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Clinical practice has long been part art, part science. But with evidence-based guidelines and electronic health record (EHR) systems with decision support becoming increasingly prevalent, some fear the art of [...]

Purpose: Motivating and enabling formal caregivers to provide individualized resident care has become an increasingly important objective in long-term care (LTC) facilities. The current study set out to examine the structure of responses to the individualized care inventory (ICI). Design and Methods: Samples of 242 registered nurses (RNs)/ licensed practical nurses (LPNs) and 326 care aides were recruited from 54 LTC facilities in 3 of 5 British Columbia health authorities. Baseline confirmatory factor analytic (CFA) models were computed separately for RNs/LPNs and care aides; invariance analyses were next undertaken to compare these CFA models. Results: For both RNs/LPNs and care aides, support was found for a 4-factor model of ICI responses mapping onto a higher order individualized care (IC) construct. This model was largely equivalent between formal caregiver groups, although the relative contribution of certain first-order factors differed between the two. Of further note, both groups appear to interpret and respond to 31 of 35 ICI items in a similar manner. Implications: The results of this study provide further sup port for the psychometric properties of ICI responses. Although further research is required, the ICI appears to be an appropriate self-report measure. This instrument may be used by researchers, policymakers, administrators, and practitioners alike to assess strengths as well as areas for improving the delivery of IC to LTC residents by formal caregivers. Key Words: Dementia care, Formal caregivers, Individualized care, Long-term care, Scale reliability, Scale validation doi: 10.1093/geront/gnp053

Primary care is increasingly geared toward standardized care and decision-making for common chronic conditions, combinations of medical and mental health conditions, and the behavioral aspects of care for those conditions. [...]

This article describes a residency educational process that considers the reciprocal impact doctors and patients have on each other, using a modified "MegaClinic" conference model. Specific description of the 1-hr, [...]

Byline: Rafael Fernandez (1), Xavier Trenchs (2), Jordi Klamburg (3), Jon Castedo (4), Jose Manuel Serrano (5), Guillermo Besso (6), Juan Pedro Tirapu (7), Antonio Santos (8), Arantxa Mas (9), Manuel Parraga (10), Paola Jubert (11), Fernando Frutos (12), Jose Manuel Anon (13), Manuela Garcia (14), Fernando Rodriguez (15), Joan Carles Yebenes (16), Maria Jesus Lopez (17) Keywords: Prone positioning; Mechanical ventilation; Acute respiratory distress syndrome; Randomized controlled trial; Survival; Acute lung injury Abstract: Objective We examined the effect on survival of prone positioning as an early and continuous treatment in ARDS patients already treated with protective ventilation. Design and setting Open randomized controlled trial in 17 medical-surgical ICUs. Patients Forty mechanically ventilated patients with early and refractory ARDS despite protective ventilation in the supine position. Interventions Patients were randomized to remain supine or be moved to early (within 48a-h) and continuous (aY=a-20a-h/day) prone position until recovery or death. The trial was prematurely stopped due to a low patient recruitment rate. Measurements and results Clinical characteristics, oxygenation, lung pressures, and hemodynamics were monitored. Need for sedation, complications, length of MV, ICU, and hospital stays, and outcome were recorded. PaO.sub.2/FIO.sub.2 tended to be higher in prone than in supine patients after 6a-h (202a-+-a-78 vs. 165a-+-a-70a-mmHg) this difference reached statistical significance on day 3 (234a-+-a-85 vs. 159a-+-a-78). Prone-related side effects were minimal and reversible. Sixty-day survival reached the targeted 15% absolute increase in prone patients (62% vs. 47%) but failed to reach significance due to the small sample. Conclusions Our study adds data that reinforce the suggestion of a beneficial effect of early continuous prone positioning on survival in ARDS patients. Author Affiliation: (1) CIBER Enfermedades Respiratorias, ICU, Hospital de Sabadell, Parc Taulis/n, 08208, Sabadell, Spain (2) ICU, Hospital de Terrassa, Terrassa, Spain (3) ICU, Hospital Germans Trias i Pujol, Badalona, Spain (4) ICU, University Hospital De Canarias, La Laguna, Spain (5) ICU, Hospital Reina Sofia, Cordoba, Spain (6) ICU, Hospital Carlos Haya, Malaga, Spain (7) ICU, Hospital de Navarra, Pamplona, Spain (8) ICU, Complexo University Hospital, Santiago de Compostela, Spain (9) ICU, Fundacion Althaia, Manresa, Spain (10) ICU, Hospital Morales Messeguer, Murcia, Spain (11) ICU, Hospital Santa Tecla, Tarragona, Spain (12) ICU, Hospital Universitario, Getafe, Spain (13) ICU, Hospital Virgen de la Luz, Cuenca, Spain (14) ICU, Hospital Virgen Macarena, Sevilla, Spain (15) ICU, Clinica San Miguel, Pamplona, Spain (16) ICU, Hospital de Mataro, Mataro, Spain (17) ICU, Hospital General Yague, Burgos, Spain Article History: Registration Date: 27/03/2008 Received Date: 07/01/2008 Accepted Date: 14/03/2008 Online Date: 22/04/2008 Article note: Electronic supplementary material The online version of this article (doi: 10.1007/s00134-008-1119-3) contains supplementary material, which is available to authorized users.

