Clinical Caseload Research Articles

Surveillance ofStaphylococcus aureusin Veterinary Teaching Hospitals

Staphylococcus aureus isolates (n = 70) from 65 patients (36 canine, 18 equine, 7 bovine, 2 avian, and 2 feline) at seven veterinary teaching hospitals in the United States were studied. The majority of patients (83%) with an S. aureus infection were canine and equine, but this may have reflected a sample bias based on clinic case loads and diagnostic lab submissions at the participating institutions. Fourteen percent of patients with an S. aureus infection were infected with a methicillin-resistant S. aureus (MRSA) isolate. Six of seven institutions had at least one MRSA infection during the study. Pulsed-field gel electrophoresis on 63 of the 70 isolates yielded 58 unique strains of S. aureus. None of the strain types of the MRSA isolates matched each other or the type of any other S. aureus isolate. The proportions of patients infected with an MRSA isolate were not significantly different between institutions or animal species (P > or = 0.222). Methicillin-resistant S. aureus isolates in this study seemed to be community acquired rather than hospital acquired.

A multidisciplinary team approach to public health working.

For several years the government's health agenda has provided a strong directive for primary care professionals to work in a more public, health focused way. There remains, however, the constant challenge to incorporate a public health focus into existing clinical practice and caseload commitments in an achievable and manageable way, while at the same time impacting on ill health. This article explores a pragmatic public health approach to addressing some of the common health needs of people, as identified collectively in the national service frameworks for mental health, coronary heart disease, diabetes, older people and cancer. A practical example of facilitating collaborative working between disciplines and agencies is offered using the author's successful experiences form a review and modernization project of health visiting services in East Somerset (Dion, 2003).

Phonological acquisition in preschoolers learning a second language via immersion: a longitudinal study

Phonological development in first and second languages (L1 and L2 respectively) has not been extensively studied in young children who are acquiring a second language via immersion. This lack of information is unfortunate, as the number of children who are acquiring a second language in this context is growing and such children make up a part of the clinical caseload of many speech‐language pathologists. To address the need for information regarding phonological development of children acquiring a second language in immersion, the present investigation sought to provide longitudinal data on the development of both L1 and L2 phonologies. Five preschoolers who were acquiring English as a L2 and who spoke different L1s participated in the study. A picture identification task was used to assess productive phonological skills in L1 and English. Analyses included a description of the children's phonetic inventories, accuracy rates, and non‐target response patterns. Both within child (across languages) and between child comparisons were made to discern possible patterns of use and to identify factors that may impact phonological skill in the L1 and L2. Results of the investigation suggest that children who are learning a L2 utilize their knowledge of the L1 to aid them in acquiring the phonological system of the L2. At the same time, they appear to maintain, at least as measured via perceptual analysis of their speech, distinct phonological systems.

Who's happy with supervision?

Aims and MethodAll psychiatry trainees and supervisors on the Southeast Scotland scheme were invited to complete a questionnaire about the regularity, responsibility, structure, content and value of supervision.ResultsSignificantly more supervisors (87%) than trainees (69%) reported regular supervision. Some trainees still find it difficult to obtain regular supervision. Although it is seen as a joint responsibility, there is uncertainty about the role and responsibility of each trainee and supervisor. Most trainees and supervisors feel that supervision is useful, but supervisors are likely to rate their quality of supervision better than their trainees. Guidelines for the structure, content and boundaries of supervision might be useful. Supervision is viewed as useful for discussing clinical management, including the trainee's own case-load.Clinical ImplicationsTraining in the use of supervision should be available to all trainees and supervisors. Regular supervision should be a priority, and it is a joint responsibility to ensure that it happens. There should be greater accountability to the College and Trusts. Discussion of the trainee's clinical case-load during supervision is a necessary part of training and the supervision process.

Should old age psychiatry develop memory clinics? A comparison with domiciliary work

Aims and MethodMemory clinics have become very popular in old age psychiatry and there is some pressure for them to be developed in old age services. However, there is little evidence to suggest that they are more advantageous over the traditional domiciliary visits or who should be seen in clinic. This was a naturalistic comparison of 76 consecutive new referrals to a memory clinic, with 74 consecutive new domiciliary requests within the same service over the same period of time. A retrospective case note review collected the clinical features and an 18-month prospective follow-up examined the subsequent clinical management.Clinical ImplicationsThe two groups were characterised more by their similarities than their differences. However, the domiciliary group had greater behavioural and psychological complications. The memory clinic patients were less likely to receive psychotropic medication and here more likely to be followed up.ResultsWe conclude that memory clinics might be less suitable for patients with prominent psychiatric complications. Memory clinics could complement the domiciliary model by providing early psychosocial/neuropsychiatric approaches, although this is likely to lead to an increased clinical case-load.

