Follow-up of nutritional and metabolic problems after bariatric surgery

Over the next several years, the number of patients who will have had bariatric surgery for morbid obesity will reach close to a million. Several well-described nutritional problems such as B12 and iron deficiency will be noted in these patients. Many of these patients will be lost to the original surgeon and will now be in the care of the "other physicians." These and other mineral and vitamin problems will need to be screened and treated. If these problems are left undiagnosed, severe and irreparable problems can result. Early problems, such as vomiting and dumping syndrome, will be easily recognized and treated, but other long-term problems, such as changes in bone metabolism, will need to be monitored. Again, if some of these long-term problems are not addressed in a timely fashion, then eventual treatment becomes much more difficult. This commentary will cover the common as well newer problems that are now developing in the patient who has had bariatric surgery. Patients who have undergone bariatric surgery require medical follow-up for reasons that are often determined by the type of surgical procedure performed. The majority of this review will deal with patients who have had the standard Roux-en-Y gastric bypass, which is a primarily restrictive procedure with a mild component of noncaloric malabsorption. At the end of this report, a short section will be devoted to the problems associated with the malabsorptive procedures.     

Utilization of prostheses among US veterans with traumatic amputation: a pilot survey

No random surveys have been done to determine how effectively veterans with amputation can utilize their prostheses, and only one limited survey has been done of Scandinavians' use of lower-limb prostheses. A pilot survey of prosthetic problems was sent to all 170 US veteran soldiers who had traumatic amputations over the last 10 years, whose addresses could be supplied by the VA, and whose medical synopses showed them to be otherwise healthy when leaving the military. This subpopulation was selected as a "best case" group: those most likely to be active, young, and healthy enough to use their prostheses, as well as close enough to the military and veterans medical systems to get adequate treatment. If they have problems, the rest of the veterans with amputation, relatively older and more debilitated, are very likely to have far worse problems. Although only 45 responded (26%), all had significant problems using their prostheses for work. Most problems were related to the attachment method. Even if all nonrespondents were problem free, at least a quarter had very significant problems using their prostheses. This means that there are significant problems with current methods for attaching prostheses that need to be addressed. The first step should be a large survey of veterans with amputation to get an accurate assessment of the extent of prosthesis-related problems.     

Sleep disorders and sleep problems in childhood

Sleep problems are common in childhood. A distinction is made between problems in which polysomnography is abnormal (i.e., the parasomnias, sleep apnea and narcolepsy) and problems that are behavioral in origin and have normal polysomnography. The parasomnias--sleep terrors, somnambulism and enuresis--appear to be related to central nervous system immaturity and are often outgrown. Obstructive sleep apnea syndrome (OSAS) is frequently missed in children and can often be cured through surgery. Behavioral sleep problems may be overcome after parents make interventions. Physicians can be of great assistance to these families by recommending techniques to parents that have been shown to be effective.     

The problems of interprofessional healthcare practice in hospitals

This article outlines the problems of interprofessional practice in the hospital setting. It examines the difficulties associated with competing ideologies and aims, inequalities in power relations, communication and role confusion and overlap. Within the hospital setting such problems often arise although the roots of the problem may go unacknowledged. The ways in which the problems occur in the hospital setting are considered, as is the underlying cause of such problems. Case studies will be used to analyse how the problems arise and ways in which they might be addressed.     

Nursing research needs of black Americans: 1989 and beyond

This article identifies problems considered to be among the most important for Black American health and suggests specific areas of research to address these problems. Black professional nurses are urged to become active researchers in order to be effective in the treatment and/or prevention of these problems.     

Menstrual Problems Experienced by Women with Learning Disabilities

Background Menstruation appears to be problematic for women with learning disabilities, yet there has been little quantitative research on their experiences, or comparisons with other groups of women. This paper considers the nature and extent of menstrual problems experienced by women with learning disabilities. Methods The data reported here come from a cross‐sectional postal questionnaire survey conducted with carers of 452 women, aged 14–55 years, who had learning disabilities. Results Women with learning disabilities appear to be as likely to experience menstrual problems as other women. However, such problems may be experienced differently and more negatively and may not always be recognized appropriately. Conclusions More attention needs to be given to menstrual problems experienced by women with learning disabilities, both in research and in practice. It is particularly important that women with learning disabilities be supported to play a central role in recognizing and defining the problems they experience.     

