Biomedical subjects
M F Ward
Publications and source records attributed to M F Ward.
Training, skills and caseloads of community mental health support workers involved in case management: evaluation from the initial UK demonstration sites.
This paper describes phase one of a three phase, Department of Health funded project, led by the Mental Health Programme of the Royal College of Nursing Institute in collaboration with the Research Unit of the Royal College of Psychiatrists and the School of Social Work at the University of East Anglia. Its project aims were to establish whether the work of demonstration sites in mental health case management had developed beyond their original structure, to compare their current profile with the general literature on case management and assertive outreach and to use this data to reach consensus about issues affecting the work of those healthcare workers who currently see themselves working as case managers. Central to these aims were the experiences and narratives of the demonstration site case managers themselves. In 1995 data were collected from six fieldwork sites in England using semistructured interviews. Similarities and differences between the literature and the fieldwork data were used to inform a consensus conference. The main areas of investigation were organizational considerations, the nature of innovative projects and user involvement. The paper concludes that there are serious problems with the perceived role of case managers, their support and training and further difficulties attributed to interagency working. Finally, it is clear that the exact nature of the client group most suited to UK case management typology has not yet been resolved.
Why don't emergency department patients have advance directives?
OBJECTIVES: In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this follow-up study was to determine the reasons why their adult ED patients do not have ADs. METHODS: This prospective study enrolled patients from a convenience sample of representative shifts in the ED selected over a three-month period. Survey questions included demographic information, whether the patients had a life-threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We excluded those who refused participation or who were incapacitated (i.e., any patient with a condition that precluded him or her from answering the questionnaire himself or herself, such as an altered level of consciousness, dementia, mental retardation, or inability to understand English). RESULTS: Four hundred seventy-six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not included in the study for the following reasons: inability to complete the survey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; males, 80%). The most frequent reasons given for not having an AD were: 40% never thought about it, 24% preferred family to make the decision, and 23% were procrastinating. Factors jointly predictive of having an AD were older age, having a specialist, having a life-threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their primary care physicians (PCPs) only 5% of the time. CONCLUSION: Many patients, even when they have life-threatening medical problems, do not have an AD, and several reasons for this have been identified. Few of these ED patients who had ADs had discussed them with their physicians. Further studies should assess whether more physician intervention would increase the percentage of patients who have ADs.
Using a supervisory framework to support and evaluate a multiproject practice development programme.
The paper describes a multiproject practice development programme undertaken over a period of 1 year. The background and development of the programme are outlined, whilst attention is paid to the innovatory nature of the work, particularly the use of inductive, deductive and integrated approaches to both change implementation and project supervision. The programme was monitored throughout using different data sources and the paper uses evaluative material retrospectively to provide answers to organizational and professional difficulties which arose during the course of the programme. The authors conclude that the use of combinations of different models for practice development has potential, but requires careful supervision. They also recommend that those involved in practice development are made fully aware of its local or micropolitics, and develop strategies to deal with change before it occurs, not after it has taken place.
Evaluating the impact of in-patient bed reduction and community nurse increases in one English Mental Healthcare Trust.
This Mental Health Task Force funded project was designed to evaluate the impact of organizational changes in Northampton, a traditional English Mental Healthcare Trust. Services in Northampton were typically provided by a large 'watertower' Victorian hospital on the outskirts of the town. The hospital had been, over a period of some years, reducing the use of in-patient beds. In February 1995 a further 10 beds were withdrawn enabling the closure of a complete building and the re-deployment of some staff into the community. By reducing in-patient beds, and increasing the number of community staff it was hoped that there would be a significant effect upon both hospital admissions, length of stay with resultant cost savings, and an increase in community nurse-patient contacts. To establish baselines quantitative data were gathered about pre-existing acute and community services, with comparisons made from qualitative and quantitative data gathered during the initial change period. Information was collected concerning in-patient admissions within the acute services, community psychiatric nurse (CPN) caseloads including new admissions, care delivery costs and interviews with service managers. The project found that changes in the general patient profile could not be attributed solely to the reduction in available beds but there did appear to be a direct correlation between bed reduction, increase in percentage bed occupancy and more demanding CPN caseloads. Concern was expressed about the ability of community staff to meet the needs of an increasingly female (age 20-39 years) user group. Savings to the Trust were estimated at Pounds 300,000 per annum. The paper concludes with recommendations for future changes.
Are emergency department patients thinking about advance directives?
OBJECTIVES: To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD. METHODS: This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3-month period. The questions included age, sex, "self-reported" health status, whether the patient had a "regular" physician, a patient-generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do-not-attempt-resuscitation (DNAR) orders. RESULTS: Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a "regular" physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians. CONCLUSION: Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a "regular" physician increased the likelihood of having an AD.
Spatio-temporal correlations in human gamma band electrocorticograms.
