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PubMed1998

Recruitment to a school-based adult smoking-cessation program: do gender and race/ethnicity make a difference?

BACKGROUND: Recruitment to interventional research, clinical trials, and community-based health programs remains a central public health challenge, particularly among low-income and multi-ethnic populations. Utilizing existing community institutions and "opportunistic" communication channels within these settings for recruitment seems an optimal strategy for overcoming barriers to participation. However, such institutions frequently serve heterogeneous populations, and little is known regarding intra-community variations in program uptake. METHODS: This paper reports the gender and race/ethnic differences in subject characteristics and enrollment patterns among 435 Latino and African American participants in a smoking-cessation program delivered through one such community institution, an inner-city school district in Los Angeles County. RESULTS: Enrollees were more likely to be female and Latino. Recruitment strategies tailored specifically to this program were more effective then recruitment through channels such as regular school activities, particularly among African Americans. CONCLUSIONS: Intragroup variations need to be carefully considered in the design and implementation of such programs if they are to receive acceptance and to succeed.

Adult↗
PubMed2002

Operator-free, film-based 3D seed reconstruction in brachytherapy.

In brachytherapy implants, the accuracy of dose calculation depends on the ability to localize radioactive sources correctly. If performed manually using planar images, this is a time-consuming and often error-prone process-primarily because each seed must be identified on (at least) two films. In principle, three films should allow automatic seed identification and position reconstruction; however, practical implementation of the numerous algorithms proposed so far appears to have only limited reliability. The motivation behind this work is to create a fast and reliable system for real-time implant evaluation using digital planar images obtained from radiotherapy simulators, or mobile x-ray/fluoroscopy systems. We have developed algorithms and code for 3D seed coordinate reconstruction. The input consists of projections of seed positions in each of three isocentric images taken at arbitrary angles. The method proposed here consists of a set of heuristic rules (in a sense, a learning algorithm) that attempts to minimize seed misclassifications. In the clinic, this means that the system must be impervious to errors resulting from patient motion as well as from finite tolerances accepted in equipment settings. The software program was tested with simulated data, a pelvic phantom and patient data. One hundred and twenty permanent prostate implants were examined (105 125I and 15 103Pd) with the number of seeds ranging from 35 to 138 (average 79). The mean distance between actual and reconstructed seed positions is in the range 0.03-0.11 cm. On a Pentium III computer at 600 MHz the reconstruction process takes 10-30 s. The total number of seeds is independently validated. The process is robust and able to account for errors introduced in the clinic.

Algorithms↗
PubMed1977

Evaluation of clinical skills for a specialty board during residency training.

Since 1971 the directors of residency training programs in internal medicine have had the responsibility for evaluating the clinical skills of their trainees for the American Board of Internal Medicine. Satisfactory performance is required by the board as a qualification for admission to its written certifying examination. This report presents the board's experience with the evaluation of clinical skills through June 1975 based on visits with the administrators of 166 residency training programs. Described are the evaluative methods employed by the programs, the delineation and observation of acceptable minimum standards of performance, and the benefits to training in internal medicine accruing from the institution of these evaluation procedures and from the related visits to hospitals by representatives of the board.

Certification↗
PubMed1994

A demonstration of validity for certification by the American Board of Anesthesiology.

PURPOSE: To investigate the validity of the certification process of the American Board of Anesthesiology. Specifically, does board certification in anesthesiology identify physicians judged to be clinically superior by evaluators who are not part of the certification process? METHOD: All 154 U.S. anesthesiology program directors (or faculty members they chose to represent them), unaware of the study's intent, were asked whether they would permit each of their residents completing training in 1991 to administer three increasingly complex anesthetic regimens to the directors themselves. This clinical skills rating was compared with the residents' performances in the certification process in 1992. A list of personal characteristics was also provided to the directors so they could identify reasons for less-than-optimal clinical skills ratings. A total of 1,310 residents participated in the certification process in 1992. RESULTS: A total of 146 programs responded. The directors would have accepted anesthetic care for all three increasingly complex operations from 828 (63.2%) of their own residents; for only the two less complex procedures, from 262 (20%); and for only the least complex procedure, from 127 (9.7%). In addition, 93 residents (7.1%) would not have been accepted to administer anesthesia to their directors for any of these operations. Certification success rates for these groups were 74.6%, 53.8%, 44.9%, and 49%, respectively (p < .00001). The personal characteristics believed important to the practice of anesthesiology were strongly linked to the clinical skills ratings; these included motivation, adaptability, clinical judgment, manual dexterity, several work habits, response to criticism, and handling of stressful situations. CONCLUSION: These data support validity for certification in anesthesiology and identify characteristics considered necessary for high-quality practice of the specialty.

