Assessing capacity is not about taking away the patient's autonomy, but making sure that the patient understands and is aware of the consequences of his decisions. In fact, it is a protective measure for the most fragile patients to ensure the best care. This is not done by a psychiatrist, but by the attending physician. There are several tests or semi-structured interviews to assess the capacity of patients, and all physicians should be familiar with these instruments. It is important that it is the attending physician who performs this assessment, because he/she is the one who previously informs the patient (informed consent) of the therapeutic plan and is the one who is best able to assess whether the patient has understood everything: what the medical problem is, what treatment is proposed, the alternatives if any, whether to accept or reject any of them and why, the consequences of making these decisions (also those of not wanting treatment), even assessing psychopathology susceptible to an ICP to Psychiatry.

An 80-year-old man is brought to the ER by the police to find him at night, on the street, several blocks from his home, somewhat lost. He tells the ER doctor "I feel fine, I was walking and I got lost". The examination, by systems, is anodyne. When asked about his medication, he does not remember. His history includes glipizide, atenolol and acenocoumarol. She has been to the ER 3 times in the last three months for "dizziness", low back pain and an INR of 5. She reports independence in basic and instrumental activities of daily living. There is no evidence of family or close friends. Several references from the social work in the area indicate that she refuses medical or nursing aids or visits. In the physical examination, only temperature of 37.7, BMI of 16, BP of 160/90, HR of 90 and SO2 of 99% stand out. He has global loss of muscle mass. He is dressed in his robe and smells of urine. He refuses to answer Minimental's questions. Laboratory tests include 13,000 leukocytes, blood glucose 300, glycosylated hemoglobin 11%, INR 0.9, urine over 50 leukocytes/field, nitrites+ and urine culture > 100,000 Gram negative bacilli. He is admitted to the hospital, receives antibiotics, insulin and restarts acenocoumarol with good evolution. He is stable and wants to go home. The ward nurse says he is unable to self-administer insulin. Which of the following is the next step in determining the patient's safety at home?

Refer to Primary Care and social work in the area to determine safety at home.

Formal evaluation of the capacity to make decisions concerning their health.

House call

The purpose of such visit is primary diagnostics and prescription of treatment and mode of conduct as well as prescribing blood, urine and other tests to be carried out at the polyclinic. The doctor also supplies the patient with a sick leave from work or study for a number of days and the leave is to be closed by the same doctor or his/her substitute and sealed at the clinic on the patient's recovery and checkout. If need be, the GP may arrange a visit to the sick person from one of specialist physicians from his/her clinic and of his/her nurse for giving injections. There are two identical state systems of outpatient clinics running parallel – for adults and for children. With the rise of private enterprise since 1990, city dwellers may place a phone order for a house call from a private medical facility (to be paid for out of patient's own money). See also Doctor's visit Home health nursing References Practice of medicine

[A consideration through the support to resident diabetic patient and care giver].

Our hospital is a National General Hospital with 585 beds. We began the visiting care service from 1990 and four visiting staffs are working at present. The number of targets was 69 in 2002 including 32 patients over 70 years old and 20 care-givers over 70 years old. Visiting care has been conduced to a 72-year-old female with diabetes since July 2000. The patient is in bedridden condition and at the beginning of visiting, she was taking oral medication but the condition was worsen by poor glycemic control and changed to insulin injection from June 2002 after admission to the hospital repeatedly. The patient undergoes the measurement of blood sugar daily and takes meals with 1,200 to 1,400 kcal prepared by her husband. The care-giver is a 71 year-old husband. He was an "all-work, no-play" type of person and had never done the housework, but he started to manage both housework and nursing because of bedridden of his wife. He is a reticent theorist, hates illogical behavior, and does not swayed by other opinions. He has accepted the things which need new knowledge and techniques such as measurement of blood glucose and insulin injection. However, for meals, he only bought side dishes and placed them. Care such as keeping the patient clean was in a same state. The patient consulted and admission to the hospital repeatedly because conditions were not stable. Visiting nurse supported daily life of patient and care giver especially in nutrition instruction to continue home life. As the result, attitude and behavior toward nursing of care-giver were changed and the patient could continue home life. Therefore we reported here.

Care under the Influence.

