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One of the most important objectives of euronia is to find the adequate tonus in situations of total rest or of maximum dynamism. The dimension of tonic mastery together with relaxation make eutonia an extremely useful method in phoniatrics and orthophony.
OBJECTIVES: To examine new evidence from studies on the estimates of the fertility rate ratio comparing HIV-infected and uninfected women, of the population change in total fertility attributable to HIV, and to review the evidence of changes in fertility in HIV-uninfected women. DESIGN: A review and analysis of data from the many individual studies that have examined the associations between HIV/AIDS and fertility. METHODS: Data from sub-Saharan Africa were collected from published studies, personal communications and the Demographic and Health Surveys. A mathematical model was used to demonstrate the impact of the HIV/AIDS epidemic on the number of births in Uganda. RESULTS: Fertility was lower among HIV-infected women than HIV-uninfected women, with the exception of those aged 15-19 years, in whom the selective pressure of sexual debut on pregnancy and HIV infection led to higher fertility rates among the HIV infected. This fertility differential resulted in a population-attributable decline in total fertility of 0.37% (95% confidence interval 0.30%, 0.44%) for each percentage point of HIV prevalence. The evidence for fertility changes in HIV-uninfected women was ambiguous. An estimated reduction of 700 000 births occurred in Uganda, as a result of the reduced fertility in HIV-infected women and premature mortality among reproductive age women. CONCLUSION: Large fertility differentials existed between HIV-infected and uninfected women, with substantial variation by age. The extent to which these could be attributed to the direct impact of the epidemic on both infected and uninfected women, as opposed to pre-existing differences in their fertility, merits further study.
PURPOSE: Little is known about which urogenital nerves are liable to be injured along surgical planes in front of or behind Denonvilliers' fascia. METHODS AND RESULTS: Using semiserial histology for five fixed male pelves, we demonstrated that: 1) left/right communicating branches of bilateral pelvic plexuses run immediately in front of Denonvilliers' fascia; and 2) a lateral continuation of Denonvilliers' fascia separates the urogenital neurovascular bundle from the mesorectum. Notably, the mesorectum contains no or few extramural ganglion cells. At the level of the seminal vesicles, incision in front of Denonvilliers' fascia seems likely to injure superior parts of the pelvic plexus and the left/right communication. Moreover, at the prostate level, this incision misleads the surgical plane into the neurovascular bundle. Fresh cadaveric dissections of five unfixed male pelves confirmed that the surgical plane in front of Denonvilliers' fascia continues to a fascial space for the pelvic plexus containing ganglion cell clusters lateral and/or inferior to the seminal vesicles. CONCLUSIONS: To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers' fascia.
BACKGROUND: Many aspects of quality of care for heart failure cannot be reliably obtained by chart review. METHODS AND RESULTS: We created and tested a telephone survey to measure provider-patient communication; satisfaction; patient education, knowledge, and self-management; and health status for the Improving Chronic Illness Care Evaluation. A total of 781 patients participated in the survey; 62% were age 65 or older, 66% had a history of coronary artery disease, and 59% were cared for by a cardiologist. The measures of communication, satisfaction, patient education, knowledge, and self-management performed very well with low rates of missing values and good psychometric properties. The self-efficacy scale had acceptable reliability (Cronbach's alpha 0.69); however, it was weakly correlated with objective measures of knowledge about self-management. The Heart Failure Symptom Scale (HFSS) showed high reliability (Cronbach's alpha 0.88) and good correlation with the SF-12 Physical Health Summary Scale (r=0.63); the HFSS was also moderately correlated with measures of mental health. CONCLUSIONS: Reliable information about processes of care and health outcomes that cannot be reliably assessed by chart can be obtained by telephone. This tool should be useful for measuring quality of care for large patient populations and determining the effectiveness of quality improvement activities.
