Community development and health project: a 5-year (1995-1999) experience in Mozambique, Africa.

The Community Development and Health Project (1995-1999) in Mozambique, East Africa, was undertaken to help alleviate the dire circumstances of daily life following years of internal warfare. The project was supported by the International United Methodist Church and was administered by the Mozambique Conference of the United Methodist Church, Chicuque Rural Hospital and Cambine Health Center. The target population, whose daily survival depended on subsistence farming, lived throughout the country, in particular in rural areas, far from health care facilities. The Project Content included the following topics: basic education in personal and environmental hygiene; proper nutrition using locally available food products; methods of agriculture that would ensure the best use of the land for growing nutritious food; economic methods to guarantee a supply of safe drinking water; disease prevention/home treatment; maternal child health; self-esteem issues; and establishing a representatively inclusive community-development committee. Indigenous women, the 'promotoras/os', were selected from their communities, attended a 4-week training session and then returned to their homes as 'Promotoras/os of Community Development and Health'.

An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH).

BACKGROUND: Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers. METHODS: Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records. RESULTS: Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively). CONCLUSIONS: Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.

Pain observed: the experience of pain from the family caregiver's perspective.

Researchers have studied pain and family caregiving across ages and various diseases. They have begun to explore barriers to family caregivers' roles in pain management and to assess family caregivers' knowledge and beliefs about pain. One consistent finding is that the fears and the inappropriate knowledge and beliefs of family caregivers often are worse than those of patients. This article provides a brief description of the program of research performed by the author and colleagues over the past 16 years related to pain management at home and to the role of family caregivers.

The finishing touches for more predictable esthetic dentistry.

The popularity of esthetic dentistry has transformed the traditional dental practice. Anterior tooth restorations impact the beauty of a smile as well as the function of the entire dentition. The long-term success of esthetic restorations can be improved by controlling the occlusal forces to which they are subjected. During sleep and periods of intense concentration, dental patients move their mandibles far beyond the accustomed positions and are able to place significant forces on anterior teeth. The dentist must test and balance new restorations to ensure that they allow for the full range of mandibular movement. Three basic types of movements are discussed.

Improving cancer care at the end of life.

Excellent care for cancer patients and their families should extend throughout the illness, and should include care provided at the end of life. Recent evidence, including a report from the Institute of Medicine, has emphasised that major reform is needed to improve relief of pain, other symptoms, and psychosocial care. This paper reviews the critical necessity for reform in end-of-life care for the field of oncology and the major educational efforts required to ensure that oncology professionals can respond to this need.

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

NHPCO Task Force Statement on the Ethics of Hospice Participation in Research.

There is an urgent need for robust empirical data to guide the assessment and treatment of patients near the end of life. Because they are important providers of end-of-life care in this country, hospices have an important role to play in facilitating this research. However, hospices may also face considerable ethical challenges in doing so. This task force statement begins by discussing the importance of hospices' potential contributions to research. Next, we describe ways in which characteristics of hospice patients, and hospices' structure, create ethical challenges that may limit these contributions. We conclude by proposing ways in which hospices and national professional organizations can begin to overcome some of these challenges.

The Geriatric Pain Measure: validity, reliability and factor analysis.

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment. OBJECTIVE: To develop and evaluate validity and reliability of a multidimensional pain assessment instrument for older persons. RESEARCH DESIGN: A series of steps in instrument development and evaluation. SUBJECTS: A total of 176 subjects (mean age 84 +/- 6.0 years) in ambulatory geriatric clinics; 64% were women, and 73% had a history of chronic pain. MEASUREMENTS: Measurements included the Geriatric Pain Measure (GPM), the McGill Pain Questionnaire, Yesavage GDS, Katz ADLs, Lawton IADLs, Tinetti Gait and Balance, Folstein MMSE, and other demographic and clinical characteristics from interview and chart review. RESULTS: The GPM demonstrated a standardized alpha = 0.9445, homogeneity ratio =0.457, and average inter-item correlation =0.415. A subgroup of 50 subjects demonstrated concurrent validity of the GPM in comparison with the McGill Pain Questionnaire (Pearson's r correlation 0.6269 (P < .0000). Test-retest reliability was demonstrated in another subgroup of 50 subjects who repeated the GPM within 48 to 72 hours (Pearson's r = 0.9018; P < .0000). Factor analysis revealed five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities. CONCLUSIONS: The GPM is a 24-item questionnaire that is easy to administer and has significant validity and reliability in older persons with multiple medical problems. The GPM may be a useful addition to the multidimensional geriatric assessment process.

Pain management.

Pain is a common problem encountered among elderly people in subacute and long-term care facilities. Pain often is underestimated and undertreated in these settings. Most pain problems can be improved by careful assessment and careful use of analgesic drugs and nondrug strategies. Subacute care and other long-term care facilities often present unique challenges to pain management. Clinicians who care for patients in these settings must help to establish a plan of care that is reasonable for the given resources and skills often available in these settings. Clinicians have an obligation to improve comfort and dignity for these patients, especially those near the end of life.

Pressure ulcers among patients admitted to home care.

CONTEXT: Pressure ulcers are an understudied problem in home care. OBJECTIVE: To determine the prevalence of pressure ulcers among patients admitted to home care services, describe the demographic and health characteristics associated with pressure ulcers in this setting, and identify the percentage of these patients at risk for developing pressure ulcers. DESIGN: Cross-sectional survey of patients on admission to home care agencies. SETTING: Forty-one home care agencies in 14 states. PATIENTS: A consecutive sample of 3,048 patients admitted March 1 through April 30, 1996 (86% of all admissions). Subjects had a mean age of 75 years; 63% were female and 85% white. MAIN OUTCOME MEASURES: Demographic, social, and clinical characteristics, functional status (Katz activities of daily living scale and Lawton instrumental activities of daily living scale), mental status (Katzman Short Memory-Orientation-Concentration test), pressure ulcer risk (Braden Scale), pressure ulcer status (Bates-Jensen Pressure Ulcer Status Tool), and a checklist of pressure-reducing devices and wound care products being used. RESULTS: In the total sample of 3,048 patients, 9.12% had pressure injuries: 37.4% had more than one ulcer and 14.0% had three or more ulcers. Considering the worst ulcer for each subject, 40.3% had Stage II and 27% had Stage III or IV injuries. Characteristics associated with pressure ulcers included recent institutional discharge, functional impairment, incontinence, and having had a previous ulcer. About 30% of subjects were at risk for new pressure ulcers. Pressure-relieving devices and other wound care strategies appeared to be underutilized and often indiscriminately applied. CONCLUSIONS: There is substantial need for pressure ulcer prevention and treatment in home care settings.