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[Behavioral and cognitive strategies in stress management].

Stress is a specific response of the individual to all nonspecific demands. However, this process of adaptation is very complex and varies considerably from person to person. The stress response or "stress reactivity" is triggered by various stressors, ranging from live events to daily hassles and including chronic stressors. These stressors need to be identified. The stress response is not univocal: it has physiological, cognitive and behavioral components. Most of the time, physiological, cognitive and behavioral responses are maladaptive and harmful for the individual. Stress management is directed at teaching individuals specific skills to modify parts of these responses in order to reduce stress. Relaxation therapies are the cornerstone of any stress management program. They mostly include autogenic training and progressive relaxation training, sometimes biofeedback. The relaxation response is a learned response. There are a variety of different methods of inducing this response. They share the common goal of countering the physiological aspects of the stress reaction. All the relaxation techniques involve long and exacting training. But proper training leads to a gradual reduction in time and effort required to relax. When properly pursued, these techniques produce a state of relaxation quickly and on demand. Cognitive approaches to stress management derive from the constatation that the individual's interpretation of events or situations which have been labeled stressful, the individual's anticipation of the consequences of the stressor and the individual's view of his or her ability to cope with the stressor or the stress reaction are fundamental in the stress process. There are a variety of cognitive theories and techniques, ranging from Beck's cognitive therapy to Ellis' Rational-Emotive Therapy. Initial phases of these therapies are directed at teaching the individual to recognize, record, analyse and modify maladaptive cognitions. The second phase is usually devoted to identifying and modifying the dysfunctional attitudes which give rise to the stressful cognitions. The basic behavioral stress response falls in line with the expectations of the fight or flight response, and a stressed individual will typically display a pattern of either aggressive or avoidance behavior (as shown in the "Type A Behavioral Pattern"). The relation between stress and behavior is bidirectional: some behaviors occur in response to stress, whereas others produce stress. Assertive training is often a component of stress management programs as it is accepted that behaving in an assertive manner (i.e. a non passive and non aggressive manner) results in an increased feeling of well-being.(ABSTRACT TRUNCATED AT 400 WORDS)

Arousal↗

Reliability and validity of spirometry measurements in a paperless home monitoring diary program for lung transplantation.

OBJECTIVE: To demonstrate that home spirometry measurements are reliable and valid and can be used as part of a home measurement monitoring system by lung transplant recipients. DESIGN: Longitudinal, observational. SETTING: University medical center. SUBJECTS: Eighteen patients who have undergone lung transplantation; age range was 24 to 63 years (mean of 49.5 years). OUTCOME MEASURES: Reliability and validity of forced expiratory volume at 1 second (FEV1) and forced vital capacity (FVC). INTERVENTION: Recording of spirometry, vital signs, and symptom measures at home each day by use of a paperless electronic diary/spirometer instrument. RESULTS: Day-to-day variability as measured by the standard deviation ranged from 0.013 L to 0.202 L for FVC and 0.015 L to 0.117 L for FEV1. The correlation between the two best forced expiratory maneuvers on any given day was 0.98 for both FVC and FEV1, with percent differences between the measurements of 2% for FVC and 3% for FEV1. The correlation between measurements performed in the pulmonary function laboratory and measurements done by the patient at home on the same day was 0.94 for FVC and 0.99 for FEV1. CONCLUSIONS: This evaluation demonstrated that home measurements are both reliable (i.e., repeatable) and valid when compared with the "gold standard" of the pulmonary function laboratory. The home monitoring program has been well accepted by patients, is easy to use, and provides data comparable to that collected during clinic visits.

Adult↗

Somatization and medicalization in the era of managed care.

Somatization, the reporting of somatic symptoms that have no pathophysiological explanation, appears to be increasing as sociocultural currents reduce the public's tolerance of mild symptoms and benign infirmities and lower the threshold for seeking medical attention for such complaints. These trends coincide with a progressive medicalization of physical distress in which uncomfortable bodily states and isolated symptoms are reclassified as diseases for which medical treatment is sought. Somatization and medicalization are likely to become more problematic in the era of managed care. Under capitation, providers will have greater incentives to reduce utilization, and somatizing patients may feel forced to express their "disease" in more urgent and exaggerated terms in order to gain access to the physician. In addition, prepaid subscribers will suffer little financial disincentive to seek medical attention for relatively minor complaints; therefore, they are likely to increase the demand for physician consultation. This situation suggests an urgent need to improve the management of somatizing patients. Innovative consultative, behavioral, and educational interventions are now available. In addition, medical professionals should greet the process of medicalization with considerable caution and educate the public more about the normative presence of symptoms and bodily distress in healthy people. Additional research is needed into somatization and its relationship to the demand for medical care. In an era of managed care, increased attention should be devoted to understanding and controlling the demand for care, a large portion of which is symptom driven.

