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Multidisciplinary Team (multidisciplinary + team)
Terms modified by Multidisciplinary Team Selected AbstractsOUT-OF-COURT STATEMENTS BY VICTIMS OF CHILD SEXUAL ABUSE TO MULTIDISCIPLINARY TEAMS: A CONFRONTATION CLAUSE ANALYSISFAMILY COURT REVIEW, Issue 1 2009Jonathan Scher Acknowledging the rapid growth of child sexual abuse in the United States, this Note advocates for the recognition of a limited exception to the blanket-hearsay ban on out-of-court statements made by unavailable declarants set out by the Supreme Court in Crawford v. Washington. In order to protect a criminal defendant's Sixth Amendment confrontation right, Crawford requires that hearsay evidence that is "testimonial" in nature be deemed inadmissible if the witness is unavailable and the defendant does not have a prior opportunity to cross-examine the witness against him. However, Crawford noted that, where nontestimonial hearsay is at issue, cross-examination may not be necessary. Accordingly, where a child sexual abuse victim makes statements during a structured or semi-structured forensic interview to a member of a multidisciplinary team, these statements should be deemed nontestimonial and thus admitted into evidence, without requiring cross-examination of the child. Allowing for this exception to the general hearsay ban in Crawford is not only consistent with current precedent, but it is also warranted to promote public policy and to curb the negative impact such abuse has on society. [source] Interactions of Valeriana officinalis L. and Passiflora incarnata L. in a patient treated with lorazepamPHYTOTHERAPY RESEARCH, Issue 12 2009María Consuelo Carrasco Abstract There is an increasing interest in the health risks related to the use of herbal remedies. Although most consumers think that phytomedicines are safe and without side effects, interactions between complementary alternative and conventional medicines are being described. The aim of this clinical case report is to highlight the importance of the safe use of herbal remedies by providing a clinical interaction study between pharmaceutical medicines and herbal medicinal products. The case of a patient self-medicated with Valeriana officinalis L. and Passiflora incarnata L. while he was on lorazepam treatment is described. Handshaking, dizziness, throbbing and muscular fatigue were reported within the 32 h before clinical diagnosis. The analysis of family medical history ruled out essential tremor, Parkinson's disease, Wilson's disease and other symptom-related pathologies. His medical history revealed a generalized anxiety disorder and medicinal plant consumption but no neurological disorder. Appropriate physical examination was carried out. An additive or synergistic effect is suspected to have produced these symptoms. The active principles of Valerian and passionflower might increase the inhibitory activity of benzodiazepines binding to the GABA receptors, causing severe secondary effects. Due to the increase in herbal product self-medication, the use of herbal remedies should be registered while taking the personal clinical history. Multidisciplinary teams should be created to raise studies on medicinal plants with impact on medical praxis. Copyright © 2009 John Wiley & Sons, Ltd. [source] Clinical practice recommendations for depressionACTA PSYCHIATRICA SCANDINAVICA, Issue 2009G. S. Malhi Objective:, To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making. Method:, A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives. Results:, The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative. Conclusion:, These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation. [source] Clinical practice recommendations for bipolar disorderACTA PSYCHIATRICA SCANDINAVICA, Issue 2009G. S. Malhi Objective:, To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making. Method:, A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives. Results:, The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative. Conclusion:, These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation. [source] Assessment of cerebral visual impairment with the L94 visual perceptual battery: clinical value and correlation with MRI findingsDEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 3 2009E ORTIBUS MD In this article we describe visual perceptual abilities of a clinical population, referred for visual problems to our multidisciplinary team and assessed with the five computer tasks from the L94 visual perceptual battery. Clinical and neuroimaging findings were correlated with the findings on this task battery. Seventy children (35 males, 35 females) constituted our cohort. Age ranged from 4 to 20 years (mean 7y [SD 3y]). Forty children were born before 37 weeks gestational age. Thirty-six children had cerebral palsy (CP), of whom 24 had spastic diplegia, five had spastic hemiplegia, and four had spastic quadriplegia. Three children had ataxic CP. Perceptual visual impairment (PVI) was established in comparison to the performance age obtained on non-verbal intelligence subtests, instead of chronological age. Our results suggest that children with a history of preterm birth and a clinical CP picture are most at risk for a specific PVI. Correlations among other clinical variables did not define a clinical subgroup more at risk. Children with periventricular leucomalacia were almost equally represented in both PVI and non-PVI groups. Normal magnetic resonance imaging did not exclude the presence of PVI. In these children, however, we found another impairment profile, more in favour of dorsal stream impairment. [source] Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapyDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue 2 2009Daniela Bruttomesso Abstract Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective. Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA1c levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon. Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA1c values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake. CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA1c or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure. CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up. Copyright © 2009 John Wiley & Sons, Ltd. [source] The advantages and disadvantages of non-surgical management of the diabetic footDIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue S1 2008Fran Game Abstract It is frequently stated that diabetic foot ulcers should be managed by a multidisciplinary team, comprising individuals who can deliver all the necessary and wide-ranging skills: medical and surgical, podiatric, nursing and orthotic. Whilst there are some data to support this multidisciplinary approach there is little to guide us in ensuring the patient is seen by the right professional for the right treatment at the right time. This article will examine the evidence supporting the most effective use of the multidisciplinary team. It will look at medical managements of ulcers including dressings, offloading and the treatment of infection, either cellulitis or osteomyelitis. By contrast, the role of surgery in offloading, and the treatment of osteomyelitis will be examined, as well as the role of vascular surgery. The most important aspect of management choice, however, is the need to focus on the needs of the person with a diabetic foot ulcer rather than simply on the treatment of the ulcer in isolation. Other complications of diabetes, which may have an effect on wound healing such as glycaemic control, renal failure and visual disturbance will be explored. Finally, there will be discussion of the relevance of outcome measure, both of ulcers as well as those more patient-centred. The ways in which these can be used to monitor individual clinical responses to treatment will be described, as well as their potential use as an aid to comparison of the effectiveness of treatment protocols adopted in different centres. Copyright © 2008 John Wiley & Sons, Ltd. [source] Diabetes care in childhood and adolescenceDIABETIC MEDICINE, Issue 2002P. R. Betts Abstract The presentation of diabetes in young people has changed significantly over recent years. Not only has there been a rising incidence of Type 1 diabetes, especially in young children, but also there is an increasing recognition of Type 2 diabetes. Young people are also increasingly being diagnosed with genetic defects of B-cell function and with diabetes in association with cystic fibrosis and other chronic diseases. There have also been significant changes in the pattern of paediatric diabetes care. This is increasingly being provided by a specialized paediatric multidisciplinary team in each health district working to agreed national standards. Despite improvements, diabetes control is still suboptimal with a high incidence of complications being reported in young adults. The challenge over the next few years is the provision of a uniform, equitable and first class paediatric service throughout the UK together with the introduction of new approaches to care, aiming to improve individual diabetic control and reduce long-term complications. Increased collaboration with adult colleagues is needed to enable the transition of care in adolescence to a service that young adults perceive to meet their needs, encourage their attendance and improve their diabetes control and quality of life. A national paediatric diabetes register together with regular audit will encourage these objectives. [source] The Health Sector Gap in the Southern Africa Crisis in 2002/2003DISASTERS, Issue 4 2004Andre Griekspoor The southern Africa crisis represents the first widespread emergency in a region with a mature HIV/AIDS epidemic. It provides a steep learning curve for the international humanitarian system in understanding and responding to the complex interactions between the epidemic and the causes and the effects of this crisis. It also provoked much debate about the severity and causes of this emergency, and the appropriateness of the response by the humanitarian community. The authors argue that the over-emphasis on food aid delivery occurred at the expense of other public health interventions, particularly preventative and curative health services. Health service needs were not sufficiently addressed despite the early recognition that ill-health related to HIV/AIDS was a major vulnerability factor. This neglect occurred because analytical frameworks were too narrowly focused on food security, and large-scale support to health service delivery was seen as a long-term developmental issue that could not easily be dealt with by short-term humanitarian action. Furthermore, there were insufficient countrywide data on acute malnutrition, mortality rates and performance of the public health system to make better-balanced evidence-based decisions. In this crisis, humanitarian organisations providing health services could not assume their traditional roles of short-term assistance in a limited geographical area until the governing authorities resume their responsibilities. However, relegating health service delivery as a long-term developmental issue is not acceptable. Improved multisectoral analytical frameworks that include a multidisciplinary team are needed to ensure all aspects of public health are dealt with in similar future emergencies. Humanitarian organisations must advocate for improved delivery and access to health services in this region. They can target limited geographical areas with high mortality and acute malnutrition rates to deliver their services. Finally, to address the underlying problem of the health sector gap, a long-term strategy to ensure improved and sustainable health sector performance can only be accomplished with truly adequate resources. This will require renewed efforts on part of governments, donors and the