The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study.

OBJECTIVE: To identify the factors that promote and compromise the implementation of reasonably adjusted healthcare services for patients with intellectual disabilities in acute National Health Service (NHS) hospitals. DESIGN: A mixed-methods study involving interviews, questionnaires and participant observation (July 2011-March 2013). SETTING: Six acute NHS hospital trusts in England. METHODS: Reasonable adjustments for people with intellectual disabilities were identified through the literature. Data were collected on implementation and staff understanding of these adjustments. RESULTS: Data collected included staff questionnaires (n=990), staff interviews (n=68), interviews with adults with intellectual disabilities (n=33), questionnaires (n=88) and interviews (n=37) with carers of patients with intellectual disabilities, and expert panel discussions (n=42). Hospital strategies that supported implementation of reasonable adjustments did not reliably translate into consistent provision of such adjustments. Good practice often depended on the knowledge, understanding and flexibility of individual staff and teams, leading to the delivery of reasonable adjustments being haphazard throughout the organisation. Major barriers included: lack of effective systems for identifying and flagging patients with intellectual disabilities, lack of staff understanding of the reasonable adjustments that may be needed, lack of clear lines of responsibility and accountability for implementing reasonable adjustments, and lack of allocation of additional funding and resources. Key enablers were the Intellectual Disability Liaison Nurse and the ward manager. CONCLUSIONS: The evidence suggests that ward culture, staff attitudes and staff knowledge are crucial in ensuring that hospital services are accessible to vulnerable patients. The authors suggest that flagging the need for specific reasonable adjustments, rather than the vulnerable condition itself, may address some of the barriers. Further research is recommended that describes and quantifies the most frequently needed reasonable adjustments within the hospital pathways of vulnerable patient groups, and the most effective organisational infrastructure required to guarantee their use, together with resource implications

Ελληνες Σαολιν: Δυναμικες και Ορια του Πολιτισμικου Υβριδισμου στην Ελλαδα

Οι εξατομικευμένες μορφές συγκρότησης του σύγχρονου πολιτισμικού πεδίου σχετικοποιουν τα όρια μεταξυ των πολιτισμών με αποτέλεσμα τη διαμόρφωση υβριδικών πολιτισμικών ταυτοτητων. Οι πολιτισμικές κατηγορίες της Δύσης και της Ανατολής συναντώνται δημιουργώντας το φαινόμενο του εξανατολισμου της Δύσης, έχοντας το Σαολιν ως παράδειγμαThe ibdividualized forms of the construction of the contemporary cultural field relationalize the limitsbof cultures by leading in the formation of hybrid cultural identities. The cultural categories of the West and the East encounter and create the phenomenon of the easternization of the West. Shaolin kung fu may be considered as a practic of the phenomena above

Η ένταξη της εκ των προτέρων αθέτησης (anticipatory breach) στο αγγλικό δίκαιο των συμβάσεων σε σύγκριση με το ελληνικό αστικό δίκαιο

Αντικείμενο της παρούσας διπλωματικής εργασίας αποτελεί η ένταξη της εκ των προτέρων αθέτησης (anticipatory breach) στο αγγλικό δίκαιο των συμβάσεων σε σύγκριση με το ελληνικό αστικό δίκαιο. Στο πρώτο μέρος, γίνεται μια συνοπτική παρουσίαση του αγγλοσαξονικού δικαίου και συγκεκριμένα των γενικών χαρακτηριστικών και των πηγών του, ενώ γίνεται αναφορά και στην έννοια της σύμβασης, όπως αυτή γίνεται αντιληπτή στο αγγλοσαξονικό δίκαιο. Στο δεύτερο μέρος, παρουσιάζεται η αθέτηση της σύμβασης, γνωστή και ως breach of contract, στο αγγλικό δίκαιο. Συγκεκριμένα γίνεται λόγος για το ενιαίο σύστημα της ανώμαλης εξέλιξης της ενοχής, ενώ παρακάτω παρουσιάζονται η υπαιτιότητα, οι συνέπειες της αθέτησης σύμβασης καθώς και τα δικαιώματα των μερών. Στο τρίτο μέρος, παρουσιάζεται ειδικότερα η εκ των προτέρων αθέτηση σύμβασης, γνωστή και ως anticipatory breach, καθώς και πως αυτή εντάσσεται στην γενικότερη έννοια της αθέτησης σύμβασης (breach of contract) στο αγγλικό δίκαιο. Αρχικά, γίνεται λόγος για την έννοια και τις μορφές της anticipatory breach, ενώ στη συνέχεια παρουσιάζονται ειδικότερα τα δικαιώματα των μερών σε περίπτωση όπου υφίσταται anticipatory breach στο αγγλικό δίκαιο. Στο τέταρτο μέρος παρουσιάζεται η εκ των προτέρων (ή προκαταβολική) αθέτηση σύμβασης στο ελληνικό δίκαιο. Συγκεκριμένα γίνεται αναφορά στο περιπτωσιολογικό σύστημα της ανώμαλης εξέλιξης της ενοχής του ελληνικού δικαίου, ενώ παρακάτω παρουσιάζεται η νομική θεμελίωση της εκ των προτέρων αθέτησης στο ελληνικό δίκαιο, οι έννομες συνέπειες και τα δικαιώματα του δανειστή. Τέλος, παρουσιάζονται οι ρυθμισμένες στον ελληνικό Αστικό Κώδικα περιπτώσεις προκαταβολικής αθέτησης και συγκεκριμένα οι διατάξεις ΑΚ 386 και 686

