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Exercise prescription when the guidelines do not work.

Because the current medical environment encourages a more conservative approach to resource use, "clinically unnecessary" exercise tests are being scrutinized and refused. This article's intent is not to debate the appropriateness of exercise tests for prescription purposes or suggest that programs should accept patients who have not been tested. These decisions are institutional specific. The intent is only to suggest an approach for those programs who feel it is safe and appropriate to accept patients who have not had an entry exercise test.

Exercise Test↗

PubMed1991

A comparison of craft use and academic preparation in craft modalities.

The purpose of this study was to compare the use of crafts in psychiatric occupational therapy practice with the actual craft-related training received by occupational therapy students. Two questionnaires were developed, one related to the crafts used in clinical practice, the other related to the amount and type of craft training received in educational programs. One thousand occupational therapists who work in psychiatry and 139 accredited and developing educational programs were asked to complete the questionnaire appropriate to their setting. The final analysis involved 121 educational programs (87% response rate) and 384 clinical programs (38% response rate). The results suggest that there may be substantial differences between craft-related training and actual clinical use of crafts. The findings imply that educational programs must reevaluate the types of crafts taught and the method by which they are integrated into the total curriculum. Implications for the profession include the need to clarify the role of crafts as a therapeutic modality and to reflect on the future direction of the profession.

Art Therapy↗

PubMed1981

Cardiac rehabilitation: evaluation and intervention less than 6 weeks after myocardial infarction.

Twenty-nine patients having myocardial infarction (MI) of recent origin (6 weeks or less) were evaluated and treated using a program in which assessment and progression were based not on generalized data but on the individual responses of each patient. Fourteen patients had complications including left ventricular impairment, continuing ischemia or rhythm disturbances, and 15 did not. Cardiac tolerance for the common self-care activities, walking and light exercise, was objectively defined by 3 levels of functional monitoring. The physician, occupational therapist and physical therapist evaluated the patient's responses to mild exertion, utilizing a 12-lead electrocardiogram (ecg), physical examination, 24-hour monitoring with a portable ecg, self-care evaluation and a modified treadmill screening test. Patient performance was assessed at each stage of testing and individualized activity levels were determined in accordance with cardiac responses. Thus patients progressed at their optimum rate with safety and without loss of time, ie, artificially induced invalidism. Following the 1st self-care evaluation, 3 patients were ordered to bedrest for further medical treatment while 26 were cleared for ward activity. When their conditions improved the 3 patients were reevaluated and began the program. The 15 patients without complications had appropriate responses to activity and proceeded to a mild exercise program with minimal observation. Of the 14 with complications, 5 experienced a temporary program interruption and 2 were dropped from the program secondary to severity of complications. The remaining 7 were progressed in the same manner as those without complication.

Adult↗

PubMed2003

Appropriateness of cholesterol and triglycerides reporting checked by External Quality Assessment programs.

BACKGROUND: The recommendations of the Second Joint Task Force of European and Other Societies on Coronary Prevention and the third Adult Treatment Panel report (ATPIII) released by the National Cholesterol Education Program are based on accumulating evidence concerning the contribution of lipoproteins and other risk factors in the development of coronary heart disease (CHD). The laboratories play an important role in the successful adoption of these guidelines. METHODS: In External Quality Assessment (EQA) programs managed by the Center of Biomedical Research, results and respective reference intervals (RI) are sent as laboratory's medical form. We assessed how well the 200 participants to EQA scheme 2002 for clinical biochemistry reported total cholesterol (TC) and triglycerides (TGs) results according to either European or National Cholesterol Education Program (NCEP) guidelines. RESULTS: Only 18% of laboratories reported total cholesterol concentrations correctly in terms of desirable, borderline-high, and high risk for the CHD development, 12% reported a single desirable value (180, 190, or 200 mg/dl), and 70% reported the RI (85 laboratories in the whole interval, 34 are the only upper reference limit and 15 are the desirable value in addition to RI). The upper reference limit was 200 mg/dl in 65% of cases, but 32% of laboratories presented higher limits, reaching values as high as 250-260 mg/dl. Only the 3.7% of laboratories reported triglyceride concentrations in terms of risk-oriented ranges for the CHD development, 6.8% the single desirable value, and 89.5% the RI. CONCLUSION: Our study demonstrates that the current practice of reporting results for cholesterol and triglycerides does not follow the guidelines, and appropriate changes are required to be made.

