Evaluation of the effect of endovascular options on infrarenal abdominal aortic aneurysm repair.

Endovascular devices designed to exclude flow to infrarenal abdominal aortic aneurysms (AAA) were approved by the Food and Drug Administration in the United States in 1999. This action allowed widespread use of this technology for AAA exclusion. The purpose of this report is to examine trends for use of these modalities, rates of rupture of AAA, and to compare results of open AAA repair with endovascular repair. Results were collected for all hospitals, except for Veterans Administration hospitals, by a state-wide repository. Data for the years 1996 through 1998 and 2001 through 2002 were evaluated, and data from 1999 through 2000 were excluded because no separate codes were available to distinguish between open and endovascular repair. The information gathered is based on the All Patient Refined Diagnostic Related Group (APRDRG; 3M, St. Paul, MN). An average of 718 open, elective AAA was performed between 1996 and 1998. This dropped to 503 open repairs from 2001 to 2002 (P < 0.005). During that same interval, 308 endovascular elective AAA repairs were performed, therefore the total rate of elective repair increased by 100. The average rate of ruptured AAA repairs from 1996 to 1998 was 121 per year, and this dropped to 89 from 2001 to 2002 (P < 0.005). The mortality of open AAA repair during the 1996 to 1998 and 2001 to 2002 intervals was unchanged (4.7%). Mortality from endovascular AAA repair between 2001 and 2002 was 1.9 per cent (P = 0.003). Major morbidity was 14.5 per cent for open, elective AAA repair and 6.3 per cent for endovascular elective repair from 2001 to 2002 (P < 0.001). These data suggest that the advent of endovascular AAA repair has contributed to a reduction in the rate of ruptured AAA repairs, an increase in total procedures performed, and a significant decrease in perioperative deaths and major complications when compared with open AAA repair.

Carotid endarterectomy: update on the gold standard treatment for carotid stenosis.

Many prospective, randomized clinical trials evaluating the safety and efficacy of carotid endarterectomy (CEA) versus medical management in the prevention of ischemic stroke were performed in the 1990s. Clinical trials are underway that will compare CEA outcomes to carotid stenting; however, relatively few studies have examined the outcomes of modern CEA. The purpose of this report is to examine current outcomes of CEA and evaluate hospital costs and length of stay. Statewide results were collected for all hospitals, except Veterans Administration hospitals, by Virginia Health Information (VHI). Data for the years 1997-2001 were evaluated, and data were based on the All Patient Refined Diagnostic Related Group (APR-DRG; 3M Company). A total of 14,095 CEAs were performed in a 5-year period. The mortality of patients undergoing CEA was 0.5 per cent. The stroke rate was 1 per cent overall and decreased each year of the study. Mean and median lengths of hospital stay were 3 and 2 days, respectively. Length of stay decreased over the course of this study. Mean and median hospital costs were 14,331 dollars and 11,268 dollars. Higher rates of mortality and stroke and higher costs were observed at low-volume hospitals. The need for CEA is substantial. CEA is safe and inexpensive. The data presented here demonstrates continued refinement in CEA, leading to a very low rate of perioperative adverse events, declining lengths of stay, and low hospital costs.

Examination of sex as an independent risk factor for adverse events after carotid endarterectomy.

