Patient care delivery and integration: stimulating advancement of ambulatory care pharmacy practice in an era of healthcare reform.

PubMed

Epplen, Kelly T

2014-08-15

This article discusses how to plan and implement an ambulatory care pharmacist service, how to integrate a hospital- or health-system-based service with the mission and operations of the institution, and how to help the institution meet its challenges related to quality improvement, continuity of care, and financial sustainability. The steps in implementing an ambulatory care pharmacist service include (1) conducting a needs assessment, (2) aligning plans for the service with the mission and goals of the parent institution, (3) collaborating with patients and physicians, (4) standardizing the patient care process, (5) proposing the service, (6) attaining the necessary resources, (7) identifying stakeholders, (8) identifying applicable quality standards, (9) defining competency standards, (10) planning for service payment, and (11) monitoring outcomes. Ambulatory care pharmacists have current opportunities to become engaged with patient-centered medical homes, accountable care organizations, preventive and wellness programs, and continuity of care initiatives. Common barriers to the advancement of ambulatory care pharmacist services include lack of complete access to patient information, inadequate information technology, and lack of payment. Ambulatory care pharmacy practitioners must assertively promote appropriate medication use, provide patient-centered care, pursue integration with the patient care team, and seek appropriate recognition and compensation for the services they provide. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Ghrelin and its promoter variant associated with cardiac hypertrophy.

PubMed

Ukkola, O; Pääkkö, T; Kesäniemi, Y A

2012-07-01

The roles of ghrelin, a peptide hormone that has a role in regulating food intake and energy homeostasis, in the cardiovascular system have not yet been unambiguously established. We evaluated the association between plasma ghrelin concentrations and -501A>C single-nucleotide polymorphism (SNP) in the ghrelin gene 5' flanking area and echocardiographic measurements in 1037 middle-aged subjects. Left ventricular mass index (LVMI) was calculated according to Devereux's method. The ambulatory blood pressure (BP) was recorded using the fully automatic SpaceLabs 90207 oscillometric unit. Results suggested that plasma ghrelin was not related to mean ambulatory BP values. However, the highest plasma ghrelin tertile was associated with increased intraventricular septum (P=0.043) and posterior ventricular wall (P=0.002) thicknesses as well as left ventricular mass (P=0.05). After adjustment for age, sex, body mass index and systolic BP, the association persisted between ghrelin tertiles and intraventricular septum (P=0.05) and posterior ventricular wall (P=0.001) thicknesses. The SNP -501A>C polymorphism was associated with LVMI after adjustments for age, sex and systolic BP. In conclusion, ghrelin and its promoter variant are associated with cardiac hypertrophy indexes independent of BP. Positive correlation between ghrelin levels and increased wall thickness parameters may reflect compensatory up-regulation of ghrelin concentrations or direct effects of ghrelin on myocardium. The effects of the SNP seem not to be mediated through its effects on ghrelin plasma levels.

Day case laparoscopic nephrectomy with vaginal extraction: initial experience.

PubMed

Baldini, Arnaud; Golfier, François; Mouloud, Khaled; Bruge Ansel, Marie-Hélène; Navarro, Rémi; Ruffion, Alain; Paparel, Philippe

2014-12-01

To assess the feasibility of laparoscopic nephrectomy with vaginal extraction in an ambulatory setting. Two patients underwent a laparoscopic (1 was robot assisted) nephrectomy with vaginal extraction for a nonfunctioning kidney in an ambulatory setting. Both interventions were performed by the same surgical team comprising a urologic surgeon and a gynecologic surgeon. The operative specimen was vaginally extracted via an incision in the posterior fornix at the end of the intervention. Patients had to respect very strict socioenvironmental and clinical criteria. Anesthesia was achieved using short-acting agents. Only first- and second-step analgesics were used (morphine-free protocol). The main judgment criteria were visual analog scale assessment for postoperative pain, the Clavien-Dindo classification for surgical complications, and the hospital readmission rate. Two female patients (37 and 41 years old) have been successfully operated with this technique. No major perioperative or postoperative complications (Clavien-Dindo grade >2) were reported, and no patient readmission was required. Postoperative pain was well managed with visual analog scale scores ≤ 5. Both patients operated in the ambulatory setting had Chung scores of 10 before their discharge. Laparoscopic or robotic nephrectomy with vaginal extraction can be performed in an ambulatory setting in carefully selected patients. The association of fast-track surgical techniques and vaginal extraction by eliminating the abdominal wound extraction source of postoperative pain allows performing this operation in this setting with a high level of satisfaction. Copyright © 2014 Elsevier Inc. All rights reserved.

Long-Term Continuous Ambulatory ECG Monitors and External Cardiac Loop Recorders for Cardiac Arrhythmia: A Health Technology Assessment

PubMed Central

Kabali, Conrad; Xie, Xuanqian; Higgins, Caroline

2017-01-01

Background Ambulatory electrocardiography (ECG) monitors are often used to detect cardiac arrhythmia. For patients with symptoms, an external cardiac loop recorder will often be recommended. The improved recording capacity of newer Holter monitors and similar devices, collectively known as longterm continuous ambulatory ECG monitors, suggests that they will perform just as well as, or better than, external loop recorders. This health technology assessment aimed to evaluate the effectiveness, cost-effectiveness, and budget impact of longterm continuous ECG monitors compared with external loop recorders in detecting symptoms of cardiac arrhythmia. Methods Based on our systematic search for studies published up to January 15, 2016, we did not identify any studies directly comparing the clinical effectiveness of longterm continuous ECG monitors and external loop recorders. Therefore, we conducted an indirect comparison, using a 24-hour Holter monitor as a common comparator. We used a meta-regression model to control for bias due to variation in device-wearing time and baseline syncope rate across studies. We conducted a similar systematic search for cost-utility and cost-effectiveness studies comparing the two types of devices; none were found. Finally, we used historical claims data (2006–2014) to estimate the future 5-year budget impact in Ontario, Canada, of continued public funding for both types of longterm ambulatory ECG monitors. Results Our clinical literature search yielded 7,815 non-duplicate citations, of which 12 cohort studies were eligible for indirect comparison. Seven studies assessed the effectiveness of longterm continuous monitors and five assessed external loop recorders. Both types of devices were more effective than a 24-hour Holter monitor, and we found no substantial difference between them in their ability to detect symptoms (risk difference 0.01; 95% confidence interval −0.18, 0.20). Using GRADE for network meta-analysis, we evaluated the quality of the evidence as low. Our budget impact analysis showed that use of the longterm continuous monitors has grown steadily in Ontario since they became publicly funded in 2006, particularly since 2011 when monitors that can record for 14 days or longer became funded, and the use of external cardiac loop recorders has correspondingly declined. The analysis suggests that, with these trends, continued public funding of both types of longterm ambulatory ECG testing will result in additional costs ranging from $130,000 to $370,000 per year over the next 5 years. Conclusions Although both longterm continuous ambulatory ECG monitors and external cardiac loop recorders were more effective than a 24-hour Holter monitor in detecting symptoms of cardiac arrhythmia, we found no evidence to suggest that these two devices differ in effectiveness. Assuming that the use of longterm continuous monitors will continue to increase in the next 5 years, the public health care system in Ontario can expect to see added costs of $130,000 to $370,000 per year. PMID:28194254

PROFESSIONAL FLASH CONTINUOUS GLUCOSE MONITORING WITH AMBULATORY GLUCOSE PROFILE REPORTING TO SUPPLEMENT A1C: RATIONALE AND PRACTICAL IMPLEMENTATION.

PubMed

Hirsch, Irl B; Verderese, Carol A

2017-11-01

Recent consensus statements strongly advocate downloading and interpreting continuous glucose data for diabetes management in patients with type 1 or 2 diabetes. Supplementing periodic glycated hemoglobin (A1C) testing with intermittent continuous glucose monitoring (CGM) using a standardized report form known as the ambulatory glucose profile (AGP) is an evolving standard of care. The rationale for this approach and its implementation with a recently approved novel monitoring technology are explored. Search of the medical literature, professional guidelines, and real-world evidence guided this introduction of an integrative practice framework that uses AGP in conjunction with intermittent flash continuous glucose monitoring (FCGM) as a supplement to A1C testing. The combination of intermittent continuous glucose pattern analysis, standardized glucose metrics, and a readily interpretable data report has the potential to practically extend the recognized benefits of CGM to more patients and clarify the relationship between A1C and average glucose levels in individual cases. Novel FCGM technologies portend greater use of continuous forms of glucose monitoring and wider adoption of AGP report analysis. Additional formal and empirical evidence is needed to more fully characterize best practice. A1C = glycated hemoglobin; AGP = ambulatory glucose profile; CGM = continuous glucose monitoring; FCGM = flash continuous glucose monitoring; IQR = interquartile range; SMBG = self-monitoring of blood glucose.

