[Dominance and resistance in nursing work]. / Dominaçao e resistência no trabalho da enfermeira.

This study aims to investigate the forms of domination which are present in the daily work of hospital nurses and the way they handle these occurrences, as well as the types of mediating processes which occur within relationship which produce confrontation and the way these help them to comprehend and transform their own work.. A qualitative methodology was used which included indepth interviews with 15 nurses, as well as analysis of official documents from both the Regional Council of Nurses and the Nurses' Union from the state of Ceará. The study concluded that forms of domination not only exist but also contribute to the reproduction of unequal relationships on the job, and that these relationships occur between nurses and doctors, between peers and between nurses and auxillary personnel. Responding to this situation, nurses have been utilizing individual and informal resistance mechanisms and strategies, but also formal and collective resistance strategies have been used, these latter less frequently.

Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial.

CONTEXT: Relapses of acute asthma following emergency department (ED) discharge can be reduced with systemic corticosteroid treatment. However, whether inhaled corticosteroids (ICSs) provide additional benefit is not known. Objective To determine whether the addition of ICSs to oral corticosteroid treatment would reduce relapses in patients with acute asthma discharged from the ED. DESIGN AND SETTING: Placebo-controlled, double-blind, randomized clinical trial conducted in a community teaching hospital ED in Canada between November 1995 and September 1997, with a 21-day follow-up. PARTICIPANTS: A total of 1006 consecutive patients aged 16 to 60 years presented to the ED with acute asthma; after excluding those using oral and/or inhaled corticosteroids as well as those meeting other exclusion criteria, 188 were included in the study. INTERVENTIONS: Patients were discharged with a nontapering course of oral prednisone (50 mg/d) for 7 days. In a double-blind fashion, patients were randomly assigned to 1600 microg/d of inhaled budesonide (n = 94) or identical placebo (n = 94) for 21 days. MAIN OUTCOME MEASURES: Incidence of relapse, defined as an unscheduled visit for worsening asthma symptoms, in budesonide vs placebo groups. Secondary outcomes included response to the Asthma Quality of Life Questionnaire, beta2-agonist use, symptom score, global asthma improvement assessment, and pulmonary function. RESULTS: Five patients in the budesonide group and 3 in the placebo group either dropped out or were lost to follow-up but were included in primary analyses. After 21 days, 12 (12.8%) of 94 patients in the budesonide group experienced a relapse compared with 23 (24.5%) of 94 in the placebo group, a 48% relapse reduction (P=.049). Asthma Quality of Life Questionnaire scores were higher (better quality) in the budesonide group (P=.001), as well as for all domain scores (P=.001 to .01). Fewer beta2-agonist activations were used at the end of the trial by patients receiving budesonide (2.4/d vs 4.2/d; P=.01). Symptom scores (P=.001 to .004) and self-assessed asthma improvement scores (based on a 7-point Likert scale) (6.2 vs 5.2; P<.001) were higher (indicating fewer symptoms) for budesonide vs placebo. There were no differences in pulmonary function between the groups (peak expiratory flow rate: budesonide, 437 vs placebo, 453 L/min; P= .39) at 21 days. Using this approach, as few as 9 patients would require budesonide to prevent 1 relapse. CONCLUSIONS: Patients discharged from the ED following treatment for acute asthma benefit from added treatment with high-dose inhaled budesonide for 21 days compared with oral corticosteroids alone.

Knowledge of periconceptional folic acid for the prevention of neural tube defects. The missing links. Northeastern Ontario Primary Care Research Group.

BACKGROUND: Periconceptional folic acid supplementation is effective in preventing primary and secondary neural tube defects (NTDs) and other congenital defects. However, debate exists regarding the effectiveness of public and physician education on patient knowledge and compliance. OBJECTIVE: To examine the level of knowledge about the usefulness of periconceptional folic acid supplementation in a sample of patients from primary care practices. DESIGN: Cross-sectional survey. A confidential, anonymous questionnaire was completed by patients before physician encounters. A maximum of 20 consecutive female patients from each of 3 age groups (16-24, 25-32, and 33-40 years) were recruited from each primary care practice. SETTINGS: Twenty-two Canadian teaching practices affiliated with the Northeastern Ontario Primary Care Research Group. OUTCOME: Women's knowledge of periconceptional folic acid supplementation for the prevention of NTDs. RESULTS: Of 1125 eligible female patients between the ages of 16 and 40 years visiting their family physician in 1996, 1124 (99.9%) completed the questionnaire. General awareness of NTDs was high (62.7%); however, knowledge that these defects were preventable was lower (22.5%). Only 7.8% of the women made the association between folic acid intake and NTDs. The specific knowledge that NTDs could be prevented with folic acid supplementation before conception was identified by 1.8% of the sample. Pregnant participants were at least twice as likely to be informed about the link. Interpractice variability existed with respect to knowledge of folic acid supplementation. CONCLUSION: Knowledge of periconceptional folic acid supplementation for the prevention of NTDs was low in this sample and is likely to be reflected in missed opportunities to prevent an important class of congenital malformations.

