Understanding barriers to emergency care in low-income countries: view from the front line

INTRODUCTION: Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care.This study investigates these barriers in a rural region of Ethiopia. HYPOTHESIS: The limited capacity of frontline healthcare workers to diagnose and treat acute medical and surgical conditions represents a major barrier to the provision of emergency care in rural Ethiopia. METHODS: Health providers at a convenience sample of 16 rural health centers in the state of Tigray, Ethiopia completed a questionnaire designed to assess the availability of diagnostic and treatment modalities, the proximity and methods of transportation to referral facilities, and health providers' level of comfort in diagnosing and treating a variety of representative emergency medical conditions. RESULTS: Thirteen (81%) providers had only a very basic level of medical training, and seven (44%) lacked access to any diagnostic equipment. While most providers could offer oral rehydration solution (ORS), anti-pyretic medications, and antibiotics, none of the providers could offer blood transfusions or any form of surgery. Ten (63%) respondents stated that their patients had to travel >10 km from the health center to a referral hospital, with only a minority of patients having access to motorized transport. For the seven emergency conditions assessed, a majority of providers felt comfortable diagnosing these conditions, though fewer felt comfortable treating them. CONCLUSION: There is a significant need for both health worker training and improvements in transportation infrastructure in order to increase access to emergency medical care in rural areas of the developing world. Low-cost interventions that improve human capacity in a context-appropriate manner are warranted as transportation and hospital network capacity expansions are considered.     

Childhood and adolescent attention-deficit hyperactivity disorder: Diagnosis, clinical practice guidelines, and social implications

Purpose: To review the diagnostic criteria for attention-deficit hyperactivity disorder (ADHD), present an overview of the effects that ADHD has on family dynamics, school performance, and substance abuse, and provide an overview of the American Academy of Pediatrics (AAP) clinical practice and treatment guidelines.
Data sources: An extensive health science literature review was carried out using PubMed and Cumulative Index to Nursing and Allied Health Literature. Other information was collected by searching reference lists of published reports.
Conclusions: The diagnostic criteria and guidelines are important to make an accurate clinical assessment and manage a child with ADHD. Early diagnosis and treatment of ADHD decreases academic failure, family conflict, social isolation, substance abuse, and occupational adversity in later years for these children.
Implications for practice: Often primary care nurse practitioners are the first healthcare provider a child with ADHD will see. Awareness of the diagnostic criteria and treatment for children with ADHD can assist with early identification and perhaps eliminate much impairment that accompanies this chronic disorder.     

The child with ADHD: using the AAP Clinical Practice Guideline. American Academy of Pediatrics

The American Academy of Pediatrics developed an evidence-based clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). This guideline, the first of two guidelines to provide recommendations on this condition, is intended for use by primary care clinicians. The second set of guidelines will address the treatment of children with ADHD. The guideline contains six recommendations for the diagnosis of ADHD: (1) in a child six to 12 years of age who presents with inattention, hyperactivity, impulsivity, academic underachievement or behavior problems, primary care clinicians should initiate an evaluation for ADHD; (2) the diagnosis of ADHD requires that a child meet the criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders; (3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms and degree of functional impairment; (4) the assessment of ADHD also requires evidence directly obtained from a teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment and associated conditions; (5) evaluation of the child with ADHD should include assessment for coexisting conditions; and (6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of coexisting conditions.     

A physician's guide to helping patients with ADHD find success in the workplace

The impact of untreated adult attention-deficit/hyperactivity disorder (ADHD) in the workplace can be substantial, and employees with ADHD often confront frustration, employer disappointment, and low performance ratings. As a result, adults with ADHD may seek treatment from primary care providers to improve occupational performance. Previously considered a behavior disorder primarily affecting children and adolescents, ADHD in adulthood presents primarily as a cognitive disorder. Self-management deficits play a greater role in adult ADHD, particularly with respect to occupational and interpersonal functioning. Although specialized resources are available to assist adults with ADHD, many afflicted individuals may be unaware or unable to access them. Primary care providers who may be treating adults with ADHD are in a unique position to help them obtain the care and support needed to build appropriate skills and manage occupational issues. In this review, a literature search of the past 10 years was conducted to identify articles concerning ADHD and its impact on individuals in the workplace. The influence of ADHD on occupational functioning is discussed in the context of self-management impairments, diagnosis and assessment, and management strategies. With early and successful intervention, adults with ADHD may be able to become more aware of the impact of ADHD on work performance and achieve successful occupational experiences.     

