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[The psychiatric reform in Distrito Federal].

This paper studies the configuration of institutional practices and their historical determinations at Hospital São Vicente de Paulo-HSVP reference hospital in the Federal District for psychiatric treatment, from 1985 to 2002. A qualitative research was chosen, using a historical-structural approach and case study technique. The authors elected ideology as analytical category and, as empirical categories, mental health care and the psychiatric reform. The research tools used were interviews with key informants and institutional subjects (16 health professionals, 12 clients and 9 family members), analysis of documents and interactive observation. The authors concluded that, from 1999 onwards, mental health practices at HSVP have suffered a retraction in regards to the Psychiatric Reform, as the hospital has implemented its policy of desinstitulization, but at the same time has submitted its clientele, patients and families to a situation characterized by poor medical assistance and social exclusion.

Brazil↗

From student laboratory to clinical environment.

OBJECTIVE: To describe a clinical laboratory practice simulation experience for clinical laboratory science (CLS) students which was intended to improve the transition from the student laboratory to the clinical environment. SETTING: University of Kentucky Center for Rural Health, a rural health professions education center for a state-assisted institution. PRACTICE DESCRIPTION: Baccalaureate-level CLS program. PRACTICE INNOVATION: Clinical laboratory practice simulation experience allows students to become familiar with the clinical environment. It also allows faculty to assess student performance and to provide students with feedback in a controlled setting. MAIN OUTCOME MEASUREMENT: Perception of benefit from the simulation experience by CLS graduates. RESULTS: CLS graduates report the simulation experience helped to prepare them for practice in the clinical environment. CONCLUSION: Clinical laboratory simulation can improve the transition to actual clinical laboratory practice and is a valuable tool to evaluate pre-clinical deficiencies.

Chemistry, Clinical↗

Environmental health and safety concerns and energy conservation practices in academic institutions and hospitals.

Although there are many energy conservation practices which are now being applied in hospitals and academic institutions, there well be additional pressures for even further reductions in such energy use in the near future. In many instances, these reductions in energy use can be done within existing standards and do not endanger the health of persons who reside within these institutions. However, this paper highlights the fact that over-eager attempts at energy reduction may result in adverse effects on patients, students, staff, research programs, or the general public. For this reason, it is important for persons making decisions regarding energy conservation practices to be aware of these potential adverse effects and design energy conservation programs accordingly.

Accident Prevention↗

Caring from the point of view of a Finnish mental health nurse: a life history approach.

Finnish mental health care went through a major change in the 1980s. Its institutions were being run down and there was a shift to a caring system that stresses non-institutional practices. The schooling and work of the mental health nurse had to adapt to the new situation. The purpose of my study was to describe and analyse the mental health nurse's work, i.e. caring, as it is experienced by a nurse in the preparation of long-term psychiatric patients for non-institutional care. The data consist of repeated interviews with Vuokko, who has been a mental health nurse for about 30 years and is now approaching her retirement. In the light of the data, the central features of caring are caring about and taking an overall responsibility for the patient, and teaching the patient to cope with everyday life. Caring is based on practical knowledge, the essential elements of which are intimacy and feelings.

Adaptation, Psychological↗

Interpreters as co-diagnosticians: overlapping roles and services between providers and interpreters.

This study examined medical interpreters' practice of the co-diagnostician role and further explored its practical, institutional, and ethical implications. Twenty-six professional interpreters (of 17 languages), 4 patients, and 12 health-care providers were recruited for this study, which involves participant observation and interviews undertaken in the Midwestern US. Constant comparative analysis was used to develop themes of interpreters' communicative practices. Interpreters justified their role performances by claiming the identity of a member of the health care team and their work as part of the team effort. Their communicative strategies as a co-diagnostician reflect their preconception of the social hierarchy of health-care settings and the emphasis on diagnostic efficacy. I have identified five strategies for the co-diagnostician role. These were assuming the provider's communicative goals; editorializing information for medical emphasis; initiating information-seeking behaviors; participating in diagnostic tasks; and volunteering medical information to the patients. Although many strategies can be attributed to interpreters' effort to conserve providers' time and to bridge the cultural differences, they also pose risks to patients' privacy, clinical consequences, and provider-patient relationships.

Communication↗

Academic incentives for faculty participation in community-based participatory research.

