Overcoming language barriers when teaching the Advanced Trauma Life Support course

OBJECTIVES: To determine whether blurred vision caused by exposure to triethylamine (TEA) can be detected by the measurement of contrast sensitivity. METHODS: 41 cold box core makers of three foundries and 82 control workers were examined. A detailed ocular and medical history was obtained from the subjects. The contrast sensitivity of the core makers was measured on Monday and Friday of the same week both before and immediately after work and also on a third day, when air samples of TEA were collected. Contrast sensitivity and visual acuity were measured by optotype figures at full contrast, 2.5% contrast, and 0.6% contrast. The changes in contrast sensitivity were used for the analysis. The results of binocular vision and the results of the dominant eye were analysed. Urine specimens for the analysis of TEA were collected on every occasion when contrast sensitivity was measured. RESULTS: 78% of the core makers had had symptoms of blurred vision, and 31% had had trouble driving or working. The breathing zone eight hour time weighted average TEA concentrations were 0.3-60 mg/m3. The mean urinary TEA concentration after the shift was 35 mmol/mol creatinine. Continuous monitoring showed high peaks of TEA leakage at a core making machine. Changes in binocular visual acuity did not differ between the exposed and unexposed workers. The contrast sensitivity decreased in 49% of the core makers and 21% of the controls (P = 0.002). CONCLUSIONS: The blurred vision caused by exposure to TEA can be documented by measuring contrast sensitivity. The mechanism by which TEA produces symptoms remains an issue of further study.     

Overcoming the barriers: national to European to G7

An information revolution is underway which will have an impact on all sectors of society. It will fundamentally change national and international health systems. The global Internet is a key influence and will change the balance of power within and between healthcare professions, and between them and the general public. This revolution offers enormous potential benefits to global health but there is also potential for harm. There are a wide range of barriers to realising the potential benefits. They lie in areas such as the protection of personal information; ownership and legal accountability; data meanings: structures and database navigation; deficiencies in the global Internet and lack of access by many communities. This paper considers the nature of those barriers. In 1994, the Group of Seven Nations launched an initiative to stimulate a global information society. Theme 8 deals with healthcare and therein Sub-project 5 'Enabling Mechanisms', which the author leads, is seeking to identify barriers and the authoritative international sources of advise and good practice. It is conducting an international survey, the results of which should be published by the end of 1997. This paper describes the aims of this Sub-project.     

Audit: teaching medical students in general practice

Audit is being seen as an increasingly important topic for medical students. Many departments of general practice in the UK now incorporate audit as part of their course work. It remains controversial as to whether this is perceived to be worthwhile by the students. Following an introductory seminar final-year medical students at the University of Glasgow were asked to perform a case-note review of 10 randomly chosen diabetic patients for a number of process and outcome measures during their practice attachments. Feedback was given in their final teaching session. 128/153 (84%) students completed an evaluation of the course on their knowledge and attitudes to audit. Unsurprisingly, 39% found the data collection boring or very boring; however, 60% found the feedback session very interesting or interesting. Both the data collection and the feedback were considered relevant by the majority of students (57% and 70% respectively). Students' self-reported knowledge also dramatically increased (P < 0.0001).     

Overcoming barriers in the study of tight junction functions: from occludin to claudin

Tight junctions (TJs) are essential structures for the physiological functions of epithelial and endothelial cells, and have been suggested to have both barrier and fence functions. Tight junctions create a primary barrier to the diffusion of solutes through the paracellular pathway, and also function as a fence between apical and basolateral membrane domains, to create and maintain cell polarity of epithelial and endothelial cells. Several peripheral membrane proteins have been shown to be concentrated at the cytoplasmic surface of TJs. However, TJ-specific integral membrane proteins had not been identified until recently, and the lack of information concerning TJ-specific integral membrane proteins has hampered a more direct assessment of the function of TJs at the molecular level. Here, we present an overview of current progress in the identification of TJ-specific integral membrane proteins.     

Attaching community psychiatric nurses to general practice

A scheme for attachment of psychiatric nurses from hospital to group practice in Oxford is described. One community psychiatric nurse can work satisfactorily with eight general practitioners covering a population of about 18,000. From analysis of a working year, it is concluded that this arrangement improves the care of patients in the community by providing psychiatric help at times when it was previously unavailable or unacceptable.The implications of such a scheme for the workings of the primary health care team and the hospital psychiatric service are considered, and a case is made for a further study involving a comparison between practices with and without the attachment of a community psychiatric nurse.     