Clinical review of Crohn's disease

PURPOSE: This clinical review presents proposed theories regarding the etiology of Crohn's disease (CD), the pathophysiology of the disorder, and current diagnostic methods. DATA SOURCES: Pertinent publications in the literature, the Crohn's and Colitis Foundation web page, and relevant texts regarding pathophysiology of the gastrointestinal system. CONCLUSIONS: CD can be a devastating disease and difficult to diagnose. The advanced practice nurse (APRN) should be aware of the etiology, pathophysiology, diagnostic methods, and current treatment options of this disorder. IMPLICATIONS FOR PRACTICE: In collaboration with a gastroenterologist, APRNs can provide much needed information to the patient with CD. Practice recommendations include patient education, pain management, and support for quality of life issues.     

National survey of psychiatric mental health advanced practice nursing: development, process, and finding

A survey was sent to all Psychiatric Mental Health (PMH) Advanced Practice Registered Nurses (APRNs) who had a registered e-mail address with the American Nurses Credentialing Center, resulting in 1,899 usable surveys. The practice of two groups of APRNs was examined and contrasted: those certified to treat children and adolescents and PMH-APRNs certified only to treat adults. Our findings raise concerns about the numbers of PMH-APRNs treating children. Considering the national demand for mental health professionals prepared to treat children, the specialty must move to increase the number of qualified APRN child providers.     

脑电诊断及脑电生物反馈治疗对注意缺陷多动障碍患儿的作用

背景对注意缺陷多动障碍(attention deficit hyperactivity disorder,ADHD)儿童进行脑电诊断和脑电生物反馈治疗逐渐受到关注.目的探讨脑功能诊断治疗仪对ADHD患儿诊断的精确性和治疗的疗效.设计以ADHD患儿为研究对象的前瞻性观察对比研究.单位一所市级医院的心理科.对象选择2003-10/2004-5到鞍山市中心医院心理科多动症门诊就诊的儿童,共113例.纳入标准年龄6～14岁到多动症门诊就诊的儿童.排除标准患神经系统器质性疾病、广泛性发育障碍、精神发育迟滞、癫痫、精神病性障碍、听觉异常和视觉异常等疾病者.其中男88例,女25例,平均年龄为(10±3)岁.方法应用A620全自动脑功能诊断治疗仪对113例儿童进行脑电检测,按照美国精神障碍诊断与统计手册第4版(DSM-Ⅳ)中ADHD的诊断标准对前来就诊的儿童进行诊断,计算脑电诊断的灵敏度、特异度;应用该仪器对27例ADHD患儿进行脑电生物反馈治疗,治疗前后检测患儿脑电波θ/β比值的变化,采用Conners儿童行为问卷评价治疗前后多动指数的变化.主要观察指标脑电波θ/β比值,Conners多动指数.结果脑电诊断ADHD的灵敏度为83.58%,特异度为82.61%;脑电生物反馈治疗后患儿的θ/β值为(8.26±4.05),较治疗前(12.38±7.96)明显下降(t=2.39,P＜0.05);Conners多动指数治疗后为(12.05±8.63),较治疗前(24.73±10.96)显著下降(t=4.72,P＜0.01).结论脑电诊断的灵敏度和特异度均较高,可以辅助诊断ADHD;脑电生物反馈治疗能够明显改善ADHD患儿的脑电异常和多动症状.     

An examination of how speech and language therapists assess and diagnose children with specific language impairment in Ireland

Three criteria for diagnosing specific language impairment (SLI) are defined in the literature: exclusionary definitions, inclusionary definitions, and qualitative markers. However, the assessment and diagnosis of this complex impairment in clinical practice can be challenging. The aims of this research were twofold: (1) to make explicit the current assessment procedures which speech and language therapists (SLTs) use when they diagnose children with SLI in Ireland, and (2) to explore SLT's perceptions and experiences of the process of diagnosing children with SLI. Both quantitative and qualitative methods were used in this study. A survey of 199 SLTs in Ireland was carried out to address aim one and a focus group was conducted to address the second aim. The findings were that SLTs use exclusionary and inclusionary definitions of SLI, and qualitative markers when assessing children who they suspect may have SLI. SLTs in Ireland consider a diagnosis of SLI when children present with a verbal-performance discrepancy, a positive family history, word finding difficulties and lack of progress in therapy. The results of the qualitative strand indicated that assessment and diagnosis of children with SLI is a complex, time-consuming process involving other professionals. What emerged was a complex picture with tensions between therapists' professional judgements, policy, evidence-based practice and resources.     

