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A neuropsychiatric approach to impulse disorders.

Disordered impulse control (or pathologic impulsivity) is a common feature of many neurologic and psychiatric illnesses. Diagnosis is founded on comprehensive neuropsychiatric evaluation. Behavioral dyscontrol often represents pathology at multiple levels of nervous system function and requires an appropriately comprehensive treatment program. Evaluation and diagnostic classification are discussed. Several clinical synopses are presented to illustrate the common complexity of evaluation and treatment in presentations of pathologic impulsivity.

Adolescent↗

Flexor tendon injuries. Part 2. Flexor tendon repair.

The principles of atraumatic flexor tendon repair are reviewed. It is noted that tendon repair of the profundus and superficialis tendons-primary or delayed primary-should be carried out in all zones of flexor tendon interruption. Whenever possible, repair of the flexor tendon sheath also seems appropriate. A supervised program of early motion may prove beneficial, though restoration of function to a digit may be long and tedious, thus requiring a high degree of patient motivation and participation.

Finger Joint↗

Integrating clinical education into the curriculum development process.

Radiologic technology education consists of three components--didactic, laboratory, and clinical. For effective education to take place and for each program to meet its goal of preparing practitioners who have a firm theoretical foundation and are proficient technologically in radiologic technology, the three components must be integrated. Integration facilitates the transfer of theoretical and practical knowledge into the intellectual, psychomotor, and affective skills necessary for patient care. The totality of the integrated educational experience makes the competent professional. Integration of the educational components is best achieved by a systematic approach to curriculum development. The steps in the curriculum development process consist of (1) the formulation of a philosophy; (2) the establishment of competencies; (3) the identification of resources; (4) the development and sequencing of courses; (5) the identification of teaching strategies; and (6) evaluation. When the clinical component of the educational program is weighted appropriately and well-integrated into a systematic process of curriculum development, student learning is maximized and graduate professional performance is enhanced.

Curriculum↗

The impact of a health screening flow sheet on the performance and documentation of health screening procedures.

We monitored physician performance of stool occult blood testing and breast exams during health maintenance visits of patients aged 50 or greater, to assess the impact of a physician education program and the use of a health screening flow sheet on performance of these health screening procedures. During the baseline study period, use of these procedures was documented for only about 40% of patients. A physician education program (conferences reviewing appropriate health maintenance screening procedures, and information on the use of a specific health screening flow sheet) did not significantly change the rate of documented physician performance of these procedures. After a health screening flow sheet was introduced into the medical record, the rate of documented performance of these screening tests increased. However, despite the presence of the screening flow sheet in the patient record, most screening evaluations were documented only in the progress notes. These results suggest that the screening flow sheet serves primarily as a memory prompting device. The usefulness of the flow sheet as a patient data storage device appears questionable.

Breast↗

Control of deaths from diarrheal disease in rural communities: II. Motivating and monitoring the community.

In 1980 the Ministry of Health of Egypt undertook a short term investigation into means and methods to reduce the annually excessive number of preschool child deaths from Diarrheal Disease. This investigation sought to identify ways to overcome constraints related to logistics, supplies, and community participation. The unifying theme of this study was to examine the feasibility of stressing Oral Rehydration Therapy (ORT) instead of the then conventional parenteral treatment and heavy use of antibiotics. Study cells were arranged to test feasibility of placing responsibility for the intervention primarily with rural mothers, secondly with itinerant nurses. Appropriate health education programs, revised supervision and data collection systems were developed and implemented. Results limited to mortality indicators demonstrating that mothers could affect a significant decrease in the diarrhea-specific death rate were reported in an earlier paper. In this paper a more comprehensive presentation of various survey data associated with the investigation are presented. These data show that mothers were indeed able to recognize diarrheal disease and institute early and effective treatment, and that they developed remarkable skills of preparing safe oral rehydration fluids from home supplies of sugar and salt. In addition, the data show that health service staff increasingly gained confidence in ORT as demonstrated by increasing rates of utilization of the method, and as mothers indicated ORT to be the preferred method of treatment of diarrheal disease.

Child, Preschool↗

Speech and hearing services in hospitals.

Because professionals in treating communication disorders work with otolaryngologists, pediatricians, surgeons, radiologists, physiatrists, dental specialists, etc., the hospital is a logical base for these shared services. Structuring a communication disorders unit within the hospital requires identifying needs, setting objectives, and developing a program that has appropriate capital support.

Audiology↗

A true experiment evaluating adult skill training for severely mentally retarded secondary students.

