조기정신증 대상자를 위한 지역사회기반 사례관리 경험

학위논문 (석사)-- 서울대학교 대학원 : 간호학과, 2017. 2. 최희승.전 세계적으로 정신병을 조기에 발견하고 치료하기 위한 관심이 높아지고 있다. 2011년 서울시 광역정신건강증진센터는 지역사회 기반의 조기정신증 사례관리 프로그램(Social Treatment for Early Psychosis Program:이하 STEP 프로그램)을 개발하였지만 아직까지 국내에서 조기정신증에 대한 연구는 미진한 상태이다. 이에 본 연구는 STEP 프로그램을 적용하는 사례관리자의 경험을 질적 내용분석 방법으로 분석하여, 지역사회에서 조기정신증 대상자를 위한 사례관리 활성화 방안을 모색하고 실무적 기초자료를 마련하고자 한다. 본 연구는 2016년 7월부터 2016년 10월까지 서울시 정신건강증진센터에서 1년 이상 조기정신증 사례관리를 담당하고 있는 정신보건전문요원 10명을 대상으로 진행되었다. 면담 질문은 조기정신증 사례관리에 영향을 주는 사례관리자 요인, 대상자 요인, 구조적 요인, 네트워크 요인으로 구분하여 진행하였고 인터뷰 내용은 연구 참여자의 동의하에 녹음되고 필사되었다. 주요 연구결과는 다음과 같다. STEP 실무자 교육을 통해 조기개입의 중요성을 인식한 사례관리자는 STEP 프로그램을 실무에 적용하기 위해 전문적인 역량을 개발하고 대상자와 라포를 형성하기 위해 정상화(Normalization) 기법을 적용하고 있었다. 이와 같은 사례관리자의 노력이 소진이 아닌 열정으로 이어지면, 사례관리자는 대상자의 빠른 회복을 통해 보람을 느꼈고 대상자와 함께 사례관리자도 성장하는 경험을 하였다. 대상자 요인에는 자녀의 질병을 인정하지 않는 부모가 장애요인이 되는 반면, 프로그램 내에서 만난 동료들이 정서적인 지지와 회복 모델을 제공하고 있었다. 또한 대상자의 욕구와 기능수준에 따른 차별적인 사례관리가 요구되었으며, 약물 중단으로 인한 잦은 재발과 높은 자살사고로 인해 정신과적인 위기가 자주 발생하고 있었다. 구조적 요인에는 상임팀장의 관심과 지원이 긍정적인 역할을 하고 있었다. 반면, 서울시 지역정신건강증진센터는 정신보건의료기관과의 협력관계에 어려움을 경험하고 있었고, 지역사회 조기정신증 사업의 지속성과 체계성의 부족이 한계점으로 지적되었다. 네트워크 요인으로 서울시 광역정신건강증진센터는 사례관리자의 역량강화를 위해 전문적인 매뉴얼과 교육을 제공하고 지역사회의 사례관리 기반을 마련하고 있었다. 정부차원으로는 사례관리자의 열악한 직무환경과 정신질환에 대한 대중의 부정적인 인식을 개선하고 조기정신증에 특화된 정신보건시스템을 구축해야 한다는 필요성이 제기되었다. 본 연구는 지역사회에서 조기정신증 사례관리자의 경험을 4가지 요인을 통해 확인하였고, 각 요인에 대한 이해를 제공하였다. 이는 지역사회에서 STEP 프로그램이 활성화되고 조기정신증 대상자를 위한 효과적인 사례관리를 제공할 수 있는 근거가 될 것이다. 주요어: 사례관리, 조기정신증, 지역사회 학 번: 2012-20432Ⅰ. 서론 1 1.1 연구의 필요성 1 2.1 연구의 목적 4 3.1 용어의 정의 4 Ⅱ. 문헌고찰 5 1.1 조기정신증 5 1.1.1 조기개입 5 1.1.2 미치료 기간(Duration of Untreated Psychosis : DUP) 7 2.1 사례관리 9 2.1.1 사례관리의 개념 9 2.1.2 사례관리 모델 10 2.1.3 사례관리 구성요소 13 2.1.4.정신건강증진센터에서의 사례관리 14 3.1 조기개입 서비스 18 3.1.1.해외 조기개입 서비스 19 3.1.2 국내 조기개입 서비스 20 3.1.3 STEP(Social Treatment for Early Psychosis Program) 22 Ⅲ. 연구방법 26 1.1 연구 참여자 선정 26 2.1 자료 수집 방법 26 3.1 윤리적 고려 28 4.1 자료 분석 방법 28 Ⅳ. 연구결과 31 1.1 연구 참여자의 일반적 특성 31 2.1 조기정신증 사례관리 경험과 관련된 범주 32 2.1.1.사례관리자 요인 33 2.1.2 대상자 요인 38 2.1.3 구조적 요인 42 2.1.4 네트워크 요인 45 Ⅴ. 논의 52 1.1 사례관리자 요인 52 2.1 대상자 요인 56 3.1 구조적 요인 61 4.1 네트워크 요인 65 Ⅵ. 결론 및 제언 76 참고문헌 79 부록 96 Abstract 98Maste

