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PubMed1990

Obstetric audit using routinely collected computerised data.

OBJECTIVE: To examine the use of routinely collected computerised data in clinical audit. DESIGN: Retrospective review of all analyses of obstetric practice based on a computerised data system from January 1983 to June 1988. SETTING: Maternity department of the regional referral hospital in Oxford. MAIN OUTCOME MEASURES: Congruence with the principles of clinical audit; that is, comparing clinical practice with previously agreed standards and changing practice to meet these standards if necessary. RESULTS: Over the five and a half years of the study the data formed the basis of 130 special inquiries into different aspects of obstetric practice. Most inquiries seemed to be aimed only at describing current activities and identifying trends. Genuine clinical audit was rare. Simple audits--for example, concerning induction for pregnancy after term--could be supported by the computerised data, but for detailed and wide ranging audits--for example, reducing antenatal clinic visits for low risk multiparas--the data had to be supplemented from other sources. CONCLUSIONS: Routinely collected computerised data enable ongoing clinical audit, but it becomes a reality only when clinicians agree on standards of practice and have a flexible attitude towards change. Even then, genuine clinical audits of obstetric practice demand more detailed and comprehensive data than are generally available on such systems.

Data Interpretation, Statistical↗
PubMedDate not supplied

Development of the acquisition and control of action-effect associations.

Voluntary action is anticipatory and, hence, must depend on associations between actions and their perceivable effects. We studied the acquisition of action-effect associations in 4-5-vs. 7-year-old children. Children carried out key-pressing actions that were arranged to produce particular auditory effects. In a subsequent test phase, children were to press keys in response to the previous effect sounds, with the sound-key mapping being either consistent or inconsistent with previous key-sound practice. As the processes underlying voluntary action controls are known to significantly improve between 4 and 7 years of age, it was expected that younger children were more prone to automatic effects of acquired sound-key associations. This hypothesis was confirmed, but reaction times and accuracy measures showed different and dissociable patterns. Four-year-olds but not 7-year-olds were more likely to commit an error--i.e., to perform a sound-compatible rather than the correct action--if the sound-key mapping was inconsistent with previous practice. This effect strongly depended on previous practice, suggesting that it reflects long-term learning. In contrast, reaction time effects of mapping consistency did not depend on previous experience but only on the consistency between stimulus and action effect in the present task. Taken altogether, the results suggest that children acquire response-effect associations automatically and that younger children are more likely to suffer from frequent goal neglect; i.e., they tend to forget the current action goal, so that their behavior is dominated by automatic, stimulus-triggered response tendencies.

Age Factors↗
PubMed2001

Long-term cortical atrophy after excitotoxic striatal lesion: effects of intrastriatal fetal-striatum grafts and implications for Huntington disease.

It is not currently clear whether the cortical atrophy observed in Huntington disease (HD) is entirely a direct consequence of the disease or at least partially a secondary consequence of striatal atrophy. This is of major importance for evaluating the possible therapeutic value of intrastriatal fetal-striatum grafts in HD. Cresyl violet-stained sections from rats that had received striatal excitotoxic lesions 1 wk or 4 wk previously showed small and statistically nonsignificant decreases in the thickness of cortical layers V and VI, while series from rats lesioned 12 months previously showed marked decreases in the thickness of the whole cortex (approximately 35% decrease), layer V (approximately 45%-50%) and layer VI (approximately 45%-50%), together with marked neuron loss in these layers. In deep layer V and layer VI, Fluoro-Jade staining showed labeled neurons in animals lesioned 1 wk previously, labeled neurons and astrocytes in animals lesioned 4 wk previously, and practically no labeling in animals lesioned 12 months previously. Intracortical injection of Phaseolus vulgaris leucoagglutinin revealed that corticostriatal fibers were practically absent from the lesioned area of striata lesioned 12 months previously. However, rats that received intrastriatal fetal-striatum grafts shortly after the lesion and were killed 12 months later showed a significant reduction in cortical atrophy, and a large number of labeled corticostriatal fibers surrounding and innervating the graft. In addition, a reduction in the number of Fluoro-Jade-labeled cells in the cortex was already apparent at 3 wk post-grafting. Regardless of whether HD has a primary effect on the cortex, the present results suggest that the striatal degeneration caused by HD contributes markedly to the cortical atrophy, and that intrastriatal grafts may ameliorate this secondary component of the cortical degeneration.

Animals↗
PubMedDate not supplied

Public nutrition in complex emergencies.

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.

Africa↗
PubMed1992

Uncomplicated amebic liver abscess: prospective evaluation of percutaneous therapeutic aspiration.

