Community occupational therapists' clinical reasoning: identifying tacit knowledge

Background: Occupational therapy interventions in the community, a fast expanding practice setting, are central to an important social priority, the ability to live at home. These interventions generally involve only a small number of home visits, which aim at maximising the safety and autonomy of community‐dwelling clients. Knowing how community occupational therapists determine their interventions, i.e. their clinical reasoning, can improve intervention efficacy. However, occupational therapists are often uninformed about and neglect the importance of clinical reasoning, which could underoptimise their interventions. Aim: To synthesise current knowledge about community occupational therapists’ clinical reasoning. Method: A scoping study of the literature on community occupational therapists’ clinical reasoning was undertaken. Results: Fifteen textbooks and 25 articles, including six focussing on community occupational therapists’ clinical reasoning, were reviewed. Community occupational therapists’ clinical reasoning is influenced by internal and external factors. Internal factors include past experiences, expertise and perceived complexity of a problem. One of the external factors, practice context (e.g. organisational or cultural imperatives, physical location of intervention), particularly shapes community occupational therapists’ clinical reasoning, which is interactive, complex and multidimensional. However, the exact influence of many factors (personal context, organisational and legal aspects of health care, lack of resources and increased number of referrals) remains unclear. Conclusion: Further studies are needed to understand better the influence of internal and external factors. The extent to which these factors mould the way community occupational therapists think and act could have a direct influence on the services they provide to their clients.     

Clinical reasoning in neurology: Use of the repertory grid technique to investigate the reasoning of an experienced occupational therapist

Background/aim:  The aim of this paper is to describe the use of a structured interview methodology, the repertory grid technique, for investigating the clinical reasoning of an experienced occupational therapist in the domain of upper limb hypertonia as a result of brain injury.
Method:  Repertory grid interviews were completed before and after exposure to a protocol designed to guide clinical reasoning and decision-making in relation to upper limb neurological rehabilitation. Data were subjected to both qualitative and quantitative analyses.
Results:  Qualitative analysis focussed on clinical reasoning content. Common themes across the pre- and post-exposure interviews were the use of theoretical frameworks and practice models, the significance of clinical expertise, and discrimination of 'broad' and 'specific' aspects, as well as differentiation between 'therapist and client-related' aspects of the clinical situation. Quantitative analysis indicated that for both pre- and post-exposure repertory grids, clinical reasoning was structured in terms of two main concepts. In the pre-exposure grid, these were related to the therapist's role, and to the 'scope' of practice tasks (either broad or specific). In the post-exposure grid the two main concepts were upper limb performance, and client-centred aspects of the therapy process.
Conclusions:  The repertory grid technique is proposed as an effective tool for exploring occupational therapy clinical reasoning, based on its capacity for accessing personal frames of reference, and elucidating both the meaning and the structure supporting clinical reasoning.     

Comparison of clinical reasoning skills in occupational therapy students in the USA and Scotland

Problem-based learning (PBL) in occupational therapy (OT) education has become increasingly important. However, the efficacy in identifying clinical reasoning skills has not been well researched. The purpose of this study was to evaluate the utilization of clinical reasoning by students in the USA and Scotland. Thirty OT students were videotaped during a PBL case. Responses were transcribed and compiled into 122 statements. The two primary investigators independently coded each of the responses into one of five categories: Procedural, Interactive, Conditional reasoning, N/A, or Other. Intraclass correlation coefficients reflected strong reliability between the two raters (ICC = 0.914). Results of this study indicated that the predominant form of clinical reasoning was procedural in nature (61%) followed by conditional reasoning (27%) and interactive reasoning (12%). Students in Scotland tended to use interactive reasoning more than the students in the USA. Further research is needed to explore educational models to foster clinical reasoning skills in occupational therapy students.     

强制性运动与作业疗法对颅脑损伤后上肢功能恢复的影响观察

目的 探讨强制性运动与作业疗法对颅脑损伤后上肢功能恢复的影响。 方法 将本院2016年2月—2017年5月90例颅脑损伤后上肢功能障碍患者分组(随机数字表法)。对照组给予单一常规训练治疗,观察组则给予常规训练联合强制性运动与作业疗法治疗。比较2组颅脑损伤后上肢功能障碍改善率、上肢功能恢复正常时间、治疗前后患者上肢功能测验评分和FMA上肢功能评分及日常生活活动能力MBI评分。 结果 观察组颅脑损伤后上肢功能障碍改善率高于对照组(P<0.05),观察组上肢功能恢复正常时间短于对照组(P<0.05),治疗前2组上肢功能测验评分、FMA上肢功能评分、日常生活活动能力MBI评分相近(P>0.05);治疗后观察组上肢功能测验评分、FMA上肢功能评分、日常生活活动能力MBI评分优于对照组(P<0.05)。 结论 常规训练联合强制性运动与作业疗法治疗颅脑损伤后上肢功能障碍的应用效果确切,可有效改善上肢功能和日常生活能力,值得推广应用。     

