The rising costs of health care and the lack of integration between parts of the delivery system has led to discussion and experiments on new forms of delivering care. Governments have included the development of ambulatory care in new statements of objectives and goals in the hope that expenditures might be reduced through the reduced use of acute care hospital beds. This is a study of the experience surrounding an acute care hospital's attempts to have a Medical Day Care Program accepted by the government as an adjunct to the existing Ambulatory Care Services of the hospital. As Director of Nursing at the hospital it was possible to follow the sequence of events, concept development, proposal design, ministry involvement, implementation and evaluation. A diary was kept for one year following implementation of the program as a pilot project and project documents have contributed to the analysis of events. What was not readily apparent were the many forces outside the hospital which were impacting on the likelihood of the proposal's acceptance. Since Ambulatory Care was the health policy of the 1970's it was puzzling to find the Ministry of Health unresponsive to a proposal which seemed most appropriate. In attempts to resolve the puzzle regarding the lack of interest in ambulatory care at the hospital level, other developments in the province were reviewed. Planning models were explored seeking explanation for inconsistencies observed between stated government objectives and government behavior in relation to the development of hospital ambulatory care. More satisfactory explanations were found in a political model than in planning models, in the light of actual developments. Some conclusions are drawn about the impact of political realities on management functions in health care institutions. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

The purpose of this research was the development of an instrument to measure the complexity of nursing care requirements in ambulatory care settings. Charles Perrow's sociological theory of organizations was adapted to nursng in order to define the complexity concept. Four research questions were investigated in this study. These questions related first, to the construct validity of the instrument's activity category system; second, to the criterion validity of the complexity weighting system; third, to the equivalent reliability to the instrument and fourth, to the instrument's clinical generalizability. Construct validity was evaluated through the regression of subjective estimations of complexity on the individual categories which make up the 154 ratings that contained measurement error, 641 independent client ratings remained for analysis. This data indicated that the classification instrument accounted for 52 percent of the total nursing care complexity in the ambulatory setting. An 18 variable equation was as statistically effective in explaining complexity as was the original 44 variable equation. Criterion validity was examined by comparing empirical complexity weights established through the regression of subjective complexity estimations on activity categories with theoretical weights determined by nurse experts in a Delphi exercise. Kendall's tau, a measure of rank association, was used for analysis. This examination revealed no statistically significant direct association between empirical and theoretical sets of complexity weights. Equivalent reliability was investigated by looking at the percent agreement among six trained raters using the classification instrument. The data indicated agreement on ratings was above 90 percent which met the criterion pre-established for interrater reliability. Finally, by a graphical analysis of residuals from regression equations, instrument generalizability across clinical services was examined. The Ambulatory Care Client Classification Instrument was not found to be generalizable in explaining the complexity of nursing care requirements across the clinical services used in this research.

No description available.

