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PubMed2003

"Risk, respect, responsibility": educational strategies to promote safe medicine use.

Nearly four billion outpatient prescriptions will be dispensed in the United States by 2005. Many people using these medicines will be targeted for educational programs promoting their safe, appropriate use. Such programs have been, or soon will be, developed by virtually all major health care system stakeholders, including: government agencies, the pharmaceutical industry, non-profit organizations and coalitions. After examining changes in 1) health professionals' communication of patient medicine information, and 2) consumers' roles and attitudes, an overview of recent U.S. and international consumer education programs is presented. Despite the proliferation of these programs, most share a weak link in evaluating success and in affecting behavior change. Finally, suggestions for future initiatives are offered, particularly regarding improving evaluation methods.

Communication↗
PubMed1996

Persistent school dysfunction: unrecognized comorbidity and suboptimal therapy.

To determine reasons for continued school dysfunction in children previously diagnosed as having attention deficit hyperactivity disorder (ADHD) or enrolled in a special education program (spec. ed.), a retrospective chart review of patients referred for interdisciplinary evaluations at a tertiary center for hyperactivity and learning problems was completed. Interdisciplinary clinical recommendations were used to define reasons for treatment failure in 116 children with prior diagnosis of ADHD or spec. ed. placement. Results showed 45% of children enrolled in spec. ed. had previously undiagnosed ADHD. Thirty-one percent of those with ADHD, 55% of those in spec. ed., and 55% of those diagnosed with ADHD and in spec. ed. (Both) received a new educationally handicapping diagnosis. Psychiatric comorbidity was present in 28% of those with ADHD, 18% of those in spec. ed., and 23% of Both subjects. Thirteen percent of those in spec. ed. had significant coexisting medical conditions. Special education services were insufficient in 55% of children in spec. ed. and 55% of Both subjects. A significant difference (P < 0.01) in medication use was noted between the groups with 56% of the ADHD group, 55% of the Both group, and none of the spec. ed. group treated with medication. Of all subjects with ADHD, 76% were receiving insufficient or no medication. This review suggests the following: (1) Comorbidity in children with school dysfunction is frequently not recognized. (2) Educational therapy alone may not be sufficient treatment for school dysfunction, and in cases where the treatment program is failing, the appropriateness of the program should be reviewed. (3) ADHD is commonly seen in conjunction with other educationally handicapping conditions. Therefore, in cases of continuing school dysfunction, children previously diagnosed has having ADHD should be assessed for other educationally handicapping conditions; those previously diagnosed as educationally handicapped should be assessed for ADHD. (4) Suboptimal medication use may be associated with treatment failure.

Attention Deficit Disorder with Hyperactivity↗
PubMed2001

Surveillance programs for early stage non-seminomatous testicular cancer: a practice guideline.

BACKGROUND AND PURPOSE: To identify an appropriate surveillance program for men with clinical stage I non-seminomatous germ cell tumors of the testis (NSGCT). MATERIALS AND METHODS: A systematic review of the published literature was combined with a consensus process, around the interpretation of the evidence in the context of conventional practice, to develop an evidence-based practice guideline. RESULTS: No randomized controlled trials (RCTs) comparing surveillance schedules were found, but data from 12 case series and one RCT which compared radiotherapy with surveillance were reviewed. Variations in the schedules were not associated with observed variations in relapse, salvage, or survival rates. CONCLUSIONS: Men with clinical stage I testicular cancer, as defined by a normal physical examination, normal radiological scans (computed tomography [CT]) and serum markers (alpha-fetoprotein [AFP] and beta-subunit of human chorionic gonadotropin (betaHCG) which are normal or fall within normal limits during their expected half-lives, are eligible for surveillance. A recommended surveillance schedule is as follows: 1) Physical examination, blood serum marker tests (AFP and HCG), and chest x-rays should be conducted every month in the first year, every 2 months in the second year, every 3 months in the third year, and every 6 months in the fourth and fifth years; and 2) CT scans of the abdomen and pelvis should be conducted every 3 months in the first year, every 4 to 6 months in the second year and every 6 months in the third year, and once a year in the fourth and fifth year.

Germinoma↗
PubMed1990

Nutritional needs assessment of rural agricultural migrants of southern Brazil: designing, implementing and evaluating a nutrition education program.

