Inappropriate and potentially avoidable emergency department visits of Swiss nursing home residents and their resource use: a retrospective chart-review.

BACKGROUND: Emergency department (ED) visits for nursing home residents lead to higher morbidity and mortality. Therefore, inappropriate visits (for conditions treatable elsewhere) or potentially avoidable visits (those avoidable through adequate chronic care management) must be minimized. This study aimed to investigate factors and resource consumption patterns associated with inappropriate and potentially avoidable visits in a Swiss tertiary hospital. METHODS: This is a single-center retrospective chart review in an urban Swiss university hospital ED. A consecutive sample of 1276 visits by nursing home residents (≥ 65 years old), recorded between January 1, 2015 and December 31, 2017 (three calendar years) were included. Case characteristics were extracted from ED electronic documentation. Appropriateness was assessed via a structured Appropriateness Evaluation Protocol; potentially avoidable visits-measured as ambulatory-care sensitive conditions (ACSCs)-were analyzed separately. Inter-group differences concerning ED resource use were tested respectively with chi-square or Wilcoxon rank sum tests. To identify predictors of inappropriate or potentially-avoidable visits, we used multivariable logistic regression analysis. RESULTS: Six percent of visits were rated as inappropriate: they had lower triage levels (OR 0.55 [95%-CI 0.33-0.92], p=0.024) and, compared to ambulance calls, they had higher odds of initiation via either patient-initiated walk-in (OR 3.42 [95%-CI 1.79-6.55], p≤0.001) or GP referrals (OR 2.13 [95%-CI 1.16-3.90], p=0.015). For inappropriate visits, overall ED resource use was significantly lower (median 568 vs. 1403 tax points, p≤0.001). Of all visits included, 29% were due to (often potentially-avoidable) ACSCs. In those cases, compared to ambulance initiation, odds of being potentially-avoidable were considerably lower for walk-in patients (OR 0.46 [95%-CI 0.27-0.77], p=0.004) but higher for GP referrals (OR 1.40 [95%-CI 1.00-1.94], p=0.048). Nurse work (93 tax points vs. 64, p≤0.001) and laboratory resource use (334 tax points vs. 214, p≤0.001) were higher for potentially-avoidable ED visits. CONCLUSIONS: We revealed substantial differences between the investigated groups. While nearly one third of ED visits from nursing homes were potentially avoidable, inappropriate visits were lower in numbers and not resource-intensive. Further research is required to differentiate potentially avoidable visits from inappropriate ones and to determine these findings' public health implications.

Elementos relevantes en la intervención terapéutica de jóvenes que cometen infracciones sexuales: la percepción de adolescentes chilenos egresados de un programa especializado / Relevant elements in the therapeutic intervention of young people who have committed sexual offences: perception of the Chilean adolescents emerging from a specialized program / Elementos relevantes na intervenção terapêutica de jovens que cometem infrações sexuais: a percepção de adolescentes chilenos egressos de um programa especializado

Resumen El objetivo de la investigación es estudiar la percepción de jóvenes chilenos egresados de un programa dirigido a adolescentes que cometen actos sexualmente abusivos. En el estudio se aplicó una metodología de tipo cualitativa, utilizando como instrumentos de producción de información la entrevista semi-estructurada y la revisión documental de fichas clínicas. El análisis se realizó mediante la técnica de la Teoría Fundamentada. Los resultados alcanzados apuntan a la importancia en la especialización de las metodologías y técnicas aplicadas, tanto en la evaluación diagnóstica como en el proceso terapéutico. Se observó también la relevancia que tiene la figura del terapeuta como elemento facilitador del éxito en la intervención, y la imperativa necesidad de perfeccionamiento en las técnicas para abordar los contenidos asociados al reconocimiento y responsabilización del hecho abusivo. Finalmente, se concluye la necesidad de mayor investigación sobre las distintas trayectorias de adolescentes que cometen delitos sexuales, a modo de generar terapias con mayor nivel de especialización.

Abstract The objective of this investigation is to study the perception of young Chilean people; they are emerging from a program addressed to adolescents who have committed sexually abusive acts. This study implements a qualitative methodology; semi-structured interview and medical records document review were used as information production instruments. The analysis was conducted by means of the grounded theory technique. The achieved results point to the importance in the specialization of methodologies and applied techniques, in both the diagnostic evaluation and the therapeutic process. It was observed the relevance of the therapist figure as a facilitator element of the success in the intervention; and also the imperious necessity of enhancing the techniques to approach the contents associated with the recognition and accountability of the abusive act. Finally, this concludes that further research is required with regard to the different trajectories of adolescents who have committed sexual offences, so therapies with a higher level of specialization to be generated.

