Focusing on these issues, Rupert and Morgan (2005) conducted a further US-based study, comparing Burnout across solo psychologist practitioners (47% of sample), those working in group practices (27% of sample) and those in agency services (23% of sample) 1 , arguably the closest equivalent to a UK NHS work environment. Their 571 participants were again drawn from the APA, but on this occasion all had to be working in clinical settings, either as clinical (80% of sample) or counselling psychologists (20% of sample). Overall levels of Emotional Exhaustion and Depersonalisation fell within the medium range for Burnout, and reported levels of Personal Accomplishment indicated low levels of Burnout. Emotional Exhaustion was shown to be significantly higher in managed care settings, although the main effect was qualified by a gender interaction which indicated that women in managed care settings were more likely to experience Emotional Exhaustion, as opposed to men in the other two settings. Participants in both solo and group private practice settings reported significantly higher levels of Personal Accomplishment than those in managed care settings, whereas Depersonalisation was not significantly different across settings. The study authors themselves highlight one particular issue in reporting mean overall Burnout levels: in this study, as potentially in many more, a closer examination reveals that although the mean for Emotional Exhaustion levels was in the medium range, 44% of participants fell within the high range, in contrast to 53.4% and 90% of participants falling in the low Burnout range for Depersonalisation and Personal Accomplishment respectively. As Emotional Exhaustion is usually regarded as the core component of Burnout, and may predict subsequent Depersonalisation and loss of Personal Accomplishment (Maslach et al., 2008), it seems imperative not to overlook this ‘red flag’.
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analyzing medication event reports in clinical settings. The event reports are manually reviewed in a case by case manner at regular time intervals, which are ineffi- cient and labor intensive. In addition, the collected re- ports are not well organized, which is a basic challenge for clinicians to review effectively and efficiently. Our proposed automated pipeline meets such an information need for improvement. The pipeline contains two steps. The first step is to identify three core attributes of a medication event from the narrative event report, the event originating stage, event type, and event cause, which are significant for summarizing the medication events in clinical settings. The F-measures for identifying the three attributes are 0.792, 0.758 and 0.925, respect- ively. For identifying the event types and causes, there are no benchmarks for comparisons. Thus, we applied a standard baseline classifier (ZeroR) as benchmark, the performances of our classifiers are much better than the baseline algorithm. The overall results are solid to sup- port the second step which is to group similar reports for further manual review and study. A human evalu- ation was conducted to test our similarity measurement, and according our two standards, the accuracies could reach 80% and 93% respectively. The evaluation proved that our method could group the relatively similar event reports together. Analyzing the similar medication event Table 5 SVM implementation for identifying the event
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Using a professionally representative sample of clinical specialists including 2 gynecologists, 3 pediatricians, 2 internists and one endocrinolo- gist, this phase was conducted. The interviewing guide comprised open-ended questions. Confi- dentiality was respected by omitting all interview- ees’ identifiable information from results. All of the main generated themes were categorized in three levels including challenges of confidentiality in clinical settings related to management, organi- zational ethics and physician-patient relationship (Table 1).
The genus Pseudomonas consists of more than 120 species that are ubiquitous in moist environments such as water and soil ecosystems and are pathogenic to animals and humans. Within the genus of Pseudomonas, P. aeruginosa is most frequently associated with human infections. The bacterium is regarded as an opportunistic pathogen, primarily causing nosocomial infections in immunocompromised patients. The existing knowledge regarding the pathogenesis of P. aeruginosa has mainly been obtained through studying clinical isolates; particularly those involved in causing chronic lung infection in cystic fibrosis patients. Nosocomial infections commonly associated with P. aeruginosa include ventilator-associated pneumonia, catheter-associated urinary tract infections, wound infections in severe burn patients and septicaemia with their pathogenesis shown to be multifactorial. The bacterium is also capable of producing a number of toxins via the type III secretion system, as well as secreting enzymes and proteins including elastase, phospholipase C and siderophores. However, P. aeruginosa is also a waterborne pathogen, commonly found in environmental waters as well as in other sources such as sewage treatment plants. The public health implication of these bacteria whilst in the environment has not been fully investigated. Here we review our present knowledge about the pathogenesis of P. aeruginosa in clinical settings and the environment.
The study focused on comparative analyses Nursing documentations in the clinical settings. Judgmental and simple random sampling methods were used to select documented nursing actions for 264 clients from tertiary, secondary and primary health care institutions all in Anambra State of Nigeria. One research question and three null hypotheses guided the study. The instrument used for data collection was checklist titled “Checklist on Nursing Documentation in the clinical setting”. Descriptive statistics of frequency, mean score and standard deviation (SD) were used to summarize the variables, and Pearson product moment correlation were used to answer the research question. Analyses of variance (ANOVA) was adopted in testing the null hypotheses at 0.05 level of significance. Nursing documentation was observed to have significant legal implications. In addition, nursing documentations in the medical, surgical and maternity units of the health facilities significantly differed with regard to timeliness, promotion of interdisciplinary communication and in the core principles of documentation.