Effects of bedtime periocular and posterior cervical cutaneous warming on sleep status in adult male subjects: a preliminary study.

PubMed

Igaki, Michihito; Suzuki, Masahiro; Sakamoto, Ichiro; Ichiba, Tomohisa; Kuriyama, Kenichi; Uchiyama, Makoto

2018-01-01

Appropriate warming of the periocular or posterior cervical skin has been reported to induce autonomic or mental relaxation in humans. To clarify the effects of cutaneous warming on human sleep, eight male subjects with mild sleep difficulties were asked to try three experimental conditions at home, each lasting for 5 days, in a cross-over manner: warming of the periocular skin with a warming device for 10 min before habitual bedtime, warming of the posterior cervical skin with a warming device for 30 min before habitual bedtime, and no treatment as a control. The warming device had a heat- and steam-generating sheet that allowed warming of the skin to 40 °C through a chemical reaction with iron. Electroencephalograms (EEGs) were recorded during nocturnal sleep using an ambulatory EEG device and subjected to spectral analysis. All the participants reported their sleep status using a visual analog scale. We found that warming of the periocular or posterior cervical skin significantly improved subjective sleep status relative to the control. The EEG delta power density in the first 90 min of the sleep episode was significantly increased under both warming of the periocular or posterior cervical skin relative to the control. These results suggest that warming of appropriate skin regions may have favorable effects on subjective and objective sleep quality.

Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative.

PubMed

Francis, Maureen D; Wieland, Mark L; Drake, Sean; Gwisdalla, Keri Lyn; Julian, Katherine A; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Smith, Amy; Sweet, David; Thomas, Kris; Varney, Andrew; Warm, Eric; Wininger, David; Francis, Mark L

2015-03-01

Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model.

Clinic Design and Continuity in Internal Medicine Resident Clinics: Findings of the Educational Innovations Project Ambulatory Collaborative

PubMed Central

Francis, Maureen D.; Wieland, Mark L.; Drake, Sean; Gwisdalla, Keri Lyn; Julian, Katherine A.; Nabors, Christopher; Pereira, Anne; Rosenblum, Michael; Smith, Amy; Sweet, David; Thomas, Kris; Varney, Andrew; Warm, Eric; Wininger, David; Francis, Mark L.

2015-01-01

Background Many internal medicine (IM) programs have reorganized their resident continuity clinics to improve trainees' ambulatory experience. Downstream effects on continuity of care and other clinical and educational metrics are unclear. Methods This multi-institutional, cross-sectional study included 713 IM residents from 12 programs. Continuity was measured using the usual provider of care method (UPC) and the continuity for physician method (PHY). Three clinic models (traditional, block, and combination) were compared using analysis of covariance. Multivariable linear regression analysis was used to analyze the effect of practice metrics and clinic model on continuity. Results UPC, reflecting continuity from the patient perspective, was significantly different, and was highest in the block model, midrange in combination model, and lowest in the traditional model programs. PHY, reflecting continuity from the perspective of the resident provider, was significantly lower in the block model than in combination and traditional programs. Panel size, ambulatory workload, utilization, number of clinics attended in the study period, and clinic model together accounted for 62% of the variation found in UPC and 26% of the variation found in PHY. Conclusions Clinic model appeared to have a significant effect on continuity measured from both the patient and resident perspectives. Continuity requires balance between provider availability and demand for services. Optimizing this balance to maximize resident education, and the health of the population served, will require consideration of relevant local factors and priorities in addition to the clinic model. PMID:26217420

Lower Extremity Muscle Thickness During 30-Day 6 degrees Head-Down Bed Rest with Isotonic and Isokinetic Exercise Training

NASA Technical Reports Server (NTRS)

Ellis, S.; Kirby, L. C.; Greenleaf, J. E.

1993-01-01

Muscle thickness was measured in 19 Bed-Rested (BR) men (32-42 year) subjected to IsoTonic (ITE, cycle orgometer) and IsoKi- netic (IKE, torque orgometer) lower extremity exercise training, and NO Exercise (NOE) training. Thickness was measured with ultrasonography in anterior thigh-Rectus Femoris (RF) and Vastus Intermadius (VI), and combined posterior log-soleus, flexor ballucis longus, and tibialis posterior (S + FHL +TP) - muscles. Compared with ambulatory control values, thickness of the (S + FHL + TP) decreased by 90%-12% (p less than 0.05) In all three test groups. The (RF) thickness was unchanged in the two exercise groups, but decreased by 10% (p less than 0.05) in the NOE. The (VI) thickness was unchanged In the ITE group, but decreased by 12%-l6% (p less than 0.05) in the IKE and NOE groups. Thus, intensive, alternating, isotonic cycle ergometer exercise training is as effective as intensive, intermittent, isokinetic exercise training for maintaining thicknesses of rectus femoris and vastus lntermedius anterior thigh muscles, but not posterior log muscles, during prolonged BR deconditioning.

Accreditation of ambulatory facilities.

PubMed

Urman, Richard D; Philip, Beverly K

2014-06-01

With the continued growth of ambulatory surgical centers (ASC), the regulation of facilities has evolved to include new standards and requirements on both state and federal levels. Accreditation allows for the assessment of clinical practice, improves accountability, and better ensures quality of care. In some states, ASC may choose to voluntarily apply for accreditation from a recognized organization, but in others it is mandated. Accreditation provides external validation of safe practices, benchmarking performance against other accredited facilities, and demonstrates to patients and payers the facility's commitment to continuous quality improvement. Copyright © 2014 Elsevier Inc. All rights reserved.

A rare case of watermelon stomach in woman with continuous ambulatory peritoneal dialysis and systemic lupus erythematosus.

PubMed

Jinga, Mariana; Checheriţă, I A; Becheanu, G; Jinga, V; Peride, Ileana; Niculae, A

2013-01-01

We report a case of a 42-year-old woman with systemic lupus erythematosus and chronic kidney disease stage 5 undergoing continuous ambulatory peritoneal dialysis, presenting asthenia, dizziness, abdominal pain and small efforts dyspnea. After a complete physical and clinical examination, including laboratory tests, esophagogastroduodenal endoscopy and gastric lesions biopsy, she was diagnosed with gastric antral vascular ectasia. We are facing a rare case of antral vascular ectasia in a patient associating both chronic kidney disease and autoimmune disease.

Developing a business-practice model for pharmacy services in ambulatory settings.

PubMed

Harris, Ila M; Baker, Ed; Berry, Tricia M; Halloran, Mary Ann; Lindauer, Kathleen; Ragucci, Kelly R; McGivney, Melissa Somma; Taylor, A Thomas; Haines, Stuart T

2008-02-01

A business-practice model is a guide, or toolkit, to assist managers and clinical pharmacy practitioners in the exploration, proposal, development and implementation of new clinical pharmacy services and/or the enhancement of existing services. This document was developed by the American College of Clinical Pharmacy Task Force on Ambulatory Practice to assist clinical pharmacy practitioners and administrators in the development of business-practice models for new and existing clinical pharmacy services in ambulatory settings. This document provides detailed instructions, examples, and resources on conducting a market assessment and a needs assessment, types of clinical services, operations, legal and regulatory issues, marketing and promotion, service development and exit plan, evaluation of service outcomes, and financial considerations in the development of a clinical pharmacy service in the ambulatory environment. Available literature is summarized, and an appendix provides valuable citations and resources. As ambulatory care practices continue to evolve, there will be increased knowledge of how to initiate and expand the services. This document is intended to serve as an essential resource to assist in the growth and development of clinical pharmacy services in the ambulatory environment.

The effect of continuous nursing intervention guided by chronotherapeutics on ambulatory blood pressure of older hypertensive patients in the community.

PubMed

Cheng, Mei; Cheng, Shu-Ling; Zhang, Qing; Jiang, He; Cong, Ji-Yan; Zang, Xiao-Ying; Zhao, Yue

2014-08-01

To explore the effect of continuous nursing intervention guided by chronotherapeutics so as to provide the easy, noninvasive, effective and acceptable intervention for older hypertensive patients in the community. Many researchers studied the effect of administration at different times on blood pressure control and circadian rhythm. However, the individual administrative time was set ambiguously in previous studies. A semi-experimental study. In the study, 90 eligible patients were recruited and separated into three groups randomly, which were the control group, intervention group A (behaviour and chronotherapy intervention) and intervention group B (behaviour intervention). At 6 and 12 months after the study, the intervention groups were measured 24-hour ambulatory blood pressure monitoring. There were significant differences in ambulatory blood pressure monitoring parameters of the two intervention groups at different measurement times, and there were interaction between measurement time and different groups. The number of patients with dipper increased and reverse dipper decreased in group A as the intervention applied. There were statistical differences between two groups. The number of patients with morning surge in group A decreased more, and there were statistical differences between two groups at six months after the intervention. The behaviour and chronotherapy intervention based on the patients' ambulatory blood pressure monitoring can control casual blood pressure much better and last longer, which can also improve patients' indexes of ambulatory blood pressure monitoring better than behaviour intervention only. The behaviour and chronotherapy intervention can increase patients' nocturnal blood pressure drop, increase the number of patients with dipper and decrease reverse dipper, and improve blood pressure surge in the morning. Nurses can use continuous nursing intervention guided by chronotherapeutics to help improve hypertension of older patients better in the community. © 2014 John Wiley & Sons Ltd.

