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PubMed1989

Community orthodontic services: a local review.

A review is presented of orthodontic treatment and working conditions in one area of the Community Dental Service over a typical period of one year (1984). Treatment totals, case load, working facilities and schedules are discussed, drawing comparisons with the hospital service and specialist practice and with previously published surveys of orthodontics in the community service. An estimate of the size of school population likely to support a full-time community orthodontist is made together with the number of referring practitioners. Comments are also made on the range of treatment provided, patients' attitudes, cooperation and such problems as missed appointments. A short section is devoted to actual timings of specific procedures in orthodontics, followed by discussion of the hospital attachment for community orthodontists, with some recommendations on working conditions and comments on career structure.

Appointments and Schedules↗
PubMed2003

Anatomy of Complications workshop: an educational strategy to improve performance in obstetricians and gynaecologists.

Many specialist obstetricians and gynaecologists feel inadequately trained to deal with certain situations such as injury to bowel, bladder, ureter and major vessels, and value further training to prevent and manage these problems. We present the structure, objectives and rationale for a surgical skills workshop, which is an intensive practical learning experience aimed to improve the performance of obstetricians and gynaecologists. The overall objective of the workshop is improvement in the prevention and management of complications in obstetric and gynaecological surgery. Over 100 participants have completed the workshop so far. Pre-workshop preparation includes anatomical illustrations to guide reading and a training video describing surgical skills, ewe anatomy and hysterectomy in the ewe. There are four modules: anatomy includes an interactive lecture, cadaveric dissection and examination of prosections with specific learning tasks. Surgical skills involves the demonstration, practice and learning of techniques needed to deal with unexpected operative injury to bowel, bladder, ureter and major blood vessels. Live animal surgery on a ewe allows further supervised practice of the previously learned skills plus the repair of serious vascular injury. Case presentations allow each participant to present a complicated case in a facilitated group session with discussion and feedback from their peers. This session is controlled, non-threatening and a valuable interactive learning experience. Participant feedback suggests that this workshop format is useful and appears to improve the confidence, competence and performance of the participants. This workshop is presented as a template on which other educational activities can be developed.

Clinical Competence↗
PubMed1999

Informed consent: British otolaryngologists surveyed.

A repeat postal questionnaire of British otolaryngologists has been carried out to assess changes in their practice of obtaining informed consent. The previously reported high level of good practice is maintained. Currently informed consent is more often obtained in outpatients or the preadmission clinic than it was in 1991. Consultants and specialist registrars are more involved in this process. Although there is little evidence given to support a persistent increase in a defensive approach towards gaining informed consent, there is some change in the reporting of surgical complications that may reflect an increased awareness of the concept of 'material risk'.

Ethics, Medical↗
PubMed2004

Determining optimal nursing intensity: the RAFAELA method.

BACKGROUND: RAFAELA is a modern system of patient classification. In the last few years the system has become widely used in Finland and has aroused international interest. It comprises three parts: (1) The Oulu Patient Classification (OPC) instrument and (2) a file on nurse resources. Using these, the daily nursing care intensity, expressed as OPC points per nurse, can be calculated. The existing nursing care intensity can then be compared with the optimal by using the third instrument, (3) the Professional Assessment of Optimal Nursing Care Intensity Level (PAONCIL). This is a daily questionnaire that nurses complete in a 2-month period at intervals every few years. The daily workload is scored from -3 to +3, where zero is the optimal level. The optimal nursing care intensity per nurse is then defined by using linear regression analysis. No expensive time studies are needed. AIMS: This paper reports on a study which aimed to identify the minimum requirements for determining optimal nursing care intensity that allow the results to be accepted as correct, in terms of: length of the PAONCIL examination period, PAONCIL questionnaire response rate, explanatory power of the regression analysis and mean values of the OPC and PAONCIL instruments. DESIGN: The results of analyses of optimal nursing care intensity from 61 wards in eight Finnish hospitals for the period 1997-2001 are presented. The data do not contain any information about the identity of the patients. METHODS: Linear regression analysis, one-way analysis of variance, t-tests and correlation analysis were used, as well as parameters of distribution of the data. RESULTS: The results of the analysis of optimal nursing care intensity can be regarded as reliable if the PAONCIL response rate is above 70%, the period of examination is at least 3-4 weeks, the mean PAONCIL value is below 0.65 and the explanatory power is above 25%. CONCLUSION: On the basis of the RAFAELA system, the optimal nursing care intensity of a ward can be reliably determined. The prerequisites for achieving reliable results were clear and mostly fulfilled. Because a study period shorter than that which has previously been the practice is enough, the use of this system will be easier than before. The credibility and usefulness of the RAFAELA system have thus received considerable additional confirmation.