Development of clinical reasoning from the basic sciences to the clerkships: a longitudinal assessment of medical students' needs and self-perception after a transitional learning unit

BACKGROUND: To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year. PURPOSE: The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years. METHOD: Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships. RESULTS: On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit. CONCLUSIONS: To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.     

职业性三硝基甲苯白内障45例治疗前后眼部血流动力学分析

目的 对职业性三硝基甲苯(TNT)白内障患者治疗前后眼部血流动力学改变进行分析,了解其治疗效果.方法 对广西壮族自治区职业病防治研究院2010-2012年期间收治45例职业性TNT白内障患者的临床资料进行回顾性的分析,采用黄芪注射液联合还原型谷胱甘肽滴眼液对45例患者实施治疗,B超检查眼动脉、视网膜中央动脉血流改变情况,比较、分析治疗前、后的眼部血流动力学情况.结果 经过一段的时间的治疗以后,45例职业性TNT白内障患者眼部的眼动脉收缩期的平均血流速度、眼动脉舒张期的平均血流速度、视网膜中央动脉收缩期的平均血流速度、视网膜中央动脉舒张期的平均血流速度与治疗前比较都有提高,其中眼动脉和视网膜中央动脉收缩期血流速度与治疗前比较差异具有统计学意义(P＜0.05).结论 职业性TNT白内障患者,其眼部周围的血液循环存在供血不足的问题,采用黄芪注射液联合还原型谷胱甘肽滴眼液的治疗方法来扩张眼部血管、增加眼部血流量,对于改善TNT白内障患者眼部的血流动力、促进其视力恢复具有积极意义.     

拮抗剂方案与其他方案在卵巢低反应患者中的临床疗效比较

目的 比较拮抗剂方案与短方案、微刺激方案在卵巢低反应患者体外受精-胚胎移植治疗中的临床疗效.方法 对南京医科大学附属南京妇幼保健院生殖中心2014年1月至2015年9月接受体外受精-胚胎移植治疗的卵巢低反应患者临床资料进行回顾性分析,比较拮抗剂方案与短方案、微刺激方案的临床疗效.结果 拮抗剂组与短方案组相比临床疗效相当,但平均促性腺激素释放激素激动剂(Gn)时间更短、Gn用量更少(t值分别为8.72、6.98,均P<0.05).拮抗剂组与微刺激方案组相比,Gn时间、Gn用量高于后者(t值分别为2.90、12.80,均P<0.05),HCG日内膜厚度明显高于后者(t=15.94,P<0.05),获卵数、可移植胚胎数、优质胚胎数均高于后者(t值分别为9.94、19.01、7.04,均P<0.05),且临床妊娠率、累计妊娠率均高于后者(χ2值分别为1.82、11.29,均P<0.05),周期取消率低于后者(χ2=11.74,P<0.05),而两组流产率无明显差异(χ2=0.19,P>0.05).结论 对于卵巢低反应患者,拮抗剂方案可以获得相对满意的临床妊娠率,同时具有经济性较高、治疗周期短、周期取消率较低等优点,值得临床推广.     

Identification of cis- and trans-verbenol in human urine after occupational exposure to terpenes

Summary Urine from sawmill workers exposed to -pinene, -pinene and -3-carene was collected and hydrolyzed with -glucuronidase at pH 5.0 for 24h at 37°C. After hydrolysis the urine was cleaned on a SEP-PAK C₁₈ cartridge. The cartridge was eluted with n-heptane. The eluate was injected onto a gas chromatograph equipped with a 25-m (0.32-mm ID) SP-1000 capillary column. The major peak in the chromatogram was identified by GC-MS as trans-verbenol by electron impact at 70 eV. cis-Verbenol was also identified. These metabolites could not be detected in non-hydrolyzed urine from the exposed workers or in hydrolyzed urine from an unexposed individual. The recoveries of the verbenols from hydrolyzed urine were in the range of 85 to 94% and the metabolites were stable both in urine and in n-heptane after sample cleaning at –20°C for at least 12 weeks. We suggest that these metabolites are formed from -pinene by hydroxylation.     