A forty-year-old man is brought to the emergency room by his wife at five in the morning, two hours after he fell down the stairs at home, hitting his head and injuring his arm. He tells the ER physician that he got up to get a drink of water and tripped in the dark. His speech is slurred, and he smells strongly of alcohol. Lab results reveal elevated liver enzymes, and his blood alcohol level is 0.1. His medical history is unremarkable. When asked about his alcohol consumption, he says he usually has one or two drinks a night with dinner but that he drinks more on holidays and special occasions. He admits he had more to drink than usual last night because it had been a stressful day at work, but he is vague about how much he drank. His wife takes the ER physician aside and describes a very different situation. She says that her husband regularly has three or four drinks a night. She always goes to bed before he does and thinks he stays up later so he can continue to drink. She says that he often has no memory of conversations they had the night before and is concerned because he makes work-related calls at night. When asked what he does for a living, she hesitates, and then answers that he is an internist. He does not work at this hospital but works at one of its affiliated clinics. The ER doctor is concerned that his patient is an impaired physician. Yet when the admitting hospitalist, to whom he explains the situation, asks if he really wants to "go there," he shrugs his shoulders. "I suppose," she replies, "you might as well call an ethics consult."

Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients.

To evaluate the relative importance of the medical history, the physical examination, and laboratory investigations in the diagnosis and management of medical outpatients some physicians recorded their diagnosis and a prediction of the method of managementafter reading the patient's referral letter, again after taking the history, and againafter performing the physical examination.  These diagnoses and predictions were compared with the diagnosis and method of management which had been adopted two months after the patient's initial attendance.  A diagnosis that agreed with the one finally accepted was made after reading the referral letter and taking the history in 66 out of 80 new patients; the physical examination was useful in only seven patients, and the laboratory investigations in a further seven.  In only one of six patients in whom the physician was unable to make any diagnosis after taking the history and examining the patient did laboratory investigations lead to a positive diagnosis.

Who rules the roost?

Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?

[Short-stay units depending on Internal Medicine].

Wetry to establish the utility that a Short Stay Unit depending on Internal Medicine has for a third level hospital. This unit manages the patients under the "appropriate stay" concept. Several clinical and epidemic variables and sanitary indicators were studied in 867 patients. Cost was measured as the origin by average stays, explorations and readmission. Effectiveness was considered as the percentage of discharges that stay in the hospital for three days or less. The average age of the patients was 65.05 years. 55% were males. 82.24% had any previous disease. The most common diagnosis (ICD-9) were respiratory diseases, nervous system diseases and digestive diseases. The average stay of the patients was 57 hours, 2,259 explorations were ordered, it supposes an average of 0.328 urgent explorations and 2,276 UCE explorations. 310 explorations were no received when the patient was sent home. 36.56% of the patients required no explorations. 62.4% of the patients were sent home. Explorations not received had a bad influence in the average stay and in the discharges. Readmissions were 9.36%. We got hay 62.4% of the patients had a stay of 2,375 days in the hospital, With a reasonably low cost in readmissions and explorations. However it wasn't possible to establish which patient coming to the Emergency Service is appropriate for this Short Stay Unit.

History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).

It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is "only" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, "daddy" he will need to ask his mother: "what letter is the letter D?" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, "if he is counting he will forget what comes after 4 and what comes after 9." Mother reports he will start crying for no apparent reason and if she asks why, he will say "I don't know why." Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, "This was not an issue before his head trauma." At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as "excellent." Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?

[Preventive medical examination in the aged; pros and cons].

Preventive medical examination in aged people has some disadvantages when executed as a form of screening of the general population. There are almost no diseases to be found in aged persons, which meet the criteria for screening. It is likely that more needless disturbance is caused than actual case-finding achieved. Non-response in aged people will be high. And at last multiple pathology in aged people brings about that the total health-state is more important than the occurrence of specific diseases. These disadvantages can be partly solved by way of pre-selection of high risk aged persons. This increases the predictive value of the diagnostic tests; partly precluding non-response by means of having the first preventive examination at home; and determining the state of health in first instance by asking questions about ADL, house-keeping abilities, state of mental health, nutrition, a.o. The possibility of the community nurse paying home visits in stead of preventive medical examination will be discussed.

Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.

Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he "screams, cries, and thrashes and can stay up for over an hour." His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing "tolerance" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index >99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?

["What an ideal clinical microbiological laboratory should be"--from the position of patient].

To think about the ideal clinical microbiological laboratory in patient's place, there are three important problems in present medical treatment. The first one, for patients, it is necessary to wait many hours to take a medical advice from a doctor. The second, patients should be checked many examinations. The third, the heavy patient's share in his medical expenses. To settle a bit these matters, the clinical laboratory should try to accept the rapid and economical examinations for patients.

The language and culture of delay.

Satish is a 3 (1/2)-year-old boy you are seeing in your primary care office for a "sick visit" due to parental concerns about his language development. He is the only child of a couple who immigrated to the United States from India shortly before his birth. He received early intervention services for speech and language delays for a few months before he attained 2 years of age. However, services were discontinued when the family moved back to India for a year. After the family returned to the United States, they lived in a different state for several months before moving again recently to his current home, so he is relatively new to your practice. Satish's mother is concerned not only about his communication skills but also about his attention and social skills. She notes that he often plays alone or in parallel with other children. She was also told by his first pediatrician that Satish had "a limited imagination." His parents feel that he has pretend play, in that he will pretend to get his haircut, talk on the phone, or ride on a train. Satish was born at term without complications. He passed his newborn hearing screen and a repeat hearing test at the age of 2 years. He has had no medical problems and takes a daily multivitamin. His parents are both of Indian descent. Satish's father is an engineer and had a history of being a late talker. His mother graduated from high school and is a homemaker. They are expecting their second child. Satish's developmental history is significant for language delays. He babbled at 6 months but did not have single words until he was 2 years. When he was 2 (1/2) years, he had 2 to 3 word sentences. He responded to his name at 15 months and could follow single step commands by the age of 2 years. Currently, Satish is noted to have difficulty with "back and forth conversation." He sometimes repeats what others are saying.The family speaks Hindi, their native language, exclusively at home. When Satish speaks, he usually speaks in Hindi. His parents describe him as using "odd language" in that he will often mix up his pronouns. Satish is in an English-speaking preschool. His preschool teachers report concerns that he seems to "withdraw into his own world," and does not interact well with the other children. They also report attentional problems and poor eye contact.In the office, Satish makes good eye contact with the examiner and his parents. He looks to his parents for approval when completing a task requested of him. He seems to like an Elmo toy that is in the room but holds it and looks at it closely rather than pretend to do anything with it. You ask him to feed Elmo, and he says, "Feed Elmo." Because it is not clear whether he understands the verbal cues given to him, his parents repeat English directions to him in Hindi several times. He eventually complies but then leaves his chair to explore the room. His parents continue to translate your questions to him with variable results. He becomes increasingly difficult to engage, despite repeated attempts, in both English and Hindi, to attract his attention. Where do you go from here?

Reta Mays

In June 2015, Mays began working as a nursing assistant at the Louis A. Johnson Veterans Medical Center in Clarksburg, West Virginia with no certification or license to care for patients. Nursing assistants at the VAMC are not qualified or authorized to administer any medication to patients, including insulin. Mays was assigned to work overnight shifts on Ward 3A of the hospital's medical surgical unit in July 2017, when elderly patients began suffering mysterious, acute drops in blood sugar levels. Over the course of eleven months, hospital staff eventually attributed the deaths of several patients on the ward to hypoglycemia. Many of the deaths were of individuals who were not insulin-dependent. Four of the deaths occurred within a sixteen-day period. One patient, Archie Edgell, an 84-year-old Korean War veteran suffered a drop in his blood sugar to 24 (a reading of less than 70 is low and can be harmful) and was able to be stabilized by staff, only to die following another plummet

Disclosure of diagnosis:  to tell or not to tell?