The usefulness of a free self-test for screening albuminuria in the general population: a cross-sectional survey

<p>Abstract</p> <p>Background</p> <p>In this study we evaluated the usefulness of a free self-test for screening albuminuria in the general population.</p> <p>Methods</p> <p>Dutch adults were invited by the Dutch Kidney Foundation to order a free albuminuria self-test, consisting of three semi quantitative dipstick tests, via the Internet. Results were classified in negative, low-positive and high-positive. In case of a positive test result, the tester was recommended to visit a GP for supplementary examination and/or treatment. Participants of the programme were sent a questionnaire for evaluation by e-mail eight weeks after receiving the self-test.</p> <p>Results</p> <p>During the first 30 days of the self-test programme, 996,927 self-tests were ordered. In total, 71,714 participants completed the questionnaire: 79% had a negative test result and 21% had a positive test result (20% low-positive and 1% high-positive). Of the positive testers, 25% visited a GP after testing for albuminuria. Among the 3,983 participants who visited a GP, 193 new diseases were detected: 25 chronic renal failure, 152 hypertension and 31 diabetes mellitus.</p> <p>Conclusion</p> <p>Using a free self-test for screening albuminuria in the general population resulted in a large response and a number of newly detected diseases. However, we found a very high percentage of positive testers of which probably a large part is false positive. Furthermore, only a small part of the positive testers visited a GP for additional examination and/or treatment. The efficiency of such a campaign could be increased by embedding the testing in health care to reduce the number of false-positive results and to ensure follow-up and treatment in case of a positive test result.</p

Intradialytic hyperalimentation as adjuvant support in pregnant hemodialysis patients: case report and review of the literature

Pregnancy in chronic dialysis patients is unusual and associated with many complications. Infants are often born both prematurely and small for gestational age. We report a case of a 36-year-old diabetic hemodialysis patient G4P3 who had prolonged hyperemesis gravidarum, for whom intradialytic parenteral nutrition (IDPN) was started at week 14 and continued throughout her pregnancy. She delivered a 3.5-kg baby girl at the 36th week of gestation by cesarean section. We discuss the use of IDPN as adjunct therapy for pregnant dialysis patients

Low documentation of chronic kidney disease among high-risk patients in a managed care population: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Early detection of chronic kidney disease (CKD) is sub-optimal among the general population and among high risk patients. The prevalence and impact of major CKD risk factors, diabetes (DM) and hypertension (HTN), on CKD documentation among managed care populations have not been previously reported. We examined this issue in a Kaiser Permanente Georgia (KPG) CKD cohort.</p> <p>Methods</p> <p>KPG enrollees were included in the CKD cohort if they had eGFRs between 60 and 365 days apart that were <90 ml/min during 1999-2006. The current analysis is restricted to participants with eGFR 10-59 ml/min/1.73 m². CKD documentation was defined as a presenting diagnosis of CKD by a primary care physician or nephrologist using ICD-9 event codes. The association between CKD documentation and DM and HTN were assessed with multivariate logistic regression models.</p> <p>Results</p> <p>Of the 50,438 subjects within the overall KPG CKD cohort, 20% (N = 10,266) were eligible for inclusion in the current analysis. Overall, CKD diagnosis documentation was low; only 14.4% of subjects had an event-based CKD diagnosis at baseline. Gender and types 2 diabetes interacted on CKD documentation. The prevalence of CKD documentation increased with the presence of hypertension and/or type 2 diabetes, but type 2 diabetes had a lower effect on CKD documentation. In multivariate analysis, significant predictors of CKD documentation were eGFR, hypertension, type 2 diabetes, congestive heart failure, peripheral artery disease, statin use, age and gender. CKD documentation was lower among women than similarly affected men.</p> <p>Conclusion</p> <p>Among patients with an eGFR 10-59, documentation of CKD diagnosis by primary and subspecialty providers is low within a managed care patient cohort. Gender disparities in CKD documentation observed in the general population were also present among KPG CKD enrollees.</p

The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study.