PURPOSE: Consumer assessments of interpersonal processes of care during prenatal care provide important information about how well clinicians satisfy the perceived needs of the women they serve, but few measures are available that tap the various components of these processes. The purpose of this study is to develop a multidimensional measure of prenatal interpersonal processes of care (PIPC) that demonstrates reliability and validity in ethnically diverse women in Medicaid managed care plans. METHODS: A telephone survey of African American, Latino (U.S. and foreign born) and Caucasian pregnant women in four Medicaid managed care plans in California was conducted in English and Spanish in 2001. Factor analytic methods were used to test the PIPC measures. A psychometric evaluation, including reliability, variability, and construct validity, was conducted with the final scales for the total sample and for each racial/ethnic group. RESULTS: Three dimensions, Communication, Patient-Centered Decision Making, and Interpersonal Style, with seven scales were supported with 30 items. The scales for each dimension exhibit acceptable reliability for the total sample (Internal Consistency Reliability ranged from 0.66 to 0.85) and for all racial/ethnic groups. All scales had significant associations with satisfaction with prenatal care and explained considerable variation in satisfaction (19-43%). The scale qualities and validity associations held for all scales and ethnic groups except some scales for U.S.-born Latinas. CONCLUSIONS: The multidimensional PIPC measure for assessing what actually happens between providers and low-income pregnant women of diverse ethnic groups demonstrates acceptable reliability and construct validity.
BACKGROUND: Semantic and inferencing abilities have not been fully examined in children with communication difficulties. AIMS: To investigate the inferential and semantic abilities of children with communication difficulties using newly designed tasks. METHODS & PROCEDURES: Children with different types of communication disorder were compared with each other and with three groups of typically developing children: those of the same chronological age and two groups of younger children. In total, 25 children aged 11 years with specific language impairment and 22 children, also 11 years of age, with primary pragmatic difficulties were recruited. Typically developing groups aged 11 (n=35; age-match), and those aged 9 (n=40) and 7 (n=37; language similar) also participated as comparisons. OUTCOMES & RESULTS: For Semantic Choices, children with specific language impairment performed significantly more poorly than 9- and 11-year-olds, whilst the pragmatic difficulties group scored significantly lower than all the typically developing groups. Borderline differences between specific language impairment and pragmatic difficulties groups were found. For inferencing, children with communication impairments performed significantly below the 11-year-old peers, but not poorer than 9- and 7-year-olds, suggesting that this skill is in line with language ability. Six children in the pragmatic difficulties group who met diagnosis for autism performed more poorly than the other two clinical groups on both tasks, but not statistically significantly so. CONCLUSIONS: Both tasks were more difficult for those with communication impairments compared with peers. Semantic but not inferencing abilities showed a non-significant trend for differences between the two clinical groups and children with pragmatic difficulties performed more poorly than all typically developing groups. The tasks may relate to each other in varying ways according to type of communication difficulty.
CONTEXT: Programs using community-based distribution (CBD) of family planning services have had mixed success in Sub-Saharan Africa. Knowledge about why these programs succeed or fail is limited. METHODS: In 1999, a total of 159 women and men of reproductive age were interviewed in a village in highland Madagascar with an active community-based family planning program. Network analysis informed by chi-square tests and multiple regression analysis was used to test whether respondents' communication with CBD agents and the location of their discussion partners were associated with their knowledge and use of family planning. RESULTS: The CBD agents were highly central in the village's family planning network; 35% of women and 19% of men directly communicated with a CBD agent about family planning or were indirectly linked to an agent. Knowledge of family planning was associated with having either a direct or an indirect link to a CBD agent; use of a modern method was associated with discussing family planning only with someone outside the village (odds ratio, 12.6) or with discussing it in the village and communicating directly with a CBD agent (10.8). CONCLUSIONS: Network analysis can improve the understanding of community-based program functioning by providing a way to examine who receives information from and is influenced by CBD agents.