The effect of a community-based police surveillance program on snowmobile injuries and deaths.

Serious snowmobile injuries are preventable and associated with late-night travel, alcohol use, and speed. We studied the effectiveness of a community-based policing (STOP) program in the prevention of serious injuries related to snowmobile trauma in Sudbury, Ontario. Volunteers were trained in police protocol and were appointed special constables to increase policing on snowmobile trails from 1993-95. Snowmobile admissions and deaths in Sudbury were examined; the pre- (1990-1992) and post- (1993-1995) STOP seasons were compared. In the pre-STOP period, 102 injuries, 87 admissions, and 15 deaths occurred compared to 57 injuries (p = 0.0004), 53 admissions (p = 0.00001) and 4 deaths (p = 0.13) in the post-STOP period. All other event and demographic features of the crashes remained similar. Significant economic savings were realized from this intervention; acute care costs savings exceeded $70,000/year and costs from death decreased by $5 million. An intervention involving enforcement on snowmobile trails can reduce the incidence of injuries from snowmobile-related trauma.

Head, neck, and facial injuries in ice hockey: the effect of protective equipment.

OBJECTIVES: To determine the factors and behaviors associated with facial, head, and/or neck injuries to those engaged in ice hockey; the use of protective equipment was also examined. DESIGN: Prospective case series. SETTING: Emergency Department of Sudbury General Hospital. PATIENTS: All patients presenting to the emergency department with a head, neck, or facial injury while playing hockey between the months of October and March 1993-94 and 1994-95 were included in the study. Physicians completed data forms on each patient. Information was validated by review of the emergency-room records; further information was obtained by telephone. RESULTS: A total of 226 patients were identified with ice-hockey-related head, neck, or facial injuries. Most injuries involved males (99%), and the mean age of patients was 23.9 (range, 4-63). Injuries occurred most frequently to the face [192 (85%)]. Many of the injuries were minor, with a mean injury severity score of 1.5 (range, 1-25). However, three patients (1%) required hospital admission, and one teenager suffered a serious spinal fracture. Protective facial hockey equipment use was low in our sample, except among younger injured players. Most of the facial injuries occurred in mature athletes playing recreational hockey. Full facial protection reduced the chance of upper facial injury (p = 0.0001), but the risk of such injury while wearing a half-visor was the same as while wearing no facial protection at all (p > 0.05). From the current study, we estimate that these hockey injuries result in approximately 2.7-3.0 million dollars of direct acute-care medical expenditure per year in emergency departments throughout Ontario. CONCLUSIONS: Head, neck, and facial injuries suffered during ice hockey participation are common problems presented to emergency departments. Moreover, serious injuries can occur while playing this sport. Most injuries appear to be preventable, and facial protection appears to be less frequently used, especially by older men, than is currently recommended. Prevention strategies are discussed.

A truncated E-code system for injury surveillance in the emergency department: description and clinometric testing.

OBJECTIVES: ED injury surveillance requires accurate information about mechanism. This study explored the clinometric properties of an E-code system specifically designed to track ED injuries. METHODS: All patients assessed in the ED had cause-of-injury information documented using a truncated E-code system. Patient records were hand-searched to determine coding compliance. A selection of 98 charts (50 injury/48 noninjury) were coded by 7 physicians, 2 nurses, and 2 nosologists. Agreements (interrater and intrarater) on the diagnosis of trauma and exact E-codes were determined (using kappa; kappa). RESULTS: E-coding compliance was high (overall 90%: 95% CI: 85-93%), and accuracy of injury classification was 99%. Compared with an expert's coding, agreement on injury classification was excellent for physicians (kappa = 0.91; 95% CI: 0.80-1.0), nurses (kappa = 0.88; 95% CI: 0.75-1.0), and nosologists (kappa = 0.92; 95% CI: 0.81-1.0). Agreement was substantial for the exact E-codes between physicians (kappa = 0.77; 95% CI: 0.60-0.94) and nurses (kappa = 0.72; 95% CI: 0.54-0.90). Recode reliability was also excellent for physicians (kappa = 0.88; 95% CI: 0.75-1.0) and nurses (kappa = 0.96; 95% CI: 0.88-1.0). CONCLUSIONS: Injury coding using a truncated E-code system can provide valid and reliable data from the ED. Differences between nurses, physicians, and nosologists in the ability to accurately code using this system were minimal, thus eliminating the need for additional staff and resources.