Commentary: quality of care and cost containment are the hospital-based ambulatory surgery challenges for the future.

PubMed

Frezza, E E; Girnys, R P; Silich, R J; Coppa, G F

2000-01-01

Cost containment and quality of care represent the most important objectives of all health care professionals. Because of its progressive growth over the past decade, ambulatory surgery has become an area where these 2 issues need to be addressed. The goal of this paper is to discuss the economic and quality of care challenges faced by hospitals as they strive to become competitive in the 21st century. The quality of care in ambulatory surgery has been improving because of multidisciplinary activities. Hospitals tend to hire the staff on the basis of their expertise in certain areas, and those personnel do not have to cover other hospital roles. Moreover, the hospital staff is able to seek information at any time from coworkers in other areas of specialty. Ambulatory surgery in a hospital offers advantages, such as multiple operating rooms, multiple skilled health care providers, and the ability to stay overnight if needed. The consolidation of supplies makes it easier to contract for a better price. Aggressive contract negotiations and implementation of cost-effective and cost-efficient strategies are the keys to success in the future. Quality improvement (QI) initiatives and quality of care (QC) indicators need to be developed to address various problems in the ambulatory surgery setting such as unnecessary admissions, inadequate staffing, efficient operating room (OR) utilization, quality of care, and assessment outcome. These initiatives should be addressed at regular meetings where opportunities to improve the ambulatory services are discussed. The number of ambulatory surgery procedures performed each year will continue to increase, although perhaps not at the rate we experienced in the past. Procedures that once were performed in an inpatient setting can now be accomplished on an outpatient basis or even in the physician's office. We will continue to see this shift of volume as technologic advancements and anesthetic agents allow more complex procedures to be performed on an outpatient basis.

Influence of lightweight ambulatory oxygen on oxygen use and activity patterns of COPD patients receiving long-term oxygen therapy.

PubMed

Casaburi, Richard; Porszasz, Janos; Hecht, Ariel; Tiep, Brian; Albert, Richard K; Anthonisen, Nicholas R; Bailey, William C; Connett, John E; Cooper, J Allen; Criner, Gerard J; Curtis, Jeffrey; Dransfield, Mark; Lazarus, Stephen C; Make, Barry; Martinez, Fernando J; McEvoy, Charlene; Niewoehner, Dennis E; Reilly, John J; Scanlon, Paul; Scharf, Steven M; Sciurba, Frank C; Woodruff, Prescott

2012-02-01

Lightweight ambulatory oxygen devices are provided on the assumptions that they enhance compliance and increase activity, but data to support these assumptions are lacking. We studied 22 patients with severe chronic obstructive pulmonary disease receiving long-term oxygen therapy (14 men, average age = 66.9 y, FEV(1) = 33.6%pred, PaO(2) at rest = 51.7 torr) who were using E-cylinders as their portable oxygen. Subjects were recruited at 5 sites and studied over a 2-week baseline period and for 6 months after randomizing them to either continuing to use 22-lb E-cylinders towed on a cart or to carrying 3.6-lb aluminum cylinders. Utilizing novel electronic devices, ambulatory and stationary oxygen use was monitored continuously over the 2 weeks prior to and the 6 months following randomization. Subjects wore tri-axial accelerometers to monitor physical activity during waking hours for 2-3 weeks prior to, and at 3 and 6 months after, randomization. Seventeen subjects completed the study. At baseline, subjects used 17.2 hours of stationary and 2.5 hours of ambulatory oxygen daily. At 6 months, ambulatory oxygen use was 1.4 ± 1.0 hrs in those randomized to E-cylinders and 1.9 ± 2.4 hrs in those using lightweight oxygen (P = NS). Activity monitoring revealed low activity levels prior to randomization and no significant increase over time in either group. In this group of severe chronic obstructive pulmonary disease patients, providing lightweight ambulatory oxygen did not increase either oxygen use or activity. Future efforts might focus on strategies to encourage oxygen use and enhance activity in this patient group. This trial is registered at ClinicalTrials.gov (NCT003257540).

[Dispensing prescriptions to persons affiliated with the Seguro Popular de Salud de México].

PubMed

Garrido-Latorre, Francisco; Hernández-Llamas, Héctor; Gómez-Dantés, Octavio

2008-01-01

Measure and compare the percentage of prescriptions fully dispensed to persons with and without Popular Health Insurance (SPS in Spanish) who use ambulatory and general hospital services associated with the Mexico State Health Services (SESA in Spanish), and taking into account insurance status. SESA user satisfaction was also measured with respect to access to medication. Information for the study was taken from four surveys of SESA ambulatory and hospital units that included probabilistic samples with state representativity. Samples of ambulatory units were selected by stratification according to level of care and association to the SPS service network. The findings indicate that the percentage of prescriptions fully dispensed in SESA ambulatory units has improved, reaching approximately 90%, especially among those units offering services to persons affiliated with SPS. Nevertheless, these percentages continue to be lower than those of ambulatory units associated with social security institutions. Percentages of prescriptions fully dispensed have also improved in SESA hospital units, but continue to be relatively low. In nearly all states, as the percentage of prescriptions fully dispensed has increased, user satisfaction with access to medication has also improved. In 2006 more than 50% of the states had high levels of fully dispensed prescriptions among persons with SPS (> or =90%). The more significant problem exists among hospitals, since only 44% of users who received a prescription in SESA hospitals in 2006 had their prescriptions fully dispensed. This finding requires a review of SPS medication policies, which have favored highly prescribed low-cost medications at ambulatory services at the expense of higher cost and more therapeutically effective medications for hospital care, the latter having a greater impact on household budgets.

Cortical bone deficit and fat infiltration of bone marrow and skeletal muscle in ambulatory children with mild spastic cerebral palsy

PubMed Central

Whitney, Daniel G.; Singh, Harshvardhan; Miller, Freeman; Barbe, Mary F.; Slade, Jill M.; Pohlig, Ryan T.; Modlesky, Christopher M.

2016-01-01

Introduction Nonambulatory children with severe cerebral palsy (CP) have an underdeveloped bone architecture, low bone strength and a high degree of fat infiltration in the lower extremity musculature. The present study aims to determine if such a profile exists in ambulatory children with mild CP and if excess fat infiltration extends into the bone marrow. Materials and methods Ambulatory children with mild spastic CP and typically developing children (4 to 11 years; 12/group) were tested. Magnetic resonance imaging was used to estimate cortical, medullary and total bone volume and width, bone strength [i.e., section modulus (Z) and polar moment of inertia (J)], and bone marrow fat concentration in the midtibia, and muscle volume, intermuscular, subfascial, and subcutaneous adipose tissue (AT) volume and intramuscular fat concentration in the midleg. Physical activity monitors worn on the ankle were used to assess physical activity. Results There were no group differences in age, height, body mass, body mass percentile, BMI, BMI percentile or tibia length, but children with CP had lower height percentile (19th vs. 50th percentile) and total physical activity counts (44 %) than controls (both p < 0.05). Children with CP also had lower cortical volume (30 %), cortical width in the posterior (16 %) and medial (32 %) portion of the shaft, total bone width in the medial-lateral direction (15 %), Z in the medial-lateral direction (34 %), J (39 %) and muscle volume (39 %), and higher bone marrow fat concentration (82.1 ± 1.8 % vs. 80.5 ± 1.9 %), subfascial AT volume (3.3 fold) and intramuscular fat concentration (25.0 ± 8.0 % vs. 16.1 ± 3.3 %) than controls (all p < 0.05). When tibia length was statistically controlled, all group differences in bone architecture, bone strength, muscle volume and fat infiltration estimates, except posterior cortical width, were still present (all p < 0.05). Furthermore, a higher intermuscular AT volume in children with CP compared to controls emerged (p < 0.05). Conclusions Ambulatory children with mild CP exhibit an underdeveloped bone architecture and low bone strength in the midtibia and a greater infiltration of fat in the bone marrow and surrounding musculature compared to typically developing children. Whether the deficit in the musculoskeletal system of children with CP is associated with higher chronic disease risk and whether the deficit can be mitigated requires further investigation. PMID:27732905

Cortical bone deficit and fat infiltration of bone marrow and skeletal muscle in ambulatory children with mild spastic cerebral palsy.

