The quality encounter between purchasers and providers: what to ask and how to answer

It is not easy to lay prejudices aside, to find and face the facts, and to let the chips fall where they may. There is no need to wait for improvements in technology before beginning to use outcomes monitoring to guide the business exchange between purchasers and providers. Although future technological improvements will greatly improve the capacity to use objective data to differentiate among providers and to identify strengths and weaknesses within a health care organization, reasonable methods are available today to undertake these important tasks. All that is needed is the courage and willingness to embrace them. The future belongs to purchaser and provider organizations that are willing to seek enlightenment rather than blame.     

微创术双针对口冲洗引流在治疗慢性硬膜下血肿中的临床应用

目的 总结微创术双针对口冲洗引流在治疗慢性硬膜下血肿中的临床应用的经验及疗效。方法常规穿刺引流组36例和双针对口冲洗引流组40例的疗效进行对比。结果双针对口冲洗引流组40例全部治愈,3例少量颅内积气。常规引流对照组31例治愈,5例颅内积气。结论微创术双针对口冲洗引流组疗效较常规穿刺引流组好。     

Biotype and antibiotic sensitivity of 100 clinical isolates of Yersinia enterocolitica.

One hundred clinical isolates of Yersinia enterocolitica were biotyped, serotyped and tested for in-vitro sensitivity to seven beta-lactam antibiotics and six other antibiotics. Twenty-four of the isolates belonged to Niléhn's and Wauters' biotype 1A, 12 to biotype 3 and 64 to biotype 4. No biotypes 1B or 2 strains were found. All isolates were sensitive to chloramphenicol, ciprofloxacin, gentamicin, tetracycline, trimethoprim and all but one to sulphafurazole. All were resistant to ampicillin with MIC's ranging from 32 to 256 mg/L, but were susceptible to ticarcillin/clavulanic acid and imipenem. With other beta-lactam agents there were different patterns of sensitivity, specific to each of the three biotypes. All biotype 4 strains were resistant to carbenicillin and ticarcillin but sensitive to amoxycillin/clavulanic acid and cefoxitin. Biotype 3 strains, by contrast, were sensitive to carbenicillin and ticarcillin but resistant to amoxycillin/clavulanic acid and cefoxitin, whilst biotype 1A strains were resistant to each of these four beta-lactam agents.     

Negative affectivity in children: Development and validation of a self-statement questionnaire

A questionnaire, the NASSQ (Negative Affect Self-Statement Questionnaire), was developed to assess self-statements associated with negative affect in children and young adolescents. Male and female 7- to 15-year-olds recalled representative self-statements (items) which were then administered to a sample along with a battery of measures used to identify criterion groups. Items discriminating between anxious/nonanxious and depressed/nondepressed criterion groups in separate 7- to 10- and 11- to 15-year-old samples were identified. Each inventory was then cross-validated on new samples. Anxious and depressive self-statement inventories were combined (separately for the age groups) to form the NASSQ. Both the 7- to 10- and the 11- to 15-year-old samples on NASSQ were found to be internally reliable and temporally stable. Additional analyses supported concurrent and construct validity. The NASSQ was found to be sensitive, and relatively specific, to an anxiety treatment, particularly with treated 11- to 15-year-olds. The NASSQ appears to be a useful measure to assess self-talk reflecting negative affectivity.     

Uncovering the ethics of suffering using a narrative approach

The purpose of this article is to portray the ethics of suffering based on the published literature. Narrative use has become common in the fields of nursing education and curriculum development and in the determination of practice competencies. Understanding the ethics of suffering implies a hermeneutic movement between alienation and dedication. To understand the ethical significance of human suffering, the scene of suffering is described through the concepts of: to endure, to struggle, to sacrifice life and health, and to become. To respond, to discover, to approach, to touch and to shape patients' different patterns of life implies responsibility: to see, to affirm their dignity by being, and to express this in ethical words. Narration plays a crucial role in transforming suffering, that is, reformulating patients' stories. It is vital that educators should create a learning environment where students can find the courage and intention to be present and listen to patients' narratives.     