医院人力资源管理的思考

目的探讨医院人力资源管理的现状，为今后人力资源管理提供积极的借鉴作用。方法分析当前我国医院存在的人力资源问题，并提出了解决对策。结果目前医院人力资源管理存在人力资源及管理观念不到位、人员结构层次有待于进一步优化、人力资源管理体制僵化、人力资源管理制度的制定与实施不合理、缺乏科学的绩效评估体系等问题。对策：树立正确的人力资源观念，建立公开、平等、竞争、择优的选人、用人制度，建立职责明确、有效放权的岗位责任制，建立科学、公正、公开的绩效考核制度及有效的人力资源激励机制。结论实施新的人才战略，可解决当前我国医院人力资源管理存在的问题。     

The natural history of drinking and alcohol-related problems after traumatic brain injury

OBJECTIVES: To describe changes in drinking from before traumatic brain injury (TBI) to 1 year after TBI. DESIGN: Inception cohort with 1-year follow-up. SETTING: Level I trauma center. PARTICIPANTS: Adults (N=197) hospitalized with a broad range of head injury severity. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Alcohol consumption and alcohol-related problems. RESULTS: Drinking and alcohol-related problems decreased substantially from preinjury to 1 year after TBI. However, about one quarter of the sample reported heavy drinking, significant problems, or both during the first year after TBI. Preinjury alcohol use and problems were highly predictive of heavy use and problems after TBI. CONCLUSION: Although drinking and alcohol-related problems decreased after TBI, there appears to be an ongoing need for prevention and intervention efforts. Screening for preinjury alcohol problems can be used to identify the vast majority of persons who will develop alcohol-related problems within 1 year after injury.     

Adolescent Perceptions of Relevant Social Problems

PROBLEM: Social problems can be a significant stressor for adolescents. Disturbed youth often experience negative outcomes to social problems, solve problems poorly, and display distortions in reasoning about social problems. METHODS: A series of focus groups was conducted with adolescents (N = 36), and the data was analyzed inductively. Activities to increase the rigor of the study data (establishing credibility, trustworthiness, and transparency) were incorporated into the phenomenological research design. FINDINGS: Five social problem themes with critical attributes were perceived to be relevant to teenagers in today's society. CONCLUSIONS: Adolescents' social problems shift in response to a changing society. Findings from this study can be used to help target assessments and treatment plans when working with disturbed youth.     

Factors related to the problems of long-term catheterization

A survey of 97 elderly catheterized patients revealed the catheter-related problems of leaking, blocking, need for irrigation, odour and irritation. Details were taken of factors thought to be related to the problems and the data were analysed by using stepwise forward multiple regression. Hospital and community patients were found to have different problems. Females in both groups had more problems than males. For hospital patients, larger catheters were found to be associated with most problems, particularly leaking and blocking. For community patients, immobility and daily changing of drainage bags were major problem causers. The common nursing practice of changing to wider-diameter catheters in an attempt to prevent bypassing is wrong.     

Multiple sclerosis: Part II. Common functional problems and rehabilitation

Cognitive impairments, often unrecognized in multiple sclerosis, include memory loss, new learning problems, denial and depression. Spasticity and incoordination of the oropharyngeal and respiratory muscles create functional problems with speech and swallowing. Genitourinary problems include sexual dysfunction and neurogenic bladder. Specific measures can be used to alleviate these problems.     

Behavioral pediatrics

The family physician can, through instruction in standard caregiving skills and discussion of parental expectations, prevent or minimize behavioral problems in infants and toddlers. Behavioral problems can be detected early by having parents describe a typical day. When detected early enough, many problems which occur at bedtime, mealtime and when dressing can be managed by the interested physician.     

Skin lesions in returned travelers.

Skin problems are commonly encountered during and after travel. Because of increasing travel and tourism to remote and previously unvisited areas, it is likely that these and other dermatologic conditions will continue to be frequent problems observed in travelers. For the nondermatologist, recognition of many of the commonly encountered skin problems can be facilitated by following the lesion-oriented approach outlined in this article.     

