Number-Between g-Type Statistical Quality Control Charts for Monitoring Adverse Events

Alternate Shewhart-type statistical control charts, called g and h charts, are developed and evaluated for monitoring the number of cases between hospital-acquired infections and other adverse events, such as heart surgery complications, catheter-related infections, surgical site infections, contaminated needle sticks, and other iatrically induced outcomes. These new charts, based on inverse sampling from geometric and negative binomial distributions, are simple to use and can exhibit significantly greater detection power over conventional binomial-based approaches, particularly for infrequent events and low defect rates. A companion article illustrates several interesting properties of these charts and design modifications that significantly can improve their statistical properties, operating characteristics, and sensitivity.     

Measuring the impact of onychomycosis on patient quality of life

According to survey research, onychomycosis, a fungal infection of the toenail or fingernail, affects quality of life including physical and social functioning and emotional health. We developed an onychomycosis disease-specific questionnaire (ODSQ) that sensitively assessed symptom distress, functional impact, and social stigma associated with the disease. Samples of patients enrolled in a randomized controlled clinical trial were used for the psychometric evaluations. The multi-item scales were internally consistent ( 0.80) and reproducible (ICC > 0.85). Interscale correlations between the ODSQ and generic scales were moderate and consistent with the hypothesized magnitude and directions. Construct validation, employing known groups analysis, supported the hypothesized impact of onychomycosis on three domains of quality of life: physical functioning, emotional health, and social functioning. Significant differences were found between clinically cured, improved, or failed patients, and between mycologically eradicated and persistent patients. The ODSQ was responsive to clinical change and more sensitive than derived Medical Outcomes Study Short Form-36 scales. The ODSQ provides reliable, validated and responsive information about the consequences of onychomycosis and its treatment.     

Absorption,metabolism and elimination of N,N-dimethylformamide in humans

Summary Excretion of N,N-dimethylformamide (DMF) and DMF metabolites N-hydroxymethyl-N-methylformamide (MF), N-hydroxymethyl-formamide (F) and N-acetyl-S-(N-methylcarbamoyl)cysteine (AMCC) has been monitored in the urine of volunteers during and after their 8-h exposure to DMF vapour at a concentration of 10, 30 and 60 mg · m^–3. The pulmonary ventilation in these experiments was typically about 101 · min^–1 and the retention in the respiratory tract was 90%. After exposure to 30 mg DMF · m^–3, the yield of compound determined in the urine represented 0.3% (DMF), 22.3% (MF), 13.2% (F) and 13.4% (AMCC) of the dose absorbed via the respiratory tract. The excretion curves of the particular compounds attained their maximum 6–8h (DMF), 6–8h (MF), 8–14h (F) and 24–34h (AMCC) after the start of the exposure. The half-times of excretion were approximately 2, 4, 7 and 23 h respectively. In contrast to slow elimination of AMCC after exposure to DMF, AMCC was eliminated rapidly after AMCC intake. This discrepancy could be explained by rate-limiting reversible protein binding of a reactive metabolic intermediate of DMF, possibly methylisocyanate.     

Percutaneous absorption of N,N-dimethylformamide in humans

Summary Skin penetration fo N,N-dimethylformamide (DMF) liquid or vapour was studied in volunteers. Exposure to liquid DMF was performed in two ways: in a dipping experiment, one hand was dipped up to the wrist in DMF for 2–20 min, while in a patch experiment, 2 mmol DMF was applied to the skin and allowed to be absorbed completely. The period of exposure to DMF vapour (50 mg · m^–3) was 4 h. The DMF metabolites N-hydroxymethyl-N-methylformamide (MF), N-hydroxymethylformamide (F), and N-acetyl-S-(N-methylcarbamoyl)cysteine (AMCC) were monitored in the urine. Liquid DMF was absorbed through the skin at a rate of 9.4 mg · cm^–2 · h^–1. Percutaneous absorption of DMF vapour depended strongly on ambient temperature and humidity and accounted for 13%–36% of totally excreted MF. The results suggest that skin absorption of liquid DMF is likely to contribute to occupational exposure substantially more than penetration of DMF vapour. The yield of metabolites after transdermal DMF absorption was only half of that seen after pulmonary absorption. Elimination of MF and F but not that of AMCC was delayed, which supports the contention that AMCC should be used instead of MF as the most suitable biomarker of DMF in cases where percutaneous intake can occur.     

