[Using social network analysis to examine care for older drug users in three major cities in Germany : Results of a pilot study]. / Soziale Netzwerkanalyse der Versorgungsstrukturen für ältere Drogenabhängige in drei deutschen Großstädten : Ergebnisse einer Pilotstudie.

BACKGROUND: Compared with the general population, chronic drug addicts already start showing typical aging problems by the age of 40 years. The increasing number of older drug addicts leads to questions of what an adequate health and social care should look like. This discussion particularly takes place in the context of a sufficient integration of different care systems. A sufficient integration requires an improvement in the networking of substance treatment, nursing care and medical care services. OBJECTIVE: The purpose of this study was to investigate the care structure of older people who use drugs and the services involved in a social network analysis. This was a descriptive design of the pilot study. The study objective was to gain first-hand knowledge about the health and social care situation, the quality of care concerning this client group and to identify supply gaps. Therefore, the three regions Cologne, Dusseldorf and Frankfurt/Main were exemplarily examined. MATERIAL AND METHODS: The data for the social network analysis was gathered by a quantitative online questionnaire. Therefore, especially central network members were contacted and asked to participate. The survey was conducted in two waves. RESULTS: In total, 65 practitioners of all surveyed cities participated in the second wave. The centrality measures assessed indicated that in all regions institutions of the substance abuse service network hold central positions in terms of conveying information. The moderate density values of the networks suggest that there are sufficient cooperation structures. Care deficits were identified most frequently in the areas of housing and nursing care. CONCLUSION: The results provide the first systematic insights and a description of the cooperation practice in the care system. Because of the limitations, further research and practice issues are raised.

[Nutrition consultation in small animal practice - a field for specialized veterinarians]. / Ernährungsberatung in der Kleintierpraxis - ein Arbeitsfeld für spezialisierte Tierärzte.

OBJECTIVE AND AIM: The study aimed to identify barriers to the implementation of nutrition consultation in veterinary practice. Differences between individual veterinarians in their problem-solving strategies in nutrition consultation were investigated. MATERIALS AND METHODS: Representative online survey of 214 veterinarians (female/male) using a standardized questionnaire. Statistical analysis by correlations, t-test, analysis of variance and factor analysis as well as cluster analysis of types of veterinarians. RESULTS: Over 90% of vets had seen an increase in owners' questions on feeding pets. Forty-one percent estimated the percentage of patients suffering from nutrition-related diseases in their practice to be 20-30%. At the same time, 70% of vets agreed that nutrition consultation was neglected in every-day practice. Vets estimated that only 30% of owners complied with recommendations on nutrition. Over 80% of vets presumed that pet owners gave false information on feeding. For other sensitive questions, including domestic and financial situations, the percentage of presumed false information was below 60%. Approximately 50% of the vets did not feel sufficiently competent with regard to nutrition consultation. Less than 50% asked for payment of nutrition consultation. Only 18% had taken part in continuing education in animal nutrition. The cluster analysis identified five different strategies to cope with nutrition consultation, four of which were based on a low priority for nutrition in their own practice. Some vets referred nutrition problems to specialized colleagues (7.2%), others consulted with representatives of pet food companies (28.2%), another group offered free, quick tips (23.4%), and a small percentage ignored nutrition (13.4%). There was one group with a strong interest in nutrition (27.8%). It is remarkable that this group felt the least competent in small-animal nutrition. Conclusion and practical relevance: The study demonstrates that sound nutrition consultation in small-animal practice requires a high degree of specialization. In addition, special coping strategies to obtain a sound nutrition history and a fair payment are necessary. Vets fulfilling these conditions may find a wide field of work.

The response of endocrine system to stress loads during space flight in human subject.

The responses of endocrine system to the exposure to stress-work load and hormonal changes during oral glucose tolerance tests were studied in the Slovak astronaut before (three weeks before flight), during (on the 4th and the 6th days of space flight), and after space flight (1-3 days and 15-17 days after space flight) on board of space station MIR. Blood samples during the tests were collected via cannula inserted into cubital vein, centrifuged in the special appliance Plasma-03, frozen in Kryogem-03, and at the end of the 8-day space flight transferred to Earth in special container for hormonal analysis. Preflight workload produced an increase of plasma norepinephrine and a moderate elevation of epinephrine levels. Plasma levels of insulin, growth hormone, prolactin and cortisol were not markedly changed immediately or 10 min after the end of work load. The higher increases of plasma growth hormone, prolactin and catecholamine levels were noted after workload during space flight as compared to preflight response. The higher plasma glucose and insulin levels were noted during the oral glucose tolerance test in space flight and also in the post flight period. Plasma epinephrine levels were slightly decreasing during glucose tolerance test; however, plasma norepinephrine levels were not changed. The similar patterns of catecholamine levels during glucose tolerance test were found when compared the preflight, in-flight and post flight values. These data demonstrate the changes of the dynamic responses of endocrine system to stress-work and metabolic loads during space flight in human subject.

