Human Services Department Heal (298 results)

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Paperback. Condition: new. Paperback. The goal of this technical review is to examine critical issues of care coordination for children with special health care needs. It is intended to supplement the more comprehensive Evidence-based Practice Center (EPC) report on care coordination currently under preparation. Experts in the field such as Perrin and colleagues and Stein have described in detail the requirements for providing coordinated care for children with complex medical needs. In addition, professional organizations such as the American Academy of Pediatrics and a variety of advocacy groups and service programs for families with children with special health care needs have developed care coordination strategies and developed very useful guidance materials regarding this issue. These sources, while embracing general principles of care coordination that are relevant for all populations and age groups, emphasize those elements of care that are of particular importance for children with special health care needs. Although quite varied, they tend to be due to (1) the dependence of children on parents or other adult caretakers; (2) the distinct epidemiology of childhood and its implications for the organization of health services; (3) the developmental nature of child health problems and the need to link care with educational institutions; and (4) the special financial basis for child health and related services. The inherent dependence of children on adults acting on their behalf adds a level of complexity to care coordination efforts in that the facilitation, monitoring, and at times the enforcement of this proxy function must always be incorporated into coordinative programs for children. The most important distinctive characteristic of the epidemiology of childhood is that unlike in the elderly, serious chronic illness is relatively rare. This requires that specialized services for children with such disorders are heavily dependent on regional referral centers, programs that maintain the expertise, volume of patients, and resource commitment to address these serious but relatively rare disorders. The developmental nature of childhood implies that the problems and service needs of children will be highly dynamic over time and involve developmental support services, such as early intervention programs, as well as school-based interactions. Because children are the poorest segment of our population, poverty and means-tested public programs, such as Medicaid, are of particular concern in developing and evaluating care coordination efforts for children. In general, these efforts for improving the coordination of care for children with special health care needs have taken two forms: Specialized care coordination interventions for selected clinical populations. These include the use of case managers, the establishment of a medical home, or home care strategies. The structural organization of health care services. The dominant current approach is managed care. What has generally been lacking is an assessment of the evidence regarding the actual impact of care coordination efforts on outcomes for children with special health care needs. In response, this technical review is directed at the evaluative literature, those published reports that attempt to assess the experience of children with special health care needs and their families in response to purposeful care coordination efforts. Specifically, the technical review addresses the following objectives: 1. To identify and critically examine studies that empirically evaluate models of care coordination interventions for children with special health care needs. 2. To identify and critically examine studies that empirically evaluate the impact of managed care on children with special health care needs, particularly those enrolled in Medicaid. 3. To develop recommendations for future research and the Shipping may be from our UK warehouse or from our Australian or US warehouses, depending on stock availability.

Paperback. Condition: new. Paperback. The systematic review "Treatments of Common Hip Fractures," completed in August 2009, was the result of a topic nomination made by the American Academy of Orthopaedic Surgeons, who were planning to formulate clinical guidelines for surgical procedures for implantable devices. The nominator was interested in understanding the interaction between patient factors, fracture types, types of surgical implants, and outcomes. Following refinement, the key questions addressed were: Key Question 1. What is the relationship between patient variables (e.g., demographic factors, comorbidities), the type of fracture (i.e., intertrochanteric, subtrochanteric, subcapital) and post-treatment outcomes (e.g., pain, mobility, mortality)? Key Question 2. What is the relationship between the type of fracture (i.e., intertrochanteric, subtrochanteric, subcapital) and post-treatment outcomes (e.g., pain, mobility, mortality)? Key Question 3. What is the relationship between implant variables (e.g., position, material, method, and design of implant) and patient posttreatment outcomes (e.g., pain, mobility, mortality)? Key Question 4. What is the relationship between the type of intervention (e.g., internal fixation versus arthroplasty) and patient post-treatment outcomes (e.g., pain, mobility, mortality)? The systematic review was unable to fully answer the research questions with the existing literature generally because of two main factors: (1) the limited perspective of discipline-specific investigations (i.e., orthopaedics or epidemiology), which tended to use incomplete sets of important independent variables in study designs and models, and (2) the generally low quality of hip fracture outcome studies to date, where specific populations were poorly defined, and the use of inconsistent outcome variables prevented aggregating or even comparing results. The latter problem of inconsistent outcomes measures is a general issue for most mobility literature. Additionally, very little literature was available to provide evidence for the multitude of comparisons of device variables within a class of devices, i.e. number of screws or the specific design for sliding hip screw implants. With this inability to show either greater effectiveness or equivalency between device variables, or between devices within a class, aggregating the comparisons at the level of head to head comparisons of classes of devices becomes problematic. Shipping may be from our Sydney, NSW warehouse or from our UK or US warehouse, depending on stock availability.