A nutritional needs assessment was conducted among rural agricultural migrant women (target group) and children (less than 5 years). The study was conducted in Vila Diogo, a slum located on the periphery of Nuporanga, a village in Sao Paulo state, Brazil. A nutrition education program was designed on the basis of evidence obtained from demographic/socioeconomic information of the study population and a nutritional needs assessment of women (target group) and children less than 5 years of age. The nutritional needs assessment consisted of anthropometry, dietary assessment, and nutrition knowledge, attitudes, and beliefs questionnaires. Formative and summative evaluation of the nutrition education program, using appropriately selected criteria and comparisons of nutrition knowledge scores before and after the program, were used to determine program effectiveness. Major findings of the study were: Diets of Vila Diogo residents were generally simplistic, consisting primarily of rice, beans, and coffee with sugar. Vila Diogo women appeared to be at a relatively high risk for vitamin A, iron, calcium, ascorbic, and riboflavin deficiencies, based on comparisons of 24-hour dietary intake data with FAO recommendations. Children (2-5 years) appeared at high risk for vitamin A, iron, and ascorbic acid deficiencies, based on comparisons of 24-hour dietary intake data with FAO recommendations. All children less than 5 years of age had been breast-fed at birth, but more than one half of children had been weaned by the third month. Infant feeding practices during fever and diarrhea were nutritionally detrimental. Women generally recognized a relationship between dietary intake during pregnancy and fetal nourishment. Using weight-for-height index, a significant number of women were probably undernourished; a small percentage of women, however, were overweight or obese. Although children less than 5 years of age did not generally appear malnourished, a relatively large number were stunted in growth. Although Vila Diogo women reported many food taboos during various physiological states (menstruation, pregnancy, immediately post partum, lactation), relatively few food taboos had potentially negative nutritional consequences. For women who participated in the nutrition education program, nutrition knowledge scores after the program showed improvement which was statistically significant at alpha = 0.05, using Wilcoxon signed rank test.

Brazil↗
PubMed2005

Peritoneal dialysis training: a multisensory approach.

Undertaking peritoneal dialysis (PD) therapy poses a challenge to all patients with renal failure. The potentially high risk of infection makes it essential that patients undertaking PD have adequate training and ongoing support. Over recent years, increasing numbers of elderly patients, patients with significant learning disabilities, and patients with marked comorbidities have been accepted onto renal replacement therapy programs. For those undertaking PD in particular, this has posed new educational challenges. The Community Dialysis Team recognized an area of weakness in their current training program for these patient groups. The degree of literacy skills as well as the volume of written material and the amount of medical terminology used did not result in a user-friendly training program. A collaborative approach involving various members of the multidisciplinary team designed an appropriate training program for patients with learning disabilities. The new program included (1) a photographic bag-exchange procedure; (2) the provision of simple, step-by-step instructions on audiotape; (3) a new assessment sheet where words were replaced with symbols; (4) a redesigned daily record sheet (used to monitor clinical parameters); and (5) a simple contact card. The quality of the new training program was assessed by a small pilot study evaluation. The reduction of training times and the satisfactory peritonitis rates suggest that the new multisensory training program could be successfully implemented. The use of pictorial aids and more symbols, with less focus on the written word, made PD training a viable option for many individuals, including elderly patients and those with learning disabilities. The increased use of pictorial aids and symbols may also be helpful in training patients where there is a language barrier as well as the pediatric population.

Comorbidity↗
PubMed2004

Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program.

BACKGROUND: Despite recent advances in the treatment and prevention of cardiovascular disease, a treatment gap for secondary prevention medications still exists. OBJECTIVE: To develop and implement a program ensuring appropriate prescription of aspirin, statins, beta-blockers, angiotensin-converting enzyme inhibitors, and warfarin at hospital discharge. DESIGN: A nonrandomized before-after study comparing patients hospitalized before (1996-1998) and after (1999-2002) implementation of a discharge medication program (DMP). Patients were followed for up to 1 year. SETTING: The 10 largest hospitals in the Utah-based Intermountain Health Care system. PATIENTS: In the pre-DMP and DMP time periods, 26,000 and 31,465 patients, respectively, were admitted to cardiovascular services (n = 57,465). MEASUREMENTS: Prescription of indicated medications at hospital discharge; postdischarge death or readmission. RESULTS: By 1 year, the rate of prescription of each medication increased significantly to more than 90% (P < 0.001); this rate was sustained. At 1 year, unadjusted absolute event rates for readmission and death, respectively, were 210 per 1000 person-years and 96 per 1000 person-years before DMP implementation and 191 per 1000 person-years and 70 per 1000 person-years afterward. Relative risk for death and readmission at 30 days decreased after DMP implementation; hazard ratios (HRs) for death and readmission were 0.81 (95% CI, 0.73 to 0.89) and 0.92 (CI, 0.87 to 0.99) (P < 0.001 and P = 0.017, respectively). At 1 year, risk for death continued to decrease (hazard ratio, 0.79 [CI, 0.75 to 0.84]; P < 0.001) while risk for readmission stabilized (hazard ratio, 0.94 [CI, 0.90 to 0.98]; P = 0.002), probably because survivors had more opportunities to be readmitted. LIMITATIONS: The study design was observational and nonrandomized, and the authors could not control for potential confounders or determine the extent to which secular trends accounted for the observed improvements. CONCLUSIONS: A relatively simple quality improvement program aimed at enhancing the prescription of appropriate discharge medications among cardiovascular patients is feasible and can be sustained within an integrated multihospital system. Such a program may be associated with improvements in cardiovascular readmission rates and mortality.

