Specialized Care Facilities Research Articles

Rule 3,000 for Screening Vestibular Schwannoma

To the Editor: We are very grateful to the author(s) of this letter for taking the time to read and respond to our recent editorial (1). With all our respect, some of his arguments are good and deserve careful consideration, although we do not find them compelling. In fact, all our patients received both the hearing test (audiometry) and the reference standard test (magnetic resonance imaging [MRI]). There is no different disease, and the sample is the same. Magnetic resonance imaging was done when the hearing test responds to one of the definition of asymmetric sensorineural hearing loss reported in the literature. The 3,000-Hz frequency was not taken into consideration to decide if an MRI is needed. It is true that the performance of a diagnostic test will be distorted if its result influences whether patients undergo confirmation by the reference standard. This situation, sometimes called "verification bias" or "work-up bias" (2), would apply, for example, when patients with suspected coronary artery disease and positive exercise tests were more likely to undergo coronary angiography (the reference standard) than those with negative exercise tests. In fact, when we did the audiogram and we suspected an asymmetric hearing loss independent of the definition, we asked for MRI. Although audiogram is the first line to exceed, we cannot consider the audiogram as the diagnostic test for vestibular schwannoma (VS); therefore, the verification bias was not violated. However, there is no bias, and we do not agree with the author of this letter. The rule 3,000 is valid for our sample and does not represent the population. The limitation of our study, already mentioned in our article, is the limited number of our sample and the important number of VS referred cases. We are processing a study with a larger number of patients from a population who seeks first-line care by the general practitioner instead of referred patients to a specialized care facility in otolaryngology, and results are promising. A comparison of the different existing definition and the rule 3,000 definition was done. Fortunately, the rule 3,000 shows its superiority to the other definition in terms of sensitivity and specificity. Results will be published shortly. In addition, the 3,000-Hz frequency shows its superiority to the other frequencies and to the speech discrimination level. All MRIs were done independently of the 3,000-Hz asymmetry. Retrospectively, during the analysis of our data, we identified that the rule 3,000 alone is simple, practical to use in our daily consultation screening, and a superior criterion to suspect VS, and MRI is therefore needed. Isaam Saliba, M.D. Department of Otorhinolaryngology Head and Neck Surgery Centre Hospitalier de l'Université de Montréal Montreal University Montreal, Quebec, Canada Geneviève Martineau Centre Hospitalier de l'Université de Montréal Montreal University Montreal, Quebec, Canada Miguel Chagnon, M.Sc. Department of Statistics Montreal University Montreal, Quebec, Canada

Evaluation of special and traditional dementia care in nursing homes: results from a cross‐sectional study in Germany

Two-thirds of all residents in nursing homes in Germany suffer from some type of dementia. We investigated whether or not dementia patients receiving special (segregated or partially segregated) care exhibited a better quality of life than their counterparts residing in traditional nursing homes. In a cross-sectional study in 28 special dementia care facilities in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) 594 residents were compared to a group of nursing home residents with dementia (n = 573) in 11 randomly selected nursing homes who were receiving traditional integrative care. Primary features such as cognitive and functional impairment, and behaviour problems were assessed by qualified nursing staff. Controlling for confounding variables, for dementia patients in special care units as compared to a reference group in traditional integrative care, the level of volunteer caregiver involvement was higher and there was more social contact to staff, fewer physical restraints, more involvement in home activities, and more frequent use of psychiatrists. There was no significant difference between the two care settings with regard to overall use of psychotropic drugs, however, residents in special dementia care used antipsychotics significantly less often and antidepressants more often. Significant differences for a number of indicators of the quality of life point in favour of special dementia care. Future evaluation studies ought to examine not only the general efficacy of types of care designed especially for dementia patients but also the efficacy of the respective individual components (i.e. caregiver ratio).

