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PubMed1995

A clinical trial of a knowledge-based medical record.

To meet the needs of primary care physicians caring for patients with HIV infection, we developed a knowledge-based medical record to allow the on-line patient record to play an active role in the care process. These programs integrate the on-line patient record, rule-based decision support, and full-text information retrieval into a clinical workstation for the practicing clinician. To determine whether use of a knowledge-based medical record was associated with more rapid and complete adherence to practice guidelines and improved quality of care, we performed a controlled clinical trial among physicians and nurse practitioners caring for 349 patients infected with the human immuno-deficiency virus (HIV); 191 patients were treated by 65 physicians and nurse practitioners assigned to the intervention group, and 158 patients were treated by 61 physicians and nurse practitioners assigned to the control group. During the 18-month study period, the computer generated 303 alerts in the intervention group and 388 in the control group. The median response time of clinicians to these alerts was 11 days in the intervention group and 52 days in the control group (PJJ0.0001, log-rank test). During the study, the computer generated 432 primary care reminders for the intervention group and 360 reminders for the control group. The median response time of clinicians to these alerts was 114 days in the intervention group and more than 500 days in the control group (PJJ0.0001, log-rank test). Of the 191 patients in the intervention group, 67 (35%) had one or more hospitalizations, compared with 70 (44%) of the 158 patients in the control group (PJ=J0.04, Wilcoxon test stratified for initial CD4 count). There was no difference in survival between the intervention and control groups (P = 0.18, log-rank test). We conclude that our clinical workstation significantly changed physicians' behavior in terms of their response to alerts regarding primary care interventions and that these interventions have led to fewer patients with HIV infection being admitted to the hospital.

AIDS-Related Opportunistic Infections↗
PubMed1996

Delivering clinical laboratory services to intensive care units.

In response to the pressures of cost reduction, we established and evaluated a carefully integrated program to deliver clinical laboratory services more promptly and efficiently to the intensive care units (ICUs). The new protocol reduced the steps and turnaround time from ordering tests by physicians to reporting results by as much as 80% on all ICUs, permitting significant reductions in personnel (exceeding $400,000 per year). For the surgical ICU there were also fewer blood collections (mean preprotocol: 7.0 per patient per 24 h; mean last 12 months: 6.0; P= 0.002). The volume of blood collected fell from 8.1 to 3.5 mL per collection, primarily following an emphasis on small containers. Consequently, the amount of blood taken from each surgical ICU patient decreased from 56 to 21 mL per 24 h (P <0.001).

Blood Specimen Collection↗
PubMed1995

Best practice in workplace hazardous substances management.

Chemical-induced injury and disease remains a significant problem in workers in industry. As a result of this problem, a number of national and international initiatives have recommended the development of conventions, regulations, and codes of practice to attempt to deal with the problems of hazardous substances at work. Within Australia, workplace hazardous substances regulations are in development which will impose legal obligations and responsibilities on the suppliers of hazardous substances and on the employers who use them. At the same time, internationally consistent ISO standards are in use, or are being developed, for quality systems, environmental management, and occupational health and safety. These standards outline a model for the management of quality, environment, or safety, and the processes involved are applicable to the management of hazardous substances. This process includes: obtaining commitment from senior management; instituting consultative mechanisms; developing a hazardous substances policy; identifying components of the hazardous substances management program; resourcing, implementing, and reviewing the program; and integrating the program into the organisation's strategic plan. Only by blending in a specific management program for hazardous substances into the overall planning of an organization will they be managed effectively and efficiently.

Accidents, Occupational↗
PubMedDate not supplied

[Alcohol dependence and psychiatric comorbidity. II. Clinical and therapeutic implications].

We revise the implications that comorbidity presents from a clinical and therapeutical point of view; either in alcohol dependence or in other psychiatric disorders connected with it. From the clinical point of view, comorbidity as a whole does not produce specific consequences but each psychiatric disorder introduces peculiar characteristics in the association. Once the stability of the associated disorder has been proved, after two or three week's withdrawal, the management of comorbidity has to be based on the treatment of every single associated disorder as if they had no connection between them, within the framework of integrated programs.

Alcoholism↗
PubMed1998

Diagnosis and treatment of depression in late life.

Major depression and dysthymia are common and often disabling disorders in late life. Several features of late-life depression, such as its frequent association with general medical conditions, polypharmacy, cognitive disturbances, and adverse life events, make accurate diagnosis a substantial clinical challenge. Yet, prompt diagnosis is an important component of implementing appropriate treatment strategies. An ideal treatment program integrates patient and family education, focused psychotherapy, and pharmacotherapy. Because of pharmacokinetic and pharmacodynamic changes associated with aging, lower doses of medication and more gradual dose increases than are required in younger adults are needed in the treatment of elderly depressed patients. In addition, medications should be selected that have minimal antihistaminic, anticholinergic, and antiadrenergic effects, minimal cardiovascular risk, and minimal drug-drug interactions. Since depression in late life tends to be at least as chronic and/or recurrent as depression earlier in life, treatment for acute depressive episodes should last at least 6-8 months, and long-term maintenance treatment should be considered in selected individuals.

