Assess your quality of care quotient.

The upsurge of large, single/multi-specialty group practices in contemporary health care has precipitated a corresponding surge in marketing strategies aimed at promoting group speed, efficiency, and/or productivity. Subsequently, the quality of care is often overlooked or redefined in financial terms. However, assessing quality of care--above and beyond strictly economic factors--can provide crucial information for executives concerned with making informed managerial decisions. This article explores one prototypical physician group's quest to assess their "quality care quotient," and explicates the process by which they obtained important data from patients, as well as how they used the assessment to improve their practice. The process may serve as an exemplar to physician groups concerned with conducting such analyses.

Communicating with staff nurses: support or hostility?

Communication researchers specializing in social support determine factors that influence and make up supportive encounters in the hospital environment. Effective communication strategies provide a vital dyad's link between nurse managers and staff nurses. Thus, supportive relationships are formed that can ease stressful situations and encourage innovative ideas.

The use of children's drawings in the evaluation and treatment of child sexual, emotional, and physical abuse.

Primary care physicians can be instrumental in the initial identification of potential sexual, emotional, and physical abuse of children. We reviewed the use of children's artwork as a method of communicating individual and family functioning. A quantitative method of analyzing children's artwork provides more reliability and validity than some methods used previously. A new scoring system was developed that uses individual human figure drawings and kinetic family drawings. This scoring system was based on research with 842 children (341 positively identified as sexually molested, 252 positively not sexually molested but having emotional or behavioral problems, and 249 "normal" public school children). This system is more comprehensive than previous systems of assessment of potential abuse.

The stress of child sexual abuse examinations.

The objective of this paper was to determine if the medical evaluation of sexual abuse victims is stressful by heart rate variability monitoring. The design of the study was a case series of children referred for sexual abuse examination to determine child stress response monitored by heart rate variability during baseline, disclosure, and anogenital examination with photographs. The setting was a referral center for the investigation of child sexual abuse in two sites (Reno and Las Vegas, Nevada, USA). Patients included a consecutive sample of 30 children; 15 in Reno ranging in age from 3-10 years with a mean age of 7.1 (1 male and 14 females); 15 in Las Vegas ranging in age from 6-10 years with a mean age of 7.8 (3 males and 12 females). Measurements and results were: each subject's heart rate was obtained during the first 3 minutes of the baseline, disclosure, and the anogenital examination with photographs, using a telemetric Vantage Performance Heart Watch consisting of a 5.5 x 1.25 inch transmitter attached to a chest strap and a microcomputer wristwatch attached to the subject's non-dominant wrist. Heart rates were taken every 5 or 15 seconds throughout the entire examination. A follow-up home visit was made 6 weeks after the examination to determine the replicability of clinic baseline measures and child behavioral sequelae. Physiologic measurements did not show statistically significant stress responses when children were prepared according to the clinic protocol in Reno and Las Vegas. There was a trend toward more responsivity among some of the older subjects during the anogenital examination with photographs, and when clinic procedures inadvertently overlapped several procedures at the same time (anogenital examination, photographs and disclosure). The conclusion of the study was that child sexual abuse investigations may be accomplished without undue psychophysiological stress when recommended precautions are taken.

Maternal sexual abuse of male children. When to suspect and how to uncover it.

Physicians need to be aware that women and mothers are capable of sexually abusing children and need to watch for signs that a mother may be at risk for perpetrating abuse or that a child may have been abused. Posttraumatic stress disorder, attention-deficit hyperactivity disorder, secondary enuresis and encopresis, nightmares, and inappropriate sexual behavior are often symptoms of sexual abuse. It is important for physicians who are attempting to elicit a report of abuse from a child to keep in mind that (1) children express themselves most easily by nonverbal means, (2) the waiting room, school, and home are settings where information might be retrieved, and (3) the child's statements need to be evaluated using established criteria for analyzing their content. Physicians also need to remember that there is often an absence of physical findings in boys who have been sexually abused, although physical abuse and sexual abuse present simultaneously in some cases.

Post-traumatic stress disorder in a child following an automobile accident.

A 3-year-old girl was diagnosed with post-traumatic stress disorder (PTSD) following a minor automobile accident. The child presented with nightmares, violent play, and trauma-specific fears. The common symptoms of PTSD in childhood are reviewed, and the importance of careful history-taking and prompt referral to a mental health professional are discussed.

Using family life drawings in medical student education.

A life drawing technique was used to educate third-year medical students in a diagnostic and therapeutic approach to young children. Students were asked to produce their own early family life drawings. A sample of 48 drawings were collected. A major goal was to sensitize students as to how their early family experiences likely shaped their current perceptions regarding children and families in the practice of medicine. Six of these student drawings were chosen to illustrate this goal. A few students even found that their drawings helped them resolve personal early life stresses.

Loss of Ribulose 1,5-Diphosphate Carboxylase and Increase in Proteolytic Activity during Senescence of Detached Primary Barley Leaves.

Symptoms typical of senescence occurred in green detached primary barley (Hordeum vulgare L.) leaves placed in darkness and in light. Chlorophyll, total soluble protein, ribulose 1,5-diphosphate carboxylase protein and activity each progressively decreased in darkness and to a lesser extent in light. In all treatments most of the total soluble protein lost was accounted for by a decrease in ribulose 1,5-diphosphate carboxylase protein, suggesting that the chloroplast was a major site of degradation early in senescence.Loss of ribulose 1,5-diphosphate carboxylase protein was negatively correlated with an increase in proteolytic activity measured against azocasein. Both rates were exponential, with about a 30% difference in apparent rate constants. Cycloheximide essentially prevented the loss of chlorophyll, ribulose 1,5-diphosphate carboxylase protein, and activity and completely inhibited the increase in proteolytic activity against azocasein. Since chloramphenicol had little effect on the loss of ribulose 1,5-diphosphate carboxylase protein or chlorophyll, or on proteolytic activity against azocasein, it is suggested that the proteolytic activity was developed on cytoplasmic 80 S ribosomes.Kinetin greatly retarded the onset of such symptoms of senescence by inhibiting the losses of chlorophyll and ribulose 1,5-diphosphate carboxylase protein and protected against inactivation of enzymic activity. It also prevented the increase in proteolytic activity measured against azocasein. Incorporation of labeled amino acids into ribulose 1,5-diphosphate carboxylase during its rapid degradation showed that the enzyme was under turnover. The changes in ribulose 1,5-diphosphate carboxylase protein and activity, chlorophyll, soluble protein other than ribulose 1,5-diphosphate carboxylase, proteolytic and esterolytic activity during senescence indicate that senescence is a selective, sequential process.

Evidence for lack of turnover of ribulose 1,5-diphosphate carboxylase in barley leaves.

Turnover of ribulose 1,5-diphosphate carboxylase in barley leaves (Hordeum vulgare L.) was followed over time in light and dark. The enzyme was degraded in prolonged darkness and was resynthesized after the plants were returned to light. Labeling with (14)C showed that simultaneous synthesis and degradation (turnover) did not occur in light. In contrast, the remaining soluble protein was turned over rapidly in light. Although ribulose 1,5-diP carboxylase can be both degraded and synthesized, these processes seem not to occur simultaneously, but can be induced independently by changing environmental conditions.