Creating a community-based comprehensive intervention to improve asthma control in a low-income, low-resourced community.

Introduction: Asthma evidence-based interventions (EBI) are implemented in the home, school, community or primary care setting. Although families are engaged in one setting, they often have to navigate challenges in another setting.Objective: Our objective is to design and implement a comprehensive plan which integrates EBI's and connects the four sectors in underserved communities such as Philadelphia.Methods: September 2015-April 2016 we implemented a three-pronged strategy to understand needs and resources of the community including 1) focus groups and key informant interviews, 2) secondary data analysis and 3) pilot testing for implementation to determine gaps in care, and opportunities to overcome those gaps.Results: Analysis of the focus group and key informant responses showed themes: diagnosis fear, clinician time, home and school asthma trigger exposures, school personnel training and communication gaps across all four sectors. EBI's were evaluated and selected to address identified themes. Pilot testing of a community health worker (CHW) intervention to connect home, primary care and school resulted in an efficient transfer of asthma medications and medication administration forms to the school nurse office for students with uncontrolled asthma addressing a common delay leading to poor asthma management in school.Conclusion: Thus far there has been limited success in reducing asthma disparities for low-income minority children. This study offers hope that strategically positioning CHWs may work synergistically to close gaps in care and result in improved asthma control and reduced asthma disparities.

Combined cardiac catheterization for uncomplicated ischemic heart disease in a Medicare population.

PURPOSE: Experts recommend left heart catheterization alone to evaluate uncomplicated ischemic heart disease, reserving right heart catheterization for specific indications. Yet some centers routinely perform combined cardiac catheterization (left heart catheterization and right heart catheterization together). SUBJECTS AND METHODS: Using 1992-1993 Pennsylvania Medicare claims for cardiac catheterizations (n = 41,180), we examined rates of combined cardiac catheterization for patients with uncomplicated ischemic heart disease for each hospital (n = 73) that performed catheterizations. We compared combined cardiac catheterization rates among hospitals and developed a multivariable model to identify hospital characteristics associated with high combined cardiac catheterization rates. A random sample of cases from the 10 hospitals with the highest combined cardiac catheterization rates were reviewed to determine justification, complications, and results of combined cardiac catheterization. RESULTS: Of the 41,180 cardiac catheterizations, 14,177 (34%) were combined procedures. Among hospitals, combined cardiac catheterization rates varied from 2% to 98%. Hospital characteristics associated with high combined cardiac catheterization rates included having a cardiology fellowship program (relative risk [RR] 1.7, 95% confidence interval [CI] 1.1-2.7), location in eastern Pennsylvania (RR 2.5, 95% CI: 1.8-3.5), and volume of catheterizations performed (RR 0.95, 95% CI: 0.91-0.99/100 procedures). For reviewed cases, the most common justification for combined cardiac catheterization was planned revascularization (44%), which is not a specific indication. Only 49% of cases had at least one specific indication for right heart catheterization (range by hospital, 30%-74%). The abnormal findings on the right heart catheterization rarely appeared to change management. CONCLUSION: There is wide variation in the practice of combined cardiac catheterization, which appears to be related to teaching status and geographic location. The most common justification for the procedure was planned revascularization, which is not one of the specific indications supported by current literature.

Using pictographs to enhance recall of spoken medical instructions.

Pictographs have been used in nonliterate societies to help people remember spoken instructions and, today, they could be used to help nonliterate people remember spoken medical instructions. This study tested the hypothesis that pictographs can improve recall of spoken medical instructions. Twenty-one junior college subjects listened to lists of 38 actions for managing fever and 50 actions for managing sore mouth. One of the action lists was accompanied by pictographs during both listening and recall while the other was not. Subjects did not see any written words during the intervention and, therefore, relied entirely on memory of what they heard. Mean correct recall was 85% with pictographs and 14% without (P < 0.0001) indicating that pictographs can enhance memory of spoken medical instruction--often to a very high level. For this technique to be clinically useful, further research is needed on how to achieve accurate recall of large amounts of medical information for long periods of time by nonliterate patients. By viewing illiteracy as a memory problem, the large body of research on learning and memory can be utilized in designing education materials for this group.

[Nutritional balance of the diet of the adult residents of Geneva]. / Equilibre nutritionnel de l'alimentation de la population adulte résidant à Genève.

Diet of the Swiss population has probably changed over the last 10 years, but these changes have not been recorded yet by nutritional studies. In the present study, 3 registered dieticians interviewed over the telephone 626 adults, resident of Canton Geneva, using a 24 hour recall. Interviews were performed during the 7 days of the week. Participants were randomly selected according to their age, sex and nationality. Participation was 80%. The following caloric (C) and nutritional intakes in proteins (P), lipids (L), carbohydrates (CH) and alcohol (A) were recorded: In non Swiss men: C = 2464 kcal/j., P = 16.2%, L = 32.4%, CH = 44.4%, A = 7.0%; in Swiss men: C = 2752 kcal/j., P = 15.3%, L = 34.0%, CH = 43.5%, A = 7.1%; in non Swiss women: C = 1897 kcal/j., P = 16.4%, L = 35.1%, CH = 46.5%, A = 2.4%; in Swiss women: C = 1865 kcal/j., P = 15.0%, L = 35.3%, CH = 46.0%, A = 3.2%. Total caloric intake and iron intake decreased with age. Older women ate less calcium than younger. In summary, the most important determinants of diet are age and sex. Proportion of lipids is relatively low in both men and women. Small differences related to nationality were observed in men.