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Our findings suggest that successful CP implementa- tion in these complex clinical settings requires address- ing barriers and enablers at multiple levels, individual providers (frontline and leadership), ED health teams, and the broader hospital context. Moreover, a systematic approach attending to all three levels of impact will be important. A motivated and well-intentioned profes- sional is not sufficient if the team is not interested, or if the system does not support the implementation. Simi- larly, the system cannot easily push a CP if the individual professionals or team culture do not buy into it. In com- parison, the implementation literature regarding clinical practice guidelines (CPGs) has identified dissemination, education and training, social interactions, and decision- support systems as successful strategies . Similar to our findings, CPG implementation is more likely to be ef- fective with the use of a multifaceted and strategic approach that addresses the context and identified barriers .
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Most studies of the effects of MALDI-TOF mass spec- trometric evaluation have been conducted in clinical set- tings featuring ASPs [12–18]. Of the hospitals included in one international survey, 58% had ASPs, but the rates were low in Africa (14%), South and Central America (46%), and Oceania (47%) . Many hospitals do not adopt ASPs because of a lack of funds, personnel, and/or information technology, or prescriber opposition. How- ever, few studies have explored the clinical outcomes afforded by MALDI-TOF MS in clinical settings lacking ASPs. In an observational study, Clerc et al.  explored the utility of the MALDI-TOF MS-based identification of Gram-negative pathogens in patients with BSIs who were not enrolled in an ASP, but included only patients who underwent ID consultations. We studied bacteremic and fungemic patients regardless of ID consultation status; this may reflect the real clinical situation in hospitals lacking ASPs.
In this study, the first theme related to dynamics of humour, with ‘Understanding humour’ emerging as the first subcategory. For the participants, the use of humour is determined by dynamics in clinical settings. Some participants believed that humour is necessary to make the working environ- ment pleasant and drives the nurses to cre- ate opportunities for the use of humour dur- ing their minimal, casual interaction with patients and colleagues (19). Studies show that nurses’ perception of sense of humour was a major factor in using sense of hu- mour at patients’ bedside. The nurses avoid using their sense of humour unless they be- lieve that joking can help the mental health of the patients and nurses, and recognize it as a caring strategy. Conversely, negative perceptions of humour limit its use in pa- tient care (20). Apt posits that, prior to the use of humour, it is essential to consider people’s perception of humour, particularly those informed by culture (21) .
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health outcomes, including assessing for physical literacy. For example, the Intermountain Healthcare system developed and integrated into their EHR system a pediatric PAVS for use at preventive care visits for children ages 6 to 18 years. 151 This tool combines the PACE 1 validated item with the addition of questions to assess activity participation on speci ﬁ c settings and domains (physical education, recreation, sports, transportation, home, after school, sedentary or screen time) in an effort to facilitate compliance assessment and guide goal-setting and domain-speci ﬁ c counseling. 151 Since 2011, the Kaiser Permanente Health System integrated into its EHR system and clinical work ﬂ ows the pediatric exercise vital sign, modeled after the YRBS questions, for youth 5 to 18 years (Fig 1). 166 Although not yet formally validated in children, implementing the PAVS as a part of the health visit and within the EHR represents a starting point in initiating the conversation around physical activity in primary care and assessing the potential to predict future disease risk 158 as well as determining the validity of the PAVS in pediatric practice. 167 Brief tools for assessing physical activity are included in Table 6 (see the Supplemental Information for a full discussion regarding the tools and methodology used to identify advantages and disadvantages of each).
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The WHO recognises the need to prevent and control cardio- vascular disease (CVD), and that managing raised lipids is a key modifiable risk factor (WHO 2011). Internationally, it is recog- nised that a universal targeted approach to identify and manage heterozygote FH is a key priority to prevent CVD (Benn 2012; Nordestgaard 2013; Reiner 2015; Robinson 2013; Watts 2015). For successful identification of FH, case finding needs to extend beyond the specialist lipid clinic to non-specialists in primary care (NICE 2008) and other community non-health settings, such as occupational health services (Kirke 2015).
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Abstract: Cardiovascular and renal disease can be regarded as progressing along a sort of continuum which starts with cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, etc), evolves with progression of atherosclerotic lesions and organ damage, and then becomes clinically manifest with the major clinical syndromes (myocardial infarction, stroke, heart failure, end-stage renal disease). The blood pressure control remains a fundamental mecha- nism for prevention of cardiovascular disease. The renin–angiotensin system is believed to play an important role along different steps of the cardiovascular disease continuum. Convincing evidence accumulated over the last decade that therapeutic intervention with angiotensin receptor blockers (ARBs) is effective to slow down or block the progression of cardiovascular disease at different steps of the continuum, with measurable clinical benefits. However, despite the shared mechanism of action, each ARB is characterized by specific pharmacological properties that may influence its clinical efficacy. Indeed, important differences among available ARBs emerged from clinical studies. Therefore, generalization of results obtained with a specific ARB to all available ARBs may be misleading. The present review provides a comparative assessment of the different ARBs in their efficacy on major clinical endpoints along the different steps of the cardiovascular disease continuum.