Cholesterol↗

PubMed2001

Applying scientific criteria to therapeutic interchange: a balanced analysis of low-molecular-weight heparins.

Under pressure to provide cost-effective healthcare, many healthcare systems have adopted Therapeutic Interchange (TI) programs-the interchange of therapeutically equivalent but chemically unique drugs-to reduce the total cost of therapy without compromising patient care. To be appropriate and feasible, a TI program for any class of drugs must meet certain rigorous criteria and undergo medical, financial, tactical, and legal reviews. Moreover, once a TI program is implemented, a process to monitor its success should be established. Application of the TI criteria to low-molecular-weight heparins (LMWHs) reveals that a blanket TI program for LMWHs does not appear advisable at this time.

Anticoagulants↗

PubMed1999

Computer support for recording and interpreting family histories of breast and ovarian cancer in primary care (RAGs): qualitative evaluation with simulated patients.

OBJECTIVES: To explore general practitioners' attitudes towards and use of a computer program for assessing genetic risk of cancer in primary care. DESIGN: Qualitative analysis of semistructured interviews and video recordings of simulated consultations. PARTICIPANTS: Purposive sample of 15 general practitioners covering a range of computer literacy, interest in genetics, age, and sex. INTERVENTIONS: Each doctor used the program in two consultations in which an actor played a woman concerned about her family history of cancer. Consultations were videotaped and followed by interviews with the video as a prompt to questioning. MAIN OUTCOME MESURESs: Use of computer program in the Consultation. RESULTS: The program was viewed as an appropriate application of information technology because of the complexity of cancer genetics and a sense of "guideline chaos" in primary care. Doctors found the program easy to use, but it often affected their control of the consultation. They needed to balance their desire to share the computer screen with the patient, driven by their concerns about the effect of the computer on doctor-patient communication, against the risk of premature disclosure of bad news. CONCLUSIONS: This computer program could provide the necessary support to assist assessment of genetic risk of cancer in primary care. The potential impact of computer software on the consultation should not be underestimated. This study highlights the need for careful evaluation when developing medical information systems.

Adult↗

PubMed1989

State family support and education programs: lessons from the pioneers.

More state governments are developing publicly supported preventive programs to strengthen families. This article describes the forces driving these initiatives, which in turn are redefining ideas about when public involvement with families is appropriate. It discusses four state programs and outlines the choices and issues policy makers faced in formulating and implementing them.

Child↗

PubMed2006

Developing research capacity building for Aboriginal & Torres Strait Islander health workers in health service settings.

