Brief Mindfulness Meditation With Night Nursing Unit Staff: A Qualitative Study.

Nurses and nursing assistants working at night on an inpatient unit are under signicant stress. Because mindfulness reduces stress and enhances workplace life, this qualitative study explored night shift staff attitudes toward brief group mindfulness practice. For 8 months, 3 times a week, the staff was called together at the nursing station around midnight and led through 2 to 5 minutes of guided mindfulness meditation. Six months after these groups ended, perceptions of this experience were gathered from 5 nurses and 5 nursing assistants via interviews and open-ended questionnaires. Data were analyzed using inductive thematic analysis, with themes identied as they emerged from the data. The study findings noted that several participants were slow to recognize the value of the practice, but this shifted so that by the end, all participants felt positively about participating. Most perceived its benet for themselves as well as for others in the following areas: relationship to self and family, ability to focus, teamwork, decreased stress, improved attitude, and increased compassion toward patients. This brief team mindfulness intervention had many benets for participants and patients but took time to achieve staff buy-in. Future research should examine the generalizability of these findings and clarify implementation strategies.

Resident physicians using modern practices for excellent documentation and care in heart failure (PUMPED CHF).

The most common indication for readmission among Medicare patients is congestive heart failure (CHF). Prior studies underscore the use of residents to bolster hospital-wide programs and reduce CHF readmissions. The authors assessed the effectiveness of a novel online training program designed to improve resident documentation and knowledge related to CHF. The findings suggest that despite a significant increase in knowledge scores following the online educational course, there was only a slight increase in documentation scores. Additional teaching modalities need to be identified to foster resident education and create sustained behavior change.

Feasibility of referral of patients with elevated blood pressure from the Emergency Department.

Recent studies suggest that patients' elevated blood pressure (BP) readings in the Emergency Department (ED) may be due to hypertension (HTN) rather than pain and anxiety. Identifying BP patterns suggestive of HTN in the ED presents an opportunity for referral. The purpose of this prospective cohort study was to assess the feasibility of referral of ED patients with elevated BP readings suggestive of HTN. Adults with elevated BP suggestive of HTN and no history of HTN were tracked as to referral status using an actively monitored ED referral system. Patients referred to a community clinic network were tracked regarding clinic visits, subsequent BP, and diagnosis of HTN. Of 662 patients with elevated BP in the ED at triage, 197 (29.8%) had a pattern of blood pressure readings that were suggestive of HTN. Of these, 63 (32.0%) were referred to in-network clinics, 5 (2.5%) were referred out of network, and 129 (65.5%) were not referred. Of the 63 referred to network clinics, 17 (27.0%) kept their appointments and of those, 5 (29.4%) were diagnosed with HTN. Elevated BP was not mentioned in any ED physician referral notes as a reason for referral and the number of appointments kept among patients who were referred was low. Referral to outpatient clinics based on BP levels suggestive of HTN may not be feasible despite active referral systems.

Mindfulness training for community-based psychotherapists: a feasibility study.

BACKGROUND: While mindfulness training's feasibility has been assessed in many health care settings, the feasibility of teaching mindfulness to psychotherapists of various orientations for both self- and patient-care has not been explored. The objectives of this feasibility assessment were to determine the degree to which clinic psychotherapists were willing to complete a skills-based mindfulness training program; evaluate the acceptability of integrating mindfulness interventions into an urban community mental health clinic; examine the training's influence on both personal mindfulness practice and integration into patient care; and explore the impact of a support group following the training. METHODS: Data on six aspects of feasibility were gathered through quantitative surveys, semi-structured qualitative interviews, and group observation and feedback, analyzed using grounded theory. RESULTS: Sixteen therapists and one administrator attended at least one session of this voluntary program and responded to the associated surveys. At 1-year post-training, 7 participants had attended one or more group support sessions, and 4 more than 50% of sessions. The following factors were identified as contributing to the training's success: significant interest on the part of clinic staff to receive the training; diversity of the teaching staff, buy-in from clinic administration, provision of meditation scripts, role-play exercises, the variety of practices taught, and case presentations. Therapists indicated that the training helped them create a personal mindfulness practice, and several proceeded to integrate mindfulness into client sessions. A bi-weekly support group organized after the training encompassed group practice, discussion, case presentations, and information about trauma-sensitive mindfulness. Clinicians identified the following challenges to integrating mindfulness into sessions: lack of scripts in client languages other than English, the unacceptability of mindfulness to some clients' religious beliefs, the lack of appropriateness for clients facing ongoing psychosocial crises, the lack of interest on the part of some clients, and the time constraints posed by brief therapy sessions. CONCLUSIONS: These findings indicate that such training may be feasible in community mental health settings given support from leadership and the presence of qualified facilitators within the organization. Adaptations to the training based on participant feedback can inform a larger scale trial that compares our protocol with another intervention in the treatment of a psychological disorder or condition identified by the participants as having responded favorably to the program.

