A interconsulta cardiológica corresponde a uma parcela considerável das atividades assistenciais e de ensino do cardiologista, refletindo gasto extra de tempo e recursos. Apesar disso, essa atividade não tem recebido a devida atenção da literatura, com poucos estudos sobre o tema. O objetivo do presente estudo foi, primariamente, comparar a evolução clínica dos pacientes envolvidos na interconsulta cardiológica que tiveram as recomendações seguidas pela equipe médica solicitante (grupo ACEITADOR) com aqueles em que as recomendações não foram seguidas (grupo NÃO ACEITADOR). De forma secundária, procuramos identificar as variáveis determinantes da aceitação das sugestões da equipe cardiológica. Para isso, foi realizado um estudo observacional envolvendo pacientes internados no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, para os quais foram solicitadas interconsultas cardiológicas, no período de março a setembro de 2008. Os dados referentes às interconsultas foram coletados pelo investigador de maneira prospectiva a partir do prontuário dos pacientes. Dentre as 589 interconsultas selecionadas para o estudo, 271 consistiam em avaliações clínicas e 318 avaliações pré-operatórias. Em relação à taxa de aceitação das recomendações cardiológicas, 77% dos pacientes foram classificados no grupo ACEITADOR e 23% classificados no grupo NÃO ACEITADOR. A análise da evolução clínica demonstrou que, dentre os pacientes do grupo NÃO ACEITADOR, 38,8% evoluíram de forma desfavorável (piora clínica ou óbito) contra 5,4% dos pacientes do grupo ACEITADOR (P<0,0001). Após análise de regressão logística, pertencer ao grupo NÃO ACEITADOR (P<0,001; OR 10,25; IC 95% 4,45 - 23,62) e a idade dos pacientes (P=0,017; OR 1,04; IC 95% 1,01 1,07) estiveram associados de forma independente a uma evolução clínica desfavorável. Foram identificados quatro preditores independentes de aceitação das recomendações: a realização de visitas de seguimento (P<0,001; OR 2,43; IC 95% 1,48 4,01), reforço verbal das recomendações (P=0,001; OR 1,86; IC 95% 1,23 2,81), número de recomendações sugeridas (P=0,001; OR 0,87; IC 95% 0,80 0,94) e idade dos pacientes (P=0,002; OR 0,98; IC 95% 0,96 0,99). Portanto, na presente análise, a não aceitação das recomendações da equipe cardiológica por parte da equipe médica solicitante esteve associada a uma evolução clínica desfavorável dos pacientes envolvidos. A realização de visitas de seguimento, reforço verbal, número limitado de recomendações e a menor idade dos pacientes estiveram associados a uma maior aceitação das recomendações da equipe cardiológica / Cardiology referral represents an important part of cardiologist activities, accounting for substantial workload and demanding extra time and resources. Despite the importance of these facts, it has received little attention in the medical literature in the last years. The purpose of this study was to compare the clinical outcome of patients involved in cardiology referral who had the cardiologic recommendations followed by the requesting service (ACCEPTING group) with those whose recommendations were not followed (NON-ACCEPTING group). Secondly, we aimed to determine which of the variables involved in cardiology referral were related to acceptance to consultants recommendations. An observational study was performed at Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, involving cardiology consultations during the months of March 2008 through September 2008. Data regarding consultations were prospectively extracted from the medical records by a physician-researcher. Among the 589 cardiology consultations selected for the study, 271 were clinical evaluations and 318 were preoperative evaluations. Regarding compliance of the referring service in following the recommendations offered by cardiology team, 77% of patients were classified in the ACCEPTING group and 23% in the NON-ACCEPTING group. A clinical outcome analysis was performed and showed that 38,8% of patients allocated to NON-ACCEPTING group had evolved unfavorably (clinical deterioration or death) against 5,4% of patients allocated to accepting group (P<0.0001). After logistic regression analysis, belong to NON-ACCEPTING group (P<0.001; OR 10.25; CI 95% 4.45 23.62) and patients age (P=0.017; OR 1.04; CI 95% 1.01 1.07) were variables independently associated to an unfavorable clinical outcome. The multivariate analysis indentified 4 independent predictors of acceptance to consultants recommendations: follow-up notes in the chart (P<0.001; OR 2.43; CI 95% 1.48 4.01), personal communication (P=0.001; OR 1.86; CI 95% 1.23 2.81), number of recommendations (P=0.001; OR 0.87; CI 95% 0.80 0.94) and patients age (P=0.002; OR 0.98; CI 95% 0.96 0.99). Therefore, in this analysis of cardiology referral, a poorer acceptance of cardiologic recommendations was associated to an unfavorable clinical outcome. Follow-up notes in the chart, personal communication, limited number of recommendations and lower patients age were associated to greater acceptance of cardiologic recommendations

