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[Assessment and improvement of the quality of nursing documentation].

The article proposes a method to verify and to improve the quality and the effectiveness of the working tools. Inside those, Authors believe essential to run out paths for revision and development of quality including projects for the evaluation and the improvement of nursing documentation considering it as an essential start to continuously modify and improve nursing care practically. The article introduces a possible example of intervention with the aim to produce, inside the professional community, a constant awareness on quality outcomes of our caring for the benefit and improvement of the quality of life of our clients.

Documentation↗

Implementing telemedicine technology: lessons from India.

Information and communications technologies have universally helped to bridge the digital divide. As an application of ICT, telemedicine is an efficient pathway for enabling health care delivery. Developing countries, too, have started reaping the benefits of this evolutionary technology, but realisation of such dreams has not been swift. The implementation of a pilot scheme in telemedicine in India has been confounded with challenges right from the very start. One of the prime lessons to be learnt from the implementation of a pilot project in a developing country is to keep the objectives of the project in small modules and to keep the deliverables within sight. An account of some of the challenges faced while developing telemedicine technology in India serves as a useful example for upcoming telemedicine programmes in Third World countries.

Benchmarking↗

[External quality assessment with reference to the certification/accreditation of medical laboratories].

Since ISO 15189 (Medical Laboratories-Particular requirements for quality and competence) was published in February 2003, interest in the accreditation of medical laboratories has increased in Japan. Under such conditions, the JCCLS (Japanese Committee for Clinical Laboratory Standards) and the JAB (Japan Accreditation Board for Conformity Assessment) are promoting a project on an accreditation program for medical laboratories in Japan. The JAB is planning to start their pilot inspections from October, 2004. In this paper, an external quality assessment scheme in Japan on proficiency testing for the accreditation of clinical laboratories is described.

Accreditation↗

Magnetic Resonance angiography of the pulmonary veins before and after radiofrequency ablation for atrial fibrillation.

PURPOSE: To study the usefulness of magnetic resonance angiography (MRA) in imaging of the pulmonary veins (PV) before and after radiofrequency ablation procedures in patients with atrial fibrillation. MATERIALS AND METHODS: Between July 2002 and April 2003, 50 patients with atrial fibrillation underwent MRA prior to ablation; 18 patients also underwent post-procedure MRA. Images were acquired with 3D-spoiled gradient echo sequences after intravenous administration of the paramagnetic contrast medium gadopentetate dimeglumine; an automatic triggering device was used to start the angiographic sequence (Smartprep, General Electric Medical Systems). Postprocessing was performed with maximum intensity projection (MIP) and virtual endoscopy (VE) software (Navigator, GEMS). RESULTS: The venoatrial junction was visualised with MRA VE in 49 of 50 patients (98.0%). Twenty-seven patients out of 49 (55.1%) had two PV ostia on both sides, 13 (26.5%) had two right ostia and a single common left ostium, 5 (10.2%) had supernumerary PV and 4 (8.2%) had both a supernumerary right PV and a single common left ostium. Flythrough navigation showed the number and spatial arrangement of second-order PV branches in 48 out of 49 patients (98.0%). In postablation examinations, mild stenosis was detected with MIP and VE in 17 out of 83 PV examined (20.5%). CONCLUSIONS: This study confirms the clinical value of magnetic resonance imaging for visualising PV ostia in patients undergoing radiofrequency ablation for atrial fibrillation. Before the ablation procedure, MRA allows an accurate evaluation of PV number, shape and size; after the procedure, MRA is useful in screening for post-ablation stenosis and describing the location and severity of stenosis when present.

Journal Article↗

[Renal toxicity in HIV-infected patients receiving HAART including tenofovir].