Capitation Fee↗

Survival of CAPD patients in a center using three two-liter exchanges as standard regime.

Our objectives were to study long-term patient survival and dialysis adequacy of continuous ambulatory peritoneal dialysis (CAPD) patients treated with a standard regime of three 2-L daily exchanges. It was a retrospective analysis of patient survival and cross-sectional analysis of adequacy of dialysis. The setting was a dialysis unit in a tertiary referral center of a teaching hospital. All patients (n = 507) accepted into the CAPD program from 1983 to June 1994, were analyzed for survival. Adequacy of dialysis was analyzed in all existing patients in 1993 to 1994. The overall patient survival was 93%, 71%, and 57% at one, three, and five years, respectively. The three-year survival rate was 40% for diabetics and 78% for nondiabetics. It was 86%, 85%, 64%, and 43% for patients aged < 35, 35-50, 50-65, and over 65 years, respectively. The mean weekly KT/V of 201 existing CAPD patients was 1.76, and creatinine clearance was 57 L/week/1.73 m2. KT/V by dialysis was only 1.57. The age- and disease-adjusted survival in our center was comparable to centers that used standard four 2-L exchange regimes, despite a substantially lower mean KT/V and creatinine clearance (CrCl).

Adolescent↗

The contribution of vitamin A to public health.

Vitamin A deficiency among children in developing countries remains the leading cause of preventable severe visual impairment and blindness, and is a significant contributor to severe infections and death, particularly from diarrhea and measles. Vitamin A deficiency is also likely to increase vulnerability to other illnesses in both women and children, such as iron-deficiency anemia, and may be an important factor contributing to poor maternal performance during pregnancy and lactation and to growth deficits in children. Benefits to public health can be expected by improving the vitamin A status of deficient populations through an appropriate mix of acceptable, affordable, and available programs including promotion of breast-feeding, control of infections, dietary diversification, food fortification, and supplementation. Benefits include not only improved health and welfare for individuals and their families, but also improved chances of survival for an estimated 254 million children.

Anemia, Iron-Deficiency↗

[Access to chronic dialysis treatment: deficient and unequal].

OBJECTIVE: To determine the fraction of patients with end-stage renal disease (ESRD) who received dialysis treatment in the city of São Paulo in 1991 and to investigate the influence of age in the access to dialysis. MATERIAL AND METHODS: All patients who received dialysis for ESRD in the city of São Paulo during 1991, and were registered in the Secretary of Health of São Paulo files were included in the study. In the same year, information was also collected on individuals who died having as basic cause of death a disease related to chronic renal failure. These data were obtained from death certificates files. Using simultaneously information from both data bases it was possible to ascertain the patients who died without receiving dialysis and to calculate the treated fraction in several age groups. RESULTS: Overall 25.6% of ESRD patients did not receive treatment. There was a progressive reduction in the fraction of patients treated for those older than 40 years. In children less or equal to 9 years of age the percentage of treatment was also reduced (29%). Individuals in the age groups 60-69 and 70-79 years had a chance about 5 and 11 times greater, respectively, of dying without receiving dialysis than those in the 20-29 years group. CONCLUSIONS: We estimate that at least one fourth of the ESRD patients died in São Paulo in 1991 without receiving dialysis treatment. Age is a major factor of discrimination for acceptance in chronic dialysis programs.

Adolescent↗

Report cards can improve choice.

Consumers want accurate and impartial information to help them select the best health plan. To arm them with such information, employers, state agencies and the media are publishing report cards for managed care plans. Disagreement exists, however, about the content and format of the report cards, as well as the best way to disseminate the information.

Choice Behavior↗

Vaccine-preventable diseases in health care.

It cannot be overemphasized that good preventive measures such as universal precautions, good hand-washing techniques, and appropriate personal protection is the mainstay of reducing the risk of nosocomial infections to other patients and HCWs. Vaccines that are safe and effective in reducing risks of nosocomial infections must be promoted through educational campaigns and made easily available to all employees, including those on night and weekend shifts. Extended hours and onsite vaccination programs help to increase acceptance of vaccines at certain times, such as during the annual influenza vaccine campaign. When more than one vaccine is recommended, consideration must be given to an appropriate vaccine schedule. Table 2 lists the interactions and contraindications of the vaccines most commonly administered to health care workers. Certain vaccines, such as rubella, should be required for susceptible employees when working in an area of a health care facility where exposure and consequent transmission to patients could have life-threatening consequences.

