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PubMed2004

Recovery of injured children: parent perspectives on family needs.

OBJECTIVE: To study the broader impact of emotional and financial burdens of injury in children on their families, along with solutions to these problems. DESIGN: Focus groups were conducted to reveal the needs of parents and children after injury. Audiotaped semistructured interviews were conducted by a team of qualitative researchers. SETTING: Tertiary care children's hospital. PARTICIPANTS: Mothers of children who had sustained traumatic injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Summary of reported themes of experience and suggested interventions. Data were analyzed by using content analysis software. RESULTS: Overall satisfaction with care was high. Parents expressed concerns with communication, access to care, and the transition both within the phases of medical care and from medical care into the community. Consistent financial and social stressors were voiced, along with the need for peer support during all phases of care. CONCLUSIONS: Parents provided valuable insight into their needs after their child's injury. Attention to constructive communication, clarification of the system of care, continued family-centered care, and development of peer support programs may meet the needs of caregivers and therefore facilitate improvement in pediatric injury recovery.

Adolescent↗
PubMed2004

[Consequences for the family of a very preterm birth two months after discharge. Results of the EPIPAGE qualitative study].

OBJECTIVES: To assess mothers' and fathers' psychological health 2 months after discharge of a very preterm infant. To describe the problems encountered with the child, the quality of the marital relationship, the organization of the family and to compare the answers made by mothers and fathers. POPULATION: Mothers having delivered before 33 weeks in two maternity units in Paris and in Rouen were contacted. Among the 38 mothers who were eligible, 21 accepted to participate. Their children were born between 26 weeks and 32 weeks and weighted from 630 to 2100 g. METHOD: A semi-structured interview was conducted at home by a psychologist with each member of the couple. It lasted approximately 1 h. Each interview was tape-recorded and fully transcribed. The analysis allowed to discover the main themes emerging from the interviews and to search for the role of factors. RESULTS: Two months after discharge, mothers expressed anxiety and feelings of depression. Fathers noted considerable fatigue and both parents expressed concerns about the child's health and development. Marital dissatisfaction and behavioural symptoms in siblings were also noted. Mothers' difficulties were not linked to the degree of prematurity or length of stay in neonatal unit but with the baby's present health state, his rehospitalizations and maternal characteristics such as isolation, lack of support and previous perinatal loss. The mother's psychological organisation modifies the role of objective factors. Fathers seemed more able to cope with and overcome the traumatic event caused by the very preterm birth. They insisted on their role of support for the mother and the mother-child relationship. CONCLUSION: The consequences of a very preterm birth are important and concern the whole family. After hospital discharge, the follow-up care of the very preterm baby should take the family social and psychological situation into account.

Adult↗
PubMed2005

Views of UK melanoma patients on routine follow-up care.

Although the need for melanoma follow-up is universally accepted, there is still much debate on the duration and frequency of appointments. The UK guidelines were revised in June 2002 to streamline melanoma follow-up. Following the change in protocol, some of our patients expressed concern at the shorter duration of follow-up. We therefore polled all our active melanoma patients to obtain their views on the outpatient clinics. In particular we asked whether they would be happy to have routine follow-up in a primary care setting. In conjunction with the department of psychology, a short questionnaire was devised assessing patient satisfaction and concerns about follow-up. This was sent to all active melanoma patients in our trust. Out of 304 eligible patients currently attending outpatients, 231 (76%) completed replies were received. Ninety-eight percent of respondents found the clinics to be useful. Twenty two and a half percent felt it was difficult to attend the clinic and this was mainly due to logistical problems, i.e. hospital car parking. The majority were reassured by the clinic visits and felt it was a chance to ask questions and check for new disease. Of the 12% of respondents who had a recurrence, 52% indicated that they had detected it themselves. Sixty percent of patients would be happy to consider routine follow-up with their GP, provided they were suitably experienced and trained. A survey of 50 local GP's found that 70% would be unhappy to monitor their patients. Patients want and benefit from follow-up. However, they are an increasing burden on outpatient clinics, given the increasing incidence of melanoma. GP follow-up may be appropriate for a small subgroup of patients. This combined with shared care and practice based clinical nurse specialists may be the way forward in melanoma follow-up.