Maternal-neonatal outcome with Staphylococcus aureus rectovaginal colonization.

OBJECTIVE: To estimate prevalence of rectovaginal colonization by Staphylococcus aureus among pregnant women with group B streptococcus (GBS) screening results and its association with maternal and infant outcomes. STUDY DESIGN: Cultures that detected both group B streptococcus (GBS) and S. aureus were obtained at > or = 35 weeks of gestation. Computerized database search and chart review determined invasive neonatal infection and maternal outcomes at the time of delivery through 6 months postpartum. RESULTS: A total of 6,626 GBS screening cultures met study criteria, and 769 (11.6%) GBS isolates and 67 (1.0%) S. aureus were identified. No maternal S. aureus-related outcomes were found. The rate of maternal methicillin-resistant S. aureus colonization was 0.1% (7 in 6,626). GBS-positive patients were twice as likely to be colonized with methicillin-susceptible S. aureus than GBS-negative patients. GBS-positive culture rates differed significantly by primary language: Spanish 10.0%, English 13.7%, Russian 26.9%, Cantonese 13.2%, Mandarin 11.5%, Arabic 15.9%, and other 17.8%. CONCLUSION: In our population, S. aureus colonization percentage (1.0%) was lower than the 7.5-8.2% reported by other medical centers, as was overall GBS carriage rate. S. aureus did not predispose to maternal or infant morbidity or mortality up to 6 months postpartum.

Survey of pediatric dentists' own oral health behavior.

Oral health behavior is voluntary and, therefore, requires motivation. Dentists serve as role models for their patients. We sought to determine the pediatric dentists' own adherence to oral health behavior recommendations through a 14-question survey administered to 129 pediatric dentists. A significant percentage of respondents fell short in brushing, flossing and regularity of dental exams. A trend was seen for decreasing exam frequency with decreasing population density and for increasing brushing frequency with increasing age. Although most dentists follow their profession's oral health guidelines, a significant percentage does not.

Health assessment of the Arab American community in southwest Brooklyn.

Data on Arab American health is lacking nationwide. This survey of the Arab American community in southwest Brooklyn assessed perceptions of health status, needs, behaviors, and access to services. Bilingual interviewers administered a structured survey to community members in public gathering places. Of 353 surveyed, 43% were men and 57% women, most spoke Arabic and were Muslim, and most had moved to the U.S. after 1990. One quarter were unemployed. Over 50% reported household incomes below federal poverty level. Nearly 30% had no health insurance. 58% reported choosing their health care venue based on language considerations. 43% reported problems in getting health care, including ability to pay, language barriers, and immigration. 42% of men, and 8% of women reported current smoking. Almost half of respondents never exercised. Rates of poverty, lack of health insurance, and smoking in men are cause for concern and were high even for immigrant groups.

Health needs in Brooklyn's Chinatown: a pilot assessment using rapid participatory appraisal.

BACKGROUND: The relatively new Chinatown of Brooklyn is medically underserved. A pilot assessment of the health needs of this community was conducted using Rapid Participatory Appraisal. METHODS: In-depth interviews with health professionals and community members plus searches of national, state, and local electronic health databases were conducted taking into account multiple determinants of health. RESULTS: Community organization, sociological factors, services, and policy were all partly responsible for unmet health needs, including the lack of an overall community structure related to health. Health concerns of all kinds were exacerbated by poverty, language barriers, immigration status, culture, and the need for acculturation. Significant health assets were present but were not adequate to address needs. DISCUSSION: While each health concern had its own unique identifiable causes, the interaction of these concerns and the limitations of assets at all levels make solutions difficult.

Strengthening the nurse-patient relationship: "what is the most important thing I can do for you today?".

We asked our patients, "What is the most important thing I can do for you today?" and analyzed the self-identified patient needs. Eleven themes emerged; we used these findings to drive a unit-based project and a hospital-based project, hard-wiring strategies into the infrastructure of Relationship-Centered Care to build relationships between patients/families and staff and to establish a healing and caring environment.

What Latina patients don't tell their doctors: a qualitative study.