Health-related quality of life in a rare disease: Hereditary hemorrhagic telangiectasia (HHT) or Rendu–Osler–Weber Disease

The levels of the health-related quality of life (HR-QoL) were analyzed in hereditary hemorrhagic telangiectasia (HHT) patients. The Short Form-36 Health Survey (SF-36) was administered to 50 HHT patients and scores were compared to a cohort of 2301 normal subjects. Clinical variables were patient age, illness duration, number of epistaxis episodes in the previous year and hemoglobin levels. Physical functioning, physical role limitations, bodily pain, social functioning, emotional role limitations and the physical component scores were lower among females. In multivariable analyses increasing age was related to lower physical functioning (P<0.04), physical role limitations (P<0.008), bodily pain (P<0.05) and emotional role limitations (P<0.01), while higher hemoglobin levels improved physical functioning(€P<0.03). The number of epistaxis episodes was negatively associated with physical role limitations (€P<0.009), vitality (P<0.002), social functioning (P<0.001), physical component summary (€P<0.001) and bodily pain (P<0.01). Illness duration was negatively related to the mental component summary (P<0.004). HHT patients had a lower HR-QoL with respect to normal controls in all domains except for bodily pain. Females had lower scores for several domains. Epistaxis was the most important clinical variable.     

Identification of obstacles for chronic pain patients to return to work: evaluation of a questionnaire

The Obstacles to Return-to-Work Questionnaire (ORQ) was developed and evaluated. A total of 154 patients with chronic musculoskeletal pain and prolonged work disability participated in the study. Factor analyses reduced the ORQ to 55 items grouped into 9 subscales. The subscales were named Depression, Pain intensity, Difficulties at work return, Physical workload and harmfulness, Social support at work, Worry due to sick leave, Work satisfaction, Family situation and support, and Perceived prognosis of work return. The subscales showed satisfactory reliability. In order to determine predictive validity a discriminant analysis was conducted with sick leave 9 months after assessment as the outcome. This analysis indicated that the scales Perceived prognosis of work return, Social support at work, Physical workload and harmfulness, Depression, and Pain intensity could significantly predict sick leave and correctly classified 79% of the patients. The Multidimensional Pain Inventory and the Disability Rating Index could also significantly predict sick leave in this sample and correctly classified as many patients as the ORQ. However, these questionnaires do not include any work-oriented items and they had a lower specificity than the ORQ. This study suggests that patients' perceptions and beliefs about work and returning to work may be a significant hindrance for actual recovery.     

In vitro susceptibility of mycelial and yeast forms of Penicillium marneffei to amphotericin B,fluconazole, 5-fluorocytosine and itraconazole