A survey of the difficulties encountered during routine hygiene and health care by persons with special needs

Purpose. This study aims to evaluate the difficulty experienced during routine hygiene and healthcare in various domains by persons with special needs attending a dental clinic compared to controls.Method. Data were gathered from 98 patients (mean age 18 SD±10.9 years) and 27 control subjects (mean age 17.3 SD±10.6 years) using a 19-item questionnaire of difficulty.Results. Seven acts showed greater difficulty in the study group: cleaning teeth (OR = 15.34; 95% CI: 3.46 – 70.10), washing ears (OR = 7.58; 95% CI: 1.70 – 33.94), dental treatment (OR = 5.54; 95% CI: 2.23 – 13.80), ear examination (OR = 3.80; 95% CI: 1.22 – 11.86), dental examination (OR = 3.06; 95% CI: 1.27 – 7.42), blood tests (OR = 2.58; 95% CI: 1.08 – 6.16) and swallowing a tablet (OR = 2.06; 95% CI: 0.01 – 0.46). Patients treated under sedation expressed significantly greater difficulty without sedation for dental examination (OR = 3.04; 95% CI: 1.21 – 7.65) and dental treatment (OR = 3.87; 95% CI: 1.54 – 9.73).Conclusions. Difficulty encountered in the acceptance of routine hygiene and healthcare could be used as an indicator for the need for Special Care facilities for outpatient treatment. Educational, behavioural and pharmacological procedures that can improve these situations are discussed.

Tontura associada a distúrbio do pânico e agorafobia: relato de caso e revisão da literatura

Tontura é uma das queixas mais freqüentes no consultório médico tanto primário quanto especializado. Muitos dos pacientes que se apresentam com tontura sem causa orgânica aparente, portanto considerados como portadores de tontura idiopática, podem ter um distúrbio psiquiátrico. Além disso, mesmo a tontura de causa orgânica pode desencadear ou exacerbar alterações psiquiátricas "latentes". Um dos distúrbios mais comumente associados à tontura é o Distúrbio do Pânico, com ou sem Agorafobia. O objetivo deste estudo é relatar o caso de uma paciente com essa associação e realizar uma revisão da literatura relacionada ao assunto.

United Kingdom Becomes the Cancer Clinical Trials Recruitment Capital of the World

at a specialized care facility was often longer than 1 month. To address the disparity, the NHS created a cancer care network during the late 1990s by dividing the country into regions and making hospitals and specialists responsible for cancer care within their designated region. Scotland and Wales followed suit. Each region set up a structured referral system, streamlining access to specialized cancer care, Kaplan explained. But these regional cancer care clusters did not coordinate clinical research. That task was added in 2000 when a consortium of health care groups and funding agencies created the NCRN. As part of its overall cancer plan, the U.K. health department joined with other government agencies and large charities to pledge substantial funds to set up the research network’s infrastructure. By 2004, the NHS had allocated an additional £570 million ($1.1 billion) each year to improve patient access to cancer care and boost clinical research.

Measuring Physical and Social Environments in Nursing Homes for People with Middle‐ to Late‐Stage Dementia

To evaluate measures of dementia care environments by comparing a special care facility (SCF) with traditional institutional facilities (TIFs). A cross-sectional comparative study of nursing home environments conducted as part of a longitudinal study on quality of life for residents with dementia. Twenty-four traditional nursing homes and one special care facility. One SCF with six distinct environments, 24 TIFs with 45 distinct environments, and 88 family members. Therapeutic Environment Screening Scale-2+ (TESS-2+); Special Care Unit Environmental Quality Scale (SCUEQS), a subset of the TESS-2+ items; Composite Above Average Quality Score (CAAQS), a composite score of all items on the TESS-2+; and Models of Care Instrument (MOCI). The SCUEQS did not detect a significant difference between the SCF and the TIFs (30.0 vs 27.2, P = .28). The CAAQS detected a significant difference between the SCF and the TIFs, whereby the SCF environments were rated as having above-average quality in 71.4% of the domains, compared with 57.3% for the TIF environments (95% confidence interval (CI) for difference = 2.6-25.6%, P = .02). Using the MOCI, SCF families were 1.8 times as likely to rate the SCF as a home or resort versus a hospital as TIF families rating TIFs (95% CI for odds ratio = 1.5-2.1, P < .001). The TESS-2+ CAAQS differentiated between physical environments better than the more established SCUQES. The MOCI distinguished between environments using a more holistic approach to measurement. The availability of environmental measures that are able to discriminate between specialized and traditional long-term care settings will facilitate future outcome-based research.