PURPOSE: The treatment a patient receives is greatly affected by what he or she chooses to disclose to a physician. This qualitative study investigated such factors as culture and background that contribute to Latina patients' nondisclosure of medical information. METHODS: Participants were 28 Latina women living in Brooklyn. In-depth interviews in English or Spanish were conducted and documented by extensive notes. We used a grounded theory approach to find emerging themes, which were coded using a continuous iterative process. RESULTS: Six primary themes emerged: the physician-patient relationship, language, physician sex and age, time constraints, sensitive health issues, and culture and birthplace. Such qualities as compassion, caring, human interest, and kindness were important to many Latinas, who did not feel safe sharing information if these qualities were absent. Language barriers caused problems with physician-patient interaction, which were complicated by the presence of a translator. Physicians being male or younger could make disclosure difficult, especially around issues of sexuality and genital examination. Time constraints and cultural differences sometimes resulted in physicians' lack of awareness of sensitive areas that patients did not wish to discuss, such as sexuality, family planning, domestic abuse, and use of recreational drugs. Birthplace (foreign born vs US born) played a role in how the women perceived barriers to disclosure. CONCLUSIONS: Staff training in techniques for building rapport can foster better communication, increase empathy and compassion, and lead to the establishment of trusting relationships in which disclosure is more likely.

Provider insights about palliative care barriers and facilitators: results of a rapid ethnographic assessment.

Palliative care remains underutilized in the United States. This may represent failure of translation of research into practice (diffusion of innovation). Qualitative methods can identify barriers to and facilitators of diffusion of innovation. The aim is to identify potential barriers to and facilitators of inpatient palliative care utilization at a large urban hospital, as articulated by health professionals. Rapid ethnographic assessment methods were used among health professionals with subsequent extraction of predominant themes illuminating factors influencing adoption of palliative care services. In all, 3 stakeholder categories and 7 major themes emerged. Analysis revealed consistent need for organized, cross-disciplinary education/training services and a clearly-defined team approach. Denial at all stakeholder levels and in most themes was a barrier to implementation of palliative care. Consistent, defined educational, policymaking, and procedural standards were requirements for best adoption of palliative care. Denial was a striking obstruction to diffusion of innovation.

Implementation of a Mindfulness Moment Initiative for Healthcare Professionals: Perceptions of Facilitators.

CONTEXT: Mindfulness practices in the workplace have experienced rapid growth, with initial evidence suggesting positive outcomes. Even so, little is known about implementing mindfulness-based interventions (MBI), especially internally driven programs led by volunteers rather than experts. OBJECTIVE: This study qualitatively explores volunteer facilitators' perceptions of a short-dose MBI (the mindfulness moment initiative) before and 6 weeks after implementation. METHODS: Mindfulness moments were 1-3-minute-guided periods of mindfulness led at the beginning of various staff meetings at an inner-city community medical center. Facilitators' perceptions were collected through thirty-one 30-minute semi-structured interviews before and after the MMI's first 6 weeks. Categorizing and connecting strategies were employed to explore the emergence of themes and patterns across responses. RESULTS: Mindfulness moment facilitators interviewed before the intervention expected their groups to experience several intra- and interpersonal benefits. After implementation, they perceived all of these benefits to have occurred, but some benefits were mentioned more frequently before than after implementation and vice versa. Five of six expected obstacles were reported after implementation, with timing issues emerging as the most frequently mentioned theme. Facilitators believed that benefits outweighed obstacles. Our data also suggested that mindfulness moments may provide managers with an additional way to address moments of tension occurring between co-workers. Most facilitators intended to continue leading mindfulness moments and wished to expand the practice to new departments. CONCLUSION: The mindfulness moment intervention may provide a way to bring mindfulness into organizations that is not dependent on formal training programs, a large time commitment, or a commitment to extended training. Prior knowledge of the obstacles and benefits found here may result in a more successful intervention.

A randomized clinical trial comparing the effect of maternal intravenous hydration and placebo on the amniotic fluid index in oligohydramnios.