Chickenpox↗

Injecting-related harm and treatment-seeking behaviour among injecting drug users.

AIMS: This study aims to identify the physical harm associated with injecting drug use and examine the treatment-seeking behaviour of injecting drug users (IDUs). Specific attention is given to the factors associated with presentation and non-presentation of injecting-related problems. DESIGN: Participants were interviewed by research staff using a semi-structured questionnaire, then physically examined by a medical team. SETTING: Needles exchanges in Glasgow. PARTICIPANTS: One hundred and twelve injecting drug users. FINDINGS: Respondents' accounts of their current injecting-related problems were found to be consistent with the clinician's findings, suggesting that IDUs are able to self-diagnose injecting-related harm. However, almost three-quarters had not sought help for these problems. Qualitative data suggest the main reasons for non-presentation, or delayed presentation, of injecting-related problems are normalization of injecting-related harm and a reluctance to attend available services. Almost half of those seeking treatment for injecting-related problems did so during an emergency or crisis. CONCLUSIONS: Low threshold services, such as needle exchanges, may have to take a more proactive stance to encourage injectors to present with injecting-related problems. This may help reduce injecting-related harms, especially the resulting medical complications, which would in turn relieve the pressure on other services such as hospital Accident and Emergency Departments.

Abscess↗

Medicare program; participation in CHAMPUS and CHAMPVA, hospital admissions for veterans, discharge rights notice, and hospital responsibility for emergency care--HCFA and OIG. Interim final rule with comment period.

We are revising requirements for Medicare participating hospitals by adding the following: A hospital must provide inpatient hospital services to individuals who have health coverage provided by either the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) or the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA), subject to limitations provided by regulations that require the hospital to collect the beneficiary's cost-share and accept payment from the CHAMPUS/CHAMPVA programs as payment in full. A hospital must provide inpatient hospital services to military veterans (subject to the limitations provided in 38 CFR 17.50 ff.) and accept payment from the Department of Veterans Affairs as payment in full. A hospital must give each Medicare beneficiary (or his or her representative) at or about the time of admission, a written statement of his or her rights concerning discharge from the hospital. A hospital (including a rural primary care hospital) with an emergency department must provide, upon request and within the capabilities of the hospital or rural primary care hospital, an appropriate medical screening examination, stabilizing treatment and/or an appropriate transfer to another medical facility to any individual with an emergency medical condition, regardless of the individual's eligibility for Medicare. The statute provides for the termination of a provider's agreement for violation of any of these provisions. These revisions implement sections 9121 and 9122 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (as amended by section 4009 of the Omnibus Budget Reconciliation Act of 1987), section 233 of the Veteran's Benefit Improvement and Health Care Authorization Act of 1986, sections 9305(b)(1) and 9307 of the Omnibus Budget Reconciliation Act of 1986, sections 6003(g)(3)(D)(xiv), 6018 and 6211 of the Omnibus Budget Reconciliation Act of 1989, and sections 4008(b), 4027(a), and 4027(k)(3) of the Omnibus Budget Reconciliation Act of 1990.

Centers for Medicare and Medicaid Services, U.S.↗

Fertility awareness / natural family planning for adolescents and their families: report of multisite pilot project.

Fertility awareness is experiential learning about cyclic fertility. This awareness, used as a family planning method, differs from contraception because it does not isolate the procreative capacity of either partner. The acceptability and effect of teaching fertility awareness on teen sexual activity and decision making was tested in a multisite pilot program which taught fertility awareness via the prospective marker of the cervical mucus (ovulation method of natural family planning). 200 US and 35 Guatemalan volunteer women ages 15-17 in a structured 1 year curriculum, monitored cycle charting and explored the implications of experiencing one's signs of fertility. Control subjects were recruited from the general population and from family planning clinics. 9% of the US study group were sexually active prior to entry. By cycle 12, 1/2 had discontinued activity. Conception rate was 0.0044. The continuation rate dropped from 90% at cycle 7 to 71% at cycle 8 due to scheduling constraints for 2 classes and to 57% at cycle 12. Postprogram follow-up of early leavers showed only 1/3 the expected rate of onset of sexual activity and pregnancy. Parent involvement correlated positively with postponement and/or discontinuation of sexual activity. Reported movement away from peer group pressure appeared 3 months after entry.

Adolescent↗

Development and pilot testing of a disease management program for low literacy patients with heart failure.