international community. Public health interventions, complementing those addressing food insecurity, were and are still needed to reduce the impact of the crisis, and to allow people to re-establish their livelihoods. These will increase the population's resilience to prevent or mitigate future disasters. [source] Forming a national multicentre collaboration to conduct clinical trials: Increasing high-quality research in the drug and alcohol fieldDRUG AND ALCOHOL REVIEW, Issue 5 2010ROB SANSON-FISHER Abstract Issues. There is a shortage of high-quality intervention-based evidence in the drug and alcohol misuse field. That is, evidence based on replicated effects using rigorous methodology, to establish a causal knowledge base around ethical, cost-effective methods relevant to clinical practice. The knowledge base in this field is limited participant recruitment challenges; difficulty generalising results from single-centre studies; lack of research culture; issues in managing research teams; incentives for descriptive research; and limited expertise in research design and working in multidisciplinary teams. Approach. An Australian national multicentre collaboration is proposed to overcome these barriers, and reduce the burden of drug and alcohol misuse by increasing the number of high-quality clinical trials in this field. It would involve: selecting a representative sample of centres nation-wide with expertise in specific drug and alcohol issues; creating an expert multidisciplinary team to facilitate clinical trials; simultaneous recruitment and implementation of clinical trials across centres; establishing a virtual infrastructure; forming an independent data-integrity and methodology review panel; and attracting and allocating funding for clinical trials. Implications. The ability to allocate funding, the involvement of multidisciplinary experts in drug and alcohol research, and the establishment of infrastructure and procedures are likely to result in the national multicentre group's capacity to prescribe the type of research conducted under its auspices. Conclusion. The proposed initiative is likely to increase the volume of high-quality clinical trials in the Australian drug and alcohol field, a key step towards reducing the burden of drug and alcohol misuse.[Sanson-Fisher R, Brand M, Shakeshaft A, Haber P, Day C, Conigrave K, Mattick R, Lintzeris N, Teesson M. Forming a national multicentre collaboration to conduct clinical trials: Increasing high-quality research in the drug and alcohol field. Drug Alcohol Rev 2010;29;469,474] [source] OUT-OF-COURT STATEMENTS BY VICTIMS OF CHILD SEXUAL ABUSE TO MULTIDISCIPLINARY TEAMS: A CONFRONTATION CLAUSE ANALYSISFAMILY COURT REVIEW, Issue 1 2009Jonathan Scher Acknowledging the rapid growth of child sexual abuse in the United States, this Note advocates for the recognition of a limited exception to the blanket-hearsay ban on out-of-court statements made by unavailable declarants set out by the Supreme Court in Crawford v. Washington. In order to protect a criminal defendant's Sixth Amendment confrontation right, Crawford requires that hearsay evidence that is "testimonial" in nature be deemed inadmissible if the witness is unavailable and the defendant does not have a prior opportunity to cross-examine the witness against him. However, Crawford noted that, where nontestimonial hearsay is at issue, cross-examination may not be necessary. Accordingly, where a child sexual abuse victim makes statements during a structured or semi-structured forensic interview to a member of a multidisciplinary team, these statements should be deemed nontestimonial and thus admitted into evidence, without requiring cross-examination of the child. Allowing for this exception to the general hearsay ban in Crawford is not only consistent with current precedent, but it is also warranted to promote public policy and to curb the negative impact such abuse has on society. [source] Interspecialty and intraspecialty differences in the management of thyroid nodular disease and cancerHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 6 2005FRACS, Jonathan R. Clark MBBS Abstract Introduction. The management of thyroid cancer includes multiple medical specialties. Physicians from different specialties may vary in opinion regarding the optimal investigation and treatment of patients. Little data exist evaluating the differences within or between various specialties treating thyroid disease. This study aims to examine responses from a variety of specialty physicians closely involved in the medical or surgical management of thyroid disease to provide evidence as to whether any difference exists. Methods. A cross-sectional survey of attendees at the 5th Biennial Course on the Management of Thyroid Nodular Disease and Cancer was conducted using an anonymous electronic touch pad system. Touch pads were given to 213 attendees who were asked to respond to 44 questions. This study analyzes the responses obtained from 19 selected questions (43%) and compares the results between endocrinologists (n = 48), general surgeons (n = 41), otolaryngologists (n = 61), and pathologists (n = 20). Results. Responses were obtained from 69% of endocrinologists, 68% of general surgeons, 72% of otolaryngologists, and 65% of pathologists. Statistically significant interspecialty differences were observed in 12 (63%) of 19 questions. Each question and a summary of responses from all touch pads were recorded. Conclusions. Significant differences in the attitudes toward, and presumably the practice of, managing thyroid nodular disease and cancer exist between specialties. An understanding of these differences is helpful when working as a multidisciplinary team to optimize patient care. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX,XXX, 2005 [source] Research Submission: Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional StudyHEADACHE, Issue 8 2010Ariovaldo Da Silva Jr MD Background., Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives., To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods., This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results., A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions., The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;50:1306-1312) [source] Adult Emergency Department Patients with Sickle Cell Pain Crisis: A Learning Collaborative Model to Improve Analgesic ManagementACADEMIC EMERGENCY MEDICINE, Issue 4 2010Paula Tanabe PhD Abstract Objectives:, The objectives were to report the baseline (prior to quality improvement interventions) patient and visit characteristics and analgesic management practices for each site participating in an emergency department (ED) sickle cell learning collaborative. Methods:, A prospective, multisite longitudinal cohort study in the context of a learning-collaborative model was performed in three midwestern EDs. Each site formed a multidisciplinary team charged with improving analgesic management for patients with sickle cell disease (SCD). Each team developed a nurse-initiated analgesic protocol for SCD patients (implemented after a baseline data collection period of 3.5 months at one site and 10 months at the other two sites). All sites prospectively enrolled adults with an acute pain crisis and SCD. All medical records for patients meeting study criteria were reviewed. Demographic, health services, and analgesic management data were abstracted, including ED visit frequency data, ED disposition, arrival and discharge pain score, and name and route of initial analgesic administered. Ten interviews per quarter per site were conducted with patients within 14 days of their ED discharge, and subjects were queried about the highest level of pain acceptable at discharge. The primary outcome variable was the time to initial analgesic administration. Variable data were described as means and standard deviations (SDs) or medians and interquartile ranges (IQR) for nonnormal data. Results:, A total of 155 patients met study criteria (median age = 32 years, IQR = 24,40 years) with a total of 701 ED visits. Eighty-six interviews were conducted. Most patients (71.6%) had between one and three visits to the ED during the study period. However, after removing Site 3 from the analysis because of the short data enrollment period (3.5 months), which influenced the mean number of visits for the entire cohort, 52% of patients had between one and three ED visits over 10 months, 21% had four to nine visits, and 27% had between 10 and 67 visits. Fifty-nine percent of patients were discharged home. The median time to initial analgesic for the cohort was 74 minutes (IQR = 48,135 minutes). Differences between choice of analgesic agent and route selected were evident between sites. For the cohort, 680 initial analgesic doses were given (morphine sulfate, 42%; hydromorphone, 46%; meperidine, 4%; morphine sulfate and ibuprofen or ketorolac, 7%) using the following routes: oral (2%), intravenous (67%), subcutaneous (3%), and intramuscular (28%). Patients reported a significantly lower targeted discharge pain score (mean ± SD = 4.19 ± 1.18) compared to the actual documented discharge pain score within 45 minutes of discharge (mean ± SD = 5.77 ± 2.45; mean difference = 1.58, 95% confidence interval = .723 to 2.44, n = 43). Conclusions:, While half of the patients had one to three ED visits during the study period, many patients had more frequent visits. Delays to receiving an initial analgesic were common, and post-ED interviews reveal that sickle cell pain patients are discharged from the ED with higher pain scores than what they perceive as desirable. ACADEMIC EMERGENCY MEDICINE 2010; 17:399,407 © 2010 by the Society for Academic Emergency Medicine [source] The impact of case discussion at a multidisciplinary team meeting on the treatment and survival of patients with inoperable non-small cell lung cancerINTERNAL MEDICINE JOURNAL, Issue 12 2009S. Bydder Abstract Patients with inoperable non-small cell lung cancer diagnosed and managed at a single institution over a one-year period were identified. Those whose case had been discussed at a multidisciplinary meeting had better survival than those whose case was not discussed (mean survival; 280 days vs. 205 days, log-rank P= 0.048). [source] Psychogastroenterology: a call for psychological input in Australian gastroenterology clinicsINTERNAL MEDICINE JOURNAL, Issue 2 2009A. Mikocka-Walus Abstract Gastroenterologists should be able to refer patients directly to psychologists with full Medicare reimbursement. Psychological comorbidities are frequently seen in patients with gastrointestinal conditions. However, time pressure and lack of expertise in non-medical therapies of psychological problems prevent gastroenterologists from initiating psychological treatment although such treatment may improve patients' outcomes and reduce health-care utilization. Psychologists are needed as part of the multidisciplinary team in gastroenterology clinics in Australia to take the leading role in the psychological management of those patients by contributing to screening, faster diagnosis and treatment of depression and anxiety disorders in particular. [source] An integrated care pathway to save the critically ischaemic diabetic footINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2006K. El Sakka Summary This prospective study describes and evaluates the efficacy of an integrated care pathway for the management of the critically ischaemic diabetic foot patients by a multidisciplinary team. A weekly joint diabetes/vascular/podiatry ward round and outpatient clinic was established where patients were assessed within 7 days of referral by clinical examination, ankle-brachial-index-pressures, duplex angiogram and transcutaneous oxygen pressures. An angiogram ± angioplasty or alternatively a magnetic resonance angiography prior to surgical revascularisation was performed