The physician as worker: what it means and why now?

Health care researchers and managers have viewed physicians traditionally through three major lenses, that is, as professionals, suppliers, and caregivers. This article makes a case for another lens, that of the physician as worker. The worker perspective complements these existing perspectives, serves as a generative metaphor in raising new assumptions and questions about physicians, and provides physicians with a dimensionality necessary because of increasing diversity within and external to the medical profession.

Characteristics and work experiences of hospitalists in the United States.

BACKGROUND: Little is known about the personal characteristics, work-related attitudes, or professional experiences of hospitalists. In considering the future of hospital medicine as a viable career choice for physicians (primarily, internists), these issues should be examined in a systematic fashion. Learning more about hospitalists and their work can enhance dialogue about the advantages and shortcomings of such a career from the perspective of the individual physician. METHODS: A self-administered mail survey was sent to 820 hospitalists who are dues-paying members of the National Association of Inpatient Physicians and who spend 50% or more of their time doing clinical work, teaching, or research related to hospital medicine. Attitudes about topics such as job-related burnout and job satisfaction were tapped, as well as information about different professional and social experiences. The analyses were performed using descriptive statistics and analysis of variance techniques. RESULTS: Analysis was based on 393 responses (48% response rate). Results show hospitalists to be a group of younger, mostly male, early-career individuals with high levels of job satisfaction and autonomy, low levels of burnout, and a long-term commitment to remaining in the role. Hospital medicine is a source of positive social and professional work experiences related to interactions with physician peers, patients and their families, and nonphysician hospital coworkers. Key components of hospitalists' jobs, practices, and workload are coalescing. However, certain developments, such as changing patterns of compensation and the enlisting of more general internists and women as hospitalists, merit further examination. CONCLUSIONS: The results offer insight into the physicians who are becoming hospitalists, the jobs and settings in which they work, and how hospitalists experience their everyday work lives. Valuable baseline data are provided for assessment of attitudes, such as burnout, that should be examined regularly in this fledgling group. This study complements research looking at the performance-related outcomes of hospitalists, and it can be used by various stakeholders to better understand and assess the long-term potential of what is being proposed as a new career path.

Exploring dual commitment among physician executives in managed care.

The growth of a medical management specialty is a significant event associated with managed care. Physician executives are lauded for their potential in bridging the clinical and managerial realms. They also serve as a countervailing force to help the medical profession and patients maintain a strong voice in healthcare decision making at the strategic level. However, little is known about their work loyalties. These attitudes are important to explore because they speak to whose interests physician executives consider and represent in their everyday management roles. If physician executives are to maximize their effectiveness in the healthcare workplace, both physicians and organizations must view them as credible sources of authority. This study examines organizational and professional commitment among a national sample of physician executives employed in managed care settings. Data used for the analysis come from a national survey conducted through the American College of Physician Executives in 1996. The findings support the notion that physician executives can and do express simultaneous loyalty to organizational and professional interests. This dual commitment is related to other work attitudes that contribute to success in the management role. In addition, it appears that situational factors increase the chances for dual commitment. These factors derive from a favorable work environment that includes both organizational and professional socialization in the management role. The results of the study are useful in specifying the training and socialization needs of physicians who wish to do management work. They also provide a rationale for collaboration between healthcare organizations and rank-and-file physicians aimed at cultivating physician executives who are credible leaders within the healthcare system.

A recombinase-mediated transcriptional induction system in transgenic plants.

We constructed and tested a Cre-loxP recombination-mediated vector system termed pCrox for use in transgenic plants. In this system, treatment of Arabidopsis under inducing conditions mediates an excision event that removes an intervening piece of DNA between a promoter and the gene to be expressed. The system developed here uses a heat-shock-inducible Cre to excise a DNA fragment flanked by lox sites, thereby generating a constitutive GUS reporter gene under control of the CaMV 35S promoter. Heat-shock-mediated excision of several, independent lines resulted in varying degrees of recombination-mediated GUS activation. Induction was shown to be possible at essentially any stage of plant growth. This single vector system circumvents the need for genetic crosses required by other, dual recombinase vector systems. The pCrox system may prove particularly useful in instances where transgene over-expression, or under-expression by antisense, would otherwise affect embryo, seed or seedling viability.