The suitability of EBC-Pb as a new biomarker to assess occupational exposure to lead

Occupational exposure to lead (Pb) requires continuous surveillance to assure, as much as possible, safe and healthful working conditions. This study addresses the suitability of assessing Pb exposure in relevant workers using their exhaled breath condensate (EBC). This study enrolled workers of two different Pb processing industries characterized by moderate and high Pb exposure levels in the work environment, and a group of non-exposed individuals working in offices who served as baseline for Pb exposure. The EBC-Pb of workers reflected the Pb levels in the work environment of all three settings, although the relationship with B-Pb was not clear. The lack of correlation between EBC-Pb and B-Pb most probably indicates the time lag for Pb to enter in the two body pools. The EBC-Pb seems to reflect immediate exposure, providing a prompt signature of Pb in the environmental that may interact directly with the organ. By delivering short-term evaluation of exposure, EBC-Pb represents a clear advantage in biomonitoring and may become an interesting tool for estimating organ burden.     

Detection and clinical relevance of a type I allergy with occupational exposure to hexahydrophthalic anhydride and methyltetrahydrophthalic anhydride

Summary Hexahydrophthalic anhydride (HHPA) and methyltetrahydrophthalic anhydride (MTHPA) belong to the group of the acid anhydrides and, among other applications, are used in the production of epoxy resins. These substances are known as potent low-molecular allergens and induce predominantly type I allergies according to Coombs and Gell. We examined 110 employees exposed to HHPA and MTHPA. With all of them a RAST was carried out with the commercially available conjugates of phthalic anhydride (PA) and a skin prick test with 1% and 5% acetonic solutions of PA. In 109 of these sera a radio allergo sorbent test (RAST) was carried out with the not commercially available conjugates of HHPA and of MTHPA. With complaints connected with the workplace the working materials used (HHPA, MTHPA) were also checked by means of the skin prick test. With at least one positive immunological finding (in the RAST and/or skin prick test) in connection with complaints at the workplace, we performed a workplace-related inhalation test under experimental conditions. Specific IgE against acid anhydrides was detected in a total of 17 (15.4%) persons. In the challenge test, six (5.4%) sensitisations were shown to be clinically relevant. On inclusion of borderline positive findings with PA conjugates the RAST produced three false negative and one false positive finding compared with a RAST with HHPA and MTHPA conjugates. With the conjugates of trimellitic anhydride, in no case could specific IgE be detected. The skin prick test led, in comparison with the RAST, to three false positive and three false negative findings. With all clinically relevant sensitisations the skin prick test was regarded as positive. RASTs with conjugates of PA and skin prick tests with native acid anhydrides can, according to our investigations, validly ascertain workplace-related sensitisations to HHPA and MTHPA.     

丙型肝炎病毒职业暴露处理与追踪随访

目的了解临床医务人员发生丙型肝炎病毒(HCV)职业暴露后处理过程及感染情况,为HCV职业暴露的防护提供经验。方法调查5例发生HCV职业暴露医务人员的暴露环节、暴露后处理方法及追踪随访结果。结果5例发生HCV职业暴露的医务人员均为临床护士,1例确诊为职业暴露后急性感染HCV。发生HCV暴露后,均给予常规心理支持和咨询,4例排除感染者很快恢复正常的工作和生活;确诊被感染者暂时调离临床一线岗位,加强心理支持,坚持完成1年聚乙二醇干扰素联合利巴韦林的抗病毒治疗后痊愈。结论医务人员发生HCV职业暴露后及时上报、进行HCV RNA感染监测;确诊感染HCV后尽早联合聚乙二醇干扰素及利巴韦林抗病毒治疗,是治愈HCV急性感染的关键措施。     

某电缆厂技术改造前后职业病危害控制效果评价

采用职业卫生现场调查、职业卫生检测等方法,对某电缆厂技术改造前后职业病危害情况进行分析。该企业在生产过程中可能产生氯化氢、四氯化碳、氯乙烯、铝尘、铜尘和噪声等职业病危害因素。改造前拉丝退火装置、挤出机产生的危害因素超标,采用在挤出机挤出部位安装轴流风机以及厂房内设置吸声板等改造措施后,职业病危害因素符合国家职业接触限值的要求,防护措施基本有效。     