Recognizing the need to overcome the obstacles of traditional university- and discipline-oriented research approaches, a variety of incentives to promote community-based participatory research (CBPR) are presented. Experiences of existing CBPR researchers are used in outlining how this methodological approach can appeal to faculty: the common ground shared by faculty and community leaders in challenging the status quo; opportunities to have an impact on local, regional, and national policy; and opening doors for new research and funding opportunities. Strategies for promoting CBPR in universities are provided in getting CBPR started, changing institutional practices currently inhibiting CBPR, and institutionalizing CBPR. Among the specific strategies are: development of faculty research networks; team approaches to CBPR; mentoring faculty and students; using existing national CBPR networks; modifying tenure and promotion guidelines; development of appropriate measures of CBPR scholarship; earmarking university resources to support CBPR; using Institutional Review Boards to promote CBPR; making CBPR-oriented faculty appointments; and creating CBPR centers.

Community Health Planning↗

Spitz tumors in children: a grading system for risk stratification.

OBJECTIVE: To describe a grading system for risk stratification of atypical Spitz tumors in children and adolescents. In some circumstances, unequivocal distinction between Spitz nevus and melanoma is practically impossible. It is likely that these lesions for which we lack specific diagnostic criteria represent a broad histological continuum extending from benign to malignant tumors. Therefore, we propose that Spitz tumors be categorized into low-, intermediate-, or high-risk categories based on the accumulation of abnormal features. DESIGN: Retrospective study. SETTINGS: Institutional practice. PATIENTS: We present 30 cases of atypical Spitz tumors in patients younger than 18 years evaluated for at least 3 years or in whom a metastatic event developed during this period. INTERVENTION: None. MAIN OUTCOME MEASURE: The grading system was formulated after data collection. RESULTS: Among the parameters studied, only diagnosis at age greater than 10 years, diameter of the lesion greater than 10 mm, presence of ulceration, involvement of the subcutaneous fat (level V), and mitotic activity of at least 6/mm2 carried a likelihood ratio greater than 1.50 and were therefore used for the grading system. CONCLUSION: The application of an objective grading system, such as the one described herein for the first time, is the first step in providing useful information for the management of atypical Spitz tumors.

Adolescent↗

Heparin monitoring and patient safety: a College of American Pathologists Q-Probes study of 3431 patients at 140 institutions.

CONTEXT: Appropriate laboratory monitoring of unfractionated heparin therapy promotes effective anticoagulation while minimizing hemorrhagic complications. OBJECTIVES: To measure heparin therapy monitoring in a "real-world" setting and to assess the degree of anticoagulation achieved. DESIGN: One hundred forty institutions abstracted laboratory and pharmacy data from up to 30 inpatients receiving standard-dose unfractionated heparin therapy for 72 hours. Institutions also reported their therapeutic ranges and described heparin prescribing and monitoring policies. RESULTS: Activated partial thromboplastin times or anti-factor Xa levels were measured at least once within the first 12 hours of administration for 95% of 3431 heparinized inpatients. Eighty-seven percent of patients had a platelet count performed within 72 hours of heparin administration. Seventy-eight percent of heparinized inpatients achieved therapeutic anticoagulation within 24 hours, but more than one third of patients entered the supratherapeutic range on at least 2 occasions during the first 72 hours. We found moderate variation in performance among the 140 institutions participating in the study, with more consistency in monitoring patients but less consistency in achieving therapeutic levels of anticoagulation. In one fourth of hospitals, more than half of the heparinized patients entered the supratherapeutic range on 2 or more occasions during the first 72 hours of therapy. None of 20 institutional practices we examined were meaningfully associated with more thorough monitoring of patients or with a higher percentage of patients achieving therapeutic anticoagulation. There was moderately wide variation in therapeutic ranges among the 140 sites. CONCLUSIONS: The prevention of heparin over-anticoagulation represents an important opportunity for improving patient safety in a significant number of institutions.

Anticoagulants↗

Increasing women's leadership in academic medicine: report of the AAMC Project Implementation Committee.

The AAMC's Increasing Women's Leadership Project Implementation Committee examined four years of data on the advancement of women in academic medicine. With women comprising only 14% of tenured faculty and 12% of full professors, the committee concludes that the progress achieved is inadequate. Because academic medicine needs all the leaders it can develop to address accelerating institutional and societal needs, the waste of most women's potential is of growing importance. Only institutions able to recruit and retain women will be likely to maintain the best housestaff and faculty. The long-term success of academic health centers is thus inextricably linked to the development of women leaders. The committee therefore recommends that medical schools, teaching hospitals, and academic societies (1) emphasize faculty diversity in departmental reviews, evaluating department chairs on their development of women faculty; (2) target women's professional development needs within the context of helping all faculty maximize their faculty appointments, including helping men become more effective mentors of women; (3) assess which institutional practices tend to favor men's over women's professional development, such as defining "academic success" as largely an independent act and rewarding unrestricted availability to work (i.e., neglect of personal life); (4) enhance the effectiveness of search committees to attract women candidates, including assessment of group process and of how candidates' qualifications are defined and evaluated; and (5) financially support institutional Women in Medicine programs and the AAMC Women Liaison Officer and regularly monitor the representation of women at senior ranks.