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barrier for nurses to engage in research activities.  Funding mechanisms are needed to support coherent programs of research.  Financial support and a strong value for generating as well as disseminating knowledge must be present within departments and schools, in the larger academic institution, and at the national level.  Positive reinforcements (rewards) increase nusrses participation and utilization of research.  Previous studies identified several actions that may contribute to overcoming barriers of nursing research participation and utilization, such as providing resources, increasing release time for participation in research, continuing education on the research process and creating positions for nurse researchers in clinical settings. [17, 19, 20]
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Abstract: Hepatitis B (HBV) is an urgent, unmet public health issue that affects Asian Americans disproportionately. Of the estimated 1.2 million living with chronic hepatitis B in USA, more than 50% are of Asian ethnicity, despite the fact that Asian Americans constitute less than 6% of the total US population. The Centers for Disease Control and Prevention recommends HBV screening of persons who are at high risk for the disease. Yet, large numbers of Asian Americans have not been diagnosed or tested, in large part because of perceived cultural and linguistic barriers. Primary care physicians are at the front line of the US health care system, and are in a position to identify individuals and families at risk. Clinical settings integrated into Asian American communities, where physicians are on staff and wellness care is empha- sized, can provide testing for HBV. In this study, the Asian Health Coalition and its community partners conducted HBV screenings and follow-up linkage to care in both clinical and non- clinical settings. The nonclinic settings included health fair events organized by churches and social services agencies, and were able to reach large numbers of individuals. Twice as many Asian Americans were screened in nonclinical settings than in health clinics. Chi-square and independent samples t-test showed that participants from the two settings did not differ in test positivity, sex, insurance status, years of residence in USA, or education. Additionally, the same proportion of individuals found to be infected in the two groups underwent successful linkage to care. Nonclinical settings were as effective as clinical settings in screening for HBV, as well as in making treatment options available to those who tested positive; demographic factors did not confound the similarities. Further research is needed to evaluate if linkage to care can be accomplished equally efficiently on a larger scale.
Table 2 reports the responses of learners across each of the 4 different practice types. Of note, there was a sig- nificant change between the T1 and T2 cohorts in the proportion of those who responded “neutral” to whether they were likely to provide comprehensive care in 1 set- ting or across multiple clinical settings (P < .01 for both). The shift indicates that learners were more definitive about the type of practices they envisioned themselves having by the time of exit from residency. Another signifi- cant change was found among T2 respondents indicat- ing they were less likely to provide comprehensive care across multiple clinical settings (P < .01). Upward non- significant trends, however, were also found across the other categories, including providing care in multiple clin- ical settings. Because the questions related to intention to provide enhanced skills and focused practices were only asked in the T2 survey, no comparisons with results from the T1 survey can be made. However, a higher percent- age of T2 respondents indicated a higher likelihood of providing comprehensive care that included a special interest (70.8%) versus a smaller number (36.6%) indicat- ing a likelihood of providing a more focused practice.
As technologies become more widely used or are being applied to more common decision points, retrospective and prospective studies become more feasible and are easier to execute. For example, the greatest utility of POC inﬂuenza tests for changing clinical decision making is evident with studies in ERs, primary care physician ofﬁces, and outpatient clinics, by showing reductions in empirical antibiotic treatment and increases in Tamiﬂu prescriptions in these clinical settings through larger retrospective and prospective studies (25, 44, 45). Similarly, a study of a gastrointestinal panel showed reduction of several patient days on antibiotic and in the length of time to discharge (46). In the future, multiplex syndromic panels for outpatients may develop evidence of clinical utility by targeting speciﬁc high-risk groups, such as immunocom- promised and pediatric patients and elderly patients in assisted living facilities. Hospital admission is a critical decision point for these patients and therefore a potential endpoint; expediting hospitalization of patients with severe infections may signiﬁcantly improve health outcomes. Furthermore, some patients with less severe infections may beneﬁt from avoiding hospital admission, limiting the potential of nosocomial infec- tions and avoiding the sizable cost of hospitalization. Information about the use of these technologies can be collected through collaborative efforts in multiple institu- tions or from a single institution that works with high volumes of vulnerable patients. Clinical workﬂow. Clinical workﬂow is substantially different in the outpatient and inpatient settings and typically is of higher priority for inpatient services. For hospitals, enhancing clinical workﬂow has the potential to signiﬁcantly improve patient care and lead to lower costs, particularly as more complex and/or labor-intensive tests may be replaced with simpler and/or more efﬁcient tests. Also, such improvements can aid hospitals in meeting
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Although our report focuses on the application of our imaging system to potentially monitor therapeutic re- sponse of KS, the same approach can be applied for screen- ing skin lesions, especially for longitudinal follow-up . While early diagnosis and treatment is the best strategy for reducing cancer mortality, overuse of expensive and/or in- vasive procedures increases morbidity and healthcare costs in developed countries [30,31] and is impractical in resource-limited settings. However, introduction of simple and inexpensive diagnostics and imaging devices has been proven to be useful in clinics. For example, the number- needed-to-excise (NNE) value, a measurement for accuracy of melanoma diagnosis, has been improved only in special- ized and not in non-specialized clinical settings in a multi- center study over a 10-year period . The main difference has been attributed to a larger use of diagnostic techniques, especially the simple and inexpensive dermato- scope, and digital monitoring [22,33]. As described earlier, our 3D imaging system may be especially useful in the tele- helth settings as high-quality and relevant images can be obtained without extensive training of the operator. More- over, it is possible to have a preliminary analysis by a soft- ware system as standardized images are obtained.