Blind separation of signals with mixed kurtosis signs using threshold activation functions.

A parameterized activation function in the form of an adaptive threshold for a single-layer neural network, which separates a mixture of signals with any distribution (except for Gaussian), is introduced. This activation function is particularly simple to implement, since it neither uses hyperbolic nor polynomial functions, unlike most other nonlinear functions used for blind separation. For some specific distributions, the stable region of the threshold parameter is derived, and optimal values for best separation performance are given. If the threshold parameter is made adaptive during the separation process, the successful separation of signals whose distribution is unknown is demonstrated and compared against other known methods.

Effect of microgravity on plasma catecholamine responses to stressors during space flight.

The effect of microgravity on the sympathicoadrenal system (SAS) activity in humans and animals has not yet been clarified. Our previous studies suggested that the SAS activity, evaluated by circulating and/or urinary catecholamine (CA) levels in astronauts during space flights, was found to be rather unchanged. However, CA levels were measured in astronauts only at rest conditions. The aim of the present study was to investigate effect of microgravity during space flight and post-flight readaptation on responsiveness of the SAS to somatic and psychic stressors evaluated by levels of catecholamines and their metabolite in the blood of the Slovak cosmonaut during his stay on board the space station Mir.

Detection limit, cut-off and specificity of an improved rapid assay for cardiac troponin T.

The performance of an improved version of the troponin T rapid test TROPT Sensitive was investigated in a multicentre evaluation at twelve centres. The detection limit and the cut-off were determined in a method comparison with Elecsys Troponin T using a total of 365 samples from patients with suspected acute coronary syndromes and 91 samples from healthy blood donors or non-cardiological patients. The analytical specificity was determined by measuring 1271 blood samples from blood donors without any myocardial injury. The test cut-off (90% of results positive) is 0.08 microg/L, and the detection limit is about 0.05 microg/L. The analytical specificity of the test is between 99.7 and 99.9%. With its small area of undefined significance between positive and negative results and its high sensitivity and specificity, TROPT Sensitive is very well suited to the reliable detection of troponin T positive patients with acute coronary syndromes.

Are US health professionals likely to prescribe mifepristone or methotrexate?

OBJECTIVE: To determine US health professionals' knowledge, attitudes, and practices regarding mifepristone and methotrexate as abortifacients. METHODS: In 1997, we conducted a nationally representative telephone survey of US obstetrician/gynecologists (OBs), family practice physicians (FPs), nurse practitioners (NPs), and physician assistants (PAs). RESULTS: Most health professionals surveyed considered themselves at least "somewhat familiar" with mifepristone or methotrexate, but few reported being "very familiar" with the methods. OBs were most likely to report being familiar with mifepristone (79%), followed by NPs/PAs (73%), and FPs (62%). FPs and NPs/PAs reported being less familiar with methotrexate than with mifepristone. If mifepristone were approved by the Food Drug Administration (FDA), 54% of OBs said they would be "very" or "somewhat" likely to prescribe the drug for abortion, including 35% of OBs who do not perform surgical abortions currently. About half of FPs and NPs/PAs were interested in offering mifepristone if approved by the FDA. Few health professionals reported ever having prescribed methotrexate for abortion. CONCLUSION: The providers most likely to express interest in offering medical alternatives were OBs who reported they "ever perform surgical abortions." Many health professionals who said they do not perform surgical abortions also said they would be interested in prescribing mifepristone, indicating a potential expansion of the number of health professionals who will provide abortion services. Medical protocol and legal issues may inhibit or slow expansion of the pool of providers offering medical abortion.

Exploring the use of qualitative methods in published health services and management research.

There is interest in promoting greater use of qualitative methods in health care research. However, little is known about the volume or characteristics of published studies that use qualitative methods. This article explores these issues through a systematic review of 3 years (1995-1997) of articles classified as research in nine core health services research and management journals. The findings show that only about one in seven published research articles used qualitative methods. Two of the nine journals reviewed contributed 45 percent of the total number of articles using qualitative methods. Four journals contributed a combined 2 percent of this total number. The primary purposes in using these methods are description and articulating stakeholder perspectives. There is no standard number of pages devoted by journals to these studies or evidence that they require more journal space on average than quantitative studies. Most of the studies reviewed presented little or no information on methodology. These findings clarify future areas of emphasis for both editors and researchers wishing to promote the use of qualitative methodology in published health care research.