Paperback. Condition: new. Paperback. Plasma cell dyscrasias (PCDs) are a group of clonal disorders characterized by the uninhibited expansion of a monoclonal population of malignant plasma cells. Plasma cells arise from B cells in the bone marrow and produce immunoglobulins that constitute the body's normal humoral immune response. The immunoglobulin molecule is composed of a heavy chain and a light chain. Plasma cells normally produce light chains in excess that do not bind to heavy chains to form a complete immunoglobulin molecule and instead enter the bloodstream as free light chains (FLCs). In PCDs, each abnormally expanded clone of malignant plasma cells produce an excess of either intact immunoglobulin or FLCs of a single type called a monoclonal protein (Mprotein) or paraprotein. The serum FLC (SFLC assay (the Freelite(TM) Assay, The Binding Site Ltd., Birmingham, United Kingdom) was introduced in 2001 to measure the FLC component in particular. The SFLC assay works by recognizing an epitope that is detectable only on light chains that are not bound to the heavy chain of the immunoglobulin molecule (i.e., FLCs) in the serum. It has been suggested that the SFLC assay could play an adjunctive role in screening, diagnosis, monitoring, and prognosis of PCDs in high-risk populations. The assay could allow for quantitative monitoring of response and remission after treatment and provide prognostic information, potentially reducing the need for frequent bone marrow biopsy for purposes of quantifying plasma cells, which is required as part of stringent monitoring for monoclonal gammopathy of undetermined significance (MGUS) progression to multiple myeloma (MM) or defining disease remission, and potentially could be used in conjunction with serum protein electrophoresis (SPEP) and serum immunofixation electrophoresis (SIFE) to replace urine tests that require 24-hour collection (urine protein electrophoresis [UPEP] and urine immunofixation electrophoresis [UIFE]), which could simplify diagnosis and disease monitoring. The SFLC assay may also be the only means of detecting a disease marker in some disease settings: nonsecretory MM, where SFLCs are often the only marker of the disease; AL amyloidosis (systemic amyloidosis in which amyloid [A] proteins derived from immunoglobulin light chains [L] are deposited in tissue), where low monoclonal protein (M-protein) concentrations may not be detected by means of conventional techniques; and light chain MM, where the M-protein consists only of FLCs. The following Key Questions are reviewed. KQ 1: Does adding the SFLC assay and the kappa/lambda ratio to traditional testing (SPEP, UPEP, SIFE, or UIFE), compared with traditional testing alone, improve the diagnostic accuracy for PCDs (MGUS, MM, nonsecretory MM, or AL amyloidosis) in undiagnosed patients suspected of having a PCD? KQ 2: As compared with traditional tests, how well does the SFLC assay independently predict progression to MM in patients with MGUS? KQ 3: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), does the use of the SFLC assay result in different treatment decisions as compared with traditional tests? Does the use of the SFLC assay affect the management of patients by allowing for earlier institution of specific therapies? Does the use of the SFLC assay influence the duration of treatment? Does the use of the SFLC assay influence the type of treatment (e.g., radiation therapy)? KQ4: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), is the SFLC assay better than traditional tests in indicating how the patient responds to treatment and of outcomes (overall survival, disease-free survival, remission, light chain escape, and quality of life)? KQ 5: In patients with an existing diagnosis of PCD (MM, nonsecretory MM, or AL amyloidosis), does the use of the SFLC assay Shipping may be from our UK warehouse or from our Australian or US warehouses, depending on stock availability.