Analysis of Variance↗
PubMed2002

Serial ECG recordings via marked chest wall landmarks: an essential requirement for the diagnosis of myocardial infarction in the presence of left bundle branch block.

Detection of acute myocardial infarction (AMI) in the presence of left bundle branch block (LBBB) continues to be problematic, although recently proposed criteria by Sgarbossa et al have contributed considerably in alleviating the diagnostic difficulties. Urgency in making the diagnosis stems from the desire to administer thrombolytic therapy as soon as possible after the patient encounter. The proposed criteria focus on ST-segment deviations, and imply that other parts of the ECG curve do not contribute much to the early diagnosis of AMI. Observations in the daily practice and some previous work suggest that significant alterations in the amplitude of ST-segment deviations are witnessed when variation of the sites of precordial lead recordings, by even 1.0 cm, is implemented. In contrast serial ECG recordings made close in time in patients with AMI are remarkably reproducible. World-wide experience in electrocardiography has shown that recordings of the precordial leads are made with astonishingly marked neglect as to the employment of the proper chest landmarks. This further compounds the diagnostic difficulty in detecting AMI in the presence of LBBB. It is proposed that ensuring the reproducibility of the recording of the precordial leads (even if the chosen landmarks are not the conventional ones) will enhance the diagnostic sensitivity for the detection of AMI in this setting. Introducing this dynamic aspect in the diagnostic effort (serial ECGs) may enhance the contribution of the static ST-segment criteria focusing on fixed thresholds of deviation amplitudes; also the non ST-segment ECG parts may receive another evaluation as to their contribution to the diagnosis of AMI in the presence of LBBB.

Bundle-Branch Block↗
PubMed2003

An analysis of Simpson's notebook data on the wet nurse.

OBJECTIVE: to understand the meaning of the qualitative data included in the Notebook of wet nurses kept by James Young Simpson. DESIGN: quantitative and qualitative analysis of data in an historical document. SETTING: a list of wet nurses kept by a 'Professor of Midwifery' in mid-19th century Edinburgh. PARTICIPANTS: the Notebook lists the names and other details of 749 women. FINDINGS: the Notebook indicates how the wet nurse was recruited, the implications for her baby, how she negotiated her role and the decision-making around her recruitment. KEY CONCLUSIONS: the ambiguity of this medical pioneer's decision-making is demonstrated. Simpson's scientific credentials may have featured much rhetoric. While in the forefront of many obstetric and medical developments, Simpson was regressive in his support for wet nursing. The social input into the selection of the wet nurse has not been identified previously. IMPLICATIONS FOR PRACTICE: the woman's ability to negotiate her terms of employment emerges. The social determinants of baby feeding decisions, identified in this document, have assumed greater significance since the time that this Notebook was written.

Breast Feeding↗
PubMed2006

[Quality of care and extent of complications in a population-based sample of patients with type 2 diabetes mellitus. The KORA Survey 2000].

