Self-Coding of Fidelity as a Potential Active Ingredient of Consultation to Improve Clinicians’ Fidelity

A key goal for implementation science is the identification of evidence-based consultation protocols and the active ingredients within these protocols that drive clinician behavior change. The current study examined clinicians’ self-coding of fidelity as a potential active ingredient of consultation for the Attachment and Biobehavioral Catch-up (ABC) intervention. It also examined two other potential predictors of clinician fidelity in response to consultation: dosage of consultation and working alliance. Twenty-nine clinicians (97% female, 62% White, M age?=?34 years) participated in a year of weekly fidelity-focused ABC consultation sessions, for which clinicians self-coded fidelity and received consultant feedback on both their coding and their fidelity. Data from the ABC fidelity measure were available for 1067 sessions coded by consultants, and clinicians’ self-coding accuracy was calculated from 1044 sessions coded by both clinicians and consultants. Alliance was measured with the Working Alliance Inventory—Trainee and Supervisor Versions. The study was observational, and fidelity and self-coding accuracy were modeled across time using hierarchical linear modeling. Clinicians’ ABC fidelity, as well as their self-coding accuracy, increased over the course of consultation. Clinicians’ self-coding accuracy predicted their initial fidelity and growth in fidelity. Working alliance was also linked to fidelity and self-coding accuracy. These results suggest that clinician self-coding should be further examined as an active ingredient of consultation. The study has important implications for the design of consultation procedures and fidelity assessments.

     

Short and long latency auditory evoked potentials in traumatic brain injury patients

Short latency auditory nerve and brainstem evoked responses (BAERs) and long latency cortical auditory evoked responses (CAERs) in 75 long-term traumatic brain injury (TBI) cases were compared. CAERs were found to be significantly correlated with clinical disability as measured by the Disability Rating Scale, while BAERs were not. Also, BAER patterns were consistently and significantly less abnormal and less sensitive to overall dysfunction than CAER patterns. Findings support previous observations that BAERs have relatively little utility for evaluating in surviving TBI patients the degree of overall brain impairment. In general, long latency AEP patterns are better able to reflect the extent and severity of brain dysfunction and overall clinical condition than are short latency AEP patterns in long-term severe TBI patients, and these patterns should be obtained routinely in the evaluation of such patients.     

Preoperative screening for perioperative cardiac risk

Preoperative screening for potential cardiac complications is crucial in making rational decisions about surgery. A number of classification schemes are available to aid the primary care physician in assessing a patient's perioperative cardiac risk. In general, these schemes enable the physician to place patients in low-risk, moderate-risk and high-risk categories. Patients at low risk can often be safely referred for surgery with minimal preoperative evaluation, while those at potentially high risk frequently need further assessment and medical or surgical treatment of cardiac disease prior to surgery. The classification schemes are most accurate in identifying patients at high risk for perioperative cardiac complications. However, patients with silent underlying cardiac disease are often underclassified with respect to potential risk. For those patients, accurate prediction of perioperative cardiac complications can be challenging.     

Reproductive outcomes in relation to malathion spraying in the San Francisco Bay Area, 1981-1982.

We studied reproductive outcomes in a cohort of 7,450 pregnancies identified through three Kaiser-Permanente facilities in the San Francisco Bay Area, in relation to exposure to the pesticide malathion, applied aerially to control an infestation by the Mediterranean fruit fly. We included in the cohort all women over age 17 who were registered at these facilities and who were confirmed as pregnant during the spraying period. Residence histories throughout the pregnancy were obtained by mailed questionnaire or telephone interview from 933 women with adverse outcomes and a sample of 1,000 women with normal outcomes, and were converted to geographical coordinates. We linked the coordinates for malathion spraying corridors with the residence coordinates to create individual exposure indices for each week of pregnancy. The statistical analysis compared each of the adverse pregnancy outcome groups against an appropriate control group using logistic regression or survival time regression approaches. After adjustment for various confounders, no important association was found between malathion exposure and spontaneous abortion, intrauterine growth retardation, stillbirth, or most categories of congenital anomalies. Gastrointestinal anomalies were related to second trimester exposure (odds ratio = 2.6), based on 13 cases and not specific to any particular International Classification of Diseases code.     

Gastric outlet obstruction caused by traumatic pseudoaneurysm of superior mesenteric artery

Traumatic pseudoaneurysms of the superior mesenteric artery (SMA) are extremely rare. We describe two cases of posttraumatic proximal SMA pseudoaneurysms with symptoms of gastric outlet obstruction. Repair was accomplished by aorta-SMA bypass with saphenous vein. Injuries to the proximal SMA are easily missed at laparotomy, especially if intestinal ischemia or hematomas are absent. Recognition and repair are stressed to avoid the complications associated with pseudoaneurysm formation.     

Continuous ambulatory peritoneal dialysis associated with peritonitis in older patients

Our recent experience with peritonitis in patients over the age of 55 years undergoing continuous ambulatory peritoneal dialysis between 1979 and 1989 is reviewed. Thirty-seven patients in this age group underwent Tenckhoff catheter insertion. Severe catheter-related peritonitis occurred at a rate of 1.41 episodes per patient per year. Overall, there were 61 episodes of peritonitis in 31 patients, with an overall mortality rate of 7%. When systemic signs of sepsis were present, this rate rose to 25%. All deaths were associated with fungal, pseudomonal, or polymicrobial infections. Management of these infections may require aggressive measures including repeated laparotomy for control of sepsis.     

Diagnoses, symptoms, and attribution of symptoms among black and white inpatients admitted for coronary heart disease.

OBJECTIVES. This study examined health care-seeking behaviors to elucidate factors that contribute to differences in patterns of coronary heart disease between African Americans and Whites. The prevalence of diagnosed coronary heart disease, patients' perceptions of symptoms and attribution of symptoms, and predictors of painful symptoms and attribution of cardiac symptoms were examined. METHODS. The study involved 2416 patients admitted with diagnoses of coronary artery disease, ischemic heart disease, or myocardial infarction or to rule out myocardial infarction. Structured interview questions were used to obtain demographic information, symptoms precipitating admission, and patients' attribution of their symptoms. Discharge diagnoses were obtained from hospital records. RESULTS. Acute myocardial infarction, unstable angina, nonacute ischemic heart disease, and atherosclerosis were more frequent in White patients. For Blacks, the odds of reporting painful symptoms were only 64% of the odds found for Whites when other factors were controlled, and the odds of attributing symptoms to cardiac origins were almost 50% lower for Blacks than for Whites. CONCLUSIONS. The tendency of Blacks to report fewer painful symptoms and to attribute their symptoms to noncardiac origins may contribute to differences in care-seeking and in medical management of heart disease in Blacks.