Confirmation and certainty in toxicology screening

Confirmation of presumptive positive urine drug screens, necessary to minimize the reporting of false-positive results, can be costly and time-consuming. The predictive value model can be used to select the confirming tests and to calculate the confidence of the result. The predictive value of a test result is the probability, based on the sensitivity and specificity of the test, that the result is a true positive or a true negative. The predictive value model applied to toxicology screening tests for drugs of abuse showed that prevalence, in addition to sensitivity and specificity, was the factor controlling the confidence level of a result. For example, the predictive value of a positive result for a screening test that has a sensitivity of 99% and a specificity of 99%, applied to screening in a population with a prevalence of 1% is 0.50; for a prevalence of 10%, it is 0.92. Confirmation with a second, chemically independent, test of equal sensitivity and specificity increases the predictive value to 0.99.     

Partners in caring: a partnership for healing

This article describes one organization's effort to create a family-friendly environment that supports the choice of patients for involvement of a family member or loved one in their care. Changing a culture requires a process that can emotionally drive the caregivers to agree with the need to change and sustain the efforts over a long period. This project, Partners in Caring, describes the philosophy, the journey of changing a culture, and the results achieved over a 7-year period. The Partners in Caring philosophy is "a commitment between a patient, care partner and healthcare team to a relationship of hands-on support based on compassion, communication and choice empowering people to heal in a nurturing manner." This concept laid a foundation for the development of a new model of care, which is described. The implementation has resulted in an improved patient and staff satisfaction and a decrease in patient complaints.     

Barriers to care: operationalizing the variable

A measure was developed to operationalize the concept of barriers as the consumer's perceptions of costs or obstacles to care. First, a 12-member panel participated in a three-stage Delphi process to identify indicators of the concept. Of the 81 items generated, 54 were selected as appropriate to a well population seeking preventive care. In a survey of 800 employees of a not-for-profit organization, respondents were asked to rate each barrier indicator on a 5-point Likert scale; the response rate was 70%. Exploratory factor analysis was used to explore the construct validity of the measure. Five factors were found: Provider-Consumer Relationship, Cost, Site-Related, Inconvenience, and Fear. Confirmatory factor analysis was used to refine the indicators for each factor category, producing a scale to measure perceived barriers to secondary preventive care. Based on the factor correlations, a model of the structure of barriers is proposed, showing the relationship factor as central.     

Pacemaker-Mediated Tachycardia: Engineering Solutions

This discussion summarizes the interaction of refractory periods and upper rate behaviors in modern dual-chamber demand (DDD) devices, the data regarding and nine events initiating VA conduction and engineering solutions proposed and/or implemented to address the problem of pacemaker-mediated tachycardia (PMT). Among the causes of PMT are premature atrial depolarization, loss of atrial capture, a return to the demand mode after asynchronous magnet mode pacing, programming from a mode that does not guarantee AV synchrony to a mode in which atrial tracking can occur, noise, certain situations involving Wenckebach behavior, loss of sensing, and the inability of a rate-smoothing algorithm to allow a rapid change in ventricular rate. Engineering solutions to prevent the occurrence of PMT include a programmable postventricular atrial refractory period (PVARP), differential AV delay, adaptive AV delay, and the ability to discriminate between P waves of atrial origin and those resulting from retrograde conduction from the ventricle. Features such as the ability to lengthen the PVARP for one cycle after exiting the magnet or noise reversion modes or programming to a new mode, lengthen the PVARP for a single cycle following a PVC or revert to DVI pacing for one cycle following a PVC have been developed to recognize initiating events. A third solution. a tachycardia termination algorithm, can recognize and terminate PMT; varying the AV delay to determine whether P waves move in a corresponding manner and using a metabolic sensor to confirm the need for a fast heart rate are other possibilities in the detection of PMT. Diagnostic data features may also be used to evaluate the appropriateness of programmed settings. This discussion concludes that PMT is no longer a significant clinical entity when more advanced DDD pacemakers are utilized.     

Estimating date of discharge at ward level: a pilot study

BACKGROUND: Reimbursement is part of the government's strategy to reduce the level of delayed patient discharge from hospital. This article describes a pilot study, undertaken on one ward in a large NHS teaching trust, to involve clinicians in estimating a date of discharge for patients, to improve discharge practice and assist the reimbursement process. Since January 2004, if a patient is not fit for discharge within a day of being designated for discharge, social services has to reimburse the acute trust up to 120 pounds sterling per day for the delay, if the reasons for the delay were attributed to a delay in the provision of service. The barriers to implementing this initiative at ward level are discussed and suggestions made for a pragmatic way forward to enable a process for estimating a date of discharge to work in practice. CONCLUSION: Estimating a date for discharge requires two fundamental steps: a clinical process to estimate and/or document a date of predicted medical fitness, followed by a communication process to document an estimated date of discharge. Effective discharge planning leading to a reduction in delayed discharges will not occur without these two steps.     