This study investigated time lost to office discipline referrals (ODRs), systematically replicating a prior study (Church, 2015) in rural school districts. An on-line survey asked administrators, general education, and special education teachers in four county districts for: a) demographic information; 2) estimated minutes lost to ODRs generally, specific ODR types, and for students with (SWD) or without disabilities (not SWD); and, 3) whether the respondent’s school implemented School-wide Positive Behavior Supports (SWPBS). ODRs generally took 16.9 minutes. Special Education teachers’ time (mean 23.6 min.), was Lost time was affected by ODR type (aggression, noncompliance, disruption mean 23 min.; not finishing work, inappropriate language, cell phone use mean 12.33 min.) and disability (SWD mean 20.2 min; Not SWD mean 15.17 min). Respondents reporting SWPBs had longer ODR times (mean 19.13 min.) than respondents without SWPBS (mean 16.77 min.). Implications for future research and the evaluation of SWPBS programs were discussed.

Transgender and gender nonconforming (TGNC) people who pursue gender affirming medical interventions, such as hormone therapy and surgery, are required to supply their physicians with referral letters from mental health professionals (Coleman et al., 2012). The process by which TGNC people are required to obtain referral letters before accessing gender affirming care is often referred to as gatekeeping in the TGNC literature (Budge, 2015; Cavanaugh, Hopwood, & Lambert, 2016). Despite implications that the current gatekeeping system may have for the relationship between TGNC clients and their therapists, few studies have examined TGNC individuals’ experiences related to obtaining referral letters in therapy (Bess & Stabb, 2009; Elder, 2016). This study used semi-structured interviews and a grounded theory approach to qualitatively examine the experiences of 15 TGNC individuals who have obtained a referral letter for gender affirming medical intervention from their therapists. Thematic analysis revealed two core themes: (1) “blessings” that TGNC individuals experienced because of the referral letter requirement and (2) “bullsh*t” (or “BS”) participants endured due to this requirement. Implications for psychotherapy practice and training, as well as healthcare policy, are discussed.

This study examined teachers’ beliefs about mental health issues in students. A quantitative research method was utilized, and survey instrument was created modeled after the theory of planned behavior. Thirty-seven teachers were surveyed in five areas in relation to their beliefs about assessment and referral; including, previous assessment and referral; mental health training; attitudes toward assessment and referral; the perceived social normality of assessment and referral; and perceived self-efficacy or behavior control. These five areas became independent variable measures, with the dependent variable being their future intention of assessing and referring students with mental health issues. Multiple regression analysis revealed that the overall model was statistically significant in predicting teachers’ intention to assess and refer students; however, independent analysis of independent variable revealed teachers’ attitudes, past behavior, and accesses to mental health training were most the most significant predictors of future intention. Implications of this study highlight the need qualified mental health professionals to be present in schools and/or expanded training of teachers.