Medical Image Resource Center--making electronic teaching files from PACS.

A picture archive and communications system (PACS) is a rich source of images and data suitable for creating electronic teaching files (ETF). However, the potential for PACS to support nonclinical applications has not been fully realized: at present there is no mechanism for PACS to identify and store teaching files; neither is there a standardized method for sharing such teaching images. The Medical Image Resource Center (MIRC) is a new central image repository that defines standards for data exchange among different centers. We developed an ETF server that retrieves digital imaging and communication in medicine (DICOM) images from PACS, and enables users to create teaching files that conform to the new MIRC schema. We test-populated our ETF server with illustrative images from the clinical case load of the National Neuroscience Institute, Singapore. Together, PACS and MIRC have the potential to benefit radiology teaching and research.

Mapping the range and scope of emergency nurse practitioner services in the Northern and Yorkshire Region: a telephone survey

Objective: To map the range and scope of emergency nurse practitioner (ENP) services in the Northern and Yorkshire Region as part one of a three phased study investigating the developing...

Breadth and depth of diversity in Minnesota: challenges to clinical competency.

This study explored the impact of recent demographic changes on clinical service delivery in the state of Minnesota. A Web-based survey was used to ask speech-language pathologists in Minnesota about their training, clinical caseloads, and professional experiences with respect to diversity. Primary survey goals were to (a) determine if, and how, recent changes in the overall state demographics were reflected on caseloads of speech-language pathologists, and (b) identify challenges clinicians faced in meeting the needs of an increasingly diverse population. The authors considered the breadth or range of economically, racially, ethnically, and linguistically diverse populations represented on caseloads, relative to depth of diversity. Survey results are discussed with respect to challenges inherent in providing services to a diverse caseload, together with the competencies needed in order to meet these professional challenges.

The 2:1 Clinical Placement Model: Perceptions of clinical educators and students

Summary Background and Purpose The need to increase availability of practice placements for undergraduate physiotherapists is now critical, particularly since higher student numbers have been commissioned with the implementation of the National Health Service Plan ( DoH, 2000 ). Exploration of non-traditional placement models which promote peer learning and accommodate more students has been proposed ( Baldry Currens and Bithell, 2000 ). This paper examines perceptions of clinical educators and students regarding the 2:1 model (two students placed with one educator), both as a learning experience and with regard to practical aspects of its management. Methods Thirty-four 2:1 placements in 12 National Health Service trusts were studied. Clinical educators new to the 2:1 model, and students from six academic institutions participated. Qualitative in-depth interviews and questionnaires were conducted in the final placement week. Interviews were audio-taped and transcribed verbatim. Data (original words and phrases from interviews and questionnaires) were subjected to a six-part content analysis and coded into emerging themes and issues. Findings were checked with peers from six groups of clinical educators and one group of students. Findings Thirty-seven clinical educators and 61 students were interviewed; questionnaires were returned from 34 clinical educators (91.9%) and 59 students (96.7%). At interview 35 clinical educators were willing to use the 2:1 model again, and in questionnaires almost all students valued peer discussion (98.3%) and peer support (81.4%). 2:1 models were considered feasible in all clinical specialties studied and for all student years. Interaction with peers was perceived to enhance the quality of placement learning, although clinical educators expressed uncertainty regarding relevant teaching and learning strategies. Although clinical educators expected difficulties in managing competition and difference between students, these aspects were rarely problematic in practice. Placements were most successful and time management most efficient when students treated more than 50% of the clinical educator's caseload. Conclusions The 2:1 model was perceived as successful by clinical educators and students in all years of study. It has potential to enhance student learning, and is appropriate for use in a variety of clinical settings.