First-year family medicine residents' use of computers: knowledge, skills and attitudes.

OBJECTIVE: To identify the computer knowledge, skills and attitudes of first-year family medicine residents. DESIGN: Cross-sectional survey of family medicine residents during the academic year 1993-94; sampling began in July 1993 and ended in October 1993. SETTING: Canada. PARTICIPANTS: All 727 first-year family medicine residents, of whom 433 (60%) responded. OUTCOME MEASURES: Previous computer experience or training, current use, barriers to use, and comfort with and attitudes regarding computers. RESULTS: There was no difference in age or sex between the respondents and all first-year family medicine residents in Canada. French-speaking respondents from Quebec were underrepresented (p < 0.001). Only 56 respondents (13%) felt extremely or very comfortable with computer use. The most commonly cited barriers to obtaining computer training were lack of time (243 respondents [56%]) and the high cost of computers (214 [49%]) but not lack of interest (69 [16%]). Most residents wanted more computer training (367 [85%]) and felt that computer training should be a mandatory component of family medicine training programs (308 [71%]). CONCLUSIONS: Computer knowledge and skills and comfort with computer use appear low among first-year family medicine residents in Canada, and barriers to acquisition of computer knowledge are impressive. Computer training should become an integral part of family medicine training in Canada, and user-friendly applicable computer systems are needed.

Regional variations of northern health: the epidemic of fatal trauma in northeastern Ontario.

OBJECTIVE: To examine the causes of traumatic death in a northern region of Ontario. METHODS: Prevalence study of trauma deaths occurring within the region of Northeastern Ontario over the years 1989-1991; regional data were compared with provincial data. RESULTS: 1,027 patient records were identified over the study period (51.4 deaths per 100,000 population/year). Non-intentional trauma accounted for 70% of all trauma deaths in the region; suicide (25%; 12.8/100,000) and homicide (5%; 2.4/100,000) were less common. Motorized vehicle trauma accounted for most of the non-intentional traumatic death (39%; 20.4/100,000). Age-standardized mortality ratios were 67% above the provincial average for non-intentional trauma, 71% above the provincial average for suicides, 55% above the provincial average for homicides, and 68% higher for all forms of traumatic death. CONCLUSIONS: Traumatic death is a major health problem in northern areas; reduction of these rates depends on the development of an effective injury prevention strategy.

Educating patients on the run.

This article discusses patient education in the endoscopy laboratory. It addresses quality usage of time available to perform patient teaching, the problems encountered and the effects of stress on the learning process.

Guanine nucleotide-induced polymerization of actin in electropermeabilized human neutrophils.

The effects of exogenous guanine nucleotides on the polymerization of actin in human neutrophils were tested in an electropermeabilized cell preparation. Close to 40% permeabilization was achieved with a single electric discharge as measured by nucleic acid staining with ethidium bromide or propidium iodide with minimal (less than 2%) release of the cytoplasmic marker lactate dehydrogenase. In addition, electropermeabilized neutrophils retained their capacity to produce superoxide anions and to sustain a polymerization of actin in response to surface-receptor dependent stimuli such as chemotactic factors. Electropermeabilization produced a rapid and transient permeabilization that allowed the entry of guanine nucleotides into the cells. GTP and, to a larger extent, its nonhydrolyzable analog guanosine 5'-O-2-thiotriphosphate (GTP[S]), induced a time- and concentration-dependent polymerization of actin, as determined by increased staining with 7-nitrobenz-2-oxa-1,3-diazolylphallacidin. The effects of the aforementioned guanine nucleotides were antagonized by GDP[S], but were insensitive to pertussis toxin. Cholera toxin potentiated to a small degree the amount of actin polymerization induced by GTP[S]. These results provided direct evidence for the involvement of GTP-binding proteins in the regulation of the organization of the cytoskeleton of neutrophils, an event that is of crucial importance to the performance of the defense-oriented functions of these cells.

Chemoattractant-induced cytoplasmic pH changes and cytoskeletal reorganization in human neutrophils. Relationship to the stimulated calcium transients and oxidative burst.