BACKGROUND AND OBJECTIVE: The aim of this study was to analyse health care processes and outcomes in type 2 diabetes in a representative population sample of persons, aged 25-74 years, in the region of Augsburg, Germany. PATIENTS AND METHODS: Based on the KORA Survey 2000, indicators of health care services and outcomes were analysed for all study subjects with known type 2 diabetes (n=149; 80 males (54%)) , mean age 62 +/- 9 years; total random population sample: 4,261 persons). Means and prevalences were calculated, including 95% confidence intervals (CI). Associated factors were analysed using multivariate regression models. RESULTS: 57% of the patients had not received adequate drug treatment concerning hypertension and 43% concerning hypercholesterolemia. 63% (CI: 54-70 %) and 38% (CI: 30-47%), respectively, reported that their eyes or feet had been examined during the past 12 months. 47% (CI: 39-56%) had been instructed about their diabetes. 69% (CI: 61-76%) of the subjects did not know the term "HbA(1c)", the proportion being higher among subjects without diabetes education or those of a low social status. 13% (CI: 8-20%) of the subjects had been told by their medical practitioner that they had a retinopathy, 5% (CI: 2- 10%) a foot ulcer, 19% (CI: 12-28%) proteinuria. Two persons were blind, one had been on renal dialysis, and 5% (CI: 2-10%) had undergone amputation of a limb. 6% (3-12%) had at least one of the end-stage diabetic complications. The mean HbA(1c) was 7.2 +/- 1.6%, significantly higher in those with a diabetes for >10 years. CONCLUSIONS: The population-based data regarding indicators of type 2 diabetes care processes and outcome in a defined region in Germany show that the treatment of hypertension and hypercholesterolemia was highly inappropriate, as was the frequency of medical control investigations. The high proportion of subjects who did not know the term "HbA(1c)" was striking, particularly among those of a low social status. A significant proportion had severe late complications. The mean HbA(1c), however, was better than had been reported in some previous German practice-based studies.

Adult↗
PubMed1994

The accuracy of human decisions and objective measurements in psychophysiological detection of knowledge.

I examined the relative detection efficiency of three measurements--skin resistance response (SRR) amplitude, respiration line length (RLL), and human respiration response evaluation (RRE)--in a guilty knowledge experiment. Thirty-two subjects were presented with lists of personal information in which only one of five items was correct. Subjects were instructed to try to avoid detection of the relevant items in the polygraph test. All three measurements discriminated better than chance between relevant and neutral items, with the objectively measured SRR and RLL superior to the subjective RRE. When SRR and RLL were compared for their relative efficiency, the former yielded better detection. The differentiation was even better with a measure that combined the SRR and the RLL. The results are discussed with respect to previous findings and practical implications.

Adult↗
PubMed2002

Management of patients aged >60 years with malignant glioma: good clinical status and radiotherapy determine outcome.

Many clinical trials have shown that the most important prognostic variable in patients with malignant glioma is advanced age. However, can some patients aged >60 years still have relatively good outcomes with conventional surgical and radiotherapeutic treatment? A previous audit of practice (1983-89) suggested that functional status was an important prognostic variable in the elderly. We have reviewed a further cohort (1989-96) to evaluate changes in practice and outcomes given advances in neuroimaging, neurosurgery and radiotherapy. The major findings in this series of 80 patients aged over 60 years with a histological diagnosis of supratentorial malignant glioma were: (i) There was a relationship between management undertaken and clinical status of the patients (p < 0.01), i.e. patients in good grade generally had tumour debulking and radiotherapy, whilst those in poor grade generally had only biopsy. (ii) There was a significant increase in survival of patients in the second period who received surgical debulking and post-operative radiotherapy (from a median of 23 to 41 weeks (p < 0.05). (iii) It is likely that case selection accounted for much of this improvement since there was a direct relationship between median survival time and good clinical grade using the WHO performance scale. (iv) A shorter radiotherapy course (30 Gy in six fractions) was as efficacious as a conventional course (60 Gy in 30 fractions), and those patients having radiotherapy survived significantly longer than those not having this treatment (p = 0.001). This study has again demonstrated the importance of preoperative clinical grade and radiotherapy treatment in determining outcomes in patients >60 years. To put these data in a societal context a recent prospective multicentre audit of patients with malignant glioma in Scotland, and another audit from our unit, showed that between 24 and 65% of patients aged >60 years, with a CT diagnosis of malignant glioma do not undergo either surgery or radiotherapy. Advanced age per se should not be a bar to interventional treatment in patients aged >60 years with suspected malignant glioma.