Animal electrocorticogram (ECoG) studies have shown that spatial patterns in the gamma band (>20 Hz) reflect perceptual categorization. Spatio-temporal correlations were investigated in the 20-50 Hz range in search for similar phenomena in human ECoG. ECoGs were recorded in a somatosensory discrimination task from 64-electrode subdural grid arrays, with inter-electrode spacing of 1 cm, overlying somatosensory, motor and superior temporal cortices in 2 patients with intractable epilepsy. Bootstrap techniques were devised to analyze the spatial and temporal characteristics of the correlations. Despite an extensive search, no evidence was found for globally correlated activity related to behavior either in narrow (1.e., 35-45 Hz) or broad (i.e., 20-50 Hz) bands. Spatial patterns, extracted using principal component analysis, could not be classified with respect to stimulus type in any time interval. Instead, spatially and temporally intermittent synchronization was observed between pairs of electrodes in 1 cm X 1 cm regions with high variability within and across trials. The distribution of correlation coefficients differed substantially from background levels at inter-electrode distances of 1 cm and 1.4 cm but not 2 cm or more. The minimum duration of correlation, the decorrelation time, of the ECoG was about 50 msec; the average correlation duration at 1 cm inter-electrode distance was about 150 msec; and the recurrence rate of significant correlation peaks was about 1.3/sec. The findings suggest that the surface diameters of domains of spatially correlated activity underlying perceptual categorization in human gamma band ECoG are limited to less than 2 cm and that the intermittent synchronization observed across separations of 1 cm and 1.4 cm is not solely due to volume conduction. Thus, if such gamma band spatial patterns exist in the human brain, no existing technology would be capable of measuring them at the scalp, and subdural electrode arrays for cortical surface recording would have to have spacings under 5 mm.
Reliability of faculty clinical evaluations of non-emergency medicine residents during emergency department rotations.
OBJECTIVES: To assess the reliability of faculty evaluations of non-emergency medicine (non-EM) residents during clinical ED rotations and to determine the effect that the "leniency" of grading by these evaluators had on the residents' final evaluations. METHODS: A prospective, observational study of the evaluation patterns of EM faculty was performed in an academic ED (50,000 visits yearly census). Each resident was evaluated on a daily basis by a board-certified or board-prepared emergency physician. The evaluation form rated 7 characteristics, but only the rating for overall clinical competence was used for data analysis. If an attending evaluated the same resident more than once, only the first evaluation was used to avoid bias from prior exposure. The scoring patterns of the evaluators, both individually and in groups, were analyzed using 1-way analysis of variance. Evaluator leniency was estimated using the mean evaluator score across all residents. Since each resident was evaluated by a different combination of evaluators, evaluator leniency for each resident was estimated from the mean leniency of the evaluators who specifically assessed that resident. RESULTS: During the period of the study, 66 residents rotated through the ED, yielding a total of 401 evaluations. When the scoring patterns of individual evaluators were analyzed, a high degree of variability was found in the mean scores (range 5.23-8.09) and SDs (range 0.45-1.55) across evaluators; p = 0.0001. There was a moderate correlation between the mean overall competence score received by each resident and that resident's evaluators' leniency, r = 0.52; p = 0.0001. CONCLUSIONS: There is significant variability in the scoring patterns of individual evaluators. The evaluators in this study showed large variations in both leniency (as measured by their mean score) and range restriction (as measured by their SD). The differences in evaluator scoring leniency have a moderate correlation with the overall score received by the resident.
C-reactive protein and serum amyloid A protein in unstable angina.
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Hierarchical planning abilities in children with specific language impairments.
The present study examined Cromer's (1983) claim that children with language impairments have a hierarchical planning deficit that affects language as well as performance on complex construction tasks. Subjects were 30 boys (ages 5-7 years), 15 with specific language impairments (SLI) and 15 with normally developing language. Children were asked to build four hierarchical structures: a block construction, a puzzle construction, a simple straw construction, and a complex straw construction. Children who failed to complete the complex straw construction were taught how to construct the model using a sequential strategy. The two groups tended to perform comparably on the block and complex straw construction, the easiest and hardest of the four constructions. The two groups performed least comparably on the puzzle, simple straw construction, and the training task. On the basis of these findings and recent work by Greenfield (1991), we concluded that it is time to reject the notion that a central hierarchical planning mechanism underlies language and non-language structures that contain hierarchical components. The possible exception is early in development before language and manual actions become more autonomous and modular in nature.
Missed psychiatric appointments: who returns and who stays away.
OBJECTIVE: This study investigated reasons for missed psychiatric appointments, rescheduling of appointments, adverse outcomes, and the association of specific diagnoses and treatments with missed appointments. METHOD: A prospective survey covering all individual outpatient visits to seven mental health clinic psychiatrists was conducted during a 3-month period in 1991. Of the 1,620 scheduled visits, 142 (8.8%) were missed, representing 130 separate patients. For each missed appointment, the psychiatrist involved completed a questionnaire on the type of visit, the patient's DSM-III-R diagnosis, the reason for missing the appointment, the date of patient recontact, and adverse outcome, if any. RESULTS: Of the 142 missed appointments, 71.1% were rescheduled spontaneously by the patients; of these, most (73.3%) were rescheduled within 2 weeks. The remaining missed appointments represented various outcomes, including dropping out of treatment. The most common stated reason for missing an appointment was patient error, such as forgetting, oversleeping, or getting the date wrong. Patients with PTSD and/or substance abuse were significantly more likely than others to miss appointments, and those with major depression were somewhat less likely to do so. CONCLUSIONS: Most patients quickly reschedule missed appointments, and those in more intensive treatments miss fewer appointments. Missed appointments for initial evaluation are not rescheduled most often. Patients in ongoing treatment who do not return may have histories of noncompliance with treatment. The high rate of rescheduling suggests that follow-up of patients who miss appointments should be a clinical decision rather than a routine policy.