Over the past 15 years, a growing body of research has shown that people with Alzheimer's disease (AD) are affected not only by brain neuropathology but also by their reactions to its effects, by the environments in which they live, and by how they are treated by others. Nevertheless, three relatively neglected social influences on people with AD remain to be examined: negative stereotyping, negative self-stereotyping and stereotype threat. Numerous studies reviewed in this paper indicate that: (1) negative self-stereotypes at conscious and unconscious levels can have adverse effects on the performance of healthy elderly people on tasks demanding explicit memory (recall in particular), and (2) the mere threat of being stereotyped negatively can have adverse effects on the performance of healthy elderly people on tasks including those involving memory. In this paper, we discuss the relevance of these phenomena for our understanding and treatment of people with AD who are exposed to negative stereotypes about old age and about AD before and after they are diagnosed. There is evidence to suggest that these influences may have significant effects on people with AD. The paper concludes with recommendations for best practice in the treatment of people with AD in the light of the most apparent effects of negative self-stereotyping and stereotype threat. These include advocacy for an approach that involves aspects of counselling. KEY WORDS--dementia, stigma, positioning theory.

For older adults, acute-care hospital stays can result in functional decline that leads to increased risk of hospitalization, nursing home admission, or mortality. This study describes functional trajectories in hospitalized older adults and identifies risk factors associated with those trajectories. Respondents (N = 45) exhibited five of six possible functional trajectory patterns. The largest change in functional status was a decline in activities of daily living (ADL) from baseline at 2 weeks before admission to the time of admission; ADL did not return to baseline during the first 4 days in the hospital. Depression scores were significantly higher in respondents who reported experiencing ADL decline before admission. Respondents whose ADL scores declined during hospitalization (regardless of baseline status) were more likely than others to die within 3 months of discharge. Functional trajectory in hospitalized elderly patients is an important and underappreciated prognostic concept requiring further attention. Keywords: aging: hospitals; functional status; patient assessment: veterans

Abstract A number of studies have shown qualitative and quantitative differences in prescribing of antipsychotics according to patient ethnicity. Black patients tend, for example, to be prescribed higher doses of [...]

OBJECTIVE: To determine whether cellular telephones used in a normal way would cause interference with medical devices located in patient care areas of hospitals. METHODS: Two cellular telephones from different [...]