in patients deemed not suitable for angioplasty based on the above vascular assessment. Between January 2002 and June 2003(18 months), 128 diabetic patients with lower limb ischaemia were seen. Thirty-four (26.6%) patients received medical treatment alone, and 18 (14.1%) were deemed ,palliative' due to their significant co-morbidities. The remaining 76 (59.4%) patients underwent either angioplasty (n = 56), surgical reconstruction (n = 18), primary major amputation (n = 2) or secondary amputation after surgical revascularisation (n = 1). Minor toe amputations were required in 35 patients. The mortality in the intervention group was 14% (11/76). This integrated multidisciplinary approach offers a consistent and equitable service to diabetic patients with critically ischaemic feet and appears to have a beneficial major/minor amputation ratio. [source] Anorexia nervosa and Raynaud's phenomenon: A case reportINTERNATIONAL JOURNAL OF EATING DISORDERS, Issue 8 2007Basak Yucel MD Abstract Objective: To describe and discuss potential relationships between anorexia nervosa (AN) and Raynaud's phenomenon, the course and concurrent treatment of these two disorders as they appeared simultaneously, and a potential treatment modification entailed in such concurrent therapies. Background: Although Raynaud's phenomenon has been described during the course of AN, the associations and interactions between these two conditions are not clear. Method: We report the medical workup, treatment, and outcomes in a 19-year old female patient who developed Raynaud's phenomenon following the onset of AN. Results: After treatment with nutritional rehabilitation, counseling, and individual and group therapy, the patient's weight, eating disorder-related behaviors, and attitudes improved significantly. Raynaud's related symptoms improved, following treatment with a calcium channel blocker and antiaggregant therapy. In conjunction with nutritional efforts to treat the patient's long-standing amenorrhea and osteopenia, the treatment team elected to also administer estrogen hormone in addition to oral calcium and vitamin D supplementation. Since oral contraceptives are to be avoided in patients with Raynaud's phenomenon who show clinical findings suggesting connective tissue disorder, the treatment team elected to treat this patient with transdermal hormone replacement therapy. Conclusion: The co-occurrence of AN and Raynaud's phenomenon merits close and persistent follow-up by a multidisciplinary team and may lead to alterations of usual therapeutic approaches. © 2007 by Wiley Periodicals, Inc. [source] Geriatric rehabilitation nursing: Developing a modelINTERNATIONAL JOURNAL OF NURSING PRACTICE, Issue 5 2004Pirkko Routasalo RN PhD In this paper, we describe a geriatric rehabilitation nursing model developed on the basis of the nursing and rehabilitation literature. That literature comprised some 120 articles addressing the rehabilitation of elderly patients and the work done by nurses in that process, various philosophical questions and the results of geriatric rehabilitation. One-third of these articles has been evaluated on the strength of the articles' evidence, and these are discussed in this paper. The findings show that the main factors in geriatric rehabilitation nursing are the patient with health or functional problems and the nurse with professional values, knowledge and skills. The patient is part of a family and the nurse works as part of a multidisciplinary team. In the geriatric rehabilitation process, the patient and the nurse work in close interaction. The aims of rehabilitation depend upon the patient's commitment to the objective and upon the nurse's commitment to help the patient achieve that objective. A health orientation, goal-oriented work, nursing decision-making and a rehabilitative approach to work are all central to this effort. Work is organized in multidisciplinary teams where nurses have equal responsibilities with other professional staff. Testing and development of the model is ongoing. [source] Medical management of patients with aneurysmal subarachnoid haemorrhageINTERNATIONAL JOURNAL OF STROKE, Issue 3 2008Gabriel J. E. Rinkel Abstract Treating patients with aneurysmal subarachnoid haemorrhage is taking care of acutely ill patients, and should be performed in centres where a multidisciplinary team is available 24 hours a day 7 days a week, and where enough patients are managed to maintain and improve standards of care. There is no medical management that improves outcome by reducing the risk of rebleeding, therefore occlusion of the aneurysm, nowadays preferably by means of coiling, remains an important goal in treating patients with aneurysms. Because the poor outcome after subarachnoid haemorrhage is caused to a large extent by complications other than rebleeding, proper medical management to prevent and treat these complications is therefore essential. On basis of the available evidence, oral (not intravenous) nimodipine should be standard care in patients with subarachnoid haemorrhage. It is rational to refrain from treating hypertension unless cardiac failure develops and to aim for normovolaemia, even in case of hyponatraemia. There is no evidence for prophylactic hypervolaemia, and the strategy of hypervolaemia and hypertension in patients with secondary cerebral ischaemia is based on case reports and uncontrolled observational series of patients. Magnesium sulphate and statins are promising therapies, and large trials on effectiveness in improving clinical outcome are underway. There is no evidence for prophylactic use of anti epileptic drugs, and routine use of corticosteroids should be avoided. [source] Chronic orchialgia: Consider gabapentin or nortriptyline before considering surgeryINTERNATIONAL JOURNAL OF UROLOGY, Issue 7 2007Andrew M Sinclair Objective: To establish if there is a role for gabapentin or nortriptyline in the treatment of chronic orchialgia. Methods: Twenty-six consecutive patients with chronic orchialgia were seen in the chronic pain clinic by a multidisciplinary team. A pain questionnaire was completed prior to commencing either gabapentin or nortriptyline. They were reviewed at 3 months and a repeat questionnaire completed. A 50% improvement in pain was considered successful. Results: Complete data was available for 19 patients. Overall, 61.5% of patients commenced on gabapentin and 66.6% of patients commenced on nortriptyline had a greater than 50% improvement in pain. Patients with post-vasectomy testicular pain were considered as a subgroup. None of these patients had a greater than 50% improvement in pain. However, 80% of patients in the subgroup with idiopathic chronic orchialgia had a greater than 50% improvement in pain. Conclusion: Although this is a small study, it appears that gabapentin and nortriptyline are effective in the treatment of idiopathic chronic orchialgia but not post-vasectomy pain. [source] Vasectomy within the public health services in Campinas, São Paulo, BrazilINTERNATIONAL NURSING REVIEW, Issue 2 2010N.M. Marchi rn MARCHI N.M., DE ALVARENGA A.T., OSIS M.J.D., DE AGUIAR GODOY H.M., SIMÕES E SILVA DOMENI M.F. & BAHAMONDES L. (2010) Vasectomy within the public health services in Campinas, São Paulo, Brazil. International Nursing Review57, 254,259 Objective:, To describe some of the characteristics of men who underwent a vasectomy in the public health network of Campinas, São Paulo, Brazil. Methods:, A descriptive study including 202 men randomly selected from a list of all the men vasectomized between 1998 and 2004 in the public health network. Results:, Most of the men were 30 years of age or older when vasectomized, had completed elementary school and had two or more children of both sexes. Most of the men came from the lowest income segment of the population: 47.6% in 1998,1999 and 61.3% in 2003,2004. Although the men knew various contraceptive methods, 51.2% reported that their partners were using combined oral contraceptives at the time of surgery. Most men initially sought information on vasectomy at health-care clinics where care was provided by a multidisciplinary team; most received counselling, however, 47.9% of the men waited more than 4 months for the vasectomy. Conclusions:, The profile of the vasectomized men in this study appears to indicate that the low-income population from Campinas, São Paulo, Brazil has access to vasectomy; however, the waiting time for vasectomy reveals that difficulties exist in obtaining this contraceptive method in the public health service. [source] Pilot Test of an Attribution Retraining Intervention to Raise Walking Levels in Sedentary Older AdultsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2007Catherine A. Sarkisian MD OBJECTIVES: To pilot test a new behavioral intervention to increase walking in sedentary older adults. DESIGN: Pre,post community-based pilot study. SETTING: Three senior centers in greater Los Angeles. PARTICIPANTS: Forty-six sedentary adults aged 65 and older. INTERVENTION: At four weekly 1-hour group sessions held at the senior centers, a trained health educator applied a theoretically grounded, standardized "attribution retraining" curriculum developed by a multidisciplinary team of investigators. Participants were taught that becoming sedentary is not inevitable with aging and that older adults should attribute being sedentary to modifiable attributes rather than to old age. A 1-hour exercise class including strength, endurance, and flexibility training followed each weekly attribution retraining session. MEASUREMENTS: Change from baseline in steps per week recorded using a digital pedometer was measured after 7 weeks. Age expectations (measured using the Expectations Regarding Aging-38 survey, a previously tested instrument on which higher scores indicate that the participant expects high functioning with aging and lower scores indicate that the participant expects physical and mental decline) and health-related quality of life were measured using in-person interviews. RESULTS: Mean steps per week increased from 24,749 to 30,707, a 24% increase,equivalent to 2.5 miles (2-sided t -test P=.002). Age expectation scores increased 30% (P<.001), and the changes in age expectations and steps per week correlated (correlation coefficient=0.39, P=.01). Participants experienced improved mental health,related quality of life (P=.049) and reported less difficulty with activities of daily living (P=.04). More than 50% of participants reported improvements in pain, energy level, and sleep quality. CONCLUSION: In this small pre,post community-based pilot study, a structured attribution retraining curriculum accompanied by a weekly exercise class was associated with increased walking levels and improved quality of life in sedentary older adults. Attribution retraining deserves further investigation as a potential means of increasing physical activity in sedentary older adults. [source] Physicians "Missing in Action": Family Perspectives on Physician and Staffing Problems in End-of-Life Care in the Nursing HomeJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2005Renée R. Shield PhD Objectives: To understand the roles of physicians and staff in nursing homes in relation to end-of-life care through narrative interviews with family members close to a decedent. Design: Qualitative follow-up interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants. Setting: Brown University interviewers conducted telephone interviews with participants throughout the United States. Participants: The 54 participants agreed to a follow-up qualitative interview and were family members or close to the decedent. Measurements: A five-member, multidisciplinary team to identify overarching themes taped, transcribed, and then coded interviews. Results: Respondents report that healthcare professionals often insufficiently address the needs of dying patients in nursing homes