Paperback. Condition: new. Paperback. Wheeled mobility or wheelchair use in the U.S. is at an all-time high and growing. A 2005 survey of noninstitutionalized Americans estimated that approximately 3.3 million people (1.4 % of the population) 15 years of age and older used a wheelchair or similar device. Of those 3.3 million, approximately 1.8 million were 65 years and older (5.2 % of that population). Among children under 15 years of age, an estimated 83,000 used a wheelchair or similar device (0.2 % of that population). A similar survey conducted in 2002 estimated use at 1.2 % of the population 15 years and older, 4.5 % of the population 65 years and older, and 0.2 % of the population under 15 years of age. An earlier survey (1994-1995 data) of noninstitutionalized individuals in the U.S. estimated that there were 1.6 million (0.6 %) wheelchair users of all ages including 88,000 under age 18 years (0.12 %) and 897,000 (2.87 %) 65 years of age and older. Of the total group of wheelchair users, 1.5 million used manual wheelchairs and 155,000 used electric wheelchairs. The leading conditions associated with wheelchair use included stroke, osteoarthritis, multiple sclerosis, absence or loss of lower extremity, paraplegia, orthopedic impairment of lower extremity, heart disease, cerebral palsy, rheumatoid arthritis, and diabetes. At the same time that the population of mobility-impaired individuals is growing, advances have been made in mobility device and component technology. Although difficult to quantify, there appears to be increased use of power mobility devices, including power wheelchairs and scooters or power-operated vehicles. Advances in wheeled mobility offer enhanced functionality. Mobility devices have been shown to increase the activity, participation, and quality of life of individuals with mobility limitations. The degree to which these wheeled mobility devices and components (notably postural seating and positioning systems) contribute to quality of life depends on the appropriateness of the wheeled mobility device selected for the patient and their utilization of the device. However, inappropriate mobility devices may result in harms (including overuse or repetitive strain injuries, pressure sores, falls, and accidents), equipment abandonment, and underutilization. Interest in identifying an evidence-based wheeled mobility service delivery process that could guide decisionmaking regarding coverage for individually configured mobility equipment and associated services, often referred to as Complex Rehab Technology (CRT), prompted the nomination of this topic. Evidence based guidelines for best practice might address areas such as critical components of the assessment and followup, selection of appropriate equipment based on patient needs, essential members of the service delivery team, provider qualifications, and frequency of reassessment. To address this need, we prepared a Technical Brief to identify and describe the literature and expert opinion regarding the process of wheelchair service delivery for long-term wheelchair users with complex rehabilitation needs (i.e., individuals with a primary diagnosis resulting from a congenital disorder, progressive or degenerative neuromuscular disease, or from certain types of injury or trauma who will require a wheelchair for mobility beyond a period of rehabilitation). The Brief provides background information on the wheeled mobility service delivery process for stakeholders interested in wheelchair service delivery, including researchers, patients, providers, suppliers, and payers of wheeled mobility. It also identifies patient, provider, supplier, and payer issues that may impact the service delivery process. We recognize that consumers may obtain wheeled mobility devices from a variety of sources. We have focused on service delivery for individuals whose complex rehabilitation need Shipping may be from our UK warehouse or from our Australian or US warehouses, depending on stock availability.

Paperback. Condition: new. Paperback. Clostridium difficile infection (CDI) is a serious healthcare-associated infection and a growing health care problem, especially with the emergence of more virulent strains in the early 2000s. Clostridium difficile was first recognized as having the ability to cause pseudomembranous colitis in the late 1970s. CDI is now the most common cause of nosocomial infectious diarrhea. Asymptomatic colonization in healthy adults has been observed in only 3 percent of persons, while the prevalence of such colonization among residents in long-term-care facilities approaches 50 percent. Individuals colonized with Clostridium difficile serve as a reservoir for infection by contaminating the environment with Clostridium difficile spores, thus leading to the spread of the organism on the hands of health care workers or via use of medical equipment. CDI is increasing in incidence and, in all likelihood, severity. The number of cases diagnosed among patients discharged from hospitals increased from 31 per 100,000 persons in 1996 to 84 per 100,000 persons in 2005. Infection due to a relatively new strain of Clostridium difficile, termed "North American pulsed-field gel electrophoresis type 1" (NAP1), is felt to be at least partially responsible for this increased incidence of CDI as well as for the increased severity of clinical illness. The NAP1 strain is capable of producing more than 15 times the quantity of both toxins A and B, which are directly responsible for the damage to the intestinal tract of infected patients. Hence, CDI is not only now more common, but also more severe, leading to an attributable mortality of up to 16 percent of all deaths. A comparative effectiveness review (CER) was prepared by the Minnesota Evidence-based Practice Center (EPC) on Comparative Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection (December 2011). The purpose of the CER was to provide an overarching assessment of the evidence for comparing