Career Mobility↗

Residents' training goals in respiratory knowledge and skills: perspective of three parties.

Medical residents, full-time respiratory teaching staff, and community-based doctors rated the importance of fifty-five respiratory training goals involving knowledge and skills necessary for the future practices of all medical residents. Residents also rated their perceived preparedness in these training areas. Intra- and inter-group analyses indicated that residents agreed more often, and consistently assigned more importance (94% of goals) to the training goals, than did the teachers and doctors. Although the residents considered themselves prepared for 69% of the training goals, they also had moderate intra-group disagreement. These results may reflect variable training experiences and/or institutional practices, but areas of less than adequate preparation were identified and can be corrected. The other two groups were in general agreement except regarding some clinical skills. This study offers possible explanations for the group responses and indicates the potential benefit for groups to discuss, identify, and survey training goals.

California↗

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism.

BACKGROUND: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach. METHODS: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded. RESULTS: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study. CONCLUSION: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Adolescent↗

Domestic violence and minoritisation: legal and policy barriers facing minoritized women leaving violent relationships.

This article on service responses to women of African, African-Caribbean, Irish, Jewish and South Asian backgrounds facing domestic violence draws on our recently completed study based in Manchester, UK () [Batsteeler, J., Burman, E., Chantler, K., McIntosh, S.H., Pantling, K., Smailes, S., Warner, S., et al. 2002. Domestic violence minoritisation: Supporting women to indepence. Women's Studies Centre: The Manchester Metropolitan University]. We frame our analysis of domestic violence and minoritisation around the question that is frequently posed in relation to women living with domestic violence: 'why doesn't she leave?' In response, we highlight the complex and intersecting connections between domestic violence, law, mental health provision, entitlement to welfare services, which function alongside constructions of 'culture' and cultural identifications, structures of racism, class and gendered oppression. All these contribute to maintain women, particularly minoritized women, in violent relationships. Further, we illustrate how leaving violent relationships does not necessarily guarantee the safety of women and children escaping domestic violence. Despite many recent legal and social policy initiatives in the UK that have usefully brought domestic violence into the public domain, there have also been counter-measures which have made leaving violent relationships correspondingly more difficult, in particular for women from minoritized communities. We offer an analysis of how state practices, particularly facets of immigration law in the UK (although , provides an equivalent U.S. analysis), interact with domestic violence. These not only equip perpetrators with a powerful tool to oppress minoritized women further, but it also indicates how state structures thereby come to impact directly on women's distress (Chantler et al, 2001). In addition, we highlight how other aspects of state policy and practice which enter into the material well-being of survivors of domestic violence, for example, housing, levels of state benefits, and child-care also pose significant obstacles to minoritized women leaving violent relationships. Whilst women from majority/dominant groups also face many of these barriers, we illustrate how the racialized dimensions of such policies heightens their exclusionary effects. It is argued that legal and psychological strategies need to address the complexity of how public, state and institutional practices intersect with racism, class and gender oppression in order to develop more sensitive and accessible ways of supporting minoritized women and children living with domestic violence.

Adult↗

Nurse practitioners--co-providers of health care.

What single program can a group practice institute to increase patient satisfaction, contain costs, improve provider accessibility, expand patient education and other services, increase market share, and most importantly, improve the overall quality of patient care? Expanding the role of nurses as co-providers of care can do all this and more for your group. The experience over the past eight years of a large multispecialty group in central Illinois offers many lessons in the successful integration of a nurse practitioner/clinician program into a group practice. Discussed in this thorough report are the scope of practice, benefits to patients and the organization, and identification of issues needing further resolution: legality, third-party reimbursement, income, distribution, and control of practice.

Consumer Behavior↗

Perceived benefits of the Pharm.D. as a second pharmacy degree.