INTRODUCTION: Aboriginal and Torres Strait Islander health workers (hereafter called health workers) can play a major role in facilitating culturally appropriate health care delivery and program development through the acquisition of improved skills in the planning, monitoring and evaluation of these programs (RCB). However, many Aboriginal and Torres Strait Islander people and communities remain concerned about research and related activities. Health workers are well placed to assist communities to not only embrace research, but to be active players and promoters of relevant, appropriate and acceptable research. One means of achieving the twin goals of RCB and community acceptance and involvement in research, is through health workers undertaking research of health priority issues and evaluation of activities, such as program delivery, that are of direct relevance to their community's aim of improving or enhancing service delivery. This article outlines the development and content of a community-based RCB framework for health workers. The focus is on the major issues that enhance a proactive service delivery model using culturally appropriate research methods. Development process: The RCB framework described here was developed, over a period of time, through community workshops and consultations aimed at deriving general consensus on the key issues and components of a culturally-appropriate, community-based training process. The framework has subsequently been reviewed by Aboriginal and Torres Strait Islander community representatives from across Australia. The overall aim of the framework is to supplement current (institutionally-based) education and training resources for health workers with community-based research training modules. These modules can be tailored to provide research and evaluation skills relevant to health workers taking a more proactive role in facilitating health and wellbeing programs in their own communities. The use of collaborative consultation and participatory methods are intended to be a two-way education process. Course content: A visual pathway is used that encompasses the impact of health and practice in the community for health workers at a grass-roots level. This enables elements of the RCB process to be divided into a series of connected modules. These are: (i 'assessing' Existing Services; (ii) methods and measures for Identifying Need at various levels; (iii) important issues in Program Development; (iv) how the former contributes to Service Improvement; (v) resultant Outcomes that will impact on community and service provision; and (vi) Evaluation Methods and applying findings to service delivery. CONCLUSIONS: Active participation by the Aboriginal and Torres Strait Islander community is fundamental for effective research practices and outcomes. The aim is to provide health workers and community members with a working knowledge of research ethics and methods so that they can assist, monitor and steer the development of culturally appropriate research activities that will lead to provision of the highest quality services 'back' to the community. This RCB framework will enable health workers to be more proactive, self-reliant and self-sufficient within their community and healthcare settings.

Community Health Planning↗

PubMed1994

Neuropsychological impairment in children with sickle cell anemia and cerebrovascular accidents.

Neuropsychological functioning of children with sickle cell anemia (HbSS) who have experienced a single stroke has not been extensively investigated. In this study, the neuropsychological functioning of 10 children with HbSS who were receiving transfusion therapy following stroke with no identifiable recurrence was examined. The patients were subgrouped into children with only left hemisphere stroke (LCI), N = 4, and those with only right hemisphere stroke (RCI), N = 6. Results indicated that these youngsters experienced significant impairments of cognitive functioning following stroke. It was found that the LCI and RCI children tended to perform more like adult stroke patients than what has been typically reported in children with infantile hemiplegia. These findings support the need for periodic neuropsychological evaluation following stroke in order to identify patterns of higher cortical dysfunction and assist in the development of appropriate rehabilitation and special education programs. Further, pediatricians, child neurologists, and psychologists who care for these children must act as strong advocates on their behalf in order to ensure that they receive appropriate rehabilitation and the special education services necessary for maximal recovery and future educational success.

Adolescent↗

PubMed2026

Handle with care: packaging the oocyte epigenome for the next generation.

During oocyte growth, substantial epigenetic programming occurs to establish a distinctive epigenome including appropriately patterned DNA methylation and histone modifications. Oocyte epigenetic programming must be tightly spatiotemporally regulated to ensure that a wide variety of epigenetic modifiers correctly establish their respective modifications to mediate precise control of gene expression. Furthermore, epigenetic modifications in oocytes include canonical and non-canonical genomic imprints, which are transmitted through meiosis to offspring. Significantly, disruptions in oocyte epigenetic programming can cause aberrant developmental outcomes in the next generation mediated by altered imprinting. Polycomb repressive complex 2 is an important epigenetic modifier that establishes histone 3 lysine 27 trimethylation and non-canonical imprints during mouse oogenesis, which are important for normal offspring development. While it is widely recognised that altered oocyte epigenetic programming can disrupt offspring development, mechanisms controlling maternal epigenetic inheritance remain poorly understood. The possibility remains that non-canonical imprinting exists in humans, although this requires confirmation. This review discusses mouse and human oocyte epigenetic programming including interactions between various epigenetic modifiers and modifications that form the unique oocyte epigenome. Understanding how oocyte epigenetic programming is regulated will be crucial in discerning how changes to the oocyte epigenome can disrupt epigenetic memory and alter developmental outcomes in offspring.

Animals↗

PubMed2005

Effectiveness of a clinical ladder program.