and that "missing in action" physicians and insufficient staffing create extra burdens on dying nursing home residents and their families. Conclusion: Sustained efforts to increase the presence of physicians and improve staffing in nursing homes are suggested to improve end-of-life care for dying residents in nursing homes. [source] The Effect of Changing Practice on Fall Prevention in a Rehabilitative Hospital: The Hospital Injury Prevention StudyJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2004Michael Vassallo FRCP Objectives: To determine whether a change in practice to introduce a multidisciplinary fall-prevention program can reduce falls and injury in nonacute patients in a rehabilitation hospital. Design: A quasi-experimental study. Setting: Three geriatric wards with a similar design, equipment, staffing levels, and skill mix. Participants: Eight hundred twenty-five consecutive patients. Intervention: The patients' fall-risk status was assessed using the Downton Score. Current practice was maintained on the two control wards (n=550). On the experimental ward (n=275), a fall-prevention program was introduced. A multidisciplinary team met weekly specifically to discuss patients' fall risk and formulate a targeted plan. Patients at risk were identified using wristbands; risk factors were corrected or environmental changes made to enhance safety. Measurements: Primary outcomes were number of fallers, recurrent fallers, total falls, patients sustaining injury, and falls per occupied bed days. Secondary outcomes were place of discharge and mortality. Results: Patients were matched for age and risk status. Control wards had proportionally more fallers (20.2% vs 14.2%: P=.033), patients sustaining injury (8.2% vs 4%: P=.025), and total number of falls (170 vs 72: P=.045). These results did not remain significant after controlling for differing length of stay. There was no reduction in recurrent fallers (6.4% vs 4.7%: P=.43) and no effect on place of discharge (home discharges; 57.5% vs 60.7%: P=.41) or mortality (15.3% vs 13.8%: P=.60). Conclusion: This study shows that falls might be reduced in a multidisciplinary fall-prevention program, but the results are not definitive because of the borderline significance achieved and the variable length of stay. More research on fall prevention in hospital is required, particularly as to what interventions, if any, are effective at reducing falls in this group of patients. [source] Quality and Outcomes of Heart Failure Care in Older Adults: Role of Multidisciplinary Disease-Management ProgramsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2002Ali Ahmed MD, FACP PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1,4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5,7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79,0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P = .003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68,0.86; test of heterogeneity, P> .50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75,1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04,1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96,1.37; test of heterogeneity, P> .15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care. [source] TNO's work on intensification: practical examples,JOURNAL OF CHEMICAL TECHNOLOGY & BIOTECHNOLOGY, Issue 2-3 2003Jan I Walpot Abstract TNO, a Dutch organisation for contract research, is and has been involved in numerous process intensification projects in close collaboration with national and international process industries. TNO has different facilities available to fulfil the demands of intensification projects. Depending on the focus of a project, a multidisciplinary team conducts experimental research, feasibility studies, process modelling, process design, pilot research and/or E-evaluations (economics, environment, energy). In this conference paper practical cases are described concerning novel processing techniques as well as novel reactors. © 2003 Society of Chemical Industry [source] The essentials of Advance Care Planning for end-of-life care for older peopleJOURNAL OF CLINICAL NURSING, Issue 3-4 2010Sarah Yeun-Sim Jeong Aims and objectives., The aim of the study was to investigate the phenomenon of Advance Care Planning and the use of Advance Care Directives in residential aged care facilities in Australia. The objectives were to: ,,investigate the implementation process of Advance Care Planning and the use of Advance Care Directives; ,,investigate the outcomes of Advance Care Planning and experiences of people involved in Advance Care Planning and Advance Care Directives, including residents, families and nursing staff. Background., Benefits of Advance Care Planning for older residents are considerable given their degenerative health-breakdown and minimal chance of recovery. To date, the use of Advance Care Planning and Advance Care Directives is limited and models of service delivery and processes are needed to enhance best practice with Advance Care Planning and positive outcomes for older Australians. Design., Case study. Methods., The study conducted using multiple sources of evidence to enrich understanding of the phenomenon of Advance Care Planning. The researcher engaged in data collection over six months involving participant observation, field notes, semi-structured interviews and document analysis. The findings contribute to the limited knowledge of options currently available to older adults and their families in their decision-making about end-of-life care options. Permission to conduct the study., Prior to commencement of the data collection, ethics clearances from the University of Newcastle and the regional Area Health Service were achieved. Permission to access the residential aged care facilities to undertake the study was obtained from the relevant residential aged care facility ethics committees or designated authorities. The researcher undertook several