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PubMed2003

Personnel standards and quality assurance practices of biochemical genetic testing laboratories in the United States.

CONTEXT: It has been suggested that specific regulation of laboratories performing genetic testing may be needed to ensure standards and quality assurance, and to safeguard the rights of patients with regard to confidentiality and providing informed consent. Previously, a comprehensive analysis of current practices of molecular genetic testing laboratories was conducted, the results of which have assisted in the assessment of the need for regulation and its impact on access to testing. However, a study designed to determine clinical laboratory practices with regard to biochemical genetic testing has not been carried out. OBJECTIVE: To collect and analyze data regarding availability of clinical biochemical genetic testing, personnel standards, and laboratory quality assurance practices. DESIGN: A mail survey of biochemical genetic testing laboratory directors and assignment of a quality assurance score based on responses to genetic testing process items. SETTING: Hospital-based, independent, and research-based biochemical genetic testing laboratories in the United States. PARTICIPANTS: Directors of biochemical genetic testing laboratories (n = 133; response rate 68.5%). MAIN OUTCOME MEASURE: Laboratory process quality assurance score based on the standards defined by the American College of Medical Genetics Laboratory Practice Committee. RESULTS: Personnel qualifications varied, although all directors had doctoral degrees. The mean quality assurance score was 77% (range 28%-100%). Higher scores were associated with the following variables: test director having an MD degree versus PhD degree (P = .002), director board certification in biochemical genetics (P = .002), research and hospital laboratory versus independent laboratory setting (P < .001), and participation in a proficiency testing program (P = .03). Twelve percent of participants had a confidentiality policy, and 19% required informed consent before testing. CONCLUSION: The finding that a number of laboratories had quality assurance scores that may reflect suboptimal laboratory practices, particularly with regard to reporting practices, suggests that personnel qualification and laboratory practice standards may be in need of improvement to ensure quality in clinical biochemical genetic testing laboratories, as well as the appropriate clinical use of the test results.

Genetic Diseases, Inborn↗

PubMed2004

Academic medicine and quality of medical care.

Academic medicine comprises education, research, and medical care, respectively provided by medical schools, research institutions, and teaching hospitals. Thus far, academic medicine has been unsuccessful in establishing, protecting, promoting, and improving the quality of care. Its role in that area should therefore be reconsidered. Quality improvement activities require constant planning and perseverance, explicit standards of good practice, quantitative measurement, and comparison with previous performance or the performance of others. Preparedness and willingness to change attitude, approach, and behavior are pivotal to the success of such activities. Early exposure of medical students to the principles and practices of quality of care improvement would be a starting point for a life long process of experience-based learning that allows physicians to change and improve practice through the application of relevant knowledge and skills. It is essential that changes in graduate and postgraduate education and training be introduced, to improve an understanding of the importance of focusing on the care process from the patient's perspective as well as on the need for interdisciplinary cooperation and team performance as prerequisites for good medical care. Their education should also emphasize the measurement of the quality of delivered care, provide an understanding of the demand of society for accountability and how to meet it, as well as competence in using the principles and practice of quality improvement to provide, document, and improve the quality of care in institutions of academic medicine.

Academic Medical Centers↗

PubMed1990

Estrogen-replacement therapy in patients with previous endometrial carcinoma.