PubMed

Whitney, Daniel G; Singh, Harshvardhan; Miller, Freeman; Barbe, Mary F; Slade, Jill M; Pohlig, Ryan T; Modlesky, Christopher M

2017-01-01

Nonambulatory children with severe cerebral palsy (CP) have underdeveloped bone architecture, low bone strength and a high degree of fat infiltration in the lower extremity musculature. The present study aims to determine if such a profile exists in ambulatory children with mild CP and if excess fat infiltration extends into the bone marrow. Ambulatory children with mild spastic CP and typically developing children (4 to 11years; 12/group) were compared. Magnetic resonance imaging was used to estimate cortical bone, bone marrow and total bone volume and width, bone strength [i.e., section modulus (Z) and polar moment of inertia (J)], and bone marrow fat concentration in the midtibia, and muscle volume, intermuscular, subfascial, and subcutaneous adipose tissue (AT) volume and intramuscular fat concentration in the midleg. Accelerometer-based activity monitors worn on the ankle were used to assess physical activity. There were no group differences in age, height, body mass, body mass percentile, BMI, BMI percentile or tibia length, but children with CP had lower height percentile (19th vs. 50th percentile) and total physical activity counts (44%) than controls (both p<0.05). Children with CP also had lower cortical bone volume (30%), cortical bone width in the posterior (16%) and medial (32%) portions of the shaft, total bone width in the medial-lateral direction (15%), Z in the medial-lateral direction (34%), J (39%) and muscle volume (39%), and higher bone marrow fat concentration (82.1±1.8% vs. 80.5±1.9%), subfascial AT volume (3.3 fold) and intramuscular fat concentration (25.0±8.0% vs. 16.1±3.3%) than controls (all p<0.05). When tibia length was statistically controlled, all group differences in bone architecture, bone strength, muscle volume and fat infiltration estimates, except posterior cortical bone width, were still present (all p<0.05). Furthermore, a higher intermuscular AT volume in children with CP compared to controls emerged (p<0.05). Ambulatory children with mild spastic CP exhibit an underdeveloped bone architecture and low bone strength in the midtibia and a greater infiltration of fat in the bone marrow and surrounding musculature compared to typically developing children. Whether the deficit in the musculoskeletal system of children with CP is associated with higher chronic disease risk and whether the deficit can be mitigated requires further investigation. Copyright © 2016 Elsevier Inc. All rights reserved.

Psychological reactions to continuous ambulatory peritoneal dialysis.

PubMed

Geiser, M T; Van Dyke, C; East, R; Weiner, M

The first twenty patients who entered our continuous ambulatory peritoneal dialysis (CAPD) program from March, 1979 to February, 1981 were interviewed to assess their psychological reactions to CAPD. Six patients were successfully maintained on CAPD for more than one year. CAPD provided patients with a greater sense of well-being, strength, and independence. This independence required adherence to a strict schedule of exchanges. Reactions to the loss of CAPD followed the pattern of a grief reaction. Those patients who were self-disciplined and comfortable assuming active control of their health care proved to be the best candidates for CAPD.

Circadian blood pressure rhythm in normotensive offspring of hypertensive parents.

PubMed

Toker, Rabia Tutuncu; Yildirim, Ali; Demir, Tevfik; Ucar, Birsen; Kilic, Zubeyir

2015-01-01

The aim of this study was to explore the circadian blood pressure (BP) rhythm using ambulatory BP monitoring (ABPM) in normotensive children with a family history of essential hypertension. Group 1 consisted of children with hypertensive mothers and/or fathers (n = 20), Group 2 consisted of children with hypertensive grandparents (n = 20), and Group 3 consisted of children with normotensive parents (n = 20). All participating children underwent a 24-h ABPM and echocardiography. Significantly higher systolic burden was found in children with hypertensive parents (p < 0.05) and grandparents (p < 0.05) compared to controls. Ambulatory BP measurements had a higher daytime systolic BP in Group 1 compared to controls (p < 0.05). While left ventricular (LV) posterior wall thickness was similar in Group 1 and Group 2, it was significantly higher in both of these groups compared to the controls. The LV mass index (LVMI) was significantly higher in Group 1 than in controls (p < 0.05). However, diastolic BP was significantly higher in dippers compared to non-dippers (p < 0.05). LV posterior wall thickness, interventricular septum thickness and LVMI were significantly higher among non-dippers compared to dippers (p < 0.05). In children with a family history of hypertension, a positive correlation between nocturnal systolic BP and LVMI was found, and increasing nocturnal BP values were associated with increasing LVMI (p < 0.01). In children with a family history of hypertension, target-organ damage may precede the clinical detection of hypertension, and in those with a nocturnal non-dipper status, a more marked effect on LVMI may occur.

Resident continuity of care experience in a Canadian general surgery training program

PubMed Central

Sidhu, Ravindar S.; Walker, G. Ross

Objectives To provide baseline data on resident continuity of care experience, to describe the effect of ambulatory centre surgery on continuity of care, to analyse continuity of care by level of resident training and to assess a resident-run preadmission clinic’s effect on continuity of care. Design Data were prospectively collected for 4 weeks. All patients who underwent a general surgical procedure were included if a resident was present at operation. Setting The Division of General Surgery, Queen’s University, Kingston, Ont. Outcome measures Preoperative, operative and inhospital postoperative involvement of each resident with each case was recorded. Results Residents assessed preoperatively (before entering the operating room) 52% of patients overall, 20% of patients at the ambulatory centre and 83% of patients who required emergency surgery. Of patients assessed by the chief resident, 94% were assessed preoperatively compared with 32% of patients assessed by other residents ( p < 0.001). Of the admitted patients, 40% had complete resident continuity of care (preoperative, operative and postoperative). There was no statistical difference between this rate and that for emergency, chief-resident and non-chief-resident subgroups. Of the eligible patients, 58% were seen preoperatively by the resident on the preadmission clinic service compared with 54% on other services ( p > 0.1). Conclusions This study serves as a reference for the continuity of care experience in Canadian surgical programs. Residents assessed only 52% of patients preoperatively, and only 40% of patients had complete continuity of care. Factors such as ambulatory surgery and junior level of training negatively affected continuity experience. Such factors must be taken into account in planning surgical education. PMID:10526519

Ambulatory surgery centers best practices for the 90s.

PubMed

Hoover, J A

1994-05-01

Outpatient surgery will be the driving force in the continued growth of ambulatory care in the 1990s. Providing efficient, high-quality ambulatory surgical services should therefore be a priority among healthcare providers. Arthur Andersen conducted a survey to discover best practices in ambulatory surgical service. General success characteristics of best performers were business-focused relationships with physicians, the use of clinical protocols, patient convenience, cost management, strong leadership, teamwork, streamlined processes and efficient design. Other important factors included scheduling to maximize OR room use; achieving surgical efficiencies through reduced case pack assembly errors and equipment availability; a focus on cost capture rather than charge capture; sound materiel management practices, such as standardization and vendor teaming; and the appropriate use of automated systems. It is important to evaluate whether the best practices are applicable to your environment and what specific changes to your current processes would be necessary to adopt them.

SURGICAL REMOVAL OF DENSE POSTERIOR CAPSULE OPACIFICATION AND VITREOUS FLOATERS IN ADULTS BY POSTERIOR CONTINUOUS CURVILINEAR CAPSULORHEXIS THROUGH THE PARS PLANA AND 23-GAUGE VITRECTOMY.

PubMed

Lin, Jijian; Su, Zhitao; Huang, Xiaodan; Ji, Xian; Yao, Ke

2016-11-01

To evaluate the safety and efficacy of posterior continuous curvilinear capsulorhexis through the pars plana and 23-gauge vitrectomy in surgical management of dense posterior capsule opacification and vitreous floaters. Fifteen pseudophakic eyes of 15 patients with dense posterior capsule opacification and vitreous floaters between September 2012 and June 2014 were included; after vitrectomy, posterior continuous curvilinear capsulorhexis through the pars plana was performed. Data were collected, including baseline preoperative characteristics, postoperative outcomes, complications, and a modified quality-of-life survey that patients completed. No intraoperative or postoperative complications were encountered in any of the 15 cases. Mean Snellen best-corrected visual acuity was 20/250 preoperatively and improved to 20/32 postoperatively (P < 0.001). All patients showed normal intraocular pressure 7 days after the procedure. The mean overall corneal endothelial cell loss at postoperative Month 3 was 1.2%. Approximately 80% of the patients had no complaint of vitreous floaters after the procedure. Except for 1 patient (7%) diagnosed with age-related macular degeneration, the rest of the patients (93%) were satisfied with the procedure and would recommend it to friends with dense posterior capsule opacification and vitreous floaters. Posterior continuous curvilinear capsulorhexis through the pars plana combined with 23-gauge vitrectomy may be used to remove dense posterior capsule opacification and vitreous floaters in pseudophakic eyes.

Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns

PubMed Central

Esch, Lindsay M.; Bird, Amber-Nicole; Oyler, Julie L.; Lee, Wei Wei; Shah, Sachin D.; Pincavage, Amber T.

2015-01-01

Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (p<0.001). All interns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered. PMID:26609962

A Model for Integrating Ambulatory Surgery Centers Into an Academic Health System Using a Novel Ambulatory Surgery Coordinating Council.

PubMed

Ishii, Lisa; Pronovost, Peter J; Demski, Renee; Wylie, Gill; Zenilman, Michael

2016-06-01

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations. Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs. Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies. The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care.

PubMed

Reddy, Ashok; Pollack, Craig E; Asch, David A; Canamucio, Anne; Werner, Rachel M

2015-07-01

Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1 percentage point. These effects were moderated by the patients' continuity with their PCP prior to turnover, with a larger detrimental effect of PCP turnover among those with higher continuity prior to the turnover. Primary care provider turnover was associated with worse patient experiences of care but did not have a major effect on ambulatory care quality.

Amyloid burden and sleep blood pressure in amnestic mild cognitive impairment

PubMed Central

Tarumi, Takashi; Harris, Thomas S.; Hill, Candace; German, Zohre; Riley, Jonathan; Turner, Marcel; Womack, Kyle B.; Kerwin, Diana R.; Monson, Nancy L.; Stowe, Ann M.; Mathews, Dana; Cullum, C. Munro

2015-01-01

Objective: To determine whether cortical β-amyloid (Aβ) deposition is associated with circadian blood pressure (BP) profiles and dynamic cerebral blood flow (CBF) regulation in patients with amnestic mild cognitive impairment (aMCI). Methods: Forty participants with aMCI were included in this study. Cortical Aβ depositions were measured by 18F-florbetapir PET and expressed as the standardized uptake value ratio (SUVR) relative to the cerebellum. Circadian BP profiles were measured by 24-hour ambulatory monitoring during awake and sleep periods. The dipping status of sleep BP (i.e., the percent changes from the awake BP) was calculated and dichotomized into the dipper (≥10%) and nondipper (<10%) groups. Dynamic CBF regulation was assessed by a transfer function analysis between beat-to-beat changes in BP and CBF velocity measured from the middle cerebral artery during a repeated sit-stand maneuver. Results: Age was positively correlated with a greater Aβ deposition in the posterior cingulate, precuneus, and mean cortex. Accounting for the age effect, attenuated reductions in sleep systolic BP were associated with higher levels of posterior cingulate SUVR. Consistently, the nondippers exhibited a higher SUVR in the posterior cingulate than the dippers. Transfer function gain between changes in BP and CBF velocity was diminished in the nondippers, and moreover those individuals with a lower gain exhibited a higher SUVR in the posterior cingulate. Conclusions: Attenuated reductions in sleep BP are associated with a greater Aβ burden in the posterior cingulate and altered dynamic CBF regulation in patients with aMCI. PMID:26537049

Redesigning the Regulatory Framework for Ambulatory Care Services in New York

PubMed Central

Chokshi, Dave A; Rugge, John; Shah, Nirav R

2014-01-01

Context While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. Methods We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. Findings The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers’ understanding of rights and responsibilities. Finally, the regulatory mechanisms employed—from mandatory reporting to licensure to regional planning to the certificate of need—should remain flexible and match the degree of consensus regarding the appropriate regulatory path. Conclusions Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery. PMID:25492604

Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.

PubMed

Nadkarni, Mohan; Reddy, Siddharta; Bates, Carol K; Fosburgh, Blair; Babbott, Stewart; Holmboe, Eric

2011-01-01

Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide. We wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements. National survey of ACGME accredited IM training programs. Directors of academic and community-based continuity clinics. Two hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed. The survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008. This national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

The evolution of ambulatory ECG monitoring.

PubMed

Kennedy, Harold L

2013-01-01

Ambulatory Holter electrocardiographic (ECG) monitoring has undergone continuous technological evolution since its invention and development in the 1950s era. With commercial introduction in 1963, there has been an evolution of Holter recorders from 1 channel to 12 channel recorders with increasingly smaller storage media, and there has evolved Holter analysis systems employing increasingly technologically advanced electronics providing a myriad of data displays. This evolution of smaller physical instruments with increasing technological capacity has characterized the development of electronics over the past 50 years. Currently the technology has been focused upon the conventional continuous 24 to 48 hour ambulatory ECG examination, and conventional extended ambulatory monitoring strategies for infrequent to rare arrhythmic events. However, the emergence of the Internet, Wi-Fi, cellular networks, and broad-band transmission has positioned these modalities at the doorway of the digital world. This has led to an adoption of more cost-effective strategies to these conventional methods of performing the examination. As a result, the emergence of the mobile smartphone coupled with this digital capacity is leading to the recent development of Holter smartphone applications. The potential of point-of-care applications utilizing the Holter smartphone and a vast array of new non-invasive sensors is evident in the not too distant future. The Holter smartphone is anticipated to contribute significantly in the future to the field of global health. © 2013.

A computerized resolution of scheduling conflicts.

PubMed

Bolinger, R E; McFarlane, M J

1989-01-01

Residency training programs in Internal Medicine require resident attendance in a continuity clinic. This inevitably engenders conflicts between scheduling in the ambulatory clinic and the required teaching activities of the in-patient services. Some of the conflicts can be resolved by allowing the in-patient service directors to indicate preferred plans for their residents to attend in the continuity clinic. With this plan, scheduling becomes quite complicated. A computer program is presented with coordinates these service requests with ambulatory clinic scheduling. As a result, a given resident may have his/her clinic day changed on different rotations. The program automatically arbitrates conflicts and publishes the attendance dates for the entire academic year. This information is supplied to the appointment desk so that patients can be scheduled accordingly. This system has resulted in a 74% continuity rate and improved satisfaction by both residents and staff.

Measurement of translymphatic fluid absorption using technetium-99m human serum albumin diethylenetriamine pentaacetic acid in continuous ambulatory peritoneal dialysis patients.

PubMed

Terawaki, Hiroyuki; Nakayama, Masaaki; Seto, Kazuhiko; Yoshimura, Kazunobu; Hasegawa, Toshio

2004-08-01

We have established a new method of measuring translymphatic fluid absorption (TLA) using technetium-99m ((99m)Tc) human serum albumin diethylenetriamine pentaacetic acid ((99m)Tc-HSAD) that can be used commonly in clinical practice. This new method was applied in 13 continuous ambulatory peritoneal dialysis patients (11 males and two females) who had various peritoneal permeability and capacities for peritoneal transport of water. (99m)Tc-HSAD 740MBq was injected in 2 L of peritoneal dialysis fluid with 2.5% glucose, mixed well, and administered intraperitoneally. The fluid was drained extraperitoneally after 4 h and TLA was determined by the in vivo loss of (99m)Tc-HSAD. TLA was 1.41 +/- 1.11 mL/min (mean +/- SD; range, 0.27-3.69 mL/min). The estimated reduction rate by TLA in trans-peritoneally removed fluid ranged from 14.2 to 84.4%, indicating that TLA could have an extremely significant negative effect in some cases on total drainage volume. The present study, using new tracer (99m)Tc-HSAD, could confirm a large individual difference in TLA, indicating TLA as an important contributing factor for fluid-removal failure in continuous ambulatory peritoneal dialysis patients.

Rare presentation of subcapsular hepatic steatosis in a woman with uncontrolled diabetes without peritoneal dialysis: a case report.

PubMed

Chowdhary, Varun; Pernicka, Jennifer S Golia; Sharma, Richa

2016-12-20

Subcapsular hepatic steatosis is a rare atypical pattern of fatty deposition of the liver reported in patients with diabetic nephropathy receiving peritoneal dialysis with intraperitoneal insulin. To date, there has been only one pediatric and zero adult cases of subcapsular hepatic steatosis with no history of continuous ambulatory peritoneal dialysis. We report the first published case of subcapsular hepatic steatosis in an adult diabetic patient without any history of peritoneal dialysis or evidence of chronic renal disease. A 46-year-old Caucasian woman with type 2 diabetes mellitus without renal disease presented to our emergency department with vague abdominal symptoms and vomiting. Her blood glucose levels were poorly controlled with a range of 400 to 500 mg/dL. She was diagnosed as having subcapsular hepatic steatosis based on magnetic resonance imaging. Of note, after improved glucose control her subcapsular hepatic steatosis had nearly resolved. Subcapsular hepatic steatosis has been exclusively described in patients with continuous ambulatory peritoneal dialysis and those on intraperitoneal insulin, except for one pediatric case, which was probably due to incorrect insulin administration. Our case demonstrates that a diagnosis of subcapsular hepatic diagnosis should not be restricted to those getting continuous ambulatory peritoneal dialysis, but rather expanded to all patients with uncontrolled blood glucose levels.