OBJECTIVE: The aim of this study was to evaluate the prevalence and the follow-up in the long run of ventricular septal defect in the neonatal period. MATERIAL AND METHODS: 222 patients with ventricular septal defect from a total amount of 30,840 newborns admitted to our Hospital were evaluated between January 1991 and December 1996 (The incidence accounts for 7.19 per 1,000 newborns). 123 of these patients were males (55.4%) and 99 females (44.6%). The mean age at the time of examination was 3.09 +/- 1.67 days (range from 1 to 11 days). Diagnosis was suspected because of a harsh systolic murmur in 207 cases (93.2%), a malformative syndrome in 10 (4.5%) or polypnea in 5 (2.3%). The study was performed with a Sonos 1000 Echocardiograph device. The mean follow-up period ranged from 1 to 72 months. 10 patients underwent cardiac catheterization (4.5%). RESULTS: A muscular defect was the common finding in 177 patients (79.7%) whereas 41 patients (18.5%) exhibited a perimembranous defect. The mean size defect was 2.9 +/- 1.2 mm (range 1-10 mm), being smaller in the muscular defects (2.56 +/- 0.68) than in the perimembranous defects (4.33 +/- 1.56) p < 0.001. Spontaneous closure occurred in 176 ventricular septal defects (79.3%), 155 of them corresponding to muscular defects (87.6%) and 18 to perimembranous defects (43.9%). The mean age at the time of spontaneous closure was 9.5 +/- 8.9 months (9.4 +/- 9 months in the muscular defects and 10.3 +/- 4 months in the perimembranous defects). Spontaneous closure occurred by age 6 months in 52% of the patients with ventricular septal defect (54.5% muscular defects, 33.3% perimembranous defects), 12 months in 72.7% (71.2% muscular defects and 83.3% perimembranous defects) and 24 months in 96% (96.1% muscular defects and 94.4% perimembranous defects). 10 patients underwent surgical repair by age 11 +/- 8 months. All of them exhibited perimembranous defects with a mean size 6 +/- 1.5 mm which were tantamount to 24.4% of this group. 3 patients died (1.4%), 2 suffering from trisomy 18 and 1 after cardiac surgical repair. CONCLUSION: The most common ventricular septal defects in the neonatal period occur in the region of the muscular septum. The prognosis is favourable. Most of the patients experience spontaneous closure and show a very low mortality rate which is basically related to extracardiac anomalies.
OBJECTIVE: Indonesian caregivers serve as essential providers of end-of-life (EOL) care in Taiwan. But often face communication challenges due to language, cultural, and hierarchical barriers. This study evaluated the effectiveness of a culturally adapted Question Prompt List (QPL). METHODS: This study employed a two-arm randomized controlled trial design supplemented with qualitative interviews. The study was conducted in a hospice ward and home care setting within a medical center in Taiwan. A total of sixty Indonesian caregivers were recruited and randomly assigned to either the intervention group (n = 30) or the control group (n = 30). The intervention group received routine end-of-life (EOL) education along with a culturally adapted Question Prompt List (QPL), which consisted of 37 items covering domains including the dying process, emotional support, communication, symptom management, and care decision-making. The control group received routine EOL education. Outcome measures included caregiving preparedness, communication self-efficacy, satisfaction, and question-asking behavior. In addition, semi-structured interviews were conducted with eight participants, and the data were analyzed using thematic content analysis. RESULTS: Analysis of covariance revealed no statistically significant between-group differences in caregiving preparedness (F = 1.58, p = .215 [-0.41, 0.44]) or communication selfefficacy (F = 0.83, p = .366 [-0.44, 0.79]). However, communication satisfaction was significantly higher in the intervention group (F = 4.19, p < .05 [0.04, 0.44]). The number of questions asked was also significantly higher in the intervention group (t = -4.35, p < .001 [-5.41, -1.98]). Thematic analysis of qualitative data identified 4 themes and 14 subthemes, illustrating how the QPL reduced anxiety, clarified care needs, and improved confidence. CONCLUSIONS: A culturally adapted QPL can enhance communication engagement and satisfaction among migrant caregivers. PRACTICE IMPLICATIONS: Integrating culturally tailored QPLs into caregiver education and palliative care practice may promote more inclusive and effective communication.
OBJECTIVES: To discuss educational issues facing the nurse and to review opportunities for genetic education. DATA SOURCES: Published articles pertaining to cancer genetics and nursing. CONCLUSIONS: Health care providers are experiencing significant changes in their professional lives. Not only is the environment where services are provided changing, but the need for consumers to be knowledgeable and the expectations of care providers are enhanced. One significant challenge is the genetic discoveries influencing available health care. Educational preparation is crucial to the application of genetic technology in practice, research, and management of all patients. IMPLICATIONS FOR PRACTICE: The science and technology of genetics offers tremendous potential change for health care delivery. This in turn requires knowledgeable nurses to provide total patient care through the integration of genetic information. Determination of preferred methods, content, access, and evaluation is the focus of genetic educational issues.
