Uniquely hospice: policies and procedures of terminal care at home.
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Advance Directives↗
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Identification and characterization of hydroxymethylbilane synthase mutations causing acute intermittent porphyria: evidence for an ancestral founder of the common G111R mutation.
Acute intermittent porphyria (AIP), the most common hepatic porphyria, results from the half-normal activity of hydroxymethylbilane synthase (HMB-synthase; EC 4.3.1.8), the third enzyme in the heme biosynthetic pathway. Because life-threatening acute neurologic attacks of this autosomal dominant disease are triggered by various ecogenic factors (e.g., certain drugs, hormones, alcohol, and starvation), efforts have been directed to identify and counsel presymptomatic heterozygotes in affected families to avoid the precipitating factors. Thus, to determine the nature of the mutations causing AIP in 26 unrelated enzyme-confirmed patients from Argentina, a long-range polymerase chain reaction method was developed to amplify the entire 10-kb gene in two fragments for efficient cycle sequencing and mutation detection. Eight new mutations were identified including two missense mutations (Q34P and G335S), four small deletions (728delCT, 815delAGGA, 948delA, and 985del12), a single base insertion (666insA), and a splice site mutation (IVS12(+1)). In addition, five previously reported mutations (G111R, R173W, Q204X, R201W, and 913insC) were detected. Notably, G111R was identified in 12 of the 26 (46%) presumably unrelated propositi; however, haplotype analysis with intragenic and flanking markers indicated an ancestral founder. Expression of the two new missense mutations (Q34P and G335S) in f1 E. coli resulted in 2.5% or less of the normal expressed enzyme, confirming their defective function. Thus, eight new and five previously reported HMB-synthase mutations, including a common lesion, were detected, permitting accurate identification and counseling of presymptomatic carriers in these 26 unrelated Argentinean AIP families with this dominant porphyria.
Adolescent↗
A pilot study comparing the level of sickle cell disease knowledge in a university in southeastern Texas and a university in Enugu, Enugu State, Nigeria, West Africa.
Sickle cell disease is the most commonly inheritable blood disorder in man. Sickle cell anemia affects approximately one in 375 Blacks in the United States. There is yet no known cure for this disease. Families of sickle cell patients continue to be financially and emotionally devastated by sickle cell disease complications. A high level of sickle cell disease knowledge will encourage non-directional sickle cell disease counseling that would reduce the incidence of this disease. A pilot study to determine the level of sickle cell disease knowledge in a university in southeastern Texas and a university in Enugu, Enugu State, Nigeria, West Africa found that there was a need to improve retention of sickle cell disease factual information.
Adult↗
Adults with ADHD. An overview.
Attention-Deficit Hyperactivity Disorder (ADHD) is a common, genetically transmitted neurological disorder, with onset in childhood, probably mediated by decreased brain dopaminergic functioning. The first author was one of the earliest to describe the persistence of symptoms into adulthood. Prevalence and natural history data suggest that of the 3 to 10% of children diagnosed with ADHD, one- to two-thirds (somewhere between 1 and 6% of the general population) continue to manifest appreciable ADHD symptoms into adult life. This paper describes how ADHD in adults can be readily diagnosed and treated, despite resembling or coexisting with other psychiatric disorders. The Wender Utah diagnostic criteria address adult characteristics of the disorder. Informant and patient interviews and rating scales are used to determine the psychiatric status of the patient as a child, make a retroactive diagnosis of childhood ADHD, and establish the current diagnosis of the adult. Stringent diagnosis is key to determining effective treatment. Dopamine agonist stimulant medications appear to be the most effective in treating ADHD. About 60% of patients receiving stimulant medication showed moderate-to-marked improvement, as compared with 10% of those receiving placebo. The core symptoms of hyperactivity, inattention, mood lability, temper, disorganization, stress sensitivity, and impulsivity have been shown to respond to treatment with stimulant medications. Non-dopaminergic medications, such as the tricyclic antidepressants and SSRIs have generally not been useful in adults with ADHD in the absence of depression or dysthymia. Pemoline is no longer approved for use in these patients, despite early favorable reports. Appropriate management of adult patients with ADHD is multimodal. Psychoeducation, counseling, supportive problem-directed therapy, behavioral intervention, coaching, cognitive remediation, and couples and family therapy are useful adjuncts to medication management. Concurrent supportive psychosocial treatment or polypharmacy may be useful in treating the adult with comorbid ADHD.