Individually adapted counseling about physical activity in medical practice

In order to investigate the effect of body mass index (BMI, kg/m2) on life expectancy, 2053 Hisayama residents, aged 40 years or older were studied for 13 years from 1974. During the follow-up period, 419 subjects died; of these, 39 deaths due to accident or suicide were excluded from further analysis. On initial examination, male subjects with BMI > or = 27 had significantly higher age-adjusted prevalence rates of hypertension, glucose intolerance, hypercholesterolemia, electrocardiogram abnormalities and proteinuria, as compared with those with 23-25 BMI. In contrast, the frequency of male smokers was inversely associated with BMI levels. Female prevalence rates of glucose intolerance, hypercholesterolemia and proteinuria were significantly higher in 25-27 BMI than in 23-25. Body Mass Index showed a U-shaped relationship with all cause mortality rates with the lowest rate in 23-27 BMI for men and in 23-25 BMI for women. These associations remained substantially unchanged, even after controlling for age, systolic blood pressure, glucose intolerance, serum cholesterol, proteinuria, electrocardiogram abnormalities, alcohol consumption, and smoking habits. When analyzing the BMI mortality relationship by cause of death, age- and sex-adjusted mortality rates from myocardial infarction and stroke significantly increased in subjects with BMI > or = 27 compared with those with 23-25 BMI. In contrast, there was a decreasing risk of death from malignant neoplasms with rising BMI levels, but the relationship was not significant. Mortality from pneumonia and other causes showed a U-shaped relationship with significantly higher rates seen in BMI < 19 than in 23-25 BMI. These data indicate that BMI has a U-shaped relationship with total mortality in the general Japanese population, which results from various associations between BMI and cause-specific mortality rates.     

General practitioners'' attitudes to psychiatric and medical illness

BACKGROUND: General practitioners are increasingly involved in the care of patients with long-term psychiatric disorders. We have previously reported that general practitioners are less willing to treat patients with schizophrenia than those without such a diagnosis, but this may have been attributable to a reluctance to treat patients with any psychiatric or chronic illness. We, therefore, examined general practitioners' attitudes to patients with chronic psychiatric or medical illnesses. METHODS: A random sample of 260 local general practitioners were each sent one of our case vignettes which were identical apart from mention of a previous diagnosis of schizophrenia, depression, diabetes or no illness. The general practitioners were asked to indicate their level of agreement with 13 attitudinal statements based on the vignette. RESULTS: One hundred and sixty-six (66%) of the general practitioners responded to the case vignettes. Those responding to the vignette about the patient with schizophrenia were less happy to have that patient on their practice list and were more concerned about the risk of violence and the child's welfare. Those responding to the depression vignette were more likely to offer the patient antidepressants or counselling; and those who replied to the diabetes case were most likely to refer the patient to a hospital specialist. These differences were not attributable to the personal or practice characteristics of the general practitioners. CONCLUSIONS: Patients with schizophrenia arouse concerns in general practitioners that are not simply due to those patients suffering from a psychiatric or chronic illness. Our results suggest that some patients with schizophrenia may find it difficult to register with a general practitioner and receive the integrated community-based health care service they require. Psychiatrists should provide education and support to general practitioners who look after patients with schizophrenia.     

School psychology practice: Organizational barriers to professional attainment.

Examined the organizational constraints to practitioner functioning that confront school psychologists. The results of a survey of 130 school psychologists show that Ss (a) spent more time testing than consulting; (b) spent their time performing many activities, such as consultation and counseling, for small amounts of time; and (c) wanted to do more consulting work, in-service training, and research. However, Ss reported significant support from other school staff members to perform duties other than testing. Ways of building on such support to enable the school psychologist to engage in these new roles are discussed. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Examination gloves as barriers to hand contamination in clinical practice

OBJECTIVE: To test the effectiveness of vinyl and latex gloves as barriers to hand contamination with gram-negative organisms and enterococci during routine hospital procedures. DESIGN AND INTERVENTIONS: We studied 137 procedures during which a health care worker's gloved hand contacted a patient's mucous membrane and was thus potentially contaminated with gram-negative rods or enterococci. Quantitative hand cultures were obtained from each health care worker before and after the gloved contact using a modified glove juice method, and the exterior glove surface was also quantitatively cultured after patient contact. Used gloves were then tested for leaks using the American Society for Testing and Materials' watertight test. SETTING: Harborview Medical Center, a 330-bed city-county hospital and level I regional trauma and burn center, is both a teaching facility affiliated with the University of Washington and the major provider of care to indigent and uninsured persons in Seattle-King County, Washington. PATIENTS AND OTHER PARTICIPANTS: Respiratory therapists performing endotracheal tube care on intubated intensive care unit patients, registered nurses performing digital rectal stimulation for bowel training on patients with spinal cord injury in the rehabilitation ward, and dentists performing routine dental examinations and procedures on healthy outpatients in the dental clinic. MAIN OUTCOME MEASURE AND RESULTS: Eighty-six of the 135 gloves cultured had gram-negative rods or enterococci on the external surface after use and were thus sources of potential hand contamination. Microbial contamination of the health care worker's hands occurred in 11 (13%; 95% confidence interval, 6% to 20%) of these 86 events, and was more frequent with vinyl (10 of 42) than latex (one of 44) gloves (P < .01). After use, glove leaks were also more frequent in vinyl gloves (26 of 61) than with latex gloves (six of 70) (P < .001). Even when leaks were present, gloves prevented hand contamination in 77% of instances and quantitative counts of microorganisms contaminating hands were 2 to 4 logs less than counts on external glove surfaces. Health care workers reported awareness of the presence of glove leaks in only seven (22%) of the 32 events in which leaks were subsequently demonstrated. CONCLUSIONS: Under conditions of routine use, gloves effectively function as a protective barrier even when leaks are present. Latex gloves were less frequently associated with leaks and hand contamination. Since hand contamination occurred after 13% of exposures and cannot be readily identified by health care workers, routine hand washing should be done after each patient contact.     