A decision tree and clinical paths for the assessment and management of children with ADHD

Attention Deficit/Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder. Children with ADHD are disproportionately represented in pediatric populations characterized by school failure, criminal behavior, and substance abuse. Many children who present with ADHD symptomatology do not receive systematic assessments nor comprehensive treatment that is well coordinated across home and school environments. And yet, evidence suggests that early detection and appropriate treatment can alter the probability of a negative developmental trajectory. The Decision Tree and Clinical Paths for Assessment and Management of ADHD identify the critical components of care through a stepwise decision-making process involving the assessment, diagnosis, treatment, and outcome evaluation of children who present with ADHD symptomatology. Preliminary field testing supports the clinical utility and validity of the ADHD Decision Tree/Paths. In addition, cross-validation comparisons indicate consistency between the ADHD Decision Tree/Paths and recently released ADHD clinical guidelines issued by several national professional organizations.     

A DECISION TREE AND CLINICAL PATHS FOR THE ASSESSMENT AND MANAGEMENT OF CHILDREN WITH ADHD

Attention Deficit/Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder. Children with ADHD are disproportionately represented in pediatric populations characterized by school failure, criminal behavior, and substance abuse. Many children who present with ADHD symptomatology do not receive systematic assessments nor comprehensive treatment that is well coordinated across home and school environments. And yet, evidence suggests that early detection and appropriate treatment can alter the probability of a negative developmental trajectory. The Decision Tree and Clinical Paths for Assessment and Management of ADHD identify the critical components of care through a stepwise decision-making process involving the assessment, diagnosis, treatment, and outcome evaluation of children who present with ADHD symptomatology. Preliminary field testing supports the clinical utility and validity of the ADHD Decision Tree/Paths. In addition, cross-validation comparisons indicate consistency between the ADHD Decision Tree/Paths and recently released ADHD clinical guidelines issued by several national professional organizations.     

Treatment of attention deficit hyperactivity disorder in children

These are controversial times for those who care for children with attention deficit hyperactivity disorder (ADHD). Class action law suits have been filed in federal courts in California and New Jersey accusing a manufacturer of methylphenidate and the American Psychiatric Association of conspiring to expand the use of this drug. These suits have recently been dismissed. This is just the latest chapter in the long-running debate over the existence, diagnosis, and treatment of ADHD. Controversies relating to ADHD continue to polarize physicians, educators, caregivers, and parents of these children. There are those who believe that ADHD does not exist as a true disorder. At the other end of the spectrum are those who are too quick to make the diagnosis without an adequate patient workup. Parents can unfortunately get caught in the middle of this debate when making treatment decisions for their children.     

Diagnostic options for early identification and management of interstitial cystitis/painful bladder syndrome

Aims: The aims of this article were to discuss options for diagnosing interstitial cystitis (IC), to compare approaches and to encourage early diagnosis of this disorder in the primary care setting. Methods: Experts discussed the tools available to diagnose IC and the advantages and disadvantages of each approach. Treatment options, both pharmacological and non‐pharmacological, were also discussed. The importance of patient follow‐up was emphasised. Results: Diagnostic options for IC include a thorough history and physical examination, laboratory evaluations, symptom screening tools, cystoscopy with hydrodistention, bladder biopsy, potassium sensitivity testing, intravesical anaesthetic challenges, urodynamics and urinary markers. Treatment options include oral and intravesical medications, dietary modification and physical therapy. Patient follow‐up can be an opportunity to educate and empower patients to participate in their treatment. Discussion: A thorough patient history, physical examination and laboratory evaluations are keys to the diagnosis of IC. Optional diagnostic approaches may help increase physician confidence in prescribing therapy for this disorder. Multimodal therapy with an emphasis on patient education can help ensure success in treating IC. Conclusion: Understanding the options available to diagnose IC may result in earlier identification and treatment for some patients.     

A school-based approach to early identification and management of students with ADHD.