Adult↗
PubMed2005

Radiation.

The US Department of Homeland Security, and other state and federal agencies, continues to express concern over the potential use of radioactive isotopes as a weapon of terror. Few emergency medicine and critical care physicians are familiar with the care and treatment of an accidentally or intentionally irradiated patient who is contaminated externally or internally. This article reviews basic radiobiology and the variety of clinical signs and symptoms exhibited by victims exposed to radiation. Preparation for patient receipt and emergency care, followed by definitive diagnosis using biodosimetry is also presented. Therapeutic measures continue to evolve for externally and internally exposed victims, including those with combined injuries caused by burns and trauma.

Decontamination↗
PubMed2004

As often as needed: appropriate use of emergency contraceptive pills.

Previous research has established that emergency contraceptive pills are safe and have the potential to reduce unintended pregnancy; however, policy makers, providers and even women themselves have expressed concern about repeat use of the method. Evidence regarding the safety, efficacy and frequency of repeat use show that the method is safe and effective, even when used multiple times. Reported rates of repeat use are actually lower than would be expected, and needed, based on the frequency of unprotected intercourse and contraceptive failure reported in most countries. Healthcare providers should encourage use of emergency contraceptive pills as a backup after recognizable failure of barrier methods or other hormonal contraceptive methods, and should expect that women may need emergency contraceptive pills multiple times during their reproductive years.

Contraceptives, Oral, Combined↗
PubMed2004

Systematic review of open access echocardiography for primary care.

Over the last few years there has been a revolution in open access echocardiography services due to an increased demand from within secondary care and primary care. There have been some concerns expressed by specialists and open access echocardiography has not been universally welcomed as a means of offering healthcare. Suspected heart failure comprises the majority of primary care referrals for open access echocardiography. There is lack of rigorously controlled studies to support widespread establishment of open access echocardiography services.

Echocardiography↗
PubMed2004

Activation of nuclear factor-kappaB and correlation with elevated plasma c-reactive protein in patients with unstable angina.

BACKGROUND: Unstable coronary syndromes are currently believed to be caused by rupture of an atherosclerotic plaque due to local events, which may be of general inflammatory etiology. There is increasing evidence that nuclear factor-kappaB (NF-kappaB) is a key transcription factor in controlling gene expression concerning inflammatory response, and that plasma concentrations of C-reactive protein (CRP) is a sensitive marker of inflammation in unstable coronary syndromes. However, whether NF-kappaB activation is associated with coronary heart disease (CHD) activity as well as plasma CRP level has been less well investigated. The aim of this study was to explore whether NF-kappaB activation was associated with CHD activity and plasma CRP elevation in patients with unstable angina (UA). METHODS: NF-kappaB activity derived from white blood cells circulating in 33 patients with CHD was determined by electrophoretic mobility shift assay. Of these, 16 had UA and were within 24h of the last episode of chest pain. The remaining 17 were being evaluated for stable angina (SA). The CRP was also evaluated in both groups using a high-sensitivity ELISA. RESULTS: There was marked NF-kappaB activation and elevated levels of CRP in UA group compared with SA group (4.02+/-0.71 AU versus 1.24+/-0.23 AU and 5.0+/-0.7mg/l versus 1.4+/-0.4mg/l, respectively, P<0.01), no NF-kappaB signal was observed in normal subjects (n=10). The NF-kappaB activation had a positive correlation with levels of CRP in patients with UA (n=11, gamma=0.771, P<0.01), but had no relationship between other clinical characteristics and the status of NF-kappaB activation. CONCLUSIONS: Our data suggest that inflammation is an important feature of unstable coronary artery disease, and both NF-kappaB and CRP are useful markers for the detection of UA or vulnerable plaques.