Professional commitment among US physician executives in managed care.

This paper examines professional commitment among physician executives working in managed care settings in the United States. The rise of an 'administrative elite' in medicine is central to the notion that physicians preserve their professional dominance despite changes in their prestige, work and employment status. Implicit in the notion of Freidson's restructuring perspective, physician executives presumably remain dedicated to professional interests in their management roles. The findings of a national survey support this assumption. Physician executives maintain meaningful, stable levels of professional commitment over time in management and the organization. This commitment is positively related to work-related characteristics involving favorable perceptions of the management job and physical and mental 'connection' to the practice of medicine. Belief in one's ability to successfully deliver appropriate clinical care, however, moderates the positive association between involvement in the management job and professional commitment. The findings provide a rationale for the maintenance of professional loyalty among physicians in management rooted in the work-related perceptions and activities of the individual physician executive.

Physician unionization in the United States: fad or phenomenon?

This article explores the current trends and issues surrounding physician unionization in the United States, using data from secondary sources and nine interviews with leaders of organizations at the forefront of physician unionizing efforts. Several key points are supported by these data and prior unionization research. First, unions should become a viable organizing alternative for the almost 50% of doctors who are salaried employees because of fewer legal barriers to collective representation, the involvement of national labor unions with resources to spend on organizing, more physicians belonging to demographic groups less hostile to organized labor. and work-related pressures faced by physician-employee under managed care. A second key point is that unions will find it difficult to represent self-employed physicians because of the influence of organized medicine and legal barriers to gaining collective bargaining rights for this group. This discussion is intended to raise awareness of the physician union issue among health care policy-makers and researchers.

Clinical Reasoning of a Novice versus an Experienced Occupational Therapist: A Qualitative Study.

The clinical reasoning process is an important aspect of occupational therapy practice. The purpose of this critical, focused ethnography was to compare the clinical reasoning process of an experienced and novice therapist. Individual semi-structured interviews were conducted with an experienced and a novice therapist after each had reviewed a sample case study to help elicit the clinical reasoning process. Observations in the clinical setting were conducted. Themes which emerged include definitions of clinical reasoning, sources used when reasoning, factors influencing clinical reasoning, ability to prioritize, patient viewed as an individual, patients' role in treatment, and clinical reasoning as an evolving process. Similarities and differences between the therapists are noted and discussed. Implications for practice, education, and future research are identified.

The paradox of legitimacy: physician executives and the practice of medicine.

This study looks at the legitimation of medical management and its effect on the likelihood of physician executives practicing medicine. The findings of a national survey show that several individual-level characteristics associated with legitimation such as working in senior management positions and for-profit organizations lower the probability that a physician executive will also be an active clinician. In addition, physician executives possessing graduate management degrees are more likely not to practice medicine than individuals without a degree. These results suggest that the specialty of medical management should pay greater attention to its unique qualities as it legitimizes if it is to be of long-term value to health care organizations and rank-and-file physicians.

Using quality function deployment to capture the voice of the customer and translate it into the voice of the provider.

BACKGROUND: Health care has a number of historical barriers to capturing the voice of the customer and to incorporating customer wants into health care services, whether the customer is a patient, an insurer, or a community. Quality function deployment (QFD) is a set of tools and practices that can help overcome these barriers to form a process for the planning and design or redesign of products and services. The goal of the project was to increase referral volume and to improve a rehabilitation hospital's capacity to provide comprehensive medical and/or legal evaluations for people with complex and catastrophic injuries or illnesses. HIGH-LEVEL VIEW OF QFD AS A PROCESS: The steps in QFD are as follows: capture of the voice of the customer, quality deployment, functions deployment, failure mode deployment, new process deployment, and task deployment. The output of each step becomes the input to a matrix tool or table of the next step of the process. CASE STUDY EXAMPLE: In 3 1/2 months a nine-person project team at Continental Rehabilitation Hospital (San Diego) used QFD tools to capture the voice of the customer, use these data as the basis for a questionnaire on important qualities of service from the customer's perspective, obtain competitive data on how the organization was perceived to be meeting the demanded qualities, identify measurable dimensions and targets of these qualities, and incorporate the functions and tasks into the delivery of service which are necessary to meet the demanded qualities. DISCUSSION: The future of providing health care services will belong to organizations that can adapt to a rapidly changing environment and to demands for new products and services that are produced and delivered in new ways.