Does Supplementary Prenatal Nursing and Home Visitation Support Improve Resource Use in a Universal Health Care System? A Randomized Controlled Trial in Canada

ABSTRACT: Background: The addition of supplementary prenatal support may improve the health and well‐being of high‐risk women and families. The objective of this randomized controlled trial was to examine the impact of supplementary prenatal care on resource use among a community‐based population of pregnant women. Methods: Pregnant women from three urban maternity clinics were randomized (a) to current standard of physician care, (b) to current standard of care plus consultation with a nurse, or (c) to (b) plus consultation with a home visitor. Participants were 1,352 women who received 3 telephone interviews. The primary outcome was resource use (e.g., attended prenatal classes, used nutritional counseling). Results: Overall, those in the nurse intervention group were more likely to attend an “Early Bird” prenatal class and parenting classes, and to use nutrition counseling and agencies that assist with child care. Women provided with extra nursing and home visitation supports were more likely to use a written resource guide, nutrition counseling, and agencies that assist with child care. Among women at higher risk (e.g., language barriers, young maternal age, low income), the nurse intervention significantly increased use of early prenatal classes, whereas the nurse and home visitor intervention significantly increased use of the written resource guide and nutrition counseling. The intervention substantially increased the amount of information received on numerous pregnancy‐related topics but had little impact on resource use for mental health and poverty‐related needs. Among those with added support, resource use among low‐risk women was generally greater than among high‐risk women. Conclusions: Additional support provided by nurses, or nurses and home visitors, can successfully address informational needs and increase the likelihood that women will use existing community‐based resources. This finding was true even for high‐risk women, although this intervention did not reduce the difference in resource use between high‐ and low‐risk women. (BIRTH 33:3 September 2006)     

Teaching ethics to paediatrics residents: the centrality of the therapeutic alliance

Context Previous research on ethical issues encountered by medical professionals in training and practice have presented the thematic content of the cases they encounter rather than the activities in which clinicians engage and in which they most often encounter ethical issues. We conducted a direct observation study of paediatrics residents and their preceptors seeing patients in an out‐patient general paediatrics clinic. Our objectives were to describe the everyday ethics‐related issues paediatrics residents encounter as they interact with patients. Our ultimate goal is to use this knowledge to enhance current efforts to teach ethics to paediatrics residents. Methods The study team directly observed paediatrics residents discussing patients with their faculty preceptors (19 half‐day sessions, 76 hours) in an out‐patient general paediatrics clinic located in an urban academic medical centre. Each interaction between resident and preceptor about a single patient was considered a case for further analysis. Results A total of 247 cases were recorded. Forty‐one of the cases were coded as having ethics‐related content. A constant comparative method of qualitative data analysis revealed that residents were most likely to encounter ethical issues when engaged in the following activities: (i) maintaining a therapeutic alliance with the caregiver (e.g. the parent); (ii) prioritising patient or family needs; (iii) adjusting to the power embodied by the role of doctors, and (iv) distinguishing suboptimal care from abuse or neglect. In addition, our findings indicate that it is through their efforts to maintain the therapeutic alliance with the caregivers of their patients that residents engage in and integrate three processes: developing their medical knowledge; adhering to professional norms, and balancing the power inherent in the doctor’s role with their responsibility to serve the patient’s interests. Conclusions Medical faculty tasked with teaching ethics to paediatrics residents can utilise the results of this project to better target and enhance their ethics education efforts directed at residents in the out‐patient setting. Future research could further examine and test these findings in other clinical settings (e.g. adult general medicine).     

Finding temporary relief: strategy for nursing recruitment in northern aboriginal communities.

To address a recurring shortage of nurses in the aboriginal communities of Northwestern Ontario, the First Nations and Inuit Health Branch, Health Canada, commissioned a study to explore the viability of establishing a relief pool among nurses from nearby small industrial towns. An open/close-ended survey completed by a random sample of 237 nurses from the target population documented levels of awareness, willingness, and preparedness for northern practice, as well as recruitment incentives and disincentives. Findings demonstrate an awareness of the overlap between the professional and personal dimensions characteristic of such practices, and suggest support for innovative rotations that would cut across federal/provincial/community jurisdictions. Although complex, given time and willingness, a regional relief system seems viable.     