Anesthesiology↗
PubMed1999

The Robert Tiffany Lectureship. Vital signs at the millennium: becoming more than we are.

Presenting this lecture named for my colleague, the late Robert Tiffany, is an honor. He was part of the first International Conference on Cancer Nursing 20 years ago, which was my first international meeting. It was part of what expanded our Texas--only cancer prevention and detection program for nurses into an international effort. Lessons acquired through this work in the past include learning to respect and honor cultural differences, adapting control programs to the resources at hand, accepting a role as a leader and being an agent for change, and passing on what has been learned to others. The challenges of today include the worldwide death and disability toll of lung cancer, the threat of breast cancer and the promise of regular screening to lower its morbidity and mortality, and the hope that a willingness to adapt screening for cervical cancer in developing countries will lower its mortality rate. Twenty years in the future we can expect nurses to remain educators, exemplars, and agents of change; cancer prevention and early detection to rise in the hierarchy of care; continued collaborative care between physicians and nurses; enhanced patient care through information access; and a larger role for cancer genetics in nursing practice.

Breast Neoplasms↗
PubMed1976

The fate of the untreated alcoholic. Toward a natural history of the disorder.

Eighty-three male alcoholics were administered a structured interview when they appeared at a large general hospital for treatment of a variety of disorders. These represent 83 consecutive cases. None received treatment aside from brief "drying-out" but all were accepted as participants in a research program. Seventy-three (88 per cent of the sample) were located for a 3-year follow-up; five of these were not seen at the 1-year follow-up, and 10 were known to be dead. This paper focuses on 58 of the alcoholics who were seen at all three evaluations, and the 10 who were known dead. The data are presented as indicating the long term results of, at best, a mild or minimal intervention with male alcoholics. A small, but significant improvement was noted on several life-adjustment scales between the initial and 1-year evaluation (OYE), but no further improvement was seen between OYE and the 3-year evaluation (TYE); 19 percent were abstinent for 1 year and 10 per cent for the full 3-year period. The best predictor of TYE abstinence was OYE abstinence, but only for the extremes, i.e., no abstinence or total abstinence. Abstinence success was also related to a tendency to use community resources, lower number of mental hospitalizations, higher occupational status, higher global rating and, curiously, lower interpersonal adjustment rating. The group using Alcoholics Anonymous showed no better outcome than the group using no community resources at all. The mortality rate was 12 per cent over the 3 years or slightly more than 4 per cent a year. The suicide rate was about 4 per cent over the 3 years. The ratings for those dying showed a pattern of more admitted drunken arrests and heavy recent drinking superimposed on lighter overall drinking for the past year. The study demonstrates that even untreated alcoholics can be traced and effective follow-up studies completed. Results also indicate that over long time periods and left to their own devices, many alcoholics do seek out some form of help. But such assistance tends not to be sustained or intensive and a good portion of it is nonprofessional and nonmedical. Moreover, a surprisingly substantial number (31 per cent) of hospital-identified alcoholics apparently neither seek out nor receive any help at all after their initial identification; yet their self-reported life-adjustment ratings do not differ significantly from those who do seek help. The no-help receivers may be the most critical group of all to follow, as they are trule untreated. It would be important to determine how consistent in fact they are in their avoidance of help, what accounts for that behavior, and whether their ultimate fate is different from those who regularly seek assistance.