HIV-infected patients may undergo renal damage related to the HIV infection itself, to the presence of co-infections, arterial hypertension, diabetes or to the exposure to nephrotoxic drugs. Tenofovir has been associated with the development of acute renal failure with Fanconi syndrome and acute tubular necrosis and, albeit rarely, with chronic liver disease. Patients with low CD4 cell count, low body weight and with concomitant diseases such as arterial hypertension and diabetes or co-infections with HCV, HBV or Treponema pallidum seem at higher risk of tenofovir-related nephrotoxicity. Other risk factors include previous exposure to nephrotoxic drugs and the association of tenofovir with boosted protease inhibitors or with didanosine. However, from the analysis of published papers the incidence of tenofovir-related renal toxicity seems low, as confirmed also by our personal casuistry (SCOLTA Project). Thus, a careful selection of patients including the evaluation of existent renal disease before starting an antiretroviral regimen including tenofovir is necessary to prevent renal damage. Furthermore, frequent monitoring of renal function in patients at higher risk of renal damage is strongly recommended, as well as a tenofovir dose adjustment if an alteration of renal function is detected.

Adenine↗

The National Schistosomiasis Control Programme in Mali, objectives, organization, results.

Schistosomiasis control started regionally, in the Bandiagara district, and as a component of a dam-building project in 1978. In 1982 a national programme was created. Control was divided into three phases: Preparation, intervention and maintenance. Districts qualifyed for schistosomiasis control activities, when the prevalence for either Schistosoma haematobium or Schistosoma mansoni exceeded 20% and/or the prevalence of persons with intensive infections for either parasite exceeded 5%. Intensive infection was defined as the excretion of more than 50 eggs per 10 ml of urine or the excretion of more than 100 eggs per one gram of stool. Preparation consisted of sample surveys to identify districts that needed to be included in control operations and the training of local health personnel. Interventions were primarily mass chemotherapy, using a single dose of praziquantel (40 mg/kg), sanitation and health education. The application was still being investigated for its cost benefit. Maintenance was to be achieved through the treatment of cases at fixed centres of the basic health services. Until 1987, control activities were carried out almost entirely through a central team based in the Institut National de Recherche en Santé Publique at Bamako in a vertical fashion. The full integration into the basic health services was retarded due to the drought and famine of the years 1983 to 1985 and other factors. The programme had been active in 136 villages located in the district of Bandiagara, the Office du Niger irrigation area, the Haute Vallée Baguineda irrigation area and the Sélingué dam zone.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

[Left ventricular wall motion. A comparison of six evaluation methods (author's transl)].

LV wall motion from monoplan, RAO projected LV angiograms is one of the most important parameters for LV function studies. Different methods to describe wall motion are reported in the lit., including procedures to correct distortions from x-ray techniques. With physiological contraction patterns as the basis a method is described, in which systolic contraction is performed radially with its center being the mean point of the diastolic long axis of the projected LV area. Wall motion was measured at 20 degrees distances circular around mean point, starting from the aorta. The mean deviation of the systolic long axis frm diastolic one was 8.5 degrees. This angle was corrected. The comparison of this procedure with six other methods reported in the lit. shows, that there are differences in wall motion up to 100%, depending on the model used. We conclude, that a standardized procedure to measure wall motion is necessary, which is described here.

Adult↗

Research in action: the training approach of the Joint Health Systems Research Project for the Southern African Region.

Over the last two decades, capacity-building in health research has been recognized as a priority by the international research community. Since 1987 the Joint Health Systems Research (HSR) Project for the Southern African Region has been making efforts to increase the national expertise for operational health research, starting in ten Southern African countries, in order to strengthen decision-making in health care at all levels. Initially, its targets were health managers and public health staff. Step-by-step, staff of different levels and disciplines have, in small groups, developed and implemented research protocols on problems experienced in their own working environment. The recommendations resulting from over 200 studies could, to a large extent, be implemented by the teams themselves. The Project was characterized by a flexible approach, allowing countries to participate at their own speed and to determine their own activities and the support they needed. As Ministries of Health as well as research institutions, in an increasing number of Southern and Eastern African countries, choose to actively participate in HSR, this has contributed to bridge the gap between the academic world and the health field. Still, sustainability of HSR activities remains a challenge. This paper describes the approach of the Joint HSR Project over the first 10 years of its operation, and its major strengths and limitations.