The performance of therapeutic aspiration in the treatment of amebic liver abscess, advocated and practiced in many centers, is controversial. Previously, this practice has been evaluated in retrospective analyses. To test the potential benefit of therapeutic aspiration, the authors undertook a prospective randomized trial in 57 patients admitted for suspected amebic liver abscess during a 15-month period. Sixteen patients were excluded from the trial. The remaining 41 patients were randomly included in one of two study groups to receive amebicidal therapy alone or amebicidal therapy coupled with image-guided percutaneous therapeutic aspiration. All patients in the trial recovered. No statistically significant benefit was demonstrated in the aspiration group for the two objective parameters evaluated: length of hospitalization and duration of time to becoming afebrile. Subjective improvement in symptoms after aspiration was greater in the aspiration group at a marginally statistically significant level. These data do not support the adjunctive performance of percutaneous therapeutic aspiration in the treatment of uncomplicated amebic liver abscess. Amebicidals alone were equally efficacious in treating the group studied.

Humans↗
PubMed1982

Attitudes of patients toward family care in a family practice group.

There is little information documenting the extent to which the ideal of whole family care is represented in the real world of family practice. A previous study of a suburban family practice group revealed that only 28 percent of families obtained whole family care from a single physician. Interviews were conducted on a sample of 97 of these patients in an effort to gain insights into the factors influencing the choice of a single physician or more than one physician providing their health care. There were no significant differences between same-physician and different-physician families with respect to demographic factors or attitudes toward physician characteristics and family care. Most families had no insights into the potential value of having a single physician for the whole family; indeed, only one family specifically selected a single physician with the belief that it would thereby gain better care. If the observations reported here are representative of the situation at large in the country, family physicians have an important task ahead in patient education.

Attitude to Health↗
PubMed1989

Factors affecting the level of interest and activity in primary care research among general practitioners.

This paper presents the results of a state-wide survey of general practitioners in Victoria, Australia. The survey assessed their level of interest in general practice research as well as factors influencing the decision to participate in research. The study was conducted during the formation of a general practice research network which was being linked to a new primary care research unit in the Department of Community Medicine at Monash University. Of the 3350 general practitioners surveyed 1116 responded. One third expressed a high degree of interest in general practice research. Previous research experience and barriers to general practice research were also studied. The areas in which the doctors felt most research was required were identified. The results are compared with another study of Canadian family physicians, which is the only study of a similar nature previously published. The implications of the results are discussed with reference to the future direction of research by general practitioners.

Choice Behavior↗
PubMed1991

Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section.

A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care.

Cesarean Section↗
PubMed2002

The institutionalization of community interventions in Chile: characteristics and contradictions.

A critical analysis of the consequences of successive institutionalization of community intervention in Chile is presented. This analysis is based on research of current community interventions in Chile, whose results are compared with Chilean community practice from previous historical periods. Chilean community intervention was formerly practiced out of governmental institutions and universities and was sustained primarily by foreign agencies and ecclesiastical institutions. Nowadays, with the return to democracy, the vast majority of community intervention programs arefinanced, partially or totally, by means of governmental resources. This institutionalization of community interventions has had consequences worthy of critical analysis: an increase in the number and stability of intervention programs; and also negative consequences for intervention goals definition of target groups, and intervention practices. Dilemmas, such as assistance vs. promotion or adaptation vs. social change, have arisen. These dilemmas show the contradictions of a Community Psychology, which has left behind the position of institutional marginality to form part of Chilean society's "normal" psychosocial care. They also show the need for a paradigm shift from a "critical" view of the social world to a constructionist one.

Chile↗
PubMed2001

Use and efficacy of tuberculosis infection control practices at hospitals with previous outbreaks of multidrug-resistant tuberculosis.

OBJECTIVE: To evaluate the implementation and efficacy of selected Centers for Disease Control and Prevention guidelines for preventing spread of Mycobacterium tuberculosis. DESIGN: Analysis of prospective observational data. SETTING: Two medical centers where outbreaks of multidrug-resistant tuberculosis (TB) had occurred. PARTICIPANTS: All hospital inpatients who had active TB or who were placed in TB isolation and healthcare workers who were assigned to selected wards on which TB patients were treated. METHODS: During 1995 to 1997, study personnel prospectively recorded information on patients who had TB or were in TB isolation, performed observations of TB isolation rooms, and recorded tuberculin skin-test results of healthcare workers. Genetic typing of M tuberculosis isolates was performed by restriction fragment-length polymorphism analysis. RESULTS: We found that only 8.6% of patients placed in TB isolation proved to have TB; yet, 19% of patients with pulmonary TB were not isolated on the first day of hospital admission. Specimens were ordered for acid-fast bacillus smear and results received promptly, and most TB isolation rooms were under negative pressure. Among persons entering TB isolation rooms, 44.2% to 97.1% used an appropriate (particulate, high-efficiency particulate air or N95) respirator, depending on the hospital and year; others entering the rooms used a surgical mask or nothing. We did not find evidence of transmission of TB among healthcare workers (based on tuberculin skin-test results) or patients (based on epidemiological investigation and genetic typing). CONCLUSIONS: We found problems in implementation of some TB infection control measures, but no evidence of healthcare-associated transmission, possibly in part because of limitations in the number of patients and workers studied. Similar evaluations should be performed at hospitals treating TB patients to find inadequacies and guide improvements in infection control.