Alcohol Drinking↗
PubMed2001

Iranian kidney donors: motivations and relations with recipients.

PURPOSE: The motivations of Iranian kidney donors and donor-recipient relationships are clarified. MATERIALS AND METHODS: A 13-page 69-item questionnaire was completed by 100 donors and interviews were videotaped. RESULTS: Of the donors 90% did not knew the recipients preoperatively and only 13% had any information on recipient fate postoperatively. In 87% of cases there was no postoperative relationship. Because of recipient failure to appreciate the donors and refusal to realize preoperative promises 51% of donors hated the recipients and 82% were unsatisfied with their behavior. Motivations for donating were purely financial in 43% of cases and mainly financial with a minor altruistic component in another 40%. Of the donors 76% agreed that kidney sale should be banned and if there was another chance they would prefer to beg (39%) or obtain a loan from usurers (60%) instead of vending a kidney. All 6 related donors were paid. The goals of vending were achieved not at all by 75% of donors. CONCLUSIONS: None of the donors studied fulfilled the criteria of compensated donation or donation with an incentive and 97% were vendors. All evidence shows that the donor-recipient relationship in Iran is pathological with no similarity to the emotionally related category of transplantation. Reports by the reformist Iranian press, which have all been banned, show that our sample is a good representative of other Iranian donors. Almost none of the criteria of an acceptable living unrelated renal donor transplant program is met in Iran. The opinion of kidney donors should be regarded as the final arbiter when labeling the act as a sale or donation and it should be considered in discussions of living unrelated donor transplantation.

Adult↗
PubMed1994

Reentry monitoring in the treatment of physicians with substance dependence.

A total of 37 physicians and other health care professionals have been accepted into a monitoring and advocacy program for an average of 24 months. Thirty-five are working in their profession, one is in treatment, and one has repeatedly relapsed and is no longer practicing medicine (an overall improvement rate of 97%). The elements of "reentry monitoring" are identified and proposed as a standard for the treatment of physicians with substance dependence.

Alcoholism↗
PubMed1999

Factors influencing morning report case presentations.

BACKGROUND: One of the most widely accepted didactic conferences among residency training programs is morning report. This study examines several factors that may influence the content of case presentations at morning report. METHODS: This prospective survey is of cases presented over a 1-year period at two morning reports--a university hospital and its affiliated Veterans Affairs (VA) hospital. RESULTS: Of 286 morning reports, 227 questionnaires (79%) were completed. The most common subspecialty categories represented in the cases were cardiology (20.3% of cases), infectious disease (13.2%), gastroenterology (11.5%), pulmonary (11.0%), hematology (10.1%), and general medicine (6.2%). The case mix was not significantly different by type of hospital nor by chief resident. The discussion was inpatient oriented in 88.6% of cases. CONCLUSION: Morning report case mix was similar at a university and its affiliated VA hospital and was predominantly inpatient oriented.

Curriculum↗
PubMed1983

The impact of patients with nonorganic physical findings on a controlled trial of transcutaneous electrical nerve stimulation and electroacupuncture.

Fifty-four patients treated in a three-week in-patient rehabilitation program were randomly assigned to and accepted treatment with electroacupuncture (n = 17), TENS (low-intensity transcutaneous nerve stimulation, n = 18) and TENS-dead battery (placebo, n = 18). Outcome measures included estimates of pain (on a visual analogue scale) and disability by both physician and patient as well as physical measures of spine function. Two groups were constructed based on the absence of nonorganic physical findings (Valid group, n = 30) and the presence of two or more nonorganic physical findings out of a possible four (Invalid group, n = 10). Multivariate and univariate analyses of covariance were utilized to determine effects of treatment (acupuncture, TENS, placebo) and the effects of over-reporting (presence of excessive nonorganic physical findings). Statistically significant findings demonstrated that the acupuncture group enjoyed more relief of peak pain and more relief of pain on an average day at the three-month return assessment. Additionally, the acupuncture group demonstrated greater improvement in extension trunk strength at the discharge assessment. The Invalid group were found to have a contaminating effect on the acupuncture results. Analysis also demonstrated associations between nonorganic physical findings and both personality traits ("Conversion V" profile on MMPI) and retention of an attorney. Researchers conducting clinical trials in chronic low-back pain patients should control for contamination by the presence of over-reporters.