Alcohol problems among young adult emergency department patients: making predictions using routine sociodemographic information

OBJECTIVES: The study aims were to explore the process of identifying young adult Emergency Department (ED) patients at risk for alcohol problems, examine the sociodemographic predictors of patient alcohol problems, and determine differences between patients who screened positive and those who screened negative for alcohol problems. Implications for ED practice are discussed. METHOD: As part of a larger study, the Alcohol Use Disorders Identification Test was administered to consenting patients ages 18 to 29. A score of greater than 5 (out of 40) was considered a positive screen for alcohol problems. Sociodemographic information was collected from a generic Individual Information Form. RESULTS: Approximately 48% (1855 of 3890) of patients screened positive for alcohol problems. Among screen-positive patients, 91% (1689) had scores that corresponded to mild to moderate alcohol problems. Compared with screen-negative patients, screen-positive patients were almost 3 times more likely to be men (odds ratio [OR] = 2.70); 2.5 times more likely to use tobacco (OR = 2.43); 2 times more likely to be single (OR = 2.03); and 1.5 times more likely to have some college education (OR = 1.41), be an 18- to 20-year-old adult (OR = 1.61), be a college student (OR = 1.60), be unemployed (OR = 1.39), and cohabitate with friends (OR = 1.19). Screen-positive patients also were more likely to have made at least one past attempt to change their drinking behavior (OR = 3.21). CONCLUSION: Routine patient information presented an accurate risk profile for alcohol problems among patients in this study. If ED-based health care professionals routinely screened patients for alcohol problems or could predict potential alcohol problems by using routinely collected information, then intervention or referral for additional services may increase.     

Alcohol consumption and related problems: Treatment and policy responses in Nigeria

Although Nigeria has a long history of alcohol production and consumption, recent increase in availability and marketing of alcohol is correlated with heavy drinking and associated health and social problems. Responses to alcohol consumption and related problems have been tepid due to lack of written policy, poor implementation of existing control measures and subversion of regulation by alcohol companies. Efforts should be made to codify evidence-based control measures into policy and to strengthen political commitment towards their implementation. Early identification and intervention on alcohol problems should be integrated into the primary healthcare system and health workers should be trained in screening and intervention in alcohol problems. Furthermore, access to treatment for alcohol use disorder should be improved through the establishment, staffing and equipping of more mental health facilities throughout the country.     

The Self-Adapting Focused Review System. Probability sampling of medical records to monitor utilization and quality of care

Medical record review is increasing in importance as the need to identify and monitor utilization and quality of care problems grow. To conserve resources, reviews are usually performed on a subset of cases. If judgment is used to identify subgroups for review, this raises the following questions: How should subgroups be determined, particularly since the locus of problems can change over time? What standard of comparison should be used in interpreting rates of problems found in subgroups? How can population problem rates be estimated from observed subgroup rates? How can the bias be avoided that arises because reviewers know that selected cases are suspected of having problems? How can changes in problem rates over time be interpreted when evaluating intervention programs? Simple random sampling, an alternative to subgroup review, overcomes the problems implied by these questions but is inefficient. The Self-Adapting Focused Review System (SAFRS), introduced and described here, provides an adaptive approach to record selection that is based upon model-weighted probability sampling. It retains the desirable inferential properties of random sampling while allowing reviews to be concentrated on cases currently thought most likely to be problematic. Model development and evaluation are illustrated using hospital data to predict inappropriate admissions.     

Reflections concerning an activity consultant by a nursing home administrator

The problems a therapist can expect as a part-time consultant in a nursing home are explored. These problems include understanding the nature of patient population, incomplete information on specific characteristics of the nursing home, and the relationships among the various constituencies found in the facility. Activities can be helpful in counteracting physical problems and especially depression and withdrawal. The consultant must be independent, objective, informed, able to stimulated creative approaches, make value judgments and appropriate decisions, and above all, must be involved.     

Critical care management of lung transplant recipients

In the last 10 years, lung transplantation has become an increasingly common procedure for patients with end-stage respiratory disease. Although long-term survival can be achieved, there is still significant morbidity within the first year. Early postoperative problems that may be anticipated include respiratory insufficiency, airway anastomotic problems, hemorrhage, infection, and episodes of acute rejection. These problems and others make the immediate perioperative period particularly challenging. With aggressive management, however, the probability of a successful outcome can be enhanced.     

Trauma and other noninfectious problems in homosexual men

Homosexual men are at risk for problems unique to their sexual orientation, and the management of even standard problems must often be altered. The recognition and management of problems related to the anorectum, breasts, and external genitalia in homosexual men are discussed.