Comparative in-vitro activities of newer cephalosporins cefclidin, cefepime, and cefpirome against ceftazidime- or imipenem-resistant Pseudomonas aeruginosa.

Three hundred and thirty-four recent clinical isolates of Pseudomonas aeruginosa were examined for susceptibility to cefclidin, cefepime, and cefpirome. Of these strains, 28.7% were resistant to ceftazidime, and 23.4% were resistant to imipenem. About half of those resistant to ceftazidime were also resistant to imipemem. Although 37.4% and 59.6% of the isolates were resistant to cefepime and cefpirome respectively, and most or all ceftazidime-resistant strains showed resistance to cefepime and cefpirome, only 3.9% were resistant to cefclidin. Ceftazidime-resistant, but cefclidin-susceptible, P. aeruginosa produced high levels of chromosomal cephalosporinases. Of the compounds tested, cefclidin showed the lowest affinity for these enzymes, suggesting that its high activity against P. aeruginosa resistant to several beta-lactams was mainly due to its high resistance to enzymatic hydrolysis. Thirteen strains resistant to cefclidin were also resistant to both cefepime and cefpirome, and eight and three of these strains were resistant to ceftazidime and imipenem, respectively. A penicillinase, which hydrolyzed cefclidin, was detected in the cefclidin-resistant P. aeruginosa, which was similar to the OXA-1 beta-lactamase.     

Stopping the active intervention: CARET

The Carotene and Retinol Efficacy Trial (CARET) was a large, multicenter randomized chemoprevention trial designed to test a combined lung cancer prevention agent in heavy smokers and workers exposed to asbestos. In January 1996, the CARET Steering Committee decided to stop the intervention due to an adverse effect. This paper describes the decision process used to apply the stopping rules and the activities engaged in by CARET participants and staff to implement the decision. The most important activity was to draft and mail a letter to the participants informing them of the disappointing CARET results and asking them to stop taking the study vitamins and to return any unused study vitamins. The steering committee, with the support of the National Cancer Institute, planned to follow participants for disease endpoints and smoking behavior for 5 years. These activities led to smooth closure of active intervention and maintained high retention rates during the transition.     

Toluene di-isocyanate-induced asthma. I. Reactions to TDI, MDI, HDI and histamine.

A group of twenty four workers handling di-isocyanates and with respiratory disease were investigated by occupational-type bronchial provocation tests for sensitivity to toluene di-isocyanate (TDI), to which all were exposed, and to diphenylmethane di-isocyanate (MDI) and hexamethylene di-isocyanate (HDI). Sixteen gave asthmatic reactions to TDI and eight of these also reacted to MDI. Four of the eight TDI and MDI reactors had histories of exposure only to TDI, and of them two reacted also to HDI. Of nine subjects tested with HDI, three gave asthmatic reactions, and all three also reacted to TDI and MDI. Thus reactions to MDI and HDI were elicited only in the TDI reactors. The possibility of specific sensitivity to these and other di-isocyanates requires tests in subjects exposed to them and not to TDI.     

Relaxation workshops in primary care

Primary Health Care Centers provide access to relaxation workshops to the general population. As objectives, these try to teach or train citizens how to manage their stress and how to confront life. These workshops make up a health sector, an educational one which teaches how to use one's personal resources and social skills to be able to manage conflicts which occur in life and how to relax. It is important to highlight the benefits of relaxation as a procedure to provide calmness to the body, confidence to the heart and clarity to the mind. The author proposes a guideline to use to set up relaxation groups in Primary Health Care Centers.     

Proteomics: clinical applications.

The word proteomics was coined in 1997 to describe the changes in all proteins expressed by a genome. Several sophisticated techniques including two-dimensional electrophoresis, imaging, mass spectrometry, and bioinformatics are used in proteomics to identify, quantify, and characterize proteins. Clinical proteomics is the application ofproteomics techniques to the medical field. The main aim of this methodology is to identify proteins involved in pathological processes and to understand how illness can lead to altered protein expression. Clinical proteomics offers the opportunity and the potential to develop new diagnostic and prognostic tests, to identify new therapeutic targets, and eventually to allow the design of individualized patient treatment. Here we present an overview of proteomics applications to the study of disease and its potential to improve diagnosis and prognosis.     