strategies to ensure all the ethical principles were considered and adhered to while conducting the project. Results., The research identified the components and factors involved in the Advance Care Planning process and in attaining desired outcomes. The conceptual framework developed elaborates how Advance Care Planning should be implemented and what may constitute successful implementation of Advance Care Planning in residential aged care facilities. The four main elements (input, throughput, output, feedback), and 20 sub-elements were requisites for nurses to initiate and implement the Advance Care Planning. Conclusion., The essential components for end-of-life care are identified in the implementation processes of Advance Care Planning in residential aged care facilities. The study contributes to greater awareness of the processes needed for ,dying well' and highlights the need to explore experiences of ,successful dying' and the way nurses contribute to these events. Relevance to clinical practice., The case study identified four determinative requisites for successful implementation of Advance Care Planning in aged care facilities: the expert nurse, discussion, education and involvement of a multidisciplinary team. Nurses should take these factors into account and use person-centred approach in formalised processes to encourage participation in plans for end-of-life care. [source] An exploration of mothers' and fathers' views of their identities in chronic-kidney-disease management: parents as students?JOURNAL OF CLINICAL NURSING, Issue 23 2008Veronica Swallow Aim., To explore parents' views of their identities as they learn to manage their child's chronic kidney disease. Background., Parents are expected to participate in management and usually learn necessary skills from the multidisciplinary team. Research highlights the importance of professionals defining parents' management roles in chronic disease; but little is known about parents' views on their own identities as the complex and dynamic process of teaching and learning unfolds around their child's condition. According to positioning theory, identity development is a dynamic and fluid process that occurs during interaction, with each person positioning themselves while simultaneously positioning the other person, yet this concept has not been considered in relation to parents' contributions to disease management. Design., A longitudinal, grounded theory study conducted in a UK Children's Kidney Unit. Method., This paper focuses on one aspect of a larger study exploring family learning in disease management. Six mothers and two fathers of six children with a recently diagnosed chronic kidney disease participated in a total of 21 semi-structured interviews during the 18 months after referral to the unit. Interviews included discussion about the parts they played in relation to professionals during the management process. Findings were interpreted within a framework of positioning theory. Results., Parents participated in teaching/learning/assessment that was both planned (involving allocated clinical lessons and tasks) and spontaneous (in response to current situations), to facilitate their participation. They positioned multidisciplinary team members as teachers as well as professionals, simultaneously positioning themselves as students as well as parents. Conclusion., Parents' clinical duties and obligations are not an automatic part of parenting but become part of the broader process of sharing disease management, this can lead to them assuming the additional identity of a ,student'. Relevance to clinical practice., Involving parents in ongoing discussions about their positions in management may help promote their active and informed participation. [source] Public Health Nurses and the delivery of quality nursing care in the communityJOURNAL OF CLINICAL NURSING, Issue 10 2008DipHE, Trish Markham MSc (Hons) Aim., The aim of the study was to explore factors which impact on quality nursing care in the community from the Public Health Nurse's (PHN) perspective. Background., Public Health Nursing has significantly evolved over the past few years with the delivery of quality nursing being a focus point. This study explores factors that impact upon the delivery of quality care in Public Health Nursing in Ireland. The findings provide an opportunity for an additional perspective to be included in the existing international findings and act as a starting point from which further research can be built. Method., A qualitative method using semi-structured interviews were conducted. Interviews were taped and content analysed. Findings., Four main categories emefrged from the data, namely role change, components of quality nursing care, barriers to quality nursing care and the factors that facilitate the delivery of quality nursing care in the community. PHNs strive for evidence-based practice; they acknowledged their inability to achieve this and referred to factors that inhibited them from reaching their goal. Conclusion., Enhanced education for PHNs will equip them in the delivery of a quality service and have a positive impact on patient care. Better communication is required between PHNs, line managers and the multidisciplinary team. The delivery of community services need to be reviewed and developed further in accordance with the health strategy policy. Relevance to clinical practice., This study has identified the evolution in clinical practice associated with the changing role and scope of Public Health Nursing. Clinical practice has evolved over time to incorporate societal change, technological advances and the delivery of an evidence-based service responsive to identified need. This study identified the presence of an increase in the specialist clinical work being undertaken as a result of new technological advances entering the community working environment. [source] | ||||||||||||||||||||||||||||||||||||||||||||||||||||