Preventing home health nursing assistant back and shoulder injuries.

BACKGROUND: Franklin County Home Health Agency (St Albans, Vermont) undertook a performance improvement project in 1996 to reduce employee injuries. A review of recent injuries led to the prevention of licensed nursing assistants' (LNAs') back and shoulder injuries as the first priority. Root causes of injuries were agency communication, employee training, patient home environment, nursing assistant body mechanics, and failure to use safety measures. Given that injury causality is complex and multifactorial, a variety of improvement strategies were implemented over the following two to three years. IMPLEMENTATION OF POTENTIAL SOLUTIONS: Short-term (a few months), mid-term (six months), and long-term (one year) potential solutions to the LNA back and shoulder injury problem were charted. Safety and health training was the major focus of the team's short-term plan. Risk management forms were to be used to identify and follow up on hazardous situations. RESULTS: Project plans that were successfully implemented included revision of LNA plans of care, standardization of the return-to-work process after injury, development of guidelines for identifying unsafe patient lifts and transfers, improved follow-up of employee reports of injury-risk situations in patient homes, improved body mechanics screening of new employees, and a stronger injury-prevention training program for current employees. A less successful initiative was aimed at collecting more data about injuries and causal factors. Employee injuries were gradually reduced from 4-10 per quarter to 0-3 per quarter. CONCLUSIONS: Injury prevention requires commitment, persistence, and patience--but not expensive improvements. Multiple interventions increase the chances of success when there are many root causes and lack of evidence regarding the effectiveness of various approaches.

Improving breastfeeding support: a community health improvement project.

BACKGROUND: Because of the brevity of the postpartum hospital stay, mothers and their newborns are discharged home before breastfeeding is well established. In 1992, feedback from patients who had given birth at Fletcher Allen Health Care (Burlington, VT) suggested a need for more consistent, expert, and timely assistance with breastfeeding in the hospital and better continuity of care during the first few weeks at home. QUALITY IMPROVEMENT TEAM: In 1993 a team developed objectives, analyzed the problem and possible solutions, and made eight recommendations on how the hospital could do more to promote breastfeeding. Implementation by team members and hospital staff included policy development, staff education, acquisition of funding, a visiting professorship, development of a lactation consultant coordinator and team, and patient surveys to evaluate the program. A late 1994 survey of 63 postpartum patients on their day of discharge indicated a high level of satisfaction with breastfeeding support in the hospital. CURRENT STATUS: Activities are being undertaken for lactation consultation coverage, further policy development, implementation of nurse competency validation, improved patient and family education materials, and continued evaluation of the breastfeeding support program through patient surveys. CONCLUSION: In the face of barriers such as the project's large scope, a paucity of internal team members, and a large number and variety of recommendations, some of the recommendations and follow-up plans have yet to be implemented. Yet the project has yielded improvements in care and provides a model of how hospitals can expand their traditional boundaries of care and quality improvement into community health issues.

Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons.

It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

The development of the Maternal Breastfeeding Evaluation Scale.

A Maternal Breastfeeding Evaluation Scale was developed from categories identified in qualitative research. Content validity was tested according to procedures described by Imle and Atwood and Lynn. A sample of 442 women who had breastfed completed an instrument of 56 Likert-scale items. A retest questionnaire was completed by a subsample of 28 women. Exploratory factor analysis resulted in three factors, accounting for 38.5 percent of the variance: Maternal Enjoyment/Role Attainment (29 percent), Infant Satisfaction/Growth (5 percent), and Lifestyle/Maternal Body Image (4 percent). A revised 30-item MBFES was developed using items loading strongly on these three factors. Cronbach's alphas for the revised scale and subscales were .93, .93, .88, and .80, respectively. Test-retest correlations (n = 28) were .93, .93, .94, and .82, respectively (p < .001 for all).

Maternal perceptions of successful breastfeeding.

Twenty-six mothers were interviewed concerning successful and unsuccessful breastfeeding. Constant comparative analysis yielded five major categories of successful breastfeeding: infant health, infant satisfaction, maternal enjoyment, desired maternal role attainment, and lifestyle compatibility. A core concept, working in harmony, emerged as a unifying theme. Mothers described successful breastfeeding as a complex interactive process resulting in mutual satisfaction of maternal and infant needs. This concept broadens definitions of successful breastfeeding often used by health professionals, which emphasize breastfeeding duration and nutritional aspects.

Hemorrhoidectomy--laser vs. nonlaser: outpatient surgical experience.

Two hundred twenty-six patients underwent operative hemorrhoidectomy by a single surgeon in a three-year period. In 170 patients (75.2 percent), the operation was performed utilizing the CO2 laser. Standard closed hemorrhoidectomy was done in the rest. Patients were monitored prospectively for postoperative pain, wound healing, and complications. The feasibility of undergoing operative hemorrhoidectomy as an outpatient was also monitored. No differences were seen between laser and nonlaser hemorrhoidectomy. Outpatient surgery was done in over 72 percent of the patients without any added risk to them.