Journal Article↗
PubMed2005

Misoprostol use in developing countries: results from a multicountry study.

OBJECTIVE: To identify information and service delivery needs for obstetric/gynecologic uses of misoprostol in developing countries. METHODS: The study included a survey of reproductive health providers in 23 countries and a qualitative study of misoprostol use in four developing countries. Researchers used purposive sampling methods for the survey and qualitative study and conducted a descriptive statistical analysis of survey data and computer-assisted text-based content analysis of qualitative data. RESULTS: In some developing countries, women frequently access misoprostol through pharmacies and self-medicate to induce early abortion. Some clinicians expressed concern about this use of misoprostol, but many stated that its availability had reduced serious complications resulting from unsafe abortions. CONCLUSION: Although misoprostol is routinely used for a range of off-label obstetric/gynecologic indications, evidence-based, up-to-date information about safety, effectiveness, and appropriate regimens is not widely available. This information is requested by providers, including pharmacists. Women need information and guidance about its use.

Abortifacient Agents, Nonsteroidal↗
PubMed2006

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

PURPOSE: In order to better understand physicians' perspectives about the use of clinical information technology (CIT) to reduce medical errors, we asked physicians about opportunities and issues around clinical use of computerized physician order entry (CPOE) systems, order sets within CPOE, and handheld computers (HHCs). METHODS: We conducted 10 focus groups including 71 physicians involved in technology implementation efforts across the US between April 2002 and February 2005. RESULTS: Two major themes emerged across focus groups around reliance on CIT to reduce errors: (1) can it work? and (2) at what cost to the medical profession? Within the first theme, physicians expressed concern about the appropriateness of physician-directed CIT as a solution for medical errors, concerns regarding the current technical capabilities and level of technical support for CIT solutions, and concern about the introduction of new errors. Within the second theme, physicians were particularly concerned about time efficiency and workload redistribution associated with the introduction of CIT. Across focus groups, physicians tended to generalize about the role of all IT in their lives, potentially biasing opinions about specific technologies. CONCLUSIONS: Health care organizations attempting to promote physician use of CIT are advised to deepen consideration of physicians' perspectives about technology adoption and use in order to address their concerns, reduce skepticism, and increase the likelihood of implementation success.

Attitude to Computers↗
PubMed2006

Ethics of justice and ethics of care. Values and attitudes among midwifery students on adolescent sexuality and abortion in Vietnam and their implications for midwifery education: a survey by questionnaire and interview.

UNLABELLED: Adolescent's sexuality and related reproductive health and rights problems are sensitive issues in Vietnam. Globalisation has had an impact on the lifestyles of young people, and rising numbers of abortion and STI/HIV risks among youth are posing major health concerns in the country. These problems need to be addressed. Midwives belong to a key category of health personnel in Vietnam, whose task it is to promote adolescents' sexual and reproductive health and prevent reproductive ill health. It is important to understand future midwives' perceptions and attitudes in order to improve their education and training programmes. AIM: The aim of this study was to investigate Vietnamese midwifery students' values and attitudes towards adolescent sexuality, abortion and contraception and their views on professional preparation. METHODS: A quantitative survey including 235 midwifery students from four different secondary medical colleges in northern Vietnam was carried out in 2003. A qualitative study addressing similar questions was performed and 18 midwifery students were individually interviewed. FINDINGS: Findings revealed a general disapproval of adolescent pre-marital sexual relations and abortion-'an ethics of justice'-but also an empathic attitude and willingness to support young women, who bear the consequences of unwanted pregnancies and social condemnation-'an ethics of care'. Gender-based imbalance in sexual relationships, limited knowledge about reproductive health issues among youth, and negative societal attitudes were concerns expressed by the students. The students saw their future tasks mainly related to childbearing and less to other reproductive health issues, such as abortion and prevention of STI/HIV. CONCLUSION: Midwifery education in Vietnam should encourage value-reflective thinking around gender inequality and ethical dilemmas, in order to prepare midwives to address adolescents' reproductive health needs.