Cardiovascular Diseases↗
PubMedDate not supplied

Cardiac rehabilitation: a patient education program.

Hospitalized cardiac patients were given an education program that covered, in five 45-minute discussion sessions, anatomy and physiology, dietary management, appropriate activity programs, the adjustment process, risk factors, and signs and symptoms of complications of therapy. A sample of 36 patients was given pre- and posttests and followed at six weeks and three months postdischarge. Significant (p less than .05) increases in knowledge were found among study subjects which resulted in improved conditions for the subjects.

Adolescent↗
PubMed2002

Substance abuse attitudes and policies in US rehabilitation training programs: a comparison of 1985 and 2000.

OBJECTIVE: To assess and compare the attitudes, beliefs, and policies of physical medicine and rehabilitation (PM&R) training programs toward substance abuse and tobacco use over the last 15 years. DESIGN: A blinded questionnaire was sent to all US rehabilitation medicine training program directors. Results were compared with a survey conducted in 1985. SETTING: US PM&R residency training programs with inpatient rehabilitation training. PARTICIPANTS: Training directors or their designated agents. INTERVENTION: A 35-item questionnaire was mailed between November 1999 and April 2000 to the 81 US training programs identified by the American Board of Physical Medicine and Rehabilitation as having rehabilitation training programs with inpatient rehabilitation units. Responses were pooled by our Survey Research Center to preserve anonymity. Training programs that did not respond received additional mailings and telephone calls to improve the response rate. MAIN OUTCOME MEASURES: Chi-square analysis to assess changes in responses with time. RESULTS: Forty-six of the 79 (58%) eligible training programs responded (1 program had merged, 1 did not provide inpatient rehabilitation). Programs were located in cities ranging from less than 100,000 (n = 2) to greater than a million inhabitants (n = 18). Eighty percent (37/46) of the respondents were "concerned or very concerned" about their patients' alcohol and drug use, and 69% routinely assessed patients for alcohol and drug use compared with only 25% in 1985 (P <.00001). Almost all respondents (43/46) supported written guidelines to prohibit alcohol and drug use by patients in the rehabilitation unit. Eighty-three percent had a prohibition policy, and 72% had written guidelines. Both of those rates represent increases from the 1985 response rates of 65% and 45%, respectively. Ambivalence persisted about appropriate treatment programs for persons with disabilities: in 1985, 51% of the respondents agreed that a person with a disability could be treated appropriately in a substance abuse program designed for persons without a disability; in 2000, the percentage had increased to 64%. All respondents believed that tobacco use is an addiction, but only 25% of their units offered tobacco cessation services to patients on their rehabilitation unit. CONCLUSION: The survey results are encouraging. Since 1985, not only have substance abuse issues been recognized, but also systemic institutionalized approaches (eg, regular screening, written guidelines) have increased markedly. Tobacco is now uniformly accepted as an addiction, but screening and access to cessation programs are similar to that available for alcohol and drug treatment programs 15 years ago.

Alcoholism↗
PubMed1989

Determining appropriate use of an air medical program.

The Therapeutic Intervention Scoring System (TISS) was evaluated as an instrument to determine appropriate use of an air medical program (AMP) from a retrospective standpoint. TISS scores of 376 consecutive patient transports to the sponsor institution were compared to two other methods of judging appropriateness of air transport: a chart review and a review of patient outcome which included length of hospital stay, need for emergency surgery, mortality rates, and Trauma Scores. Statistically significant correlations were found between the TISS and the other two methods. We concluded that the TISS is a valid instrument for use in determining the appropriateness of air medical transports. The TISS is used as a quality assurance tool during retrospective, bi-weekly patient review sessions; and follow-up on appropriate use of the helicopter is provided to referring and receiving agencies accordingly.

