiscal implications and may be clinically contraindicated for less characterologically disturbed and dangerous youth. The authors advocate greater investment of public funds in the development and refinement of community-based intervention programs. It is believed that clinically and legally integrated programming, using newer social-ecological methodologies and supports, offers promise of reducing the number of youth who require residential placement, shortening residential lengths of stay and improving the transition of residentially treated youth back into community settings. Key concepts relevant to bolstering community-based programming for juvenile sexual offenders are identified and discussed. Two programs are described, and program evaluation data reviewed, in support of the viability of innovative community-based approaches to the management of this population.

Community Mental Health Services↗

PubMed2003

Mentoring youth: a service-learning course within a college of nursing.

Faculty at the University of Southern Maine College of Nursing and Health Care Professions developed a service-learning course that connected students and faculty with at-risk children in a local community. Nursing students, with faculty supervision and support, developed, implemented, and evaluated interventions to reduce risk factors and increase protective factors to build and strengthen the participants' resiliency. Students enrolled in the service-learning course worked in the community where they gained an understanding of what it was like for children and adolescents to live in an impoverished community setting with disorganized family units and weak community support. The students learned to collaborate with police, schools, public health nurses, and churches, as well as students in other major programs. The benefits of this course for students and the community were far reaching and even life changing.

Adolescent↗

PubMed2006

Clinical perspectives on atypical antipsychotics for treatment of agitation.

In the past, the use of atypical antipsychotics in treating acute agitation was limited by a lack of data in behavioral emergencies and by the lack of intramuscular formulations or alternate rapid-acting oral formulations. This article evaluates current data from studies of atypical antipsychotics in agitated patients in both short- and long-term care settings. For patients with underlying psychosis, intramuscular atypical antipsychotics are effective and help ease the transition from intramuscular therapy in the acute care setting to oral dosing in inpatient or community settings. Evidence exists that atypical antipsychotics demonstrate antiagitation effects in schizophrenic patients for as long as 10 weeks and that overall clinical response may be partly mediated by these antiagitation properties. Intramuscular and oral atypical antipsychotics effectively treat acute agitation in both emergency and long-term care settings. For bipolar patients, these agents are valid therapeutic options for acute as well as longer-term alleviation of manic symptoms, including agitation. Safety concerns, however, limit their use in agitated elderly patients with dementia.

Acute Disease↗

PubMed1990

Nutritional status and dietary management of elderly diabetic patients.

Dietary treatment of diabetes has long been the cornerstone of management of this common disease. Recent recommendations to increase the proportion of carbohydrate with concomitant reduction of dietary fat appear to be prudent, but scant data are available to support this supposition in the elderly. Modification of the source of carbohydrate as a means of providing better blood glucose control is based on limited data in controlled settings and needs to be tested in community settings before widespread alterations in the dietary composition can be widely recommended. Current recommendations for protein composition of the diet are probably adequate for the elderly diabetic patient who does not have obvious protein depletion. General guidelines for the dietary management of elderly diabetic patients are summarized in Table 5. Management of the elderly diabetic patient presents a strong challenge to the physician. Dietary recommendations for such patients should be highly individualized; patients' food preferences, ethnic background, financial resources, and support system should be taken into consideration. Simple recommendations drafted with the help of the patient are more likely to be successful. The elderly are often at risk for nutritional deficiency, and the presence of chronic disease such as diabetes profoundly affects metabolism, putting these individuals at still higher risk. Unfortunately, our current understanding of this problem is limited and additional research in this area is essential.

Aged↗

PubMed2006

An analysis of the feasibility of home rehabilitation among elderly people with proximal femoral fractures.