Cervical Fusion for Absent Pedicle Syndrome Manifesting with Myelopathy.

PubMed

Goodwin, C Rory; Desai, Atman; Khattab, Mohamed H; Elder, Benjamin D; Bydon, Ali; Wolinsky, Jean-Paul

2016-02-01

Absent congenital pedicle syndrome is a posterior arch defect characterized by numerous congenital and mechanical abnormalities that result from disconnection of the anterior and posterior columns of the spinal canal. Absent congenital pedicle syndrome is a rare anomaly that is most commonly diagnosed incidentally, after evaluation of minor trauma, or after complaints of chronic neck pain. We report a case of absent congenital pedicle syndrome in a patient who presented with myelopathy and lower extremity weakness and review the literature on the surgical management of this entity. A 32-year-old woman with a history of systemic lupus erythematosus presented to the Neurosurgery Service with progressive weakness in her upper and lower extremities, clonus, and hyperreflexia. Magnetic resonance imaging revealed congenital absence of the pedicles of C2, C3, C4, C5, and C6 with a congenitally narrow canal at C4-5. The patient underwent a staged anterior and posterior cervical decompression and fusion. She was placed in a halo after surgery; at the 1-year follow-up, she was ambulatory with demonstrated improvement in weakness and fusion of her cervical spine. Absent congenital pedicle syndrome is rare, and most reported cases were treated conservatively. Surgical management is reserved for patients with myelopathy or instability. Copyright © 2016 Elsevier Inc. All rights reserved.

The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care

PubMed Central

Reddy, Ashok; Pollack, Craig E.; Asch, David A.; Canamucio, Anne; Werner, Rachel M.

2017-01-01

IMPORTANCE Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326 374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184 501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, −5.3; 95% CI, −6.0 to −4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, −1.1; 95% CI, −2.1 to −0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, −1.44; 95% CI, −2.2 to −0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1 percentage point. These effects were moderated by the patients’ continuity with their PCP prior to turnover, with a larger detrimental effect of PCP turnover among those with higher continuity prior to the turnover. CONCLUSIONS AND RELEVANCE Primary care provider turnover was associated with worse patient experiences of care but did not have a major effect on ambulatory care quality. PMID:25985320

Mechanical complications of continuous ambulatory peritoneal dialysis: Experience at the Ibn Sina University Hospital.

PubMed

Flayou, Kaoutar; Ouzeddoun, Naima; Bayahia, Rabia; Rhou, Hakima; Benamar, Loubna

2016-01-01

Peritoneal dialysis is a new renal replacement therapy recently introduced in Morocco since 2006. Continuous ambulatory peritoneal dialysis has proven to be as effective as hemodialysis. However, it is associated with several complications. The aim of this study was to evaluate the outcome of complications in patients treated with peritoneal dialysis at our center. The nature of non-infectious complications was noted during follow-up in these patients. Fiftyseven complications were noted among 34 patients between June 2006 and June 2014. Catheter migration was the most common complication (36.8%), followed by obstruction (14%), dialysate leaks (14%), hemorrhagic complications (10.5%) and, finally, hernia (12.2%), catheter perforation (5.2%) and externalization (3.5%).

Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial.

PubMed

Hudson, Arlene J; Walter, Robert J; Flynn, John; Szpisjak, Dale F; Olsen, Cara; Rodgers, Matthew; Capaldi, Vincent F; McDuffie, Brent; Lettieri, Christopher J

2018-04-15

The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population. This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care. Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpO 2 nadir did not significantly change postoperatively from baseline. Cumulative percentage of time oxygen saturation < 90% significantly increased N1 as compared to baseline for all patients except for those with moderate to severe OSA. Ambulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA. Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798. © 2018 American Academy of Sleep Medicine.

Hospitalization Costs of Total Knee Arthroplasty With a Continuous Femoral Nerve Block Provided Only in the Hospital Versus on an Ambulatory Basis: A Retrospective, Case-Control, Cost-Minimization Analysis

PubMed Central

Ilfeld, Brian M.; Mariano, Edward R.; Williams, Brian A.; Woodard, Jennifer N.; Macario, Alex

2007-01-01

Background and Objectives Following total knee arthroplasty (TKA), hospitalization may be shortened by allowing patients to return home with a continuous femoral nerve block (CFNB). This study quantified the hospitalization costs for 10 TKA patients receiving ambulatory CFNB versus a matched cohort of 10 patients who received CFNB only during hospitalization. Methods We examined the medical records (n=125) of patients who underwent a unilateral, primary, tricompartment TKA with a postoperative CFNB by one surgeon at one institution in an 18-month period beginning January 2004. Each of the ten patients discharged home with an ambulatory CFNB (cases) was matched with a patient with a hospital-only CFNB (controls) for age, gender, body mass index, and health status. Financial data were extracted from the hospital micro-costing database. Results Nine patients with ambulatory CFNB (cases) were discharged home on postoperative day (POD) 1, and one on POD 4. Of the controls, 3 were discharged home on POD 3, 6 on POD 4, and 1 on POD 5. The median (range) costs of hospitalization (excluding implant and professional fees) was $5,292 (4,326 – 7,929) for ambulatory cases, compared with $7,974 (6,931 – 9,979) for inpatient controls (difference=$2,682, 34% decrease, P<0.001). The total charges for hospitalization, the implant, and professional fees was $33,646 (31,816 – 38,468) for cases, compared with $39,100 (36,096 – 44,098) for controls (difference=$5,454, 14% decrease, P<0.001). Conclusions This study provides evidence that ambulatory CFNB for selected patients undergoing TKA has the potential to reduce hospital length-of-stay and associated costs and charges. However, the current study has significant inherent limitations based on the study design. Additional research is required to replicate these results in a prospective, randomized, controlled trial and to determine whether any savings exceed additional CFNB costs such as from complications, having caregivers provide care at home, and additional hospital/health-care provider visits. PMID:17196492

Prevalence, Treatment, and Control Rates of Conventional and Ambulatory Hypertension Across 10 Populations in 3 Continents.

PubMed

Melgarejo, Jesus D; Maestre, Gladys E; Thijs, Lutgarde; Asayama, Kei; Boggia, José; Casiglia, Edoardo; Hansen, Tine W; Imai, Yutaka; Jacobs, Lotte; Jeppesen, Jørgen; Kawecka-Jaszcz, Kalina; Kuznetsova, Tatiana; Li, Yan; Malyutina, Sofia; Nikitin, Yuri; Ohkubo, Takayoshi; Stolarz-Skrzypek, Katarzyna; Wang, Ji-Guang; Staessen, Jan A

2017-07-01

Hypertension is a major global health problem, but prevalence rates vary widely among regions. To determine prevalence, treatment, and control rates of hypertension, we measured conventional blood pressure (BP) and 24-hour ambulatory BP in 6546 subjects, aged 40 to 79 years, recruited from 10 community-dwelling cohorts on 3 continents. We determined how between-cohort differences in risk factors and socioeconomic factors influence hypertension rates. The overall prevalence was 49.3% (range between cohorts, 40.0%-86.8%) for conventional hypertension (conventional BP ≥140/90 mm Hg) and 48.7% (35.2%-66.5%) for ambulatory hypertension (ambulatory BP ≥130/80 mm Hg). Treatment and control rates for conventional hypertension were 48.0% (33.5%-74.1%) and 38.6% (10.1%-55.3%) respectively. The corresponding rates for ambulatory hypertension were 48.6% (30.5%-71.9%) and 45.6% (18.6%-64.2%). Among 1677 untreated subjects with conventional hypertension, 35.7% had white coat hypertension (23.5%-56.2%). Masked hypertension (conventional BP <140/90 mm Hg and ambulatory BP ≥130/80 mm Hg) occurred in 16.9% (8.8%-30.5%) of 3320 untreated subjects who were normotensive on conventional measurement. Exclusion of participants with diabetes mellitus, obesity, hypercholesterolemia, or history of cardiovascular complications resulted in a <9% reduction in the conventional and 24-hour ambulatory hypertension rates. Higher social and economic development, measured by the Human Development Index, was associated with lower rates of conventional and ambulatory hypertension. In conclusion, high rates of hypertension in all cohorts examined demonstrate the need for improvements in prevention, treatment, and control. Strategies for the management of hypertension should continue to not only focus on preventable and modifiable risk factors but also consider societal issues. © 2017 American Heart Association, Inc.