Adolescent↗
PubMed2003

A practice approach for identifying previously unsuspected environmental contributors to systemic lupus erythematosus and other complex diseases.

Existing medical records and health surveys provide insights into potential environmental contributors to complex chronic diseases. Those recognizable risks (e.g., workplace exposures and behaviors including smoking) do not, however, exhaust the domain of potential environmental contributors. Qualitative ethnographic investigation can be used to generate statistically testable hypotheses about environmental contributors to complex disease that otherwise would not be recognized as such. Consequently, we can empirically specify lifestyle beliefs and behaviors usually summarized by proxy identities such as race, ethnicity, gender, class, and culture. The investigation of potential environmental contributors to complex diseases may be particularly useful in confirming or disconfirming suggestive or established linkages and for indicating the kind of gene-environment interaction that may be involved.

Environmental Exposure↗
PubMed1982

Indapamide in hypertension: a study in general practice of new or previously poorly controlled patients.

A multi-centre general practitioner study was carried out in 2497 hypertensive patients. 81% of whom were already being treated for their condition, to assess the antihypertensive activity and tolerance of indapamide (2.5 mg/day in a single dose) when given in conjunction with or as replacement for existing therapy, if any. The results showed that, over a 3-month period, indapamide produced a gradual reduction in blood pressure (mean decrease of 24/14 mmHg) and there was a direct correlation between the initial diastolic pressure and the observed reduction. Side-effects with indapamide therapy were relatively few and mild, the most frequently reported being nausea, dizziness and headache. There were no consistent changes in any of the haematological or biochemical parameters monitored. An increase was noted in subjective well-being, measured by a visual analogue scale. Analysis of the results in 772 of the patients who were aged over 65 years showed that the response to and tolerance of indapamide was similar to that in younger patients.

Aged↗
PubMed1999

Addressing barriers to change: an RCT of practice-based education to improve the management of hypertension in the elderly.

BACKGROUND: In the future, primary care groups (PCGs) will have to consider how best to apply audit and education to fulfil their commitment to clinical governance and to facilitate the implementation of research findings. AIM: To establish whether an exploration of 'barriers to change' can enhance the effectiveness of an educational intervention designed to improve the management of hypertension in the elderly. METHOD: A parallel-arm, randomized, single-blind, controlled trial of practice-based educational visits in 18 practices. These practices had previously taken part in a multipractice audit of the management of hypertension in the elderly. Both groups received outreach visits in their own practice, during which they received the results of the previous audit. The nine 'intervention' practices were encouraged to explore barriers that would prevent them from implementing pertinent research findings. The control group was not encouraged to do this. The main outcome measure of the trial was determined in advance as 'the stated management of systolic hypertension in patients aged 70 to 79'. A secondary endpoint was the stated management of a specific patient scenario. The endpoints were tested by questionnaire before and after the educational intervention. RESULTS: For the primary endpoint, there was a statistically significant difference in the stated threshold for treating systolic hypertension between intervention and control groups after the visits (161.8 mmHg versus 167.2 mmHg; P = 0.007). For the secondary endpoint, there was also a statistically significant difference between the two groups, after the visits, in their willingness to treat a 70-year-old male with mild hypertension (89% of doctors would treat in the intervention group versus 57% in the control group; P = 0.047). CONCLUSION: The effectiveness of an educational intervention is significantly improved by addressing the barriers preventing practitioners from implementing the findings of research.

Aged↗
PubMed2005

Management of fractures in small animals.

Fracture repair in small animals has arrived at a crossroads because of advances in fracture repair and client demands. Research into bone healing and repair techniques, collective professional experience,economics, and client demands are obligating veterinarians to greater expertise in the actual act of repairing fractures. The influx of surgery specialists into burgeoning private practices has improved access to specialty service beyond what the limited number of academic practices could previously provide and has raised the local standard of practice for orthopedic surgery at the same time. The necessity to deal with the preoperative and postoperative management of traumatized small animals by the general practitioner has not changed, however. Treatment of the small animal patient with a fractured bone does involve accurate definition of the fracture, selection of an appropriate method of fracture fixation from the variety of devices available, and correct application of the fixation. Far more than these, however, it involves assessment and treatment of the traumatized patient as a whole,including preanesthetic evaluation of critical body systems, preoperative preparation of the patient and client, and postoperative management of the repaired fracture and patient.