BACKGROUND: The incidence of adverse events after carotid endarterectomy (CEA) for women compared with men is controversial. This report compares the incidence of perioperative stroke and death in men and women by examining the effect of comorbidities and hospital setting on CEA outcomes. METHODS: All CEAs performed in non-Federal acute-care Virginia hospitals between 1997 and 2001 were reviewed. Patient demographics, comorbidities, and hospital characteristics were compared for possible relationships to perioperative adverse events. RESULTS: A total of 14,095 CEAs were performed in 34 urban and 28 rural hospitals (9 high-volume and 53 low-volume hospitals); 42% were performed on women, and 58% were performed on men. Women experienced a significantly higher stroke rate (1.23%) than men (0.87%; P = .04) with bivariate analysis. However, logistic regression analysis of comorbidities and hospital settings demonstrated that sex was actually not independently related to adverse outcomes in CEA ( P = .08). Preoperative neurologic symptoms could not be evaluated as risk factors for adverse events. Acute coronary ischemia, history of arrhythmia, end-stage renal disease, nonwhite race, advanced age, and low hospital volume were all significantly related to mortality. History of arrhythmia was the only factor that was significantly related to the incidence of stroke. CONCLUSIONS: Logistic regression analysis of comorbidities and hospital setting indicated that female sex is not independently associated with higher mortality or a higher stroke rate during CEA. These data indicate that patients with carotid stenosis frequently have multiple medical problems that need to be carefully examined and controlled before any single patient or hospital factor is designated as significantly related to adverse outcomes.

Measuring risk and protective factors for substance use, delinquency, and other adolescent problem behaviors. The Communities That Care Youth Survey.

Risk and protective factors predictive of adolescent problem behaviors such as substance abuse and delinquency are promising targets for preventive intervention. Community planners should assess and target risk and protective factors when designing prevention programs. This study describes the development, reliability, and validity of a self-report survey instrument for adolescents ages 11 to 18 that measures an array of risk and protective factors across multiple ecological domains as well as adolescent problem behaviors. The instrument can be used to assess the epidemiology of risk and protection in youth populations and to prioritize specific risk and protective factors in specific populations as targets for preventive intervention.

The quantity and quality of the social networks of young people with early psychosis compared with closely matched controls.

This study compares the social networks and perceived social support of 26 people with early psychosis and 26 people without a mental illness. The two groups were closely matched for age, sex, education level, and employment and relationship status, and had equivalent levels of depression. There were no differences between the two groups in the amount of perceived social support, number of family members, and number of participants with acquaintances. However, the psychosis group identified significantly smaller networks, t (50)=-2.34, P=0.024, with fewer friends, t (48)=-3.61, P=0.001, fewer people to turn to in a crisis, t (22.97)=-2.34, P=0.028, and a higher likelihood of service providers as members, chi(2)(1)=7.02, P=0.008. Given the important relationship between strong social networks and high levels of community functioning and tenure, future research needs to evaluate the type of social support most beneficial for people with early psychosis and to develop strategies to maintain and facilitate that support.

At-risk and not at-risk primary school children: an examination of goal orientations and social reputations.

AIMS: The purpose of the present research was to examine whether at-risk and not at-risk primary school aged students differ in two social and psychological domains (future goal orientations and social reputation). SAMPLE: A total of 886 years 5, 6 and 7 students from five primary schools in the Brisbane metropolitan area of Queensland, Australia, participated in the study. METHOD: The Children's Activity Questionnaire which constitutes three parts (demographic information, the Importance of Goals Scale, and the Reputation Enhancement Scale) was administered under standardised conditions. RESULTS: A series of multivariate analyses of variance (MANOVA) and univariate F-tests performed on each of the sets of dependent variables (goal orientations and reputation enhancement) revealed significant differences between the at-risk and not at-risk participants on both goals and reputation. CONCLUSIONS: Not at-risk children sought to attain an Academic Image through education and interpersonal goals, whereas at-risk children sought a Social Image and attached greater importance to physical goals. In line with this, children in the not at-risk group perceived themselves and ideally wished to be perceived as a conforming person, while at-risk children perceived themselves and ideally wished to be perceived as non-conforming. Significant gender differences were also found on both sets of dependent variables. COMMENT: The findings are compared to recent research conducted with high school adolescents.

Stress and coping in early psychosis. Role of symptoms, self-efficacy, and social support in coping with stress.