Ambulatory Healthcare Utilization in the United States: A System Dynamics Approach

NASA Technical Reports Server (NTRS)

Diaz, Rafael; Behr, Joshua G.; Tulpule, Mandar

2011-01-01

Ambulatory health care needs within the United States are served by a wide range of hospitals, clinics, and private practices. The Emergency Department (ED) functions as an important point of supply for ambulatory healthcare services. Growth in our aging populations as well as changes stemming from broader healthcare reform are expected to continue trend in congestion and increasing demand for ED services. While congestion is, in part, a manifestation of unmatched demand, the state of the alignment between the demand for, and supply of, emergency department services affects quality of care and profitability. The central focus of this research is to provide an explanation of the salient factors at play within the dynamic demand-supply tensions within which ambulatory care is provided within an Emergency Department. A System Dynamics (SO) simulation model is used to capture the complexities among the intricate balance and conditional effects at play within the demand-supply emergency department environment. Conceptual clarification of the forces driving the elements within the system , quantifying these elements, and empirically capturing the interaction among these elements provides actionable knowledge for operational and strategic decision-making.

Detection of cough signals in continuous audio recordings using hidden Markov models.

PubMed

Matos, Sergio; Birring, Surinder S; Pavord, Ian D; Evans, David H

2006-06-01

Cough is a common symptom of many respiratory diseases. The evaluation of its intensity and frequency of occurrence could provide valuable clinical information in the assessment of patients with chronic cough. In this paper we propose the use of hidden Markov models (HMMs) to automatically detect cough sounds from continuous ambulatory recordings. The recording system consists of a digital sound recorder and a microphone attached to the patient's chest. The recognition algorithm follows a keyword-spotting approach, with cough sounds representing the keywords. It was trained on 821 min selected from 10 ambulatory recordings, including 2473 manually labeled cough events, and tested on a database of nine recordings from separate patients with a total recording time of 3060 min and comprising 2155 cough events. The average detection rate was 82% at a false alarm rate of seven events/h, when considering only events above an energy threshold relative to each recording's average energy. These results suggest that HMMs can be applied to the detection of cough sounds from ambulatory patients. A postprocessing stage to perform a more detailed analysis on the detected events is under development, and could allow the rejection of some of the incorrectly detected events.

Unhealthy Competition: Consequences of Health Plan Choice in California Medicaid

PubMed Central

Chattopadhyay, Arpita; Bindman, Andrew B.

2010-01-01

Objectives. We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice. Methods. This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care–sensitive conditions by duration of plan enrollment. Results. Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P < .001). Annual ambulatory care–sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI] = 6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI = 6.27, 6.28). Conclusions. Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care–sensitive conditions. PMID:20864718

New antithrombotic agents in the ambulatory setting.

PubMed

Gibbs, Neville M; Weightman, William M; Watts, Stephen A

2014-12-01

Many patients presenting for surgical or other procedures in an ambulatory setting are taking new antiplatelet or anticoagulant agents. This review assesses how the novel features of these new agents affect the management of antithrombotic therapy in the ambulatory setting. There have been very few studies investigating the relative risks of continuing or ceasing new antithrombotic agents. Recent reviews indicate that the new antithrombotic agents offer greater efficacy or ease of administration but are more difficult to monitor or reverse. They emphasize the importance of assessing the bleeding risk of the procedure, the thrombotic risk if the agent is ceased, and patient factors that increase the likelihood of bleeding. The timing of cessation of the agent, if required, depends on its pharmacokinetics and patients' bleeding risks. Patients at high risk of thrombotic complications may require bridging therapy. Once agreed upon, the perioperative plan should be made clear to all involved. As there are few clinical studies to guide management, clinicians must make rational decisions in relation to continuing or ceasing new antithrombotic agents. This requires knowledge of their pharmacokinetics, and a careful multidisciplinary assessment of the relative thrombotic and bleeding risks in individual patients.

Treatment of end-stage renal disease with continuous ambulatory peritoneal dialysis in rural Guatemala

PubMed Central

Moore, Jillian; Garcia, Pablo; Flood, David

2018-01-01

A 42-year-old indigenous Maya man presented to a non-profit clinic in rural Guatemala with signs, symptoms and laboratory values consistent with uncontrolled diabetes. Despite appropriate treatment, approximately 18 months after presentation, he was found to have irreversible end-stage renal disease (ESRD) of uncertain aetiology. He was referred to the national public nephrology clinic and subsequently initiated home-based continuous ambulatory peritoneal dialysis. With primary care provided by the non-profit clinic, his clinical status improved on dialysis, but socioeconomic and psychological challenges persisted for the patient and his family. This case shows how care for people with ESRD in low- and middle-income countries requires scaling up renal replacement therapy and ensuring access to primary care, mental healthcare and social work services. PMID:29705734

[Pleuroperitoneal communication detected at the beginning of continuous ambulatory peritoneal dialysis; report of a case].

PubMed

Tamaki, Masafumi; Ikeda, Mayumi; Norimura, Naoko; Miura, Kazumasa; Yoshizawa, Kiyoshi

2012-02-01

A 61-year-old female was diagnosed as having end-stage renal failure developed dyspnea soon after introduction of continuous ambulatory peritoneal dialysis (CAPD). Chest X-ray showed a right-side massive pleural effusion. Pleuro peritoneal communication was suspicious, because the hydrothorax significantly improved by the stop of CAPD. We performed video-assisted thoracic surgery. Using indigo carmine containing peritoneal dialysis fluid through a CAPD catheter, we found a fistula on the diaphragm from which blue dialysis solution flowed out like a fountain. The fistula of the diaphragm was directly closed with a surgical stapler and covered using cellulose oxidized (Surgicel) and fibrin glue. She could restart CAPD on postoperative days 7, and no recurrence of hydrothorax has been detected for 10 months after surgical treatment.

The Evolution of Ambulatory Medical Record Systems in the U.S

PubMed Central

Kuhn, Ingeborg M.; Wiederhold, Gio

1981-01-01

This paper is an overview of the developments in Automated Ambulatory Medical Record Systems (AAMRS) from 1975 to the present. A summary of findings from a 1975 state-of-the-art review is presented with the current findings of a follow-up study of the AAMRS. The studies revealed that effective automated medical record systems have been developed for ambulatory care settings and that they are now in the process of being transfered to other sites or users, either privately or as a commercial product. Since 1975 there have been no significant advances in system design. However, progress has been substantial in terms of achieving production goals. Even though a variety of system are commercially available, there is a continuing need for research and development to improve the effectiveness of the systems in use today.

What matters to low-income patients in ambulatory care facilities?

PubMed

DeLia, Derek; Hall, Allyson; Prinz, Timothy; Billings, John

2004-09-01

Poor, uninsured, and minority patients depend disproportionately on hospital outpatient departments (OPDs) and freestanding health centers for ambulatory care. These providers confront significant challenges, including limited resources, greater demand for services, and the need to improve quality and patient satisfaction. The authors use a survey of patients in OPDs and health centers in New York City to determine which aspects of the ambulatory care visit have the greatest influence on patients' overall site evaluation. The personal interaction between patients and physicians, provider continuity, and the general cleanliness/appearance of the facility stand out as high priorities. Access to services and interactions with other facility staff are of significant, although lesser, importance. These findings suggest ways to restructure the delivery of care so that it is more responsive to the concerns of low-income patients.

Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo.

PubMed

Lopez-Escamez, Jose A; Gamiz, Maria J; Fernandez-Perez, Antonio; Gomez-Fiñana, Manuel; Sanchez-Canet, Isabel

2003-07-01

To determine the impact of the particle repositioning maneuver on posterior canal benign paroxysmal positional vertigo-related quality of life using the Medical Outcomes Study 36-Item Short Form Health Survey and the Dizziness Handicap Inventory Short Form. Prospective, consecutive new cases of posterior canal benign paroxysmal positional vertigo. Ambulatory, primary referral hospital. Forty individuals with posterior canal benign paroxysmal positional vertigo were investigated. The diagnosis was made on the basis of the history of recurrent sudden crisis of vertigo and positional-induced nystagmus during the Dix-Hallpike test. All patients were treated by a single particle repositioning maneuver, and relapses were investigated at Days 7 and 30 posttreatment. Percentage of patients with negative Dix-Hallpike test after treatment, scores obtained on the 36-Item Short Form Health Survey and Dizziness Handicap Inventory Short Form before and 30 days after treatment. DHT was found negative in 76% (28 of 37) individuals at 30 days. The eight scales of the 36-Item Short Form Health Survey had a good internal consistency reliability (Cronbach's alpha > 0.7) in patients with posterior canal benign paroxysmal positional vertigo. The average standardized score for each 36-Item Short Form Health Survey scale was compared with the reference population normative data, showing differences with norms for all scales, except for Vitality. After particle repositioning maneuver, patients scored closer to norms, and Social Function and Mental Health scores were significantly higher than the scores obtained before the particle repositioning maneuver (p < 0.05). Dizziness Handicap Inventory Short Form total score significantly decreased from 18.05 +/- 9.91 (mean +/- standard deviation) at the first day to 9.54 +/- 9.94 at 30 days (p < 0.001). All 36-Item Short Form Health Survey scale scores were correlated significantly with Dizziness Handicap Inventory Short Form total scores at 30 days after treatment. Posterior canal benign paroxysmal positional vertigo has a significant impact on health-related quality of life, and patients experienced a decrease in quality of life as compared with norms. The particle repositioning maneuver improves health-related quality of life in posterior canal benign paroxysmal positional vertigo.