The mycelial (25°C) and yeast-like (37°C) forms of Penicillium marneffei clinical and type strains were investigated for their in vitro susceptibility to amphotericin B (AmB), 5-fluorocytosine (5-FC), fluconazole (FLU) and itraconazole (ITZ), using Bacto antibiotic medium 3, yeast-nitrogen, Sabouraud's dextrose (pH 5.7) and high resolution (pH 7.1) broth media (1ml/tube), respectively. Results indicated that the minimal inhibitory and minimal fungicidal concentrations (MICs and MFCs) for the mycelial cultures of P. marneffei to AmB were in the range 0.78–1.56 and 0.78–3.125 g/ml, respectively, as against 3.125–25 g (MICs) for the yeast form cultures. The MFCs to AmB for the yeast form were one dilution higher. The MICs to FLU were generally lower for the yeast form (6.25–25 g) than the mycelial form (25–50 g/ml), whereas MFCs for the mycelial cultures were > 100 g as compared to 6.25–100 g for their yeast form. The MICs for the mycelial form to 5-FC ranged from < 0.195–0.39 g. Higher MICs (6.25 g) were recorded for their yeast form. The MFCs to 5-FC for the yeast form were 25–100 g/ml. The MICs for the mycelial form to ITZ ranged from < 0.195 to 3.125 g/ml. Higher values (< 0.195–50 g) were recorded for their yeast-like form. The MFCs to ITZ for mycelial and yeast forms ranged from < 0.195–0.39 and 25–100 g/ml, respectively. Results indicate that P. marnefei's yeast form is more sensitive to FLU and ITZ (8 of 10 strains) while the mycelial form displayed greater susceptibility to AmB and 5-FC. The MICs for ITZ remained steady in SD medium, pH 5.7 to 7.1. However, some strains gave higher MIC values (0.39–1.56 g/ml) when tested in the HR.     

In a Secular Spirit: Strategies of Clinical Pastoral Education

The Clinical Pastoral Education (CPE) model forthe provision of spiritual care represents theemergence of a secularized professionalpractice from a religiously-based theologicalpractice of chaplaincy. The transformation ofhospital chaplaincy into spiritual careservices is one means by which religioushealthcare ministry negotiates modernity, inthe particular forms of the secular realm ofbiomedicine and the pluralism of thecontemporary United States healthcaremarketplace. Spiritual is a labelstrategically deployed to extend the realm ofrelevance to any patient's belief system,regardless of his or her religious affiliation.Theological language is recast as a tool forconceptualizing the spiritual lens. Suchmoves transform chaplaincy from a peripheralservice, applicable only to the few religiouspatients, into an integral element of patientcare for all. Such a secularized professionalpractice is necessary to demonstrate therelevance and utility of spiritual care for allhospital patients in an era of cost-containmentpriorities and managed care economics.     

The need for “psychological parents” by children in residential treatment

The literature on the socialization of children is reviewed. It is concluded that a major factor contributing to conduct problems in children is the lack of effective child caring at home. The special adult-child relationship which differentiates biological from psychological parenting is described. Implications for the residential treatment of children are discussed.     

Susceptibility of clinical isolates of campylobacter pylori to 24 antimicrobial and anti-ulcer agents

Forty-nine isolates of Campylobacter pylori were tested for their susceptibility to twenty antibiotics and four anti-ulcer agents by an agar dilution technique. Penicillin and amoxycillin were the most active drugs (MIC₉₀, 0.06 /ml); erythromycin, cefazolin, minocycline, ciprofloxacin, ofloxacin and gentamicin were sligthtly less active (MIC₉₀, 1 g/ml). Moderate activity was found for doxycyclin, rifampin, nitrofurantoin, norfloxacin, pefloxacin, enoxacin, paromomycin, metronidazole and tinidazole. All strains were resistant to trimethoprim (MIC > 512 g/ml). Nalidixic acid (MIC₉₀, > 256 g/ml) and colistin (MIC₉₀, > 64 gg/m1) had little to no activity. Of four anti-ulcer drugs, only bismuth subcitrate showed activity (MIC₉₀, 64 g./ml).Strains resistant to all 4-quinolones were found in patients who had previously received ofloxacin as part of a clinical trial aimed at eradication of C. pylori. These isolates remained susceptible to amoxycillin, tetracyclines and to other classes of antibiotics.Corresponding author.     