Jimmy is an 8-year-old boy with hepatitis B, e antigen (HBeAg)-positive, HIV and hepatitis C negative, who was adopted from Vietnam when he was 5 years and has been followed in your primary care practice since that time. Before adoption, he lived in an orphanage, where he was placed soon after birth. Jimmy currently lives with his adoptive mother and grandparents. His adoptive father has amyotrophic lateral sclerosis and recently moved to a nursing home due to a need for more intensive care. Jimmy continues to see him regularly.Jimmy's mother presents today upset about a recent encounter with his hepatologist. During this visit, Jimmy's doctor was insistent that Jimmy should be told about his illness immediately. He felt that Jimmy "had a right to know" and that it was important for the protection of other children. Jimmy's family practices universal precautions and Jimmy is compliant with these safety measures. Jimmy's mother has chosen not to share his diagnosis with the school and in addition has not felt the time was right to disclose the diagnosis to Jimmy. He is asymptomatic, takes no medications, and is followed yearly by a hepatologist. His mother is concerned that Jimmy would have difficulty managing this information and maintaining a "secret." However, she also worries that he may feel his trust has been violated if she delays telling him.Jimmy is currently 8 years old, in second grade, and is struggling academically with math and reading. Socially, he is reported to have difficulty making friends and reading social cues. For example, he displays inappropriate boundaries, often standing too close or touching others, which has resulted in children avoiding him. During your annual visit, Jimmy presented as a friendly and engaging boy. He maintained conversation about school and some of his interests, but he was often distractible, impulsive, at times grabbing things, and fidgety, frequently standing up and then sitting back down. Jimmy's mother reports that this behavior is similar to what he exhibits in the classroom. He is currently receiving English as a Second Language services and is enrolled in a weekly "lunch bunch." What advice would you give the family?

[Criteria for evaluation in family medicine].

For successful evaluation and the follow up of the family medicine team work it is necessary to develop evaluation criteria. Monitoring and evaluation criteria are numerous and different among countries depending on the health care development and the economic power of the country. In the present circumstances, taking in consideration health care reform through Primary Health Care (PHC) through family medicine team, the following criteria are proposed: equity, availability, cost-effectiveness, efficiency, efficacy, quality and satisfaction of user and health services providers. Indicators for the above mentioned criteria are also defined to estimate criteria achieved development. First indicator group relates on the medical-social indicator (for example number of families, structure of families and structures of concerning population) and the others social-economic indicators (GNP, expenditure in the health and social sector per capita, etc.). Second indicator group follows up the content of family medicine team work as follows: indicator of active and passive health care (for example number of doctor services, number of doctor and nurses home visits, consultation services, diagnostic procedures etc.). Third indicator group relates on the economic aspect, meaning the cost of implementation of such program, according indicator on content of work. Suggested criteria with indicators present the basic minimum databases, which would give the possibilities to have continuous overview in family medicine team functioning as well in its quality of work.

Bullying and ADHD: which came first and does it matter?

Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.You speak with Aiden in the office and ask him about school. He says, "It's bad. I'm failing." He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and "gives hard homework." He describes his history teacher as "annoying." When you ask what he means he states this teacher "Can be not nice and says mean things. She picks on me a lot." His description is consistent with the use of shaming as a behavior he experiences at school.You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.A week later, you receive a telephone call from Aiden's mother. "Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school." She is not aware if retention has been recommended for Aiden.What would you say to Aiden's mother? What would you do next?

Technical notes: when all things are not equal.

This article addresses 2 questions. First, how useful is adult patients' information about health and healthcare when they use the Internet for a "health checkup"? We find that patietns' reports are very strongly associated with medical record information for blood pressure, cholesterol, and blood glucose. Second, what are the biases in information from Internet respondents? Although we find that "health checkup" Internet users seem to be representative for patients in actual practice, much more research will be needed to fully address this question.

Bullying and ADHD: Which Came First and Does it Matter?

[Diabetes in elderly subjects].

Problems raised by diabetes in subjects above 65 years of age are of three kinds: diagnostic, therapeutic and social. Passed the age of 40, there is a regular physiological increase of glycaemia, and this must be taken into account to diagnose diabetes and to set the threshold for therapeutic intervention. The treatment of elderly people has its specific imperatives, due to feeding habits and age-related changes in hepatic and renal functions. The presence of complications, sometimes multiple, explains that the patient often takes several drugs, which increases the risk of interaction between these drugs and oral antidiabetics. The therapeutic objectives must be adjusted to these imperatives, and neither the diabetic... nor his doctor must be afraid of insulin. The social status of elderly patients must not be neglected: the help of private nurses and the training in diabetology of the patient's entourage often permit to postpone the date of institutionalization.