What does health literacy mean to children?

This study employed the Delphi technique to define the meaning of health literacy to children and to investigate possible ways lead to them to become health literate. According to the experts' perspectives, the meaning of health literacy to children is "to perform physical and psycho-social activities with appropriate standards; being able to interact with people; cope with necessary changes and demand reasonable autonomy so as to achieve complete physical, mental and social well-being". In order to assist children develop healthy physical, psycho-social well-being so as to demonstrate that they are health literate, parents, teachers and significant others have to support and guide the children by demonstrating good practices regarding health-related behaviors. The study serves as a reference for developing healthy childhood that leads to healthy adulthood and healthy elderly.     

Antibiotic sensitivity of bacteria associated with community-acquired urinary tract infection in Britain.

Twelve laboratories in different parts of Britain each supplied approximately 80 consecutive urinary bacterial isolates from community patients. All strains were identified by a central laboratory, where sensitivity to a variety of orally administered antimicrobials was determined by microtitre broth dilution. 65.1% of isolates were Escherichia coli, 23.4% 'coliforms' other than E. coli, 4.6% Proteus and Morganella spp., 1.8% Pseudomonas spp., 2.4% enterococci, 0.7% group B streptococci, 1.5% coagulase-negative staphylococci and 0.5% Staphylococcus aureus. Using previously published breakpoint sensitivity values, 98.9% of all isolates were found to be sensitive to norfloxacin and to ciprofloxacin, 95.7% to co-amoxiclav, 86.8% to nitrofurantoin, 77.4% to cephalexin, 75.6% to trimethoprim, 75.0% to cephradine and 51.7% to amoxycillin. There were some differences in sensitivities between centres, particularly those of the cephalosporins. Using standard breakpoints, submitting laboratories were found to overestimate sensitivity to nitrofurantoin and to underestimate sensitivity to the quinolones and to co-amoxiclav; there was considerable overestimation of sensitivity to cephalosporins.     

In vitro development of resistance to five quinolones and amoxicillin-clavulanate in Streptococcus pneumoniae

The ability of 50 sequential subcultures in subinhibitory concentrations of ciprofloxacin, levofloxacin, grepafloxacin, sparfloxacin, trovafloxacin, and amoxicillin-clavulanate to select for resistance was studied for six penicillin-susceptible and four penicillin-intermediate pneumococci. Subculturing in ciprofloxacin, grepafloxacin, levofloxacin, and sparfloxacin led to selection of mutants requiring increased MICs for all 10 strains, with MICs rising from (i) 0.5 to 4.0 to (ii) 4.0 to 32.0 microgram/ml after 7 to 12 passages for ciprofloxacin, from (i) 0.06 to 0.25 to (ii) 0.5 to 8.0 microgram/ml after 5 to 23 passages for grepafloxacin, from (i) 0.5 to 1.0 to (ii) 4.0 to 64 microgram/ml after 14 to 49 passages for levofloxacin, and from (i) 0.125 to 0.25 to (ii) 1.0 to 16.0 microgram/ml after 8 to 26 passages for sparfloxacin. Subculturing in trovafloxacin led to increased MICs for eight strains, with MICs rising from (i) 0.06 to 0.125 to (ii) 0.5 to 8.0 microgram/ml after 6 to 28 passages. Subculturing in amoxicillin-clavulanate led to raised MICs for only one strain, with the MIC rising from 0.015 to 0. 125 microgram/ml after 24 passages. Double mutations in both ParC and GyrA led to high-level quinolone resistance when ParC mutations were at S79. Trovafloxacin MICs were 1 to 2 microgram/ml in double mutants with ParC mutations at positions other than S79 (e.g., D83). Mutations in ParE (at D435, R447, and E474) and GyrB (at S405, D406, and D435) were found in four and six mutants, respectively. In the presence of reserpine, 29 mutants had lower ciprofloxacin MICs (2 to 16 times lower), 8 mutants had lower levofloxacin MICs (2 times), and one mutant had a lower trovafloxacin MIC (2 times), suggesting the involvement of an efflux mechanism. In contrast to the case for quinolones, subculturing in the presence of amoxicillin-clavulanate did not select for resistance to this drug.     

