Experience of primary care among homeless individuals with mental health conditions

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons' needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers

Intraâ abdominal chylovenous bypass treats retroperitoneal lymphangiomatosis

BackgroundRetroperitoneal lymphangiomatosis (RL) is a rare form of primary lymphedema featuring aberrant retroperitoneal lymphatic proliferation. It causes recurrent cellulitis, repeated interventions, and poor life quality. This study aimed to investigate proper diagnositc criteria and surgical outcomes for RL with extremity lymphedema.MethodsBetween 2012 and 2018, 44 primary lowerâ extremity lymphedema cases received lymphoscintigraphy, magnetic resonance imaging, and singleâ photon electron computed tomography to detect RL. RL patients underwent vascularized lymph node transfers (VLNT) for extremity lymphedema and intraâ abdominal sideâ toâ end chylovenous bypasses (CVB) for chylous ascites. Complications, CVB patency, and quality of life were evaluated postoperatively.ResultsSix RL patients (mean age of 30.3 years) had chylous ascites with five had lowerâ extremity lymphedema. All CVBs remained patent, though one required reâ anastomosis, giving a 100% patency rate. Four unilateral and one bilateral extremity lymphedema underwent six VLNTs with 100% flap survival. Patients reported improved quality of life (Pâ =â 0.023), decreased cellulitis incidence (Pâ =â 0.041), and improved mean lymphedema circumference (Pâ =â 0.043). All patients resumed a normal diet and activity.ConclusionsEvaluating primary lowerâ extremity lymphedema patients with MRI and SPECT could reveal a 13.6% prevalence of RL and guide treatment of refractory extremity lymphedema. Intraâ abdominal CVB with VLNT effectively treated RL with chylous ascites and extremity lymphedema.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/152842/1/jso25514.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/152842/2/jso25514_am.pd

Meditation Awareness Training (MAT) for Work-related Wellbeing and Job Performance: A Randomised Controlled Trial

Due to its potential to concurrently improve work-related wellbeing (WRW) and job performance, occupational stakeholders are becoming increasingly interested in the applications of meditation. The present study conducted the first randomized controlled trial to assess the effects of meditation on outcomes relating to both WRW and job performance. Office-based middle-hierarchy managers (n = 152) received an eight-week meditation intervention (Meditation Awareness Training; MAT) or an active control intervention. MAT participants demonstrated significant and sustainable improvements (with strong effect sizes) over control-group participants in levels of work-related stress, job satisfaction, psychological distress, and employer-rated job performance. There are a number of novel implications: (i) meditation can effectuate a perceptual shift in how employees experience their work and psychological environment and may thus constitute a cost-effective WRW intervention, (ii) meditation-based (i.e., present-moment-focussed) working styles may be more effective than goal-based (i.e., future-orientated) working styles, and (iii) meditation may reduce the separation made by employees between their own interests and those of the organizations they work for

A new method for determining physician decision thresholds using empiric, uncertain recommendations

<p>Abstract</p> <p>Background</p> <p>The concept of risk thresholds has been studied in medical decision making for over 30 years. During that time, physicians have been shown to be poor at estimating the probabilities required to use this method. To better assess physician risk thresholds and to more closely model medical decision making, we set out to design and test a method that derives thresholds from actual physician treatment recommendations. Such an approach would avoid the need to ask physicians for estimates of patient risk when trying to determine individual thresholds for treatment. Assessments of physician decision making are increasingly relevant as new data are generated from clinical research. For example, recommendations made in the setting of ocular hypertension are of interest as a large clinical trial has identified new risk factors that should be considered by physicians. Precisely how physicians use this new information when making treatment recommendations has not yet been determined.</p> <p>Results</p> <p>We derived a new method for estimating treatment thresholds using ordinal logistic regression and tested it by asking ophthalmologists to review cases of ocular hypertension before expressing how likely they would be to recommend treatment. Fifty-eight physicians were recruited from the American Glaucoma Society. Demographic information was collected from the participating physicians and the treatment threshold for each physician was estimated. The method was validated by showing that while treatment thresholds varied over a wide range, the most common values were consistent with the 10-15% 5-year risk of glaucoma suggested by expert opinion and decision analysis.</p> <p>Conclusions</p> <p>This method has advantages over prior means of assessing treatment thresholds. It does not require physicians to explicitly estimate patient risk and it allows for uncertainty in the recommendations. These advantages will make it possible to use this method when assessing interventions intended to alter clinical decision making.</p

Rossby wave dynamics of the North Pacific extra-tropical response to El Niño: importance of the basic state in coupled GCMs

The extra-tropical response to El Nino in a "low" horizontal resolution coupled climate model, typical of the Intergovernmental Panel on Climate Change fourth assessment report simulations, is shown to have serious systematic errors. A high resolution configuration of the same model has a much improved response that is similar to observations. The errors in the low resolution model are traced to an incorrect representation of the atmospheric teleconnection mechanism that controls the extra-tropical sea surface temperatures (SSTs) during El Nino. This is due to an unrealistic atmospheric mean state, which changes the propagation characteristics of Rossby waves. These erroneous upper tropospheric circulation anomalies then induce erroneous surface circulation features over the North Pacific. The associated surface wind speed and direction errors create erroneous surface flux and upwelling anomalies which finally lead to the incorrect extra-tropical SST response to El Nino in the low resolution model. This highlights the sensitivity of the climate response to a single link in a chain of complex climatic processes. The correct representation of these processes in the high resolution model indicates the importance of horizontal resolution in resolving such processes

Teaching and learning about dementia in UK medical schools: a national survey

Background: Dementia is an increasingly common condition and all doctors, in both primary and secondary care environments, must be prepared to competently manage patients with this condition. It is unclear whether medical education about dementia is currently fit for purpose. This project surveys and evaluates the nature of teaching and learning about dementia for medical students in the UK. Methods: Electronic questionnaire sent to UK medical schools. Results: 23/31 medical schools responded. All provided some dementia-specific teaching but this focussed more on knowledge and skills than behaviours and attitudes. Only 80% of schools described formal assessment of dementia-specific learning outcomes. There was a widespread failure to adequately engage the multidisciplinary team, patients and carers in teaching, presenting students with a narrow view of the condition. However, some innovative approaches were also highlighted. Conclusions: Although all schools taught about dementia, the deficiencies identified represent a failure to sufficiently equip medical students to care for patients with dementia which, given the prevalence of the condition, does not adequately prepare them for work as doctors. Recommendations for improving undergraduate medical education about dementia are outline

Collegial nests can Foster Critical Thinking, Innovative Ideas, and Scientific Progress.

How can management and strategy scholars organize to generate more productive, more innovative, and more impactful research? With appropriate cultures and leaders, small and egalitarian discussion groups that we call “collegial nests” can become powerful generators of innovative ideas and creators of extraordinary scholars. Collegial nests need cultures that free participants to think critically, to cherish new viewpoints, and to speak freely without fear of ridicule. They also need leaders who model such cultures and facilitate frequent discussions. Two case examples illustrate how productive collegial nests can create better science and better scientists. To generate scientific innovation and progress on a large scale, many autonomous groups tackling related issues are desirable. Modern communication technology is making it feasible for groups to operate over large distances and to coordinate with each other at very low cost. Collegial nests offer greater potential for enhancing scholarly productivity and innovation than do attempts to regulate scholarship via hierarchical structures. Multiplicity can lower the probability of wasting resources on low-yield paths, egalitarian control can reduce the influence of vested interests, and a combination of shared goals and partial autonomy can integrate enthusiasm with sensible risk taking