Skill acquisition by secondary-level severely mentally retarded students was assessed on functional community and living skills task analyses. Students were trained in natural settings according to a behavioral analysis of the curriculum into systematic teaching and error-correction procedures. Classroom training in the district high school supported the teaching that occurred in the community. The evaluation of student performance on specific skills was done using random assignment to training and control conditions in a cross-over design. Students showed significantly greater gains on those tasks for which they were trained than on those for which they were not. In addition to this specific skill training, a daily checklist showed significant progress by all students on a broad array of skill sequences. Discussion stressed the contribution of the project to ideologically appropriate public school programs for severely mentally retarded students, to behaviorally based instructional technology, and to evaluation using true experimental designs.

Activities of Daily Living↗

Health-care trends influencing the financial management of hospital pharmacies.

Current trends affecting health care and the response of the health-care industry to these trends are described, and recommended actions for hospital pharmacy departments are presented. The effects of societal changes, technological advances, information collection and exchange, excess physician population, cost constraints, and competition are examined. Appropriate responses include programs to lower costs, improved financial-monitoring systems, creative methods for attracting patients and donations, specialization of care, corporate formation and restructuring, emphasis on ambulatory and preventive programs, partnership with medical staff, deregulation initiatives, and standardization of hospital statistics. More aggressive management, financial expertise, and greater accountability will be expected of hospital pharmacy managers.

Costs and Cost Analysis↗

Children in classes for the severely emotionally handicapped.

This report will describe the clinical findings of a collaborative program to provide appropriate neuropsychiatric skills for 60 children ages 8 to 14 (grade 3 to 8) and their teachers, comprising the entire population of two self-contained units (eight classes) for the treatment of children designated as severely emotionally handicapped but not autistic. Of the 60 children, 36 (60%) were suffering from learning disabilities. Eighteen of these had neurological signs suggestive of organic defect of the central nervous system; the remaining 18 children with learning disabilities had specific or development learning disabilities characterized by perceptual immaturity in spatial orientation and/or temporal organization, but the classical neurological examination administered to them was within normal limits. Ten additional children were classified as having an attentional deficit disorder, and 11 additional children were functioning at a borderline level of cognitive ability. Fifty-nine of the 60 children were suffering from diagnosable psychiatric disorders: 21 (35%) severely anxious, 13 (22%) clinically depressed, 12 (20%) conduct disorders, 6 (10%) oppositional, 3 (5%) schizophrenic, 2 (3%) obsessive-compulsive disorder, and 2 (3%) personality disorder. Applications of these findings are suggested.

Adolescent↗

Archie: the use of a microcomputer in an allergy clinic.

In an attempt to improve the efficiency and quality of allergy history taking we surveyed the practice of 57 allergy clinics in the UK. After studying their methods we developed a computer program based on a relatively inexpensive (pounds 2500) microcomputer system to obtain a detailed history from patients suffering from asthma or rhinitis. The program automatically suggests appropriate allergy tests depending on the answers given to the questions. Details of the history and the results of tests are collated and printed in a form suitable for storing in the patient's records, and are filed on magnetic disk for subsequent analysis. Computer interrogation was accepted and enjoyed by patients.

Asthma↗

Computer-assisted customized antimicrobial dosages.

The use of a computer-based consultation program to customize dosage regimens of antimicrobials for patients with meningitis or bacteremia is described. Using clinical and laboratory information entered by the user, the program determines causative organisms, recommends therapeutic regimens, and generates a graph depicting the expected blood level of each drug as a function of time. During therapy selection, the program considers the site of infection, the susceptibility of the organism to antibiotics, and the patient's clinical status and drug history. Individualized pharmacokinetic values allow for dosage adjustments in renal failure and estimation of blood levels. If renal impairment is present, dosage regimens for drugs excreted by the kidneys are adjusted to assure the desired steady-state blood levels. To help in selection of the optimal regimen, estimated blood levels for each regimen are graphed along with the minimum inhibitory concentration for the organism and the toxic level of the drug. A bulit-in knowledge base in conjunction with patient-specific information enables the computer program to determine appropriate treatment specific to a patient's age, renal function, and prior drug reactions.

Adult↗

Alternatives in the handling, processing and storage of electrocardiograms.

Physicians and administrators are becoming aware that computer technology can play a significant role in the electrocardiology department. Problems related to the large number of requests for electrocardiograms, the production and communication of electrocardiographic tracings and reports, the access to stored tracings and the overall cost of providing effective services have led administrators to look for assistance through automation. Before expensive equipment and new procedures are introduced, a survey of the electrocardiology department's functions and procedures can lead to important insights. Automation can be achieved in stages, and problems can be solved by separate steps. Options range from basic word-processing support to completely automated electrocardiographic interpretation and computerized storage of records. Choosing the appropriate equipment and programs requires knowledge of the present system, awareness of the options and analysis of the costs and savings.