Access to specialized health care for asthmatic children in Norway: The significance of parents’ educational background and social network

What determines access to the Voksentoppen Children's Asthma and Allergy Centre, the most specialized health care facility for asthmatic children in Norway? This publicly funded national institution is mandated to serve all segments of the population equally. The paper reports from the experiences of families with children having a confirmed diagnosis of moderate to severe asthma. The study population was selected from a national register of state cash-benefit recipients. Within this register, all families with a child under the age of 9 and with the diagnosis of asthma at the end of 1997 were selected ( N = 2564 ). Further information about the population was gathered in a postal survey. It was found that access to the facility, measured as at least one admission during the period of the disease, was primarily determined by variations in morbidity. In particular, measures of health condition that presupposed a professional's evaluation of the child's health condition were significant. In addition, access was influenced by several factors not directly related to the need for treatment. Notably, children from families in which parents had a graduate education were over-represented among those with access to the top level of the institution's medical hierarchy. Multivariate analysis was used to search for causal mechanisms. It was found that families with a doctor in their social network had greater likelihood of access, and this in part accounted for the observed association between education and access. The pattern of access was also influenced by geographical factors, but not in a way that reduced the significance of educational background. Membership of, and participation in, patient organizations also increased the families’ chances of receiving top-level professional treatment. The results depart from professional norms and officially stated health policy in Norway, which assert that health condition is the only valid criterion for allocating scarce medical goods.

Moving Hospitalized Children All Over the Southeast: Interstate Transfer of Pediatric Patients During Hurricane Katrina

RACTICAL QUESTIONS: The question was, and is, “Can hospitalized children, in a geographic area, have their continuing medical needs met when capacity in that geographic area to provide care is exceeded?” Events after the landfall of Hurricane Katrina on the city of New Orleans, Louisiana, generated significant information about pediatric care delivery during a disaster. In particular, Katrina helped answer 3 key questions regarding the care of children under disaster conditions: 1. In a disaster, will regional capabilities be used to augment local capabilities to care for children? In particular, will there be a preference for bypassing nearby providers of adult care to send pediatric patients to more specialized pediatric care facilities that are more geographically distant? 2. Can the communication and logistic challenges associated with regional pediatric patient movement be overcome during a disaster? 3. Do government disaster plans at the local, state, and federal levels facilitate pediatric patient movement across jurisdictions during a disaster? We will provide a chronological timeline of pediatric activities related to the care of patients in 3 New Orleans hospitals (Tulane University Hospital, Children's Hospital of New Orleans, and Alton Ochsner Foundation Hospital) at the time of Katrina's landfall. After outlining the relevant sequence of activities, we will relate these activities to the 3 questions posed above. Our discussion focuses on New Orleans, because it is an urban center with the highest concentration of pediatric inpatients that were impacted by Katrina. Our timeline is based on selected interviews and publicly available information. Despite the biased, qualitative, and focused nature of the analysis, the New Orleans experience demonstrates the need for significant adjustments in our disaster plans for pediatric care during disasters. Ironically, pediatric health care providers from 5 states had been participating in the Southeastern Regional Pediatric Disaster Response Network for 1 year before Hurricane Katrina in … Address correspondence to Crayton A. Fargason, MD, Children's Hospital of Alabama, ACC Suite 512, 1600 7th Ave S, Birmingham, AL 35233. E-mail: crayton.fargason{at}peds.uab.edu

A Comparison of Three Methods of Measuring Dementia-Specific Quality of Life: Perspectives of Residents, Staff, and Observers

This exploratory study compared three methods of assessing dementia specific quality of life, corresponding to the perspectives of residents, staff members, and trained observers. We collected data on 172 residents with dementia in four special care nursing facilities and three assisted living facilities. Analyses assessed the relationship of each quality-of-life method or perspective to the others and to resident characteristics such as cognitive and functional status. The relationship of staff quality-of-life measures to resident characteristics varied by care setting while no significant relationships were found for resident quality-of-life measures. Staff and observational measures were moderately correlated in both settings. Moderate correlations of resident measures with staff and observational measures were found in the assisted living sample. Each perspective is relatively independent and somewhat unique. Measures that focus on specific aspects of quality of life may be more appropriate to use with assisted living residents than with residents of special care facilities.

