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Interprofessional collaboration is understood to improve efficiencies and quality of care but is associated with challenges such as professionals’ differing routines, knowledge, and identities, as well as professional hierarchies and time constraints. Given these challenges, there is limited understanding of how professionals collaborate effectively in providing patient-centred care. This study, with a convergence triangulation mixed-methods study design, explored interprofessional staffs’ perceptions of interprofessional collaboration and patient-centred care when working with hospitalized older adults. Thirty-six staff responded to a survey which included the Patient-Centred Care measure and the Modified Index of Interdisciplinary Collaboration; we also interviewed 14 nursing staff. Although all scores suggested a high value was placed on interprofessional collaboration, scores were low related to activities that facilitated team processes. We identified three themes from the data: knowing the patient/family, functional needs, and communication processes. Staff identified daily rounds with interprofessional teams as supportive of interprofessional collaboration and patient-centred-care.
To explore eating patterns and snacking among US infants, toddlers and pre-school children.
The Feeding Infants and Toddlers Study (FITS) 2008 was a cross-sectional national survey of children aged 6–47 months, weighted to reflect US age and racial/ethnic distributions. Dietary data were collected using one multiple-pass 24h recall. Eating occasions were categorized as meals, snacks or other (comprised of all feedings of breast milk and/or infant formula). The percentage of children consuming meals and snacks and their contribution to total energy, the number of snacks consumed per day, energy and nutrients coming from snacks and the most commonly consumed snacks were evaluated by age.
A national sample of US infants, toddlers and pre-school children.
A total of 2891 children in five age groups: 6–8 months (n 249), 9–11 months (n 256), 12–23 months (n 925), 24–35 months (n 736) and 36–47 months (n 725).
Snacks were already consumed by 37 % of infants beginning at 6 months; by 12 months of age, nearly 95 % were consuming at least one snack per day. Snacks provided 25 % of daily energy from the age of 12 months. Approximately 40 % of toddlers and pre-school children consumed fruit and cow’s milk during snacks; about 25 % consumed 100 % fruit juice. Cookies were introduced early; by 24 months, 57 % consumed cookies or candy in a given day.
Snacking is common, contributing significantly to daily energy and nutrient needs of toddlers and pre-school children. There is room for improvement, however, with many popular snacking choices contributing to excess sugar.
We examined caregiver report of externalizing behavior from 12 to 54 months of age in 102 children randomized to care as usual in institutions or to newly created high-quality foster care. At baseline no differences by group or genotype in externalizing were found. However, changes in externalizing from baseline to 42 months of age were moderated by the serotonin transporter linked polymorphic region genotype and intervention group, where the slope for short–short (S/S) individuals differed as a function of intervention group. The slope for individuals carrying the long allele did not significantly differ between groups. At 54 months of age, S/S children in the foster care group had the lowest levels of externalizing behavior, while children with the S/S genotype in the care as usual group demonstrated the highest rates of externalizing behavior. No intervention group differences were found in externalizing behavior among children who carried the long allele. These findings, within a randomized controlled trial of foster care compared to continued care as usual, indicate that the serotonin transporter linked polymorphic region genotype moderates the relation between early caregiving environments to predict externalizing behavior in children exposed to early institutional care in a manner most consistent with differential susceptibility.
This paper engages with a changing politics of male circumcision. It suggests that various shifts which have occurred in how the issue is debated challenge legal constructions of the practice as a private familial issue. Although circumcision rates have declined in those Western nations which have traditionally practised it, the procedure is now being promoted as a medicalised response to the HIV/AIDS pandemic in sub-Saharan Africa. Such initiatives propose a new biomedical rationale for the practice and have been difficult to confine to the African context or to adult bodies, prompting a resurgence of enthusiasm for neonatal male circumcision on the part of professional bodies in the USA and elsewhere. Although we have reservations about such public health policies, which we suggest downplay risks inherent in the procedure both for the individual and for the advancement of public health, we argue that such strategies have the potential to move debates about circumcision beyond the parameters of traditional ‘medical law’, with its focus on the doctor–patient nexus and the issue of who can validly consent to medical procedures. We suggest that, as with female genital cutting, male circumcision ought to be debated within a paradigm of social justice which gives adequate weighting to the interests of all affected parties (including women whose health may actually be compromised by the procedure) and which renders visible the socio-economic dimensions of the issue. In line with a social justice approach, we argue that public health initiatives must comply with international ethico-legal standards and be attentive to the emergence of an international human right to health. The shift in analytical frame that we propose has the potential not only to make us re-think our approach to the ethics and legality of male circumcision by challenging its construction as a familial decision but also to impact on the need for a broader conceptualisation of health law as rooted in social justice.