Self-reported HIV and AIDS experience, practices, and knowledge of Pennsylvania family physicians.

BACKGROUND: Patients with disease caused by the human immunodeficiency virus (HIV), while still more commonly treated in urban settings, are being seen in nonurban areas in numbers rapidly outstripping the local availability of specialists with expertise in HIV or acquired immunodeficiency syndrome (AIDS). METHODS: A questionnaire designed to measure self-assessed experience, practices, and knowledge regarding basic aspects of HIV was mailed in 1989 to the 2177 members of the Pennsylvania Academy of Family Physicians. RESULTS: The response rate was 72 percent. Approximately 95 percent of physicians surveyed had been asked questions by patients about AIDS, 30 percent had a patient with a confirmed positive blood test, and 27 percent had a patient with symptomatic HIV disease in their practice. CONCLUSIONS: Although most family physicians indicated that they were comfortable in recognizing persons at risk, counseling, and using tests to diagnose HIV and AIDS, more than one-half reported practice patterns at variance with published guidelines. Respondents were most uncomfortable with their knowledge and skills regarding legal issues, state and community resources, and caring for patients with AIDS. Continuing medical education courses at local hospitals and written materials were the two methods of AIDS education most likely to be used by respondents.

Reliability and validity of judgments concerning adverse events suffered by hospitalized patients.

To evaluate a process for identifying adverse events through review of medical records, multiple reviews of 360 medical records from two teaching hospital were performed. The data from these multiple reviews provided information about the validity and reliability of our two-phase review process. In particular, it was found that the initial phase, involving review of the medical records by medical-record-room administrators using explicit criteria, was valid, with a sensitivity of 84% and negative predictive value of 92%. Results also showed that the second phase, involving judgments by physicians guided by an adverse event analysis form, was reliable (Spearman Brown Rm = 0.78, m = 2) and demonstrated construct validity when compared with a review by a set of senior physicians employing a different method of review (Kappa = 0.57). In addition, it was found that these cases classified as difficult to judge from causation were judged less reliable (Rm = 0.48, for difficult case, Rm = 0.65, for other cases, m = 1). These results indicate that a two-step review process of medical records can produce judgments about adverse events that are both reliable and valid.

Sexual abuse of patients by therapists: strategies for offender management and rehabilitation.

Many therapists are unsure of how to respond to reports of sexual abuse of patients by previous therapists. The results of strategies developed in Minnesota and other jurisdictions suggest ways to handle the reporting, management, and rehabilitation of offenders in therapist-patient sexual abuse cases.

Management and rehabilitation of sexually exploitive therapists.

State legislators and mental health professionals in Minnesota have been active in developing strategies to improve reporting, management, and rehabilitation of sexually exploitive therapists. In 1985 and 1986, the legislature criminalized sexual contact by a therapist with a current or emotionally dependent former patient, established sexual exploitation by a therapist as a statutory cause of action, and required that all licensed health professionals report to the Board of Medical Examiners any physician who engages in sexual or sexually suggestive contact with a patient. The Walk-In Counseling Center, a nonprofit agency in Minneapolis, has taken an active role in evaluating exploitive therapists for licensing boards and employers to determine their rehabilitation potential. Mental health professionals and lawmakers have also collaborated in the development of strategies for preventing sexual exploitation and abuse by therapists.

Psychiatric residents' sexual contact with educators and patients: results of a national survey.

In a national survey of PGY-4 psychiatric residents, 4.9% of the 548 respondents indicated that they had been sexually involved with psychiatric educators and 0.9% reported that they had been sexually involved with patients. Most residents reported no or minimal instruction in their residency programs about educator-resident and resident-patient sexual contact. The authors compare these results with those from previous surveys of psychologists. They discuss the need for expanding training curricula to include specific education on sexual exploitation.

Psychiatrist-patient sexual contact: results of a national survey, II: Psychiatrists' attitudes.

In a national random-sample survey of 1,423 practicing psychiatrists, the overwhelming majority of the respondents (98%) said that therapist-patient sexual contact is always inappropriate and usually harmful to the patient. However, 29.6% said that such contact after termination of therapy might sometimes be acceptable. Psychiatrists who acknowledged having had sexual contact with one or more patients (N = 84) differed markedly from their peers in their attitudes. The majority (74%) of these offenders believed that sexual contact could be appropriate after termination; many apparently rationalized their behavior in this manner. The authors discuss the need for systematic professional education on the subject.

Psychiatrist-patient sexual contact: results of a national survey. I: Prevalence.

In a nationwide survey of U.S. psychiatrists, 7.1% (N = 1,057) of the male and 3.1% (N = 257) of the female respondents acknowledged sexual contact with their own patients. Eighty-eight percent of the sexual contacts occurred between male psychiatrists and female patients. All offenders who had been involved with more than one patient were male. Forty-one percent of the offending psychiatrists sought consultation because of their sexual involvement with patients. The authors compare these results with those of previous surveys of psychiatrists and psychologists and discuss the need for addressing this problem within the psychiatric profession.