The perceived benefits of the Pharm.D. as a second degree was studied among pharmacists who earned the degree after the B.S. degree in pharmacy. A questionnaire was mailed to post-B.S. Pharm.D. recipients who graduated after 1968. The 224 pharmacists (72%) who responded represented 54 baccalaurate and 12 Pharm.D. programs. Sixty-seven percent had gained hospital practice experience prior to returning to school for their Pharm.D. degree. The data did not show "job dissatisfaction" to be a major factor prompting pursuit of the Pharm.D. Most initially sought the advanced degree in an attempt to gain greater patient involvement (43%). In 10 years, 51% hope to have attained some kind of administrative position, 15% desire to have combined clinical and administrative responsibilities, while 37% prefer a purely clinical position. Thirty-four percent would like to have a position in education. Most respondents in institutional practice (59.4%) and education (88.6%) felt they would not have their present position without the Pharm.D. degree. Fifty-nine percent receive an annual salary greater than $21,000 including fringe benefits. Most pharmacists who earned a post-B.S. Pharm.D. degree believe they have benefited from their advanced professional degree, both in job responsibilities and salary.

Attitude of Health Personnel↗

Using numerical results from systematic reviews in clinical practice.

Systematic reviews summarize large amounts of information and are more likely than individual trials to describe the true clinical effect of an intervention. Traditional statistical outputs from systematic reviews cannot immediately be applied to clinical practice. The number needed to treat (NNT) has that clinical immediacy. This number can be calculated easily from raw data or from statistical outputs, and the principle involved in its calculation can be applied to different outcomes: treatment efficacy, adverse events (harm), or other end points. The NNT defines the treatment-specific effect of an intervention, and we suggest it as a currency for making decisions about individual patients. Knowing the NNT for different interventions that have the same outcome for the same disorder can help shape individual and institutional practice. Knowing or estimating the number needed to harm is also an important part of the equation. Knowing or estimating an individual patient's risk can, with the NNT, be a guide to the overall or net value of a prophylactic intervention. We advocate an approach to systematic reviews that distills information into, in effect, one number: the NNT. This is simple to remember and directly supports efforts to work with patients to make the best possible clinical decisions for their care.

Data Interpretation, Statistical↗

Should pregnancy testing be routine in adolescent patients prior to surgery?

The reliability of the preoperative history obtained from adolescent patients in ruling out pregnancy was prospectively evaluated. Four hundred forty-four patients who underwent 525 procedures were questioned preoperatively regarding the possibility of pregnancy. Regardless of the history, a urine pregnancy test was ordered in accordance with institutional practice. In 508 cases, patients denied the possibility of pregnancy. Eight patients stated that they might be pregnant, and in six cases the parents responded for the patients and denied the possibility of pregnancy. Seventeen patients were not tested due to patient/parent refusal (n = 9) or inability to void (n = 8). All pregnancy tests were negative except one that was questionably negative. This patient had denied the possibility of pregnancy and had been anesthetized prior to test results. Follow-up revealed that the patient was not pregnant. Our data demonstrate that the preoperative history obtained from adolescent patients at our institution regarding their pregnancy status was in agreement with pregnancy test results. We suggest that a detailed history regarding last menstrual period, contraception, sexual activity, and the possibility of pregnancy be obtained in all postmenarchal patients presenting for surgery. Although in other populations history and pregnancy testing did not agree 100% of the time, for our adolescent population, human chorionic gonadotrophin (HCG) testing appears to be necessary only if indicated by patient history.

Adolescent↗

The Resident Choice Scale: a measure to assess opportunities for self-determination in residential settings.

BACKGROUND: A 26-item Resident Choice Scale was designed to assess service practices for promoting resident choice. METHOD: The staff working with 560 UK/Irish adults with intellectual disability were interviewed. Specific examples of practices promoting resident choice were requested and independently rated by the interviewer. RESULTS: The interrater reliability of Resident Choice items was found to be acceptable (subsample n = 50). The psychometric properties of the Resident Choice Scale total score and scores on eight subscales were also acceptable. Consistently strong associations were found between greater resident choice and greater resident ability and, to a lesser extent, fewer resident challenging behaviours. Few associations were found between resident choice and autism or mental health problems. Even when controlling for resident ability and challenging behaviour, consistent associations were found between greater resident choice and the concurrent variables of greater community presence, fewer institutional practices, and greater user self-reported satisfaction (subsample n = 50). CONCLUSIONS: Taken together, this pattern of results indicates that the Resident Choice Scale shows promise as a measure of the environmental opportunities available for adults with intellectual disability to exercise self-determination. Areas for future research testing the reliability and validity of the Resident Choice Scale are outlined.

Adult↗