Towards a realistic echographic simulator

Echography is a useful tool to diagnose a thrombosis; however, since it is difficult to learn to perform this procedure, the objective of this work is to create a simulation to allow students to practice in a virtual environment. Firstly, a physical model of the thigh was constructed based on experimental data obtained using a force sensor mounted on a robotic arm. We present a spring damper model consisting of both linear and non-linear elements. The parameters of each of these elements are then fitted to the experimental data using an optimization technique. By employing an implicit integration to solve the dynamics of the system we obtain a stable physical simulation at over 100 Hz. Secondly, a haptic interface was added to interact with the simulation. Using a PHANToM force-feedback device may touch and deform the thigh in real-time. In order to allow a realistic sensation of the contact we employ a local modeling technique allowing to approximate the forces at much higher frequency using a multi-threaded architecture. Finally, we present the basis for a fast echographic image generation depending on the position and orientation of the virtual probe as well as the force applied to it.     

Doctoring: the philosophic milieu

To understand fully a physician's role in society, and to deal successfully with the current sense of crisis, the medical profession must evolve a world-view that appropriately relates a physician to the patient, to the practice environment, to the base of knowledge, and to the physician's own sense of self. Such a world-view would be multilevel and interdisciplinary, and would be based on interactions and adaptations of physicians to life systems. Medicine's world-view must provide a philosophic milieu intérieur that leads to a proper equilibrium between medicine's technologic skills and its humanistic concerns.     

Support psychotherapy in traumatic situations

It seems that a certain consensus exists to speak about a traumatic situation as an experience which is made up of a threat on the physical or psychological integrity of a person and against which one responds with fear, desperation and intensive horror. Different psychological phenomena are involved with the manner through which a human being confronts his/her past. In particular, the response to traumatic situations, mourning, and blame share their characteristic of being an irreversible living reality related to facts, loss or past impacts and it is necessary to integrate these in one's life in order to advance; these comprise a triangle frequently coexisting and interconnected. Aid for these three situations has, therefore, as common elements, two premises: an active task is required by the person who suffers this situation; this person must, in some form, desire to move ahead. One can not toil in mourning, in a traumatic experience, or in a life of blame if these have a positive symbolic value for this person; for example, mourning as a manner not to treason the dead person by forgetting that person, the reliving a trauma as an attempt to provide some sense to the actions which occurred, or blame as a desire to not forget an error or as a final punishment of this active task; the final objective of this active task is not usually to forget but to integrate in order to live. If a person does not perceive this clearly, this person may not become actively involved in the task to overcome a traumatic situation and to move ahead, nor will that person accept that a person who tries to help questions this person's realities or experiences.     

Developing a cost-effective clinical preceptorship program

We began to explore the development of a Preceptor Program for orientation in order to provide an improved orientation program and to better use the resources available to us for orientation purposes. By creating a Task Force with varied representation, we were able to design a program that is applicable to all nursing units and which allows each unit to tailor orientation to its specific needs. The Preceptor Program has proven to enhance our ability to provide the new staff nurse with a personalized orientation that is both thorough and consistent, while providing existing staff nurses with an opportunity to enhance their professional practice. The improved quality of orientation coupled with significant cost savings has been particularly dramatic in our intensive care units. Though we remain committed to the concept of a Preceptor Program for orientation on all nursing units, we need additional data so that a decision can be made on valid criteria. It is our hope that the extension of our pilot program during 1987 will provide us with the opportunity to fully measure costs and benefits, so that we can move to a house-wide program. In addition to the benefits we originally anticipated, we now believe that a Preceptor Program will be a significant recruitment tool. During the interview process, nurse applicants frequently inquire about the availability of such a program and have been very favorably impressed when we have been able to offer them this approach to orientation. With a projected nationwide nursing shortage and expected increase in staff nurse turnover rates, we believe that a Preceptor Program will become a significant tool for both recruitment and retention of staff nurses.     

Interaction of recombinant apolipoprotein(a) and lipoprotein(a) with macrophages.

Elevated plasma levels of lipoprotein(a), Lp(a), represent a major, inherited risk factor for coronary heart disease, although the mechanism of its action remains unknown. Lp(a) is distinguished from the related LDL particle by the addition of apolipoprotein(a), apo(a). The presence of this large glycoprotein is likely to affect the binding of the particle to the LDL receptor and/or other receptors which may contribute to the atherogenic potential of Lp(a). Here we demonstrate the binding to macrophages of Lp(a) and pure recombinant apo(a) protein, via a specific, high-affinity receptor. This binding could lead to foam cell formation and the localization of Lp(a) to atherosclerotic plaques.     