Age Factors↗
PubMed1999

Secret patterns: validation of a screening tool to detect bulimia.

We prospectively validated a two-item screening tool for bulimia. Subjects recruited from a women's health practice completed the previously developed two-item screening tool ("Do you ever eat in secret?" and "Are you satisfied with your eating patterns?") at their initial office visit. This was validated against a telephone interview with a licensed psychologist. The prevalence of current bulimia was 16% in 75 subjects, determined by psychologists' assessment (sensitivity 75%, specificity 49%) and 4% by DSM-III-R criteria. The positive and negative predictive values of one screening question positive were 22% and 91%, respectively, when compared with the psychologists' assessments as the gold standard. This screening tool allows physicians to identify patients who warrant further valuation for bulimia.

Adolescent↗
PubMedDate not supplied

Computational methods for reconstructing and unfolding the cerebral cortex.

We describe computational methods for constructing three-dimensional models and unfolded, two-dimensional maps of the cerebral cortex. These methods consist of four procedures, including (1) sampling of a surface within the cortex, (2) reconstruction of a three-dimensional model of that surface, (3) unfolding of the surface to generate a two-dimensional cortical map, and (4) visualization of data on the model and the map. These methods produce structurally accurate representations of the cortex and have practical advantages over previous manual and automated approaches for flattening the cortex. We illustrate the application of these methods to neuroanatomical data obtained from histological sections of cerebral cortex in the macaque monkey. The approach should be equally useful for structural and functional studies in other species, including humans.

Algorithms↗
PubMed1997

Key moral principles applied to managed care.

Although MCOs pose many challenges to the ethics of healthcare delivery, they also have the potential to minimize some previously existing unethical practices. The focus on maximum quality and cost-effectiveness places more demands on the provider with increased accountability. In the old unstructured, noncompetitive healthcare environment, providers were not as accountable to the patient for providing the best quality care at the best price. As home care agencies integrate with managed care networks, outcome measurement becomes increasingly important (National Association for Home Care, 1996). In the managed, integrated market, competition is strong and quality becomes a benchmark when alliances and mergers occur. Home care is in a prime position to be a major player in this new healthcare system and continue to expand services in a capitated environment while being challenged to uphold the ethical practice philosophy outlined in the basic moral principles discussed in this article.

Community Health Nursing↗
PubMedDate not supplied

SARS: a quality management test of our public health safety net.

Emergence of severe acute respiratory syndrome in March 2003 tested all aspects of BC Centre for Disease Control (BCCDC) operations. In addition to its public health responsibilities, BCCDC was pivotal in the science defining SARS. These events occurred under international scientific and media scrutiny over a 4-month period and were seen as an opportunity to learn about how the Centre performed under extreme pressure as a QM-based (quality-management-based) organization. A retrospective review of the QM practices over the previous 6-months was initiated on June 30, 2003. Key management documentation during the study period was reviewed. Structured interviews were conducted with front line personnel. Customized instrumentation was developed to correlate management decisions with recognized QM criteria: anticipatory management; keeping programs on track; ongoing adjustment, improvement, and revision; identifying and improving sources of error, waste, and redundancy; feedback from key stakeholders; and data-driven decision-making methods. The team structure between laboratory science and epidemiology was critical. This was attributed to the culture of scientific discovery of the organization. All knowledge gained was shared with other organizations around the world. The consensus is that British Columbia was very lucky this time around. This review is part of BCCDC's commitment to fighting emerging infectious diseases.

British Columbia↗
PubMed1996

Sigmoidoscopy and rectal biopsy: a survey of current UK practice.