For patients with previous endometrial cancer, ERT is not the accepted practice in the U.S. The therapeutic dictum that estrogen is contraindicated in patients with previous uterine adenocarcinoma is, however, not substantiated by clinical data. The relation of unopposed estrogen stimulation to endometrial hyperplasia and carcinoma, and the published studies relating ERT to endometrial cancer, have resulted in the clinical perception--and cautionary statements to that effect--that estrogen is contraindicated for patients with a history of endometrial carcinoma. The exact biologic effects of ERT on endometrial adenocarcinoma have not yet been studied adequately, however; the initial clinical data suggest that there is no increase in recurrence or mortality. In the meantime, the clinician is left with contradictory data as a basis for determining the proper management of symptomatic patients. The total impact of estrogen deficiency on the health of women and the ratio of benefits and risks of ERT are yet to be defined completely. The preponderance of evidence suggests that estrogen has a beneficial effect on the major cause of death in women, coronary heart disease, by increasing the high-density lipoprotein (HDL) fraction of cholesterol. It is established that estrogen prevents the demineralization of bone and delays the ravages of osteoporosis. No one has died from vaginal atrophy, bladder dysfunction, or hot flashes; the quality of life and marriage have been improved, however, by relieving these symptomatic conditions with ERT. Several studies have attempted to analyze with various statistical models the ratio of benefits to risks, and the majority of authors have concluded that the beneficial effect on cardiovascular disease alone clearly outweighs any known risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗

PubMed1989

[Legal foundation and practical execution of slaughtering and meat examination of game animals].

Meat regulations also involve game inspection. On the one hand the previous publications dealt with the regulations and their practice concerning game intended for slaughter, especially the control of fences and the gaining of meat. On the other hand regulations concerning game hunted for food (deer: red deer, sika deer, fallow deer, roe deer; horned ungulates: European mufflon, chamois; wild boar; European hare; European rabbit; game such as badger and raccoon) and regulations to be observed by hunters, mainly for the gaining of meat were discussed. At the beginning the following publication completes the previous ones concerning game hunted for food and later deals with the meat inspection of slaughtered game.

Abattoirs↗

PubMedDate not supplied

Intuition in psychiatric-mental health nursing.

A descriptive study was done to explore how psychiatric-mental health nurses define and act on intuition in clinical practice with children and adolescents, and to identify supports for and barriers to taking such action. Interviews of 16 nurses were tape-recorded, transcribed, and analyzed for manifest and latent content. Findings support previous studies about intuition in nursing practice and have implications for psychiatric-mental health nurses working with high-risk populations of children and adolescents.

Adult↗

PubMed1999

Predictors of QoL in renal transplant recipients: bridging the gap between research and clinical practice. Posttransplant Quality of Life Intervention Study Group.

Previous research in quality of life (QoL) in renal transplant recipients has identified three factors predictive of improved QoL: reduction in adverse events, facilitation of employment, and enhancement of social support. After a decade of QoL outcome research, the researchers have proposed a multidisciplinary approach to posttransplant care by developing a clinical pathway using the three predictive factors. Putting into practice the research outcome, this pathway systematically addresses and evaluates each of the study arms and the impact on QoL. A clinical team has been instrumental in developing a model of practice that incorporates the research outcomes.

Critical Pathways↗

PubMed1993

Esophagogastroduodenoscopy by family physicians phase II: a national multisite study of 2,500 procedures.

We have prospectively studied 1,783 upper gastrointestinal tract endoscopy procedures as performed by family physicians from thirteen separate office practices. Phase I of the study previously reported on 717 procedures in which patient management was enhanced, diagnostic yields were high, and biopsies were performed where appropriate. In Phase II, the data totaled 2,500 procedures representing 51.1 years of cumulative practice experience by the entire group. All cases were gathered prospectively and biopsies were confirmed by a pathologist's independent tissue analysis. In this series, family physicians were asked to record all complications, and to specify the exact manner in which performance of the procedure enhanced patient management. There have been biopsies in 1,230 (69% biopsy rate) Phase II cases with biopsy reports available in 1,194 (97% reporting rate) cases. There is pathological confirmation of the family physicians' visual diagnosis in 1,104 of 1,194 (93%) available biopsy reports for a 92% accuracy rate. There have been no complications, and the complication rate for the total series (1/2, 500) is now 0.0004.

Biopsy↗

PubMed1988

Do physicians spend less time with older patients?