The relationships between the chemotactic factor-stimulated mobilization of calcium, activation of the NADPH-oxidase, changes in cytosolic pH, and in the level of polymerized actin in human neutrophils have been examined. The approach taken was to use intracellular calcium chelators, and pharmacologic modulators (both positive and negative) of the NADPH-oxidase to measure the aforementioned responses under conditions where the calcium transients were abrogated and/or the generation of superoxide anions was either inhibited or augmented. The decrease in cytosolic pH induced by chemoattractants was inhibited by the calcium chelator BAPTA and by the diglyceride kinase inhibitor 6-[2-(4-[(4-fluorophenyl)phenylmethylene]-1-piperidinylethyl ]-7-methyl-5H-thiazolo[3,2-alpha]pyriimidin-5-one (R59022) (this latter compound enhanced the oxidative response of the cells). Furthermore, a specific inhibitor of the NADPH-oxidase (diphenyleneiodonium) had no significant effect on the cytosolic acidification induced by FMLP or leukotriene B4. These results indicate that the initiation of the cytosolic acidification induced by chemotactic factors is a calcium-dependent event that is not directly linked to the activation of the NADPH-oxidase. In contrast, the stimulated polymerization of actin was insensitive to BAPTA, R59022, and diphenyleneiodonium. Thus, neither the calcium transients nor the oxidative burst play a signaling role in the initiation of actin polymerization elicited by chemoattractants. These data indicate that additional investigations are needed to uncover the biochemical basis of the signals initiated in human neutrophils by chemotactic factors that lead to the polymerization of actin and to the cytosolic acidification.

[The physician and disability certificates: preconceived attitudes and behaviors]. / Le médecin face aux certificats d'invalidité: attitudes et comportements préconisés.

Five attitudes and predicted behaviors characterize the physicians' responses (strategies) to invalidity certificates. These are: 1- scientific objectivation; 2- complicity (meaning: always completing the certificates without objective preoccupations of any kind); 3- socio political (meaning: influenced by the physician's ideas concerning ways the society should consider the non-working people: permissive or repressive); 4- negotiation (implicating a psychobiosocial approach to the patient and the problem); 5- indifference (never completing certificates, referring this role to someone else). Our recent survey (September 1986) including 92 physicians of a General Hospital (Cité de la Santé) in Laval demonstrates a preponderant attitude, the "socio political" one (A3). But, it has no relation to the preponderant predicted behavior which is the negotiation (C4), characterizing a psychobiosocial approach to the patient and the problem. This behavior has been chosen in a statistically significant way. Nevertheless, there is a relation between the attitude A1: scientific objectivation and the corresponding predicted behavior C1: scientific objectivation. Notions of rationability, professionalism and sociable desirability are evoked as explanations of these results.

Calcium mobilization, actin polymerization and right-angle light scatter responses to leukotriene B4, 12(R)- and 12(S)-hydroxyeicosatetraenoic acid in human neutrophils.

The presence of microgram quantities of 12(R)-hydroxyeicosatetraenoic acid (12(R)HETE) in psoriatic scales has been reported. 12(R)HETE has been found to be 5-10 times more potent than its isomer 12(S)HETE in inducing neutrophil locomotion and aggregation. In this study, the ability of these two eicosanoids to elicit a mobilization of calcium and a polymerization of actin was examined and compared to that of leukotriene B4. These two cell-biochemical assays were chosen in view of the likelihood that they are relevant to the motile functions of the neutrophils. 12(R)HETE was found to induce an increase in the cytoplasmic level of free calcium and in the amount of polymerized actin. 12(S)HETE also raised the level of free calcium, though to a lesser extent than 12(R)HETE, but did not induce a detectable polymerization of actin. Leukotriene B4 was more active, on the basis of concentration and maximal response, than either 12(R)HETE or 12(S)HETE. The activity of 12(R)HETE detected and reported in this communication provides support for the suggestion that this eicosanoid may play a significant role in the pathogenesis of the inflammatory reactions in psoriasis.

Procollagen segment-long-spacing crystallites: their role in collagen fibrillogenesis.

Naturally occurring segment-long-spacing crystallites of procollagen collagen have been found in the culture medium of fibroblasts from chick embryo tendon, human skin, and dermatosparaxic calf skin; in whole-mount preparations of cultured human skin fibroblasts; in homogenates of lathyritic chick embryo tendon, cartilage, and cornea; and in a partially purified preparation of procollagen. Bundles of similar aggregates occurred within secretory vacuoles of collagen-synthesizing fibroblasts and chondrocytes. These observations suggest that fibroblasts and chondrocytes secrete procollagen assemblies that are stable in the extracellular environment. We propose that subsequent enzymatic processing is accompanied by direct incorporation of such structures into the assembling fibril, which then may be considered as an n X 67 nm staggered array of segment-long-spacing crystallites.