OBJECTIVE: To evaluate the feasibility and predictors of success of home-based rehabilitation (HBR) in older adults after hip fracture. DESIGN: Prospective inception cohort study with 12 months of follow-up. SETTING: Acute and subacute care with follow-up in a community setting in Italy. PARTICIPANTS: Community-dwelling older adults (N=199) aged 70 years or older, discharged from an acute orthopedic unit after repair of a nontraumatic proximal femoral fracture. INTERVENTIONS: Patients' choice of pursuing HBR or institutional-based rehabilitation (IBR). MAIN OUTCOME MEASURES: Proportion of subjects discharged home for rehabilitation. Rates of institutionalization assessed at 3, 6, and 12 months postdischarge. Mean changes of the Barthel Index from baseline and proportion of subjects who regained their prefracture levels of function at the time of follow-up in the 2 intervention groups (HBR, IBR). RESULTS: Ninety-nine (49.7%) patients chose HBR, and the rest (50.3%) were discharged to a rehabilitation facility. With regard to the baseline characteristics, the 2 patient groups (HBR, IBR) differed with respect to living arrangement (P< or =.001), prefracture functional status in basic (Barthel Index, P=.033; Katz Index, P=.041) and instrumental activities of daily living (IADLs) (P=.041), and occurrence of delirium (P=.022). During the follow-up, the number of subjects institutionalized at 3, 6, and 12 months was 52, 26, and 22, respectively. In the multiple logistic regression model, the only significant variable affecting the choice of IBR at discharge was the absence of relatives at home (odds ratio [OR], 6.7; 95% confidence interval [CI], 3.33-13.46; P< or =.001), whereas a prefracture functional impairment in more than 3 IADLs (at 12 mo: OR=3.99; 95% CI, 1.57-10.18; P=.004), the absence of relatives at home (at 12 mo: OR=8.81; 95% CI, 2.47-31.46; P=.001), and delay to surgery longer than 3 days (at 12 mo: OR=5.51; 95% CI, 1.28-23.81; P=.022) resulted in significant risk factors for long-term institutionalization. Compared with subjects who received traditional rehabilitation, those discharged home showed--after controlling for prefracture Barthel Index score, IADLs, cognitive status and age--a slightly lower functional decline and a higher rate of recovery during the follow-up (mean change in Barthel Index score +/- standard deviation at 12 mo: HBR, -11.2+/-24.7 vs IBR, -23.7+/-28.5; P=.015). CONCLUSIONS: In an unselected population of hip-fractured older adults previously living in the community, HBR seems to be a feasible alternative to IBR in those subjects living with relatives.

Activities of Daily Living↗

PubMed2005

Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting.

Community-acquired pneumonia (CAP) is a common illness with high rates of morbidity and mortality. Nearly 80% of the treatment for this condition is provided in the outpatient setting. Among the etiologic agents associated with bacterial CAP, the predominant pathogen is Streptococcus pneumoniae. Treatment of CAP for the most part is empirical; therefore, any antibiotic treatment should cover both typical and atypical pathogens. The beta-lactams have historically been considered standard therapy for the treatment of CAP. However, the impact of rising resistance rates is now a primary concern facing physicians. For patients with comorbidities or recent antibiotic therapy, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone. Fluoroquinolones are broad-spectrum antibiotics that exhibit high levels of penetration into the lungs and low levels of resistance. Evidence from clinical trials indicates clinical success rates of > 90% for moxifloxacin, gatifloxacin, and levofloxacin in the treatment of CAP due to S pneumoniae. Data from comparative clinical trials suggest fluoroquinolone monotherapy is as efficacious as beta-lactam-macrolide combination therapy in the treatment of CAP patients. The respiratory fluoroquinolone levofloxacin has also been shown to be effective in CAP patients for the treatment of macrolide-resistant S pneumoniae. The use of azithromycin, telithromycin, and fluoroquinolones in short-course regimens has been shown to be efficacious, safe, and tolerable in patients with CAP. Based on clinical evidence, high-dose, short-course therapies may represent a significant advance in the management of CAP.

Ambulatory Care↗

PubMed2000

Carotid endarterectomy for severe asymptomatic carotid stenosis: a perioperative experience at a community hospital.

The purpose of this study was to evaluate the safety and feasibility of carotid endarterectomy (CEA) for severe asymptomatic carotid stenosis in a community setting with direct surgical resident participation. The medical records of all patients who had undergone CEA for severe asymptomatic carotid stenosis between 1989 and 1997 were retrospectively reviewed to ascertain perioperative morbidity and mortality. One hundred forty-seven CEAs were performed on 131 patients over the 8-year interval. Perioperative stroke and death rate was 0 per cent. However, one patient had a postoperative transient ischemic attack, and one patient had vocal cord dysfunction due to vagus nerve injury (1.3%). Three other patients had perioperative complications not directly related to CEA (2.1%). Therefore the total perioperative complication rate of (3.4%) compares favorably with results reported by several large tertiary referral centers. CEA for severe asymptomatic carotid stenosis can be safely performed in a community hospital setting with direct surgical resident participation.

Aged↗

PubMedDate not supplied

A cost-benefit analysis of community and institutional placements for persons with mental retardation in Oklahoma.

Matched samples of 174 pairs of persons with mental retardation who live in either community settings or congregate care settings were compared on both cost and outcome dimensions. It was learned that costs were significantly lower in community programs. Greater levels of service and integration were evident in the community programs, but institutional programs offered vocational opportunities for more individuals. Although we were able to predict with accuracy who lived in community and institutional settings, we were unable to predict costs.

Adult↗

PubMed1999

[Pediatric research in an office-setting network--a new dimension in pediatric research in Israel].