Paecilomyces variotii grows rapidly on standard agar and forms velvety olive brown colonies. Conidiophores of P. variotii are irregularly branched, and the phialides have a broad base ending in a long and slender neck. Samson (41) noted that P. variotii is a morphologically variable species, and the taxonomy of P. variotii and the related Byssochlamys teleomorphs has recently been revised (45). This revision is based on morphol- ogy, extrolites, and molecules and shows that P. variotii sensu lato comprises five species, namely, Byssochlamys spectabilis (the sexual state of P. variotii), P. brunneolus, P. formosus, P. divaricatus, and P. dactylethromorphus. The last species was incorrectly named P. saturatus because P. dactylethromorphus was validly described in 1957 and has priority. The aim of the present study was to determine the prevalence of these species in clinical samples and settings. A total of 34 isolates originat- ing from various clinical specimens and settings were identified by sequencing the intergenic transcribed spacer (ITS) regions, * Corresponding author. Mailing address: CBS-KNAW Fungal Biodi-
Action learning is seen as one of the most effective means to develop management and leadership skills (Dilworth 1998, Weinstein 1999, Marquardt 2004). Haith and Whittingham (2012) place great emphasis on using action learning ALPs as a supportive means to empower healthcare professionals in today’s challenging healthcare setings, and also in clinical learning and educational environments (Haith and Whittingham 2012). This study supports Fulmer and Wagner (1999) findings in that ALP’s deliver a learning experience that is concerned with the organisation's and learners' development with the participants solving actual real life problems, and the feedback the participants receive, in terms of colleagues and also improvements in the management of CRP fosters this development. However, although improvements were seen post intervention in this study, it is clear that continuous interprofessional staff education and development needs to be supported in order to maintain high standards of practice. In order to ensure that this remains high on the agenda and support remains consistent, it should be contained within the organisations quality improvement strategy.
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sporotrichosis, blastomycosis, chromoblastomycosis, coc- cidioidomycosis, phaeohyphomycosis, lobomycosis and paracoccidioidomycosis have close resemblance to myce- toma . Knowledge of their epidemiology and clinical progression will assist the physician in making a presump- tive diagnosis. Focused investigation at various levels of facility also helps the physician to hit the diagnosis as shown in the algorithm (Fig. 2). Table 1 reveals findings and results in some of the available tests to confirm myce- toma and Table 3 summarizes the differences between actinomycetoma and eumycetoma. A disease condition producing chronically swollen and deformed foot char- acterised by draining sinuses should be considered as a differential diagnosis of mycetoma as shown in Table 4. Additionally, some important diagnostic tools, their pit- falls and the level of health care system to find them are provided in Tables 2 and 5 to aid in diagnosis.
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After three years of joint work, the awareness of the patients and parents on care organization and processes at their centre was high – similar to that of the professionals – concerning matters relevant to them: multidisciplinary care, patient education, the clinic visit process… But their awareness on some aspects of the organization such as the information system (patient electronic record) and the management of care guidelines, remained low. Even so, these aspects are not to remain fatally out of their atten- tion for quality of care improvement: the impact of educating parent in care guidelines on clinician adhering to them has been demonstrated in a pediatric CF program  and patient-led training in medical education has had an impact on the application of safety guidelines by clinical teams . In Sweden, patient electronic records have been opened to allow patients access to their health record and provide input such as the schedule of the next visit, results on health outcomes followed at home and various mailings . When these matters are explicitly shared with them as part of their care, patients and parents will probably be able to contribute to improve these fields by reporting their experience and needs.
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