The breast-feeding experience of women with type I diabetes.

The purpose of this exploratory study was to identify the factors influencing the initiation and maintenance of breast-feeding in women with insulin-dependent diabetes. The lack of research in this area and the need for in-depth data necessitated exploratory methodology. Twenty-two mothers who were insulin dependent before pregnancy and who had given birth in the past 2 years were interviewed. Diabetes was not a principal factor in the decision to breast-feed or bottle-feed for the majority of the women. When diabetes was a factor, women were seeking a "normal" childbearing experience, including breast-feeding. Although the women did not perceive diabetes as influencing their breast-feeding experiences, they did find that maintaining good diabetic control required greater effort and flexibility during breast-feeding.

[It is imperative to stop environmental degradation]. / Es urgente detener la degradacion ambiental.

PIP: Environmental demography deals with socioenvironmental determinants of demographic processes. The fertility decline of recent years in Mexico is not associated with economic transformation, as the economic crisis, poverty, unemployment, and social inequality have been barely mitigated. Mexico is mainly urban: 51% of the population lived in cities with more than 100,000 inhabitants in 1990 taking an increasing toll on the environment. The metropolitan area of Mexico City has 50% of industrial production with 36,000 industrial plants, 2100 of all 5400 chemical plants, 22% of total population, and 25% of economically active population. There are 3 million cars. 11,000 tons of solid waste is generated daily (75% domestic and 25% industrial), and 5 million tons of contaminants are emitted annually. Sulphur, dioxide, nitrogen, ozone, and suspended particulate levels often exceed international standards. In the federal district more than 1000 squatter colonies are without drainage that affects 5 million people; and 30% of the population is without a sewage network. There are 35 cities with over 100,000 population that cannot meet their needs of drinking water with the result of a high level of gastrointestinal ailments, enteritis, diarrhea, rabies, and dengue fever caused by pathogenic microorganisms, the major cause of mortality. The degradation of the environment produces a pathological environmental emergency from chemical contamination of the air and from exposure to industrial emissions, to agrochemical products and toxic substances, to lead, insecticides, arsenic, and asbestos. Mexico has one of the highest levels of lead in the blood and DDT in mother's milk. In Mexico City lead concentration of 5 mg/cubic meter in the air, 20 mg/100 ml in maternal blood, and 13 mg/100 ml in the umbilical cord was detected associated with retardation of mental development in the 1st year of life and chronic lead poisoning.^ieng

Comparison of the effectiveness of videotape versus live group infant care classes.

Postpartum women on a hospital maternity unit viewed a videotape on infant care or attended a group class on infant care. Content quiz scores for the two groups were not significantly different. Although the majority of both groups thought the live class was a better way to teach new mothers about infant care, no significant differences on measures of convenience, ease of understanding, level of interest, amount learned, and how relaxed the mother felt were identified.

Hemorrhoids.

Hemorrhoids often may be relieved by relatively simple medical management. When this fails, a number of office procedures are available, including rubber band ligation, which is most widely used. Surgical therapy is still useful and preferred for patients with large third-degree or fourth-degree hemorrhoids; cryotherapy is no longer a popular alternative with either patients or physicians. More experience is needed with infrared photocoagulation. Studies of laser hemorrhoidectomy have not been sufficient to assess its role in the treatment of hemorrhoidal disease.

Expression of neurofilament and neuron-specific enolase in small cell tumors of skin using immunohistochemistry.

Trabecular carcinoma of the skin (Merkel cell tumor), a neoplasm of putative neural origin, must be differentiated from other small cell tumors primary or metastatic to skin. In order to provide more objective diagnostic criteria, four were examined using monoclonal antibodies against neurofilament proteins (NF) and antiserum specific for neuron-specific enolase (NSE). Immunohistochemistry demonstrated immunoreactive NF in three and NSE in four cases. NF immunoreactivity was arranged in paranuclear balls, consistent with ultrastructural observations of aggregated intermediate filaments. A case of pulmonary oat cell carcinoma metastatic to the skin also contained immunoreactive NF and NSE. Although NF and NSE do not discriminate metastatic oat cell carcinoma from trabecular carcinoma of skin, they are useful antigens that provide objective criteria for recognizing tumors of neural histogenesis or neural differentiation. They should make it possible to exclude non-neural lesions from the differential diagnosis of small cell tumors of the skin.

Anastomotic recurrences after low anterior resection. Stapled vs. hand-sewn.

A retrospective study was done comparing the rates of local recurrence in cancer of the rectum treated by low anterior resection using the stapling device or hand-sewn. It was found that there was no increase in recurrences when the stapler was used, even though lower lesions were treated.