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Paramedics Providing Palliative Care at Home was launched in two provinces, including a new clinical practice guideline, database, and paramedic training. The aim of this study was to evaluate patient/family satisfaction and paramedic comfort and confidence.
In Part A, we gathered perspectives of patients/families via surveys mailed at enrolment and telephone interviews after an encounter. Responses were reported descriptively and by thematic analysis. In Part B, we surveyed paramedics online pre- and 18 months post-launch. Comfort and confidence were scored on a 4-point Likert scale, and attitudes on a 7-point Likert scale, reported as the median (interquartile range [IQR]); analysis with Wilcoxon ranked sum/thematic analysis of free text.
In Part A, 67/255 (30%) enrolment surveys were returned. Three themes emerged: fulfilling wishes, peace of mind, and feeling prepared for emergencies. In 18 post-encounter interviews, four themes emerged: 24/7 availability, paramedic professionalism and compassion, symptom relief, and a plea for program continuation. Thematic saturation was reached with little divergence. In Part B, 235/1255 (18.9%) pre- and 267 (21.3%) post-surveys were completed. Comfort with providing palliative care without transport improved post launch (p = < 0.001) as did confidence in palliative care without transport (p = < 0.001). Respondents strongly agreed that all paramedics should be able to provide basic palliative care.
After implementation of the multifaceted Paramedics Providing Palliative Care at Home Program, paramedics describe palliative care as important and rewarding. The program resulted in high patient/family satisfaction; simply registering provides peace of mind. After an encounter, families particularly noted the compassion and professionalism of the paramedics.
The marriage in 1490 of Francesco Gonzaga, Marquis of Mantua, and Isabella d’Este, daughter of the Duke of Ferrara, cemented an important Italian dynastic alliance and was in no sense a love match. Francesco and Isabella were well aware, however, that they had to establish a harmonious conjugal rapport if the strategic aims of their union were to be realized. This study examines the ways in which the Este-Gonzaga couple built familiarity, affection, and shared interests through frequent letter exchanges that both shaped and facilitated their domestic and political collaboration. The epistolary evidence provides new insights into how an aristocratic Renaissance marriage was experienced by the couple themselves and about the means by which a relationship that was exposed to the full force of contemporary politics, with all its conflicts of dynastic loyalty, was sustained through dialogue and negotiation.
This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.
The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.
Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.
Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.
Parental responses to their children are crucially influenced by stress. However, brain-based mechanistic understanding of the adverse effects of parenting stress and benefits of therapeutic interventions is lacking. We studied maternal brain responses to salient child signals as a function of Mom Power (MP), an attachment-based parenting intervention established to decrease maternal distress. Twenty-nine mothers underwent two functional magnetic resonance imaging brain scans during a baby-cry task designed to solicit maternal responses to child's or self's distress signals. Between scans, mothers were pseudorandomly assigned to either MP (n = 14) or control (n = 15) with groups balanced for depression. Compared to control, MP decreased parenting stress and increased child-focused responses in social brain areas highlighted by the precuneus and its functional connectivity with subgenual anterior cingulate cortex, which are key components of reflective self-awareness and decision-making neurocircuitry. Furthermore, over 13 weeks, reduction in parenting stress was related to increasing child- versus self-focused baby-cry responses in amygdala–temporal pole functional connectivity, which may mediate maternal ability to take her child's perspective. Although replication in larger samples is needed, the results of this first parental-brain intervention study demonstrate robust stress-related brain circuits for maternal care that can be modulated by psychotherapy.
Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.
Akathisia is one of the most vexing problems in neuropsychiatry. Although it is one of the most common side effects of antipsychotic medications, it is often difficult to describe by patients, and is difficult to diagnose and treat by practitioners. Akathisia is usually grouped with extrapyramidal movement disorders (ie, movement disorders that originate outside the pyramidal or corticospinal tracts and generally involve the basal ganglia). Yet, it can present as a purely subjective clinical complaint, without overt movement abnormalities. It has been subtyped into acute, subacute, chronic, tardive, withdrawal-related, and “pseudo” forms, although the distinction between many of these is unclear. It is therefore not surprising that akathisia is generally either underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as poor adherence to medications, exacerbation of psychiatric symptoms, and, in some cases, aggression, violence, and suicide. In this article, we will attempt to address some of the confusion surrounding the condition, its relationship to other disorders, and differential diagnosis, as well as treatment alternatives.