A 5-hospital system shares results of the evaluation of a clinical ladder program. Improvements were noted in overall satisfaction with the program, nurse retention of those who participated in the program, and costs savings due to decreased turnover. The authors point out the importance of evaluating the effectiveness of advancement programs for nurses. The analysis of a clinical ladder program in relation to costs, financial impact, and benefits helps to justify the salary increments for the ladder programs. This article provides the nurse executive with appropriate justification and outcome data to effectively champion these programs.

Career Mobility↗

PubMed1993

Antimicrobial strategies in the care of organ transplant recipients.

Since the early days of transplantation, infection has been a major consequence of antirejection immunosuppressive therapy. Increasingly effective prophylactic and preemptive strategies are being developed to prevent the infectious consequences of immunosuppressive therapy. Although the data base is incomplete and there remains a compelling need for well-designed, randomized, comparative trials, the potential for controlling life-threatening viral, bacterial, fungal, and protozoal infections exists. The cornerstone of this effort is the recognition that effective immunosuppressive strategies require an antimicrobial program to make them safe and that such an antimicrobial program needs to be individualized in order to be appropriately matched with the needs of the antirejection program. Thus, escalation and de-escalation of the antimicrobial program should be carried out to match the immunosuppressive program. Infection and rejection remain closely intertwined, linked by the immunosuppressive program that is prescribed.

Anti-Infective Agents↗

PubMed1984

Personal characteristics of health professionals: can they be changed by an educational program?

The objectives of many graduate programs in the health sciences include the development of various personal characteristics, attitudes, and beliefs. A study was carried out to assess whether personal characteristics of graduate students could be affected by program participation and, if so, which specific personal characteristics could be changed. Three attitude tests were administered to three consecutive classes of mature health professionals, using a repetitive pre-post design. Results showed no difference from pre- to posttesting on the California Personality Inventory; a positive difference on one main scale and two subscales of the Personal Orientation Inventory (inner directedness, flexibility in application of values, and self-acceptance); and a negative difference on the Health Professional Survey (attitude toward working in teams). These findings suggest that many personal characteristics deemed important by program planners in the health sciences may more appropriately be criteria for admission than objectives of the program.

Adult↗

PubMed1993

Dietary intervention and chemoprevention--1992 perspective.

BACKGROUND: Diet, including excess or scarcity of specific foods and nutrients, is important in the etiology of 30-60% of a variety of cancers. Dietary changes may favorably affect cancer risk and incidence. This overview summarizes recommended dietary changes and their nutritional implications and considers the problems of selecting and implementing such a program and identifying and targeting appropriate populations and subjects. RESULTS: Dietary changes that decrease the intake of fat and pickled/smoked foods, limit calorie intake and alcohol consumption, and increase the intake of fiber, fruits, and vegetables should help to decrease risk for cancers of the breast, colon, oral cavity, upper gastrointestinal tract, lung, and cervix. Micronutrients to increase include vitamins C, E, A, beta-carotene and other carotenoids, and folic acid. The diet should contain a variety of yellow-orange fruits and vegetables, green leafy and cruciferous vegetables, legumes, whole grains, low-fat dairy products, and lean meats, fish, and poultry. This diet must be adequate in proteins and minerals, palatable, affordable, and add to the quality of life. It is important that we target appropriate subjects and populations, modify foods, and design and fund research studies in areas of nutrient availability and metabolism and the biologic mechanisms of nutritional chemoprevention. CONCLUSION: A program of nutritional intervention by sound dietary changes that is effective, safe, and acceptable in chemoprevention should be the cornerstone of a cancer prevention strategy starting now. Directions for future research are discussed.

Anticarcinogenic Agents↗

PubMed1998

Hospital-wide educational program decreases red blood cell transfusions.