Drug utilisation by children and adolescents with mental retardation: a population study

Little is known about the utilisation of drugs by mentally retarded children; population studies are even more sparse. In this study the chronic drug utilisation in children aged 4-18 years with mental retardation in a large population in the Netherlands was investigated. Throughout all special schools and (day) care facilities for children with mental retardation in Friesland, parents/representatives were approached requesting participation of their children. Participants were interviewed about a number of aspects including medication use. For 921 of the 1,057 participants, information was available on medication use for those physical and psychiatric illnesses that bothered them or was expected to bother them for at least 3 months per year; 912 of the participants were within the age category under study: 4-18 years. About 22% of the 912 participants used chronic medication, 47% of whom used two or more drugs. The prevalence of drug use increased with severity of mental retardation from about 17% to 49%. The exception was the 6% of children with borderline intellectual functioning: their medication prevalence was 27%. Overall, 17% of the study population used a nervous system drug, 4% used a respiratory system drug and 3% used an alimentary tract drug. Of the drugs for the nervous system, alimentary tract and respiratory tract, 32% was prescribed off-label. For 3%, we were unable to establish on/off-label use. Chronic drug utilisation patterns in children and adolescents with mental retardation are different from those in the general paediatric population. These different patterns suggest the need for additional research.

Incidence and diagnosis of unilateral arterial cerebral infarction in newborn infants

Magnetic resonance imaging (MRI) is accepted as the gold standard for the diagnosis of arterial cerebral infarction (ACI), but few studies have reported the incidence of neonatal ACI based on MRI findings. We provide new population-based epidemiologic and diagnostic data on all infants diagnosed between 1997 and 2002 in our center with an MRI-confirmed diagnosis of unilateral neonatal ACI. Nine patients were identified, giving an incidence of 1:2300 unilateral ACIs in our inborn population. In all patients the middle cerebral artery was affected. Seven patients showed epileptic seizures, usually starting within the first 3 days of life. EEG was pathologic in all patients. Only three infarctions were diagnosed by ultrasound. Initial MRI established diagnosis of ACI in eight out of nine patients and subsequent MRI described the exact location of infarctions in all patients. Six out of nine patients developed hemiparesis and five had deficits in language development. There is a substantial need for special care facilities and long-term therapeutic interventions. The incidence of neonatal ACI is higher than previously reported. The sensitivity of early cerebral ultrasound for diagnosis of ACI is low. Seizures in the first 3 days of life combined with pathologic EEG findings should lead to MRI, regardless of normal cerebral ultrasound.

Influence of cognitive impairment, functional impairment and care setting on dementia care mapping results

Quality of life (QOL) for people with dementia has become a major focus over the past decade. Dementia care mapping (DCM) is an observational measure of quality of care given by staff in formal care settings, as well as a measure of QOL that has been used in many studies of people with dementia in residential care settings. However, the method itself has not been rigorously studied in a scientific manner. For this report, mapping data were collected for 166 persons with dementia in three types of care settings: special care facilities that are licensed nursing homes, assisted living facilities, and adult day centers. The relationships between DCM and several independent variables including cognitive status, functional status, care setting, depression, length of stay, and co-morbid illnesses were assessed. Both cognitive status and functional status were found to be associated with DCM scores. Moreover, DCM was sensitive in differentiating among persons with four levels of cognitive impairment. Implications for practice are discussed.

Congenital Heart Disease In Adults: A Historical Perspective

Congenital Heart Disease In Adults: A Historical Perspective

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

A Case for Community and Hospital-Based Long-Term Care Facilities in Saudi Arabia

Epidemiology of dementia

Because of the increasing life expectancy during the next decades the number of demented will steeply rise. The estimated number of people suffering from dementia in Austria will increase from 90,500 persons in the year 2000 to 233,800 persons in the year 2050. During the same period the estimated number of those developing a dementia within one year will rise from 23,600 to 59,500. In contrast, in the next five decades, the population being in an employable age will decrease to 77%. Thus, the proportion of demented in relation to employable people will considerably increase. While in year 2000 there were 56 employable persons per one demented person, in the year 2050 there will be only 17 employable persons per one demented person. Dementing disorders are a main reason for being admitted to nursing homes. In Austrian nursing homes 63.5% of those newly admitted suffer from dementia. Despite of the fact that a large proportion of dementia sufferers are being cared in nursing homes, the majority lives in their private households supported by their family members. Relatives of demented persons experience a large amount of burden, and need more professional help than is available today. The costs of dementing disorders are high and a large proportion is paid by the patients family. In the future, in Austria more specialized day care facilities for the demented and more nursing homes are necessary.

Physical and Mental Health Problems and Related Factors of Main Care-Givers of Middle-Aged and Elderly Patients who have been Discharged from a Specialized Care Facility

Physical and Mental Health Problems and Related Factors of Main Care-Givers of Middle-Aged and Elderly Patients who have been Discharged from a Specialized Care Facility

The promise of a good death

The promise of a good death

Strategies for promoting ethical decision-making.