Abortion, Legal↗
PubMed2005

Incorporating human genetics into dietetics curricula remains a challenge.

This descriptive survey was undertaken to assess integration of genetics into undergraduate didactic dietetic education. The response rate was 35% (n=82) of all directors (N=232) of accredited or approved Didactic Programs in Dietetics. Although most directors (n=58 of 82) agreed that genetics is an important component of dietetics education, they expressed concerns about already-crowded curricula and lack of time, resources, and knowledge. Thirty-eight directors indicated that they had no familiarity with the core competencies in genetics for all health professionals. Genetics is included in some way in 69 of the 82 programs that responded. Courses in which genetics was most likely to be incorporated included nutrition, physiology, microbiology, and biochemistry. Only four directors reported a required course entirely devoted to genetics. Programs were most likely to meet the knowledge competency of the role of genetic factors in maintaining health and preventing disease and least likely to address the genetic counseling process and indications for referral to specialists. Applications of genetics in dietetics will continue to grow in importance. Evidence from this study indicates that current curricula provide little to no genetics content. Nutrition faculty must become more knowledgeable about genetics before being expected to increase genetics content in entry-level dietetics curricula.

Curriculum↗
PubMed2006

Telepsychiatry with incarcerated youth.

PURPOSE: Incarcerated adolescents have a high prevalence of psychiatric disorders but lack psychiatrists to provide ongoing care. Telepsychiatry may provide one solution to treating this underserved population. METHODS: Interactive video conferencing was used to connect a minimum security correctional facility with a regional telemedicine program. Clinical records were reviewed to examine utilization, demographics, diagnoses, pharmacotherapy, and patient satisfaction. RESULTS: During the 29-month study period, 115 youth were treated using 275 telepsychiatry visits. Substance-use, behavioral, and emotional disorders were highly prevalent. Eighty percent (80%) of the youth were successfully prescribed medications. Youth expressed confidence with the psychiatrist's recommendations but expressed concerns about privacy. CONCLUSIONS: Telepsychiatry can successfully deliver services to incarcerated adolescents with a wide range of psychiatric needs. A patient-centered approach that directly assesses adolescents' satisfaction is recommended to ensure youths' optimal involvement in needed services.

Adolescent↗
PubMed2005

Evaluation of the validity of the UN SADT H.4 test for solid organic peroxides and self-reactive substances.

Many self-accelerating decomposition temperatures (SADTs) of solid organic peroxides and self-reactive substances have been determined with the UN test method H.4, which is a scaled down test in a small Dewar vessel. For solid organic peroxides and solid self-reactive substances Fierz has questioned this procedure in a recent paper. Fierz concluded that the Dewar test results should not be extrapolated to beyond 8l packages, owing to the thermal insulation value of solids. On the other hand, long term experience with the test, with a great variety of solid organic peroxides and self-reactive substances show about equal critical temperatures in the small Dewar vessel and on 50 kg scale. In the present work, we first checked, by numerical simulations, the Dewar scale versus the larger scale, in a way comparable with Fierz' method: both scales are simulated by spheres, consisting of a number of annular layers, for the large scale the usual external heat loss term is used but for the small scale the outside heat transfer is strongly limited. The outcome of these simulations, covering a variety of physical parameters, supports the concerns expressed by Fierz. After this, we performed accurate cooling and heating experiments with solid organic peroxide in the usual Dewar vessel, provided with a large set of thermocouples. The results of these experiments showed that the simulation model for the Dewar vessel has to be changed from a spherical analogue to a short cylinder of solid material with heat exchange mainly via its top (U(top) approximately 3.5 W/(m(2)K), overall heat transfer coefficient) and some heat exchange (U(side) approximately 0.29 W/(m(2)K)) through its cylindrical and bottom part. With this "modified cylinder" model (being neither an infinitely long cylinder nor a slab) of the Dewar vessel, we found that the UN method H.4 enables an accurate prediction of the SADT, with small deviations of 0+/-2.5 degrees C. Further, by performing a truly three-dimensional (3D) finite element calculation in FEMLAB, the new heat characteristics of the Dewar vessel as well as a 50 kg package of dilauroyl peroxide, a solid organic peroxide, were checked. The outcome was compared with the critical ambient temperatures known for various package sizes, which agreed well.