Toddler Sleep Challenges: All in a Day's Work.

Leo is a 26-month-old boy who you are seeing for an urgent care visit due to "sleep difficulty," particularly sleep onset. Since age 1, he screams, hits, and kicks his mother every day, starting after she gets home from work at 5 PM (or before the family's dinnertime on her days off) and escalating over the course of the evening until he "wears himself out" and falls asleep in a crib in his own room around 9 to 10 PM Once asleep, he sleeps well through the night and wakes easily around 7 AM in a pleasant mood; his mother leaves for work soon after he awakens. He naps after lunch for 2 to 3 hours on weekdays at an in-home child care with 1 to 2 adult caregivers and 5 other children aged 0 to 5 years. He refuses to nap at home.Leo goes to bed easily when his father puts him to bed if his mother is not at home, but his mother feels that evenings are the only time she can spend with Leo, and so, she tries to put him to bed most nights. However, because of Leo's behaviors at bedtime with her, she feels inadequate, depressed, and guilty; when she tries to disengage or allow her husband to help, Leo screams, "Mommy, mommy!" and tries to gain access to her and resists his father putting him to bed until his mother returns. Both parents worry that "he would not grow out of this," and his mother now avoids coming home from work for fear of Leo's behavior. Both parents feel that this situation is causing marital strain.Leo was born healthy at full-term and is an only child; pregnancy was complicated by hyperemesis gravidarum. Leo has been healthy and meeting developmental milestones. His parents describe his temperament as "like his father at that age," "easy, but never able to self-soothe," "intense" in his emotional reactions, persistent, "strong-willed and serious," and "shy and observant, withdrawn at first and then getting more pleasant after a while" in novel situations. Behaviorally, he engaged in noninjurious head-banging at home when upset between 12 and 15 months; bit children a few times at child care between 20 and 24 months; and lately refuses to share or will push other children at child care every few weeks. His parents recently read a book about parenting "spirited" children but did not find it helpful. What would you do next?

[Impact of peer visits].

To measure the impact of an intervention on the general practitioners (GP) of Reunion in order to improve the management of patients with type 2 diabetes, in conforming with the recommendations of the Anaes. Randomised intervention study on a random sample of 120 practitioners out of a total of 630 GP in Reunion, 60 in the intervention group (IG) and 60 in the control group (CG). Each doctor of the IG received 2 visits by a "visiting GP" which have had specific training. The period of observation included the 12 months before, and the 6 months after the date of the intervention. Data were collected retrospectively, at the end of 18 months of observation; in medical records of 25 diabetics seen consecutively in consultation, the GP collected the dates of performance of six procedures under surveillance: HbA1c, examination of the feet, fundoscopy, ECG, estimation of the creatinine clearance, level of micro-albuminuria. Outcome measures were delays in performance of the procedures conforming to the recommendations. 42 GP out of 60 in the IG, and 40 out of 60 in the CG participated to the study. Patients included, 792 in the IG and 789 in the CG, were comparable for age, sex-ratio and profession. The distribution of delays in performance before the intervention was comparable in the two groups. The comparison between the groups after the intervention showed a significantly important improvement in the IG for 4 to 6 of the procedures: examination of the feet, fundoscopy, creatinine clearance and micro-albuminuria. In the short-term, a "outreach visit" or "academic detailing" improves the delay in performance of most of the surveillance procedures in type 2 diabetes.

Attention deficit hyperactivity, fetal alcohol spectrum disorder, or something else: the broad differential of kindergarten suspension.

Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating "and his doctor must see him before he can come back." His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds. The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as "hyperactive" by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom. His parents have always described him as a "difficult child." He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited. Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed "partying" with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant. All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?