OBJECTIVE: To establish the pattern of practice of sigmoidoscopy and rectal biopsy in the UK, and to estimate the rate of occurrence of important complications. DESIGN: Postal questionnaire enquiring about practice in the previous 2 years. SUBJECTS: Consultant members of the British Society of Gastroenterology. MAIN OUTCOME MEASURES: Bleeding or perforation following sigmoidoscopy and rectal biopsy. RESULTS: Completed replies were received from 277 consultants, giving a response rate of 84%. Of the sigmoidoscopies performed, 71% were rigid and the remainder fibreoptic flexible sigmoidoscopy (FOS). The complication rate after sigmoidoscopy and rectal biopsy was 0.01%. Perforation was significantly more common in FOS than in rigid sigmoidoscopy (eight in 134,482 sigmoidoscopies versus five in 328,815, chi2 = 5.18, P < 0.05). The distance from anal margin and wall of biopsy did not influence perforation rates. Significant bleeding was similar with both techniques (eight in 134,482 versus 35 in 328,815, chi2 = 2.27, NS). CONCLUSION: Rigid sigmoidoscopy is still more widely used than FOS in the UK, and is probably safer. Complications resulting from rectal biopsy are uncommon but perforation occurs more frequently with FOS than with rigid sigmoidoscopy. The site of biopsy appears to be unimportant.

Biopsy↗
PubMed2002

Continuing HIV transmission among injection drug users in Eastern Central Canada: the SurvUDI Study, 1995 to 2000.

OBJECTIVE: To document HIV prevalence/incidence trends from 1995-2000 and associated risk factors among injection drug users (IDUs) in Eastern Central Canada as an indication of harm reduction strategy effectiveness. METHODS: Nonnominal cross-sectional data (one-time participants) and longitudinal data (repeat participants) were collected using convenience sampling. Participants provided informed consent for face-to-face interviews focused on injection drug use and sexual practices during the previous 6 months; oral fluid samples were taken for HIV testing by enzyme immunoassay. Unique encrypted codes for initially HIV-negative repeat participants permitted incidence rate calculations. RESULTS: In all, 6387 IDUs (median age, 31 years; range, 13-67; males, 73.5%) participated on 9724 occasions. HIV prevalence ranged from 4.7% (95% confidence interval [CI], 2.9-6.5) in semiurban areas to 20.1% (95% CI, 17.6-22.7) in Ottawa, Ontario. HIV incidence was 6.0 (95%CI, 4.5-7.6) per 100 person-years (py) in Montréal, Québec, 3.2 (95% CI, 2.2-4.2) per 100 py in Québec City and 7.0 (95% CI, 4.1-9.8) per 100 py in Ottawa/Hull. Reusing other IDUs' needles was reported by 38.4%. In multivariate logistic regression, IDUs injecting for 6 or more years were more likely to be HIV positive, particularly if cocaine was the predominant drug injected. Multivariate Cox regression revealed higher HIV incidence among those who predominantly injected cocaine, reused others' needles, had injected 6 years or more, injected with strangers, or were men reporting commercial sex work. CONCLUSIONS: These results reveal a volatile situation of continuing HIV transmission among IDUs in Eastern Central Canada.

AIDS Serodiagnosis↗
PubMed2002

Long-term effects of and physiological responses to nitrous oxide gas treatment during alcohol withdrawal: a double-blind, placebo-controlled trial.

BACKGROUND: Nitrous oxide gas (N2O) has been proposed to be effective in the treatment of the alcohol withdrawal syndrome (AWS). This has not been proved, however, in studies performed according to good clinical practice guidelines. Moreover, previous studies have not measured end tidal N2O concentrations or physiologic responses during N2O treatment. We have recently reported that in a double-blind, randomized, controlled setting, N2O was not superior to placebo in relieving AWS symptoms. In this previous study, we did not find significant differences between the treatments either in the Clinical Institute Withdrawal Assessment of Alcohol scores or in the total use of benzodiazepines (diazepam and temazepam). The aim of the present study was to characterize other effects and side effects of the N2O treatment using several objective measures and to study the possible long-term efficacy of the treatment. METHODS: A total of 105 inpatients who had AWS and were admitted to the A-Clinic detoxification center were included in the study. The subjects were randomly assigned to one of the following three treatments: (1) N2O/oxygen (from 30 to 70% in oxygen), (2) air/oxygen (30%/70%), and (3) medical (normal) air. During the single 45-min treatment period, end-tidal N2O, carbon dioxide, and oxygen concentrations were measured. The physiologic responses were studied by measuring heart rate, blood pressure, pulse oximetric saturation, frontal muscle electromyographic activity, and plethysmographic pulse amplitude. Long-term effects were studied by measuring craving with the Obsessive-Compulsive Drinking Scale; severity of dependency with Severity of Alcohol Dependence Data; and liver enzymes with aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase 3 and 6 months after the treatment. RESULTS: Patients in the N2O group demonstrated significantly higher facial muscle electromyographic activity and higher pulse amplitude than the air-treated subjects. Self-reported side effects between the gas treatments, however, did not differ between the groups. Regarding long-term effects of the treatments, there were no differences between the groups. CONCLUSIONS: Contrary to previously published data, N2O treatment did not decrease craving or liver enzymes during the 6-month follow-up. At the concentration used, N2O treatment produced signs of arousal instead of strong sedation.

