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PubMed1998

Practice guidelines and the practice of medicine: is it the end of clinical judgment and expertise?

Clinical practice guidelines are an increasing part of efforts to improve the quality and reduce the cost of health care. They are recommendations for the evidence-based care of average patients, not rules for all patients. At best they are developed by panels representing a wide array of expertise and experience related to the clinical question, are based on comprehensive, critical review of scientific evidence, make clear how value judgments affect recommendations, and take into account all of the issues bearing on clinical decisions, such as effectiveness, risk, convenience, cost, cost-effectiveness, and the resources needed to carry out the recommendations. Physicians have a mixed opinion of guidelines, believing they are both useful summaries to improve the quality of care and potential tools to judge and control them. Although guidelines may point out the best research evidence to guide the care of average patients, they are not a substitute for clinical judgment, which should be applied to each individual patient.

Clinical Competence↗
PubMed1976

The Adlerian approach: a practical psychology for family practice.

A systematic approach to understanding the patient's personality and helping him cope with common life problems is found in Adlerian Psychology. It is uniquely appropriate to family practice because it stresses the interpersonal purposes of behavior and symptoms and the influence of family constellation on the development of the individual life-style. By obtaining a small amount of data about the patient's present life situation and his family of origin, the physician can gain a basis for understanding how the patient developed his unique way of acting and reacting to the physical and social stresses of life. Interpretation of two or three early recollections reveals what the patient expects of himself, others, and life. The insight thus gained is used as the basis for a holistic assessment of the problem; a directive, supportive, action-oriented plan for treatment; and an ongoing doctor-patient relationship of mutual respect.

Adolescent↗
PubMed2002

Improving family practice residents' compliance with asthma practice guidelines.

OBJECTIVES: This study primarily determined the effect of an educational and system intervention on residents' documentation of the severity classification of asthma. Secondarily, the study assessed the effect of classification on pharmacologic treatment, as outlined by national asthma treatment guidelines. METHODS: We reviewed the charts of all patients with asthma seen by the residents in the Center for Family Medicine (CFM) between October 1, 1998, and March 31, 1999. Data gathered from each chart included, but was not limited to, disease severity classification and medication regimen. Between July 1999 and October 1999, efforts at increasing residents' knowledge of asthma severity classification were made via formal and informal teaching. A post-intervention chart review was performed on all patients with asthma seen by the residents in the CFM between October 1, 1999, and March 31, 2000. RESULTS: A total of 8.5% of 198 and 51% of 271 patient visits were classified with respect to asthma severity in the pre- and post-intervention periods, respectively. Classified patients were treated appropriately 100% of the time in the pre-intervention period and 76% of the time in the post-intervention period. CONCLUSIONS: A comprehensive protocol significantly improved compliance with national asthma treatment guidelines with respect to severity classification but not pharmacologic treatment.

Asthma↗
PubMed1996

Gun storage patterns in US homes with children. A pediatric practice-based survey. Pediatric Practice Research Group.

OBJECTIVE: To describe gun storage patterns in gun-owning families with children. DESIGN: Survey of parents attending participating offices. SETTING: Twenty-nine urban, suburban, and rural pediatric practices in Chicago, Ill; New Jersey; Houston, Tex; Utah; Georgia; Iowa; and South Carolina. SUBJECTS: Parents of children attending offices for well- or sick-child care. SELECTION PROCEDURE: Consecutive sample of families seen during the 1-week study period. MEASUREMENTS AND ANALYSES: Logistic regression models were constructed to identify sociodemographic factors associated with keeping guns loaded. RESULTS: Of 5233 surveys, 1682 (32%) indicated ownership of at least one powder firearm. Of the gun-owning families, 61% reported at least one gun unlocked, and 15% reported at least one gun loaded. Rifles were more often stored unlocked (62% rifles vs 52% handguns, P<.001, z=4.60; two-proportion z-test), but handguns were more likely to be kept loaded (3% rifles vs 27% handguns, P<.001). Seven percent of gun-owning families reported at least one gun unlocked and loaded (handguns 12 times more likely than rifles). Only 30% of households reported all guns stored unloaded and locked up. The best-fit logistic regression model for keeping a gun loaded identified four predictor variables: owning a gun for self-protection, work-related gun ownership, owning a handgun, and no men in the home. CONCLUSIONS: Because most gun-owning families store guns loaded, unlocked, or both, anticipatory guidance should address gun storage in all such families. Interventions designed to alter the way work guns are dealt with after work, and to provide safe and effective means of self-protection might affect these storage patterns.

Child↗
PubMed1999

Autonomic and EEG patterns during eyes-closed rest and transcendental meditation (TM) practice: the basis for a neural model of TM practice.

In this single-blind within-subject study, autonomic and EEG variables were compared during 10-min, order-balanced eyes-closed rest and Transcendental Meditation (TM) sessions. TM sessions were distinguished by (1) lower breath rates, (2) lower skin conductance levels, (3) higher respiratory sinus arrhythmia levels, and (4) higher alpha anterior-posterior and frontal EEG coherence. Alpha power was not significantly different between conditions. These results were seen in the first minute and were maintained throughout the 10-min sessions. TM practice appears to (1) lead to a state fundamentally different than eyes-closed rest; (2) result in a cascade of events in the central and autonomic nervous systems, leading to a rapid change in state (within a minute) that was maintained throughout the TM session; and (3) be best distinguished from other conditions through autonomic and EEG alpha coherence patterns rather than alpha power. Two neural networks that may mediate these effects are suggested. The rapid shift in physiological functioning within the first minute might be mediated by a "neural switch" in prefrontal areas inhibiting activity in specific and nonspecific thalamocortical circuits. The resulting "restfully alert" state might be sustained by a basal ganglia-corticothalamic threshold regulation mechanism automatically maintaining lower levels of cortical excitability.