Claus von Bülow

In 1982, Bülow was arrested and tried for the attempted murders of Sunny on two occasions in two consecutive years. The main medical and scientific evidence against him was that Sunny had low blood sugar, common in many conditions, but a blood test showed a high insulin level. The test was not repeated. A needle was used as evidence against Bülow in court, with the prosecution alleging that he had used it and a vial of insulin to try to kill his wife. His mistress of two years, the soap opera actress Alexandra Isles, testified "He said that they had been having a long argument, talk, about divorce that had gone on late into the night. She had drunk a great deal of egg nog. And then he said, ‘I saw her take the Seconal.’ And then he said that the next day when she was unconscious that he watched her knowing that she was in a bad way, all day, and watched her and watched her. And finally, when she was at the point of dying he said that he couldn’t go through with it and he called (the

[A consideration through the support to resident diabetic patient and care-giver].

Our hospital is a National General Hospital with 585 beds. We began the visiting care service from 1990 and four visiting staffs are working at present. The number of targets was 69 in 2002 including 32 patients over 70 years old and 20 care-givers over 70 years old. Visiting care has been conducted to a 72-year-old female with diabetes since July 2000. The patient is in bedridden condition and at the beginning of visiting, she was taking oral medication but the condition was worsen by poor glycemic control and changed to insulin injection from June 2002 after admission to the hospital repeatedly. The patient undergoes the measurement of blood sugar daily and takes meals with 1,200 to 1,400 kcal prepared by her husband. The care-giver is a 71-year-old husband. He was an "all-work, no-play" type of person and had never done the housework, but he started to manage both housework and nursing because of bedridden of his wife. He is a reticent theorist, hates illogical behavior, and does not swayed by other opinions. He has accepted the things which need new knowledge and techniques such as measurement of blood glucose and insulin injection. However, for meals, he only bought side dishes and placed them. Care such as keeping the patient clean was in a same state. The patient consulted and admission to the hospital repeatedly because conditions were not stable. Visiting nurse supported daily life of patient and care-giver especially in nutrition instruction to continue home life. As the result, attitude and behavior toward nursing of care-giver were changed and the patient could continue home life. Therefore we reported here.

Parents seek early intervention services for a two-year-old without autism.

Sam is a 27-month-old boy who you have followed since birth. He lives with his parents in a small resort town approximately 90 miles outside a major city. Both his parents are professionals in their late 30s and have been highly involved in his care since birth. At the 12-month visit, they were concerned about his difficulty regulating. He was not sleeping through the night and had significant difficulty with baths. His physical examination and growth were normal. His eye contact was good, although it was difficult to see him smile. He had 1 or 2 words and was beginning to walk independently.At the 15-month checkup, they continued to be concerned about his poor regulation. He napped sporadically, and he was very difficult to take out on errands as he did not like his car seat. He now had approximately 10 single words, was using his fingers to point, and very clearly waved "bye bye" as soon as you entered the room.At the 18-month checkup, they state that he has not yet learned the word "no." He will follow a 1-step command when he wants to but now has 15 single words without any combinations. He points for his needs and to show them something. He has become increasingly "shy" around strangers and prefers to play with one other child as opposed to a larger group. He does not like loud noises and prefers to go barefoot constantly. His physical examination was again normal as was his growth. He is referred for a full hearing evaluation, which is also normal. The family was referred to early intervention, and he began receiving speech and language therapy and occupational therapy for his sensory challenges as well as a play group.At the 24-month checkup, his language continued to consist of single words-now approximately 30. When the parents do not understand what he wants, he will often tantrum and has started banging his head on the floor when frustrated. He has no repetitive behaviors and is starting to demonstrate imaginative play. Bath time has becoming increasingly challenging because he does not like the sensation of soap and the water temperature must be "just right." You refer the child to a Developmental and Behavioral Pediatrician for evaluation and at 28 months he is seen. During his testing visit, he had decreased eye contact and followed his own agenda but improved significantly as testing progressed. As he got more comfortable, he began making good eye contact, social referenced, and exhibited joint attention with his parents and the examiner. He did not meet criteria for an autism spectrum disorder or specifically pervasive developmental disorder-not otherwise specified (PDD-NOS). He was given a diagnosis of mixed receptive and expressive language delay and disruptive behavior disorder with sensory processing problems.The parents come to you a month after their evaluation visit asking you to give him a "listed diagnosis of PDD-NOS" that could be removed when he turns 3 years so that he may qualify for increased hours of services-up to 15 hours per week-as well as applied behavioral analysis therapy. A behavioral therapist through early intervention has told the family that he would benefit from this increased intervention, specifically applied behavioral analysis but the only way he can receive it is with a "medical diagnosis" on the autism spectrum. What do you do next?

