New approaches and emerging issues in negotiation

This article is a brief summary of recent events in Australia and how the Royal Australian Nursing Federation (RANF) has attempted with some success to solve the problems of nurses in our country. This paper was presented at the ICN SEW Resource Group meeting in Geneva.     

A confidential study of deaths after emergency medical admission: issues relating to quality of care

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.     

The emerging pattern of disability in Rwanda

Abstract

Purpose: The purpose of this paper is to describe the emerging pattern of disability (activity limitation) in terms of its prevalence, age and gender distribution in Rwanda. Method: A door-to-door survey was conducted in all households in villages from two districts selected through a multi-stage sampling procedure. Identified persons were screened for activity limitations using age-appropriate instruments developed from domains in the ICF. Proportions were computed and disaggregated by age group, gender, district and activity limitation. A multi-disciplinary rehabilitation team including community members participated in the development of instruments, community mobilisation, data collection and collation. Results: Prevalence rates of 8.6% (Bugesera) and 14.7% (Musanze) were obtained. The prevalence of disability was higher in adults than in children in both districts (10.4% versus 6.6% in Bugesera and 19.6% versus 7.7% in Musanze). Visual limitations occurred the most frequently in both adults and children in both districts. Mobility and mental health limitations also notably contributed to the overall disability burden. Conclusion: The prevalence of disability obtained was higher than all previously reported data for Rwanda. Despite the limitations, the findings provide useful information for planning rehabilitation services and to direct future enquiry into the epidemiology of disability in Rwanda.

• Implications for Rehabilitation

• It is important to design specific surveys to measure disability using contemporary methods to gauge the situation accurately and qualitatively.

• Currently, the ICF provides the best framework to describe the epidemiology of disability meaningfully; it enables comparisons within and between countries and regions of the world; and enables the active participation of a wide range of rehabilitation stakeholders including PWDs and lay community members.

• The vast majority of disabilities in Rwanda are limitations in visual, mobility and mental health functions.

     

Ethical issues in medical malpractice

The interrelationships between biomedical ethics and the law are perhaps nowhere as starkly apparent as in the realm of medical malpractice. Although ethical and legal conduct and practices are often in harmony, in many areas ethical principles and the issues surrounding medical liability appear to come into conflict. Disclosure of errors; quality improvement activities; the practice of defensive medicine; dealing with patients who wish to leave against medical advice; provision of futile care at the insistence of patients or families; and the various protections of Good Samaritan laws are just a few of these. In addition, the ethical principles governing the conduct of physicians serving as expert witnesses in medical malpractice cases have become a subject of intense interest in recent years.     

Some methodological issues in the development of quality of life measures for the evaluation of medical interventions*

This paper discusses a series of important methodological issues in developing targeted health-related quality of life measures in studies of the effects of medical interventions. Such measures cannot be developed unless the evaluator understands the life domains that medical interventions affect. Qualitative discovery methods are needed to obtain this understanding. Once domains are targeted for measurement, careful and systematic laboratory pilot work should be used to select initial scale items. Psychometric evaluation of response patterns in subsequent field tests is needed to assess the measures. Less concern should be directed to internal consistency reliability of scales in the psychometric evaluation and more to the ability of short scales to reproduce total scale variance and to provide precise measurement within the range of the outcome where effects are expected. The paper closes with a discussion of modern methods of item response scaling that can be used to address these issues.     

Special issues in the medical assessment of musicians

The health of performing artists may be affected not only by occupational risks but by concomitant illness and injuries also. It is essential that those responsible for their health care have an appreciation of all that is involved in performance careers, including the training, requisites for success, life style issues, and a basic understanding of the mechanics of each performing art form. This article briefly considers why the health care of performing artists necessitates a specialized approach and gives some suggestions for a modus operandi for success.     

Use of admission troponin in critically ill medical patients

Serum troponin I (TnI) is a sensitive marker of cardiac injury. A relation between elevated TnI and mortality has been suggested. In this retrospective chart review of 221 patients admitted to the medical intensive care unit (MICU) during a 6-month period, the authors studied the use of admission TnI levels in predicting mortality in MICU-admitted patients. Data retrieved included demographics, admission diagnosis, troponin, electrocardiogram, Acute Physiology and Chronic Health Evaluation (APACHE) II score, echocardiogram, requirements for mechanical ventilation and vasopressor support, development of multiorgan failure, mortality, and discharge disposition. There were 132 patients for whom TnI level was sent within 24 hours of admission; these patients comprised the study group. The median age was 70 years; 59% were female. The mean APACHE II score was 22. Troponin I was positive in 31% of patients (median level, 0.4 Ug/L; range 0-358 Ug/L). The hospital mortality was 39%. Positive TnI showed a weak association with intensive care unit (ICU) mortality (P = .049) but not with overall mortality. There was no significant correlation between admission TnI concentration and APACHE II score (P = .33), administration of vasopressor medications (P = .115), or development of multiorgan failure (P = .64). The authors concluded that there is no benefit in obtaining a routine admission troponin level in MICU patients when an acute coronary event is not suspected.     

Ethical issues in computerized medical records

Greater use of computer technology has permitted rapid access to many forms of data. Hospitals have traditionally been slower to accept this technology for patient medical records. With the rapid approach of the new millennium, hospitals are being forced into re-evaluating many processes, including the volumes of data collected on paper. Electronic medical records are one approach to reducing storage and streamlining care across the health care continuum. This article examines the ethical impact of computerized medical records, including access to data, ownership of data, confidentiality, and medical record brokering.     

隐球菌脑膜炎治疗的若干问题

一、隐球菌脑膜炎治疗现状2000年美国真菌治疗协作组制定的隐球菌病诊治指南中将隐球菌脑膜炎治疗分为3个阶段,具体如下:①急性期:首选两性霉素B 0．7～1 mg·kg~(-1)·d~(-1)联合氟胞嘧啶100 mg·kg~(-1)·d~(-1)诱导治疗2周;②巩固期:改用氟康唑400 mg/d巩固治疗10周以上;③慢性期:氟康唑200～400 mg/d,长     

Research agenda: emerging issues in the management of health and illness

Today, in our capitalistic society, demographics, economics, and quality assessments are major systemwide drivers of research in the management of health and illness. Future trends promise a continued emphasis on outcomes, with a likely focus on rationing of care. Changes in quality definitions and changing acceptance of the levels and locations of care, with continued cost shifting into a broadened form of tax-supported health care, are anticipated. Concomitant and reflexive with these macroscopic trends are more microscopic organizational and professional trends and research agendas.     

Developmental Stifling: an emerging symptom pattern

"Developmental Stifling" is a term recently developed by us to denote a symptom pattern observed in a variety of clinical practice sites. The purpose of our paper is to define developmental stifling and compare this recently identified condition with Munchausen Syndrome by Proxy. A case example of developmental stifling is provided, as well as recommendations for early identification and treatment.