Africa, Southern↗

The rice genome project in Japan.

Since 1991, the Rice Genome Research Program in Japan has carried out rice genomics, such as large-scale cDNA analysis, construction of a fine-scale restriction fragment length polymorphism map, and physical mapping of the rice genome with yeast artificial chromosome clones. These studies have made a great impact on research into grass genomes and made rice a model plant for other cereal crop research. Starting in 1998, the Rice Genome Research Program will step into a new stage of genomics-that of genome sequencing. This project eventually should reveal all of the genomic sequence information in the rice plant and be an indispensable aid in understanding the genomics of other grass species.

Journal Article↗

Changes resulting from increasing appointment length: practical and theoretical issues.

The experience of one urban teaching practice in changing its appointment length from 7.5 to 10.0 minutes is described. Observed benefits to patients attending routine surgeries included an increased consultation time (mean 8.6 minutes before, 9.1 minutes after) and reduced waiting time (mean 19.1 minutes compared with 14.6 minutes). Overall, workload was unchanged but improving the 'fit' between supply and demand was associated with loss of flexibility--a greater number of extra patients required to be seen, apparently because fewer appointments were available at the start of each day. Waiting and consultation times in teaching surgeries and trainee surgeries (booked throughout at 10.0 minute intervals) were unchanged in response to the new arrangements. The changes introduced were well received by medical and reception staff although their response was not formally measured. Planning the organization of an appointment system requires several distinct decisions to be made. The preferred or actual average length of consultations has to be decided and booking arrangements designed to enable this to take place without the doctors persistently running over time. The number of appointments per week required to meet anticipated demand has to be calculated on the basis of list size and expected annual consultation rate. However, an exact fit between supply and demand will lead to congestion of the system and it appears that flexibility in the form of an overprovision of appointments to projected demand of about 120% should be built in. Sufficient vacant slots must be provided at the start of each day to allow sufficient flexibility to avoid excessive numbers of patients having to be accommodated.(ABSTRACT TRUNCATED AT 250 WORDS)

Appointments and Schedules↗

Implementing shared governance: a false start.

A case study of the implementation of shared governance in a large teaching hospital in Western Canada has been presented. The project was placed in jeopardy due to two major contingencies: turnover in the chief nursing executive position, and a sudden reduction in the operating budget of the nursing division necessitating significant layoffs. Other factors that threatened the survival of shared governance included lack of systematic, long-range planning; the number and diversity of major changes introduced concurrently in the nursing division; and insufficient support systems to sustain organizational change. In particular, some senior and first-line managers could not adapt to or accept the radical philosophical change and so they were unable to empower their staff and to provide the necessary reinforcement needed to ensure the success of shared governance. This combination of these factors contributed to the loss of momentum in the implementation of shared governance. Lowered morale in the wake of layoffs, together with union grievances, and lack of clarity of the role to be played by union representatives in shared governance produced conflict and confrontation within the nursing division and between union and management. Despite the difficulties encountered, there remains optimism and commitment to the challenge of making shared governance succeed. As this article goes to press, remarkable strides have been made in addressing the described issues. A task force composed primarily of staff nurses has developed a "customized" model of governance that meets the needs of the hospital and deals with the identified flaws of the first implementation attempt. The organization is optimistic that by taking time to develop a solid foundation for the proposed change and tending carefully to the details of decision-making processes, an effective structure to support the professional role of the nursing staff will be a reality.

Attitude of Health Personnel↗

"Short stops": peer support of scholarly activity.