INTRODUCTION: Family-oriented communication with parents by transport teams eases the stress associated with transferring children to tertiary care. This study was conducted to determine the duration of family-oriented visits and whether the visit contributed significant cost to the mission. METHOD: Data collection was prospective and double-blind; questions were incorporated into another study. Subjects were infants or children requiring assisted ventilation and air transport to tertiary care. Time from completion of stabilization to departure and reasons for any delay were recorded. Cost of contact time longer than 20 minutes (total acceptable time for family visit and transfer to vehicle) was calculated at paramedic overtime at $0.82/minute and aircraft wait time at $200/hour if incurred. RESULTS: Forty-six patients were enrolled. In 16 cases (35%), time between completing stabilization and hospital departure exceeded 20 minutes, with "family visit" listed as the explanation. Nine of these visits incurred overtime, and two incurred aircraft wait costs. Total costs for providing communication visits more than 10 minutes long were $607 or approximately $13 per patient. CONCLUSION: The costs for visit time longer than 10 minutes are small compared with the documented benefits of family-oriented communication. However, transport personnel must be mindful of the potential to incur additional cost through overtime, aircraft wait time, or pilot replacement.
BACKGROUND: On June 20, 1994, a discharged serviceman with a psychiatric history opened fire with a MAC-90 assault rifle at Fairchild Air Force Base in Spokane, Washington. The attack killed 5 people and wounded 22. This report reviews the communication, triage, transport, injuries, and the community medical response to this mass casualty. METHODS: Data for the review were obtained from city-wide debriefing sessions, medical records, and evaluation forms from prehospital agencies. RESULTS: A total of 19 patients were triaged to four community hospitals, while 3 victims with comparatively minor injuries stayed at the Base hospital. All fatalities except a child in utero died at the scene. All victims surviving to hospital were discharged recovered from their injuries. Two patients were undertriaged, 1 of whom sustained a pelvic and buttock wound. CONCLUSIONS: Rapid triage was possible due to: (1) initial treatment by military medical personnel; (2) an established and practiced disaster plan; (3) the use of disaster packs and triage tags; (4) the immediate initiation of triage and transport; and (5) coordinated ground and air transport.
OBJECTIVE: To test the simultaneous effect of various established predictors of breast and cervical cancer screening (breast self-examination, clinical breast examination by a physician, Papanicolaou [Pap] smear, and pelvic examination) in a low-income, Mexican-American sample. MATERIAL AND METHODS: A total of 188 Mexican-American women participated in a face-to-face structured interview in their preferred language. We tested a model with four established predictors of breast and cervical cancer screening--communication skills, knowledge of cancer, access to health care (finances and availability of care), and anxiety about cancer. Simultaneous structural equations analysis was used to form latent variables and to control for the effect of all predictors concurrently. RESULTS: Screening behavior was inversely associated with anxiety about cancer when all other predictors were statistically controlled. In addition, anxiety substantially affected the relationship between communication skills and screening behavior. Unexpectedly, knowledge of cancer was positively, rather than negatively, associated with anxiety about cancer. Predictors in the model demonstrated an excellent fit of the proposed model to the data. CONCLUSION: Successful cancer screening programs for Mexican-American women must address not only access barriers but also communication skills, knowledge, and, perhaps most importantly, anxiety.
