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Educational strategies: Kaiser Permanente of Ohio shares its successful techniques.

What strategies are effective for educating your medical staff about medications and medication-related issues? Kaiser Permanente of Ohio has developed an educational program for its medical staff that involves four key components: a custom-designed formulary handbook, drug fairs, traditional letter/newsletter communication pieces and educational meetings, and collaborative projects between its pharmacy and medical staffs. These educational techniques--many of which have been successfully adapted from the pharmaceutical industry--can be adopted for use at your institution.

Communication↗

Profile of Journal of Dentistry for Children and Pediatric Dentistry journal articles by evidence typology: thirty-year time trends (1969-1998) and implications.

PURPOSE: This study was performed to assess the profile of Journal of Dentistry for Children and Pediatric Dentistry journal articles by evidence typology and measure their changes over a thirty-year period (1969-1998). METHODS: All issues of both journals during the study period (1969-98) were manually reviewed. The publications were ranked by the quality of the evidence. Editorials, letters to the editor, abstracts, and organization-related communications were excluded from consideration. The publications were analyzed by journal and also by decade of publication, i.e., 1969-78, 1979-88 or 1989-98. RESULTS: There were 2848 publications included in the data set with descriptive studies, case reports, etc. comprising the majority (71%). No distinctive trends in the evidence typology were detected over the decades in either journal. CONCLUSION: There is a need to improve the quality of the evidence in the two pediatric dental journals reviewed.

Case-Control Studies↗

Apolipoprotein E polymorphism and Alzheimer's disease.

We aimed to determine the association and related factors of the apolipoprotein E (ApoE) genotype and Alzheimer's disease (AD) in Taiwan. We examined ApoE genotypes in 50 Chinese patients with AD and 50 age- and sex-matched controls. The patients met the criteria of probable AD of the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and AD of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV). There were 28 females and 22 males in the case and control groups. The mean age of onset of AD was 72. 62 years. The average interval between onset and research was 3.85 years. The frequency of ApoE epsilon 4 in the AD group was significantly higher than that in the controls (0.13 versus 0.02, p < 0.05). The odds ratio for AD in individuals with at least one ApoE epsilon 4 allele was 6.0 (95% CI 1.34 to 55.3, p < 0.001). The linear trend for AD in proportion to alleles of ApoE epsilon 4 was significant (chi 2 = 8.3, p = 0.004). The risk of ApoE epsilon 4 allele for the late-onset AD patients, males, or those who received less education was higher than that for the early-onset AD patients, females, or those who had received more education. The sensitivity of the epsilon 4 allele was 24%, the specificity 96%, the positive predictive value 86%, and the negative predictive value 56%. Our results supported that the ApoE epsilon 4 allele is related to AD in Taiwan. In addition, sex and education may play important roles in the presence of ApoE epsilon 4 allele. The epsilon 4 allele seemed helpful as an adjunct for diagnostic testing of AD.

Aged↗

Enhancement of basic computer skills. Evaluation of an intervention.

A series of self-paced tutorials was developed for use by graduate students on the assumption that acquisition of skills in accessing e-mail accounts, use of the World Wide Web, file-transfer protocols, Excel spreadsheet, and PowerPoint presentation software would help students succeed in their program of graduate studies. The postproject evaluation tool was sent to participants via e-mail, to reinforce the acquired skills and demonstrate the successful accomplishment of project objectives. Pre- and postevaluation data indicated an increase in self-rated skill level after participation in the tutorial series. Analysis showed an overall mean gain score of 2.3 points, with pre- and posttutorial gain scores significantly increased for all topic areas.

Adult↗

Development of a 'communication disability model' and its implication on service delivery in low-income countries.

