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Federal law often avoids setting minimum standards for women’s health and reproductive rights issues, leaving legislative and regulatory gaps for the states to fill as they see fit. This has mixed results. It can lead to state innovation that improves state-level health outcomes, informs federal health reform, and provides data on best practices for other states. On the other hand, some states may use the absence of a federal floor to impose draconian policies that pose risks to women’s and maternal health. Health reforms at the federal level must trod carefully to enable state innovation, while imposing foundational safeguards for promoting women’s health nationwide.
Acute psychiatric care has historically had limited involvement from psychological practitioners and there is limited published assessment of the efficacy of psychological treatments in this context. Recently a number of authors have argued strongly that Cognitive Behaviour Therapy (CBT) should be more available to psychiatric inpatients. Hoewever, the evidence for the efficacy of psychological therapies in this setting is estremely limited. Furthermore the acute environment provides a number of challenges in gathering evidence for psychological approaches. In particular, the complexity of this setting often does not lend it self to single model approaches and many psychological interventions may be preparatory. It may often be difficult to define good outcomes and psychological interventions frequently occur in conjunction with other treatments.
Several attempts to measure outcomes and studies based on user experiences are reviewed. It is argured that these actually provide very little in the way of evidence for psychological therapies. Particular attention is paid to difficulties in translating existing research into an acute psychiatric setting and measuring outcomes. A number of suggestions are made for developing research in this area including consideration of a range of outcome indicies and the ways in which psychological ideas may be employed in care planning.
Conserving species and achieving the Convention on Biological Diversity's international conservation targets necessitates stopping extinctions, recovering depleted populations and maintaining viable populations. The contribution of ex situ management to species conservation has long been debated, and there is limited information on ex situ management activities available in a format that allows success to be assessed. We therefore gathered information from three sources to explore cases in which ex situ management was considered to have had a positive conservation impact for terrestrial vertebrate species. We (1) reviewed the published literature, (2) examined for which taxa ex situ management had contributed to the downlisting of species on the IUCN Red List and (3) surveyed a global network of ex situ management practitioners. We found that ex situ management has contributed to improvements in conservation status for a range of vertebrate species. Ex situ management was reported as contributing to the downlisting of 18 species on the IUCN Red List over a 10-year period. Across sources, the most common role of ex situ management was the provision of individuals to increase population numbers in situ. The strength of evidence for the impact of ex situ management varied within and among sources. Therefore, for the role of ex situ activities in conservation to be understood fully, and for such interventions to reach their potential, documentation of intended and actual benefits needs to be improved. Better reporting of ex situ activities would enable improved learning, facilitating better targeting of ex situ activities to global species conservation goals.
Large ground-dwelling Neotropical gamebirds are highly threatened by habitat loss and hunting, but conservationists rarely attempt to distinguish between these two threats in the management of populations. We used three different types of species records to determine the status (i.e. persistence level) of the Endangered red-billed curassow Crax blumenbachii in 14 forest remnants in north-east Brazil, as either persistent, precarious or extirpated. We related these persistence levels to variables measured in a 2-km buffer radius, including variables associated with habitat quality (proportion of forest cover, length of rivers, patch density, distance from rivers) and hunting pressure (proportion of cacao agroforests and farmlands, length of roads, total area occupied by settlements, distance from roads and from settlements). Curassows were more persistent in forest patches located (1) more distant from settlements, (2) in landscapes with few settlements, (3) in landscapes with a high incidence of roads, (4) in a mosaic with a high proportion of forest, shaded cacao agroforest and farmland, and (5) more distant from other forest patches. Hunting pressure potentially exerts more influence on persistence than habitat quality: (1) hunting pressure submodels had a higher explanatory power than habitat quality submodels, (2) final models comprised four hunting pressure variables but only two habitat quality variables, and (3) hunting pressure variables appeared in all models whereas habitat quality variables appeared in only one final model. If hunting pressure is driving declines in curassows, regions with low human presence and a high proportion of forest cover are recommended for establishing new reserves.
Introduction / Innovation Concept: Trauma resuscitation requires a multidisciplinary team to perform at a high level within a dynamic, high-stakes environment. The unpredictable nature of trauma care increases the possibility for errors, often from underlying latent safety threats (LSTs). In-situ simulation (ISS) is a point-of-care training strategy that occurs within the patient care environment involving the actual healthcare team and provides a novel approach to team training and LST identification. Using ISS, critical events can be recreated providing an opportunity to explore and learn from past challenges. We developed and piloted a risk-informed, multidisciplinary ISS trauma training program to assess teamwork performance and identify LSTs within the trauma care environment. Methods: A comprehensive process was initiated to gain support from all stakeholders within the trauma program. Simulation cases were derived from a review of adverse events and unexpected deaths. Human factors experts aided with the integration of system- and process-related elements into the case design. ISS sessions involved all trauma team members. Debriefing after each session facilitated a team-based discussion and an opportunity for reflective practice and video recording was used for teamwork evaluation and process mapping. Curriculum, Tool, or Material: We conducted monthly, unannounced, multidisciplinary, high-fidelity ISS scenarios at a Canadian Level 1 trauma centre. The trauma team was activated by the usual notification process and care provided in the same manner as an actual trauma patient. A semi-structured debriefing followed each session with a focus on team performance and LST identification. Teamwork was measured using a previously validated tool, the Clinical Teamwork Scale. Findings were used to inform discussion at multidisciplinary trauma rounds as part of an iterative process of evaluation and implementation. Conclusion: This multidisciplinary ISS trauma training program offers a novel approach to team performance evaluation and LST identification. Using risk-informed scenarios combined with human factors analysis we are able identify knowledge and technical skill proficiency gaps, LSTs and integrate formative team assessment. An iterative process beginning with ISS followed by multidisciplinary rounds provides a robust framework for system-based changes to improve team performance and overall patient care.