Adolescent↗
PubMed2002

Protective effect of practice on cognition during aging: implications for predictive characteristics of performance and efficacy of practice.

In the present study, the effect of previous experience on spatial memory, which required the retention of information either over long intervals or within a single session, was longitudinally tested in the water maze in male F-344 rats that were from 6 to 24 months of age. Performance in these tasks was found to be age-dependent (Markowska, 1999). Other behavioral tasks in the straight alley and with a visible platform in the water maze controlled the noncognitive components of performance. For all tasks, performance was significantly correlated between 12-month-old and 18-month-old rats, indicating that cognitive performance at the early, but not advanced, stage of aging could be predicted from performance at a younger age if the novelty of the first exposure to the task was eliminated. The protective effect of experience was more robust in the reference memory task as compared to the working memory task and was modified by age when training was initiated. Behavior during the probe trials was more sensitive to the effect of aging and more resistant to the beneficial effect of practice as compared to the performance in the platform trials. The speed of swimming of experienced rats progressively decreased with age only when tested in the cognitive tasks but not in the straight alley. This indicates that speed of swimming during cognitive tasks does not exclusively reflect the ability to swim, but might be also affected by the cognitive demands of the task. Protective effect of experience on cognition was not modified by restriction in diet.

Aging↗
PubMed1993

Factors associated with serum cholesterol level in a pediatric practice. Cholesterol screening in a pediatric practice.

The associations between age, sex, height, Quetelet index, blood pressure, and serum cholesterol level were examined among 1406 routinely screened children, aged 4 to 19 years, in a pediatric practice. After adjustment for sex and age, height and Quetelet index were associated with serum cholesterol levels. Quetelet index was shown by multiple linear regression to be positively related to cholesterol levels (b = 0.780, P < 0.01), but the predictive value of screening based on an elevated Quetelet index was marginal. Clustering of elevated serum cholesterol level, Quetelet index, and systolic blood pressure was observed. Familial aggregation of cholesterol levels was demonstrated using analysis of variance for 742 children from 342 families included in the regression analysis (F341,400 = 1.56, P < 0.0001). The intraclass correlation coefficient, a measure of familial aggregation, was 0.205 (P < 0.0001). Age, sex, height, Quetelet index, and familial aggregation accounted for 10.6% of the variance in serum cholesterol levels. Siblings of children with high cholesterol levels are a high-yield group in cholesterol screening.

Adolescent↗
PubMed2004

Practical aspects of fast reversed-phase high-performance liquid chromatography using 3 microm particle packed columns and monolithic columns in pharmaceutical development and production working under current good manufacturing practice.

The potential and limitations of fast reversed-phase high-performance liquid chromatographic separations for assay and purity of drug substances and drug products were investigated in the pharmaceutical industry working under current good manufacturing practice using particle packed columns and monolithic columns. On particle packed columns, the pressure limitation of commercially available HPLC systems was found to be the limiting factor for fast separations. On 3 microm particle packed columns, HPLC run times (run to run) for assay and purity of pharmaceutical products of 20 min could be achieved. As an interesting alternative, monolithic columns were investigated. Monolithic columns can be operated at much higher flow rates, thus allowing for much shorter run times compared to particle packed columns. Compared to particle packed columns, the analysis time could be reduced by a factor up to 6. However, some compounds investigated showed a dramatic loss of efficiency at higher flow rates. This phenomenon was observed for some larger molecules supporting the theory that mass transfer is critical for applications on monolithic columns. At flow rates above 3 ml/min some HPLC instruments showed a dramatic increase in noise, making quantifications at low levels impossible. For very fast separations on monolithic columns, the maximum data acquisition rate of the detector is the limiting factor.

Chromatography, High Pressure Liquid↗
PubMed2006

Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations.

The Resource Center of the American Alliance of Cancer Pain Initiatives provided templates, faculty, and ongoing consultation to assist seven state pain initiatives to implement programs to improve pain management practices. A total of 113 health care organizations participated. Each organization committed to support a team of two to three staff through a 10-month pain quality improvement process, which included a site visit, two educational conferences, pre- and postprogram analyses of the organizational structures in place to support pain assessment and management, quality improvement work plan development, and patient survey data collection. Postprogram results showed statistically significant increases in the presence of structural elements that are critical to effective pain management, as well as statistically significant, though modest, decreases in the percentage of patients who reported pain of any severity, and specifically moderate to severe pain, in the previous 24 hours. The largest changes occurred in long-term care facilities. Nevertheless, the percentage of patients in moderate to severe pain remained unacceptably high.

Delivery of Health Care↗
PubMed1995

Modern veterinary blood banking practices and their applications in companion animal practice.

There are two main reasons for blood component therapy: the need for an increase in oxygen-carrying capacity and improved hemostasis. Additionally, blood component therapy is used to increase plasma protein concentrations. Component therapy entails separating whole blood into its cellular and plasma components and administering the appropriate blood component based on the patient's needs. General considerations such as compatibility, defined expectations of benefits, and topics including specific disease screening, preparation of blood components, preparation of blood products for administration, and typing and crossmatching in relation to blood component therapy and its application in companion animal practice are discussed.

Animals↗
PubMed2001

Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice.

INTRODUCTION: Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization. METHODS: We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected. RESULTS: PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes. CONCLUSIONS: We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.

Health Plan Implementation↗