Development and pilot-testing of a health-related quality of life chronic generic module for children and adolescents with chronic health conditions: A European perspective

Health-related quality of life (HRQOL) assessment in children and adolescents with chronic health conditions is increasingly considered as a relevant topic. The aim of the EU-funded DISABKIDS project is to develop, test, and implement European instruments for the assessment of HRQOL of children and adolescents with disabilities and their families. The current paper describes the development and pilot testing of a chronic generic HRQOL measure. Using literature searches, expert consulting and focus groups with children/adolescents and their families, items of the instruments were developed and translated into the respective languages. A pilot test with 360 children and adolescents was conducted. Children and adolescents (8–12, 13–16years) with different chronic health conditions (asthma, epilepsy, diabetes, arthritis, atopic dermatitis, cerebral palsy, and cystic fibrosis) as well as their families were included. Data were analysed according to predefined psychometric and content criteria. Psychometric analyses resulted in a 56-item chronic generic HRQOL questionnaire with six domains (Medication, Physical, Emotion, Independence, Social Inclusion, Social Exclusion) with acceptable internal consistency.The DISABKIDS Group - The DISABKIDS Group comprises a coordinating group (Prof. Monika Bullinger, Dr. Corinna Petersen, Dr. Silke Schmidt, Institute of Medical Psychology, University Clinic Hamburg-Eppendorf) and study centres in seven countries: Prof. Michael Quittan, Dr. Nilouparak Hachemian and Dr. Othmar Schuhfried, Department of Physical Medicine and Rehabilitation, University of Vienna, Austria; Dr. Marie Claude Simeoni and Dr. Audrey Clement, Department of Public Health, University Hospital of Marseille, France; Dr. Ute Thyen. and Dipl.-Psych. Esther Müller-Godeffroy, Department of Paediatrics, Medical University of Lübeck, Germany; Dr. Athanasios Vidalis, Ass. Prof. John Tsanakas, Dr. Elpis Hatziagorou and Dr. Paraskevi Karagianni, Department of Psychiatry, Hippocratio Hospital, Greece; Dr. Hendrik Koopmann and Drs. Rolanda Baars, Department of Paediatrics, Leiden University Medical Centre, Netherlands; Dr. John Eric Chaplin, Department of Paediatrics, University Hospital Lund, Sweden; Prof. Mick Power, Dr. Clare Atherton and Dr. Peter Hoare, Department of Psychiatry, University of Edinburgh, United Kingdom.     

Financial “Rules” for Child and Youth Care Managers

Contemporary realities demand that child and youth care managers cast off their traditional avoidance of all things financial. This article offers a jargon-free list of twelve financial rules for thriving in turbulent times. Grounded in a concept of client-centered, results-based agency performance, rules include promoting an entrepreneurial spirit throughout the organization, destroying the taboo on open discussion of financial matters, slashing program development time, and spending lavishly on recruitment and universal staff training.     

Advancing child and youth care: A model for integrating theory and practice through connecting education,training, and the service system

This article presents a comprehensive model for enabling connections to be made between theory and practice in the field of child and youth care, based on an analysis of current training and education in the field and a multi-step concept of theory-to-practice and practice-to-theory. The model presents a logical sequence of activities that generate and convey knowledge from two sources. One is formal empirical and research information; the other is the conceptualization of practitioners' direct experience. Both are reinforced by trainers and educators with dual connections with practice and training and education settings. The paper stresses that academic programs are a significant component of any profession, in that they are responsible for collecting and codifying emergent knowledge gathered from multiple sources.There is nothing so practical as a good theory. —Kurt Lewin (quoted in Hunt, 1987, p. 4) There is nothing so theoretical as good practice. —David Hunt (1987, p. 11)An earlier version of this paper was the winner of the 1989 Albert E. Trieschman Prize Competition, published author category, for the best original contribution to the literature of child care.     