Environmental Monitoring↗
PubMed2004

Giant-cell tumor of the distal forearm.

PURPOSE: Many authorities express concern that giant-cell tumors of the distal forearm are more frequently recurrent and difficult to treat chiefly because of the proximity to the carpus and the resultant diminished range of motion in the hand and forearm. We have studied the results from our institution for 49 patients with giant-cell tumors of the distal forearm treated from 2 to 28 years (mean, 14 +/- 7 years) and compared the results for different methods of treatment. METHODS: Through the computer database 49 patients with giant-cell tumors of the distal forearm (46 of the radius, 3 of the ulna) were identified. By using material from patient visits, chart review, and when necessary telephone interviews it was possible to gather demographic and outcome data for the 49 patients. For the radial lesions, 15 of the patients had a marginal resection of the distal radius along with the periosteum and ligamentous structures and implantation of cadaveric allografts. Twenty-six patients had intralesional curettage and insertion of polymethylmethacrylate (PMMA) and 5 had curettage and autograft insertion. The 3 patients with ulnar lesions were treated with Darrach resections. RESULTS: There were no deaths, infections, metastases, or amputations. In addition to the 49 original surgeries, the patients required 41 additional surgical procedures, 17 of which were for recurrent disease. The greatest numbers of recurrences were in the patients who underwent curettage with autograft or PMMA implantation. Only 2 recurrences were in patients who had a marginal resection and implantation of cadaveric allografts. The overall results for the patients showed that many had mostly minor complaints referable to function or pain and that only 18 of the 49 patients were asymptomatic. CONCLUSIONS: Although the patients with distal forearm giant-cell tumors have had a difficult course in terms of local recurrence and subsequent surgeries required for treatment failures, the ultimate outcomes for both allograft transplantation and curettage and insertion of PMMA are satisfactory. The patients with complete distal radial allografts had a better record for prevention of recurrence than the patients treated with curettage and PMMA insertion but the percentages of currently asymptomatic patients are approximately the same for both series (40% [6/15], 35% [9/26]). These data support the concept that marginal resection and complete distal radial allograft implantation should be used for patients with tumors that have destroyed much of the bone and have extensive soft tissue components and that curettage and PMMA insertion should be reserved for patients where the structural alteration of the bone is minimal.

Adolescent↗
PubMed2004

CT scan and the pediatric trauma patient--are we overdoing it?

BACKGROUND: Recent literature expresses concern for an increased risk of cancer in children exposed to low-dose radiation during computed tomography (CT). In response, children's hospitals have implemented the ALARA (as low as reasonably achievable) concept, but this is not true at most adult referring institutions. The purpose of this study was to assess the diagnostic necessity of CT in the evaluation of pediatric trauma patients. METHODS: A retrospective review was conducted of the trauma database at a large, level I, freestanding children's hospital with specific attention to the pattern of CT evaluations. RESULTS: From January 1999 to October 2003, 1,653 children with traumatic injuries were evaluated by the trauma team, with 1,422 patients undergoing 2,361 CT scans. Overall, 54% of obtained scans were interpreted as normal. Fifty percent of treated patients were transferred from referring hospitals. Approximately half arrived with previous CT scans with 9% of these requiring further imaging. Of the 897 patients that underwent abdominal CT imaging, only 2% were taken to the operating room for an exploratory laparotomy. In addition, of those patients who had abnormal findings on an abdominal CT scan, only 5% underwent surgical exploration. CONCLUSIONS: CT scans are used with regularity in the initial evaluation of the pediatric trauma patient, and perhaps abdominal CT imaging is being used too frequently. A substantial number of these scans come from referral institutions that may not comply with ALARA. The purported risk of CT radiation questions whether a more selective approach to CT evaluation of the trauma patient should be considered.