the accuracy of diagnostic tests and the effectiveness of prevention and treatment interventions on initial and recurrent CDI related patient outcomes in adults. Key informants, provided input to the EPC on the scope of the CER, agreed that its greatest contribution to the field could be to have an independent organization provide a comprehensive review of the major concerns of the field for both clinicians and researchers. The major impetus underlying the SR was a concern about the presence of clinical disease, not asymptomatic carriage of the Clostridium difficile organism.1 Molecular epidemiological studies whose main purpose was to identify the strains of Clostridium difficile present in the population were outside the scope of the CER. The CER focused on adult patients as they, particularly elderly adults, carry the most of the morbidity and mortality burden.The CER addressed the following Key Questions (KQs): 1. How do different methods for detection of toxigenic Clostridium difficile to assist with diagnosis of CDI compare in their sensitivity and specificity? a. Do the differences in performance measures vary with sample characteristics? 2. What are effective prevention strategies? a. What is the effectiveness of current prevention strategies? b. What are the harms associated with prevention strategies? c. How sustainable are prevention practices in health care (outpatient, hospital inpatient, extended care) and community settings? 3. What are the comparative effectiveness and harms of different antibiotic treatments? a. Does effectiveness vary by disease severity or strain? b. Does effectiveness vary by patient characteristics: age, gender, comorbidity, hospital versus community-acquired setting? c. How do prevention and treatment of CDI affect resistance of other pathogens? 4. What are the effectiveness and harms of nonstandard adjunctive inter Shipping may be from our UK warehouse or from our Australian or US warehouses, depending on stock availability.

Paperback. Condition: new. Paperback. Mixed treatment comparisons (MTCs) are meta-analytic statistical techniques that incorporate the findings from several studies, where in most cases none of the studies compared all the treatments at one time, to address the comparative effectiveness and safety of interventions accounting for all sources of data. In the MTC data framework, since few head-to-head comparisons are available, we must rely on indirect comparisons, typically each investigated treatment against a control or a standard treatment. The biggest assumption in MTCs is exchangeability among studies; that is, any ordering of the true treatment effects across studies is equally likely a priori. In addition, populations in selected studies should be similar to the target population for valid clinical interpretation. Bayesian hierarchical statistical meta-analysis for MTCs with a single binary outcome has been investigated actively since the 1980s. However, compared with the binary outcome setting, there has been comparatively little development in Bayesian MTCs for continuous outcomes. Our interest in Bayesian MTC methods for multiple continuous outcomes is motivated by a systematic literature review at the Minnesota Evidence-based Practice Center (EPC) that investigated the effectiveness of physical therapies on chronic pain secondary to knee osteoarthritis (OA) for community-dwelling adults. OA treatments aim to reduce or control pain, improve physical function, prevent disability, and enhance quality of life. We recorded means of measured pain, disability, function, and quality of life scores associated with various physical therapy interventions from randomized studies. As our OA data contain many studies reporting multiple outcomes, and measured on the same subjects, correlations across arms and outcomes are likely, but this case has not been discussed much in the literature. For example, similar types of drugs or physical therapies may tend to behave similarly inducing correlated results, and multiple outcomes also can induce correlations (e.g., subjects with severe pain would be more likely to have disability). Most randomized controlled trials (RCTs) include only two or three treatment arms, including a control group, due to limited resources. This results in extremely sparse data for MTCs when used across all possible treatments. Suppose that we can calculate the missingness rate as the summation of the ratio of the number of missing arms to the total number of treatments across all studies. Then, the missingness rate is 40 to 60 percent when we compare 5 treatments, and the rate could increase up to about 70 percent if 10 treatments are considered. Lu and Ades's approach, a standard MTC model, uses only the observed data. However, we can borrow strength from those missing data after imputing them in a Bayesian hierarchical model that accounts for between-treatment and between-outcome correlations using Markov chain Monte Carlo (MCMC) algorithms. Especially when the missingness does not occur randomly but depends on some observed or unobserved information, ignoring such missing data can cause biased estimators. In this report we review existing MTC models and propose novel Bayesian missing data approaches to combine multiple continuous outcomes. The main objectives are to (1) impute unobserved arms by considering them as unknown parameters which can be modeled along with the other unknown, (2) incorporate between-treatment or between-outcome correlations, and (3) introduce an arm-based approach that features fewer constraints than standard contrast-based methods. We also rank the treatments with a sensible scoring system incorporating such multiple outcomes. We apply our models to the OA data and interpret our findings. Finally, we include a simulation study to investigate the performance of our methods in terms of Type I error, pow Shipping may be from our UK warehouse or from our Australian or US warehouses, depending on stock availability.