Community-level legal and policy innovations or “experiments” can be important levers to improve health. States and localities are empowered through the 10th Amendment of the United States Constitution to use their police powers to protect the health and welfare of the public. Many legal and policy tools are available, including: the power to tax and spend; regulation; mandated education or disclosure of information, modifying the environment — whether built or natural (e.g., zoning, clean water laws); and indirect regulation (e.g., court rulings, or deregulation). These legal and policy interventions can be targeted to specific needs at the community level and are often relatively low-cost, but high impact interventions. As every community is different, effective laws and policies will vary. This freedom allows states and localities to, as Justice Louis Brandeis argued, truly serve as “laboratories of democracy.”
The average charge per patient due to nosocomial infection for 215 nosocomial infections in 183 study patients was $693. These costs, however, were concentrated in very few patients; 5% of patients accounted for nearly one-third of total charges. The 10% of patients with highest nosocomial infection costs were patients on Medical or Surgical services; these services were utilized in 71% of patients with nosocomial infection and accounted for 86% of the attributable charges. Among the 22 most costly infections, 17 occurred in surgical wounds and lower respiratory tract. Although these sites accounted for 46% of the infections, they resulted in 77% of the total nosocomial infection charges. Patients with a primary diagnosis of injury had particularly costly infections. Combined analysis of these variables revealed two groups for whom nosocomial infections were especially costly: surgical patients who acquired wound infections after injuries, and medical patients with lower respiratory infections.
Over the past decade, a flurry of media stories devoted to sports-related concussions have drawn attention to the previously “silent epidemic” of traumatic brain injury (TBI) in athletes. From 2001 to 2009, the annual number of sports-related TBI emergency department visits in individuals age 19 and under climbed from 153,375 to 248,414, an increase of increase of 62 percent. Multiple head injuries place youth athletes at risk for serious health conditions, including cerebral swelling, brain herniation, and even death — postconcussive conditions that have collectively (and controversially) been referred to as “second impact syndrome.” Studies have shown that children and teens — and girls, in particular — are more likely to sustain a concussion and have a longer recovery time than adults. Recent research also suggests that even subconcussive hits in children and adolescents may result in longer-term health effects such as decreased cognitive functioning, increased rates of depression, memory problems, and mild cognitive impairment (a pre-Alzheimer’s condition).
To identify risk factors associated with methicillin-resistant Staphylococcus aureus (MRSA) acquisition in long-term care facility (LTCF) residents.
Multicenter, prospective cohort followed over 6 months.
Three Veterans Affairs (VA) LTCFs.
All current and new residents except those with short stay (<2 weeks).
MRSA carriage was assessed by serial nares cultures and classified into 3 groups: persistent (all cultures positive), intermittent (at least 1 but not all cultures positive), and noncarrier (no cultures positive). MRSA acquisition was defined by an initial negative culture followed by more than 2 positive cultures with no subsequent negative cultures. Epidemiologic data were collected to identify risk factors, and MRSA isolates were typed by pulsed-field gel electrophoresis (PFGE).
Among 412 residents at 3 LTCFs, overall MRSA prevalence was 58%, with similar distributions of carriage at all 3 facilities: 20% persistent, 39% intermittent, 41% noncarriers. Of 254 residents with an initial negative swab, 25 (10%) acquired MRSA over the 6 months; rates were similar at all 3 LTCFs, with no clusters evident. Multivariable analysis demonstrated that receipt of systemic antimicrobials during the study was the only significant risk factor for MRSA acquisition (odds ratio, 7.8 [95% confidence interval, 2.1–28.6]; P = .002). MRSA strains from acquisitions were related by PFGE to those from a roommate in 9/25 (36%) cases; 6 of these 9 roommate sources were persistent carriers.
MRSA colonization prevalence was high at 3 separate VA LTCFs. MRSA acquisition was strongly associated with antimicrobial exposure. Roommate sources were often persistent carriers, but transmission from roommates accounted for only approximately one-third of MRSA acquisitions.
Stigma and discrimination related to mental-health problems impacts negatively on people's quality of life, help seeking behaviour and recovery trajectories. To date, the experience of discrimination by people with mental-health problems has not been systematically explored in the Republic of Ireland. This study aimed to explore the experience impact of discrimination as a consequence of being identified with a mental-health problem.