Adult↗
PubMed1998

[Prevalence of psychiatric disturbances and psychopathologic status in patients with systemic lupus erythematosus].

BACKGROUND: Psychiatric disorders are commonly associated with systemic lupus erythematosus (SLE). Some authors consider that these disorders can be associated with cognitive impairment. OBJECTIVES: The objectives of this study were to establish the particular prevalence of psychiatric disorders in these patients and to investigate the relationship between psychiatric disorders, cognitive impairment, life quality, psychological status and adjustment to illness. MATERIAL AND METHODS: A cross-sectional study is reported of 46 spanish patients with systemic lupus erythematosus (SLE) attending the outpatients clinics of the Internal Medicine and Rheumatology Departments at a University Hospital. The following instruments were used: a Structured Clinical Interview for DSM-III-R, the Nottingham Health Profile, the Symptom Check-List 90-Revised, the Psychological Adjustment to Illness Scale and the Integrated Program of Neuropsychological Assessment Test-Barcelona. RESULTS: The prevalence of psychiatric disorders at interview was 33%. The most common diagnoses were affective disorders and psycho-organic syndrome. Affective disorders were associated with a poorer life quality, number of hospitalizations and psychiatric background. Adjustment to illness accounted for the psychologic status of the patients.

Adult↗
PubMed1996

Maternal Serum Markers of Fetal Abnormalities: Progress in Prenatal Screening.

Second-trimester screening of a pregnant woman's serum for markers of such congenital abnormalities as fetal trisomy 21 (Down syndrome) and neural tube defects has become an important part of antenatal care. The protocol most commonly used is the triple marker screen, which measures serum levels of alpha-fetoprotein (AFP), unconjugated estriol (uE3), and beta-human chorionic gonadotropin (beta-hCG). The results of these tests are used to derive a value known as a multiple of the median (MoM). An algorithm that combines maternal age with MoMs can be used to calculate the risk for such chromosomal disorders as trisomy 21 and 18. AFP alone--corrected for weight, race, insulin-dependent diabetes, and multiple pregnancy--can be used to predict the risk of fetal neural tube defect. Prenatal screening is best performed within an integrated program providing biochemical testing in conjunction with knowledgeable experienced counselors, expert ultrasonographers, and physicians with special expertise in maternal fetal medicine and neonatal care. Prenatal screening provides parents with the information they need to make informed pregnancy decisions and, if necessary, organize support and resources essential to the care of an infant with special needs.

Journal Article↗
PubMedDate not supplied

Community-based heart health promotion: perceptions of facilitators and barriers.

This paper examines factors that facilitate or impede the implementation of heart health activities in Ontario public health departments using survey (n = 262) and depth interview (n = 56) data from Canadian Heart Health Initiative-Ontario Project (CHHIOP). The data were consistent in revealing factors related to leadership, staffing, resources, internal organization, and characteristics of the surrounding community as the primary facilitators or barriers. Diversity within these common themes reflected variation due to external factors in the communities served by the health unit and factors internal to the health unit itself. The findings advance knowledge of the factors that influence predisposition and capacity to undertake community-based heart health promotion in public health departments, and they underscore the challenge of achieving integrated programs among partner agencies.

Attitude of Health Personnel↗
PubMed1998

A vertical curriculum to teach the knowledge, skills, and attitudes of medical informatics.

It is becoming increasingly apparent that medical schools must begin teaching the knowledge, skills and attitudes of information literacy and applied medical informatics as core competencies in undergraduate medical education. The University of Vermont College of Medicine recognized that these core competencies were lacking in its curriculum, and in 1992 it implemented a four year, integrated program to give students the information habits essential to twenty-first century practice. The first graduates of the program are now in residencies and feedback has enabled the College to refine the program to better meet the informatics education needs of the next generation of physicians. The result of these efforts is the Vertical Curriculum in Information Literacy and Applied Medical Informatics; its process of development, the product of the process, and its outcomes are discussed.

Computer Literacy↗
PubMed1986

Balancing program and research integrity in community drug abuse prevention: project STAR approach.

This paper focuses on the process of community-based drug prevention programming using an ongoing, multiple community project (Project STAR) as an illustration. Particular attention is paid to problems and strategies for balancing program and research integrity over the long-term. Specific strategies are discussed for obtaining and sustaining support for the program, quality control throughout program delivery, and accommodation of both research and program objectives.

