Role of the School Eye Clinic in Modern Ophthalmology

Routine sight tests for children at intervals throughout their school career are clearly important; three-quarters of those referred to the school eye clinics in this area had some ocular defect. It is probably no longer necessary for myopic schoolchildren to be treated by a consultant ophthalmologist after their initial examination.Forty-five per cent. of children referred to the school eye clinics in this area were found to have squint and/or hypermetropic/anisometropic/astigmatic refractive errors. Priority should be given to this group because of the association of amblyopia with these conditions. Their treatment requires closer association with the hospital ophthalmic department, perhaps even complete unity. Transfer of children at present seen in the school eye clinic to a hospital-based “children''s eye clinic” would also fit in with a unified health service administration structure and be better placed to indicate, evaluate, and control future developments towards the prevention of amblyopia.     

MENTAL HEALTH—A Discussion of Various Program Approaches Used in California and the Basic Assumptions Involved

The nation''s Number One health problem, mental illness, compels careful reevaluation of past and current methods of attack. It also invites consideration of the ways and means of integrating preventive measures that emphasize the conservation of mental health with prophylactic efforts that stress the avoidance of mental illnesses.A review of the development of both local and statewide mental health programs in California reveals that three fundamentally different approaches have been used: (1) The traditional approach which confines itself to the protection of society from the “insane” by the state, and to the treatment of those who are not legally insane through “private enterprise”; (2) the public health approach which seeks to minimize the causes and/or spread of selected types of psychiatric disorder regarded as mass phenomena; and (3) the sociological approach which stresses the importance of social factors both in the causation and in the rehabilitation of those mental conditions that are considered to be symptomatic of a “sick” society.An approach that combines the theoretical and practical implications of all three viewpoints offers some new solutions to the problems of (1) fitting mental health programs to populations; (2) financing; and (3) balancing preventive and clinical services.Mental illness is not a single disease-entity but a long list of distinctly different conditions. The causes and manifestations are multiple. Biological, psychological and social components in either mental health or mental illness cannot be dissociated in any attempt to understand and deal with so wide a range of illnesses and states of comparative health. Therefore, many professions and multiple public and private agencies are involved in planning, developing and administering a mental health program.     

Evaluation of Health Centre Community Nurse Team

This report gives an account of the work during six months of a community nurse team attached to the doctors working from a new health centre. The team consisted of two community nurses, who had both health visiting and Queen''s nursing qualifications, and a State-enrolled nurse. The community nurses, in addition to undertaking all the health visiting for the population at risk, assessed the social and nursing needs of patients at the request of the general practitioners and ensured that these needs were met. When necessary they undertook practical nursing tasks in the home and in the health centre, but most of the bedside nursing in the home was done by the State-enrolled nurse.The needs of the population at risk were such that only one State-enrolled nurse could usefully be employed, and this proved to be a considerable disadvantage. Despite this, the experimental work pattern held advantages to patients, doctors, and nurses, and is potentially capable of providing a satisfying and economic division of responsibilities, with different tasks being carried out by the individual most appropriately qualified.     

Psychiatric Emergencies in an Urban Borough

An analysis is presented of all emergency calls made in one year, “out of hours,” to local authority mental health social workers as part of a comprehensive psychiatric service in an urban community. Of 212 calls received, more related to men than women, and in both sexes the peak age group was 40 to 49 years; 72% of referrals were in the psychosis or personality disorder diagnostic groups. A minority of cases referred had symptoms of only recent onset, and 70% of all calls related to patients previously known to the local services.     

Counsellors in English and Welsh general practices: their nature and distribution.

OBJECTIVE--To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of "counsellors." DESIGN--Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. SETTING--English and Welsh general practices. SUBJECTS--1880 general practitioners of whom 1542 (82%) completed questionnaires. MAIN OUTCOME MEASURES--Prevalence and distribution of practice counselling services; counsellors'' qualifications and funding; types of patients referred. RESULTS--586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); "practice counsellors" (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; p < 0.001); and for clinical psychologists list size of > or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; p < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. CONCLUSIONS--Counselling services are wide-spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.     

Immunisation of children by a nurse without a doctor present.

Over 16 months 148 children were referred by health visitors and general practitioners to a specially trained nurse for failing to complete courses of immunisation. A further 91 children of travellers'' families were identified as needing immunisation. The nurse carried out 810 immunisations on 237 of these children in their homes without a doctor being present. There were only two refusals, and one child suffered a mild anaphylactic shock. The cost per immunisation, in nurse''s salary and travel expenses, was pounds 8. This is an effective and fairly inexpensive way of achieving uptake of immunisation in such groups of children, and there seems no reason why trained nurses should not give immunisations either in a child health clinic or at home, without a doctor present.     

An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people.