Attention Deficit Disorder with Hyperactivity↗
Roles and value added contributions of the occupational health nurse. Corporate perceptions.
This study replicated a study by Martin (1993) to examine the corporate perceptions of the current and future roles and activities of the occupational health nurse and the nurse's value added contributions in the local operating units of a large Fortune 100 company. A descriptive design was used for this study. The sample consisted of 44 corporate officials. The study findings are consistent with Martin (1993) and suggested that management is aware of the traditional roles and activities of the nurse, including direct care, education and counseling, and case management. The desired future activities identified were trend analysis, conducting plant rounds, and developing health programs specific to the needs of the corporation. The activities identified as adding value to the corporation included: planning and developing educational programs specific to the needs of the corporation, supervising the provision of nursing care, assisting in rehabilitation of injured workers, and providing follow up on workers' compensation claims. Corporate officials are aware of the traditional roles of the nurse. However, they may not be aware of the newer nursing roles, such as trend analysis, research, and budget development.
Attitude to Health↗
Risk reduction in general practice and the role of the receptionist.
Medical receptionists play a crucial role in any practice as they are usually the first points of contact for patients and the intermediaries through whom contacts with medical practitioners are made. This article reports the findings of a qualitative study of medical receptionists undertaken to explore their role in general practice, particularly in relation to activities involving direct patient assessment, monitoring, counselling and therapy. The findings highlight a number of significant issues in relation to the potential liability of receptionists, medical practitioners, medical centre owners and insurers.
Australia↗
Use of social networks to identify persons with undiagnosed HIV infection--seven U.S. cities, October 2003-September 2004.
An estimated 250,000 persons living with human immunodeficiency virus (HIV) in the United States are not aware of their infections and their risk for transmitting HIV. As part of CDC's Advancing HIV Prevention Initiative, identifying persons with undiagnosed HIV infection and linking them to medical care and prevention services is a national priority. In 2003, a 2-year demonstration project was begun with nine community-based organizations (CBOs) in seven cities to evaluate the effectiveness of using a social network strategy at multiple sites to identify persons at risk for HIV infection and direct them to HIV counseling, testing, and referral (CTR). In this strategy, HIV-positive persons and HIV-negative persons at high risk (i.e., recruiters) are enlisted to recruit for CTR persons from their social, sexual, and drug-use networks (i.e., network associates [NAs]) believed to be at risk for HIV infection. This report summarizes preliminary results from the first year of this 2-year project, which indicated that 133 persons recruited 814 NAs, resulting in 46 newly identified HIV infections (approximately 6% of all persons tested). Health departments and CBOs should consider this strategy as an effective method for recruiting persons for CTR and identifying those with undiagnosed HIV infection.
AIDS Serodiagnosis↗
Hispanic adolescent pregnancy testers: a comparative analysis of negative testers, childbearers and aborters.
Fifty-six Hispanic adolescents who requested a pregnancy determination at a municipal outpatient adolescent clinic participated in a comparative study of negative testers, childbearers, and aborters. The study's purposes were to assess differences between negative and positive pregnancy testers and to evaluate the pregnancy resolution decision-making process of positive testers. Data were collected using a two-part structured interview administered prior to and following knowledge of pregnancy test results. Results indicated that negative and positive pregnancy testers were similar in all areas evaluated. However, positive testers were slightly older and had higher self-esteem than negative testers. Of the 36 positive testers, 29 chose to deliver and keep the baby. None of the adolescents chose adoption. Adolescents were consistent in their pregnancy resolution decision before and after knowledge of pregnancy test results. The pregnant adolescents considered themselves to be the most influential person in the decision-making process. There were no significant differences between the childbearers and the aborters, although the former demonstrated higher self-esteem and greater religiosity. Most of the teenagers were at risk for unintended pregnancy; therefore, subsequent family planning counseling efforts should be directed at this population.
Abortion, Induced↗
Dementia: the importance of clinical evaluation, autopsy confirmation, and research.