BACKGROUND: There has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors. METHODS: This was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities. RESULTS: Staff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders. CONCLUSIONS: The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents, and may be difficult to attribute as causal to the harm suffered. Acts of omission (failure to give care) are more difficult to recognise, capture and monitor than acts of commission (giving the wrong care). In order to improve patient safety for this group, the reasonable adjustments needed by individual patients should be identified, documented and monitored

Lessons learned from the London Exercise and Pregnant (LEAP) Smokers randomised controlled trial process evaluation : implications for the design of physical activity for smoking cessation interventions during pregnancy

BACKGROUND: The challenges of delivering interventions for pregnant smokers have been poorly documented. Also, the process of promoting a physical activity intervention for pregnant smokers has not been previously recorded. This study describes the experiences of researchers conducting a randomised controlled trial of physical activity as an aid to smoking cessation during pregnancy and explores how the effectiveness of future interventions could be improved. METHODS: Two focus groups, with independent facilitators, were conducted with six researchers who had enrolled pregnant smokers in the LEAP trial, provided the interventions, and administered the research measures. Topics included recruitment, retention and how the physical activity intervention for pregnant smokers was delivered and how it was adapted when necessary to suit the women. The focus groups were audio-recorded, transcribed verbatim and subjected to thematic analysis. RESULTS: Five themes emerged related to barriers or enablers to intervention delivery: (1) nature of the intervention; (2) personal characteristics of trial participants; (3) practical issues; (4) researchers' engagement with participants; (5) training and support needs. Researchers perceived that participants may have been deterred by the intensive and generic nature of the intervention and the need to simultaneously quit smoking and increase physical activity. Women also appeared hampered by pregnancy ailments, social deprivation, and poor mental health. Researchers observed that their status as health professionals was valued by participants but it was challenging to maintain contact with participants. Training and support needs were identified for dealing with pregnant teenagers, participants' friends and family, and post-natal return to smoking. CONCLUSIONS: Future exercise interventions for smoking cessation in pregnancy may benefit by increased tailoring of the intervention to the characteristics of the women, including their psychological profile, socio-economic background, pregnancy ailments and exercise preferences. Delivering an effective physical activity intervention for smoking cessation in pregnancy may require more comprehensive training for those delivering the intervention, particularly with regard to dealing with teenage smokers and smokers' friends and family, as well as for avoiding post-natal return to smoking. TRIAL REGISTRATION: ISRCTN48600346 , date of registration: 21/07/2008

Exercise interventions for smoking cessation

Background Taking regular exercise, whether cardiovascular‐type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain. Objectives To determine the effectiveness of exercise‐based interventions alone, or combined with a smoking cessation programme, for achieving long‐term smoking cessation, compared with a smoking cessation intervention alone or other non‐exercise intervention. Search methods We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019. Selection criteria We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non‐exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow‐up of at least six months. Data collection and analysis We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention‐to‐treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta‐analyses where appropriate, using Mantel‐Haenszel random‐effects models. Main results We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group‐based cardiovascular‐type exercise supplemented by a home‐based exercise programme and combined with a multi‐session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi‐session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low‐certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I2 = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular‐type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular‐type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low‐certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long‐term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I2 = 0%; 453 participants). Authors' conclusions There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.PLAIN LANGUAGE SUMMARY: Can exercise help people quit smoking? Background We reviewed the evidence about whether exercise helps people who want to quit smoking, or have recently stopped smoking, to stop smoking for at least six months. Taking regular exercise may help people give up smoking by helping with cigarette withdrawal and cravings, and by helping them to manage weight gain, which can be a concern among people trying to quit. Study characteristics We found 24 studies with a total of 7279 people. Two studies focused on helping those who had recently stopped smoking and the rest of the studies included current smokers who wished to quit. All the studies were conducted with adults. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most studies offered supervised and group‐based, aerobic‐type exercise. The evidence is up‐to‐date to May 2019. Key results When we combined the results of 21 studies (6607 participants) which compared exercise and smoking‐cessation programmes to smoking cessation programmes alone, there was no evidence that exercise increased quit rates at six months or longer. There was no evidence that the effect was different for different types of exercise. When we combined results from two studies (453 participants), there was no evidence that exercise helped people who had recently quit to stay quit. Quality of evidence We judged the quality of evidence for whether exercise programmes help people quit smoking as low certainty, suggesting that future research could change these results. The low certainty is because we cannot rule out chance as an explanation for the suggested slight benefit. It could be that exercise may not help at all, or it could be that supporting people to do exercise modestly increases quit rates. We do not know which of these is true. We also consider that a good number of the trials may be biased. We have concerns that small studies which found smaller effects were less likely to be published than small studies which found bigger effects, making the average result misleading. We judged the evidence from two studies examining whether exercise helps people to avoid relapse to smoking to be of very low certainty, again suggesting that more research is needed. This is due to imprecision of the estimated effects and a high risk of bias in the methods used by one of the studies