The rate of obesity continues to rise in the United States and globally, placing populations at increased risk of obesity related conditions, such as diabetes, hypertension, heart disease, cancer, and other disease states. Literature review shows that there have been many different methods utilized to halt obesity's progression, however rates continue to increase. The United States Preventative Services Task Force (USPSTF), American Heart Association (AHA), and other agencies recommend obesity screening and counseling at every patient encounter, but most hospitals do not have a current obesity policy in place to accomplish this task. The purpose of this project is to develop a program proposal for a hospital-based, obesity tool based on the 5 A's framework to increase screening and referrals of obese, adult patients ages 18 and over. The logic model was utilized to guide the program development, implementation, evaluation, and dissemination. The program was accepted by the hospitalist group and nurse leaders for full development and evaluation. Key stakeholders and content experts were convened to create a proposal and algorithm to guide the project. The obesity program will increase screenings and referrals upon full adoption. Increase in screenings and referrals will improve care, quality of life, weight status, and decrease health care expenditure. The results of dissemination of the program may stimulate other facilities to adopt the program to combat obesity and contribute to social change The rate of obesity continues to rise in the United States and globally, placing populations at increased risk of obesity related conditions, such as diabetes, hypertension, heart disease, cancer, and other disease states. Literature review shows that there have been many different methods utilized to halt obesity's progression, however rates continue to increase. The United States Preventative Services Task Force (USPSTF), American Heart Association (AHA), and other agencies recommend obesity screening and counseling at every patient encounter, but most hospitals do not have a current obesity policy in place to accomplish this task. The purpose of this project is to develop a program proposal for a hospital-based, obesity tool based on the 5 A's framework to increase screening and referrals of obese, adult patients ages 18 and over. The logic model was utilized to guide the program development, implementation, evaluation, and dissemination. The program was accepted by the hospitalist group and nurse leaders for full development and evaluation. Key stakeholders and content experts were convened to create a proposal and algorithm to guide the project. The obesity program will increase screenings and referrals upon full adoption. Increase in screenings and referrals will improve care, quality of life, weight status, and decrease health care expenditure. The results of dissemination of the program may stimulate other facilities to adopt the program to combat obesity and contribute to social change The rate of obesity continues to rise in the United States and globally, placing populations at increased risk of obesity-related conditions, such as diabetes, hypertension, heart disease, cancer, and other disease states. A review of the literature showed that multiple methods have been used to address the rate of progression; however, obesity rates continue to increase. The U.S. Preventative Services Task Force, American Heart Association, and other agencies recommend obesity screening and counseling at every patient encounter; most hospitals do not have a policy to accomplish this task. The purpose of this project was to develop an obesity screening and referral tool for the hospital setting. The resulting tool was based on the 5 As framework to increase screening and referrals of obese patients. The logic model was used to guide program development, implementation, evaluation, and dissemination. Results of the obesity screening and referral program showed an increase in screenings and referrals upon a trial adoption, raising the number of identified referrals to 23, compared to 2 patients identified for referral prior to program implementation (p = 0.035). An increase in screenings and referrals can bring about positive change by improving care, quality of life, and weight status of patients and decreasing health care expenditure.

Disruptive classroom behavior has led many schools to implement positive behavioral strategies intended to create orderly learning environments. Despite initiation of such a strategy, an elementary school in the mid-Atlantic region still experienced an increase in office referrals and a decline in student achievement. The purpose of this mixed methods case study was to investigate the connections between a blended behavior program and student behavior and academic achievement, as well as staff perceptions about their experience with the program, and the degree to which the practices were implemented with fidelity. Skinner's behavioral theory served as the theoretical basis for the investigation. Office referrals and standardized math scores of 72 students were analyzed across 3 years, including the year before and the 2 years following the implementation of the blended behavior program, to determine whether significant differences existed within-subjects. Interviews were conducted with 9 teachers, representing kindergarten-6th grade, to explore staff perceptions of the blended behavior program. Quantitative results indicated a reduction in referrals after the 1st year of implementing the blended program and an improvement in math achievement after the 2nd year. While a decline in math scores occurred the 1st year of implementation and an increase the 2nd year, the difference in net performance rendered the results inconclusive to determine the influence of the program on achievement. Qualitative results revealed inconsistencies in the way teachers implemented the program initiatives. This study contributes to positive social change by providing stakeholders a deeper understanding of the blended program and increasing staff capacity to manage challenging behaviors.