Changing trends of infective endocarditis according to the change in health care system in Korea

Background: In July 2000, there was a dramatic change in Korean health care system with the medical reform, the separation system of pharmacies and prescriptions. Before then, patients could easily get antibiotics without doctors’ prescriptions. Since the symptoms and signs of infective endocarditis are very nonspecific, prior self treatment with antibiotics before admission was common. This study was performed to determine the changing trends of infective endocarditis according to the change in health care system. Methods: One hundred eighty eight patients from 8 different medical institutions were included. Medical records were reviewed retrospectively for each patient who was diagnosed as infective endocarditis by Modified Duke criteria. Patients were separated into two different groups (Group I : patients diagnosed before July 2000, Group II : patients diagnosed after November 2000). Clinical characteristics, blood culture positivity, and in-hospital mortality were compared. Results: There was no difference in clinical manifestation between two groups other than malaise. Blood culture positivity was 57.4% in group I and 71.1% in group II. Blood culture positivity was significantly higher in group II (p=0.038). In-hospital mortality tends to be lower in group II, which was 22.3% in group I and 12.9% in group II (p=0.066). The relationship between higher blood culture positivity and lower in-hospital mortality couldn’t be clarified. Conclusion: There was an increase in blood culture positivity and a tendency to decrease in in-hospital mortality after July, 2000, possibly due to health care reform. This, to my knowledge, is the first effort to investigate the changing trends of an actual clinical disease according to the change in health care system.ope

Epidemiology of HIV/AIDS in East Asia

Background:Recent predictions of catastrophic epidemic surge of HIV infection in East Asia concern experts and governmental organizations. As in many other areas, countries in East Asia show diversities in their HIV epidemics, both geographically and temporally. However, they have similar regional, cultural and racial characteristics which allow them to have certain common factors. Having a clear picture of the current extent and feature of HIV/AIDS in this region is a very difficult task largely due to the fast pacing of expending epidemic and difficulty in data-sharing among countries in the region. Hence, we decided to study the epidemiologic feature of HIV/AIDS in East Asia through East Asia Network on HIV (EAN-HIV). Materials and Methods:The epidemiological patterns of HIV/AIDS in East Asian countries were investigated by collecting data through EAN-HIV. Results:The HIV/AIDS epidemic in East Asia started relatively late at mid 1980s. Since then, the number of newly infected HIV/AIDS cases has been steadily increasing with stiffer escalation in recent years. In China and Taiwan, IDU plays an important part in the swiftly growing HIV epidemics; however, in other regions like Korea, Japan, and Hong Kong, MSM (men who have sex with men) seems to be more of a problem. The major subtypes of HIV in East Asia are subtype B, C, and CRF01_AE, and rapidly evolving circulating recombinant forms (CRF) between subtypes such as CRF07_BC give dynamic change to the current status. Conclusion:The incidence of HIV/AIDS is rapidly increasing in East Asia. The epidemic pattern has undergone dynamic changes over time. China seems to be the leading source of HIV/AIDS epidemic in East Asia due to its large population and rapidly growing epidemics.ope