Resumo O objetivo da pesquisa é analisar a percepção dos jovens chilenos egressos de um programa dirigido a adolescentes que cometem atos sexualmente abusivos. No estudo foi utilizada uma metodologia qualitativa, usando como instrumentos para a coleta de dados a entrevista semiestruturada e a revisão documental de fichas clínicas. A análise realizou-se por meio da técnica de teoria fundamentada. Os resultados obtidos apontam a importância da especialização das metodologias e técnicas aplicadas, tanto na avaliação diagnóstica quanto no processo terapêutico. Observaram-se também a relevância da figura do terapeuta como facilitador para o sucesso da intervenção e a imperativa necessidade de aperfeiçoamento das técnicas para a abordagem dos conteúdos associados ao reconhecimento e responsabilização do ato abusivo. Finalmente, concluise que é necessária uma pesquisa mais ampla acerca das distintas trajetórias de adolescentes que cometem delitos sexuais, de modo que sejam fomentadas terapias com maior nível de especialização.

The association of activity level, parent mental distress, and parental involvement and monitoring with unintentional injury risk in fifth graders.

OBJECTIVE: Extend findings with young children by examining the strength of association of activity level, parent mental distress, and parental involvement and monitoring with fifth graders' unintentional injuries. METHODS: Ordinal logistic regression models were used to predict unintentional injury frequency among 4745 fifth-graders. Examined predictors included demographics, parent reports of mental distress, temperamental activity level (tendency to be fidgety, restless, and constantly in motion), and parental involvement and monitoring in adolescents' lives. RESULTS: Higher levels of both activity level and parent mental distress predicted more frequent injuries. CONCLUSIONS: As has been found with younger children, unintentional injuries in fifth graders are associated with both parent and child characteristics. The result is discussed in the context of adolescent development. Implications include those for injury prevention (multi-dimensional prevention strategies that incorporate environmental modifications as well as training of youth and parents) and future research (study of potential mechanisms behind injury risk behavior via longitudinal and experimental research; study of injury risk during this phase of child development).

Connectedness as a predictor of sexual and reproductive health outcomes for youth.

To review research examining the influence of "connectedness" on adolescent sexual and reproductive health (ASRH). Connectedness, or bonding, refers to the emotional attachment and commitment a child makes to social relationships in the family, peer group, school, community, or culture. A systematic review of behavioral research (1985-2007) was conducted. Inclusion criteria included examination of the association between a connectedness sub-construct and an ASRH outcome, use of multivariate analyses, sample size of >or=100, and publication in a peer-reviewed journal. Results were coded as protective, risk, or no association, and as longitudinal, or cross sectional. Findings from at least two longitudinal studies for a given outcome with consistent associations were considered sufficient evidence for a protective or risk association. Eight connectedness sub-constructs were reviewed: family connectedness (90 studies), parent-adolescent general communication (16 studies), parent-adolescent sexuality communication (58 studies), parental monitoring (61 studies), peer connectedness (nine studies), partner connectedness (12 studies), school connectedness (18 studies), and community connectedness (four studies). There was sufficient evidence to support a protective association with ASRH outcomes for family connectedness, general and sexuality-specific parent-adolescent communication, parental monitoring, partner connectedness, and school connectedness. Sufficient evidence of a risk association was identified for the parent overcontrol sub-construct of parental monitoring. Connectedness can be a protective factor for ASRH outcomes, and efforts to strengthen young people's pro-social relationships are a promising target for approaches to promote ASRH. Further study regarding specific sub-constructs as well as their combined influence is needed.

Coordinated school health programs and academic achievement: a systematic review of the literature.

BACKGROUND: Few evaluations of school health programs measure academic outcomes. K-12 education needs evidence for academic achievement to implement school programs. This article presents a systematic review of the literature to examine evidence that school health programs aligned with the Coordinated School Health Program (CSHP) model improve academic success. METHODS: A multidisciplinary panel of health researchers searched the literature related to academic achievement and elements of the CSHP model (health services, counseling/social services, nutrition services, health promotion for staff, parent/family/community involvement, healthy school environment, physical education, and health education) to identify scientifically rigorous studies of interventions. Study designs were classified according to the analytic framework provided in the Guide developed by the Community Preventive Services Task Force. RESULTS: The strongest evidence from scientifically rigorous evaluations exists for a positive effect on some academic outcomes from school health programs for asthmatic children that incorporate health education and parental involvement. Strong evidence also exists for a lack of negative effects of physical education programs on academic outcomes. Limited evidence from scientifically rigorous evaluations support the effect of nutrition services, health services, and mental health programs, but no such evidence is found in the literature to support the effect of staff health promotion programs or school environment interventions on academic outcomes. CONCLUSIONS: Scientifically rigorous evaluation of school health programs is challenging to conduct due to issues related to sample size, recruitment, random assignment to condition, implementation fidelity, costs, and adequate follow-up time. However, school health programs hold promise for improving academic outcomes for children.