OBJECTIVES: Clinical and administrative responsibilities limit time for faculty to pursue scholarly activities. Scholarly work is, for most, difficult to accomplish in isolation. Yet organized opportunities for faculty interaction toward this goal are often lacking. To support one another in scholarly pursuits, three faculty members met in small groups every four to six weeks for about an hour. These "short stops" within hectic clinical and teaching schedules were brief, at intervals long enough to accomplish individual work, feasible in most faculty schedules, and based on the expectation that participants would prepare for the sessions and ask for specific input from the other participants. DESCRIPTION: Involvement as a fellow in the Ambulatory Pediatrics Association's Faculty Development Scholars Program illustrated the benefit of peer support and encouragement in embarking upon and making a commitment to clinical and educational research. In an effort to create such an environment, the author invited two pediatrics faculty members involved in student and resident education to meet every four to six weeks for about an hour with several goals in mind: (1) to define research questions based on clinical and educational work, (2) to brainstorm solutions for research barriers, (3) to interpret already-collected data, (4) to help each other meet deadlines, (5) to read and edit each other's work, and (6) to provide encouragement to fit this work into short stretches of time in busy schedules. Participants came to meetings prepared to present specific aspects of their work and to ask for specific input. Each meeting ended with the participants' setting personal goals for the next meeting. Frequent communication by e-mail and phone between meetings maintained the momentum. This continuity optimized the benefit of the short meetings. DISCUSSION: Within a year of implementing "short stops," there was an increase in new projects, submissions of abstracts to national meetings, presentations at national meetings, and submissions to journals. Although it cannot be shown that this was a direct result of "short stops," the three participants believe they are related. It appears that this format is optimal to promote active participation, sustain interest, and make use of mutual expectations to keep work on target. An unanticipated, but probably related, change was an increase in mentoring of residents' research projects by the program participants. As a result of our belief that the "short stops" method was successful in our small group, we went on to apply it in our 12-member division of general pediatrics. Twice-monthly breakfast or lunchtime meetings led by the author and another faculty member allow interested division members to attend depending on availability. Although this new process is in its early stages, half of the division members have already attended meetings. Just two months after starting the new group, each faculty participant has made a commitment to a next step toward a completed scholarly project.

Communication↗

Intensive short-term research training for undergraduate, graduate, and medical students: early experience with a new national-level approach in geriatric mental health.

OBJECTIVE: There is an urgent need for research training in psychiatry at early career stages, especially in geriatric psychiatry. The authors describe their first-year experience with the Summer Training in Aging Research Topics-in Mental Health (START-MH), a new federally funded national-level training program intended to offer intensive short-term research training for undergraduate, graduate, and medical students. METHODS: The funding was used primarily to pay stipends for trainees who spent 10 weeks during the Summer working on research projects under established research mentors. At the end, a workshop brought together all the trainees who presented research posters. RESULTS: Thirty trainees were selected from among 85 applicants. They worked on projects including basic, translational, clinical, or services research. Evaluations from trainees and mentors were uniformly positive. All the trainees reported that the START-MH program enhanced their interest in pursuing a career in geriatric mental health research. Several trainees later submitted their work for presentation or publication. CONCLUSIONS: The initial data suggest that the START-MH program can be a potentially useful model for attracting talented early-career trainees into mental health research.

Aging↗

Problems and solutions with the design and execution of an epidemiological study of white spot disease in black tiger shrimp (Penaeus monodon) in Vietnam.