Ovarian Cystadenofibroma in a Patient with Familial Adenomatous Polyposis

Familial adenomatous polyposis (FAP) is a hereditary disease characterized by the appearance of numerous polyps in the large bowel with a high potential for malignant transformation unless untreated. A variety of extracolonic manifestations were reported such as osteoma, epidermoid cyst, desmoid tumor, gastroduodenal polyps, small bowel tumor, congenital hypertrophy of the retinal pigment epithelium, hepatobiliary tumor, thyroid tumor, and tumor of 12 the central nervous system. However, the ovarian involvement of FAP as an extracolonic manifestation was very rare and there have been only few reports. We experienced a rare case of ovarian cystadenofibroma in a patient with FAP as an extracolonic manifestation. We also found colon cancer with multiple hepatic metastasis initially manifested as intestinal obstruction in the same patient. Surgical treatment and subsequent chemotherapy for colon cancer and intraoperative radiofrequency ablation of hepatic metastasis were 15 performed.ope

Viral shedding of 2009 pandemic H1N1 and evaluation of quarantine recommendations

Public health authorities recommend that isolation precautions for influenza should be continued for 7 days after illness onset or until 24 h after the resolution of symptoms, whichever event lasts longer. However, little data are available regarding the duration of isolation for patients with 2009 pandemic H1N1 (pH1N1). We recruited patients with confirmed pH1N1 virus infection at a 2,000-bed tertiary care center. Influenza viral loads from oropharyngeal swab specimens were serially determined by reverse transcriptase quantitative polymerase chain reaction every other day, and the risk factors for prolonged viral shedding were investigated. To evaluate the current recommendations for isolation precautions, we measured the intervals between symptom onset and the last viral RNA detection, and that between the last viral RNA detection and the point at which the patient was symptom-free for 24 h. From November 2009 to January 2010, 26 patients were enrolled, and viral RNA was detected in more than half of the eligible patients (10 of 19, 52.6%) for ≥7 days after symptom onset. While evaluating the policy for lifting quarantine, we found that viral RNA was detected in 4 of 15 patients (26.7%) beyond the recommended duration of isolation. In conclusion, viral RNA was detected in a substantial proportion of hospitalized patients even when they fulfilled the recommended conditions for lifting quarantine, and we believe that more prudence is required in this aspect.ope

A Case of Brucellar Spondylitis with Multiple Spine Involvement

Brucellosis, a zoonosis with world wide distribution, is a systemic infection that affects several organs and has protean presentation. Although spondylitis is universally the most common complication of brucellosis and difficult to treat, there is no consensus on the preferred combination of antibiotics use. The authors report a case of a 58-year-old male patient with brucellar spondylitis involving several vertebrae. Diagnosis was made by positive blood culture and magnetic resonance imaging. The authors use a combination method of doxycycline, ciprofloxacin and streptomycin for a period of 3 months. The systemic symptoms were improved after treatment.ope

Clinical features of re-emerging hepatitis A: an analysis of patients hospitalized during an urban epidemic in Korea.

From April 2008 to November 2008, many cases of hepatitis A were reported in Seoul and Gyeonggi Province in Korea. Furthermore, the rate of severe or fulminant hepatitis have significantly increased during the latest epidemic (13.4% vs. 5.2%, p=0.044). Therefore, widespread use of vaccine is warranted to reduce the burden of hepatitis A in Korea.ope