OBJECTIVE--To determine the accuracy of psychiatric diagnoses made by two community psychogeriatric teams operating a multidisciplinary assessment procedure. DESIGN--Comparison of team diagnosis with independent formal assessment and consensus diagnosis by research psychiatrists. SETTING--Two community psychogeriatric teams with similar operational policies in an inner London health district. SUBJECTS--100 people aged 65-90 (70 women) newly referred to the teams. MAIN OUTCOME MEASURES--Concordance between team and research diagnoses. RESULTS--Agreement between team and research diagnoses ranged from 90% to 99% for the specific psychiatric disorders studied. There was no significant difference between medical and non-medical team members in their diagnostic performance compared with the research psychiatrists. Increased diagnostic accuracy by team members was associated with longer experience of team working, regardless of the team members'' professional background. CONCLUSIONS--The multidisciplinary approach to the assessment of referrals to these community teams for the elderly is not associated with misdiagnosis of psychiatric disorder.     

Linking Student Performance in Massachusetts Elementary Schools with the “Greenness” of School Surroundings Using Remote Sensing

Various studies have reported the physical and mental health benefits from exposure to “green” neighborhoods, such as proximity to neighborhoods with trees and vegetation. However, no studies have explicitly assessed the association between exposure to “green” surroundings and cognitive function in terms of student academic performance. This study investigated the association between the “greenness” of the area surrounding a Massachusetts public elementary school and the academic achievement of the school’s student body based on standardized tests with an ecological setting. Researchers used the composite school-based performance scores generated by the Massachusetts Comprehensive Assessment System (MCAS) to measure the percentage of 3^rd-grade students (the first year of standardized testing for 8–9 years-old children in public school), who scored “Above Proficient” (AP) in English and Mathematics tests (Note: Individual student scores are not publically available). The MCAS results are comparable year to year thanks to an equating process. Researchers included test results from 2006 through 2012 in 905 public schools and adjusted for differences between schools in the final analysis according to race, gender, English as a second language (proxy for ethnicity and language facility), parent income, student-teacher ratio, and school attendance. Surrounding greenness of each school was measured using satellite images converted into the Normalized Difference Vegetation Index (NDVI) in March, July and October of each year according to a 250-meter, 500-meter, 1,000-meter, and 2000-meter circular buffer around each school. Spatial Generalized Linear Mixed Models (GLMMs) estimated the impacts of surrounding greenness on school-based performance. Overall the study results supported a relationship between the “greenness” of the school area and the school-wide academic performance. Interestingly, the results showed a consistently positive significant association between the greenness of the school in the Spring (when most Massachusetts students take the MCAS tests) and school-wide performance on both English and Math tests, even after adjustment for socio-economic factors and urban residency.     

A psychogeriatric survey of old people's homes.

An assessment of mental impairment and behavioral disabilities in 289 residents in six old people''s homes indicated that 50.6% were probably demented and 54% needed considerable help in daily living, 74% were taking prescribed medication, and 11% were taking four or more prescribed drugs. There was a wide variation between homes in those rated as behaviourally disabled, and in the amount of medication prescribed. A follow-up of 60 mentally impaired residents showed few remediable psychiatric disorders or psychotoxic drug effects. A community psychiatric nurse working with the psychogeriatric team would provide a useful support service to old people''s homes, particularly where there is a high proportion of disturbed residents and where the staff lack nursing experience.     

Randomised trial of personalised computer based information for patients with schizophrenia

ObjectivesTo compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia.DesignRandomised trial of three interventions. Modelling of costs of alternatives.Participants112 patients with schizophrenia in contact with community services; 67 completed the intervention.InterventionsThree interventions of five educational sessions: (a) computer intervention combining information from patient''s medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) “combination” (first and last sessions with nurse and remainder with computer).ResultsRates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper.ConclusionsThe computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.

What is already known on this topic

Education of patients with schizophrenia has limited but positive outcomesComputer based approaches have not been thoroughly evaluated

What this study adds

A computer based method of education for patients with schizophrenia, which personalised the information with details from each patient''s medical record, was acceptable and as effective as educational sessions given by a community psychiatric nurseHowever, because of the need to provide transport for patients to attend their sessions, the computer based intervention was as costly as the nurse based oneInvestigating the addition of computer based education to other routine patient contacts would be worthwhile     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Practitioner attitudes in the United States and United Kingdom toward decisions at the end of life: are medical ethicists out of touch?

Objective To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing or withholding treatment, ordinary or extraordinary interventions, and the doctrine of double effect. Design, subjects, and setting Answers to a 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on “Death and Dying” were compared with those of a similar questionnaire administered to 759 US nurses and 687 US physicians taking the Hastings Center course on “Decisions Near the End of Life.” Results Practitioners accept the relevance of concepts widely disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic and ordinary interventions and withholding and withdrawing treatment. Within the UK nurses'' group, the responses of a “rationalist” axis of respondents who describe themselves as having “no religion” are closer to the bioethics consensus on withholding and withdrawing treatment. Conclusions Professionals'' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners.     