This study was designed to answer two research questions. First, factors associated with placement decisions to three treatment modalities in a university counseling center were examined; the skills training group for dialectical behavior therapy plus individual therapy (DBT), the interpersonal process group plus individual therapy (IP), and individual therapy only (IND). Individual therapy in all three conditions did not follow a specific theoretical orientation. Of 203 participants (55 males, 148 females), 83 were in DBT, 53 were in IP, and 67 were in IND. Client information included demographic variables (e.g., age, gender) and clinical variables (i.e., diagnosis, and scores from Global Assessment of Functioning, the Outcome Questionnaire-45; OQ-45, and the College Adjustment Scale; CAS). As predicted, the results indicated that clinical characteristics played a significant role in referral decision making, with clients in the DBT condition reporting higher clinical severity. Second, the effectiveness of the skills training group (DBT) was examined, testing the hypothesis that people in DBT start out with more clinical problems but make greater progress than those in IP and IND. Treatment outcome was measured by the OQ-45 and the CAS, each collected at multiple time points. Data from 101 people were available for the OQ-45, and 77 people for the CAS. The results did not provide support for the hypothesis. Although significant change was observed over the course of treatment, no clear patterns of superior outcomes for any of the three treatment conditions emerged.

This thesis concerns a research project about psoriasis care and conse¬quences of psoriasis in the county of Västerbotten in Northern Sweden. The overall aim of the thesis is to contribute to improvement of psoriasis care through increased knowledge of the use and accessibility of psoriasis care, and knowledge of impact of psoriasis on patients’ daily lives by describing and interpreting: (i) accessibility and use of psoriasis care, (ii) consequences of having psoriasis in everyday life, and (iii) dilemmas in psoriasis care and visions of future care among professionals, politicians and administrators. The theoretical framework in the psoriasis project was based on previous research, theories and concepts about priority setting, stigma, coping and qual¬ity of life. Parts of the framework were basis of the project plan and other parts were included in order to analyse the findings. Two different methodological approaches were used as complement to each other. The project started with a questionnaire to all known persons with psoriasis in Västerbotten with ques¬tions about socio-economic factors, psoriasis symptoms, psoriasis care, and quality of life. These formed the basis for two studies. The first focused on quality of life, and the other on gender differences in psoriasis care. Qualita¬tive research interviews were made with persons with psoriasis, and with ad¬ministrators, politicians and professionals. The interviews formed the basis for two studies focusing on consequences of psoriasis, and priorities and visions in psoriasis care, respectively. Findings from the studies are reported in four papers. Accessibility of psoriasis care influenced the use among persons with pso¬riasis. Use was also influenced by age, income, joint symptoms and quality of life. Men used psoriasis care more often than women. Both genders expected professional care and amelioration, while more women valued polite treat¬ment. Expectations were fulfilled apart from amelioration. Among decision makers, accessibility and issues on organisation and ethics involved priority dilemmas. The persons with psoriasis stated that visibility of both skin psoria¬sis and joint changes, as well as being stigmatised, was the worst with living with psoriasis. The visibility and stigmatisation were most difficult in younger ages. Some of those with both rashes and joint changes thus felt stigmatised in a twofold way. In order to deal with these difficulties, commonly used coping strategies were routinisation of both treatment and of adjustment to the stigma¬tising process, a strategy which could not be found in literature, and accep¬tance. These strategies developed with age. Those with large disease extent and joint symptoms run the highest risk of impaired health-related quality of life. Most of the interviewed participants, took power over their lives and by using coping strategies created an acceptable personal quality of life for them¬selves. Still they could not find anything positive with having psoriasis. In specialised care as well as local health care, special attention should be paid to gender differences and distance to treatment facilities, and handling of possible stigmatisation in patient care. This thesis suggests that the coping theories should be complemented with routinisation as a coping strategy for psoriasis patients. Also, more research on the usefulness of the letter of referral and its consequence on equality and fairness are suggested.