Alcoholism↗
PubMed2005

Measurement of ADAMTS13 activity and inhibitors.

PURPOSE OF REVIEW: Acquired or congenital deficiency in the plasma von Willebrand factor-cleaving protease ADAMTS13 causes life-threatening thrombotic thrombocytopenic purpura. This condition is characterized primarily by thrombocytopenia and microangiopathic hemolytic anemia, accompanied by variable degrees of neurologic dysfunction, renal failure, and fever. Measurement of ADAMTS13 activity is important in the diagnosis of microangiopathies such as thrombotic thrombocytopenic purpura. This review introduces both established and emerging assays for ADAMTS13 activity, focusing on their impact on clinical practice. RECENT FINDINGS: Previously established assays are useful screening methods to identify suspected thrombotic thrombocytopenic purpura. Novel assays measuring ADAMTS13 activity using either recombinant peptides or synthetic substrates directly measure the activity quantitatively. These assays can also detect neutralizing autoantibodies in the plasma of patients with acquired ADAMTS13 deficiency. Although ADAMTS13 in control subjects exhibits a broad variation in activity, ranging from 30 to 200%, significant decreases in ADAMTS13 activity have been observed in several physiologic and pathologic conditions. A portion of thrombotic thrombocytopenic purpura patients, however, did not display severe ADAMTS13 deficiency, suggesting that as-yet-unidentified environmental or genetic factors may contribute to the etiology of thrombotic thrombocytopenic purpura. SUMMARY: New assays measuring ADAMTS13 activity will contribute significantly to the accurate diagnosis of microangiopathies, ultimately leading to improved clinical treatment of these diseases. These assays may also help to clarify the role of ADAMTS13 activity in additional thrombotic disorders, including disseminated intravascular coagulation, stroke, and myocardial infarction.

ADAM Proteins↗
PubMed2000

Long-term protective immunity to rinderpest in cattle following a single vaccination with a recombinant vaccinia virus expressing the virus haemagglutinin protein.

A recombinant vaccine, produced by using a highly attenuated smallpox vaccine (LC16mO) as a vector and which expresses the rinderpest virus (RPV) haemagglutinin protein, has been developed. The properties of this vaccine, including its heat stability, efficacy in short-term trials, safety and genetic stability, have been confirmed in an earlier report. In the present study, the duration of the protective immunity generated by the vaccine in cattle was examined for up to 3 years following the administration of a single vaccination dose of 10(8) p.f.u. The vaccinated cattle were kept for 2 (group I) or 3 years (group II) and then challenged with a highly virulent strain of RPV. Four of five vaccinated cattle in group I and all six cattle in group II survived the challenge, some showing solid immunity without any clinical signs of rinderpest. Neutralizing antibodies were maintained at a significant level for up to 3 years and they increased rapidly following challenge. Lymphocyte proliferative responses to RPV were examined in group II cattle and were observed in four of the six vaccinated cattle in this group. The long-lasting protective immunity, in addition to the other properties confirmed previously, indicate the practical usefulness of this vaccine for field use.

Animals↗