Assessing the Quality of Tuberculosis Evaluation for Children with Prolonged Cough Presenting to Routine Community Health Care Settings in Rural Uganda

Background

Improving childhood tuberculosis (TB) evaluation and care is a global priority, but data on performance at community health centers in TB endemic regions are sparse.

Objective

To describe the current practices and quality of TB evaluation for children with cough ≥2 weeks'' duration presenting to community health centers in Uganda.

Methods

Cross-sectional analysis of children (<15 years) receiving care at five Level IV community health centers in rural Uganda for any reason between 2009–2012. Quality of TB care was assessed using indicators derived from the International Standards of Tuberculosis Care (ISTC).

Results

From 2009–2012, 1713 of 187,601 (0.9%, 95% CI: 0.4–1.4%) children presenting to community health centers had cough ≥ 2 weeks'' duration. Of those children, only 299 (17.5%, 95% CI: 15.7–19.3%) were referred for sputum microscopy, but 251 (84%, 95% CI: 79.8–88.1%) completed sputum examination if referred. The yield of sputum microscopy was only 3.6% (95% CI: 1.3–5.9%), and only 55.6% (95% CI: 21.2–86.3%) of children with acid-fast bacilli positive sputum were started on treatment. Children under age 5 were less likely to be referred for sputum examination and to receive care in accordance with ISTC. The proportion of children evaluated in accordance with ISTC increased over time (4.6% in 2009 to 27.9% in 2012, p = 0.03), though this did not result in increased case-detection.

Conclusion

The quality of TB evaluation was poor for children with cough ≥2 weeks'' duration presenting for health care. Referrals for sputum smear microscopy and linkage to TB treatment were key gaps in the TB evaluation process, especially for children under the age of five.     

Randomised comparison of the effectiveness and costs of community and hospital based mental health services for children with behavioural disorders

ObjectiveTo test the hypothesis that a community based intervention by secondary child and adolescent mental health services would be significantly more effective and less costly than a hospital based intervention.DesignOpen study with two randomised parallel groups.SettingTwo health districts in the north of England.ParticipantsParents of 3 to 10 year old children with behavioural disorder who had been referred to child and adolescent mental health services.InterventionParental education groups.Results141 subjects were randomised to community (n=72) or hospital (n=69) treatment. Primary outcome data were obtained on 115 (82%) cases a year later. Intention to treat analyses showed no significant differences between the community and hospital based groups on any of the outcome measures, or on costs. Parental depression was common and predicted the child''s outcome.ConclusionsLocation of child mental health services may be less important than the range of services that they provide, which should include effective treatment for parents'' mental health problems.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

COMMUNITY MENTAL HEALTH SERVICES—Operation in San Jose

Recent attempts to cope with the growing and costly problem of mental illness are progressively emphasizing prophylaxis and early detection and treatment. California has joined this trend forcefully since the passage of the Short-Doyle Act in 1957.San Jose is one of the communities with a Community Mental Health program, financed 50 per cent by the local government and 50 per cent by the State of California. It implements its program by offering consultative services to the city''s public health nurses, police officers, teachers, social workers, ministers, sanitarians and members of staffs of a number of public and private agencies.Results of the program have been: (1) Increased demand for education in mental health; (2) growing number of requests for case consultation in lieu of patient-referral to already overburdened psychiatric facilities, and (3) growing recognition by consultees of the importance of their own self-awareness.     

Community Mental Health

The distinctive feature of a community mental health program is the comprehensive responsibility assumed for the mental health as well as the psychiatric needs of a particular area. Not only must programs provide psychiatric services but, in addition, they are concerned with assessing the community''s psychiatric and mental health status; with preventive services; with mental health education; with contributions directed toward the solution of certain social problems; as well as with a variety of other indirect services, including, importantly, mental health consultation. This form of consultation can support and help the large number of community care-takers whose contribution is vital to the promotion of community mental health.     

Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

ProblemDelay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.DesignAudit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.

Background and setting

The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.

Key measures for improvement

Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes

Strategies for change

In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).

Effects of change

Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.

Lessons learnt

Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework''s targets for door to needle times can be achieved.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

School Screening for Scoliosis—One Experience in California Using Clinical Examination and Moiré Photography

In 1980 the legislature of the state of California mandated that school screening programs for scoliosis be implemented. This law resulted in variations in methods and efficacy of the programs. One such program using clinical examination and moiré photography was administered to adolescent girls in two secondary schools in Santa Clara County. The findings of 10% of the clinical examinations were ruled to be “positive,” 18% on moiré photography alone and 8% on both examinations. The correlation between the two diagnostic procedures was poor (r = .16). Follow-up was done to determine the outcome of the “positive” cases. In all, 25% of the children classified as having scoliosis had no medical follow-up one year from the request by the screening program team. The documented false-positive rate was 15% based on the screening examination. Definitive radiographic evaluation was reported in very few of the positive cases.Our experience shows the weakness of local programs that have no subject follow-up. It is suggested that public education may be a more effective solution than mass school screening mandates.