The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder.
OBJECTIVE: In an attempt to surmount the problem of retrospectively establishing the childhood diagnosis of attention deficit hyperactivity disorder, the authors constructed the 61-item Wender Utah Rating Scale (WURS) for adults to use to describe their own childhood behavior. In this paper they present their initial data collection and evaluation of the instrument's validity. METHOD: The scale was administered to 81 adult outpatients with attention deficit hyperactivity disorder, 100 "normal" adults, and 70 psychiatric adult outpatients with unipolar depression. The authors analyzed data from the 25 items of the scale that showed the greatest difference between the patients with attention deficit hyperactivity disorder and the normal comparison subjects and the relationship between the WURS and the patients' parents' judgment of childhood activity as measured by the Parents' Rating Scale. RESULTS: The patients with attention deficit hyperactivity disorder had significantly higher mean scores on all 25 items than did the two comparison groups. The difference between the mean total scores of the patients with attention deficit hyperactivity disorder and the normal subjects was also highly significant. A cutoff score of 46 or higher correctly identified 86% of the patients with attention deficit hyperactivity disorder, 99% of the normal subjects, and 81% of the depressed subjects. Correlations obtained between WURS scores and Parents' Rating Scale scores were moderate but impressive. The ability of WURS scores to predict response to methylphenidate replicated the authors' finding regarding the ability of Parents' Rating Scale scores to predict response to pemoline. CONCLUSIONS: The WURS is sensitive in identifying childhood attention deficit hyperactivity disorder and may be useful in recognizing attention deficit hyperactivity disorder in patients with ambiguous adult psychopathology.
The introductory placebo washout: a retrospective evaluation.
We examined the effects of the "introductory placebo washout" technique by reanalyzing the results of a recent trial of an experimental antidepressant. At the beginning, all patients were placed on placebo in a single-blind design. Patients who were rated as placebo responders with the physician-administered Hamilton Rating Scale for Depression (HRSD) were excluded from the trial. In spite of this technique, an alternative measure of depression indicated that many patients with a positive response to placebo had been entered in the trial. In the reanalysis, elimination of these "hidden placebo responders" did not lower the final placebo response rate and actually diminished the differences observed at the end of the study between the active treatment and placebo groups. These data suggest that the introductory placebo washout may have unpredictable, possibly confounding effects on patient samples in trials of antidepressant agents.
Microcomputer servo-controlled bicycle ergometer system for psychophysiological research.
Steady state exercise is widely used for psychophysiological studies in which a constant heart rate at a predetermined level is desired. We have developed a microcomputer servo-controlled bicycle ergometer system that can be used for administering steady state exercise. Fourteen healthy male subjects, with a wide range of fitness levels (measured by VO2max) were exercised to either a fixed workload (130 watts) or a predetermined heart rate level (servo-heart rate) of 122 bpm (i.e., 65% of maximum calculated heart rate for the sample). Servo-heart rate was implemented using a feedback loop that automatically adjusted workload to compensate for immediate variations in heart rate, resulting in a more consistent heart rate. Heart rate varied from the predetermined value by 17 bpm during fixed workload but only 3 bpm during servo-heart rate (p less than .05). Therefore, by using the microcomputer servo-controlled bicycle ergometer, heart rate was maintained at a predetermined level regardless of the subject's fitness level. VO2max and workload during servo-heart rate were significantly correlated (r = .85, p less than .05). Therefore, the workload necessary to maintain heart rate at a constant level may provide an approximate index of aerobic fitness level.
Microcomputer automated system for measuring systolic time intervals in response to exercise and a psychophysiological task.
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Sertraline, a selective inhibitor of serotonin uptake, for the treatment of outpatients with major depressive disorder.
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Computed tomography for internal derangements of the temporomandibular joint: a technical report.
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Behavioral treatment for depression: an evaluation of therapeutic components.
Designed study to determine the "active ingredients" in Lewinsohn's behavioral treatment for depression. Fifty-six men and women were screened for significant depression and were assigned to four experimental treatment groups: (1) an activities-increase group instructed to increment participation in reinforcing activities; (2) an expectancy-control group that participated in a fitness program; (3) a self-monitoring control that simply recorded activities and mood daily; and (4) an attention-control group. Consistent with an operant model of depression, the resulted indicated that increases in activities that Ss had rated as pleasureable alleviated depressed mood over a 30--day time period. While all Ss evidenced some improvement in mood, the activities-increase group showed significantly greater improvement than Ss in groups that did not increase their activity levels. Correlational analyses of daily activity and Depression Adjective Check List Scores proved additional support for the behavioral model of depression. The outcome for the four experimental groups was not different on a measure of belief in internal vs. external control of reinforcement.