Pediatric care in the community is gradually replacing traditional care in hospitals. Despite that, research activity in the community setting is minimal due to objective difficulties. These are mainly constraints of time, office work and lack of research-supporting logistics. In the past decade, throughout the world, primary physicians interested in research have grouped together and formed research networks. The aim of such networks is to support and promote research in the community. An Israel Pediatric Research in Office-Setting network (IPROS) was established 2 years ago by the Israel Ambulatory Pediatric Association (IAPA). Today, there are over 140 pediatricians listed in IPROS, representing the heterogeneous composition of pediatricians in Israel. The network's policy is defined by a joint steering committee. The committee is composed of IAPA representatives, senior network members and Schneider Hospital senior investigators. The research subjects are diverse, and represent common practical issues. Effective intra-net communication is vital to the existence of the network, and is accomplished by 3 modalities: 1) semiannual updates by mail, 2) e-mail, using an electronic mailing list to facilitate connection between members, 3) semi-annual meetings. Research budgets are derived from public sources like the Ministry of Health and IAPA, and private sources such as pharmaceutical companies. The administration of the network is supported by Schneider Children's Medical Center, and financed by IAPA.

Ambulatory Care↗

PubMed1994

A multileaf collimator field prescription preparation system for conventional radiotherapy.

PURPOSE: The purpose of this work is to develop a prescription preparation system for efficient field shaping using a multileaf collimator that can be used in community settings as well as research institutions. The efficiency advantage of the computer-controlled multileaf collimator, over cerrobend blocks, to shape radiation fields has been shown in conformal treatments, which typically require complete volumetric computerized tomographic data for three-dimensional radiation treatment planning--a utility not readily available to the general community. As a result, most patients today are treated with conventional radiation therapy. Therefore, we believe that it is very important to fully use the same efficiency advantage of multileaf collimator as a block replacement in conventional practice. METHODS AND MATERIAL: The multileaf collimator prescription preparation systems developed by us acquires prescription images from different sources, including film scanner, and radiation treatment planning systems. The multileaf collimator angle and leaf positions are set from the desired field contour defined on the prescription image, by minimizing the area discrepancies. Interactive graphical tools include manual adjustment of collimator angle and leaf positions, and definition of portions of the field edges that require maximal conformation. Data files of the final leaf positions are transferred to the multileaf collimator controller via a dedicated communication link. RESULTS: We have implemented the field prescription preparation system and a network model for integrating the multileaf collimator and other radiotherapy modalities for routine treatments. For routine plan evaluation, isodose contours measured with film in solid water phantom at prescription depth are overlaid on the prescription image. Preliminary study indicates that the efficiency advantage of the MLC over cerrobend blocks in conformal therapy also holds true for conventional treatments. CONCLUSION: Our model of computer-controlled prescription, evaluation, and treatment using multileaf collimators can be effectively implemented in both community settings and research institutions. The resultant increase in treatment efficiency and accuracy is now available for conventional radiotherapy.

Humans↗

PubMed1995

A multileaf collimator field prescription preparation system for conventional radiotherapy.

PURPOSE: The purpose of this work is to develop a prescription preparation system for efficient field shaping using a multileaf collimator that can be used in community settings as well as research institutions. The efficiency advantage of the computer-controlled multileaf collimator, over cerrobend blocks, to shape radiation fields has been shown in conformal treatments, which typically require complete volumetric computerized tomographic data for three-dimensional radiation treatment planning--a utility not readily available to the general community. As a result, most patients today are treated with conventional radiation therapy. Therefore, we believe that it is very important to fully use the same efficiency advantage of multileaf collimator as a block replacement in conventional practice. METHODS AND MATERIAL: The multileaf collimator prescription preparation system developed by us acquires prescription images from different sources, including film scanner and radiation treatment planning systems. The multileaf collimator angle and leaf positions are set from the desired field contour defined on the prescription image, by minimizing the area discrepancies. Interactive graphical tools include manual adjustment of collimator angle and leaf positions, and definition of portions of the field edges that require maximal conformation. Data files of the final leaf positions are transferred to the multileaf collimator controller via a dedicated communication link. RESULTS: We have implemented the field prescription preparation system and a network model for integrating the multileaf collimator and other radiotherapy modalities for routine treatments. For routine plan evaluation, isodose contours measured with film in solid water phantom at prescription depth are overlaid on the prescription image. Preliminary study indicates that the efficiency advantage of the MLC over cerrobend blocks in conformal therapy also holds true for conventional treatments. CONCLUSION: Our model of computer-controlled prescription, evaluation, and treatment using multileaf collimators can be effectively implemented in both community settings and research institutions. The resultant increase in treatment efficiency and accuracy is now available for conventional radiotherapy.

Equipment Design↗