This paper argues that higher priority should be given to the development of services which support people with communication disabilities in low income countries and that these services should be different from those in other countries. Present services for this population group have poor coverage levels, tend to be centrally located and are orientated to specialist services. WHO (Health Programme Evaluation, Geneva, WHO, 1981) argue that health services should be based on meeting people's needs. This paper describes an analysis of 'needs related' qualitative data concerning people with communication disabilities and their families in two low income countries and examines the results in relation to service development. The data was collected as part of five different studies concerning people with communication disabilities carried out in Uganda and Nigeria. Using the principles of established theory, these data helped develop, a theoretical model. This model is compared with WHO's classification of Impairment Disability and Handicap ICIDH-2 WHO (International Classification of Impairments Disabilities and Handicaps (ICIDH-2), A manual of classification relating to the consequences of diseases, Geneva, WHO. 1997a; 1999). Suggestions are made as to how this model might inform planning and practice from the perspective of the five major stakeholder groups; government and non-government organizations, people with communication disabilities, their families and professionals. Consideration is also given as to how this theory can be used to strengthen existing services, or encourage a complete paradigm shift, with the creation of different services in new and innovative ways.

Adult↗

DSEARCH: sensitive database searching using distributed computing.

UNLABELLED: We present a distributed and fully cross-platform database search program that allows the user to utilize the idle clock cycles of machines to perform large searches using the most sensitive algorithms. For those in an academic or corporate environment with hundreds of idle desktop machines, DSEARCH can deliver a 'free' database search supercomputer. AVAILABILITY: The software is publicly available under the GNU general public licence from http://www.cs.may.ie/distributed CONTACT: tom.naughton@may.ie SUPPLEMENTARY INFORMATION: Full documentation and a user manual is available from http://www.cs.may.ie/distributed.

Algorithms↗

The relationship of Asperger's characteristics and schizotypal personality traits in a non-clinical adult sample.

The study examines the relationship between Asperger's Disorder (AD) and Schizotypal Personality Disorder (SPD), mutually exclusive but similar diagnoses [DSM-IV-TR; American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. Washington, DC: Author]. The literature and comparison of diagnostic criteria suggest that the two disorders may overlap: AD social impairment with SPD interpersonal problems and AD communication deficits with SPD disorganized features. Questionnaire measures of AD and SPD were administered to a large non-clinical adult sample. Consistent with expectations, the Asperger's and Schizotypal questionnaires were positively correlated. Further, the social-interpersonal and communication-disorganized areas were positively correlated, though the relationship between social-interpersonal areas is particularly strong. Future research should continue to explore the relationship between AD and schizotypy to confirm current findings and improve understanding of distinctions between the disorders.

Adolescent↗

Psychological linguistics: implications for a theory of initial development and a method for research.

Presented here are an hypothesis of language development and a description of a method for studying language, both based on Kantor's psychological linguistics. According to our hypothesis, language develops in four stages. In the first, which spans the first 9 to 15 months, random movements evolve into body management, manual, and locomotor skills that enable an infant to engage in play activities, among other things, with the mother and others. Simple gestural communication soon follows. Random babbling progresses beyond the sounds that are more universal in the language to the family's particular pattern of intonations and inflections, and receptive speech begins, that is, the infant learns to react to simple verbal-vocal requests. During the second stage, which coincides with the child's second year, vocalizations evolve into "idiosyncratic expressions" and rough approximations of heard sound patterns. Language is now holophrastic--one-word utterances--mostly of the mediative variety. During the third stage, which extends to about 30 months of age, language skills are described as first-approximation referential interactions: they are longer and more detailed, include some narrative interchanges, and refer to past and future events. Typically the child now talks to him or herself, or engages in expressive referential interactions. In the fourth stage, when the child reaches the age of 52 months or so, second-approximation speech begins. By now the vocal apparatus is sufficiently developed to enable a child to make most of the vowel sounds, and the enhanced language skills set the occasion for more frequent linguistic interchanges. He or she also begins to respond to symbols and other representations of objects and events. In other words, he or she begins to engage in symbolizing behavior. Language obviously continues to develop beyond the fourth stage. Social conditions outside of the family further affect language style and generate specialized forms of speech, notably the jargon of a particular occupation or hobby. The method for studying language interactions involves, through the use of TV tapes, a description of the behavior of a speaker and the listener, the referent, and the setting conditions. The behavior of a speaker is analyzed in terms of the frequency with which he or she begins a language interchange, the average length of the initiation, the modality (verbal-vocal, gestural, or both) and the accompanying behavior. It is also analyzed for content, including time frame, actuality, and persons, animals, objects, activities, and others. Noted, too, are the feeling reactions regarding the referents.(ABSTRACT TRUNCATED AT 400 WORDS)

Child↗

A case of oral myiasis due to Chrysomya bezziana.