BACKGROUND: Although coping with stress is important in early psychosis, little is known about how this population copes with the range of stressors they encounter in their daily life. This study aims to identify how people with early psychosis cope with a range of stressful situations and to identify what factors might influence their use of coping strategies. METHOD: Participants included a clinical group of 50 people with early psychosis and a non-clinical group of 22 people matched on age and gender. Data were obtained on symptomatology and social support for the clinical group, and stress and coping, and self-efficacy for all participants. RESULTS: The clinical group reported coping less well than the non-clinical group and they most commonly used emotion-focused coping. For the clinical group, effective coping correlated with less severe negative symptoms, greater perceived self-efficacy, social support and greater use of problem-focused coping. Self-efficacy and social support predicted increased frequency of the use of problem-focused coping. CONCLUSION: People with early psychosis who have greater feelings of self-efficacy and perceived social support, and the flexible use of problem-focused coping strategies, appear to be more likely to cope with day-to-day stressors.

Cognitive-linguistic subgroups in closed-head injury.

This study examined variability in the interrelationship between language skill and neuropsychological function within a group of 25 severe closed head injury (CHI) subjects and 23 matched controls. All subjects underwent a battery of standardized language and neuropsychological tests. Cluster analyses were conducted to determine whether the CHI sample was universally or differentially impaired. Further subgroup analysis using a Q-type factor analysis outlined the differences in performance profiles within the group of CHI subjects. Results support the hypothesis that while some deficits were common to all CHI subjects, impairments delineated by whole group analysis do not necessarily represent universal impairments. In particular, ability to perform tasks involving auditory comprehension, naming, verbal memory, visual memory and visuospatial skills appeared to be important components in group differentiation. The cognitive-linguistic impairments which were common to all CHI subjects and considered to be the 'cardinal' cognitive-linguistic deficits following severe CHI were deficits in lexical-semantic and sentential semantic skills, verbal fluency, complex auditory comprehension, and attentional operations. Profile analysis revealed the existence of a double dissociation between performances on naming and verbal memory tasks and performances on visually related cognitive tasks. Results are discussed with reference to findings on previous studies of subgroups in the CHI population.

Social skill as determinant of social networks and perceived social support in schizophrenia.

Factors influencing supportive social networks of people with schizophrenia are little understood. Data from 46 outpatients with schizophrenia were analysed using structural equation modelling to test plausible sets of inter-relationships between social skill, social networks, and social support. The data supported a tentative model about the causal relationships between variables. Paths showed that people with greater social skill had larger social networks, but did not necessarily perceive greater support from these networks. Negative symptoms accounted for some of the effect of social skill on social networks. Whereas groups of single-admission and multiple-admission participants did not differ in terms of social skill, social networks, or support, the age of the participants influenced their social skill and the size of their social networks. Younger participants had greater social skill and larger social networks. The results appear to suggest the importance of early intervention for young people with first-episode psychosis.

Length of stay, leave and re-offending by patients from a Queensland security patients hospital.

OBJECTIVE: The release of patients from a security patients hospital has been the subject of public controversy. The present study uses empirical data to examine the length of stay, leave, and re-offending of patients from a security hospital. METHODS: Survival analysis was used to examine factors that may be predictive of length of stay and time under restriction, as well as time to first overnight leave. Data on re-offending were obtained from a variety of sources and were compared with seriousness of index offences. RESULTS: Consistent with international research, patients with more serious offences had longer hospitalisations. Patients with more serious offences were also hospitalised for longer periods before leave was granted. Compared with international studies, re-offending was in the lower range. CONCLUSIONS: Despite concerns raised in the media regarding patient 'dangerousness', time spent in hospital and the granting of leave, patients with serious offences were more likely to be hospitalised longer, which suggests decision makers do take into account public safety.

Subject-based problem-based learning in the veterinary science course at the University of Queensland.

