'Restricting choices and limiting independence': social and economic impact of multiple sclerosis upon households by level of disability.

OBJECTIVE: To examine the relationship between the social and economic impact of multiple sclerosis (MS) and levels of MS-related disability upon households in the following domains: household composition, housing modification, employment, standard of living, children, intimate and close relationships, and social life. METHODS: A national sample of people with MS (pwMS) (n = 920), consisting of members of the MS Society and those accessing the MS Society website, completed a cross-sectional survey to generate quantitative and qualitative data. RESULTS: Over three-quarters of the sample reported that MS had impacted on at least some areas of daily life. The reported impact increased significantly in a linear fashion in each domain with increasing disability, as measured by an activities of daily living index, although there was a discernible 'levelling off' in terms of impact in some domains among those at the higher levels of disability and dependency. Analysis of the qualitative data suggests that this impact can be conceptualized as a gradual process of 'restricting choices' and 'limiting independence' for both pwMS and their households. DISCUSSION: MS restricts social and economic opportunities for pwMS and those who they live with. These findings extend the literature to households to illustrate the impact of MS not only on pwMS but also on their partners, children and other family members.

Systematic assessments of need and care planning in severe mental illness: cluster randomised controlled trial.

BACKGROUND: Surveys have shown high levels of unmet need in representative samples of people with severe mental illness. Introducing standardised needs assessment into the care planning process might reduce these needs and improve outcome. AIMS: To determine whether feedback from a standardised assessment of need enhances the effectiveness of care planning and whether exposing care coordinators to feedback on some patients improves their care of other patients. METHOD: A single-blind, cluster randomised trial involving a within-cluster individually randomised arm: patients' needs were evaluated using the Cardinal Needs Schedule and the findings were fed back to their care coordinators under the care programme approach. A total of 304 patients were recruited from 72 care coordinators and 242 patients (79.6%) were reassessed at 12 months. RESULTS: The only significant effect of the intervention was on patient satisfaction. Patients cluster-randomised to receive feedback were more satisfied than controls, but patients individually randomised to receive feedback were not. CONCLUSIONS: Standardised needs assessment did not substantially enhance care planning in this trial. However, giving care coordinators some experience of feedback from a standardised assessment of need could improve satisfaction.

Emergency medicine in the Bahamas.

The Bahamas is an archipelago of 700 islands with the majority of the population concentrated on just 2 islands: New Providence and Grand Bahama. Most emergency medical services are provided by Princess Margaret Hospital and Rand Memorial Hospital located respectively on those 2 islands. A detailed description of the delivery, training, and organization of emergency medicine, as well as out-of-hospital care, is provided. Furthermore, disaster preparedness and the future direction of emergency medicine are discussed.

An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified.

Some children with autism and pervasive developmental disorder-not otherwise specified (PDD-NOS) have been reported to have atypical feeding behavior, such as sensitivity to food texture and selective preferences for particular foods. No systematic studies of feeding behavior in this population have been published. Munk and Repp (1994) developed methods for assessing feeding problems in individuals with cognitive and physical disabilities that allow categorization of individual feeding patterns based on responses to repeated presentations of food. In this study, we systematically replicated the Munk and Repp procedures with children with autism and PDD-NOS. Thirty children, ages 3 to 14 years, were exposed to 12 food items across 6 sessions. Food acceptance, food expulsion, and disruptive behavior were recorded on a trial-by-trial basis. Approximately half of the participants exhibited patterns of food acceptance, indicating selectivity by food category or food texture. Others consistently accepted or rejected items across food categories. Whether these patterns of food acceptance are atypical remains to be determined by comparison with the feeding patterns of typically developing children and other children with developmental delays.

Philosophy for managers? An exploration of what the great philosophers can do to assist ethical decision making.

Ethics is attracting increasing attention in management of both public- and private-sector organisations. For managers within health-care systems, ethical issues can be most acute, especially given the human nights issues involved in new legislation. This paper explores some of the ways in which philosophy may potentially offer guidelines to managers faced with the need to make decisions ethically. It draws on a small number of philosophical perspectives to demonstrate how they can assist in informing ethical decision making, and illustrates its arguments through one topic, suicide prevention, an area of relevance to health managers but one that is beset by some of the most profound ethical dilemmas. The ways in which philosophy may assist in decision making in this one example are, it is argued, generalisable to many other health issues where complicated decisions have to be made. The paper develops a philosophical framework consisting of the ethical considerations of "self-love", "humanity", "the value of human life" and "duty to others" and demonstrates, through the use of two hypothetical case studies, how these can be applied to a decision-making process so as to reduce inconsistencies in attitudes and practice.

An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project).