Investigations on neurotoxicity of chemical substances at the workplace

Summary A cross-sectional study was performed in order to investigate the influence of chronic lead-exposure on the peripheral nervous system. We examined 148 male workers of a storage battery manufacturing plant, who had been exposed to lead metal and inorganic lead compounds for 1 to 28 years (mean 11 years). Fifteen workers with non-occupational risks of peripheral neuropathy (former diseases, alcohol abuse, medication) were excluded from the study. The investigation program comprised: case history, physical examination, analyses of blood- and urine-samples and determination of maximal motor, mixed and sensory conduction velocity (NCV) of the ulnar and median nerve of the right forearm. Objectively no worker showed any signs of health effects related to lead exposure. The Biological Monitoring included the determination of (1) Blood-lead level (Pb-B), (2) Free erythrocyte porphyrins (FEP), (3) -Aminolevulinic acid dehydratase (ALA-D) and (4) -Aminolevulinic acid in urine (ALA-U). Further time-weighted-average (TWA)-values of Pb-B were calculated on the basis of several determinations over the period 1975–1981. The following actual (TWA) median values resulted: Pb-B 53 g/dl (54 g/dl), ALA-U 5.6 mg/l (8.4 mg/l), FEP 2.0 mg/l (2.0 mg/l). The Biologischer Arbeitsstoff Toleranz Wert (BAT) of 70 g//dl for Pb-B was exceeded in 15 workers (11%), and of 15 mg/l for ALA-U in 30 cases (23%). In comparison with age-matched controls, the lead workers showed a mild slowing of NCV with mean values between 0.8 and 2.0 m/s. Multiple stepwise regression analyses revealed statistically significant correlations between the four NCV and age as well as Pb-B. There were better correlations by using TWA than actual data of Pb-B. Consideration of the results of the regression analyses, together with an evaluation of the individual neurophysiological status as a function of internal lead exposure, a dose-effect-relationship was found only in the case of Pb-B exceeding 70 g/dl. From our study it is concluded that chronic lead exposure resulting in blood-lead levels of below 70 g/dl is no occupational risk causing a functionally significant slowing of nerve conduction velocities.With Grants from the Deutsche Forschungsgemeinschaft, Bonn (Project no. Va 23/19-1)     

Treatment of a constellation of inappropriate sexual and social behaviors in a 20 year old man with Down's Syndrome

In 1983, a Down's Syndrome male (I.Q. 72) AB who resided in a community residence was charged by local police with Exposing his genitalia, as a result of an incident of exhibitionism. Upon investigation by the New Jersey Division of Mental Retardation (a State of New Jersey Agency now named the New Jersey Division of Developmental Disabilities), it was found that AB had a constellation of inappropriate sexual and social behaviors. A treatment plan was designed by a State Psychologist, a private Psychologist, a State Special Educator, a State Social Worker, and residential staff, with the full cooperation of AB's parents. The treatment approach combined traditional psychotherapy, a token economy plan, and vigorous social skills training. AB has been followed for 7 years and the treatment plan has been modified a number of times, as AB's behavior has continued to improve. Over the 7 years, AB has not had any more arrests on sexual charges and his overall social behavior has shown marked improvement.     

Comprehensive pediatric primary care vs traditional care in an israeli population: Their influence on pediatric emergency room use and hospitalization

Emergency room (ER) utilization and hospitalization were studied as indicators of the impact of improvements in pediatric primary care services in an Israeli development town, Ofakim, population 12,000. One of the two pediatric services was upgraded in 1976 through the introduction of pediatric faculty, integration of preventive and curative services and conversion of the medical records to a problem-oriented format ( experimental clinic B ). The primary care system remained unchanged in the second clinic ( traditional clinic A ). During 1980, ER utilization by the B clinic population was 9.3/100 compared with 17.6/100 for the A clinic population. Fifty two percent of the B clinic population patients reaching the ER were hospitalized compared with 25% of A clinic patients.The lower ER utilization rate represents a significant saving for the health services, and educational interventions are suggested from the study. Analysis of ER utilization data seems to offer useful information for overall planning and monitoring of ambulatory services for a community.Corresponding author.     