An efficient referral system is essential in providing access to emergency obstetric care at higher levels of care by supporting antenatal and delivery services in the primary level of care facilities (PLCF). The aim of this thesis was to assess community and health service factors affecting the quality of maternal referrals in rural Tanzania. Ten focus group discussions (FGDs) with health workers and community members were conducted to describe their perceptions on maternal referrals. Women (n=1118) were interviewed to determine awareness of obstetric danger signs and associated factors. Compliance with referral advice was analysed for 1538 women referred from PLCF. Counselling on danger signs and adherence to referral criteria was observed in 438 antenatal consultations. FGDs indicated that women had limited influence, especially on emergency referrals. The process of deciding to seek referral care considered the perception of seriousness and past experience of referral, access to transport, and the cost involved. Women had low awareness of danger signs of obstetric complications: higher years of schooling increased the likelihood of being aware of danger signs. Demographic risks accounted for 70% of referred women but less than half complied with the advice. Compliance was higher for historical obstetric risks, prenatal, natal, and postnatal complications groups. Few women were counselled on pregnancy danger signs and a significant number with ≥5 pregnancies and primigravidae &lt;20 years were not informed of the risk factors. This thesis demonstrated a need for reviewing referral guidelines and an increase in supportive supervision for health workers counselling on obstetric danger signs to enhance acceptance of referrals advices. Women’s education should be given priority for increasing participation in decisions and becoming more aware of danger signs. Costs involved in maternal referrals can be relieved by improving family income, infrastructure, and alleviating the cost of referral through mobilising community transport and financial schemes.

Muscle fatigue is ubiquitous in every day life.Muscle fatigue might be considered as an altered state of motor behaviour, which impairs motor performance. By contrast, muscle fatigue could also be considered a positive phenomenon, which protects muscle tissue from damage that might be incurred to it by overuse. The principal aim of the thesis was to explore some of the mechanisms of muscle fatigue at the spinal level in animal models.The activation of multiple motor units of a single calf muscle may influence contractile properties of its neighbouring, otherwise inactive units, providing evidence for spatial spreading of fatigue between different muscle parts. The release of metabolites, their action on inactive muscle units and the effects of local hypoxia are the most likely causes. Fatigue-induced metabolite shift in the interstitium provokes excitation and/or sensitisation of high-threshold afferent fibers, with complex effects on the spinal premotoneuronal network involved in the modulation of motoneuronal output. This was examined by studing the intrasegmental lamellar distribution of the lumbar spinal interneurons following fatiguing contractions of the triceps surae muscle. Furthermore, fatigue of calf muscles enhanced the activity of fusimotor neurons to these muscles irrespective of the regime of muscle activity (isometric vs. lengthening) in conditions that simulate locomotion. Altered fusimotor activity, through increased or maintained muscle spindle afferent responsiveness may be advantageous, providing support to the skeletomotor activity and enhanced information about muscle periphery to higher nervous centres. The particular effects of interneuronal network at motor input (presynaptic inhibition system) and output (recurrent inhibition system) stages were then addressed. Fatigue of triceps surae muscle induced a suppression of the monosynaptic reflex. The intensity of presynaptic inhibition increased, while the intensity of recurrent inhibition decreased. Post fatigue-evoked changes in monosynaptic reflexes and presynaptic inhibition indicate the possibility that high-threshold afferents inhibit group Ia terminals pre-synaptically, which would allow fatigue-induced signals from the muscle to reduce the relevance of proprioceptive feedback. Besides intrasegmental, intersegmental spreading of nociceptive signals was explored. Activation of sensory afferents from dorsal neck muscles by capsaicin induces powerful activation of interneurons located in the cervical spinal cord, as well as a widespread activation of cells in lumbar spinal cord segments. The results confirm the pivotal role of small diameter muscle afferents in the orchestration of segmental responses to fatigue and show complex interactions that may lead to limited accuracy of motor output. They also depict processes that may be related to, and even become precursors of chronic muscle pain.