OBJECTIVE: To compare the treatment of acute intravenous hydration with placebo in term pregnant women manifesting oligohydramnios. METHODS: All patients with oligohydramnios who met the inclusion criteria were offered participation in this randomized, double-blind, placebo-controlled study. After ruling out rupture of membranes and maternal and fetal complications, we recruited 44 women with third trimester singleton pregnancies having an amniotic fluid index (AFI) of less than 6. Patients were randomized into treatment or control groups. Patients in the treatment group received a continuous intravenous infusion of (1/2) normal saline (NS) at a rate of 1000 mL/h for two hours. Patients in the placebo group received an intravenous infusion of (1/2) NS at 10 mL/h for two hours. The AFI was re-assessed by the same sonographer one hour after the hydration was completed. Both the patient and the examiner were blinded to the study groups. RESULTS: Maternal age, parity, gestational age, and birth weight were not significantly different between the two groups. The AFI increased significantly in both treatment (3.8 +/- 1.2 vs. 5.3 +/- 2.5, p < 0.05) and placebo (4 +/- 1.3 vs. 5.5 +/- 2.4, p < 0.05) groups. Moreover, the changes in AFI did not significantly differ between the treatment and the placebo groups (1.2 +/- 2.1 vs. 1.5 +/- 2.1, respectively; p > 0.05). CONCLUSIONS: There are statistically significant short-term increases in the AFI in patients with oligohydramnios whether the patients are treated with intravenous fluids or not. The short-term increase in AFI may reflect physiologic diurnal variations in the amniotic fluid.

Antibiotic ointment in the treatment of Grover disease.

Grover disease, or transient acantholytic dermatosis, chiefly affects the upper part of the trunk in men older than 40 years. Lesions may last for weeks, months, or years, and often are accompanied by intense pruritus. Some patients respond to topical steroid treatment but many do not. This article reports major or total resolution of Grover disease in 6 of 9 patients following topical application of a triple antibiotic ointment. It also proposes using a case registry as a way of further investigating the efficacy of this treatment so that dermatologists may participate.

Measuring thoracic excursion: reliability of the cloth tape measure technique.

OBJECTIVE: To assess the reliability of using a cloth tape measure to determine thoracic respiratory excursion as a measurement of chest expansion or mobility. METHODS: Physicians and residents experienced in osteopathic manipulative treatment measured thoracic excursion with a cloth tape measure held around the circumference of healthy male subjects' chests at two levels. Upper thoracic excursion measurements were taken at the level of the fifth thoracic spinous process and the third intercostal space at the midclavicular line. Lower thoracic excursion measurements were taken at the level of the 10th thoracic spinous process and the xiphoid process. At peak inhalation and exhalation, three examiners measured thoracic excursion at both levels. In the first session (n=5), examiners measured the same subject inhalation and exhalation. In the second session (n=4), examiners measured separate respiratory cycles. For each session, interexaminer intraclass correlation coefficients (ICCs) were calculated for thoracic excursion, inhalation, and exhalation in the upper and lower positions using a two-way random-effects analysis of variance model. RESULTS: Intraclass correlation coefficients for thoracic excursion ranged from 0.81 to 0.91 (95% confidence interval, 0.69-0.99) at both measurement levels in both sessions. When inhalation and exhalation were considered separately, interexaminer ICCs were 0.99 and greater. Standard deviations for measurements of each subject's thoracic excursion at both levels ranged from 0.5 cm to 0.8 cm with a mean of 0.6 cm. CONCLUSION: The method of using a tape measure to assess thoracic excursion was highly reliable in men, resulting in ICCs of substantial reliability. The SDs at each level of measurement indicate that this method may be most useful in measuring changes in thoracic excursion that are expected to be 0.6 cm or greater.

Communication between CAM and mainstream medicine: Delphi panel perspectives.

Healthcare practitioners' models of health affect their patient interactions and services. We surveyed mainstream (MM), integrative (IM) and CAM providers to investigate their models of health. This study generated ideas for actions to improve MM/CAM communication based on survey findings. Through the Delphi technique, a panel of 14 MM, IM and CAM experts participated in two rounds of questioning regarding survey findings. MM panel members were less supportive of almost all suggestions for actions than IM and CAM members. Suggestions most likely to be implemented were enabling the patient to take an active role in care, establishing understanding between patient and practitioner of treatment and its goals, fostering patients' taking responsibility for their health and communicating about patient assessment in ways understandable to others. Actions to foster better MM/CAM communication promote focus by a team of providers on the patient's goals, functioning and involvement in their care.

Towards a model for planning clinical research in Oriental medicine.