Background. Disease-specific beliefs may impact patients' perceptions of the efficacy of various treatment options, thus, it is important to understand these beliefs. We examined the relationship between patients' demographic characteristics and arthritis-specific beliefs related to aging. Methods. We performed a cross-sectional survey of 591 elderly primary care patients, who had symptomatic osteoarthritis (OA) of the knee and/or hip, at the Louis Stokes VA Medical Center in Cleveland, Ohio. Data were collected on age, race, educational level, income, and whether patients agreed or disagreed with four statements regarding aging and arthritis. We also assessed OA symptom severity using the Western Ontario McMaster Universities Index (WOMAC) and depressive symptoms using the Geriatric Depression Scale, We used logistic regression analyses to examine relationships between patients' age, race, and educational level and arthritis-specific health beliefs, while adjusting for OA symptom severity, radiographic confirmation of OA, OA joint burden, depressive symptoms, and income. Results. Patients 70 years old or older, as compared to patients 50-59 years old, were more likely to believe that: arthritis is a natural part of growing old; people should expect that when they get older, they won't be able to walk as well, and people should expect to live with pain as they grow older. Conclusion. Among older, male veterans, health beliefs regarding the relationship between aging and arthritis vary by age. Clinicians should consider these differences when discussing treatment strategies with their patients with knee and/or hip OA.

Objective: Centralization of vascular surgery services has resulted in patients being transferred longer distances for treatment of life-threatening conditions. The purpose of this study was to determine whether patient transfer [...]

Background: Complications of the residual postoperative pleural space (RPPS) after partial pulmonary resections increase hospital stay, cost and morbidity. The objectives of this study were to define and identify the [...]

Introduction: Infection after total hip replacement (THR) adversely affects patients' function and health-related quality of life (HRQL). A prosthesis with antibiotic-loaded acrylic cement (PROSTALAC) was designed to improve the function [...]

ABSTRACT Background Nocturnal hypoglycemia frequently occurs in patients with type 1 diabetes mellitus (T1DM). It can be fatal and is believed to promote the development of the hypoglycemia-unawareness syndrome. Whether [...]

Transformation of patients who undergo the various phases of clinical trials, using semi-Markov stochastic process, is examined.

The incidence of depression in acne patients using isotretinoin was assessed in 100 patients with moderate and nodulocystic acne. All patients received 0.75-1.00 mg/kg/day of isotretinoin for 20-28 weeks after acne was assessed. All patients' ache lesions were improved at the end of the treatment period. Psychological state was evaluated at baseline, at Month 3, and Month 6 by a psychiatrist using a Turkish version of the Hamilton Depression Rating Scale. Only one patient's score increased to the clinical level of depression at Month 3 of treatment and declined to subclinical levels at Month 6. Although Hamilton scores increased at Month 3 over baseline scores, except for one patient, others' scores remained below the subclinical level for depression. At the end of Month 6, the mean score decreased below that at Month 3. These changes in means might be related to the onset of clinical effect of isotretinoin.

Background to the study: When compared to the United Kingdom general population, rates of deliberate self-harm (DSH) are increased among certain ethnic groups, particularly in those from the Indian diaspora. Aim: To investigate differences between ethnic groups in the demographic and clinical features of patients admitted after episodes of DSH and subsequently assessed by a nurse-led DSH liaison team. Method: A retrospective case-note study (N = 297) with completion of a standardized data collection instrument. The ethnic origin of each patient was assessed by a variety of means. Results: Asian patients (n = 38) were more likely to be female (p = 0.043), married (p = 0.027), and cite problems with their partner (p = 0.017) as a precipitant to DSH. The indigenous group (n = 234) were more likely to have previous contact with psychiatric services (p = 0.023), to have used alcohol preceding DSH (p = 0.014), and to have a criminal record (p = 0.007). Conclusions: In this population, the demographic and clinical features of patients assessed after DSH vary significantly with ethnic group. A case-control study is warranted to examine these differences in more detail.

Given the availability of violence risk assessment tools, clinicians are now better able to identify high-risk patients. Once these patients have been identified, clinicians must monitor risk state and intervene when necessary to prevent harm. Clinical practice is dominated by the assumption that increases in psychiatric symptoms elevate risk of imminent violence. This intensive study of patients (N = 132) at high risk for community violence is the first to evaluate prospectively the temporal relation between symptoms and violence. Symptoms were assessed with the Brief Symptom Inventory and threat/control override (TCO) scales. Results indicate that a high-risk patient with increased anger in 1 week is significantly more likely to be involved in serious violence in the following week. This was not true of other symptom constellations (anxiety, depression, TCO) or general psychological distress. The authors found no evidence that increases in the latter symptoms during 1 week provide an independent foundation for expecting violence during the following week. Keywords: mental illness, symptoms, violence, risk, anger