BACKGROUND AND PURPOSE: Despite general recognition that surviving very-low-birth-weight (VLBW) infants are at risk for neurodevelopmental impairments and educational achievement difficulties, there has been relatively little study on their functional status in areas such as locomotion, communication, cognition, self-care, and interpersonal relationships. This study assessed the functional status of VLBW infants and full-term infants in early childhood, and sought to identify risk factors for functional morbidity. METHODS: A total of 238 VLBW infants and 91 full-term infants were included in this prospective follow-up study. The functional status of the infants was assessed using the Chinese Child Development Inventory (CCDI) and neurodevelopment was evaluated using the Bayley Scales of Infant Development, second version (BSID-II) at 3 years of corrected age. Perinatal and sociodemographic data were collected through review of medical records. RESULTS: The VLBW infants had lower scores on all the CCDI measures compared with the full-term infants. Functional limitation (defined as more than 2 standard deviations below the means of the full-term infants) occurred more frequently in the VLBW infants than in the full-term infants: gross motor, 23% vs 3%; fine motor, 12% vs 1%; expressive language, 21% vs 2%; comprehension-conceptual, 23% vs 4%; situation comprehension, 17% vs 4%; self-help, 17% vs 1%; and personal-social, 19% vs 3% (all p < 0.01). Significant risk factors associated with functional morbidity included gestational age < 30 weeks, grade III-IV intraventricular hemorrhage, chronic lung disease, stage III-IV retinopathy of prematurity, male gender, and maternal education below high school. CONCLUSION: VLBW infants have a higher risk of functional morbidity than their full-term counterparts in early childhood. Infants with functional limitations on CCDI screening might require comprehensive developmental assessment and continued follow-up.
PURPOSE: To examine the value of measurement of the interuncal distance in the diagnosis of mild to moderate Alzheimer disease. METHODS: We measured interuncal distance from coronal MR scans acquired on a 1.5-T imager. We estimated interuncal distance from a total of 141 subjects: 54 patients diagnosed according to the National Institute of Neurological and Communicative Disorders and the Alzheimer's Disease and Related Disorders Association criteria of probable Alzheimer disease, 40 subjects fulfilling the National Institute of Mental Health criteria of age-associated memory impairment, 27 healthy cognitively normal older control subjects, and 20 control subjects younger than 50 years of age. For comparison we normalized interuncal distance for a horizontal line drawn through the inner cranium at the level of the uncus (interuncal distance/intracranial width ratio), for the brain area (interuncal distance/brain area) and for the intracranial area (interuncal distance/intracranial area). RESULTS: The standard interuncal distance and the interuncal distance/intracranial width differed between the young control subjects and the other groups, but did not differ among the control, age-associated memory impairment, and Alzheimer disease groups. The Alzheimer disease group had significantly greater interuncal distance/intracranial area and interuncal distance/brain area compared with age-matched controls. A considerable overlap was found, however, in the values of patients with Alzheimer disease and control subjects. The cutoff point of 30 mm for interuncal distance yielded 37% sensitivity and 72% specificity to distinguish patients with Alzheimer disease from nondemented elderly subjects. Interuncal distance was not significantly related to the clinical severity of Alzheimer disease as assessed by Clinical Dementia Rating Scale and Mini-Mental Status Examination. Instead, there was a strong correlation between standard and normalized interuncal distance and age in the whole study population and in nondemented subjects. CONCLUSIONS: Our results showed that in a series of 54 patients with mild to moderate Alzheimer disease, interuncal distance was not a reliable diagnostic tool. The study also confirmed the strong age dependence for interuncal distance.
CONTEXT: The Partners in Health Education (PHE) program is an elective that pairs first and second year medical students with local classroom teachers to promote health messages to students in kindergarten through grade eight. Designed with the primary goal of helping medical students improve their communication skills through the process of teaching children about health, the PHE program has secondary goals of supporting community teachers in their efforts to promote health and of teaching children about health and the prevention of disease and injury. This report contains the results of the assessment of program impact on the school children. METHODS: A total of 327 elementary grade students in 14 experimental classrooms and 13 comparison classrooms comprised the participants for the study. Students were individually interviewed twice over an eight-week period using a structured interview form designed to capture self-report information about health and healthy living. Repeated measures analysis of variance was conducted. The effect of interest in each case was the treatment x time interaction. RESULTS: There were significant treatment x time interactions for several measures of children's reported knowledge and attitudes about health. DISCUSSION: Although designed primarily to help medical students improve their communication skills, the PHE program produced a secondary gain such that elementary students in participating classrooms reported learning more about health than did students in comparison classrooms. Programs such as PHE can provide ways to meet the goal of helping children become empowered to take charge of their own health and to make healthy choices.