This chapter covers pre-screening, history and physical for evaluation of patients who are potential candidates for procedures under sedation, as well as instructions for patients. Patients for elective procedures may be referred by their primary care physician or may be self-referred. Screening, evaluation, and instruction of patients requires clinical experience, and clerical staff members should not be performing any more than simple initial screening or instructing patients as to time, location, and routine standard instructions. The scope of practice of the surgeon/practitioner/physician(s) involved and the individual facility determine the range of procedures possible. The setting may be quite flexible and general (an operating room) or very specifically designed and equipped. Procedures should be scheduled in locations equipped both for the procedure and for sedation and any contingencies that can be routinely expected as a result of either the procedure or the patient.
During the past 7 years, considerable new evidence has accumulated supporting the use of prophylactic hypothermia for traumatic brain injury (TBI). Studies can be divided into 2 broad categories: studies with protocols for cooling for a short, predetermined period (e.g., 24–48 h), and those that cool for longer periods and/or terminate based on the normalization of intracranial pressure (ICP). There have been no systematic reviews of hypothermia for TBI that include this recent new evidence.
This analysis followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the QUOROM (quality of reporting of meta-analyses) statement. We developed a comprehensive search strategy to identify all randomized controlled trials (RCTs) comparing therapeutic hypothermia with standard management in TBI patients. We searched Embase, MEDLINE, Web of Science, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, ProceedingsFirst and PapersFirst. Additional relevant articles were identified by hand-searching conference proceedings and bibliographies. All stages of study identification and selection, quality assessment and analysis were conducted according to prospectively defined criteria. Study quality was determined by assessment of each study for the use of allocation concealment and outcome assessment blinding. Studies were divided into 2 a priori–defined subgroups for analysis based on cooling strategy: short term (≤ 48 h), and long term or goal-directed (> 48 h and/or continued until normalization of ICP). Outcomes included mortality and good neurologic outcome (defined as Glasgow Outcome Scale score of 4 or 5). Pooling of primary outcomes was completed using relative risk (RR) and reported with 95% confidence intervals (CIs).
Of 1709 articles, 12 studies with 1327 participants were selected for quantitative analysis. Eight of these studies cooled according to a long-term or goal-directed strategy, and 4 used a short-term strategy. Summary results demonstrated lower mortality (RR 0.73, 95% CI 0.62–0.85) and more common good neurologic outcome (RR 1.52, 95% CI 1.28–1.80). When only short-term cooling studies were analyzed, neither mortality (RR 0.98, 95% CI 0.75–1.30) nor neurologic outcome (RR 1.31, 95% CI 0.94–1.83) were improved. In 8 studies of long-term or goal-directed cooling, mortality was reduced (RR 0.62, 95% CI 0.51–0.76) and good neurologic outcome was more common (RR 1.68, 95% CI 1.44–1.96).
The best available evidence to date supports the use of early prophylactic mild-to-moderate hypothermia in patients with severe TBI (Glasgow Coma Scale score ≤ 8) to decrease mortality and improve rates of good neurologic recovery. This treatment should be commenced as soon as possible after injury (e.g., in the emergency department after computed tomography) regardless of initial ICP, or before ICP is measured. Most studies report using a temperature of 32°–34°C. The maximal benefit occurred with a long-term or goal-directed cooling protocol, in which cooling was continued for at least 72 hours and/or until stable normalization of intracranial pressure for at least 24 hours was achieved. There is large potential for further research on this therapy in prehospital and emergency department settings.
As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective inter¬ventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates.
A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact).
Eleven acute care facilities in a large health system.
More than 26,000 nonphysician employees.
Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P < .001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites.
Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.
Renewed focus on public health has brought about considerable interest in workforce development among public health nutrition professionals in Canada. The present article describes a situational assessment of public health nutrition practice in Canada that will be used to guide future workforce development efforts.
A situational assessment is a planning approach that considers strengths and opportunities as well as needs and challenges, and emphasizes stakeholder participation. This situational assessment consisted of four components: a systematic review of literature on public health nutrition workforce issues; key informant interviews; a PEEST (political, economic, environmental, social, technological) factor analysis; and a consensus meeting.
Information gathered from these sources identified key nutrition and health concerns of the population; the need to define public health nutrition practice, roles and functions; demand for increased training, education and leadership opportunities; inconsistent qualification requirements across the country; and the desire for a common vision among practitioners.
Findings of the situational assessment were used to create a three-year public health nutrition workforce development strategy. Specific objectives of the strategy are to define public health nutrition practice in Canada, develop competencies, collaborate with other disciplines, and begin to establish a new professional group or leadership structure to promote and enhance public health nutrition practice. The process of conducting the situational assessment not only provided valuable information for planning purposes, but also served as an effective mechanism for engaging stakeholders and building consensus.