UNLABELLED: Development and pilot testing of a disease management program for low literacy patients with heart failure. BACKGROUND: Randomized trials have shown that disease management programs can reduce hospitalizations and improve symptoms for patients with congestive heart failure. We sought to create and pilot test such a program for patients with low literacy skills. METHODS: We used focus groups and individual cognitive response interviews (CRIs) to develop an educational booklet for low literacy patients with heart failure. We incorporated the booklet into a disease management intervention that also included an initial individualized 1-h educational session and scheduled supportive phone calls that were tapered over 6 weeks. We then conducted a 3-month before-after study on patients with low literacy skills (<9th grade literacy level) in a university internal medicine clinic to test the acceptability and efficacy of our program. Outcomes of interest included heart failure-related knowledge, self-care behavior and heart failure-related symptoms measured on the Minnesota Living with Heart Failure (MLwHF) scale. RESULTS: Twenty-five patients were enrolled and 23 (92%) completed 3-month follow-up. Mean age was 60 years (range 35-74), 60% were men, 60% were African-American, and 74% had household income under $15,000 per year. The median reading level was fifth grade with 32% reading at or below the third grade level. Mean knowledge score at baseline was 67% and did not improve after the intervention. The proportion of patients reporting weighing themselves daily increased from 32% at baseline to 100% at 12 weeks. Mean improvement on the MLwHF scale was 9.9 points over the 3-month trial (95% CI: 0.5, 19.2), which corresponds to an improvement in one class on the New York Heart Association heart failure scale. CONCLUSION: A heart failure disease management program designed specifically for patients with low literacy skills is acceptable and is associated with improvement in self-care behavior and heart failure related symptoms.

Adult↗

Arthritis self-management. A five-year history of a patient education program.

There are several lessons to be learned from the ASM experience. First, and most outstanding, is the willingness of large numbers of people across the United States to participate in both the ASM course and the research. Second, we have found that lay leaders can be trained to offer a rather complex arthritis course. They have proved to be reliable and, most important, are acceptable to the public and most health professionals. When their acceptance has been questioned, it is usually by persons with little or no experience with either the course or the lay leaders. Third, a national organization, in this case the Arthritis Foundation, has been able to disseminate the course widely and, to some extent, to conduct evaluations. From the national evaluation experience, we have learned that local areas are much more interested in service than evaluation and almost too readily accept an unproven yet hopeful arthritis education program. However, this acceptance of a new innovation before thorough testing is no different than that seen with other new medical technologies from medication to coronary bypass. Finally and most intriguing, we have found that such standard arthritis treatments as exercise and relaxation seem to directly contribute only slightly to the reductions in pain experienced by ASM participants. This unexpected lack of correlation has led us to begin studying other mediating factors such as self-efficacy, depression or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

The DANOP-DATA system: a low-cost personal computer based program for monitoring of wound infections in surgical ward.

A low-cost personal computer program to monitor surgical wound infections was developed in parallel to the Danish national guidelines for recording postoperative wound infections. Internationally accepted definitions were used. The program offers three fixed-data entry screens and produces user-specified variations of four standard tables, comprising most of the epidemiological data needed for surveillance and infection control. The program was tested in Danish hospitals and was found to serve well as a simple local tool for the operating staff, offering fast information on infection rates. Results from two hospitals consisting of 3904 operations are presented. Infections occurring after discharge were included. Overall infection rates for clean wounds were 2.3%, clean-contaminated wounds 4.7%, contaminated wounds 4.3% and dirty operations 8.3%. None of the hospitals had used infection surveillance systems before.

Denmark↗

The development of an educational collaborative to address comprehensive pressure ulcer prevention and treatment.

The prevention and treatment of pressure ulcers is a growing public policy concern. Driven by a more informed consumer and the exploding costs of care, policy makers are looking for ways to integrate health-care research and long-term care practices in an effort to improve the quality of care and ultimately reduce costs. This paper presents a case study that demonstrates how training is being integrated at the facility level, utilizing a collaborative. The collaborative was a joint public-private partnership supported through resources from state, federal, and private agencies, with an overarching goal of delivering high-quality, easily accessible geriatric education and training. Direct care providers and other practitioners were recruited to attend a live, interactive videoconference that featured nationally known experts. The content of the educational program was drawn from nationally accepted guidelines that discuss appropriate procedures for wound cleansing, dressings, positioning techniques, proper nutrition and risk assessment protocols. Evaluation of the program indicated that the highest-rated objectives related to the application of training content in the implementation of treatment and prevention procedures important to quality patient care. An examination of publicly available data revealed that an escalating increase in the percentage of facilities in the state cited for deficiencies because of the incidence of pressure ulcers from 1996 to 1999 was reversed in 2000, subsequent to the videoconference. Future programs are planned to sustain the availability of opportunities for practitioners to get critical updates from the experts in the field via live interactive sessions.

Analysis of Variance↗