Using icon arrays to communicate medical risks: Overcoming low numeracy.

Objective: Icon arrays have been suggested as a potentially promising format for communicating risks to patients—especially those with low numeracy skills—but experimental studies are lacking. This study investigates whether icon arrays increase accuracy of understanding medical risks, and whether they affect perceived seriousness of risks and helpfulness of treatments. Design: Two experiments were conducted on samples of older adults (n = 59, 62 to 77 years of age) and university students (n = 112, 26 to 35 years of age). Main Outcome Measures: Accuracy of understanding risk reduction; perceived seriousness of risks; perceived helpfulness of treatments. Results: Icon arrays increased accuracy of both low- and high-numeracy people, even when transparent numerical representations were used. Risks presented via icon arrays were perceived as less serious than those presented numerically. With larger icon arrays (1,000 instead of 100 icons) risks were perceived more serious, and risk reduction larger. Conclusions: Icon arrays are a promising way of communicating medical risks to a wide range of patient groups, including older adults with lower numeracy skills. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Overcoming roadblocks to effectiveness: Incorporating management of performance barriers into models of work group effectiveness.

This study investigated how work groups manage performance barriers in their immediate environment to achieve effectiveness. Relationships were tested using data collected from 473 group members, 88 foremen, and 21 managers pertaining to 88 maintenance and construction road crews in a state department of transportation. Performance constraints were found to have a direct negative relationship with performance. Through problem-management strategies, crews were able to minimize these effects both directly and indirectly by maintaining crew cohesion under more frequent and severe performance problems. In turn, self-management, leadership, and teamwork processes were found to be related to crew use of problem-management actions and strategies. Areas for future research and research designs that can allow for capturing the dynamic and reciprocal nature of this relationship are suggested. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Legal aspects of epilepsy and coexisting psychiatric disorders

Major advances in understanding the neurobiology of epilepsy have led to more precise diagnosis, early rational treatment with new drugs, useful new neurosurgical techniques, etc. This has led to significant control of seizures, a marked reduction in concurrent psychopathology, improved quality of life of the epileptic patient, the almost complete abolition of old-style institutions for these patients, etc. However in spite of greater scientific knowledge about epilepsy, this has not led to an equally great advance socially. Old-fashioned restrictions and limitations based on mistaken ideas as to the nature of epilepsy still remain. Epilepsy is still considered in the same light as the psychopathological disorders seen in some epileptics, as a result of different variables which are not necessarily related to seizures. Current legal rulings on epilepsy, with or without co-existing mental disorder, are reviewed in relation to their effect on driving motor vehicles, carrying out military service, the condition of minusvalia, the possibility of legal incompetence, and the nullity of marriage and of priesthood. It is concluded that although the limitations maintained by some statutory requirements are reasonable, it would be fairest to abolish restrictions which, in view of present scientific knowledge, are out of date and prevent the return to normal and full social integration which should prevail for people with epilepsy.     

Patients as teachers: an integrated approach to teaching medical students about the ambulatory care of HIV infected patients

Our experience with medical students in a large inner city hospital left us concerned that students' fears affect their ability to learn about and care for HIV-positive people. Therefore, we decided to create an environment in which the students could feel safe exploring their own attitudes and feelings about HIV. To accomplish the goal, we developed a curriculum in the ambulatory care of HIV-positive people. We recruited and trained patients from an HIV support group at our hospital to work with students in one-on-one sessions to teach interviewing, physical exam, and patient counseling skills. As part of a 4-week ambulatory clerkship for third year students we developed a minicourse which included four sessions with didactic and experiential components. The first week consisted of an orientation and group discussion in which patients told the students about what its like to live with HIV. During each of the following three sessions, students met with a preceptor to learn about HIV in an ambulatory care setting. The didactic session was followed by one-on-one student/patient encounters in which students practised skills discussed that week and patients gave them feedback. At the close of the day, the entire group reconvened to discuss what had happened. As a result of this integrated approach, students are experiencing the relational aspects of providing medical care, often for the first and only time. In the process they are learning to take good social histories and are learning how patients with HIV relate to and sometimes reorganize their family and social support systems. Students have the opportunity to get to know, in depth, a relatively healthy person who is living with a chronic, stigmatizing illness. Both patients and students are talking to each other on a level of intimacy that is rare in the training environment. Patients express a new appreciation of their own role and power in the relationship and a new insight into the struggles of the provider. Faculty experience a renewed commitment to the importance of creating an environment where the students can discover for themselves the joy of the connection between doctor and patient. Students have an opportunity to relate to patients not as pathology, but as people with lives before and beyond the medical system. This model is practical and may be useful in teaching about other chronic diseases in the ambulatory setting.