Computers↗

Affecting health personnel distribution through AHECs.

The United States Government has had a long and enduring interest in the health of its citizens and in the training of health care providers. It was not, however, until 1963 that federal funds were specifically appropriated for health professions education. Almost ten years after the first legislation which authorized funding of health personnel training, the Carnegie Commission on Higher Education assessed the health care of the nation and concluded that in spite of sizeable appropriations to educational programs, health care providers were still in short supply in the inner city and in rural areas of the country. The Carnegie Commission's report triggered congressional interest in the maldistribution problem and led to funding of the Area Health Education Center (AHEC) program in 1972. Since the funding of the initial 11 AHECs in 1972, the Bureau of Health Manpower (renamed the Bureau of Health Professions) has funded more than 20 AHECs. In reviewing the annals of health personnel and projecting the future needs of this nation, it is encouraging to note that many of the Carnegie Commission's goals for better health care are being met through AHECs.

Area Health Education Centers↗

Audit of an oral anticoagulant teaching program.

Quality assurance criteria for a pharmacist-conducted oral anticoagulant teaching program were studied. The teaching program involved the presentation of descriptive diagrams accompanied by a reinforcing explanation given by a pharmacist. Topics discussed included clotting, warfarin therapy, diet and drug interactions. An audit, consisting of a pretest and posttest, was developed to measure patient knowledge as a measurement of the program's effectiveness. Forty ambulatory patients participated in the study over a three-month period. Before instruction, only five patients were adequately knowledgeable about all of the information components. After instruction, this number increased to 20 patients, and all 40 patients had a better knowledge of each topic. The audit revealed that the program's standards were not completely appropriate and that other methods of program delivery must be evaluated and implemented.

Anticoagulants↗

Resident physician performance in a continuing education format. Does newly acquired knowledge improve patient care?

As part of an educational program in preventive dentistry for family medicine residents, we evaluated changes in systemic fluoride prescribing habits related to newly acquired knowledge. Residents, unaware of the study, were randomly assigned to one of two groups and shown a videotape describing preventive dental techniques. We supplemented the tape viewed by one group with specific instructions explaining the implementation of the information in patient care. Residents in both groups demonstrated the ability to learn and maintain their level of knowledge during a three-month period. Daily chart audits, however, revealed no substantial increase in correct prescribing of systemic fluoride to pediatric patients for either group. Only subsequent individual monitoring and reinforcement achieved the desired behavior. The acquisition of new knowledge by resident physicians under these circumstances did not lead to its application in daily patient care. This result parallels reported difficulties in altering physician behavior by continuing medical education, and suggests that residency programs are an appropriate setting to initiate improved physician performance in response to acquired knowledge.

Child↗

Prediction of special education placement from birth certificate data.

The overall goal of this research effort was to develop procedures for accurately identifying children at high risk for special education placement, based on information available at the time of birth. A file containing information on all births in New York City between 1976 and 1986 was matched against the 1992 BIOFILE, which contains information on all children enrolled in the New York City public school system in 1992. A matched file containing birth and school information on 471,165 children resulted from this process. Three sets of risk factors were derived from birth certificate data: parental, pregnancy-related, and child-related. Using these risk factors as independent variables, a survival analysis model was developed predicting special education placement for each of three major disability categories: learning disability, emotional disorder, and mental retardation. A model combining all disability categories was also developed. The significant predictors of special education placement were Medicaid payment for birth (a poverty indicator), unmarried status of mother, large family size, low parental education, a mother born in the United States, a low level of prenatal care, male gender, low birthweight, and a low Apgar score. Male gender was the strongest risk factor in all models. Examination of selected survival curves indicated that the predictive power of the models is substantial. The methodology described in this article can be used to identify at-risk children for whom screening and other early interventions, including preschool programs, may be appropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

Apgar Score↗

Psychosurgery.

Surgical treatment of psychiatric disease can be helpful in certain patients with severe, disabling and treatment refractory major affective disorders, obsessive compulsive disorders, and chronic anxiety states. Psychosurgical treatment should be carried out by an expert multidisciplinary team with experience in these disorders. Surgery should be considered as one part of an entire treatment plan and must be followed by an appropriate psychiatric rehabilitation program.

Brain↗