Improving Team Skills of Health Care Practitioners: Effects of an Interprofessional Education Program.

INTRODUCTION: Health care practitioners in Parkinson's care need to learn effective interprofessional team skills. This study examines posttraining effects on team skills of health practitioners attending an interprofessional education (IPE) program for team-based Parkinson's care. METHODS: Using a quasi-experimental pre-post design, practitioners (n = 236) in nine professions (physician, nurse and nurse practitioner, physician assistant, occupational, physical and music therapy, speech-language pathology, and social work) completed the validated, self-report Team Skills Scale, before and after the training. Associations of Team Skills Scale change with intention to change practice, measured at end of each training day, and with improved attitudes toward team, knowledge, confidence, and amount of new information were examined. RESULTS: All professions, except physician assistant, significantly improved perceived team skills, as did those showing greatest intention to change practice, with no meaningful differences in magnitude of change across profession groups. Team skills change was significantly associated with improved attitudes toward health care teams, increased knowledge about team and the role of other professions, and new knowledge gained. Confidence in Parkinson's care showed modest, statistically significant association with team skills improvement. DISCUSSION: The Allied Team Training for Parkinson-IPE program significantly improved perceived team skills of health care practitioners, effectively teaching about skills for collaborative teamwork. Future IPE research should explore whether similar programs in other settings achieve the enhanced team skills competencies with postlicensure practitioners observed here and validate our findings from self-developed measures using larger samples, additional professions, and follow-up of transfer of learning effects through direct observation of skills of actual teams.

Clinical social work in the care of Parkinson's disease: role, functions, and opportunities in integrated health care.

Healthcare reform, including the focus on chronic illness, the growing role of neuroscience, the emphasis on collaborative interprofessional care, and more recently, on integrated medical and behavioral healthcare, have important implications for social work education and practice. Parkinson's disease, a chronic neurodegenerative illness exemplifying these trends, is an area in which social workers are increasingly involved. This paper provides (1) an overview of Parkinson's disease and its complexity, (2) a summary of role and functions identified in a survey of health social workers working with Parkinson's disease and/or neurology, and (3) education and practice recommendations for the social work profession.

Interprofessional education increases knowledge, promotes team building, and changes practice in the care of Parkinson's disease.

OBJECTIVE: Examine outcomes for the National Parkinson Foundation (NPF) Allied Team Training for Parkinson (ATTP), an interprofessional education (IPE) program in Parkinson's disease (PD) and team-based care for medicine, nursing, occupational, physical and music therapies, physician assistant, social work and speech-language pathology disciplines. BACKGROUND: Healthcare professionals need education in evidence-based PD practices and working effectively in teams. Few evidence-based models of IPE in PD exist. METHODS: Knowledge about PD, team-based care, the role of other disciplines and attitudes towards healthcare teams were measured before and after a protocol-driven training program. Knowledge, attitudes and practice changes were again measured at 6-month post-training. Trainee results were compared to results of controls. RESULTS: Twenty-six NPF-ATTP trainings were held across the U.S. (2003-2013). Compared to control participants (n = 100), trainees (n = 1468) showed statistically significant posttest improvement in all major outcomes, including self-perceived (p < 0.001) and objective knowledge (p < 0.001), Understanding Role of Other Disciplines (p < 0.001), Attitudes Toward Health Care Teams Scale (p < 0.001), and the Attitudes Toward Value of Teams (p < 0.001) subscale. Despite some decline, significant improvements were largely sustained at six-month post-training. Qualitative analyses confirmed post-training practice changes. CONCLUSIONS: The NPF-ATTP model IPE program showed sustained positive gains in knowledge of PD, team strategies and role of other disciplines, team attitudes, and important practice improvements. Further research should examine longer-term outcomes, objectively measure practice changes and mediators, and determine impact on patient outcomes.

Mental health care of families affected by the child welfare system.

The primary aim of this paper is to introduce practitioners to the mental health needs of children and families who are under the care and supervision of the child welfare system because of substantiated child maltreatment. Emphasis is placed on children and families who are receiving foster care services. The paper draws attention to the most prevalent mental health conditions that affect foster care children and their families based on type of maltreatment. Given that young children under age 5 are more likely to be placed in out-of-home placements and to spend a significant portion of their lives in foster care, their unique mental health needs are highlighted. Treatment approaches that are informed by both practice wisdom and evidence-based practice--such as ego-supportive intervention and trauma-focused, cognitive-behavioral therapy--are stressed. A case study is presented as a way of illustrating how mental health care may be delivered to families affected by the child welfare system.