Connecting patients,practitioners, and regulators in supporting positive experiences and processes of shared decision making: A progress report

This paper describes a novel approach to explore how regulators, working with patients and practitioners, may contribute to supporting person‐centred care and processes of shared decision making in implementing professional standards and reducing harms. Osteopathic patients report high levels of patient care. However, areas of consultations less likely to be rated as high included “fully understanding your concerns,” “helping you to take control,” and “making a plan of action with you,” suggestive of a paternalistic approach to care and a barrier to the effective implementation of standards. This programme explored how to support patients and practitioners to make more explicit what is important to support consultations with better communication in accordance with standards. A series of workshops took place involving approximately 80 participants, which explored and identified practitioner and patient values; these were themed to develop a common framework and tested using case studies. Aspects of what enables or presents a barrier to a positive consultation were further explored with real patient narratives, and a range of resources were subsequently developed, which may support patients and practitioners to make explicit what is important to them in a consultation. A series of approaches and tools were then developed for piloting including patient curriculum vitae; patient goal planner; patient animation to support preparation for an appointment; infographic: a patient poster or leaflet; practitioner reflective tool; and an audio recording to increase awareness and understanding of values‐based practice. In conclusion, a range of approaches may help to support patients and practitioners to make explicit what is important to them in a consultation. The next phase of our programme will use a range of methods including cluster sampling, pre‐testing and post‐testing with the Consultation and Relational Empathy (CARE) measure tool, and interviews and focus groups with users and practitioners to demonstrate impact.     

Job engagement's paradoxical role in nurse burnout

Interviews were undertaken with 11 community health nurses and qualitative analysis sought to illuminate the ways in which job engagement was connected to their health and functioning. High job engagement followed from the nurses' deep feeling of calling to the nursing profession and contributed to a strong sense of duty and strict self-demand regarding one's own and other's levels of performance. In nine cases, perceived failures to live up to their own performance demands contributed to the nurses' near-burnout. This triggered extensive introspection and reflection, leading to positive coping and avoidance of burnout. The nurses coped by using their well-honed skills in introspection and reflection, which they had practiced habitually all their careers, to help them determine which personal and professional changes were required to maintain job engagement and satisfaction. Paradoxically, job engagement can not only promote thriving on the job, but also contribute to negative processes leading to poor functioning.     

1904株革兰阴性杆菌耐药性检测

目的 :了解临床分离的革兰阴性杆菌耐药状况及耐药性变迁。方法 :1997年 1月至 2 0 0 3年 12月临床分离革兰阴性杆菌 190 4株 ,排除同一患者的重复菌株 ,按统一方案用Kirby Bauer法进行药敏试验 ,按美国国家临床实验室标准委员会2 0 0 0年版标准判读结果。结果 :多数年份革兰阴性杆菌对氨苄西林耐药率高达 80 %以上。大肠埃希菌对哌拉西林、喹诺酮类耐药率为 5 0 %左右 ,对第三代头孢菌素、阿米卡星耐药率逐步上升 ,1997、2 0 0 0、2 0 0 3各年相比 ,P <0 .0 5 ,差异有显著性 ,未见亚胺培南耐药株。克雷伯菌属对哌拉西林、第三代头孢菌素、喹诺酮类耐药率增加迅速 ,1997、2 0 0 0、2 0 0 3各年相比 ,P <0 .0 5。铜绿假单胞菌对哌拉西林、头孢哌酮耐药率上升明显 ,在 2 0 0 3年对头孢哌酮、头孢他啶耐药率为 2 6 .2 %、16 .4 %。对亚胺培南耐药率为 6 %。不动杆菌属对第三代头孢菌素的耐药率为 70 % ,对亚胺培南耐药率为 10 .3%。嗜麦芽窄食单胞菌对氨苄西林、头孢曲松、氨曲南、亚胺培南、庆大霉素和阿米卡星耐药率极高 ,仅对环丙沙星和复方磺胺甲唑耐药率较低。结论 :近年来革兰阴性杆菌的耐药性呈上升趋势 ,特别是对第三代头孢菌素耐药性上升最快 ,亚胺培南仍是目前对革兰阴性杆菌最有效的药物。     