Because of the increasingly elderly population, dementia is a major public health problem, currently affecting over 50,000 Oklahomans at an approximate cost of one billion dollars annually. The marked overlap in symptomatology between Alzheimer's disease and other primary central nervous system degenerations makes antemortem diagnosis based on a clinical assessment tentative at best, with error rates of 25% commonly reported. Accurate diagnosis is of vital importance in improving our understanding of these illnesses, evaluating potential therapies, and providing appropriate genetic counseling to family members. Direct neuropathologic examination at autopsy is currently the only reliable method for assuring accurate diagnosis and should be undertaken in all demented patients.
Aged↗
Women at risk of family violence.
Presented here are the basic, core picture and pathognomonic features of spouse (or partner) violence, stripped of obscuring traditional, often male-dominated misinformation. Spouse abuse, like other forms of intentional injury or violence, should no longer be considered tolerable or "normal." It represents a form of psychopathology, corrupting the family emotional setting, provoking human anguish and even death. It often perpetuates itself into the next generation. Assault or murder by an abusive male or lover must be recognized as an all too common, preventable, public health issue. Health care and legal professionals, as well as the public at large, must be informed to recognize the features of this tragic family drama. State laws and welfare agencies have started to accommodate this problem, directing victims to appropriate counseling, support and protection. Reluctant or passive police, attorneys and judges may present considerable frustration to those trying to assist these families.
Female↗
Health education: what anthropology can teach us.
Understanding how or why people from different countries relate to a situation because of their cultural background and experience is helpful whenever health professionals are counselling or teaching. With direct input from the ethnic communities, NHS services are more likely to be responsive to the needs and beliefs of different cultures. Public health ideas from the developed West should never be imported to a developing country without a thorough understanding of the culture of that country. People's beliefs about disease are shaped partly by their cultural background. Lay people voice their experience of disease in a language passed on from generation to generation. A good working rule in health education is to "start where the people are", even if this sometimes means resisting the urge to impart the latest scientific knowledge.
Anthropology, Cultural↗
[Risk assessment for familial occurrence of breast cancer].
There is now unequivocal evidence that an estimated 5% of breast cancer cases is inherited in families. Inherited predisposition of cancer in these families is thought to be the result of a mutation in one of several highly penetrant autosomal dominant genes such as BRCA1 or BRCA2. The BRCA1 gene which is localized on chromosome 17 q was recently isolated and at about the same time BRCA2 was localized to chromosome 13 q. A number of other genetic mutations is also associated with predisposition to breast cancer but accounts for a very small proportion of inherited breast cancer. Many women want to know whether they have inherited a gene predisposing to breast cancer. Those with a family history of breast cancer are particularly concerned about their risk of disease. Currently the assessment of an individual's risk of breast cancer can be undertaken using prediction models based on family history and can be further refined when molecular genetic investigations became available. Without molecular characterisation the Claus tables derived from the Cancer and Steroid Hormone Study data set are best suited to predict breast cancer risk based on age of onset of affected relatives. Direct screening for mutations in breast cancer genes in not yet generally available. Testing for inherited susceptibility is currently being offered to selected families where multiple cases of breast and/or ovarian cancer are diagnosed at an early age (younger than 45 years) as part of research protocols. In these families the so-called indirect gene analysis for linkage of disease to BRCA1 and BRCA2 or the direct analysis of mutations with functional significance in the BRCA1 gene allows relatively refined risk assessment for non-diseased female family members. Some examples will be presented to illustrate risk assessment in different familial and individual situations. Risk assessment including test result interpretation and counselling can be appropriately provided directly to the patient by physicians and genetic counsellors in a coordinated genetic counselling setting.
Adult↗
Clinical practice guidelines: necessary but not sufficient for evidence-based patient education and counseling.
While clinical practice guidelines provide direction for the management of specific diseases or particular clinical problems, there are major gaps between guidelines and their implementation. The purpose of this paper is to illustrate how an existing guideline can be used to develop an evidence-based patient education program. Congestive heart failure (CHF) represents a range of complex, chronic illnesses which offer little hope of cure yet require symptom management by health care providers, patients, and their families. Successful self-monitoring, self-care, and decision making are based on acquisition of appropriate knowledge and management skills. We describe a comprehensive teaching program in which the content was built on the clinical evidence from the Agency for Health Care Policy and Research recommendations for CHF, and the implementation process was built on adult education evidence, adapted to health issues and patient learning challenges.