Vegetative state and minimally responsive patients – Regional survey, long-term case outcomes and service recommendations

A regional survey of Consultant level Neurology, Neurosurgical and Rehabilitation staff identified a retrospective estimate of patients in vegetative or minimally responsive states from their own clinical caseloads (October 1995--97). 35 patients were identified; the majority of whom were not currently placed in specialist brain injury facilities following acute hospital intervention. In addition, a retrospective review of referrals to this unit (1995--2001) was also undertaken. Of twelve patients referred as being in a vegetative or minimally responsive state, 4 were considered as having been misdiagnosed (emerged) at follow-up; 2 had been presumed to be vegetative for at least one year. All patients remained severely physically disabled (i.e., totally dependent for care) but four were nevertheless able to communicate their preference in quality of life issues, care decisions etc. either by verbal or non-verbal means. Vegetative-minimally responsive patients or those who are very severely and multiply disabled need skilled and frequently prolonged assessment. Appropriate management requires an experienced inter-disciplinary as opposed to multidisciplinary team working style, whose skill repertoire equips them to recognise often-subtle improvements in cognitive function and act to maximise individual patient's quality of life. The current paucity of service provision for this vulnerable group of patients is highlighted.

Investigating the nursing contribution to commissioning in primary health-care.

This study set out to investigate nurses', doctors' and managers' perceptions of the nursing contribution to commissioning in primary health-care. The study was undertaken in the light of the proposal in the government's White Paper The new NHS, Modern, Dependable that community nurses should play a lead role in commissioning health services as members of the new primary care groups. Semistructured taped interviews were conducted, with seven community nurses, two community midwives, seven managers and four general practitioners, covering three geographical locations in the UK. The data were transcribed and analysed using a template approach, where text is analysed through the use of an analysis guide, or codebook, consisting of categories, or themes, relevant to the research questions. The main themes to emerge were that nurses had an important contribution to make to commissioning on the basis of their clinical knowledge, their awareness of health need and their knowledge of health promotion. Additionally, the ability of nurses to negotiate at different levels across professional groups and with the public was perceived as an important skill in a commissioning role. However, findings also indicated that nurses need additional knowledge and skills if they are to perform their role effectively. Being sidelined from the commissioning arena, poor interprofessional collaboration and the potential for resistance from some general practitioners and managers were identified as constraints on the nursing contribution to commissioning. Combining clinical caseloads with commissioning responsibilities and a lack of support systems for nurses in commissioning were also identified as constraints. Nurses' commissioning-related knowledge and skills will have to be developed and constraints on the commissioning role of nurses challenged if the perspectives and values of nursing are to help to reshape our healthcare system.

Attachment Quality and Post-treatment Functioning Following Sexual Trauma in Young Adolescents: A Case Series Presentation

Children and adolescents who suffer sexual abuse evidence symptoms that may persist into adulthood. Attachment theory may lend some insight into the psychological sequelae following sexual trauma. A clinical case series presents four sexually abused young adolescents from the first author's clinical caseload. Each case is rated regarding the quality of attachment, the severity of trauma, and the child's functioning at the time of follow-up. Ratings are made by the first author and qualified by a second clinician who is familiar with each case. Findings suggest that those youngsters who had the benefit of a strong and secure attachment evidence more positive outcome at follow-up.

Large Hypopharyngeal Tongue: A Shared Anatomic Abnormality for Difficult Mask Ventilation, Difficult Intubation, and Obstructive Sleep Apnea?