Chrysomya bezziana is a causative agent of obligatory myiasis. We report the first case of human infestation of Chrysomya bezziana in Hong Kong in an 89-year-old woman who had previously had a stroke. One day after hospital admission for fever, a small fissure at the labial gingiva of the upper incisors and several ulcerative lesions at the hard palate were noticed during routine mouth care. A live maggot was seen protruding from the small fissure. In the following few days, a total of seven maggots were removed by forceps. Urgent computed tomography and magnetic resonance imaging of the oral cavity showed an ulcerative soft-tissue lesion over the anterior palate, with a fistula communicating to the labial gingiva. The tissue loss was limited to the bony margin of the hard palate. The infestation was managed by manual removal of maggots and surgical debridement. Medical personnel taking care of old or debilitated patients need to bear in mind the possibility of Chrysomya bezziana infestation to be able to make a prompt diagnosis and implement relevant intervention to prevent extensive tissue destruction.

Aged↗

Short communication. Witch's milk: potential for neonatal diagnosis.

The study population comprised 106 infants ranging from 4 days to 19 wk old. Fluid (witch's milk) was obtained from the infants breasts by manual expression. To measure volume, fluid was drawn into calibrated capillary pipettes. The frequency of obtaining witch's milk was 71% for all infants and 100% for infants less than 3 wk of age. It declined with increasing age. The median volume of fluid obtained was 20 microliter per sampling for all infants and 55 microliter for babies less than 3 wk of age. Frequency of witch's milk recovery was significantly related to the degree of manual pressure applied but was not related to sex of the baby.

Breast↗

Use of a low-cost, PC-based image review workstation at a radiology department.

Despite the increasing use of diagnostic workstations, film reading is still commonplace in most radiology departments all over the world. The purpose of this work is to assess the adoption of image review workstations in a radiology department where the usual primary diagnosis is film-based and cannot be replaced with diagnostic workstations. At our institution, a tertiary care center specialized in diagnostic imaging, a pair of PC-based review workstations running a Digital Imaging and Communications in Medicine (DICOM)-conformant public domain software for image display and analysis were installed in two reading rooms. Studies are automatically routed after acquisition from the picture archiving and communication system (PACS) server to the workstations and remain available for visualization for approximately 15 to 20 days. Data from two radiologists and two technologists collected over a 3-month period were analyzed, including purpose of use, time savings as compared to traditional manual methods, and overall user satisfaction. The results from the analysis presented in this work indicate a high degree of approval from the users, who report significant timesavings in numerous circumstances, in particular when it comes to discussing findings with referring physicians whenever films are not available. It also enriches communication between radiologists, facilitating peer review on the telephone when one of them has questions at the outcome of any given study. One of the main advantages associated with the system is the possibility of using it as a powerful tool for teaching and research. In conclusion, even when primary diagnosis is performed on film, the availability of a PACS for review can be helpful to enhance communication with referring physicians, as well as technologists and radiologists' efficiency. Our experience shows that it is possible to implement such a system using low-cost or freely available components without compromising ease of use while keeping costs down, which is a major concern in developing countries.

Cost Control↗

Hazard communication/right-to-know for health care facilities.

This manual is intended to provide useful information on the various new and pending health and safety regulations that affect hospitals. The governing bodies promulgating these regulations are the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and state and local governments. The majority of this document is dedicated to the OSHA Hazard Communication Standard (or federal Employee Right-to-Know Law) and the EPA Superfund Amendment Reauthorization Act (SARA) Title III Regulations (or federal Community Right-to-Know Law).

Communication↗

Planes, kangaroos, and the CAPD manual.