[Why are blood pressure values higher in the doctor's office than at home?].

Blood pressure values measured by the patients at home are lower than those measured during medical consultation. To test whether the person measuring the blood pressure is responsible for this difference, the blood pressure of 127 patients was measured first by the doctor and then by the patients themselves during the consultation. There was a good agreement and no significant difference between the two measurements. Values taken at home were however significantly lower. Our results indicate, that difference between clinic and home blood pressure values does not depend on the person performing the measurement.

Electrocardiogram before starting stimulant medications: to order or not?

D is an 8-year-old boy brought to his paediatrician for evaluation. His mother is concerned as his teacher has been frequently complaining that he is very restless and often disturbs the rest of the class by getting up on some pretext or the other. He is unable to concentrate on his work and gets distracted very easily. He makes many careless mistakes and can hardly finish his tasks on time. He is frequently reprimanded for talking during class. He often answers out of turn or before the question has been completed; however, so far, he has been managing to get passing grades. At home, he is constantly on the go while he is awake. If he is forced to sit, like at mealtimes, he fidgets a lot. He also needs to be constantly nagged to do everything, even his daily activities such as brushing his teeth, or he forgets to do them or leaves them incomplete. He takes ages to finish his food. It is a major job to get him to do his homework. His mother says that at home he has been like that since the last 2 to 3 years, but now she is concerned because of the difficulties he is experiencing at school as well. After obtaining his medical history, examination, and getting response from parents and teachers--using Vanderbuilt Assessment Scales--the paediatrician diagnoses him to have attention deficit hyperactivity disorder. Besides behavioural interventions, he considers medications for his management. The paediatrician is debating the merits of performing electrocardiogram and/or referring the boy to a cardiologist before starting stimulant medications. If you were caring for this patient, how would you proceed?

Screening elderly people in primary care: a randomized controlled trial.

A randomized controlled trial was carried out to test the effectiveness of a screening programme carried out by nurses for elderly people aged 75 years and over in a general practice. A total of 151 people were randomly allocated to the test group and 145 to the control group. The test group received a home visit from a nurse at which an assessment lasting 45 minutes was made of: activities of daily living, social functioning, sensory functions, mental and emotional problems, current medical problems, blood pressure, urinalysis, haemoglobin level and compliance with medication. Both groups completed a selection of items from four health indices before and 20 months after the intervention. At follow up, the test group scored significantly better than the control group on a morale scale. However, this trial provided no evidence for better resolution of physical problems or finding activities of daily living easier in the test group compared with the control group. It is suggested that the main benefit of such a screening process is that the special attention and education provided improves adaptation to old age and awareness of the support systems available. The government has proposed an annual review of elderly people in their own home and this study suggests that the objectives of this scheme should be clarified.

A school-aged child with delayed reading skills.

During a health supervision visit, the father of a 7.5-year-old African American second-grader asked about his son's progress in reading. He was concerned when, at a recent teacher-parent conference to review Darren's progress, the teacher remarked that Darren was not keeping up with reading skills compared with others in his class. She said that he had difficulty sounding out some words correctly. In addition, he could not recall words he had read the day before. The teacher commented that Darren was a gregarious, friendly child with better-than-average verbal communication skills. His achievement at math was age-appropriate; spelling, however, was difficult for Darren, with many deleted letters and reversals of written letters. A focused history did not reveal any risk factors for a learning problem in the prenatal or perinatal periods. Early motor, language, and social milestones were achieved on time. Darren had not experienced any head injury, loss of consciousness, or chronic medical illness. He had several friends, and his father denied any behavioral problems at home or at school. His teacher completed a DSM-IV-specific behavioral survey for attention-deficit/hyperactivity disorder (ADHD). It did not show any evidence of ADHD. Darren's father completed 1 year of college and is currently the manager of a neighborhood convenience store. His mother had a high school education; she recalled that she found it difficult to complete assignments that required reading or writing. She is employed as a waitress. Darren does not have any siblings. The pediatrician performed a complete physical examination, the results of which were normal, including visual acuity, audiometry, and a neurological examination. It was noted that Darren seemed to pause several times in response to questions or commands. On two occasions, during finger-nose testing and a request to assess tandem gait, directions required repetition. Overall, he was pleasant and seemed to enjoy the visit. His pediatrician concluded that he had a learning problem but she was uncertain about the next step. She asked herself, "Is there anything else I can do in the office to evaluate Darren's problem with learning? Should I quickly refer him for educational testing or encourage a reading tutor? What questions can I ask his teacher that would be helpful? Am I missing a medical disorder?"