Ultraviolet and volatility loss of herbicides

Herbicide 2,4-D formulated as a urea-type polymer was readily destroyed by long-wave uv (356-nm) irradiation, whereas conventional 2,4-D was more resistant. The opposite relationship was noted for polymeric and conventional formulations of dicamba. Polymerized 2,4-D was more resistant to thermal degradation (60°C) than non-polymerized formulations. Ultraviolet degradation of polymerized 2,4-D was eliminated by the incorporation of RYLEX-H and UVINUL D-50, industrial uv absorbers. Exposure of polymeric dicamba to 60°C heat, followed by trapping of the volatile component, indicated that 21 percent was lost by thermal degradation and 46.6 percent by volatilization. Comparable values for non-polymerized dicamba were 37.9 and 60.1 percent.     

Relationship between inhibition of erythrocyte pyrimidine 5′-nucleotidase activity and biological response for porphyrin metabolism in workers occupationally exposed to lead

Summary A rapid determination of erythrocyte pyrimidine 5-nucleotidase (P5N) activity in lead workers was carried out using a high-performance liquid chromatograph (HPLC). The P5N activity had a good negative correlation with the concentration of lead in blood (PbB) ranging from 16 to 96 g/dl (r = -0.82, n = 77). Further, the P5N was compared with other biological parameters: erythrocyte -aminolevulinic acid dehydratase (ALAD) activity, erythrocyte protoporphyrin (PROTO), urinary -aminolevulinic acid (ALA) and urinary coproporphyrin (COPRO).The correlation coefficients between P5N and ALAD, log PROTO, log ALA, and log COPRO were 0.59, –0.72, –0.65, and –0.61, respectively. On the other hand, the normal value of P5N obtained from 72 healthy subjects was 11.9 ± 2.1 units; ol uridine/h/g Hb (mean ± SD), indicating that the lower limit of 95% confidence interval for normal P5N was about 8 units. When P5N was cut off at 8 units in 77 lead workers, the validity (sensitivity + specificity) for PbB 40 g/dl, PbB 60 gg/dl, erythrocyte PROTO 150 g/dl RBC, urinary ALA 6 mg/l, and urinary COPRO 150 g/l was 1.66, 1.76, 1.57, 1.68, and 1.60, respectively. From these results, it was confirmed that the erythrocyte P5N test is suitable for the biological monitoring of exposure to lead in a wide range, and its activity is useful in predicting the disturbance of porphyrin metabolism induced by lead.     

Preschool programs for developmentally disabled children and their families: Are they meeting mothers' expectations?

This study examines the amount of agreement between preschool program staff and mothers of developmentally disabled children on the variables child-rearing values and amount of parental program contact. The findings indicate that although there is a high degree of consonance on child-rearing values, the two groups hold discrepant perceptions of the amount of parental program contact. Such discrepancies may be important indicators of mothers' level of program satisfaction.     

What is a normal family? Common assumptions and current evidence

The social and applied human sciences have been built upon the assumption that the normal family consists of a first-marriage conjugal couple cohabiting with biological children. It is taken for granted that the wife should be responsible for child and domestic work, and that the husband should be the family's economic provider and ultimate authority. In the professional literature such traditional family structure is often described as normal in the sense of most common, as well as normal in the sense of well-functioning. Current psychological, sociological, anthropological and historical studies, however, do not support the assumption that the traditional nuclear family is the most natural, common, and/or healthy form of family arrangement. The idealization of the traditional nuclear family has had implications for theory, research, mental health practice, and social policy. Scientists and practitioners have been slow to recognize pathology in traditional nuclear families. Families other than traditional nuclear ones have been rendered invisible or pathologized. It is time for contemporary social and applied human sciences to recognize that the traditional nuclear family is a culturally- and historically-specific construct. It is also time for contemporary social and applied human sciences to develop an account of, and a research agenda about, families that take into consideration their variations across time, place, social class, ethnicity, and culture.