Objectives: 1. To describe the development of a dietary assessment tool (Rapid Eating and Activity Assessment for Patients [REAP]) that quickly assesses a patient's diet and physical activity and facilitates brief counselling by a primary care provider, and 2. To describe the evaluation of the REAP in terms of its reliability, validity, and ease of use by primary care providers. Design, Setting and Participants: The evaluation of REAP included: 1) an implementation feasibility study conducted with 61 medical students and practicing physicians in practice settings at various medical schools; 2) a calibration study with 44 Brown University Medical School students; 3) cognitive assessment testing with 31 consumers in Rhode Island; and 4) a reliability and calibration study of the revised tool with 94 consumers in Rhode Island and Massachusetts. Results: The feasibility study revealed moderately high rankings on usefulness, ease, practicality, and helpfulness. The calibration studies demonstrated that REAP has excellent test-retest reliability (r = 0.86, P < .0001), is correlated with the Healthy Eating Index score (r = 0.49, P = .0007), and is significantly associated with intake of most nutrients studied. Conclusions and Implications: REAP has adequate reliability and validity to be used in primary care practices for nutrition assessment and counselling, and is also user-friendly for providers.

Objectives. We examined time trends of hospitalization, a main outcome measure in health care, in the diabetic and nondiabetic populations in Germany and their associations with sociodemographic variables. Methods. Using data from 2 national health surveys, we estimated hospital days per person-year in the diabetic and nondiabetic populations in 1998 (n = 5422) and 1990-1992 (n=7363) in Germany. We used Poisson regression to estimate relative risks and interaction of secular time with age, gender, and educational level, considering the cluster sample design of the study. Results. Hospital days per person-year decreased between 1990-1992 and 1998--from 3.59 (95% confidence interval [CI]=2.59, 4.97) to 3.14 (95% CI=2.16, 4.56) for the diabetic population and from 1.38 (95% CI = 1.23, 1.55) to 1.33 (95% CI = 1.17, 1.51) for the nondiabetic population--but the decrease was not statistically significant. In the diabetic population, the decrease tended to be more pronounced (interaction year x time not significant; P=.756). Also, there was a notable decrease in men and in the group aged 25 to 39 years, and a decrease in both high- and low-educational-level subjects. Conclusions. There seems to have been a larger decrease in hospitalization in the diabetic population than in the nondiabetic population in Germany. An increase in social disparity in this health outcome measure in the diabetic population could not be confirmed. doi:10.2105/AJ PH. 2005.063339

Classifying patients as 'active' or 'passive' with regard to healthcare decision making is misleading, since patients have different desires for different components of the decision-making process. Distinguishing patient' desired roles is an essential step towards promoting care that respects and responds to individual patients' preferences. We included items on the 2004 Wisconsin Longitudinal Study mail survey measuring preferences for four components of the decision-making process: physician knowledge of patient medical history, physician disclosure of treatment choices, discussion of treatment choices, and selection of treatment choice. We characterized preference types for 5199 older adults using cluster analysis. Ninety-six percent of respondents are represented by four preference types, all of which prefer maximal information exchange with physicians. Fifty-seven percent of respondents wanted to retain personal control over important medical decisions ('autonomists'). Among the autonomists, 81% preferred to discuss treatment choices with their physician. Thirty-nine percent of respondents wanted their physician to make important medical decisions ('delegators'). Among the delegators, 41% preferred to discuss treatment choices. Female gender, higher educational attainment, better self-rated health, fewer prescription medications, and having a shorter duration at a usual place of care predicted a significantly higher probability of the most active involvement in discussing and selecting treatment choices. The overwhelming majority of Older adults want to be given treatment options and have their physician know everything about their medical history; however, there are substantial differences in how they want to be involved in discussing and selecting treatments. Keywords: US; Decision making; Patient preferences; Communication; Survey research; Cluster analysis