White spot disease (WSD) is caused by white spot syndrome virus (WSSV) and is an acutely fatal pandemic disease of crustaceans. It has resulted in massive losses to the shrimp-farming industry in Asia and has now spread to the Americas. This paper reports the problems and solutions associated with the design and execution of a longitudinal epidemiological study of shrimp (Penaeus monodon) health on farms practising a crop rotation of rice and shrimp in the Mekong Delta of Vietnam. The pre-sampling phase of the project involved selecting an appropriate site and sampling variables, obtaining permission and establishing the necessary laboratory and logistic facilities. At the start of the sampling phase, 40 farmers were selected and 32 of these were visited and interviewed. This resulted in the enrolment of only 17 farmers. A further seven had to be enrolled to obtain the maximum number of farmers that could be sampled by the study team. Compliance was enhanced through meetings, regular visits by senior members of the project team and ensuring that visits were punctual and that all information was treated confidentially. The production cycle began in January 1998 and lasted for approximately 5 months. An attempt was made to collect 500 post larvae (PL) before each pond was stocked to assess the health of the batch and to test for the presence of WSSV by one-step PCR. After stocking, the wild crustaceans also were sampled from the pond for PCR analyses. Information was collected on the management practices and samples of water, pond bottom, feed and shrimp collected throughout the production cycle. Water quality variables with predictable diurnal variation were sampled in the morning and afternoon, twice a week. Two months after stocking, the first outbreak of WSD occurred; subsequently, 18 farms conducted a complete emergency harvest due to the actual or perceived presence of a WSD outbreak. Detectable mortalities were reported from 19 farms, and moribund shrimps were collected from four of these for PCR and histological analyses.

Animals↗

Auditory pathways to the cortex in Tupaia glis.

The auditory system of the tree shrew, Tupaia glis, was investigated by identifying axonal degeneration after lesions of the lateral lemniscus, the inferior colliculus, the medial geniculate nucleus and the auditory cortex. The results show that the lateral lemniscus projects to the central nucleus of the inferior colliculus which in turn projects principally to the ventral division of the medial geniculate nucleus but to a lesser extent to the magnocellular division of the medial geniculate nucleus. The final step in the pathway to the cortex is achieved by a projection from the ventral division to the fourth layer of auditory koniocortex. There appear to be several auditory pathways parallel to this primary path. The lateral lemniscus projects to the dorsal division of the medial geniculate nucleus; the deeper layers of the superior colliculus project to the posterior nucleus; and both the dorsal division and the posterior nucleus project to the belt caudal to auditory koniocortex. The caudal division of the medial geniculate nucleus may constitute a relay in still another path from the pericentral division of the inferior colliculus. Finally, the magnocellular division also appears to be distinct insofar as its cortical projections are confined chiefly to the deeper layers. A comparison between the tree shrew and the cat reveals a similar organization in the two species. In the cat the starting point for understanding the organization of the several auditory pathways is the distinction between a core cortical zone which corresponds to konicortex and to AI and a peripheral belt. The core receives essential projections from the ventral division; the belt receives sustaining projections from the cell groups which surround the ventral division. It is reasonable to hypothesize that this difference between the core and the belt is characteristic of all mammals.

Animals↗

Topographic spinocerebellar mossy fiber projections are maintained in the lurcher mutant.

A variety of recent studies of cerebellar development have focused attention on the role of Purkinje cells as organizing elements for the topography of afferent fiber connectivity in the cerebellum. We have investigated the involvement of Purkinje and granule cells in the maintenance of topographic spinocerebellar mossy fiber projections by analyzing the distribution of spinocerebellar mossy fiber terminals in lurcher (+/Lc) mutant mice. Purkinje cells in the +/Lc mutant degenerate starting after the first week of postnatal development because of an intrinsic genetic defect. The loss of their Purkinje cell targets also results in the death of 90% of the granule cells. We examined the distribution of spinocerebellar mossy fiber terminals in the juvenile and adult +/Lc mutant to determine how the pattern of afferent projections is affected by the loss of Purkinje cells shortly after innervation of the cerebellum. Labeling of spinocerebellar mossy fiber terminals with WGA-HRP in the P38 and adult +/Lc mutant showed that, despite the loss of almost all Purkinje cells and 90% of the granule cells, spinocerebellar mossy fibers project to the appropriate folia and segregate into relatively normal parasagittal bands. While we cannot rule out the possibility that Purkinje cells may be involved in the initial establishment of topographic maps, our results indicate that Purkinje cells are not necessary for the maintenance of the normal spinocerebellar mossy fiber topographic map.

Animals↗