In view of the additional time that older persons require for giving and receiving information, as well as for the examination process, it is important for manpower and reimbursement planning to better understand the nature of the physician-patient encounter with the elderly. We examined a series of national surveys of physicians' professional activities and found that physicians tend to spend less time with their older patients and also that encounter time by physicians in different specialties varies widely. Internists and cardiologists spend substantially more time with patients compared with general and family practitioners. For 65-74-year-old ambulatory patients, the average visit lengths are 18.3 minutes for internists, 18.0 for cardiologists, 11.2 for general practitioners, and 12.1 for family practitioners. Compared with ambulatory visit lengths for patients aged 45 to 64 years, average encounter times for 75-year-olds with family physicians were 0.8 minutes shorter, with general practitioners 1.2 minutes shorter, with internists 2.3 minutes shorter, and with cardiologists 3.0 minutes shorter. However, when all characteristics of the visit were considered, the effect of patient age remained significant only for general practitioners. A multivariate analysis of factors related to physician time for ambulatory care showed that more time is associated with multiple problems, problem severity, and the use of diagnostic testing. For general and family practice, the greater the number of previous visits for a problem, the shorter the encounter time is. Additional characteristics associated with shorter physician-patient encounter times include the volume of patients per week and the use of physician assistants within the practice. These findings have implications for medical education and manpower projections.

Age Factors↗

PubMedDate not supplied

Rural child welfare practice from an organization-in-environment perspective.

An "organization-in-environment" perspective can help researchers understand how rurality influences child welfare practice. Drawing from theoretical perspectives on environment and organizations, researchers find rural/urban differences in practice at the level of the organization, which is the immediate environment of child welfare practice, and also in the relationship between organization and environment. Results challenge previous findings of few differences between rural and urban practice and offer particular implications for rural child welfare practice.

Child↗

PubMed2000

A brief history of advanced practice nursing and its implications for WOC advanced nursing practice.

Although the evolution of clinical nurse specialists and nurse practitioners during the previous several decades has led to a sense of novelty regarding advanced practice, it is important to remember that nurses have engaged in such roles for nearly 100 years. This article will review the history of advanced nursing practice, summarize current definitions of specialty and advanced practice, discuss the evolution of advanced practice and its impact on contemporary nursing, and provide a background for advanced practice considerations for the WOC nurse, which are discussed in detail in subsequent articles by Janice Beitz (pp 55-64) and Dorothy Doughty (pp 65-8) in this issue.

History, 20th Century↗

PubMed1996

Cancer occurrence and screening in family practice. A 20-year experience.

BACKGROUND: This article is a sequel to a previously published article describing the occurrence of cancer in a rural family practice and the contribution of screening to the diagnosis of breast, colorectal, and cervical cancer. Together, the two articles describe a 20-year family practice experience in diagnosing and screening for cancer. METHODS: The study is a retrospective chart review of all cancers diagnosed in a family practice from January 1985 through December 1994. Records of a regional tumor registry were reviewed to validate and ensure completeness of the cancer diagnoses. RESULTS: One hundred twenty-one cancers were identified during the 10-year study period in a population of approximately 4000 patients. Screening by fecal occult blood testing identified 11 of 20 colorectal cancers, mammography and physician examination identified 9 of 12 breast cancers, and a program of biannual Papanicolaou smears resulted in the diagnosis of 3 of 3 cervical cancers. Only 3 melanomas, 3 ovarian cancers, and 1 testicular cancer were diagnosed in this practice during the entire 20 years of the combined studies. CONCLUSIONS: The five most common cancers--skin, colorectal, lung, breast, and prostate--accounted for 71% of the cancers diagnosed. A high rate of provider and patient compliance with screening was achieved. Screening detected a majority of breast and colorectal cancers. Annual Papanicolaou smear screening would have provided no incremental benefit over the biannual screening used in this practice.

Adult↗

PubMed1991

Effect of low dose iodide supplementation on thyroid function in potentially susceptible subjects: are dietary iodide levels in Britain acceptable?