Groupe Hospitalier Pitié-Salpêtrière, Paris, France. olivier.langeron@psl.ap-hop-paris.frIn Reply:—We greatly appreciate the interest expressed by Drs. Chou and Wu regarding our article. 1As reported previously, 2some subjects in whom the trachea is difficult to intubate are at increased risk of obstructive sleep apnea (OSA). Moreover, patients who have difficult intubation (DI) and OSA may share upper airway anatomical abnormalities with a difficult mask ventilation (DMV) situation. In our study, we identified five independent factors (age > 55 yr, body mass index > 26 kg/m2, beard, lack of teeth, and history of snoring) associated significantly with DMV. Some of these risk factors for DMV (age > 55 yr, body mass index > 26 kg/m2, and history of snoring) are related to malproportion of overall body size or malproportion between the oropharyngeal free space and internal structures of the oropharynx, as in OSA. Our first comment in response to Drs. Chou and Wu is that the purpose of our study was to identify factors predicting DMV and not to correlate DMV to OSA. Second, Drs. Chou and Wu reported that a longer mandible and hyoid distance (MHD) indicated an increased tongue mass in the hypopharynx, compromising the posterior airway space. 3Unfortunately, measurement of MHD may be difficult because of its wide variation among the adult population and the need for experience as mentioned in their letter. Moreover in their previous study, 3MHD was obtained from lateral cervical spine radiograph measurements and not from clinical findings. Last, in a more recent study, 2MHD was not significantly different in DI and non-DI patients and was not related to OSA. Nevertheless, we are convinced that MHD could be valuable information in predicting an OSA–DMV–DI situation if it could be validated in a clinical setting without performing measurements from radiographs. Therefore, further studies are required to determine if MHD could be a reliable clinical predictor of OSA–DMV–DI cases.We thank Dr. Takenaka et al. for the interest in our work and their valuable comments. We fully agree that the jaw-thrust maneuver can reopen the obstructed airway by lifting up the base of the tongue and the epiglottis in anesthetized patients. Moreover, Calder et al. 4reported that impaired mandibular protrusion was associated with a more difficult laryngoscopy in patients with cervical spine disease. Indeed, in patients with an occipito-atlanto-axial disease as in the study of Calder et al. , 4a poor mandibular protrusion is recognized. Consequently, we may assume that decreased mandibular protrusion in an awake patient is a good predictor of a reduced cervical spine mobility associated with impaired laryngoscopy. In addition, this test may not assess reliably a potential decreased airway patency in the anesthetized patient without spine disease. Therefore, we cannot extrapolate information related to difficult laryngoscopy and difficult intubation to those with DMV requiring specific investigation. In our opinion, the relation between a reduced mandibular protrusion in the awake state and DMV remains to be shown.We thank Dr. Gentili for his interest in our work and the comments. The purpose of our study was to identify factors predicting DMV per se and not to determine the influence of the degree of clinical experience of the anesthesiologist in a DMV situation. Consequently, as mentioned in the article, this study involved staff anesthesiologists. Nevertheless, we agree with Dr. Gentili that the annual clinical case loads for an individual anesthesiologist may influence his or her clinical practice. However, this is true for any daily clinical activity for a physician and was not the purpose of our study. Last, incidence of DMV has been assessed rarely in previous studies related to airway management, and no specific investigation has been performed to study DMV. This point may explain largely the discrepancy for the DMV incidence in our study in comparison with other studies.

Distribution of case-load in community mental health teams

Aims and MethodAn audit project was carried out in a mental health trust in North-West London on two successive years to determine the average case-load size of defined severe mental illness for each professional discipline.ResultsThe average case-load for non-consultants varied from 16 (for occupational therapists) through to 98 patients (for senior house officers). Community psychiatric nurses had an average case-load of 21 and consultants had an estimated average case-load of between 185 and 317 patients. The proportion of patients with severe mental illness ranged from 49% to 67%.Clinical ImplicationsThe case-loads of consultants in community health teams are too large to exercise the statutory duties of a responsible medical officer and, therefore, need revision.

Attention-Deficit Hyperactivity Disorder: How Much Do We See?

A postal questionnaire survey of senior clinical psychologists, child psychiatrists and community paediatricians in the Trent region (85% response) revealed that a total of 826 new ADHD cases were seen over the index period, 1997–1998. Approximately a third of these were adolescents. Wide variations in individuals' clinical caseloads, both within and between professional groups, were revealed. No respondent could identify any local formal transitional arrangements or adult services for older ADHD cases. This would suggest that there is a pressing need to establish such services for patients with ADHD irrespective of their age.

Attention-Deficit Hyperactivity Disorder: How Much Do We See?

A postal questionnaire survey of senior clinical psychologists, child psychiatrists and community paediatricians in the Trent region (85% response) revealed that a total of 826 new ADHD cases were seen over the index period, 1997–1998. Approximately a third of these were adolescents. Wide variations in individuals' clinical caseloads, both within and between professional groups, were revealed. No respondent could identify any local formal transitional arrangements or adult services for older ADHD cases. This would suggest that there is a pressing need to establish such services for patients with ADHD irrespective of their age.