Evidence-Based Medicine↗
Improving the quality of Medicaid personal assistance through consumer direction.
As states seek to improve home and community-based services for people with disabilities, many are incorporating consumer-directed supportive services into their Medicaid programs. The national Cash and Counseling Demonstration uses a randomized design to compare an innovative model of consumer direction with the traditional agency-directed approach. This paper presents findings from the first demonstration program to be implemented, in Arkansas. Our survey of 1,739 elderly and nonelderly adults showed that relative to agency-directed services, Cash and Counseling greatly improved satisfaction and reduced most unmet needs. Moreover, contrary to some concerns, it did not adversely affect participants' health and safety.
Adult↗
Role of pharmacist counseling in preventing adverse drug events after hospitalization.
BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.
Directive Counseling↗
Personality assessment and counseling psychology.
This article examines the place of personality assessment in counseling psychology. Three areas are considered: (a) the types of tests counseling psychologists use, (b) the perspective counseling psychologists apply to the use of tests, and (c) projective techniques and counseling psychology. Each area is examined, and the issues it raises for counseling psychology are presented. Some conclusions about personality assessment practices in counseling psychology are made, and several directions for future training are identified.
Counseling↗
The effectiveness of physical activity counseling in a work-site setting. A randomized, controlled trial.
Voluntary employees (N = 155) from nine different companies were screened by questionnaire for the study. They were randomized into three study groups: counseling (n = 52), counseling + fitness testing (n = 51) and control group (n = 52). The counseling was based on a goal-oriented conversation session for each participant and three follow-up appointments with an occupational nurse over a period of 1 year. The fitness tests were adapted from the UKK Health-related Fitness Test Battery. The outcome measures were the changes in the amount of leisure-time physical activity (LTPA) assessed by diary, pedometer and questionnaire at baseline and at 6 and 12 month follow-up visits. As a result, no statistically significant differences were detected between the three groups at either of the follow-up visits. It seemed, thus, that the two PA counseling methods implemented had no direct mid- or long-term effects on the LTPA of voluntary employees with no specific disease-related indication to increase LTPA.
Adult↗
Physicians Taking Action Against Smoking: an intervention program to optimize smoking cessation counselling by Montreal general practitioners.
In 1997 the Direction de la santé publique de Montréal-Centre initiated "Physicians Taking Action Against Smoking," a 5-year intervention program to improve the smoking cessation counselling practices of general practitioners (GPs) in Montreal. Program development was guided by the precede-proceed model. This model advocates identifying factors influencing the outcome, in this case counselling practices. These factors are then used to determine the program objectives, to develop and tailor program activities and to design the evaluation. Program activities during the first 3 years included cessation counselling workshops and conferences for GPs, publication of articles in professional interest journals, publication of clinical guidelines for smoking cessation counselling and dissemination of educational material for both GPs and smokers. The program also supported activities encouraging smokers to ask their GPs to help them stop smoking. Results from 2 cross-sectional surveys, conducted in 1998 and 2000, of random samples of approximately 300 GPs suggest some improvements over time in several counselling practices, including offering counselling to more patients and discussing setting a quit date. More improvements were observed among female than male GPs in both psychosocial factors related to counselling and specific counselling practices. For example, improvements were noted among female GPs in self-perceived ability to provide effective counselling and in the belief that it is important to schedule specific appointments to help patients quit; in addition, the perceived importance of several barriers to counselling decreased among female GPs. A greater proportion of the female respondents to the 2000 survey offered written educational material than was the case in 1998, and a greater proportion of the male GPs devoted more time to counselling in 2000 than in 1998; however, among male GPs the proportion who discussed the pros and cons of smoking with patients in the pre-contemplation stage declined between 1998 and 2000, as did the proportion who referred patients in the preparation stage to community resources. Our experience suggests that an integrated, theory-based program to improve physicians' counselling practices could be a key component of a comprehensive strategy to reduce tobacco use.
Counseling↗