Pain, spasticity, tremor, spasms, poor sleep quality, and bladder and bowel dysfunction, among other symptoms, contribute significantly to the disability and impaired quality of life of many patients with multiple sclerosis (MS). Motor symptoms referable to the basal ganglia, especially paroxysmal dystonia, occur rarely and contribute to the experience of distress. A substantial percentage of patients with MS report subjective benefit from what is often illicit abuse of extracts of the Cannabis sativa plant; the main cannabinoids include delta-9-tetrahydrocannabinol (Δ9-THC) and cannabidiol. Clinical trials of cannabis plant extracts and synthetic Δ9-THC provide support for therapeutic benefit on at least some patient self-report measures. An illustrative case is presented of a 52-year-old woman with MS, paroxysmal dystonia, complex vocal tics, and marijuana dependence. The patient was started on an empirical trial of dronabinol, an encapsulated form of synthetic Δ9-THC that is usually prescribed as an adjunctive medication for patients undergoing cancer chemotherapy. The patient reported a dramatic reduction of craving and illicit use; she did not experience the “high” on the prescribed medication. She also reported an improvement in the quality of her sleep with diminished awakenings during the night, decreased vocalizations, and the tension associated with their emission, decreased anxiety and a decreased frequency of paroxysmal dystonia.
Standing order programs (SOPs), which allow for vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested settings for the utilization of SOPs are hospital inpatient units, because they provide care for those most likely to benefit from vaccination. The cost-effectiveness of this approach for elderly hospitalized persons is unknown. The purpose of this study was to estimate the cost-effectiveness of SOPs for pneumococcal polysaccharide vaccine (PPV) vaccination for patients 65 years of age or older in 2 types of hospital.
In 2004, a 1,094-bed tertiary care hospital implemented a pharmacy-based SOP for PPV, and a 225-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients 65 years of age or older were screened for PPV eligibility and then offered PPV. Vaccination rates before and after initiation of SOPs in the United States, incidence rates of invasive pneumococcal disease in the United States, and US economic data were the bases of the cost-effectiveness analyses. One-way and multivariate sensitivity analyses were conducted.
PPV vaccination rates increased 30.5% in the tertiary care hospital and 15.3% in the community hospital. In the base-case cost-effectiveness analysis, using a societal perspective, we found that both pharmacy-based and nursing-based SOPs cost less than $10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost $4.16 per patient screened, and nursing-based SOPs cost $4.60 per patient screened) and vaccine costs ($18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided ($12,436 per case). Sensitivity analyses showed SOPs for PPV vaccination to be cost-effective, compared with PPV vaccination without SOPs, unless the improvement in vaccination rate was less than 8%.
SOPs do increase PPV vaccination rates in hospitalized elderly patients and are economically favorable, compared with PPV vaccination rates without SOPs.
Four semi-hard Italian goats' milk cheeses, Flor di Capra (FC), Caprino di Cavalese (CC), Caprino di Valsassina (CV) and Capritilla (C), were compared for compositional, microbiological, biochemical, volatile profile and sensory characteristics. Mean values for the gross composition in part differed between cheeses. At the end of ripening, cheeses contained 7·98−8·51 log10 cfu/g of non-starter lactic acid bacteria. Lactobacillus paracasei, Lb. casei and Lb. plantarum were dominant in almost all cheeses. As shown by the Principal Component Analysis of RP-FPLC data for the pH 4·6-soluble fractions and by the determination of free amino acids, secondary proteolysis of CC and CV mainly differed from the other two cheeses. A total of 72 volatile components were identified by steam distillation-extraction followed by gas chromatography-mass spectrometry. Free fatty acids and esters qualitatively and quantitatively differentiated the profile of CV and CC, respectively. The lowest concentrations of volatile components characterized FC. Descriptive sensory analysis using 17 flavour attributes was carried out by a trained panel. Different flavour attributes distinguished the four goats' cheeses and relationships were found with volatile components, biochemical characteristics and technology.
Surface mass-balance and geometry data are key to quantifying the climate response of glaciers, and confidence in data synthesis and model interpretations and forecasts requires data from as wide a range of locations and glacier types as possible. This paper presents measurements of surface elevation change at the Svalbard surge-type glacier Finsterwalderbreen, by comparing a 1990 digital elevation model (DEM) with a surface GPS profile from 2003. The pattern of elevation change is consistent with that previously noted between 1970 and 1990, and reflects the continued quiescent-phase evolution of the glacier, with mass loss in the down-glacier/receiving area of up to –1.25mw.e. a–1, and mass gain in the up-glacier/reservoir area of up to 0.60 mw.e. a–1; the area-weighted, mean change for the whole glacier is 0.19mw.e. a–1. The spatial pattern of elevation increase and decrease is complex, and the boundary between thickening and thinning determined by combining GPS and DEM data does not appear to correspond with the equilibrium-line altitude determined from surface mass-balance measurements. There is no evidence yet of a decrease in the rate of reservoir area build-up driven by mass-balance change resulting from the warmer winter air temperatures, and decreased proportion of snowfall in total precipitation, noted at meteorological stations in Svalbard.