OBJECTIVE The aim of the study was to evaluate the risk of exposure to an increase in dietary iodide intake amongst potentially susceptible population groups in Britain. DESIGN A randomized controlled trial was performed in healthy women and in women with underlying thyroid abnormalities due to subclinical Hashimoto's thyroiditis (diagnosed on the basis of antithyroid antibodies) or previous iodide deficiency of supplementation with 500 micrograms/day iodide (giving a total intake of approximately 750 micrograms/day) for 28 days versus placebo. PATIENTS Two hundred and twenty-five women aged 25-54, randomly selected from a general practice in Cardiff, were screened for thyroid microsomal antibody. Antibody positive women (n = 20), and antibody negative controls (n = 30) were recruited into the trial comparing iodide and placebo. In addition, groups of patients aged 60-75 randomly selected from the Cardiff practice (n = 29), an iodide sufficient area, and a practice in Dowlais (n = 35), a previously iodide deficient area, were also enrolled into the trial. MEASUREMENTS Changes in free thyroxine and thyrotrophin levels were measured after 14 and 28 days of iodide supplementation. RESULTS All the iodide supplemented groups responded in the same way with a small fall in free thyroxine and rise in thyrotrophin levels (combined fall in free thyroxine 14 days after the start of supplementation -1.22 (95% confidence interval -0.59 to -1.84) pmol/l and at 28 days -0.86 (-0.30 to -1.43) pmol/l and rise in thyrotrophin at 14 days 0.55 (0.19 to 0.92) mU/l and at 28 days 0.59 (0.12 to 1.07) mU/l). In two of the iodide supplemented subjects thyrotrophin levels rose above the laboratory reference range and in a further three subjects initially elevated thyrotrophin values increased further. In contrast, no changes in thyroid function were observed in the placebo treated controls and none developed biochemical hypothyroidism. CONCLUSIONS Dietary iodide intakes of 750 micrograms/day or more may adversely affect thyroid function, especially in individuals with borderline hypothyroidism.

Adult↗

PubMed1996

Registered nurse empowerment. Model testing and implications for nurse administrators.

OBJECTIVE: The author developed and tested a model formulated to determine what combination of organizational, leadership, and personal characteristics maximize the prediction of registered nurse empowerment in an acute care hospital. BACKGROUND: Recent innovations in patient care delivery and nursing governance are more successful with an empowered nursing staff. However, the contexts for empowerment and management practices that foster empowerment are poorly understood. Previous empowerment studies suggest that personal characteristics such as age, experience, and education are related to empowerment. Additionally, specific leadership practices and organizational cultures have been shown to foster empowerment. METHODS: Registered nurses (N = 113) who were employed in an academic health center participated in the study. Participants completed measures of organizational culture, connective leadership, empowerment, and a demographic questionnaire designed to elicit the personal characteristics included in the model. RESULTS: Regression analysis identified constructive organizational culture and connective leadership as positive predictors of empowerment, whereas defensive culture was a negative predictor. The three variables combined to explain 45% of the variance in empowerment (P < 0.001). Personal characteristics were not significant predictors, but education and position level were significantly related to connective leadership (P < 0.01). CONCLUSIONS: The Registered Nurse Empowerment Model can serve as a framework for identifying and targeting areas requiring organizational change. The quantitative measures for organizational culture, connective leadership, and empowerment provide practical assessment and evaluation tools for data-based change. Education programs for nurses at all levels should address the behaviors and strategies that promote constructive cultures and connective leadership, minimize defensive cultures, and thus, foster empowerment of nursing staff.

Academic Medical Centers↗

PubMed2004

Attitudes to independent dental hygiene practice: dentists and dental hygienists in Ontario.

This study examined Ontario dentists' and dental hygienists' attitudes to independent dental hygiene practice and changing the scope of practice. Data were collected from a mail survey of a systematic, stratified sample of Ontario dentists (483 respondents) and dental hygienists (437 respondents) conducted in the winter and spring of 2002 to assess what practising dentists and dental hygienists think about independent practice and other professional issues. Contrary to previous research, this study found that male and female dentists did not differ in their attitudes to independent dental hygiene practice and university education for dental hygienists: both strongly opposed the former and tended to support the latter. Similarly, few differences in attitude amongst dentists by specialty were found. Dental hygienists were generally supportive of independent practice and of expanding their scope of practice. On some measures, however, sex and age differences in attitudes were evident: at times dental hygienists who were older or male seemed to be stronger advocates for professional change than others.