BACKGROUND: Suicide prevention is a health priority in many countries. Improved management of suicide risk may improve suicide prevention. This study aimed to assess the feasibility of health district-wide training in the assessment and management of people at risk of suicide; and to assess the impact of training on assessment and management skills. METHODS: Staff in three health care settings, namely primary care, accident and emergency departments and mental health services (N = 359), were offered suicide risk management training in a district-wide programme, using a flexible 'facilitator' approach. The main outcomes were the rate of attendance at training, and changes in suicide risk assessment and management skills following training. RESULTS: It was possible to deliver training to 167 health professionals (47 % of those eligible) during a 6 month training period. This included 95 primary care staff (39%), 21 accident and emergency staff(42%) and 51 mental health staff (78%). Of these, 103 (69%) attended all training. A volunteer sample of 28 staff who underwent training showed improvements in skills in the assessment and management of suicide risk. Satisfaction with training was high. The expected costs of district-wide training, if it were able to produce a 2.5% reduction in the suicide rate, would be 99,747 pound sterling per suicide prevented and 3,391 pound sterling per life year gained. CONCLUSIONS: Training in the assessment and management of suicide risk can be delivered to approximately half the targeted staff in primary care, accident and emergency departments and mental health services. The current training package can improve skills and is well accepted. If it were to produce a modest fall in the suicide rate, such training would be cost-effective. However, a future training programme should develop a broader training package to reach those who will not attend.

Proposed curriculum for an "observational" international emergency medicine fellowship program.

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Clinical service lines bring patients into focus.

In 1996, SSM St. Joseph Hospital of Kirkwood, Mo., was in crisis mode. A radical structure change from centralized nursing to clinical service lines helped to keep the organization in the black.

Proposed fellowship training program in international emergency medicine.

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

The good side after stroke: ipsilateral sensory-motor function needs careful assessment.

Twenty subjects were examined 4-6 weeks after stroke to establish whether a sensory-motor ipsilateral deficit occurs early after stroke. Each underwent a timed test of repetitive side-to-side movement of both the upper and lower limbs ipsilateral to the cerebral infarct, and an assessment of motor disability using the Motor Assessment Scale. Results were compared with a group studied almost a year after their stroke, and with 41 age-matched healthy volunteers. There was a significantly worse performance (p < 0.005) on the right ipsilateral side, but not the left ipsilateral side, compared with normal volunteers, a finding similar to that of a group previously studied about a year after the stroke. There was no relationship between the severity of the motor deficit and performance of the side, possibly owing to reduction in cerebral activation as a result of a right hemispheric lesion. These observations have importance in rehabilitation and education as well as practical skills, including driving a car and maintaining balance.

Assessment tools: small area analysis.

Small area analysis, the examination of geographic variation in the medical care utilization of populations, provides a method for analyzing medical care resource use and can lead to improved medical care. Variations in rates of hospital admissions for most common causes of hospitalization are related to differences in the supply of medical care resources, such as hospital beds, and uncertainty in the outcomes of different diagnostic and therapeutic procedures. Introducing clinicians to practice variation can lead to process improvements. The article describes small area analysis and the limitations of this methodology.

Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments.

STUDY OBJECTIVE: Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. DESIGN: During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. SETTING: One suburban and three urban EDs. RESULTS: We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% (P < .0001). Of the 60 patients who tested positive for cocaine, only 43 (72%) admitted recent use. CONCLUSION: Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable.

Substantial improvement in compliance with universal precautions in an emergency department following institution of policy.

Seven months following the introduction of an institutional policy mandating compliance with universal precautions (UPs), we observed 127 health care workers performing 1421 interventions on 155 critically ill and injured patients in an emergency department setting in July 1989. Results were compared with a similar study undertaken exactly 1 year previously when UPs were considered as guidelines only. Overall adherence to UPs improved from 44.0% to 72.7% from 1 year to the next. Adherence to UPs improved from 19.5% to 55.7% during interventions on patients with profuse bleeding and from 16.7% to 54.5% during performance of major procedures. Compliance improved from 47.9% to 81.0% for emergency department-based health care workers (residents, attending physicians, nurses, x-ray film technicians). Prehospital care providers, a group not accountable to the institution, remained particularly noncompliant with only 13% adherence. We conclude that mandating UPs as policy with a monitoring component is effective in ensuring a reasonable level of adherence. However, given current barrier technology, achieving appropriate levels of compliance during unscheduled visits by patients requiring immediate attention and rapid intervention remains a challenge.

Submaximal aerobic running economy and treadmill performance in prepubertal boys.

Although the determinants of running economy and its relationship to endurance performance have been evaluated in adults, little data are available in pediatric subjects. Twenty-eight prepubertal boys with diverse athletic abilities underwent progressive maximal treadmill testing. Running economy was defined as (1) VO2 at 9.6 kph and (2) VO2 expenditure for increasing running speed 1.6 kph (delta VO2). Treadmill running times ranged from 12.6 to 23.0 min. Mean VO2 at 6 mph was 48.7 m.kg-1.min-1 (SD 4.3) and delta VO2 averaged 6.8 m.kg-1.min-1 (SD 1.7). VO2max correlated closely to treadmill time. Treadmill endurance times were significantly related to running economy by both definitions; submaximal VO2 levels did not, however, correlate with maximal aerobic power. Delta VO2 was associated with stride frequency, but no other relationships were observed between economy and height, age, respiratory exchange ratio, ventilatory equivalent for oxygen, stride length: leg length ratio, or body surface area: mass ratio. These findings suggest that among older prepubertal boys, greater running economy is associated with superior treadmill endurance performance and that stride frequency may influence submaximal VO2 expenditure in children.