The Pathology of Interstitial Lung Disease in Nylon Flock Workers

Flocking is a widely used industrial process in which short lengths of synthetic fibers are applied to backing fabric to produce plush material. In response to an apparent outbreak of interstitial lung disease in flock workers, the Centers for Disease Control hosted a clinical-pathological workshop to identify the defining characteristics of the disease and possible etiologic agents. Six pathologists reviewed 15 biopsies of 15 cases (out of a clinical caseload of 20 patients) and assessed the pattern, extent and degree of pulmonary inflammation, fibrosis, and other changes. A consensus clinical-pathologic diagnosis was reached for each patient and correlated with clinical and radiologic findings. Four of eight open lung biopsies and one of seven closed (transbronchial) lung biopsies demonstrated a characteristic pattern to which the descriptive terminology lymphocytic bronchiolitis and peribronchiolitis with lymphoid hyperplasia was applied. The other biopsies showed nonspecific inflammatory changes, airspace organization, and diffuse alveolar damage. One open lung biopsy demonstrated respiratory bronchiolitis with lymphoid hyperplasia. None of the lung biopsies showed more than mild interstitial fibrosis and no granulomas were identified. The consensus of the workshop was that lymphocytic bronchiolitis and peribronchiolitis with lymphoid hyperplasia was a characteristic and distinctive pattern of injury in the flock workers' lung biopsies. Although the etiology of this disease remains undefined at present, the injury pattern and environmental studies suggest a chronic immunologic response to inhaled material.

A plan for the NHS for the 21st century.

A plan for the NHS for the 21st century.

Predicting length of stay in an acute psychiatric hospital.

Multivariate statistical methods were used to identify patient-related variables that predicted length of stay in a single psychiatric facility. The study investigated whether these variables remained stable over time and could be used to provide individual physicians with data on length of stay adjusted for differences in clinical caseloads and to detect trends in the physicians' practice patterns. Data on all patients discharged over two six-month periods were collected at an acute psychiatric inpatient facility. Stepwise multiple regression analyses were conducted on the two datasets. The results from both analyses revealed that five variables significantly predicted length of stay and were stable over time. They were a primary diagnosis of schizophrenia, the number of previous admissions, a primary diagnosis of a mood disorder, age, and a secondary diagnosis of an alcohol- or other drug-related disorder. For some physicians, the mean length of stay of their patients differed significantly from the length predicted by the regression model--generally, it was shorter. The results demonstrate that patient-related predictors of length of stay in a single psychiatric hospital can be identified using relatively simple statistical procedures and can be consistent across a large dataset and over time.

A Methodology Report of a Randomized Prospective Clinical Trial to Assess Velopharyngeal Function for Speech Following Palatal Surgery

Cleft lip and palate occurs in approximately 1 in every 750 live human births, making it one of the most common congenital malformations. Surgical closure of the palatal cleft does not always result in a velopharyngeal port capable of supporting normal speech. The University of Florida (UF), in collaboration with the University of São Paulo (USP), is engaging in a 5-year prospective, randomized controlled study to compare velopharyngeal function for speech outcomes between patients undergoing palatoplasty for complete unilateral cleft lip and palate performed using the von Langenbeck procedure with intravelar velarplasty and those receiving the Furlow double-reversing Z-plasty palatoplasty. The von Langenbeck procedure was selected as the time-tested standard against which the Furlow procedure could be judged. The Furlow procedure, a relatively new operation, has been reported to yield substantially higher rates of velopharyngeal competency for speech than have most other reported series and theoretically should result in less disturbance to midfacial growth. A total of 608 patients will be entered into one of two age categories. Inclusion of two age groups will allow a comparison of results between patients having surgery before 1 year of age (9–12 months) and patients undergoing surgery at approximately 1.5 years of age (15–18 months). Speech data will be collected and will be available for definitive analysis throughout the last 3 years of the study. Collection of preliminary growth data will require more than 5 years; growth analysis is anticipated to continue until all patients have reached maturity. The Hospital for Research and Rehabilitation of Patients with Cleft Lip and Palate at the University of São Paulo (USP-HPRLLP) in Bauru, Brazil, is uniquely situated for conducting this study. The well-equipped and modern facilities are staffed by well-trained specialists representing all disciplines in cleft-palate management. In addition, an already existing social services network throughout Brazil will ensure excellent follow-up of study cases. The clinical caseload at this institution currently exceeds 22,000, and more than 1200 new cases are added annually. This project represents a unique opportunity to obtain prospective data from a large number of subjects while controlling the variables that have traditionally plagued cleft-palate studies. This study is designed to determine which of the two proposed surgical procedures is superior in constructing a velum capable of affecting velopharyngeal competency for the development of normal speech.