BACKGROUND: Oriental medicine (OM) is widely practiced internationally and embraces many schools of thought. Western medical research is currently struggling to understand OM in purely biomedical terms, with limited success. OBJECTIVE: We propose a research model for applying Western research methodologies to OM in a way that respects its theory and modes of clinical application. This would facilitate systematic investigations of OM's specific assumptions and make explicit the way OM studies could build on each other. METHODS: To develop this model, the authors extracted key assumptions of Western research methodology germane to clinical research, put them in a developmentally logical sequence, and related them to the diagnostic and clinical processes of OM. RESULTS: The model categorizes studies into seven levels. Foundation studies (level one) establish the conceptual basis for OM research by establishing the internal validity of its basic "truth statements." Measurement studies (level two) determine how OM identifies and measures diagnostic indicators, treatment outcomes, and other basic aspects of health. Group studies (level three) describe populations in ways meaningful to their health. Pattern/diagnosis studies (level four) identify and define OM patterns of disharmony. Treatment technique studies (level five) describe particular techniques or principles of treatment, their indications, and rationale. Treatment effectiveness studies (level six) evaluate techniques of treatment, often by comparing the results of one technique with those of another in similar patients. Systematic reviews (level seven) draw together studies on the same topic to see if conclusions are thereby strengthened. CONCLUSION: The levels can be used to establish relationships between already published studies, determine if sufficient background research has been done to enable a study idea to be carried out, and generate ideas for future studies.

Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis.

HYPOTHESIS: Outcome following laparoscopic adjustable gastric banding (LAGB) in super morbidly obese patients is significantly worse compared with the standard laparoscopic Roux-en-Y gastric bypass (LRYGB). DESIGN: Prospective case series. SETTING: Community teaching hospital (490 beds). PATIENTS: A prospectively maintained database identified patients who underwent operative treatment for morbid obesity between February 2001 and June 2004. The study group included super morbidly obese patients (body mass index >50 [calculated as weight in kilograms divided by the square of height in meters]) following LAGB and LRYGB. INTERVENTIONS: Among 106 patients with super morbid obesity, 60 (57%) and 46 (43%) underwent LAGB and LRYGB, respectively. MAIN OUTCOME MEASURES: Patient demographics, weight loss, percentage of excess weight loss, change in body mass index, early (<30 days) and late (> or =30 days) complications, reoperations, medical comorbidity, and patient satisfaction were studied. Analysis was performed using the t test and Pearson chi 2 analysis. RESULTS: Overall median follow-up was 16.2 months (range, 1-40 months). Preoperative factors of patient age, sex, weight, body mass index, and medical comorbidity were similar between the 2 groups. Compared with LRYGB, patients who underwent LAGB experienced a greater incidence of late complications (P < .05), reoperations (P < .04), less weight loss (P<.001), and decreased overall satisfaction (P < .006). Likewise, patients who underwent LRYGB had a greater resolution of concomitant diabetes mellitus (P < .05) and sleep apnea (P<.01) compared with the LAGB group. Furthermore, postoperative adjustments to achieve consistent weight loss for LAGB recipients ranged from 1 to 15 manipulations. Our single mortality was in the LAGB group. CONCLUSIONS: In super morbidly obese patients, LAGB is significantly associated with more late complications, reoperations, less weight loss, less reduction of medical comorbidity, and patient dissatisfaction compared with LRYGB. Further evaluation of LAGB in this patient population appears warranted.

Comparison of nutritional counseling between provider types.

OBJECTIVE: The goal of this study was to compare the provision of and attitudes toward nutritional counseling between pediatricians and pediatric dentists. METHODS: Questionnaires were mailed to 500 US members of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics. RESULTS: The survey had a response rate of 33% (pediatric dentists=36%; pediatricians=29%). 84% of pediatricians routinely offered nutritional counseling compared to 71% of pediatric dentists. With respect to cariogenic foods, 82% of pediatric dentists and 74% of pediatricians correctly recommended bottle contents, and 33% of pediatric dentists and 19% of pediatricians correctly recommended snacks. 79% of pediatric dentists compared to 69% of pediatricians believed nutritional counseling had at least some effectiveness. Eighty-nine percent of both specialties somewhat or strongly agreed that nutritional counseling was an important aspect of oral health care. CONCLUSIONS: While pediatric dentists made slightly better recommendations than pediatricians regarding cariogenic foods, both provider types demonstrated a need for more education regarding nutritional counseling.

Definitions of health among healthcare providers.

Providers' definitions of health may affect the kind of care they provide. This study examined healthcare practitioners' definitions of health across practitioner types. Interviews with 73 healthcare practitioners were analyzed for themes. Most practitioners identified health as the interrelatedness of several factors. Physical, mental, and spiritual factors all played important roles. Mainstream and integrative practitioners emphasized health as good functioning, absence of disease, and chronic disease under control. Integrative and alternative practitioners emphasized health as balance and as the free flow of elements such as motion and energy. All types of practitioners freely combined elements from models of health described as separate in the literature. Understanding providers' definitions of health could enhance communication among them.