A review of the nature and effectiveness of nutrition interventions in adult males--a guide for intervention strategies.

BACKGROUND: Energy excess, low fruit and vegetable intake and other suboptimal dietary habits contribute to an increased poor health and the burden of disease in males. However the best way to engage males into nutrition programs remains unclear. This review provides a critical evaluation of the nature and effectiveness of nutrition interventions that target the adult male population. METHODS: A search for full-text publications was conducted using The Cochrane Library; Web of Science; SCOPUS; MEDLINE and CINAHL. Studies were included if 1) published from January 1990 to August 2011 and 2) male only studies (≥18 years) or 3) where males contributed to >90% of the active cohort. A study must have described, (i) a significant change (p<0.05) over time in an objective measure of body weight, expressed in kilograms (kg) OR Body Mass Index (BMI) OR (ii) at least one significant change (p<0.05) in a dietary intake measure to qualify as effective. To identify emerging patterns within the research a descriptive process was used. RESULTS: Nine studies were included. Sample sizes ranged from 53 to 5042 male participants, with study durations ranging from 12 weeks to 24 months. Overlap was seen with eight of the nine studies including a weight management component whilst six studies focused on achieving changes in dietary intake patterns relating to modifications of fruit, vegetable, dairy and total fat intakes and three studies primarily focused on achieving weight loss through caloric restriction. Intervention effectiveness was identified for seven of the nine studies. Five studies reported significant positive changes in weight (kg) and/or BMI (kg/m2) changes (p≤0.05). Four studies had effective interventions (p<0.05) targeting determinants of dietary intake and dietary behaviours and/or nutritional intake.Intervention features, which appeared to be associated with better outcomes, include the delivery of quantitative information on diet and the use of self-monitoring and tailored feedback. CONCLUSION: Uncertainty remains as to the features of successful nutrition interventions for males due to limited details provided for nutrition intervention protocols, variability in mode of delivery and comparisons between delivery modes as well as content of information provided to participants between studies. This review offers knowledge to guide researchers in making informed decisions on how to best utilise resources in interventions to engage adult males while highlighting the need for improved reporting of intervention protocols.

Fat necrosis below musculocutaneous flap mimicking carcinoma of breast.

The increasing rate of breast reconstruction after modified radical mastectomy has led to the adoption of several techniques including transverse rectus abdominis musculocutaneous flap. Although the method creates a life-like breast both in texture and appearance, among other complications resulting from this operation, fat necrosis mimicking carcinoma on mammography clearly is common. We focus on the case history of 1 patient and detail our findings.

Perforated duodenal ulcer in the elderly.

In a 10-year retrospective review of 41 patients aged greater than or equal to 65 years and treated for perforated duodenal ulcer, an attempt was made to characterize the clinical and laboratory profile and evaluate treatment policy for this surgical emergency in the elderly. In 1/3 of the series no accurate history was obtainable. Peroperative findings were sometimes discordant with laboratory data. Vagotomy and drainage were performed in ten low-risk patients and simple closure with omentopexy in 26. Conservative treatment was employed in four patients, three of whom recovered while one later required closure. Gastroenterostomy was performed in one case. A patient with severe mesenteric thrombosis had no perforation-related surgery. Vagotomy and drainage were associated with significantly fewer complications and shorter hospital stay than simple closure, no mortality (vs. 8%) in closure) and only one recurrence during follow-up averaging 37 months. This small, non-randomized series does not permit conclusive recommendations, but the data advocate definitive surgery in properly selected cases and stress the importance of associated pathology for decisions on treatment.

Cecal volvulus.

A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, and recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was performed primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned.

The role of second-look procedure in improving survival time for patients with mesenteric venous thrombosis.

Since 1978, 21 patients (12 men and nine women) suffering from mesenteric venous thrombosis (MVT) were treated at the Hadassah University Medical Center. The cause of MVT was multifactorial, and in only six patients was the process defined as primary or idiopathic. A preoperative diagnosis of MVT was made in eight patients. Surgical management of the individual patient was based on the extent of the ischemic process, the viability of infarcted intestine and the general condition of the patient. Nineteen patients were operated upon. Exploratory laparotomy without any attempt of intestinal resection was performed upon two patients. Eleven patients underwent resection and primary anastomosis. Second-look procedures were done upon ten patients, and in six, intestinal resection was followed by creation of a double ostomy. The over-all survival rate was reported to be 60 per cent; it was 71 per cent among the patients who were operated upon. The role of second-look procedures in improving survival time is outlined.