The Western Australian (WA) Remote Area Dialysis Programme was developed in 1988 due to the cultural need to dialyze an increasing number of aboriginal patients in their own communities, rather than relocating them up to 3000 km away in Perth. The success of the program relies on remote area health services (RAHS), which have no prior experience in continuous ambulatory peritoneal dialysis (CAPD), providing consistent routine and emergency medical care to the patients. Our aim was to standardize the care of all CAPD patients in remote WA by providing the RAHS with an easy-to-follow manual. Although the RAHS received treatment protocols, and in-service education, consistent care was not always provided. We confirmed this by: (1) examining the existing quality assurance tools, peritonitis and hospital admission rates, (2) discussion with remote area staff regarding patients, and (3) informal assessment of remote area staff receptiveness to in-service education by a CAPD nurse. We identified the causes of the inconsistent care to be: (1) high remote area staff turnover (six months average for a registered nurse), (2) the protocols were difficult to follow, and (3) confusion for the RAHS as to the appropriate contact person at our hospital. In 1994, the situation was exacerbated by the dramatic increase in the number of patients and RAHS involved (14 new patients, bringing the total to 20 patients in 12 centers) plus the introduction of a second treating hospital (with differing protocols). A team of two CAPD nurses and two nephrologists was established, to collaborate with two remote area hospitals and the second treating hospital to produce the "Remote Area CAPD Manual." The manual is an easy-to-follow, step-by-step guide for the management of CAPD by non-dialysis personnel. It has led to improved management of CAPD, improvement in communication with RAHS, and the increased confidence of remote area staff in the management of CAPD patients. In conclusion, RAHS can give consistent care if provided with clear, concise guidelines.

Adult↗

E-health, phase two: the imperative to integrate process automation with communication automation for large clinical reference laboratories.

The initial efforts of e-health have fallen far short of expectations. They were buoyed by the hype and excitement of the Internet craze but limited by their lack of understanding of important market and environmental factors. E-health now recognizes that legacy systems and processes are important, that there is a technology adoption process that needs to be followed, and that demonstrable value drives adoption. Initial e-health transaction solutions have targeted mostly low-cost problems. These solutions invariably are difficult to integrate into existing systems, typically requiring manual interfacing to supported processes. This limitation in particular makes them unworkable for large volume providers. To meet the needs of these providers, e-health companies must rethink their approaches, appropriately applying technology to seamlessly integrate all steps into existing business functions. E-automation is a transaction technology that automates steps, integration of steps, and information communication demands, resulting in comprehensive automation of entire business functions. We applied e-automation to create a billing management solution for clinical reference laboratories. Large volume, onerous regulations, small margins, and only indirect access to patients challenge large laboratories' billing departments. Couple these problems with outmoded, largely manual systems and it becomes apparent why most laboratory billing departments are in crisis. Our approach has been to focus on the most significant and costly problems in billing: errors, compliance, and system maintenance and management. The core of the design relies on conditional processing, a "universal" communications interface, and ASP technologies. The result is comprehensive automation of all routine processes, driving out errors and costs. Additionally, compliance management and billing system support and management costs are dramatically reduced. The implications of e-automated processes can extend beyond the specific transaction problems they are designed to solve. The ready access and communication of process details required by e-automation can apply to many other business functions.

Accounts Payable and Receivable↗

External quality assessment (EQA) of Belgian clinical laboratories. The telematics paradigm.

Technology that enables communication between information systems has recently become cheaper and more powerful. It is therefore timely to consider the effects of the introduction of such techniques in external quality assessment (EQA) schemes on both users and organizers. Traditionally, results are returned to EQA organizers as hand-written numbers on structured forms. These data are then manually entered into a computer. The process is time-consuming, slow (as it depends on the postal service), prone to error at every transcription stage, and expensive, as clerical staff must be employed to input the data. Computer-to-computer communication allows this process to be improved. A telematics system for electronic data interchange has been developed for the Belgian EQA programme and it offers several advantages, such as the use of standardized semantics, expression of results in laboratory familiar units, possible interface with the Laboratory Information System, faster data analysis, shorter report time and long-term performance evaluation.