Animals↗
PubMed1988

A prospective randomized trial on efficacy of antibiotic prophylaxis in asymptomatic teeth with pulpal necrosis and associated periapical pathosis.

A recent study from a private endodontic practice compared "prophylactic" antibiotic (high-dose, 1-day) regimens of penicillin V and erythromycin (base or stearate) for patients who had asymptomatic teeth with pulpal necrosis and associated periapical radiolucent lesions (PN/PL). A 2.2% flare-up incidence was found, with no statistically significant differences for penicillin (0.0%), base (2.9%), and stearate (3.8%). No hypersensitivity responses occurred, and gastrointestinal side effects were found primarily with the erythromycins (12.4%). To ascertain whether or not similar results would occur with student operators in a dental school clinic population, the current study was undertaken. One-hundred ninety-five patients with quiescent PN/PL were randomly given either penicillin V or erythromycin (base or stearate). A 2.6% flare-up incidence was found, with no statistically significant differences for penicillin (3.1%), base (1.5%), and stearate (3.1%). No hypersensitivity responses occurred, and GI side effects were found primarily with the erythromycins (17.7%). As can be seen, the results were very similar to those of the recent endodontic practice study. Hence, it can be concluded that the results of the previous endodontic practice study were not unique to any one clinician or method. A comparison was also made between the "prophylactic" penicillin group of the current study and the placebo control group of our previous dental school clinic, student operator study (in which the methods, population, and regimen were almost identical to those of the current study). The results showed that the "prophylactic" penicillin group had significant fewer flare-ups and non-flare-up-associated swelling and pain than did the placebo group. In view of these findings and those from studies from the literature in which "prophylactic" antibiotics were not used, it is our opinion that the antibiotic regimens used in the current study should be a component of clinical endodontic therapy for quiescent PN/PL.

Adolescent↗
PubMedDate not supplied

[The changing spectrum of fever of unknown origin: trends and comparison with previous series at the Salvador Zubirán National Institute of Nutrition].

We reviewed 400 medical records of patients admitted because of fever at the National Institute of Nutrition Salvador Zubirán between January 1, 1988 to December 31, 1992. Patient characteristics, diagnostic methods, final diagnosis and patient progress were analyzed, comparing these data with the previous series of the institute. We found 77 cases of fever of unknown origin (FUO), 47 males and 30 females, between 14 to 87 years of age. The final diagnosis encountered were: infections (40%), neoplasias (23%), collagen diseases (13%), and other diagnosis (8%). Sixteen percent of the cases remained without a final diagnosis. The most frequent infections were HIV infection (19%), tuberculosis (19%) and endocarditis (13%). The most common neoplasia was lymphoma (55.6%), with 90% of Hodgkin's disease. SLE was the most common autoimmune disease found. The methods to establish a final diagnosis were: biopsies (52%), serology (17%), cultures (12%), image (11%), and clinical (8%). Final diagnosis by serology tests increased from 2 to 17% in comparison with previous reports. Eight laparotomies were done, which is a less frequent practice than previously (10 vs 35%). We saw only one case of amebic hepatic abscess and had no cases of malaria and salmonellosis as final diagnosis of FUO; HIV infection was found to be a new major cause of FUO.

Adolescent↗
PubMed2003

Evidence-based treatment of stuttering: I. Definition and application.

UNLABELLED: The philosophy guiding evidence-based treatment and its application to decision-making in stuttering treatment is described. Limitations to the use of evidence-based treatment principles to guide stuttering treatment, namely the lack of a substantial treatment research literature that can serve as the basis for meta-analyses and systematic reviews of effective treatment studies, are bemoaned. Guidelines are provided to aid clinicians in their own conduct of critical evaluations of treatment research. EDUCATIONAL OBJECTIVES: The reader will learn about and be able to (1) describe the four steps that characterize evidence-based practice, (2) evaluate previous efforts to develop practice guidelines for stuttering, (3) assess the importance of an evidence-based approach to stuttering treatment, and (4) discuss the need for more research that will contribute to the evidence base.

Decision Making↗
PubMed2006

Human becoming practice around the globe: exploring the art of living true presence.

In this column, the human becoming practice methodology is illuminated and some of the questions that people have asked about living the art of human becoming are presented. The human becoming teaching-learning processes are discussed as a way of coming to know what it takes to live true presence, and the role of stories in teaching-learning human becoming practice is explored. Previously published human becoming practice stories are presented as an answer to many of the questions that persons have asked about human becoming-guided practice.

Adaptation, Psychological↗