The structured controversy as a strategy for helping the non-licensed caregiver make ethical decisions as well as develop critical thinking skills was an innovative teaching technique. Students in the Homecare/Special care aide program are essential providers of care to residents or clients in a special care facility or in a homecare setting. Theory and practice of ethical decision-making is not usually dealt with in the curriculum of the non-licensed caregiver. Implementation of this approach helped students learn theory and skills necessary when dealing with controversial issues in making ethical decisions. Thompson and Thompson's (1985) ten steps of bioethical decision-making were implemented to assist in the process. Structured controversy was defined and the process of implementing structured controversy outlined. A variety of ethical issues were presented based on the ethical principles of beneficence, justice, autonomy, truthfulness, confidentiality, and integrity (Yeo, 1991). Several definitions of critical thinking are presented.

Chronically exposed calvarium following electrical burns

Electrical burns of the scalp and calvarium are uncommon, but due to various conditions peculiar to India such injuries are seen frequently. The presentation of such patients at hospital is late because of the paucity of specialized care facilities and understanding of the disease process. Such injuries usually cause necrosis of the scalp and underlying calvarium with sequestered bone being retained in situ by the flimsy adhesions of underlying granulation tissue and overhanging edges of the scalp all around caused by secondary wound contraction. This paper gives our experience of 14 such cases, explaining the reasons for the chronic state and their subsequent clinical management.

Should Nutrition and Hydration be Provided to Permanently Comatose and Other Mentally Disabled Persons?

The title of this article can be understood either as a legal or as an ethical question. It is treated only insofar as it is an ethical question--that is, a moral issue.(1) But it is the author's hope that this discussion will contribute to the current debate about what law ought to require in this matter, for, of course, questions about what law should require are, at least in large part, moral questions. In its reflection on moral questions, ethics has a task very different from that of legal studies, which focus on the making and application of social rules. Ethics tries to discover what is good and right for persons and groups of persons, considered insofar as they are agents. In other words, ethics tries to learn the truth about what ways of acting will make persons and communities truly flourish. Thus, the aim of this article is not to try to use ideas and words to channel anyone's behavior, but to articulate the author's own effort to arrive at a sound view on the question, in the hope that doing so will help others who want to know what they ought to do about it. Permanently is understood to refer to all who are in fact permanently unconscious, no matter what their specific condition is or its underlying cause.(2) The author presupposes that even comatose human individuals are persons.(3) For brevity's sake, the single word comatose shall be used to refer to the permanently unconscious, and the single word food to refer to nutrition and hydration. For the purpose of this article, two types of cases are excluded from the discussion: First, sometimes a choice is made to kill someone, and that choice is carried out by withholding food. It seems that this is exactly what has been done in some of the widely publicized cases. Now, if food is withheld precisely in order to kill someone, that calculated omission is homicide and cannot be morally justified. The author has argued this view elsewhere and shall not repeat those arguments here.(4) Second, sometimes a comatose or other mentally disabled person is dying, and providing food will not prolong life or give the person comfort, but perhaps even will increase discomfort. The author agrees with the general consensus that in such cases food should not be provided. Just as is true of any other sort of care or treatment, the reason for providing food is to benefit the person being cared for; therefore, when doing so is no benefit, and perhaps is a burden, it is not reasonable to continue trying to provide food. Also set aside is the method of called total parenteral feeding or hyperalimentation.(5) It differs significantly in its burdens from other methods of and is used in few if any cases to sustain comatose persons. So, it is not considered relevant to the general question to be treated here. Thus, this article concerns only cases of the following sort: no choice is made to kill the comatose or otherwise mentally disabled person, the person is not dying, but the burdens of care and its limited benefits make some or all of those concerned wonder whether it is right to continue providing food. A Change of Mind In 1986, the author published a lecture which dealt with the issue of persons who are comatose. That lecture stated: If a patient is not in imminent danger of death but is in an irreversible coma, as the late Miss Karen Quinlan was, life-support care more sophisticated than ordinary nursing care is very costly. It seems to me that such costly care exceeds a permanently comatose person's fair share of available facilities and services. Thus, I believe that when Miss Quinlan was removed from intensive care, she ought not to have been placed in a special care facility, but should instead have been sent home or cared for in the hospital with only the sorts of equipment and services available in an ordinary household. …