Patient awareness of physical medicine and rehabilitation.

The present study examined the extent to which patients referred to a specialist in physical medicine and rehabilitation (PM&R) could correctly identify the name or essential scope of the specialty the physiatrist practiced. The hypothesis, based on the author's experiences as a staff physiatrist, was that most patients would not be aware of the name and scope of the specialty of physical medicine and rehabilitation. This prospective study involved the administering of a questionnaire to 202 consecutive referrals to a University-affiliated PM&R outpatient clinic. Of the respondents, 19% were able to correctly identify that the physician they were referred to was either a PM&R specialist, a physical medicine specialist, a rehabilitation specialist or a physiatrist. Among the incorrect responses, orthopedist, neurologist and rheumatologist were most prevalent, and 33% of the respondents thought the physiatrist performed surgery. The implications of the findings are discussed. There continues to be a need to educate the public about the scope of practice of physiatry.     

The efficacy of a nursing challenge to patients: testing a new intervention to decrease self-harm behaviour in severe personality disorder

The efficacy of a nursing challenge to patients: testing a new intervention to decrease self-harm behaviour in severe personality disorder.
This paper describes the study of a new intervention, which was intended to increase therapeutic engagement with patients and to decrease self-harm behaviour. As a result of nursing observations in a unit that specialized in severe personality disorders, a psychodynamic perspective to treatment was introduced in the form of a nursing challenge. The intervention was evaluated in a new service for young adults at a psychiatric hospital in the south of England, as part of a clinical research apprenticeship. The care and treatment of persons with severe personality disorders present a major challenge to coherent and cohesive teamwork. A test and retrospective comparison study is described and its findings reported. Data from the study point to the need for more than a single challenge, to achieve a sustained reduction in self-harm, along with staff training to ensure working knowledge of a particular framework.     

Rapid methods in microbiology for in-office testing

There are now a variety of rapid test methods available to assist in the diagnosis of the three most common infectious diseases seen in ambulatory medicine: pharyngitis, urinary tract infection, and venereal disease. Before choosing to implement any of these methods, several aspects should be carefully considered. The objectives met by onsite testing should be clearly identified and the appropriate test chosen to meet those objectives. For example, if the goal is to establish a diagnosis while the patient is still available in the office, a test method that requires more than 20 to 30 minutes to perform will not fulfill the objective. Similarly, if tests must be batched for maximum efficiency, timeliness of results will be compromised. The prevalence of the specific agent or disease in the patient population should be established, as prevalence will significantly influence the predictive value of a diagnostic test. The lower the prevalence of a disease, the lower the predictive value of a positive result and the higher the predictive value of a negative result. Conversely, the higher the prevalence, the higher the positive predictive value and the lower the negative predictive value. Thus, in one setting a test may serve best as a screen to rule out disease and, in another setting, as a confirmatory test to establish a diagnosis. The impact of false-positive and/or false-negative results must be clearly appreciated to avoid diagnostic errors. The technical features of a test method should be carefully appraised. How difficult is the test to perform and what skill level is necessary to ensure the validity of results? How much quality control is necessary? How much additional equipment is needed to perform the assay, and does the equipment have multiple applications or just a single application? Finally, does the cost-benefit ratio of providing on-site testing exceed that of referring the specimens to a reference laboratory?     

Validation of a 3D reconstruction algorithm for EIT of human brain function in a realistic head-shaped tank

Previous work has demonstrated that electrical impedance tomography can be used to image human brain activity during evoked responses, but two-thirds of the reconstructed images fail to localize an impedance change to the expected stimulated cortical area. The localization failure may be caused by modelling the head as a homogenous sphere in the reconstruction algorithm. This assumption may lead to errors when used to reconstruct data obtained from the human head. In this study a 3D reconstruction algorithm, based on a model of the head as a homogenous sphere, was characterized by simulating the algorithm model, the head shape and the presence of the skull in saline-filled tanks. EIT images of a sponge, 14 cm3 volume with a resistivity contrast of 12%, were acquired in three different positions in tanks filled with 0.2% saline. In a hemispherical tank, 19 cm in diameter, the sponge was localized to within 3.4-10.7% of the tank diameter. In a head-shaped tank, the errors were between 3.1 and 13.3% without a skull and between 10.3 and 18.7% when a real human skull was present. A significant increase in localization error therefore occurs if an algorithm based on a homogeneous sphere is used on data acquired from a head-shaped tank. The increased error is due to the presence of the skull, as no significant increase in error occurred if a head-shaped tank was used without the skull present, compared to the localization error within the hemispherical tank. The error due to the skull significantly shifted the impedance change within the skull towards the centre of the image. Although the increased localization error due to the skull is not sufficient to explain the localization errors of up to 50% of the image diameter present in the images of some human subjects, the future use of a realistic head model in the reconstruction algorithm is likely to reduce the localization error in the human images due to the presence of the skull.     

