The complexity of managing COPD exacerbations: a grounded theory study of European general practice.

OBJECTIVES: To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). DESIGN: 21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs. SETTING: Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong). PARTICIPANTS: 142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians. RESULTS: Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from 'dealing with comorbidity' through 'having difficult patients' to 'confronting a hopeless disease'. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label 'difficult' exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with 'a hopeless disease' due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition. CONCLUSIONS: Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning.

Microfungal contamination of damp buildings--examples of risk constructions and risk materials.

To elucidate problems with microfungal infestation in indoor environments, a multidisciplinary collaborative pilot study, supported by a grant from the Danish Ministry of Housing and Urban Affairs, was performed on 72 mold-infected building materials from 23 buildings. Water leakage through roofs, rising damp, and defective plumbing installations were the main reasons for water damage with subsequent infestation of molds. From a score system assessing the bioavailability of the building materials, products most vulnerable to mold attacks were water damaged, aged organic materials containing cellulose, such as wooden materials, jute, wallpaper, and cardboard. The microfungal genera most frequently encountered were Penicillium (68%), Aspergillus (56%), Chaetomium (22%), Ulocladium, (21%), Stachybotrys (19%) and Cladosporium (15%). Penicillium chrysogenum, Aspergillus versicolor, and Stachybotrys chartarum were the most frequently occurring species. Under field conditions, several trichothecenes were detected in each of three commonly used building materials, heavily contaminated with S. chartarum. Under experimental conditions, four out of five isolates of S. chartarum produced satratoxin H and G when growing on new and old, very humid gypsum boards. A. versicolor produced the carcinogenic mycotoxin sterigmatocystin and 5-methoxysterigmatocystin under the same conditions.

How much do we count? Interpretation and error-making in the decennial census.

Following a critique of the 1990 decennial census procedures, we conducted a field study among low-income, inner-city residents in 1991 to examine how they conceptualized and managed the civic task of census response. Interpretations about the purpose and meaning of the census, about commitment to the task, and about connection to government, singly and together with literacy skills (e.g., reading and general literacy competence), were associated with errors that are not detectable by evaluative methodologies used regularly by the Census Bureau. The validity and reliability of census data, and possibly other self-administered survey research, will be increased by greater use of knowledge about both interpretation and literacy skills in formulating data collection procedures.

Occupational social work for the 21st century.

Economic restructuring and radical changes in welfare policy are causing increasingly severe employment dislocation and disadvantage among many urban residents, particularly women, members of racial and ethnic minority groups, and youths. Despite the profession's historic commitment to poor people, little advanced social work practice is reported in work-enhancement programs. This article outlines employment-related needs among poor people in the context of economic and policy change. A brief discussion of successful work programs and traditional occupational practice frames the reformulation suggested in the article. Role definitions, settings, and skills needed for expanded occupational social work practice are followed by implications for social work.

[Pushing technique in the expulsive phase of labor. A randomized study]. / Presseteknik i uddrivningsfasen. En randomiseret undersøgelse.

Pushing in the expulsive phase of labour can be forced or follow the spontaneous urge to bear down. Recent studies have shown that spontaneous pushing results in a longer second stage, fewer CTG changes, higher pH in the umbilical artery and less damage to the birth canal. In a randomized trial of spontaneous vs. forced pushing in 350 primipareous women, we found no difference between the two randomized groups with regard to the mentioned variables. Sixty-five point six percent allotted to spontaneous pushing used the closed glottis technique for more than half the expulsive phase. When divided into two groups according to the actual pushing technique used most, the women who used the open glottis technique had a shorter second stage of labor and gave birth to infants with lower birth weight. Recommendation to use spontaneous bearing down efforts did not result in fewer complications to the infant or the mother than recommendation of expulsion by the closed glottis technique.

Pushing method in the expulsive phase of labor. A randomized trial.

BACKGROUND: Pushing in the second stage of labor can be forced or follow the spontaneous urge to bear down. Recent studies have shown that spontaneous pushing results in a longer second stage, fewer CTG changes, higher arterial pH and less damage to the birth canal. METHOD: Randomized trial of spontaneous vs. forced pushing in 350 primiparous women. RESULTS: There was no difference between the randomized groups in duration of second stage of labor, umbilical arterial pH or damage to the birth canal. Of the women allotted to spontaneous pushing, 65.6% used the closed glottis technique for more than half the expulsive phase. When dividing the women into two groups according to the actual pushing technique used most, open or closed glottis, it turned out that women who used the open glottis technique had a shorter second stage of labor and gave birth to infants with lower birth weight. CONCLUSION: Recommending of spontaneous bearing down during the expulsive phase of labor did not result in a significant difference in duration of the second stage of labor, fetal arterial pH or less damage to the birth canal. Women who chose the open glottis technique had a shorter expulsive phase and gave birth to smaller infants than those who used the closed glottis technique.

Successful CPR in a severely hypothermic patient using continuous thoracostomy lavage.

Severe hypothermia with cardiopulmonary arrest often requires prolonged resuscitation while rewarming procedures are implemented. A 63-year-old male in cardiopulmonary arrest with a core body temperature of 23.7 C was resuscitated successfully after core rewarming by means of a two-chest-tube continuous thoracostomy lavage procedure. This lavage procedure resulted in effective and rapid rewarming after other conventional rewarming methods had failed.

A quantitative study of nursing staff interactions in psychiatric wards.

Data from 2 studies investigating staff-patient and staff-staff interaction rates are presented. In the first the staff-patient ratio was varied by holding patient numbers constant and systematically varying staffing levels. The results showed that although the percentage of time nurses spent interacting with patients did not change, staff-staff interaction increased as a function of increased staffing levels. In the second study the interaction rates from 4 wards were combined. These data showed that, as in the first study, staff-patient interaction remained constant, as staff numbers increased, whilst staff-staff interaction increased. However, unlike the first study, when analysed in terms of the staff-patient ratio, both categories of interaction increased as the staff-patient ratio increased.

Licensure: help or hindrance to women social workers.

It is generally believed that licensure benefits the social work profession. In this article, the author argues that licensure both positively and negatively affects the employment of women in the social work profession and that the issue of licensure should be closely studied.

[Modification of the Aue 302 artificial kidney for use with the capillary kidney]. / Umbau der künstlichen Niere "Aue 302" zum Einsatz der Kapillarniere.

By installation of a warm water rotating pump type USp 20-KMR and the forming of a by-pass in the recirculation we could produce the underpressure necessary for the capillary dialysis. This underpressure can be regulated by opening and shutting of a valve. The consequence is the aimed ultrafiltration according to the weights of the dialysis patients. The construction is described in detail and demonstrated by photos.