Impact of the media on adolescent sexual attitudes and behaviors.

BACKGROUND: Adolescents in the United States are engaging in sexual activity at early ages and with multiple partners. The mass media have been shown to affect a broad range of adolescent health-related attitudes and behaviors including violence, eating disorders, and tobacco and alcohol use. One largely unexplored factor that may contribute to adolescents' sexual activity is their exposure to mass media. OBJECTIVE: We sought to determine of what is and is not known on a scientific basis of the effects of mass media on adolescent sexual attitudes and behaviors. Method. We performed an extensive, systematic review of the relevant biomedical and social science literature and other sources on the sexual content of various mass media, the exposure of adolescents to that media, the effects of that exposure on the adolescents' sexual attitudes and behaviors, and ways to mitigate those effects. Inclusion criteria were: published in 1983-2004, inclusive; published in English; peer-reviewed (for effects) or otherwise authoritative (for content and exposure); and a study population of American adolescents 11 to 19 years old or comparable groups in other postindustrial English-speaking countries. Excluded from the study were populations drawn from college students. RESULTS: Although television is subject to ongoing tracking of its sexual content, other media are terra incognita. Data regarding adolescent exposure to various media are, for the most part, severely dated. Few studies have examined the effects of mass media on adolescent sexual attitudes and behaviors: only 12 of 2522 research-related documents (<1%) involving media and youth addressed effects, 10 of which were peer reviewed. None can serve as the grounding for evidence-based public policy. These studies are limited in their generalizability by their cross-sectional study designs, limited sampling designs, and small sample sizes. In addition, we do not know the long-term effectiveness of various social-cultural, technologic, and media approaches to minimizing that exposure (eg, V-Chips on television, Internet-filtering-software, parental supervision, rating systems) or minimizing the effects of that exposure (eg, media-literacy programs). CONCLUSIONS: Research needs to include development of well-specified and robust research measures and methodologies; ongoing national surveillance of the sexual content of media and the exposure of various demographic subgroups of adolescents to that content; and longitudinal studies of the effects of that exposure on the sexual decision-making, attitudes, and behaviors of those subgroups. Additional specific research foci involve the success of various types of controls in limiting exposure and the mitigative effects of, for example, parental influence and best-practice media-literacy programs.

Can education policy be health policy? Implications of research on the social determinants of health.

Research on the social determinants of health has demonstrated robust correlations between several social factors, health status, and life expectancy. Some of these factors could be modified through policy intervention. National-level public policies explicitly based on population health research are in various stages of development in many Western countries, but in spite of evident need, seemingly not at all in the United States. Because research shows such a strong association between education and good health, we offer evidence to show that at least two pressing problems in American society, namely the uneven distribution of educational attainment and health disparities linked to socioeconomic position, may be ameliorated through policy initiatives that link quality early childhood care, child development programs, and parental training in a seamless continuum with strengthened K-12 education.

John T. Edsall: his key role in the determination of the structure of proteins.

A letter, written in 1947 by John Edsall, outlined a declared intent to set up an X-ray crystallographic laboratory devoted to the study of crystalline heavy atom derivatives of proteins in an attempt to learn more about their structure. The fundamental idea, to the recipient (B.W.L.) totally new, revolutionary, and wholly contrary to all learned certainties, led to a correspondence, presented here in excerpt. Detailed plans were made for the laboratory to be built in the Department of Physical Chemistry at the Harvard Medical School. The proteins to be studied were reviewed and debated. The work of the laboratory is briefly described. Lack of success, the fatal consequence of a then unknown feature of the protein first chosen for study, is now only recently understood. The history of the Edsall idea and initiative is explored, from its beginnings to its acceptance and exploitation. John Edsall is here recognized as prime proponent and developer of the fundamental idea behind the most powerful and, for more than three decades, the only successful approach to the determination of protein structure.