BACKGROUND: Because of the numerous risks associated with the use of packed red blood cells (RBCs), it is critical that they be transfused only when appropriate. A hospital-wide educational program was developed in an attempt to improve the transfusion practices and provide a framework for blood bank audit at a Veterans Affairs teaching hospital. MATERIALS AND METHODS: The program required physicians to fill out an information sheet that listed appropriate criteria for transfusion. Charts were reviewed to determine if the transfusion met these criteria. If the transfusion was deemed inappropriate by peer review, the staff physician was notified by letter. The information sheet was used on a voluntary basis without chart review in 1989 and on a mandatory basis beginning in 1990. Transfusion rates and mortality were adjusted to patient days of hospitalization and evaluated using chi 2 analysis. RESULTS: While voluntary use did not affect transfusion rate, mandatory implementation resulted in a 26% decline (P < 0.001) between 1989 and 1990 in the number of RBC units transfused per patient days of hospitalization. A diminished use of RBCs persisted in the subsequent years. There was no increase in mortality during this time to suggest a detrimental effect from the decrease in RBC transfusion. No apparent variation in the hospital population could account for the changes. CONCLUSION: Use of a unique and simple transfusion request sheet as an educational tool resulted in improved transfusion practices at a Veteran Affairs teaching hospital.

Blood Grouping and Crossmatching↗

PubMed1996

Quality of care at school-aged child-care programs: regulatable features, observed experiences, child perspectives, and parent perspectives.

This study investigates children's experiences at 30 school-aged child-care (SACC) programs. Regulatable features such as total enrollment, child-staff ratio, and staff education were assessed via director report. Observers recorded positive/neutral and negative staff-child interactions, and rated programs in terms of flexibility and age appropriateness. Negative staff-child interactions were more frequent when child-staff ratios were larger and when staff had less formal education. The presence of a greater number of different types of program activities was associated with staff having more frequent positive interactions with children and with observers rating programs as flexible and age appropriate. These regulatable and observed features were examined in relation to children's (N = 180) and parents' (N = 152) perceptions of program psychosocial climate. Children's reports of overall climate, emotional support from staff, and autonomy/privacy provisions were predicted by program features. Children reported poorer program climate when programs had larger enrollments and when observers recorded more frequent negative staff-child interactions. Children had more positive program perceptions when programs offered a greater variety of activities. Children's reports of program climate in addition to observed child-staff ratios were associated with parental perceptions of the programs. Parents had more positive perceptions when child-adult ratios were smaller and when their children reported more positive climates. This study suggests a convergence between observer, child, and parent about factors contributing to quality of after-school programs.

Attitude↗

PubMed1983

Utilization analysis of a pedestrian safety training program.

A previously developed and analyzed pedestrian safety training program was used to teach appropriate street-crossing behaviors to kindergarteners and first graders. Adult crossing guards were trained to provide pedestrian safety instruction. Trained observers monitored the quality of instructions given by crossing guards and the pedestrian behavior of young children as they crossed the street. A multiple-baseline analysis of the effects of two training programs indicated that guards were able to deliver the pedestrian safety program to several groups of children with a high degree of competence after receiving a single videotape and role playing training session. Furthermore, children's level of appropriate street crossing increased contemporaneous to the change in guard behavior both on the street where training was delivered and on a second street where no training was previously delivered. Utilization analysis of the guard training program indicated that one cannot expect to produce consistently high levels of street-crossing behavior by implementing only the "show and tell" portions of the training package. Similarly, results suggested that one is unlikely to produce consistently high quality guard training behavior by only giving written instructions describing how pedestrian training should be administered.

Journal Article↗

PubMed1988

Targeting the hospitalized elderly for geriatric consultation.

This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve-hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered "too independent" to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged "too impaired" to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged "too independent." These data suggest that a large majority of the hospitalized elderly may be too well to benefit from geriatric consultation, thus making targeting by age alone inefficient. A realistic estimate of the percentage of hospitalized patients appropriate for geriatric intervention lies somewhere between 18% (the combined percentage of those found appropriate and those already enrolled in geriatric programs) and 24% (the proportion of the clinically evaluated group found appropriate). Targeting of subjects may be accomplished inexpensively using the authors' explicit criteria. Such targeting may help focus the use of interdisciplinary geriatric expertise on those most in need.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