Use of metaphors when treating unexplained medical symptoms

The words one chooses to describe personal pain mirror current usage, but may also hold echoes of an individual’s lived experience. They may provide clues to the origin of physical symptoms that are medically hard to explain. The aim of this commentary is to propose, on the basis of the available literature, that verbal metaphors can prove effective in the psychotherapy of such conditions. I provide a case history of a 45 year old woman referred to psychiatry because of extreme ‘burning’ pain in her mouth and tongue. She had been to numerous doctors, had undergone a variety of tests, had tried many medical treatments, and had been prescribed a number of different pharmaceutical agents. She had changed her diet, done her daily dental mouth exercises, drunk a lot of water, but the burning continued and interfered, with her job (she was a teacher), her friendships, and her everyday life. This made her angry and recalcitrant to therapy, but the metaphor ‘burning with rage,’ as applicable to her pain, worked to establish a good alliance that led to a decrease of symptoms. Burning Mouth Syndrome is a medically unexplained condition of complex etiology that psychotherapy alone cannot reverse. The literature bears out, however, that the use of metaphors can help to open avenues of psychological exploration that accelerate adaptation to pain and improve quality life.     

Communication with the patient. A question of quality

Interpersonal communication as a means to promote health and well-being is presented as a strategical orientation in the nursing care process. Meanwhile, in our medium, we have observed the development of communication from a perspective much more related to complying with a service. This article has these objectives: a) to investigate this theme by highlighting analytical instruments of interaction found in bibliographical references, b) to disclose the results of research about nurse-patient communication indicators, in the context as a forum for reflection, bearing in mind the quality of treatment. The authors highlight the need to assume a responsibility shared by teaching nurses and assistants, with the goal to constantly seek to develop communicative competence and thus to contribute to a greater efficiency and an improvement in the quality of nursing care.     

Constructivism applied to psychiatric-mental health nursing: an alternative to supplement traditional clinical education

With the popularity of accelerated pre-licensure nursing programmes and the growth in nursing student enrolments, traditional clinical education continues to be a challenge to deliver. Nursing faculty members are required to develop and implement educational innovations that achieve effective learning outcomes, while using fewer resources. The purpose of this qualitative study was to explore the effectiveness of a constructivism-based learning project to achieve specific learning outcomes and to supplement approximately 30 clinical hours in a psychiatric-mental health nursing course. Students participated in a 10-week, multistage project that examined life histories, treatment resources, and evidence-based practice, as applied to a single individual with a mental illness. Students reported increased understanding of mental health and illness, developed personal relevance associated with the knowledge gained, and learned to problem solve with regard to nursing care of individuals diagnosed with mental illness. For many students, there also appeared to be a reduction in stigmatized attitudes towards mental illness. Constructivism-based learning is a promising alternative to supplement clinical hours, while effectively achieving learning outcomes. Future research is needed to further validate the use of this method for the learning of course content, as well as the reduction of stigma.     

Detection of consistently task-related activations in fMRI data with hybrid independent component analysis

fMRI data are commonly analyzed by testing the time course from each voxel against specific hypothesized waveforms, despite the fact that many components of fMRI signals are difficult to specify explicitly. In contrast, purely data-driven techniques, by focusing on the intrinsic structure of the data, lack a direct means to test hypotheses of interest to the examiner. Between these two extremes, there is a role for hybrid methods that use powerful data-driven techniques to fully characterize the data, but also use some a priori hypotheses to guide the analysis. Here we describe such a hybrid technique, HYBICA, which uses the initial characterization of the fMRI data from Independent Component Analysis and allows the experimenter to sequentially combine assumed task-related components so that one can gracefully navigate from a fully data-derived approach to a fully hypothesis-driven approach. We describe the results of testing the method with two artificial and two real data sets. A metric based on the diagnostic Predicted Sum of Squares statistic was used to select the best number of spatially independent components to combine and utilize in a standard regressional framework. The proposed metric provided an objective method to determine whether a more data-driven or a more hypothesis-driven approach was appropriate, depending on the degree of mismatch between the hypothesized reference function and the features in the data. HYBICA provides a robust way to combine the data-derived independent components into a data-derived activation waveform and suitable confounds so that standard statistical analysis can be performed.