Recurrent Coccidioidomycosis Manifesting as Osteomyelitis in Korea

Coccidioidomycosis is a fungal infection that results from inhaling the airborne arthroconidia of the Coccidioides species. It is an endemic disease in the southwest part of North America and rarely diagnosed in Korea. As tourism to endemic areas and the number of immunocompromised patients have been increasing, the incidence of this infection has increased in non-endemic areas. Treatment is usually successful with antifungal agents; however, recurrence is common. It is difficult to decide when to discontinue the antifungal treatment especially in non-endemic areas where doctors are not familiar with the disease. We report a case of recurrent coccidioidomycosis manifesting as osteomyelitis after the treatment of the patient for disseminated coccidioidal infection. The complement fixation test was a useful tool for the assessment of patient response and to evaluate suspected recurrenceope

Prevalence and Clinical Characteristics of Pulmonary Arterial Hypertension in Human Immunodeficiency Virus-Infected Patients

Background/Aims: Human immunodeficiency virus-associated pulmonary arterial hypertension (HIV-PAH) is a complication of HIV infection. Due to improvements in HIV survival rates following the introduction of highly active antiretroviral therapy, HIV-PAH has become an important cause of HIV-related morbidity. Thus, the objective of this study was to explore the prevalence and characteristics of HIV-PAH. Methods: Ninety-two patients were enrolled in the study from March to August 2010. We investigated clinical characteristics and performed echocardiography. HIV-PAH was defined as having a mean pulmonary arterial pressure (mPAP)≥25 mmHg based on Mahan`s equation, without lung disease or heart disease. The HIV-PAH-possible group was defined as having a tricuspid regurgitation velocity (TRV) of 2.9-3.4 m/s and a pulmonary arterial systolic pressure (PASP) of 37-50 mmHg. Results: Fifteen patients (16.3%) met the criteria of HIV-PAH based on mPAP. With respect to TRV, six patients met the criteria of the HIV-PAH-possible group. Based on the criteria of mPAP, the duration of HIV infection was not different with or without HIV-PAH. HIV RNA titers and CD4 T cell counts tended to be higher in HIV-PAH patients (8,607±11 vs. 1,067±64 copies/mL, p=0.371; 471±148 vs. 499±252 cells/mm3, p=0.680, respectively). Echocardiographic indices of the right ventricle were significantly deteriorated in the HIV-PAH group as compared with the non-HIV-PAH group (TASPE: 20.52 vs. 23.2, p=0.001; Tei index: 0.42 vs. 0.39, p=0.037). In a multivariate regression analysis, HIV activity factors (HIV duration, HIV RNA titer, and CD4 cell count) were not associated with echocardiographic indices of PAH (mPAP, PASP, and pulmonary vascular resistance). Conclusions: In this study, the prevalence of HIV-PAH was comparable to that of previous studies.ope

Prognosis Factors of Clostridium difficile Associated Diarrhea

Background:Clostridium difficile associated diarrhea (CDAD) has a wide range of clinical manifestations. The prognostic factors of CDAD are not fully understood. Materialsand Methods:A retrospective cohort study of 115 patients with CDAD from Aug. 2002 to Dec. 2003 was conducted to evaluate prognostic factors of CDAD. Bacteriologic factors were determined by detecting the binary toxin gene, tcd A, tcd A rep and tcd B gene. Poor prognosis was defined as diarrhea more than 10 days even with classic treatment, recurrence, death, and moribund discharge. Results:Approximately 79% of isolated strains were toxin A+/B+ strains and 21% were toxin A-/B+ strains. There was no difference in prognosis between toxin A+ and toxin A- strains. 39 (33.9%) cases showed poor prognosis and 76 (66.1%) cases showed good prognosis. Univariate analyses revealed that the poor prognostic factors were old age over 70 years old, male, the number of antibiotics used after onset of symptom, the administration of carbapenems, aminoglycosides, glycopeptides after onset of symptom, history of DM and stroke, and high Charlson comorbidity index. Multiple logistic regression analysis identified old age over 70 years old (odds ratio=3.378, P=0.009) and the administration of carbapenems after onset of symptom (odds ratio 7.210, P<0.001) as the independent poor prognostic factors. Conclusion:Old age over 70 and the administration of carbapenems after onset of symptom were the poor prognostic factors for CDAD caused by none-binary toxin producing strains.ope