Acupuncture Therapy↗
PubMed2005

Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany.

OBJECTIVES: To investigate a new method for evaluating counselling performance of staff in community pharmacies and to assess the quality of patient counselling. METHOD: Trained pseudo customers, instructed to play their role according to two different self-medication scenarios, visited voluntarily participating community pharmacies in Berlin. After documenting the counselling process, immediately after each visit, outside the pharmacy on an assessment form, the pseudo customer re-entered the pharmacy and gave detailed performance feedback to the counsellor and the pharmacist in charge in order to provide support for improving counselling skills and practice behaviour, when appropriate. This was followed with a written summary of the general performance of all participating pharmacies and additional individual feedback and suggestions for improvement. Educational needs were identified for subsequent performance-based educational strategies such as group-workshops, team-training and on-site team-coaching. RESULTS: Forty-nine community pharmacies in Berlin volunteered to participate in this pilot study. Ninety-eight per cent of the participating pharmacies offered advice. However, in 36% of the cases, advice was only given on request. The different types of scenarios--presentation of a symptom or request for a specific product--made a great difference to the spontaneity of questions and advice. At least one question to check on accuracy of self-diagnosis was asked in 95% of the cases of symptom presentation but in only 47% of the cases of specific product request. Information on appropriate self-medication was provided on at least one item in 74% of pseudo customer visits, but most of the time the information was not sufficient. Communication skills (nonverbal elements, comprehensibility etc.) were very good or good in 54% of the visits. Potential for improvement was mainly in relation to the use of open-ended questions to gain more information and on counselling about appropriate self-medication. Direct feedback was given in 96% of the pharmacies (one person refused to accept feedback and one feedback had to be postponed because of time shortage). All of the participants regarded counselling as an important subject in pharmacy practice. CONCLUSION: The pseudo customer method was successfully used in this study of German community pharmacies. It was shown that pseudo customer visits and performance feedback following the counselling process, were feasible in daily practice and well accepted by the participants. A training program, focussing on areas in most need of improvement, has been developed. The promising results have led to the Federal Chamber of Pharmacists in Germany adopting this method as part of a continuous quality improvement program in community pharmacies.

Community Pharmacy Services↗
PubMedDate not supplied

An issue of access: delivering equitable health care for newly arrived refugee children in Australia.

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents' ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice.

Australia↗
PubMed2006

Race, segregation, and physicians' participation in medicaid.

Many studies have explored the extent to which physicians' characteristics and Medicaid program factors influence physicians' decisions to accept Medicaid patients. In this article, we turn to patient race/ethnicity and residential segregation as potential influences. Using the 2000/2001 Community Tracking Study and other sources we show that physicians are significantly less likely to participate in Medicaid in areas where the poor are nonwhite and in areas that are racially segregated. Surprisingly-and contrary to the prevailing Medicaid participation theory--we find no link between poverty segregation and Medicaid participation when controlling for these racial factors. Accordingly, this study contributes to an accumulating body of circumstantial evidence that patient race influences physicians' choices, which in turn may contribute to racial disparities in access to health care.

Adult↗
PubMed1996

Management of acute fulminant myocarditis using circulatory support systems.