Faculty of Health Sciencs School of physiology 0010633J bnkeh@uycdc.uninet.m / Blood pressure (BP) is a heritable trait. However, the loci responsible and the mechanisms by which these genes determine BP are uncertain. Based on widely published data regarding frequent phenotypic characteristics that exemplify essential hypertension (EHT) in persons of African ancestry, in the present thesis I explored the role of gene candidates most likely to contribute to BP in this group. In this regard a high frequency of persons of African descent experience increases in BP in response to an enhanced salt intake (salt-sensitive hypertension). In addition, many patients of African origin with EHT fail to respond to inhibition of angiotensin-converting enzyme (ACE) with an appropriate decrease in BP, a factor that cannot be explained entirely on the basis of reduced plasma renin levels in this group. Thus, I evaluated the role of several gene variants that could influence either renal salt handling or the activity and effects of the renin-angiotensin system on BP in subjects of African ancestry. Although the angiotensinogen (AGT) gene has at least 3 variants in the promoter region that influence angiotensinogen expression and which occur with a remarkably high frequency in populations of African ancestry, their role in this group is still controversial. To-date, interactions between these variants have not been considered. Using a casecontrol study design in a sample of 1325 subjects, as well as association analysis with 24 hour ambulatory BP (ABP) values in 626 hypertensives, I confirmed that an independent effect of functional AGT gene variants on the risk for EHT or 24 hour ABP was weak at best. Importantly, however, interactions between the -20A C and -217G A variants were noted to strongly impact on the risk for EHT as well as ABP. Furthermore, interactions between the -20A C and -217G A variants played a major role in iii contributing toward the variability of ABP responses to ACE inhibitors, but not calcium channel blockers in this population group, with genotype determining whether or not ACE inhibitor responses occurred. Although the 825C T polymorphism of the guanosine triphosphate (G) protein 3 subunit (GNB3) gene influences the activity of a substance that modifies renal salt handling, namely the Na+/H+ exchanger, its impact in hypertensives of African descent is controversial. In the present thesis I confirmed in a large sample that the GNB3 variant was not associated with the risk for EHT or ABP values in subjects of African ancestry. However, because the activity of the exchanger is enhanced in obesity I hypothesised that the GNB3 gene variant could mediate a clinically relevant BP effect by modifying the impact of body size on BP (type I or II genetic effect). Indeed, GNB3 genotype proved to be a strong determinant of the impact of body size on systolic BP values, with genotype determining whether or not the effect occurred. The epithelial sodium channel (ENaC) and atrial natriuretic peptide (ANP) have an important influence on renal salt handling. The T594M polymorphism of the -subunit of the ENaC gene only exists with a relatively high frequency in subjects of African ancestry. Previous studies conducted in this population group in relatively small samples have indicated that the ENaC and ANP gene variants determine BP in subjects of African descent. In a larger sample of subjects of African descent I demonstrated that the T594M polymorphism of the ENaC gene has no impact on BP in this population group. However, my results suggest that the ANP gene may be a candidate worthy of further study. In conclusion, the results described in this thesis provide evidence that lends some clarity to the role of likely gene candidates for BP control in people of African descent. iv Importantly, data from this thesis suggest that interactions between functional variants of specific loci (e.g the AGT gene), and clinically relevant type I or II genetic effects (no independent actions, but modifier gene effects, e.g, GNB3) should be considered before excluding loci as playing an important role in BP control. Moreover, this thesis provides the first substantial data to indicate that gene variants determine the variability of BP responses to pharmacological agents in hypertension in this population group.

Thesis (M. Soc. Sc.)--University of Hong Kong, 2003.

Thesis (Ph. D.)--Georgia State University, 2008. / Title from file title page. Upkar Varshney, committee chair; Peter Meso, Yi Pan, Anu Bourgeois, committee members. Electronic text (192 p. : ill. (some col.)) : digital, PDF file. Description based on contents viewed Sept. 23, 2008. Includes bibliographical references (p. 184-192).

Thesis (M.A.)--York University, 2008. Graduate Programme in Kinesiology and Health Science. / Typescript. Includes bibliographical references. Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&res_dat=xri:pqdiss&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&rft_dat=xri:pqdiss:MR45926

published_or_final_version / abstract / toc / Surgery / Master / Master of Surgery

No description available.

Walking is an essential task important to recovery after stroke. However, there is a limited understanding regarding the characteristics of walking in in-patients with stroke. The objectives of this thesis were to: 1) develop an instrument capable of acquiring temporal characteristics of everyday walking; 2) investigate the quantity and control of everyday walking; and 3) profile the task-specific link between walking and cardiorespiratory response. In study 1 we developed and validated a wireless monitoring system (ABLE system). Study 2 revealed low quantities of everyday walking (4816 steps; SD 3247) characterized by short bout durations (59.8s; SD 23.4) and asymmetric walking. In study 3 we observed a modest task-related response in HR(19.4% HRR); however, the intensity and duration of everyday walking did not approach the guidelines for aerobic benefit. Monitoring in-patient walking can help guide clinical decision making in developing methods to maximize recovery after stroke.