Belgium↗

Policy and procedure manual: keeping a high quality manual.

Policy and procedure manuals are now commonly used in hospitals. The policy and procedure manual provides critical care nurses with a wealth of information. Policies are developed to guide the staff to perform nursing care adequately. Together policies and the corresponding procedures let critical care nurses know how to proceed to meet the organisation and the unit goals. As critical care expands the number of policies increases, which may make it more difficult to find a specific policy quickly. Critical care nurses need to look at other solutions for communicating some necessary pieces of information and check to make sure that policy is stated briefly, to the point and logical. It is also necessary to check to see if the information included in the manual is policy and associated procedures. If it is drug information, equipment usage, standards of care, or patient/family teaching material it could be incorporated in a different format or separate manual. As care givers nurses must monitor policies and procedures that are written and make sure they are simple to read, logically written, and easy to find.

Critical Care↗

Brain-injured persons in an altered state of consciousness: measures and intervention strategies.

We evaluated the states of consciousness of seven persons who had sustained a severe head injury, and describe the behavioural manifestations associated with four treatment strategies. The subjects were between the ages of 19 and 55 and were recruited from both acute and long-term care facilities; all were in an altered state of consciousness. The severity of the injury was measured by time in coma, the scores on the Glasgow Coma Scale [1] and the Coma Near Coma Scale [2]. Structured interventions consisted of visual, auditory, olfactory, gustatory and tactile stimulation; behaviour was measured using the Disability Rating Scale [3, 4] and a portion of the Levels of Cognitive Functioning Scale [5]. Sensory-motor indications were recorded using a questionnaire developed by Freeman [6] and a quality-of-life instrument, developed for use with individuals having multiple disabilities [7], was adapted for the purpose of this study. Our results suggest that the use of structured interventions in the first 24 months following severe head injury is associated with a trend towards improved auditory and visual skills performance, manual performance, swallowing and language. Whereas initially no subject had any form of verbalization, by the final evaluation five subjects had some form of communication, either verbal or non-verbal.

Adult↗

A synopsis of the practice parameters on dementia from the american academy of neurology on the diagnosis of dementia.

OBJECTIVE: The objective of this paper is to review the current practice guidelines as developed by the American Academy of Neurology (AAN) for the diagnosis of dementia. DATA SOURCES: The data sources were the Report of the Quality Standards Subcommittee of the American Academy of Neurology paper, which was published in the May 2001 issue of the journal Neurology. STUDY SELECTION: The studies used in this paper are those reviewed by the AAN Practice Parameter Committee, which reviewed the literature for evidence-based human studies pertaining to the diagnosis of dementia. Studies on Alzheimer's disease (AD) included had to have more than 25 subjects. Each article was classified based on the quality of evidence. After review of the evidence, the committee drafted recommendations and placed the evidence into Practice Standards, Guidelines, or Options. DATA SYNTHESIS: The main results of this review were the guidelines for diagnosing dementia of various forms. To diagnose dementia, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-IIIR) should be used. For AD, the NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer s Disease and Related Disorders Association) criteria should be used. The Modified Hachinski Ischemic Score criteria can be used in the diagnosis of vascular dementia. The Consortium for DLB (Dementia with Lewy Bodies) criteria may be of use in clinical practice. Neuroimaging with a noncontrast CT or MRI scan in the routine initial evaluation of persons with dementia is appropriate; other methods of neuroimaging are not recommended at this time. Genetic testing and use of apolipoprotein E (ApoE) genotyping is not recommended at this time. Depression, B12 deficiency, and hypothyroidism should be screened for and treated in patients with dementia. Unless the patient lives in an area in the United States with a high rate of syphilis, screening for tertiary syphilis is not warranted. CONCLUSION: The guidelines and their clinical applications are pertinent and important knowledge for consultant pharmacists. This practice parameter will need to be updated every few years to include new studies and information that becomes available.

Journal Article↗