OBJECTIVE: To assess students' perceptions of subject-based problem-based learning in the fourth year of the veterinary science course at the University of Queensland. DESIGN: A questionnaire-based study. PROCEDURE: Subject-based problem-based learning was introduced into parts of two fourth year subjects in a 5-year veterinary science course. The problem-based learning exercise used modified clinical cases and was computer-assisted. Students worked in groups of two to four, and small group discussion sessions were tutorless. Lectures were replaced by large group discussion and feedback sessions, led by the teacher, with approximately 85 students. RESULTS: There was a significant increase in the percentage of students who strongly agreed that they had better understanding of the subject, and had learned to apply principles from this class in new situations. The only consistent criticism by students was directed at the extra time required compared to traditional lecture-based subjects. CONCLUSION: Students' perceptions of the learning outcome were very favourable for problem-based learning when compared to the lecture-based subject.

Team managed outpatient care for early onset chronic inflammatory arthritis.

OBJECTIVE: To determine whether an outpatient team management program for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional, nonteam outpatient rheumatologic care in a clinic setting. METHODS: One hundred eighteen patients with chronic inflammatory arthritis were randomly assigned to a team managed outpatient care program (TEAMCARE) or to traditional, one on one, nonteam managed rheumatologic care (TRADCARE). The TEAMCARE program consisted of a half day educational program, a needs assessment intake interview, and quarterly telephone calls, monthly team meetings, and routine rheumatologic care. TRADCARE patient received unconstrained, routine primary and specialty outpatient care as practised typically by rheumatologists at this large multi-specialty clinic. All patients had numerous physical and laboratory outcome assessments by rheumatologists at office visit. Every 6 months, patients completed several self-report measures of functional status, pain, psychosocial status, and costs. RESULTS: One hundred seven patients completed one year of study participation. No significant differences were found between groups in measures of physical status, physical functioning, psychosocial status, or pain. There were no differences between groups in economic or utilization measures. CONCLUSION: This team managed outpatient program for persons with recent onset chronic inflammatory arthritis afforded no advantage to routine outpatient care, characterized mainly by one on one relationships between patients and primary care doctors and rheumatologists, in our active outpatient clinical environment.

A structural model of the dimensions of teacher stress.

A comprehensive survey of teacher stress, job satisfaction and career commitment among 710 full-time primary school teachers was undertaken by Borg, Riding & Falzon (1991) in the Mediterranean islands of Malta and Gozo. A principal components analysis of a 20-item sources of teacher stress inventory had suggested four distinct dimensions which were labelled: Pupil Misbehaviour, Time/Resource Difficulties, Professional Recognition Needs, and Poor Relationships, respectively. To check on the validity of the Borg et al. factor solution, the group of 710 teachers was randomly split into two separate samples. Exploratory factor analysis was carried out on the data from Sample 1 (N = 335), while Sample 2 (N = 375) provided the cross-validational data for a LISREL confirmatory factor analysis. Results supported the proposed dimensionality of the sources of teacher stress (measurement model), along with evidence of an additional teacher stress factor (Workload). Consequently, structural modelling of the 'causal relationships' between the various latent variables and self-reported stress was undertaken on the combined samples (N = 710). Although both non-recursive and recursive models incorporating Poor Colleague Relations as a mediating variable were tested for their goodness-of-fit, a simple regression model provided the most parsimonious fit to the empirical data, wherein Workload and Student Misbehaviour accounted for most of the variance in predicting teaching stress.

Opportunities for communication in classrooms serving children with developmental disabilities.

Documented the number and types of opportunities for communication provided by teachers in seven classrooms for children with developmental disabilities and by teachers of nonhandicapped preschoolers in a day care center. In the special education settings, less than 14% of the more than 6,000 observation intervals contained an opportunity for communication. Most opportunities involved naming an object or event followed in frequency by opportunities to request, answer, and imitate. Similar results were obtained in the day care center. In the special education classrooms, a strong positive correlation was found between a child's existing communication skills and the number of opportunities received. Results suggest that these teachers did incorporate opportunities for communication into classroom activities.

Relationship between Type A behavior pattern and mental and physical symptoms: a comparison of global and component measures.