Attitude of Health Personnel↗

PubMed1995

Utilization of advanced practice nurses in healthcare systems and multispecialty group practice.

Cost-effective strategies for delivering primary care require the appropriate mix of healthcare providers. The authors define the scope of practice for the advanced practice nurse. Results of a nationwide survey of 26 large healthcare systems and multispecialty group practices are presented. Findings from these practice settings are contrasted with those previously reported in the literature. Implications for the future are discussed.

Cost-Benefit Analysis↗

PubMed1990

Effect of a practical neck cooling device on core temperature during exercise.

Previous studies have documented the effectiveness of combined head and neck cooling in reducing thermal stress during exercise. However, these studies investigated low intensity exercise and devices that are not practical for use on a widespread basis during recreational exercise. In the present study, we investigated the effect of a commercially available, practical neck cooling device on core temperature during strenuous exercise. In a randomized cross-over fashion, 10 male endurance athletes (age 29 +/- 2 yr) performed a 45-min submaximal run (Borg rating of perceived exertion approximately 15) at a constant speed, with and without neck cooling. Runs were conducted on an indoor track, where the ambient temperature was maintained at approximately 21 degrees C dry bulb and approximately 17 degrees C wet bulb. Exercise heart rates and subjective perception of effort were not significantly modified by neck cooling. In contrast, rectal temperature rises (by 0.21 degrees C or 9.5%, P less than 0.02) and sweat rates (by 92 ml.h-1 or 6.4%, P less than 0.02) were reduced by neck cooling. Our study therefore concludes that this practical neck cooling device is capable of inducing reductions in thermal stress during strenuous exercise that, although numerically small, are in a direction of potential benefit.

Adult↗

PubMed2007

Neural correlates for learning to read Roman numerals.

This study examined the neuronal correlates of reading Roman numerals and the changes that occur with extensive practice. Subjects were scanned by functional Magnetic Resonance Imaging (fMRI) three times the first day of the experiment and once following two to three months of practice. This allowed comparison of brain activations with varying levels of practice on the same day and across the two to three months of training. The results revealed that upon learning that the alphabetical symbols had numeric meaning subjects immediately activated a network of brain areas, many of which have been previously implicated in numerical processing. Subsequent practice led to a change in the pattern of neuronal activity in only a single region of the mid-dorsolateral prefrontal cortex in the left hemisphere. Implications of these findings are argued with regard to the prevalent neuronal model for the implementation of elementary numerical abilities.

Adult↗

PubMed2000

Survey of moonlighting practices and work requirements of emergency medicine residents.

We conducted an anonymous moonlighting and academic practice survey of all emergency medicine residents enrolled in accredited programs during 1997. Expanding on previous work, this survey included specific details and practice trends of moonlighting emergency medicine residents and for comparison also included academic work requirements. The typical emergency residency program requires residents to work 204 hours monthly. However, the range of required work-hours is strikingly large (120-300). Half of emergency medicine residents moonlight. The typical moonlighting resident works as a solo emergency department practitioner in multiple facilities outside of residency-affiliated institutions. Moonlighting salaries generally double a resident's annual income and are used to pay off student loans and other debt. Residents with higher student debt are more likely to moonlight. Despite the fact that most residency programs restrict moonlighting, a majority of moonlighting residents have violated an Accreditation Council for Graduate Medical Education prohibition restricting work within one period of a regular residency-scheduled shift. Half of all residents surveyed, whether involved in moonlighting practice or not, would violate a ban on the practice. Residents universally felt that moonlighting enhanced residency performance and was a positive educational experience. Use of these data may aid in the development of formal guidelines regarding emergency medicine moonlighting practice.

Accreditation↗