某村石英粉加工行业技改前后职业卫生状况调查

目的探讨小型石英粉加工行业的职业病危害状况和治理经验.方法对某村石英粉加工企业进行技改,分析技改前后职业卫生状况.结果技改前该村石英粉加工业无任何防尘措施,9个粉尘浓度检测点有8个超过国家最高容许浓度标准,最高超标361倍.粉尘游离SiO2含量平均高达72.73% .技改后作业场所检测点全部符合国家职业卫生标准.对技改前该村务工的290名农民工摄X射线胸片检查,诊断矽肺60例,患病率为20.69 % ;患者发病年龄(35.75±6.10)岁,接尘工龄3个月～3.17年,平均1.33年.结论大批工人暴露于无任何防尘措施的石英粉工作环境中发生严重的群体性爆发矽肺事件是必然的.通过技改,采取生产设备密闭,安装有效防尘设施等,可明显改善作业环境,防止矽肺病的发生.     

田间作业致有机磷农药中毒与口服中毒的临床比较

目的 探讨田间作业中毒和口服有机磷农药中毒在临床表现及治疗上的差异.方法 回顾性分析我院2007年7月至2010年7月收治的85例中、重度急性有机磷农药中毒患者的临床资料,按中毒途径分为口服组(51例)和非口服组(34例),比较不同途径中毒后的临床表现、治疗特点及预后.结果 口服组中度中毒患者的肌颤肌痉挛和共济失调的发生率(86.4%、90.9%)均明显高于非口服组(50.0%、55.0%),差异有统计学意义(P＜0.05,P<0.01);口服组重度中毒患者的肺水肿、肌颤肌痉挛及昏迷的发生率(100.0%、89.7%、93.1%)均明显高于非口服组(71.4%、64.3%、50.0%),差异有统计学意义(P<0.05 ).非口服组解毒时间[中度:(35.0±6.2)h、重度:(45.0±11.1)h]较口服组[中度:(49.0±7.7)h、重度:(77.0±10.3)h]明显缩短,差异有统计学意义(P＜0.05).治疗后24、48、72 h,中、重度非口服组胆碱酯酶活力明显高于口服组,差异有统计学意义(P<0.05或P<0.01);中、重度非口服组的氯磷定用量、阿托品化用量及阿托品总量明显低于口服组,差异有统计学意义(P＜0.05或P<0.01).结论 田间作业有机磷农药中毒在临床表现上与口服中毒不尽相同,且治疗的阿托品及氯磷定用量相对较少,胆碱酯酶活力恢复较快.

Abstract：

Objective To investigate the differences of clinical manifestation and therapy of organophosphorus pesticide poisoning (OPP) between oral exposure and occupational exposure in field work. Methods From July 2007 to July 2010, 85 patients with acute severe OPP were treated in a hospital, which were divided into oral poisoning group (51 cases) and non-oral poisoning group (34 cases). The differences of clinical manifestations, curative effects and prognosis between two groups were compared. Results The rates of myoclonus and ataxia in cases with moderate poisoning of oral poisoning group were 86.4% and 90.9%, which were significantly higher than those (50.0% and 55.0% ) of non-oral poisoning group (P<0.05 or P< 0.01). The rates of myoclonus, lung fluid and coma in cases with severe poisoning of oral poisoning group were 100.0%, 89.7% and 93.1%, respectively, which were significantly higher than those (71.4%, 64.3% and 50.0%) of non-oral poisoning group (P<0.05). The mean detoxification hours in cases with moderate poisoning and cases with severe poisoning of non-oral poisoning group were (35.0±6.2) and (45.0±11.1) hours which were significantly lower than those [(49.0±7.7) and (77.0±10.3) hours] in cases with moderate poisoning and cases with severe poisoning of oral poisoning group (P<0.05). In 24, 48 and 72 h after treatment, the cholinesterase (ChE) activities of non-oral poisoning group were higher than those of oral poisoning group (P< 0.05 or P<0.01). The used doses of pyraloxime methylchloride (PAM-Cl) or atropine and the used total dose of atropine in non-oral poisoning group were lower than those in oral poisoning group (P<0.05 or P<0.01). Conclusions The clinical manifestation of non-oral poisoning group is different from the clinical manifestation of oral poisoning group due to the high morbidity of OPP occurred at field site in summer. The used doses of atropine and PAM-Cl are less and the ChE activity recovers quickly for non-oral poisoning group.