Attention-deficit/hyperactivity disorder (ADHD) is one of the most challenging chronic conditions for children, families, schools, and physicians. Because symptoms of ADHD can be mistaken for other health conditions and misdiagnosis can occur, accurate diagnosis and treatment require comprehensive evaluation. This article introduces a school-based framework- ADHD Identification and Management in Schools (AIMS)-developed by a multidisciplinary team composed of a pediatrician, school nurses, and school psychologists that sought to improve communication between school personnel and physicians, standardize practice, and improve the quality of care for children with ADHD. The framework provides school nurses with an evidence-based, systematic method for early identification and management of children with ADHD.     

Veteran Suicide

Current statistics emphasize the national concerns with rising veteran suicides. Advanced practice registered nurses (APRNs) treat veterans in many settings, and establishing a therapeutic relationship may allow the veteran to express symptoms that lead to feelings of hopelessness, guilt, shame, and remorse. A key component is the role of the APRN in identifying those at risk, prevention, and treatment for veterans expressing symptoms that might lead to suicide. Exploring evidence-based therapeutic approaches for the treatment of posttraumatic stress disorder and other mental disorders is critical for APRNs treating veterans who are at risk for suicide.     

Diagnostic accuracy of acute maxillary sinusitis in adults in primary care

OBJECTIVE: To evaluate the diagnostic value of symptoms and signs used in diagnosing acute community-acquired maxillary sinusitis (ACAMS), and to find useful clinical predictors for diagnosing it in adults in primary care. DESIGN: Prospective study in the study group and retrospective study in the reference group. SETTING: One primary care centre in the study group and another in the reference group. Subjects: 50 adults with prolonged upper respiratory tract infection > or = 7 days) or self-suspected maxillary sinusitis. As a reference group, an analysis of records and diagnoses made by GP of 45 adult patients with the same inclusion criteria from another primary care clinic. MAIN OUTCOME MEASURES: The signs and symptoms associated with the diagnosis of ACAMS by GP and otorhinolaryngologist. The value of CRP, ultrasound and peak nasal expiratory flow in the diagnosis. RESULTS: Neither ultrasound nor any of the clinical signs increased the accuracy of diagnosis. Peak nasal expiratory flow below the normal range was associated with the diagnosis of ACAMS (p = 0.03). The presence of an otorhinolaryngologist had an influence on GP practice when compared with the reference group. CONCLUSION: The diagnosis of ACAMS is difficult with the available clinical methods. Peak nasal expiratory flow needs further study. New diagnostic means are needed.     

Establishing a practice-based research network of advanced practice registered nurses in southern New England

BACKGROUND: Biomedical research focuses on highly controlled clinical trials in academic health centers, where the emphasis is on disease treatment and rehabilitation. The results, therefore, are not readily applicable to patient populations that primary care clinicians encounter in their community practices, where the focus is on health promotion and disease prevention. Although the number of practice-based research networks (PBRNs) is growing in primary care, these networks are governed by the physicians who created them and address research questions reflective of physicians' practices and perspectives. Other primary care clinicians, such as advanced practice registered nurses (APRNs), who routinely provide care for underserved and minority populations lack a forum for studying their practice problems and processes. A PBRN of APRNs in primary care provides a means for this research. SUMMARY: The Advanced Practice Registered Nurses' Research Network in southern New England is the first PBRN established for APRNs. This article describes the development of the network.     

Evaluating the Contributions of ADHD, OCD, and Tic Symptoms in Predicting Functional Competence in Children with Tic Disorders

Children with chronic tic disorders (CTD), including Tourette’s Disorder (TD), demonstrate a higher incidence of comorbid conditions, including attention-deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD). The relative contributions of tics versus ADHD and OCD symptoms for predicting impaired functioning in children with TD is unknown and existing studies on the topic are inconsistent. This study evaluated the unique contributions of tic severity, ADHD diagnostic status, and OCD symptom severity in predicting competence scores on the Child Behavior Checklist (CBCL) in a sample of children with CTD. Results of a hierarchical regression analysis show that both ADHD and OCD symptoms predicted decreased CBCL competence scores. When tic complexity was added, however, only ADHD and tic complexity continued to predict CBCL competence scores. These findings begin to resolve inconsistencies in existing literature and have important implications for understanding and treating children with CTD.