Although the Type A behavior pattern (TABP) is typically considered a set of distinct components, most studies of TABP have used global measures, which collapse several components into a single index. These measures are inherently multidimensional and, as such, contain several conceptual and methodological problems. In this study, data from 240 executives were used to compare global and component TABP measures as predictors of mental and physical symptoms. Global measures included the Bortner scale, the Framingham scale, and the Jenkins Activity Survey. Component measures were constructed by recombining items from the global measures on the basis of results from previous confirmatory factor analyses (Edwards, Baglioni, & Cooper, 1990). Results indicate that the component measures were superior to the global measures in terms of number of relationships detected, interpretability, and total explanatory power. Implications for research and practice are discussed.

The psychometric properties of the Bortner Type A Scale.

Recent evidence indicates that the relationship between Type A behaviour pattern (TABP) and coronary heart disease (CHD) is dependent upon the method of measuring TABP. This suggests that the psychometric properties of TABP measures should be carefully investigated. This article examines one widely used TABP measure, the Bortner Scale, using data from 1320 working adults divided into three random samples. The reliability of the Bortner Scale as an overall TABP index is unacceptably low. However, further analyses indicate that, rather than reflecting a single dimension, the Bortner Scale contains two independent dimensions, one reflecting speed and the other reflecting competitiveness. The speed dimension was negatively related to job satisfaction and, to a lesser extent, positively related to anxiety and somatic symptoms, whereas the competitiveness dimension was positively related to job satisfaction. Implications for the use of the Bortner Scale are discussed.

Examining the relationships among self-report measures of the Type A behavior pattern: the effects of dimensionality, measurement error, and differences in underlying constructs.

The most widely used self-report measures of the Type A behavior pattern (TABP) are the Bortner scale, the Framingham scale, and the Jenkins Activity Survey (JAS). Though high scores on each of these measures have been linked to the development of coronary heart disease, their intercorrelations are rather low, suggesting that they may reflect different aspects of TABP. This study indicates that the low correlations among the Bortner scale, the Framingham scale, and the JAS are due not only to differences in underlying constructs but also to measurement error and multidimensionality. These results also identify several psychometric problems, which raise serious questions regarding the use of these measures in TABP research. Suggestions for the development of new measures of TABP are offered.

DRG ripple and the shifting burden of care to home health.

It is no secret to any nurse in community health care that the DRG system has caused major shifts in the nature of the patient load, types of patients served, and level of care technology required. Phillips et al. detail the mechanism by which the care demands of the community have changed.

A reexamination of the effectiveness of self-care education for persons with arthritis.

We examined the effectiveness of 2 models of arthritis self-care intervention, the home study model and the small group model. The effects of disease diagnosis and duration, self-care behavior, perceived helplessness, social support, treatment choice, and formal education level on outcomes among persons with arthritis who participated in these programs were evaluated. A pretest-posttest control group design was utilized in the initial experimental study; comparison group designs were used in the longitudinal studies. Three hundred seventy-four subjects completed the interventions and 12 months of research followup. We found that the intervention models had a statistically significant positive impact on arthritis knowledge, self-care behavior, perceived helplessness, and pain. These findings did not vary when the effects of education level, disease diagnosis and duration, informal social support, and treatment choice were controlled. The small group intervention was more effective in bringing about initial improvements in pain and depression, whereas the home study intervention was more effective in maintaining improvements in perceived helplessness. Changes in perceived helplessness and self-care behavior appear to explain in part the observed improvement in pain.

A structural model approach toward the development of a theory of the link between stress and mental health.

This study attempts to develop an empirical model of the link between stress and mental health, focusing particularly on occupational stress. Three different models were assessed-the person-stress model, the dispositional model, and the indigenous model--using structural equation modelling. The indigenous model was found to be the most predictive of mental health. In this model, personality and coping strategies precede and determine the perception of job stressors, which ultimately affect the mental well-being of the individual.