Although the natural history of acute myocarditis leads to complete recovery in the majority of patients, rapid and irreversible cardiac decompensation resulting in death is known to occur. One possible therapy to improve the poor prognosis of this patient group may be the implantation of circulatory support systems that allow myocardial recovery or bridging to heart transplantation. Therapeutic protocols have been suggested, but clinical experiences in this area are few. In this paper we report on our clinical experiences in cardiogenic shock after acute fulminant myocarditis using different types of circulatory support systems. Three different systems were used: a biomedicus centrifugal pump as a ventricular assist device (VAD) or femoro-femoral bypass (FFB) including oxygenator; Abiomed BVS 5000, and Thoratec ventricular assist device. Hemodynamic criteria for implantation of support systems were cardiac index < 2.0 L/min/m2. SVR = 1000 dyne-s-cm-5, central venous pressure (CVP) or left atrial pressure (LAP) > 20 mm Hg, and urine output < 20 ml/h despite maximal pharmacological therapy. Age total of 5 patients (mean age 29 years, range 15-55 years) in cardiogenic shock after acute fulminant myocarditis were included. Two patients initially were supported for stabilization and transportation from an outside hospital by FFB. Both patients died after a support time of 24 h because of multiorgan failure or neurological disorders after longer periods of resuscitation in the referral hospital. The third patient (55 years) received the Biomedicus pump as CVAD. Myocardial function recovered after a support time of 120 h, and the patient could be weaned. Unfortunately, 2 days after weaning, he developed malignant arrhythmias and died. The 2 remaining patients (15 years and 27 years) with diagnosis of acute fulminant virus myocarditis were supported by biventricular assist device (1 x Thoratec/111 days, 1 x Abiomed/7 days). During the entire time of support, there were no signs of myocardial recovery. The patients were accepted for the heart transplantation (HTX) program. In both cases, HTXs were performed without any complication. The postoperative course was uneventful. The results of mechanical circulatory support in patients with acute fulminant myocarditis are encouraging and justify the resources.

Adult↗
PubMed1996

Models of job-related stress and personal achievement among consultant doctors.

The antecedents and outcomes of feelings of job-related stress and personal achievement were studied in a large sample of consultant doctors working in Scotland. In a sample of 333 doctors it was found that a tendency to use emotion-oriented coping strategies and negative appraisals of organizational changes in the practice of medicine mediated the effect of the personality dimension of Neuroticism on reported job stress. Job stress levels predicted the degree of 'burnout' experienced by doctors, i.e. their tendencies to be emotionally exhausted by their work and to dehumanize patients. Higher clinical workloads were related to higher levels of stress but also to higher feelings of personal achievement. A substantial proportion of the variance in many of the variables in the stress model was accounted for by a general tendency to experience negative emotions, closely related to Neuroticism; this general factor appeared to be similar to the recently formulated concepts of 'negative affectivity' and 'somatopsychic distress'. The personality factors of Extraversion and Conscientiousness both contributed to positive feelings of personal achievement (N = 344); the effect of Extraversion was direct, whereas the effect of Conscientiousness was mediated by a tendency to use task-oriented coping strategies. Models of the processes of stress and personal achievement were tested for acceptability using the EQS Structural Equations Program. The implications of the models for transactional theories of stress are discussed.

Achievement↗
PubMed1980

Computerized measurement and analysis of scoliosis: a more accurate representation of the shape of the curve.

A computer program was created to identify and accept spatial data regarding the location of the thoracic and lumbar vertebral bodies on scoliosis films. With this information, the spine can be mathematically reconstructed and a scoliotic angle calculated. There was a 0.968 positive correlation between the computer and manual methods of measuring scoliosis. The computer method was more reproducible with a standard deviation of only 1.3 degrees. Computerized measurement of scoliosis also provides better evaluation of the true shape of the curve.

Diagnosis, Computer-Assisted↗
PubMed2004

Community perception and readiness for anti-helminth programmes in rural Nepal.

We report on the community perception of helminth infection and readiness to participate in and pay for a community-based anti-helminth programme in rural Nepal. For data collection, 28 focus group discussions (FGDs) were conducted in 28 communities. The FGD results revealed that community members were lacking in scientific knowledge about helminth infection. They also had an unusual perception about it--they believed that a 'mul juka' (vital worm) should reside in every person's stomach from birth, and must never be killed. Nonetheless, the results showed that the community members were willing to participate in and were ready to contribute their resources to the anti-helminth programmes as long as modern medicine would not kill the 'mul juka'. Such community readiness provides us with hope for developing a sustainable anti-helminth programme at the community level through effective health education.

Anthelmintics↗