Aircraft↗
PubMed1998

Defining appropriate health status and management programs for specific-pathogen-free swine for xenotransplantation.

Swine are expected to be utilized as xenograft donors for both whole-organ and cellular transplantation. In order to meet the criteria for regulatory guidelines, donor animals are going to have to be free of potential zoonoses and other complicating diseases. Screening of animals will have to include tests for viruses, bacteria, parasites, congenital defects, and other inapparent diseases such as neoplasia or metabolic dysfunctions. The term Specific-Pathogen-Free (SPF) swine is a proprietary designation in the U.S. that does not include screening for all appropriate organisms for xenotransplantation. A program for breeding animals as xenograft donors will have to be conducted in a biomedical research facility rather than a conventional farm setting. The research programs at such a facility should include serology, microbiology, necropsy, histology and parasitology. The use of sentinel animal monitoring in a research facility is one method to ensure compliance. It will be impossible to provide complete individual animal screening in a timely fashion prior to performing a xenograft transplant. Quality control measures need to ensure that there is a reasonable confidence that the donor tissue is appropriate for the procedure to be performed. It is suggested that a term such as xenograft-defined flora be used to designate the appropriate health status of donor animals rather than SPF in order to avoid confusion with existing standards.

Animals↗
PubMed2000

Hereditary colorectal cancer: risk assessment and management.

There are at least nine major cancer susceptibility syndromes that infer an increased risk for colorectal cancer and/or colorectal polyposis; hereditary nonpolyposis colorectal cancer syndrome, Muir-Torre syndrome, Turcot syndrome, the I1307K polymorphism of the APC gene, familial adenomatous polyposis, attenuated familial adenomatous polyposis, Peutz Jeghers syndrome, juvenile polyposis, and the PTEN hamartoma tumor syndrome. As a result, the differential diagnosis of hereditary colorectal cancer can be complex. In addition, there has been a dramatic increase in the knowledge available regarding risk assessment and management of hereditary colorectal cancer syndromes. The literature was reviewed to develop this concise review of the hereditary colorectal cancer syndromes to facilitate the accurate diagnosis of each syndrome and the appropriate medical care for individuals with these diagnoses. Referral to a qualified Clinical Cancer Genetics program is appropriate if any of these syndromes is suspected and they will ensure the most up-to-date information is available to the patient, their family, and their health care professionals.

Colorectal Neoplasms↗
PubMed1997

Bilingual telephone-assisted computerized speech-recognition assessment: is a voice-activated computer program a culturally and linguistically appropriate tool for screening depression in English and Spanish?

The purpose of this study was to evaluate an automated voice-interactive program for screening depression in English and Spanish. The Center for Epidemiological Studies-Depression Scale (CES-D) was administered in two interview formats: a speech recognition program presented by cellular telephone, and a face-to-face method. In a single-session counterbalanced design, 32 English speakers and 23 Spanish speakers completed randomly ordered administrations of the two CES-D methods, the Beck Depression Inventory (BDI), and the Short Acculturation Scale (SAS). There was strong evidence that the two CES-D methods were psychometrically equivalent, reliable, and valid in both languages. The two methods were highly rated by both language groups. The Spanish speakers did not display a preference for either method, but the English speakers preferred the face-to-face method. The results also suggested that verbal response latency time was positively correlated with depression scores. Last, the Spanish-speakers' acculturation levels were not correlated with depression scores. Differences in age, education, and income between the language groups were confounded by unequal sample sizes. The findings generally supported the viability of the automated CES-D as a culturally and linguistically appropriate tool for screening depression in English and Spanish. Furthermore, the analyses of respondent voice characteristics show promise as a method for screening depression in both languages.

Acculturation↗
PubMedDate not supplied

Pressuring children to learn versus developmentally appropriate education.

Preschool and kindergarten programs have changed focus from an emphasis on play to an emphasis on formal academics. This trend is evaluated in light of research on children's development and learning. An alternative model of a developmentally appropriate program for young children is discussed.

Child Development↗
PubMed1989

Developmental approach to pediatric neurogenic dysphagia.

The approach to children with neurogenic dysphagia is unique due to their development, growth, and behavior. Multiple streams of development (cognitive, oral-motor, fine and gross motor) have direct and indirect effects on feeding. Provision of an appropriate feeding program requires that the multiple needs, abilities, and disabilities of each child be assessed and managed appropriately.

Adult↗
PubMed2001

Human sex differences in sexual psychology and behavior.