Effect of Temperature on the Longitudinal Variability of Quantitative Ultrasound Variables

It is unclear whether longitudinal change in phantom measurements bears any relation to the long-term in vivo instrument performance of quantitative ultrasound devices. Longitudinal quantitative ultrasound phantom data were obtained by measuring the manufacturer-provided phantom at ambient temperature and two different sets of Leeds phantoms at either ambient temperature or following a phantom temperature-control protocol. Measurements were performed using the Achilles Plus bone densitometer. Changes in longitudinal phantom data were compared to in vivo quantitative ultrasound data obtained from seven healthy, young volunteers. A cosinor model with linear trend and Hotelling's T2-test were used to quantify seasonal rhythms and long-term drift in quantitative ultrasound variables. Temperature effects and marked seasonal rhythms on quantitative ultrasound phantom measurements were evident but were far less apparent in vivo. Longitudinal precision of quantitative ultrasound variables was poorer for the manufacturer-provided phantom than for phantoms that were subjected to a temperature-control protocol or for healthy volunteers. This study has shown that longitudinal precision and longitudinal change differs between in vivo and phantom data. Longitudinal quantitative ultrasound measurements for monitoring change in skeletal status cannot, as yet, be properly controlled.     

A preliminary investigation into the long-term injury consequences reported by retired baseball players

Seventy-five retired baseball players participated in a survey (37.8% response rate) in order to establish the long-term consequences of injuries sustained during their playing careers. Respondents had a mean age of 55.8 (+/-11.4) years with a mean age of 41.3 (+/-11.4) years at retirement from play. The mean overall rate of injury suffered per player/playing career was 5.6 (+/-7.1). 54.7% of respondents experienced a major injury (i.e. injury resulting in 5 or more consecutive weeks absence from training and play) with a mean major injury per player/playing career of 1.5 (+/-2.2). The rate for significant injuries (i.e. injury resulting in more than 1 week but less than 5 weeks absence from training and play) was 4.1 (+/-6.5) per player/playing career. Catchers had significantly less injuries than all other positions (p=0.027). 18.7% of all respondents reported suffering from arthritis, 24% from restricted joint mobility and 4% from chronically stiff fingers; all of these conditions were associated with their participation in baseball based on medical examination by their GP or medical specialist. 29.3% of respondents indicated that they had incurred additional medical costs and 12% reported significant loss of income associated with their injuries. Some injuries were severe enough that they resulted in extended stays in hospital producing costs carried by the health care system.     

The readability of American Academy of Pediatrics patient education brochures.

INTRODUCTION: The purpose of this study was to evaluate the readability of American Academy of Pediatrics (AAP) patient education brochures. METHOD: Seventy-four brochures were analyzed using two readability formulas. RESULTS: Mean readability for all 74 brochures was grade 7.94 using the Flesch-Kincaid formula, and grade 10.1 with SMOG formula (P = .001). Using the SMOG formula, no brochures were of acceptably low (< or =8th grade) readability levels (range 8.3 to 12.7). Using the Flesch-Kincaid formula, 41 of the 74 had acceptable readability levels (< or =8th grade). The SMOG formula routinely assessed brochures 2 to 3 grade levels higher than did the Flesch-Kincaid formula. DISCUSSION: Some AAP patient education brochures have acceptably low levels of readability, but at least half are written at higher than acceptable readability levels for the general public. This study also demonstrated statistically significant variability between the two different readability formulas; had only the SMOG formula been used, all of the brochures would have had unacceptably high readability levels. Readability is an essential concept for patient education materials. Professional associations that develop and market patient education materials should test for readability and publish those readability levels on each piece of patient education so health care providers will know if the materials are appropriate for their patients.     

Treatment of perianal infection following bone marrow transplantation

PURPOSE: Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life-threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT. METHODS: The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner. RESULTS: Over a ten-year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty-four patients were diagnosed with perianal infections foEowing their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms were Escherichia coli, Bacteroides, Enterococcus,and Klebsiella.For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing. CONCLUSIONS: Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Lung function, smoking and survival in severe alpha 1-antitrypsin deficiency, PiZZ

Lung function, smoking, age and mortality data in 158 adult severe alpha₁-antitrypsin deficient, PiZZ individuals, followed from 1963 to 1982 were analyzed. Low initial FEV₁ value was significantly associated with increased mortality (p < 0.005). A 3 yr mortality rate of 40% was found in individuals whose initial FEV₁ values were less than 30% of that predicted. In contrast, the corresponding 3-yr mortality among those whose initial FEV₁ values were between 30 and 65% of that predicted was only 7%. Smokers were found to have significantly lower FEV₁ levels (p = 0.008) and higher mortality (p < 0.005) than non-smokers. The difference between current and ex-smokers in mortality and FEV₁ level were not statistically significant (p = 0.9 and p>0.25, respectively). Cross-sectional analysis of the initial FEV₁ values indicated a significant decline (p < 0.005) of FEV₁ with increasing age. This decline was greater among smokers than non-smokers. Longitudinal analysis of FEV₁ rates of decline in 80 cases with follow-up FEV₁ measurements failed to detect any significant differences between smokers and non-smokers, but was performed late in the disease process. The application of these results to the planning of studies on replacement therapy, smoking intervention strategy and longitudinal follow-up is discussed.