Segmental hepatic resection utilizing the ultrasonic dissector

Hepatic resection continues to become a more widely accepted therapeutic modality, with increased use as improved imaging modalities more precisely define the nature and extent of various liver abnormalities. The surgical anatomy of the liver indicates that there are eight segments with single or multiple segmental resections able to be performed. The use of the ultrasonic dissector facilitates the performance of transparenchymatous segmental resection without obtaining vascular inflow or outflow control. This report describes the segmental anatomy of the liver and the use of the ultrasonic dissector. Thirteen patients have undergone segmental hepatic resection with the ultrasonic dissector. Five patients had cirrhosis. Mean +/- 1 SD operative time required for segmental resection was 128 +/- 57 minutes, and blood loss was 830 +/- 623 mL. Utilization of the ultrasonic dissector to perform segmental hepatic resection may increase our versatility in the management of various hepatic and biliary tract diseases.     

Responsibility and autonomous nursing practice

In this paper, the consequences were there greater autonomy in nursing practice, are considered. Autonomous practice implies accountability which entails both personal and professional responsibility: a personal responsibility to endorse ethical conduct consistent with professional practice; and a professional responsibility to exercise discretionary powers to the ultimate benefit of the patient. In this context, discretionary responsibility implies: recognizing a patient's wants may not be consistent with a patient's needs; abstaining from collusion with noncompliant patients; supporting the patient's right to refuse treatment only after full psychological exploration; understanding the psychological ramifications of informed consent from a practitioner and recipient point of view; maintaining appropriate personal and professional boundaries; and fostering collegiate relationships with the medical fraternity grounded on egalitarian principles. The author provides a philosophical and psychological analysis of responsibility in an effort to achieve a deeper understanding of the relationship this has with the concepts of 'freedom' and 'accountability'.     

Pregnant women's working conditions and their changes during pregnancy: a national study in France

In a study of 2387 employed women who had worked for more than three months of their pregnancy the data were extracted from a survey carried out on a national sample of births in France in 1981. Manual, service and shop workers had a higher preterm delivery rate than professional, administrative, or clerical workers. Assembly line work was associated with a higher preterm delivery rate even when production workers only were considered. Cumulated physically tiring working conditions--standing work, carrying of heavy loads, assembly line work, and considerable physical effort--were related to higher preterm delivery and low birthweight rate. During pregnancy, sickness absences were commoner when the working conditions were arduous. Changes in the working conditions were less clearly related to arduous work than sick leaves; they were not significantly more frequent for standing work or for assembly line work. Refusals from employers to grant favourable arrangements were more frequent when the working conditions were tiring and sick leaves were more common among women whose requests had been refused.     

Paramedic versus nurse crews in the helicopter transport of trauma patients

INTRODUCTION: A wide variety of opinions exist about using paramedics on flight teams, most of which have not been substantiated by research findings. This study was conducted to explore the outcomes of patients transported by helicopter crews that consisted of either two nurses or a nurse and a paramedic. METHODS: Using data from the New York State Trauma Registry and prehospital care reports, a retrospective comparison was made between the outcomes of 1193 air medical patients transported either by crews consisting of two nurses (N/N) or a nurse and a paramedic (N/P). The sample included blunt and penetrating trauma patients with an Injury Severity Score greater than or equal to 9 and who were older than 16 years. RESULTS: The findings indicate the percentages of patients who lived, died, or were discharged home or to rehabilitation were similar for N/P and N/N groups. Using TRISS methodology and the Z statistic, no statistically significant difference was found in observed versus predicted mortality for both groups (P <.05). CONCLUSION: No significant difference existed in patient outcomes between N/P and N/N crews.     

The Total Health Care Audit System: a systematic methodology for clinical practice evaluation and development in NHS provider organizations

Writing in Medical Education in 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black & Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that 'many doctors did not understand how to undertake audit', and major research by both Hopkins (1993, 1994) and Buttery et al. (1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider organizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore disturbing that methodological deficiencies may still be observed in general approaches to audit (Buttery et al. 1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first time.     

Attention-Deficit/Hyperactivity Disorder: A Neurodevelopmental Approach

TOPIC. Attention-deficitlhyperactivity disorder is frequently overdiagnosed when a complete evaluation by a knowledgeable clinician is not undertaken. Because of the recent negative media campaign regarding psychos t im ulan t medication, it becomes more imperative that a thorough and accurate evaluation be completed before starting children and adolescents on psychostimulant medications.
PURPOSE. To describe the neurodevelopmental perspective in the assessment and treatment of ADHD.
SOURCES. Published literature and clinical experience.
CONCLUSION. It is useful in practice to conceptualize the dmelopmental path of children with ADHD not as disordered but as delayed, and to build on each child's strengths. The neurodmeloprnental approach provides the child psychiatric nurse a child-focused framework for assessment and development of individualized interventions.     

Impact of a Negative Evaluation for Underlying Coronary Artery Disease on One-year Resource Utilization for Patients Admitted with Potential Acute Coronary Syndromes

Reduction in emergency department (ED) overcrowding is a major Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiative. One major source of ED overcrowding is patients waiting for telemetry beds. OBJECTIVE: To determine whether, in patients admitted with a potential acute coronary syndrome, a negative evaluation for underlying coronary artery disease would reduce ED and hospital revisits over the subsequent year compared with patients who did not receive an evaluation for underlying coronary artery disease. METHODS: Nine hundred ninety-nine consecutive patients admitted for potential acute coronary syndromes through the ED during a one-year period were screened for inclusion. Patients who had a negative evaluation for underlying coronary disease were compared with patients who were not evaluated for underlying coronary artery disease for subsequent ED visits, hospital admissions, and cardiac resource utilization over the year following the index visit via a health system-wide computerized record review. Patients with positive tests or biomarkers at the index visit were excluded. Each repeat visit was rated as "potentially cardiac" or "noncardiac." Results of echocardiograms, stress tests, and catheterizations and information about in-hospital deaths were obtained. RESULTS: Six hundred ninety-two patients met the inclusion criteria: 556 patients received no evaluation for underlying coronary artery disease, 116 had a negative stress test, and 20 had a negative cardiac catheterization during the index visit. Patients with no evaluation for underlying coronary artery disease and patients with a negative evaluation had similar likelihoods of a repeat ED visit (negative test 39.0% vs. no test 40.3%; p = 0.85) and repeat hospital admission (28.7% vs. 31.5%; p = 0.61). The rates of a potentially cardiac-related ED visit (21.3 vs. 23.4%; p = 0.65) and hospital admission (17.7% vs. 20.7%; p = 0.48) were not significantly different. The two populations had similar utilization rates of echocardiograms, stress tests, and catheterizations (p > 0.70 for all). CONCLUSIONS: For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.     

Nurses' attitudes towards aggressive behaviour, following attendance at 'The Prevention and Management of Aggressive Behaviour Programme'

The issue of aggression and violence is current in society Recent reports indicate that this is not just an issue for society at large, but also for its organizations and institutions The health care industry is no exception in this regard Nursing, among other disciplines, has focused an increasing amount of attention on this problem for its members This is evidenced by the increasing amount of literature on the topic One feature of this writing is the study of programmes designed to train professionals in techniques to prevent and manage aggression and violence To date, little attention has been paid to the evaluation of such programmes In these times of economic difficulty, this position cannot be supported This paper describes the study of one such educational programme In this case the evaluation focused on the study of attitude change in participants following attendance at'The Prevention and Management of Aggressive Behaviour Programme'Although the indications are that the programme had a positive effect on attitudes, the author concludes that further study is required to illuminate the statistical significance of this positivity