Adolescent↗
PubMed1998

In situ assessment of pesticide genotoxicity in an integrated pest management program: II. Maize waxy mutation assay.

The mutagenicity induced by pesticides applied in an integrated pest management (IPM) program was evaluated in situ with the maize forward waxy mutation bioassay. Three pesticide application rates were prescribed as follows: (1) Low--no field pesticide spray; (2) Medium--IPM test rate: banded cyanazine plus metolachlor (2.7 kg a.i. and 2.3 l a.i./ha of herbicides, respectively); and (3) High--a preventative pesticide application program: broadcast cyanazine plus metolachlor (same application rates as above) plus chlorpyrifos (1 kg a.i./ha of insecticide). In general, there was no significant reduction in the genotoxic effects from the high to the medium treatment levels of the IPM program. This suggests that the reduction in pesticide application rates attained with the implementation of the proposed IPM program was not sufficient to abate the genotoxicity of the pesticides. The results indicate that replacing genotoxic compounds may be the only effective remediation measure if concern about environmental mutagenesis were to result in changes in agricultural management.

Acetamides↗
PubMed2001

[Differentiated short- and long-term effects of a "Training of Emotional Intelligence" and of the "Integrated Psychologic Therapy Program" for schizophrenic patients?].

Social cognition was shown as a rate limiting factor for both psychosocial outcome and response to psychosocial intervention in schizophrenia. In a randomized controlled trial a new cognitive-behavioral group treatment for schizophrenic inpatients (the "Training of Emotional Intelligence", TEI) was tested against the well evaluated "Integrated Psychological Therapy Program" (IPT) of H. Brenner. Within the framework of P. Salovey's work the Training of Emotional Intelligence focussed on three domains of deficits in schizophrenia: emotional perception, emotional understanding and emotional management. In the randomized controlled trial with 41 DSM-IV schizophrenic inpatients no differences were found in problem-solving and negative symptoms, both post treatment and in the 12 months-follow up. Additionally there was a better outcome in affect decoding capacity post treatment, and a progess in regulation of negative affects in the follow up. Emotional role taking behavior and social anxiety returned to baseline level, perhaps by reasons of no "booster sessions" in the follow up. Unfortunately in contrast to our hypotheses we failed to show treatment-specific effects, which may be due to an underpowered statistical testing. There was only one exception of this: While the Integrated Psychological Therapy Program showed a greater reduction of global psychopathology after treatment, the Training of Emotional Intelligence reduced psychopathology in the follow up more strongly. Possible reasons for these results are discussed.

Adult↗
PubMed1994

Information for integration. A senior services program spurs development of a multi-hospital integrated network.

In 1985 St. Charles Hospital, Oregon, OH, and Mercy Hospital of Toledo, OH, launched a plan to jointly offer a continuum of services to area seniors. A multidisciplinary team of professionals from both hospitals decided that a membership program (titled the Senior Advantage Program) would be the most effective way to market the services and make them available. As part of the program's development, professionals from the two facilities created a personal computer-based software package that enabled them to capture and update information about Senior Advantage participants. The software program includes a detailed application form and a section for recording enrollees' service utilization. The program enables care givers to enter data when they interact with clients in any healthcare or community-based setting. To complement the personal computer software, a program to construct a central data base was written for the two hospitals' main computer systems. In 1991 St. Charles and Mercy hospitals joined two other facilities to form First InterHealth Network, a for-profit integrated delivery network. The Senior Advantage Program became the basis for the first package of services offered by First InterHealth. In 1992 the program became the catalyst for yet another collaborative venture, linking two rural Ohio Mercy hospitals to St. Charles and Mercy hospitals. The expanded network encouraged rural patients to remain within the Mercy network, utilizing inner-city and suburban Mercy-sponsored hospitals when appropriate.

Aged↗
PubMed2006

Development of an integrated diabetes prevention program with First Nations in Canada.

Type 2 diabetes mellitus is a major cause of morbidity and mortality among First Nations in Canada. We used multiple research methods to develop an integrated multi-institutional diabetes prevention program based on the successful Sandy Lake Health and Diabetes Project and Apache Healthy Stores programs. In-depth interviews, a structured survey, demonstration and feedback sessions, group activities, and meetings with key stakeholders were used to generate knowledge about the needs and resources for each community, and to obtain feedback on SLHDP interventions. First Nations communities were eager to address the increasing epidemic of diabetes. Educating children through a school prevention program was the most popular proposed intervention. Remote communities had poorer access to healthy foods and more on-reserve media and services than the smaller semi-remote reserves. While the reserves shared similar risk factors for diabetes, variations in health beliefs and attitudes and environmental conditions required tailoring of programs to each reserve. In addition, it was necessary to balance community input with proven health promotion strategies. This study demonstrates the importance of formative research in developing integrated health promotion programs for multiple communities based on previously evaluated studies.