Pain narratives and narrative practitioners: a way of working 'in-relation' with children experiencing pain

Children's narratives about their pain are often drowned out by the more pervasive, scientific, dominant, academic and professional discourses. The ideas I propose in this paper are drawn from narrative inquiry and from the narrative medicine movement to illustrate how a narrative approach can positively influence nursing (and other) practice. Sharing children's narratives of pain allows to be 'in-relation' with children and their experiences of pain, requiring practitioners to be less distanced and passive. In order to start and to understand their pain we need to be prepared to be hurt by it. Attending to children's stories helps them to articulate their experiences and gives them voice and agency. A narrative approach to practice can help us to be more the sort of professionals we wanted to be, i.e. more generous, more affective, more remembered and more effective. By helping to 'fix' children's broken stories we can help them move towards stories of healing.     

Cognitive interviewing: verbal data in the design and pretesting of questionnaires

PURPOSE: The purpose of this paper is to discuss problems that occur in questionnaire responses and how cognitive interviewing can be used to identify problematic questions prior to using the questionnaire in the field. BACKGROUND: Questionnaire design involves developing wording that is clear, unambiguous and permits respondents successfully to answer the question that is asked. However, a number of problems in relation to respondents' understanding and successfully completing questionnaires have been identified. Cognitive interviewing, an amalgamation of cognitive psychology and survey methodology, has been developed to identify problematic questions that may elicit response error. The overall aim is to use cognitive theory to understand how respondents perceive and interpret questions and to identify potential problems that may arise in prospective survey questionnaires. METHODS: A literature review is used to examine the process of questionnaire design and how cognitive interviewing can be used to reduce sampling error and increase questionnaire response rates. FINDINGS: Cognitive interviewing involves interviewers asking survey respondents to think out loud as they go through a survey questionnaire and tell them everything they are thinking. This allows understanding of the questionnaire from the respondents' perspective rather than that of the researchers. Cognitive interviews have been used in a number of areas in health care research to pretest and validate questionnaires and to ensure high response rates. Interviewing has been found to be highly effective in developing questionnaires for age specific groups (children and adolescents) and in ascertaining respondents' understanding in health surveys prior to distribution. However, cognitive interviews have been criticized for being overly subjective and artificial. CONCLUSION: Cognitive interviews are a positive addition to current methods of pretesting questionnaires prior to distribution to the sample. They are most valuable in pretesting questions that are complex, where questions are sensitive and intrusive and for specific groups for whom questionnaire completion may pose particular difficulties.     

Intervention in the process of work-health-disease based on the Betty Neuman's systems model

This article proposes a referential landmark directed to the worker's area, attempting to answer theoretical and methodological needs in this field of action and professional intervention. The controversy of the relation work-health-disease and its implications to nursing are very challenging and, at the same time, quite intriguing as we seek for its interrelationships. Therefore, we intend to unfold them adopting the structural path of The Neuman Systems Model, systematizing a proposal of nursing action compromised with the relation work-health-disease. Also, we wish to investigate stress factors at work, environment and individual resources to deal with them, and the goals established to the interaction between nurse and worker. This interaction is seen as fundamental to the proposal of educational and/or assistencial actions to the worker's health. It is our intention to contribute with information and propositions to induce reflective thought and debate about the subject.     

Genomics education for nurses in practice.

Genomics information will make it possible to identify individuals who have, or are at risk to develop, health problems and to diagnose and treat them in ways that until recently were not possible. The majority of nurses in practice today do not have adequate knowledge about genomics. This article describes a diverse and extensive education program initiated to provide information to nurses. Important aspects to consider for all nursing genomics education programs are that they need to be relevant to practice, multifaceted, and ongoing as information continues to unfold about the human genome and application to healthcare.