To determine whether central line–associated bloodstream infections (CLABSIs) increase the likelihood of readmission.
Retrospective matched cohort study for the years 2008–2009.
Acute care hospitals.
Medicare recipients. CLABSI and readmission status were determined by linking National Healthcare Safety Network surveillance data to the Centers for Medicare and Medicaid Services’ Medical Provider and Analysis Review in 8 states. Frequency matching was used on International Classification of Diseases, Ninth Revision, Clinical Modification procedure code category and intensive care unit status.
We compared the rate of readmission among patients with and without CLABSI during an index hospitalization. Cox proportional hazard analysis was used to assess rate of readmission (the first hospitalization within 30 days after index discharge). Multivariate models included the following covariates: race, sex, length of index hospitalization stay, central line procedure code, Gagne comorbidity score, and individual chronic conditions.
Of the 8,097 patients, 2,260 were readmitted within 30 days (27.9%). The rate of first readmission was 7.1 events/person-year for CLABSI patients and 4.3 events/person-year for non-CLABSI patients (P<.001). The final model revealed a small but significant increase in the rate of 30-day readmissions for patients with a CLABSI compared with similar non-CLABSI patients. In the first readmission for CLABSI patients, we also observed an increase in diagnostic categories consistent with CLABSI, including septicemia and complications of a device.
Our analysis found a statistically significant association between CLABSI status and readmission, suggesting that CLABSI may have adverse health impact that extends beyond hospital discharge.
To assess the impact of a novel, silver-coated needleless connectors (NCs) on central-line–associated bloodstream infection (CLABSI) rates compared with a mechanically identical NCs without a silver coating.
Prospective longitudinal observation study
Two 500-bed university hospitals
All hospitalized adults from November 2009 to June 2011 with non-hemodialysis central lines
Hospital A started with silver-coated NCs and switched to standard NCs in September 2010; hospital B started with standard NCs and switched to silver-coated NCs. The primary outcome was the difference revealed by Poisson multivariate regression in CLABSI rate using standard Centers for Disease Control and Prevention surveillance definitions. The secondary outcome was a comparison of organism-specific CLABSI rates by NC type.
Among 15,845 hospital admissions, 140,186 central-line days and 221 CLABSIs were recorded during the study period. In a multivariate model, the CLABSI rate per 1,000 central-line days was lower with silver-coated NCs than with standard NCs (1.21 vs 1.79; incidence rate ratio=0.68 [95% CI: 0.52–0.89], P=.005). A lower CLABSI rate per 1,000 central-line days for the silver-coated NCs versus the standard NCs was observed with S. aureus (0.11 vs 0.30, P=.02), enterococci (0.10 vs 0.27, P=.03), and Gram-negative organisms (0.28 vs 0.63, P=.003) but not with coagulase-negative staphylococci (0.31 vs 0.36) or Candida spp. (0.42 vs 0.40).
The use of silver-coated NCs decreased the CLABSI rate by 32%. CLABSI reduction efforts should include efforts to minimize contamination of NCs.
Linkages between neuropsychological functioning (i.e., response inhibition, processing speed, reaction time variability) and word reading have been documented among children with attention-deficit/hyperactivity disorder (ADHD) and children with Reading Disorders. However, associations between neuropsychological functioning and other aspects of reading (i.e., fluency, comprehension) have not been well-documented among children with comorbid ADHD and Reading Disorder. Children with ADHD and poor word reading (i.e., ≤25th percentile) completed a stop signal task (SST) and tests of word reading, reading fluency, and reading comprehension. Multivariate multiple regression was conducted predicting the reading skills from SST variables [i.e., mean reaction time (MRT), reaction time standard deviation (SDRT), and stop signal reaction time (SSRT)]. SDRT predicted word reading, reading fluency, and reading comprehension. MRT and SSRT were not associated with any reading skill. After including word reading in models predicting reading fluency and reading comprehension, the effects of SDRT were minimized. Reaction time variability (i.e., SDRT) reflects impairments in information processing and failure to maintain executive control. The pattern of results from this study suggest SDRT exerts its effects on reading fluency and reading comprehension through its effect on word reading (i.e., decoding) and that this relation may be related to observed deficits in higher-level elements of reading. (JINS, 2014, 20, 1–10)
In accord with social neuroscience's progression to include interactive experimental paradigms, parents' brains have been activated by emotionally charged infant stimuli – especially of their own infant – including baby cry and picture. More recent research includes the use of brief video clips and opportunities for maternal response. Among brain systems important to parenting are those involved in empathy. This research may inform recent studies of decreased societal empathy, offer mechanisms and solutions.