Child↗
PubMed2006

An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth.

OBJECTIVE: to determine risk factors for the occurrence of severe perineal trauma (third and fourth degree tears) during childbirth. DESIGN: a prospective cohort study was conducted using the hospital's computerised obstetric information system. Additional data were gathered on women who sustained severe perineal trauma. Descriptive statistics and logistic regression were used to assess risk factors for severe perineal trauma. Midwives were asked to comment on possible reasons for severe perineal trauma. Written responses made by midwives were analysed using content analysis. Discussion groups with midwives were held to further explore their experiences. SETTING: Royal Prince Alfred Hospital, Sydney, Australia. PARTICIPANTS: all women having vaginal births (n=6595) in a 2-year period between 1 April 1998 and 31 March 2000, in both the birth centre and the labour ward. MEASUREMENTS AND FINDINGS: 2% of women (n=134) experienced severe perineal trauma. One hundred and twenty-two women had third-degree tears and 12 had fourth-degree tears. Primiparity, instrumental delivery, Asian ethnicity and heavier babies were associated with an elevated risk of severe perineal trauma. Midwives identified several factors they believed contributed to severe perineal trauma. These were lack of effective communication with the woman during the birth, different birth positions, delivery technique, ethnicity and obstetric influences. KEY CONCLUSIONS: findings support current knowledge that primiparity, instrumental birth, heavier babies and being of Asian ethnicity are associated with increased rates of severe trauma. Specific attention needs to be paid to the strong association found between being of Asian ethnicity and experiencing severe perineal trauma. IMPLICATIONS FOR PRACTICE: further identification and validation of the concerns expressed by midwives to reduce severe perineal trauma is warranted so that preventative strategies can be used and researched.

Adult↗
PubMed2004

A qualitative study of compliance with medication and lifestyle modification in Chronic Obstructive Pulmonary Disease (COPD).

AIM: The aim of this study is to examine patients' perceptions of factors that influence their compliance with inhaled therapy for COPD, and their compliance with health related behaviours related to smoking cessation, exercise and diet. METHODS: Five focus groups of 29 diagnosed COPD patients who had not attended pulmonary rehabilitation were recruited from secondary and primary care. The severity of their illness ranged from mild to severe. For each group, the moderator asked patients what they had been told and what they actually did with regard to medication, smoking, exercise and diet. RESULTS: All patients except one reported good compliance with medication but some patients expressed concerns about technique. All patients reported being told to stop smoking, but patients varied as to whether they believed that smoking was harmful or not. Some had stopped smoking, some had tried to cut down, and others continued as normal. Patients had not been offered constructive help to quit smoking. Patients had been told to exercise but were given inadequate information as to why this was helpful. Patients were unsure how much they should exercise, and were unsure whether breathlessness during exercise was harmful. Patients had been given minimal advice about diet. CONCLUSIONS: Patients with COPD have low levels of intentional non-compliance with medication in COPD, probably because, unlike asthmatics, these patients are chronically symptomatic. Fear of dyspnoea and feelings of vulnerability also appear to contribute to good compliance. Information given by health professionals about lifestyle modification was poor. COPD patients require better education to manage their disease effectively.

Journal Article↗
PubMed2005

Socio-economic status of the patient and doctor-patient communication: does it make a difference?

This systematic review, in which 12 original research papers and meta-analyses were included, explored whether patients' socio-economic status influences doctor-patient communication. Results show that patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterised by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. Doctors' communicative style is influenced by the way patients communicate: patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor's misperception of their desire and need for information and their ability to take part in the care process. A more effective communication could be established by both doctors and patients through doctors' awareness of the contextual communicative differences and empowering patients to express concerns and preferences.

Affect↗