Community Health Services↗
PubMedDate not supplied

A program for successful integration of international medical graduates (IMGs) into U.S. surgical residency training.

OBJECTIVE: U.S. surgery residency programs have traditionally attracted international medical graduates (IMGs). However, the qualifications and performance of IMGs are variable and difficult to predict. Poor performance negatively affects patient care, the residency program, and the IMGs. We sought to identify causes of poor performance and to develop a program to identify those with chances to succeed. DESIGN: Longitudinal study. Retrospective analysis. Description of a new program. SETTING: University of Washington, a tertiary care teaching hospital. PARTICIPANTS: Performance of former IMG residents was reviewed to define the most common reasons for failure. In August 2002, we developed an IMG Certificate Program that enrolls IMGs into a formal 8-week clinical experience with duties, responsibilities, and evaluations similar to fourth-year medical students. A final global score is given for potential for success as a resident in our program. RESULTS: Poor performance in past IMG residents could be attributed to: credential problems and poor performance. Performance problems were further subdivided to include knowledge issues and personal/cultural issues. Since August 2002, our Certificate Program enrolled 15 IMGs. Fourteen graduated, and 10 were offered preliminary spots in our program: 4 are successful interns, 1 returned to Italy, and 5 will start in 2004. One entered the 2004 match in Anesthesiology, and 1 was counseled to not be a candidate for a U.S. program. Three had above average performance and were felt to be better suited to a smaller program (1-2 hospitals). The mean "potential for success" global score was 3.9 (all grads), 4.6 (current interns), 1.0 (nongraduate), and 3.0 for the above average performers better suited to a smaller U.S. program. CONCLUSIONS: We developed a program that provides IMGs an 8-week clinical experience in a busy U.S. training program; it provides them with enough experience to successfully integrate into a U.S. residency and identifies those with better chances to succeed. Wide application of this program and exchange of information among program directors may facilitate recruitment and the successful completion of training of IMGs and provide the number of residents needed to fill critical positions in the United States.

Certification↗
PubMed2003

Short-term changes of fatigability and muscle performance in severe obese patients after an integrated body mass reduction program.

The effects of a short-term (3-week) integrated body weight reduction (BWR) program on fatigue perception and on lower limb anaerobic power output were evaluated in 200 severely obese in-patients (40 males and 160 females, age: 18-83 yr, BMI: 35.0-65.3 kg/m2). Fatigue was assessed by a 7-point Likert-type scale questionnaire (Fatigue Severity Scale, FSS), while average lower limb power output (W) during a maximal effort was determined with a modification of the Margaria test for stair climbing. In both genders, total FSS score was influenced by both age and obesity level, resulting significantly (p < 0.001) lower in younger subjects (< 45 yr) than in older (> 45 yr) and in patients with lower BMI (< 40 kg/m2) than in those with a higher one (> 40 kg/m2). An opposite trend was observed in W. The 3-week BWR integrated program with moderate aerobic exercise and free standing and ground gymnastic routines induced a significant reduction in body weight (p < 0.001), in total FSS score (p < 0.001) and a significant increase in W, both in absolute terms (p < 0.05) and relative to body mass (p < 0.001). Total FSS score and absolute or relative power output were positively correlated both before and after the BWR program (p < 0.001, Wilcoxon rank test). It is concluded that: a) subjective fatigue perception, assessed by a FSS questionnaire, can be considered an indirect indicator of effective lower limb power output in severely obese patients and, b) in spite of a relatively small, although significant, decline of BMI, the full-time participation in a hospital-based, integrated BWR program with moderate exercise activity is associated with significant short-term improvements of both fatigue sensation and power output. Dia

Adolescent↗
PubMed1995

Parent perspectives of peer relationships and friendships in integrated and specialized programs.

In-depth interviews of a large community-based sample of mothers of preschool-age children with established disabilities and those classified as at-risk were conducted focusing on issues of children's peer relations and friendships. Results revealed that mothers of children enrolled in both integrated and specialized programs perceived their respective settings as valuable for the development of their child's peer relations and friendships. Mothers of children in integrated settings reported that their child played better and was more social due to the participation of children without special needs. A similar pattern was obtained for mothers of children enrolled in specialized programs in response to a hypothetical situation. Nevertheless, both groups of mothers were clearly concerned about peer rejection and noted the importance of having other children with special needs in the program available as a means of promoting tolerance and acceptance.

Attitude↗