Critically significant parental effects in behavioral genetics may be partly understood as a consequence of maternal brain structure and function of caregiving systems recently studied in humans as well as rodents. Key parental brain areas regulate emotions, motivation/reward, and decision making, as well as more complex social-cognitive circuits. Additional key environmental factors must include socioeconomic status and paternal brain physiology. These have implications for developmental and evolutionary biology as well as public policy.
Abstract. Poliheuristic theory (PH) is an innovative attempt to conceptualize decision making in a way that recognizes patterns deriving from both cognitive and rational schools of thought about how foreign policy is made. Crisis decision making, a setting in which the political aspects emphasized by PH can be expected to operate, is the subject of this article. The study focuses on Turkey and China, two important states that frequently are characterized as sui generis and possibly unsuited to comparative analysis in the context of any overarching theory. As will become apparent, PH is capable of explaining crisis decision making for China and Turkey and the common pattern we explore is perhaps only the tip of the iceberg when it comes to cross-national application of the theory within the crisis domain.
Résumé. La théorie poliheuristique (PH) est une tentative novatrice de concevoir la prise de décision en reconnaissant l'apport des modes de comportement issus des écoles de pensée cognitive et rationnelle. Cet article porte sur la politique étrangère en temps de crise et offre un cadre politique au sein duquel les modes de comportement identifiés par la théorie poliheuristique devraient normalement opérer. Plus particulièrement, l'étude se concentre sur le cas de la Chine et de la Turquie, deux États souvent considérés comme singuliers et possiblement inadaptés à l'analyse théorique de la politique étrangère comparée. Toutefois, comme cet article le démontre, la PH est en mesure d'expliquer de manière comparée la prise de décision de la Chine et de la Turquie en temps de crise. Les conclusions de recherche laissent penser que cette étude pourrait bien être le prélude de nombreuses recherches employant la PH dans le domaine de la politique étrangère comparée en temps de crise.
Decentralization of forest management has become a common policy globally which has allowed communities to regain rights removed through colonization and central state management of forests. However, socioeconomic and environmental outcomes of such community-based forest management schemes have been mixed. Studies have shown the importance of institutions in influencing the success of these new governance arrangements. Based on an extensive literature review supplemented by qualitative research, using focus groups and semi-structured interviews, conducted in nine villages in the humid forest zone comprising three community forests, this research investigated the successes and challenges from decentralization of forest management in Cameroon. A key constraint on success was the inappropriate institutional structure at the local level with responsibility to manage community forests. Community forest management committees with no internally recognized legitimacy and dominated by local elites had replaced roles once played by traditional authorities. Qualitative research showed that in the humid forest zone of Cameroon, the system of accountability for forest resources, prior to the enactment of community forest legislation, included those with historical traditional cultural authority, in the form of clan or lineage heads, as well as the village chief, a legacy of colonial power. Village chiefs or other members of the village council are also selected on the basis of their good moral character. Community forest management committees that are a hybrid of customary authorities and other representatives of the population chosen following the criteria for local legitimacy may capture the best of historical social regulation and build on it so that the local committee may be seen as being accountable to the local population. Since such hybrid institutions are not without their risks, it is important that these institutions be accountable to a local democratic government to further increase their transparency and accountability. Models of community-based natural resource management that incorporate culturally appropriate requirements of legitimacy and accountability in crafting local institutions may have more success in accomplishing both socioeconomic and environmental goals.