Acute mesenteric ischemia: improved results--a retrospective analysis of ninety-two patients.

Acute mesenteric ischemia (AMI) is a curable disease if diagnosis and therapy are instituted before irreversible changes have occurred. AMI has been diagnosed with increasing frequency, during the last two decades, yet the mortality rate remains as high as 80% to 95%. Ninety-two patients with AMI were treated at Hadassah University Hospital between 1952 and 1987. Seventy-seven patients were treated surgically: 15 underwent only explorative laparotomy, and 62 underwent bowel resection or revascularization or both. The latter patients were divided into two groups: 17 patients treated surgically between 1952 and 1976, in whom bowel resection and primary anastomosis was the only surgical procedure carried out (group 1), and 45 patients treated in the last decade (group 2), in whom one or more of the following procedures were performed: bowel resection with primary anastomosis (n = 16), revascularization (n = 16), "second-look" (n = 18), and delayed anastomosis (n = 10). The overall mortality rate in 62 surgically treated patients was 40% (82% in group 1 and 24% in group 2) and 21% in 29 patients treated in a combined surgical approach. The reasons for improved results in group 2 patients are discussed, and an algorithm for surgical treatment of patients with AMI of different causes is proposed.

Survival after ultrasonographic demonstration of portal venous gas due to mesenteric artery occlusion.

Portal vein gas as a result of bowel necrosis following occlusion of the superior mesenteric artery has an extremely grave prognosis. Only two previous cases have been recorded as having survived. In both those cases the diagnosis of portal vein gas was made on an abdominal radiograph. The present report is of the first such case surviving after ultrasonic demonstration of portal gas. In this case, no evidence of portal gas was seen on the abdominal radiograph. The increased sensitivity of ultrasound over plain radiography mandates urgent liver and portal ultrasound in all cases of suspected mesenteric event.

Solitary nonparasitic cyst of the liver: a rare cause of abdominal distension.

Solitary nonparasitic liver cysts are clinically rare, and fewer than 900 patients have been documented over the years. A case is described of a female patient with a large solitary cyst containing 7 L of fluid, which was treated successfully by unroofing. The literature relating to the clinical features, incidence, pathogenesis, histopathology, diagnostic imaging, and surgical management of such cysts is reviewed.

Intra-abdominal lymphangioma.

The historical background, aetiology, clinical features, radiographic findings and treatment of abdominal lymphangiomas are reviewed. The condition may give rise to the acute surgical abdomen.

Dependence of oxygen consumption on cardiac output in sepsis.

We studied the relationship between oxygen consumption (Vo2) and cardiac output in 17 hemodynamically stable, septic and eight nonseptic ICU patients. Each received 300 ml of fresh-frozen plasma or 25% albumin with up to 500 ml of crystalloids, in addition to regular maintenance fluids; this treatment increased pulmonary wedge pressure (WP) by 3 to 4 mm Hg. Measurements were performed before and after approximately 5 h of volume loading. Because cardiac index (CI) decreased as WP increased in four septic and three nonseptic patients, we grouped the data according to the state of flow instead of the recording time sequence. From low to high flows, mean CI increased in septic patients and nonseptic patients. Oxygen delivery (Do2) increased in septic and nonseptic patients. Vo2 remained unchanged in nonseptic patients, while it increased in septic patients. Accordingly, arteriovenous oxygen difference narrowed in nonseptic patients from 4.46 +/- 1.62 to 3.59 +/- 1.21 ml/dl (p less than .05) but did not change in septic patients. In the septic group, the difference in CI between high and low flows was significantly (p less than .05) greater in survivors than in nonsurvivors. We conclude that the septic state is accompanied by a peripheral oxygen deficit, which can be partially reversed by maintaining an above-normal CI and Do2.

Cyclo-oxygenase products mediate hypoxic pulmonary hypertension.