[Effects of written intervention on the number of laboratory studies per patient].

In the context of economic measures in health care we followed over a period of nine months the consequences of a written intervention on the attitude of house staff to prescribe laboratory tests. Since it is well known that these tests have a major impact on health costs several studies have been conducted to test whether costs can be reduced without sacrifice of treatment quality. The study was undertaken in 1997. It had three phases of three months duration each: one for observation, one with the intervention and a follow-up phase. The laboratory tests requested by eleven physicians for their patients during the first month after the initial visit were analyzed. During the intervention--phase six physicians chosen at random were informed about their own average as well as that of the entire group (mean of the entire observation period of all physicians). Unexpectedly the hypothesis that the number of laboratory tests requested per patient would drop only in the group of informed physicians and should stay the same for the physicians without this intervention did not materialize. The number of performed tests dropped in both groups.

Scott: an 11-year-old boy with repetitive lying.

Scott, an 11-year-old boy in the fifth grade, is brought to his pediatrician, Dr. Lewis, by his maternal grandparents with the principle concern that "he lies constantly." Scott lived with his maternal grandparents since he was 2 years old, and they have full custody. His mother and father had serious substance abuse problems. The grandparents provide a stable home for Scott and his 15-year-old sister. Scott has had no contact with his mother in more than 6 years and sees his father infrequently. During the last visit with his father, he was so inebriated that he was thrown out of the movie theatre and barely avoided several car accidents on the way home. He left the children at the curb of their home and made them promise that they would lie to their grandparents about the reasons for the early return. Scott was diagnosed with attention-deficit hyperactivity disorder (ADHD) in second grade. Methylphenidate (36 mg) provides improvement in attention and concentration. His grandfather describes Scott as highly unpredictable. When he is the "good Jake," he is eager to help, polite, and caring. When Scott gets behind in school or is avoiding his chores and assignments, he lies by saying that he got it all done, even though he knows his grandfather will discover the lie and punish him. When confronted with reports from school, Scott often lies and may develop more elaborate confabulatory stories. His grandfather admits that he becomes irate at these moments. He responds by removing Scott's privileges. When he planned to take Scott to see his favorite sport team in the playoffs, Scott was caught in a lie the day of his departure. His grandfather offered him a chance to fess up, pay a small price in extra chores, and save the trip. Scott stubbornly refused to admit that he lied and lost the trip. His grandfather worries that Scott has no "moral compass." He takes things that do not belong to him and violates household curfew rules. He has never been physically aggressive or has never stole items from a store. He takes his sister's CD player or his grandfather's cell phone even when he has been told not to. He will then lie that he did not take it. Even when it is pulled out of his backpack, he will say he did not put it in there. His grandfather is a businessman with high moral integrity. He loves his grandson and is eager to help him. He asks Dr. Lewis what they should do about Scott's persistent lying.

Lot (unit)

A lot is an old unit of weight used in many European countries since the Middle Ages until the beginning of the 20th century. Most often it was defined as either or of a pound (or more precisely of whatever mass value one local pound had at the time). Recorded values range from 10 to 50 grams. In the Imperial and US customary systems of measurement, a lot is of a pound, or an ounce, making it exactly 14.174 761 562 5 grams if derived from the international pound. See also Old Polish units of measurement Obsolete Finnish units of measurement Obsolete Russian units of measurement Obsolete Tatar units of measurement External links :sk:Libra (hmotnosť) an extensive (20+) list of values (in grams) a pound had at various times and places in Europe :bg:Фунт (единица) a historical value of lot in Bulgaria Obsolete units of measurement Units of mass

Maintaining Safety and Planning for the Future.

Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a "clock-training" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to "cook." After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a "home" where someone will "do bad things to him."What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?