AIMS: A study was undertaken to identify variations in knowledge, attitudes, experiences, and communication among different categories of hospital staff with regard to immigrant patients in order to identify potential barriers for effective diagnosis, treatment, and care of immigrant patients. METHODS: The study is based on a questionnaire mailed to doctors, nurses, and assistant nurses at Bispebjerg Hospital, a major general hospital in Copenhagen. Among the 1,012 persons included the total response rate was 58%. RESULTS: A majority of all three professional groups obtain their knowledge on immigrants through the media and patient contact, and less through travels, courses, and colleagues. Doctors and nurses showed the most positive attitudes towards different statements about immigrants, and assistant nurses the most negative. Doctors and nurses also had most frequent contacts with immigrant patients and found their communication more satisfactory compared with assistant nurses. Many health workers expressed complaints about immigrants' inappropriate use of health services. That doctors and nurses had more positive attitudes towards immigrants than assistant nurses could be explained by their higher education providing a more "fundamental safety feeling", or a feeling of not being in a competitive situation with immigrants. Assistant nurses had the least satisfactory communication with immigrant patients, possibly because they had less frequent contacts compared with doctors and nurses. CONCLUSIONS: The study provides a foundation for new interventions and priorities within the healthcare system regarding immigrant patients.
BACKGROUND: Secondary involvement of the mitral-aortic intervalvular fibrosa and the anterior mitral leaflet (subaortic structures) can occur in patients with aortic valve endocarditis. The secondary involvement of these structures occurs as a result of direct extension of the infection from the aortic valve or as a result of an infected aortic regurgitant jet striking the ventricular surfaces of the mitral-aortic intervalvular fibrosa and the anterior mitral leaflet. The abscess of mitral-aortic intervalvular fibrosa can expand to form an aneurysm. Subsequently, this mitral-aortic intervalvular fibrosa aneurysm can develop a perforation and communicate with the left atrium, resulting in the systolic regurgitation of blood from the left ventricular outflow tract into the left atrium. Secondary infection can also occur on the ventricular surface of the anterior mitral leaflet and result in the formation of an aneurysm or perforation of anterior mitral leaflet. METHODS AND RESULTS: This study examines the utility of transesophageal echocardiography in the detection of these subaortic complications in 55 consecutive patients with aortic valve endocarditis. A total of 24 patients (44%) had involvement of subaortic structures, including four with an abscess in the mitral-aortic intervalvular fibrosa, four with mitral-aortic intervalvular fibrosa aneurysm, seven with perforation of the mitral-aortic intervalvular fibrosa with communication into the left atrium, two with an aneurysm of the anterior mitral leaflet, and seven with perforation of the anterior mitral leaflet. The transesophageal echocardiographic findings were confirmed at surgery in 20 patients and at necropsy in two. By comparison, transthoracic echocardiography visualized these lesions in five of 24 patients (21%), including none of four with mitral-aortic intervalvular fibrosa abscesses, two of four with mitral-aortic intervalvular fibrosa aneurysms, one of seven with mitral-aortic intervalvular fibrosa perforations, one of two with anterior mitral leaflet aneurysms, and one of seven anterior mitral leaflet perforations. Eccentric mitral regurgitation-type systolic jets were noted in eight additional patients by transthoracic color flow imaging, and this finding suggested the possibility of these unusual subaortic complications. If these patients are included, then transthoracic echocardiography suggested the presence of these subaortic complications in 13 of 24 patients (54%). CONCLUSIONS: The results indicate that 1) involvement of the subaortic structures in patients with aortic valve endocarditis may be more common than previously recognized, 2) patients with aortic valve endocarditis and eccentric jets of mitral regurgitation on transthoracic echocardiography should undergo further evaluation by transesophageal echocardiography to exclude these unusual complications, 3) precise recognition of these complications is of value in the optimal medical and surgical management of these patients, and 4) these complications may be responsible for unexplained congestive heart failure and hemodynamic deterioration in some patients with aortic valve endocarditis.