High-risk infants with a fetal pattern of circulation demonstrate hyperactivity of the pulmonary vascular bed in response to stimuli including mucous plugging, atelectasis, and endotrachial tube suctioning. The resultant increase in pulmonary vascular resistance (PVR) leads to pulmonary hypertension, severe right-to-left shunting, and hypoxemia. Stimuli that trigger pulmonary hypertension cause hypoxia, suggesting the importance of hypoxic pulmonary vasoconstriction (HPV). Although many humoral mediators of HPV have been hypothesized, none have been proven. This study investigates the possible role of the cyclo-oxygenase derivatives thromboxane A2 and prostacyclin as determinants of hypoxic pulmonary hypertension. Open-chested lambs were ventilated with 13% O2 prior to and following treatment with OKY 046, a selective thromboxane inhibitor. In untreated lambs, the partial pressure of arterial oxygen fell from 80 +/- 27 (mean +/- SD) to 35 +/- 13 mm HG (P less than .01). The mean arterial pressure (MAP) remained at 50 +/- 7 mm HG, and the cardiac output (CO) was unchanged at 0.8 +/- 0.2 L/min. The mean pulmonary arterial pressure (MPAP) rose from 11 +/- 4 to 20 +/- 4 mm HG (P less than .01) whereas the PVR increased 70% (P less than .01). TxB2 rose from 147 +/- 85 to 271 +/- 154 pg/mL (P less than .05), and 6-keto-PGF1 alpha rose from 105 +/- 96 to 142 +/- 110 pg/mL. These substances are the hydrolysis products of TxA2 and prostacyclin respectively. In animals treated with OKY 046 prior to ventilation with 13% O2, values for MAP, CO, and PVR were similar to those of the nontreatment period.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary and systemic consequences of localized acid aspiration.

Acid aspiration may recruit a generalized inflammatory reaction that can potentiate the local injury. After surgical isolation of bronchi in a group of 15 dogs, 1 milliliter per kilogram of 0.37 normal hydrochloric acid was instilled into either side. After five minutes, platelet and white blood cell counts fell to 10,000 and 1,000 per cubic millimeter (p less than 0.05). Platelet aggregates were noted in blood smears. 111Indium-platelet activity doubled over both the aspirated and nonaspirated lung (p less than 0.05). Physiologic dead space rose from 18 to 67 per cent and to 46 per cent in the aspirated and nonaspirated lung (p less than 0.05). Physiologic shunt increased from 12 to 47 per cent and to 43 per cent (p less than 0.05) on the two sides. Plasma thromboxane B2 levels at 30 minutes rose from 0.28 to 0.93 nanograms per milliliter (p less than 0.05). Edema fluid from the aspirated lung had thromboxane B2 values of 2.87 nanograms per milliliter, indicating pulmonary synthesis. Within five minutes of aspiration, systemic effects were prominent; mean arterial pressure fell from 114 to 46 milliliters of mercury (p less than 0.05), and the cardiac index fell 24 per cent from 106 to 81 milliliters per kilogram per minute (p less than 0.05) along with an 18 per cent decrease in contractility of a rat papillary muscle bathed in plasma from the aspirated dog. Mean pulmonary arterial pressure rose from 12 to 18 millimeters of mercury (p less than 0.05). Despite fluid infusion at 36 milliliters per kilogram per hour to keep wedge pressure constant at 5.5 millimeters of mercury, and sampling of one-third the blood volume, hemoglobin concentration rose 0.9 grams per cent (p less than 0.05) indicating increased microvascular permeability. At autopsy, the aspirated and nonaspirated lung were indistinguishable with congestion, interstitial hemorrhage, and white blood cell infiltrates. Systemic organs showed vascular congestion and edema. These data demonstrate that local aspiration leads to generalized inflammatory sequelae with cardiopulmonary failure.

A simplified one stage modification of portoazygos disconnection for massive variceal hemorrhage.

A one stage, complete abdominal portoazygos disconnection procedure is a safe and efficient method for the treatment of acute variceal bleeding. This method was performed upon five patients who were bleeding due to severe cirrhosis of the liver, with no operative mortality. No recurrence of bleeding occurred during a follow-up study of one to four years.

A simplified method for repeated nasotracheal suction.

The use of a Tiemann curved tip urethral catheter for repeated nasotracheal suction in 120 instances of postoperative pulmonary complications was proved to be more efficient than the use of a regular suction catheter. The curved tip is better adapted to the anatomy of the nasotracheobronchial tract and allows easy selective catheterization of the trachea and major bronchi.