Because age and sex constitute the only distinct anatomical and physiological morphs (types) of the human species, universal sex differences ought to be expected. According to Darwinian theory, the most numerous sex differences are likely to be found in the domains of sexuality and reproduction. We first briefly review the basic model of the adaptationist program of modern Darwinian psychology. We then present evidence suggesting substantial sex differences in the following domains of sexual behavior: Mate preferences, interest in casual sex, interest in partner variety, jealousy, fantasy, sexual "plasticity," and magnitude of intrinsic sexual motivation. We then propose a program for research and explanation of sex differences that invokes both proximate and ultimate variables where appropriate. This program is based in modern Darwinian theory, neuroendocrinology, human genetics, and social and behavioral sciences. We conclude by considering sociopolitical implications of research on sex differences.

Adaptation, Psychological↗
PubMed2006

Prevention in translation: tobacco use prevention in India.

Mobilising Youth for Tobacco-Related Initiatives in India (Project MYTRI) is a randomized community trial to prevent tobacco use among students in Grades 6 through 9 in 32 private and government schools in Delhi and Chennai, India (N=12,484). The project is a partnership between researchers and practitioners in the United States and India. This article describes the steps that were carried out to ensure that prior effective programs are appropriate and applicable to India. These steps involve (a) developing a conceptual behavioral intervention model, (b) ensuring the appropriateness of the model for urban India, (c) developing intervention strategies that modify factors in the model, (d) implementing the MYTRI program with more than 5,000 students, and (e) evaluating the process and outcomes of the intervention. Data to date suggest that this process has been successful, including high participation rates, teacher perceptions of appropriateness, and agreements for further implementation.

Adolescent↗
PubMedDate not supplied

Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review.

OBJECTIVE: To review the literature concerning the management with placement of covered stent-grafts of traumatic pseudoaneurysms of the extracranial internal carotid artery (ICA) resulting from penetrating craniocervical injuries or skull base fractures. METHOD: We have reviewed, from the Medline database, all the published cases in the English literature since 1990 and we have added a new case. RESULTS: We identified 20 patients with traumatic extracranial ICA pseudoaneurysms due to penetrating craniocervical injuries or skull base fractures who had been treated with covered stent-graft implantation. Many discrepancies have been ascertained regarding the anticoagulation therapy. In 3 patients the ICA was totally occluded in the follow-up period, giving an overall occlusion rate 15%. No serious complication was reported as a result of the endovascular procedure. CONCLUSION: Preliminary results suggest that placement of stent-grafts is a safe and effective method of treating ICA traumatic pseudoaneurysms resulting from penetrating craniocervical injuries or skull base fractures. The immediate results are satisfactory when the procedure takes place with appropriate anticoagulation therapy. The periprocedural morbidity and mortality and the early patency are also acceptable. A surveillance program with appropriate interventions to manage restenosis may improve the long-term patency.

Adult↗
PubMed1992

GC-MS studies of 16-androstenes and other C19 steroids in human semen.

Human semen was examined for the presence of 16-androstenols, 16-androstenones and androgens. Extracts were analysed by gas chromatography-mass spectrometry after derivatization of steroids under study. In a qualitative study, 5 alpha-androst-16-en-3 alpha- and 3 beta-ols, 5,16-androstadien-3 beta-ol and 5 alpha-androstan-3 beta-ol were detected in a semen pool A. Hydroxyl groups were converted to tert-butyldimethylsilyl ethers, the ions selected for monitoring being [M-57]+, consistent with loss of the tert-butyl group. For a more detailed quantitative study, a second semen pool B was used. In this case, all hydroxyl groups were converted to trimethylsilyl ethers, while oxo groups were not derivatized. As with semen pool A, separation of steroids was achieved using capillary gas chromatography with appropriate temperature programming. Quantification was carried out by mass spectrometry using selected ion monitoring of two significant ions and appropriate internal standards. The following steroids were identified at the concentrations indicated: 5 alpha-androst-16-en-3 alpha- and 3 beta-ols and 5,16-androstadien-3 beta-ol (concentration range, 0.5-0.7 ng/ml). 5 alpha-Androst-16-en-3-one and 4,16-androstadien-3-one were also present at levels of 0.7-0.9 ng/ml. Two androgens, testosterone and 5 alpha-dihydrotestosterone were found at concentrations of 0.5 and 0.3 ng/ml, respectively. These data, showing the presence of 16-androstenes and androgens in human semen, appear to be consistent with testicular formation of these steroids. The possible significance of the odorous 16-androstenes is discussed.

Androgens↗