Transcripts of semi-structured interviews with 30 people about their experience of discrimination were subject to thematic analysis and presented in summary form.
People volunteered accounts of discrimination which clustered around employment, personal relationships, business and finance, and health care. Common experiences included being discounted or discredited, being mocked or shunned and being inhibited or constrained by oneself and others.
Qualitative research of this type may serve to illustrate the complexity of discrimination and the processes whereby stigma is internalised and may shape behaviour. Such an understanding may assist health practitioners reduce stigma, and identify and remediate the impact of discrimination.
Information technology has dramatically changed all our lives over recent years. For those working in the health sector, this has been no exception. This chapter begins with an overview by Nicholas Hardiker of the information needs of clinicians and the technology and information systems that may be used to answer them. This is followed by two examples of that technology in action: the first is a description of the Map of Medicine clinical information system by Joanna Dundon, and the second, by Jessie McGowan, describes a project which uses personal digital assistants (PDAs) to bring clinical information directly to the clinicians who need it.
CLINICIANS’ INFORMATION NEEDS
Nicholas R. Hardiker
Clinicians face important decisions every day. They must be able to answer, sometimes immediately, a range of questions: ‘What is the accepted assessment process for a particular group of patients?’; ‘What is the most likely diagnosis given a set of signs and symptoms?’; ‘What is the most effective treatment for a particular condition?’; ‘What are the potential adverse effects of a particular medicine?’; and so on. The process of asking and answering clinical questions has been summarized as: (1) recognizing uncertainty; (2) formulating a question; (3) pursuing an answer; (4) finding an answer; and (5) applying the answer in practice. Most questions go unanswered – clinicians do not always pursue answers to their questions, perhaps because of doubt that an answer actually exists. And where clinicians do pursue answers, the answers cannot always be found, perhaps due to lack of time, an inability to access appropriate resources or an inability to navigate a particular resource (Ely et al., 2005). Potential solutions rest with clinicians themselves – selecting the most appropriate resource, formulating questions to match particular resources and using more effective search terms. Other solutions concern clinical inform ation resources and systems that seek to make relevant information more accessible at the point of care – anticipating questions that may arise in practice and providing clearer, more explicit and actionable answers (Ely et al., 2007). An understanding of clinical infor mation needs is an important precondition to the development of clinical information resources and systems (Smith, 1996). The focus of this chapter is on the resources and systems themselves.
There is widespread concern for many understorey and ground-dwelling bird species in the Philippines that appear intolerant of forest alteration. We present density estimates for 18 key bird species in old growth forest, advanced and early secondary growth and active cultivation within the Puerto Princesa Subterranean River National Park in Palawan. Six species were not recorded in cultivation and the abundance of these and several others increased along the successional gradient from cultivation to old growth forest. Eleven species, including five endemics and three of four threatened species, had highest density estimates in old growth forest. However, several species had high density estimates in the heavily disturbed habitats and every habitat type held highest densities of at least one of the bird species. The commonest habitat association across the bird community was a preference for areas containing large trees, indicating the importance of retention of such trees in allowing suitable ground and understorey microhabitats to persist. Old growth forests have the highest conservation value for Palawan’s endemic birds and, while some species thrive in the anthropogenic habitats that occur within the Park, the present extent of cultivation and associated successional stages within its boundaries should not be increased. We caution against extrapolation of the abundance figures from the Park to the whole island but we suggest that population sizes for the threatened species are likely to be much greater than previously thought. We urge authorities to strengthen management within the protected area network in Palawan to ensure survival of key species.
An analysis is made of the sound generated by the time-dependent throttling of a nominally steady stream of air through a small orifice into a flow-through resonant cavity. This is exemplified by the production of voiced speech, where air from the lungs enters the vocal tract through the glottis at a time-variable volume flow rate Q(t) controlled by oscillations of the glottis cross-section. Voicing theory has hitherto determined Q from a heuristic, reduced complexity ‘Fant’ differential equation. A new self-consistent, integro-differential form of this equation is derived in this paper using the theory of aerodynamic sound, with full account taken of the back-reaction of the resonant tract on the glottal flux Q. The theory involves an aeroacoustic Green's function (G) for flow–surface interactions in a time-dependent glottis, so making the problem non-self-adjoint. In complex problems of this type, it is not usually possible to obtain G in an explicit analytic form. The principal objective of this paper is to show how the Fant equation can still be derived in such cases from a consideration of the equation of aerodynamic sound and from the adjoint of the equation governing G in the neighbourhood of the ‘throttle’. The theory is illustrated by application to the canonical problem of throttled flow into a Helmholtz resonator.
Medico-legal death investigation systems have the potential to play an important role in disease surveillance. While these systems are in place to serve a public function, the degree to which they are independent of central government can vary depending on jurisdiction. How these systems use this independence may present problems for public health initiatives, as it allows death investigators to decline to participate in government-led surveillance regardless of how critical the studies may be to public health and safety. A recent illustration of this problem in the UK is examined, as well as general lessons for removing impediments to death investigation systems participating in public health research.