Can health indicators and psychosocial characteristics predict attrition in youths with overweight and obesity seeking ambulatory treatment? Data from a retrospective longitudinal study in a paediatric clinic in Luxembourg.

PubMed

Pit-Ten Cate, Ineke M; Samouda, Hanen; Schierloh, Ulrike; Jacobs, Julien; Vervier, Jean Francois; Stranges, Saverio; Lair, Marie Lise; Beaufort, Carine de

2017-09-03

The current study aimed to identify factors that could predict attrition in youths starting ambulatory treatment to control or lose weight. Retrospective longitudinal study. Paediatric clinic: ambulatory treatment programme. A youth sample (n=191; 89 boys; aged 7-17 years) completed measures of demographic characteristics, and health and psychosocial traits before starting an ambulatory weight management programme. Anthropometric and biological markers related to obesity were also obtained. Tests of mean differences and regression analyses were used to investigate the relationship between these variables and attrition after 1 year. The χ 2 and t test results showed both psychosocial and health indicators differentiated between participants who continued attending the treatment programme and those who dropped out. More specifically, youths that dropped out of treatment were significantly older, had higher body mass index z scores, higher levels of insulin, triglycerides and HOMA-IR, reported poorer health, had more conduct problems and were more dissatisfied with themselves and their bodies before starting treatment. Results of regression analyses revealed that weight status (anthropometric and biological markers), age and body dissatisfaction predicted attrition (overall prediction success 73%; prediction success for continued attendance 90/91%; prediction success for dropouts 42/44%). Attrition, but especially the continued attendance in treatment, can be successfully predicted by age, weight status and body dissatisfaction. For patients who present with one or more risk factors, careful consideration is needed to decide which (combination of) inpatient or outpatient programme may facilitate prolonged engagement of the patient and hence may be most effective in establishing weight loss. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Combined endovascular laser with ambulatory phlebectomy for the treatment of superficial venous incompetence: a 2-year perspective.

PubMed

Sadick, Neil S; Wasser, Samuel

2004-05-01

Non-invasive radiofrequency and endovascular technologies are becoming increasingly popular in the treatment of superficial venous incompetence. In conjunction with stab avulsion of truncal varicosities, these technologies have been able to address functional as well as cosmetic superficial venous incompetence in a non-invasive fashion. The present study presents a 2-year follow-up of 30 patients with combined axial incompetence of the greater saphenous vein (GSV) in conjunction with truncal varicosities treated with combination diode laser technology and ambulatory phlebectomy. Thirty patients (mean age 49 years) with Sapheno-Femoral Junction reflux associated with GSV incompetence (mean 9.2 x 8.5 mm) and enlarged branch varicosities, as documented by Duplex ultrasound, were enrolled. Patients were treated with an endovascular diode laser (810 nm, 14 W, continuous mode), followed by ambulatory phlebectomy of residual truncal varicosities. Patients were examined 3, 6, 12 and 24 months following this procedure to determine the long-term efficacy of this procedure. A 2-year closure rate of 96.8% was documented by Duplex evaluation. All 273 ambulatory phlebectomy vein segments were eradicated. Two cases of transient hyperpigmentation and one case of telangiectatic matting were documented. The combination of endovascular laser and ambulatory phlebectomy appear to be an effective and safe treatment approach for the management of combined saphenous and truncal varicose vein incompetence.

Toward an integrated computerized patient record.

PubMed

Dole, T R; Luberti, A A

2000-04-01

Developing a comprehensive electronic medical record system to serve ambulatory care providers in a large health care enterprise requires significant time and resources. One approach to achieving this system is to devise a series of short-term, workable solutions until a complete system is designed and implemented. The initial solution introduced a basic (mini) medical record system that provided an automated problem/summary sheet and decentralization of ambulatory-based medical records. The next step was to partner with an information system vendor committed to continued development of the long-term system capable of supporting the health care organization well into the future.

[Survey of pain after ambulatory surgery: An internet-based instrument].

PubMed

Schwarze, C; Zenz, D; Orlowski, O; Wempe, C; Van Aken, H; Zahn, P; Maier, C; Pogatzki-Zahn, E M

2016-04-01

Pain after surgery continues to be undermanaged. Studies and initiatives aiming to improve the management of postoperative pain are growing; however, most studies focus on inpatients and pain on the first day after surgery. The management of postoperative pain after ambulatory surgery and for several days thereafter is not yet a major focus. One reason is the low return rate of the questionnaires in the ambulatory sector. This article reports the development and feasibility of a web-based electronic data collection system to examine pain and pain-related outcome on predefined postoperative days after ambulatory surgery. In this prospective pilot study 127 patients scheduled for ambulatory surgery were asked to participate in a survey to evaluate aspects related to pain after ambulatory surgery. The data survey was divided in (1) a preoperative, intraoperative and postoperative part and (2) a postoperative internet-based electronic questionnaire which was sent via e-mail link to the patient on days 1, 3 and 7 after surgery. A software was developed using a PHP-based platform to send e-mails and retrieve the data after web-based entries via a local browser. Feasibility, internet-based hitches and compliance were assessed by an additional telephone call after day 7. A total of 100 patients (50 female) between 18 and 71 years (mean 39.1 ± 12.7 years) were included in the pilot study. Return rates of the electronic questionnaires were 86% (days 3 and 7) and 91% (day 1 after surgery). All 3 electronic questionnaires were answered by 82% of patients. Aspects influencing the return rate of questionnaires were work status but not age, gender, education level and preoperative pain. Telephone interviews were performed with 81 patients and revealed high operability of the internet-based survey without any major problems. The user-friendly feasibility and operability of this internet-based electronic data survey system explain the high compliance and return rate of electronic questionnaires by patients at home after ambulatory surgery. This survey tool therefore provides unique opportunities to evaluate and improve postoperative pain management after ambulatory surgery.

Experience with external pump trial prior to implantation for intrathecal baclofen in ambulatory patients with spastic cerebral palsy.

PubMed

Bleyenheuft, C; Filipetti, P; Caldas, C; Lejeune, T

2007-01-01

To evaluate effectiveness and safety of intrathecal baclofen administration (ITB) testing with continuous infusion via an external pump before the implantation of an internal one in ambulatory spastic patients with cerebral palsy (CP). Seven CP patients (3 diplegic, 4 quadriplegic - 18.4+/-7.0 years) with a progressive decrease in walking ability were included. Assessments included: Ashworth's scale, Observational Gait Scale (OGS), and GMFM-66. During the ITB test (45-150 microg/24h), spasticity decreased by more than two points on Ashworth's scale (p<0.001) and walking ability improved (median OGS increased from 7 to 9, p

Efficacy and safety of sacubitril/valsartan in patients with essential hypertension uncontrolled by olmesartan: A randomized, double-blind, 8-week study.

PubMed

Cheung, Deanna G; Aizenberg, Diego; Gorbunov, Vladimir; Hafeez, Kudsia; Chen, Chien-Wei; Zhang, Jack

2018-01-01

A majority of patients with hypertension fail to achieve blood pressure (BP) control despite treatment with commonly prescribed drugs. This randomized, double-blind phase III trial assessed the superiority of sacubitril/valsartan 200 mg (97/103 mg) to continued olmesartan 20 mg in reducing ambulatory systolic BP after 8-week treatment in patients with mild to moderate essential hypertension uncontrolled with olmesartan 20 mg alone. A total of 376 patients were randomized to receive either sacubitril/valsartan (n = 188) or olmesartan (n = 188). Superior reductions in 24-hour mean ambulatory systolic BP were observed in the sacubitril/valsartan group vs the olmesartan group (-4.3 mm Hg vs -1.1 mm Hg, P < .001). Reductions in 24-hour mean ambulatory diastolic BP and pulse pressure and office systolic BP and diastolic BP were significantly greater with sacubitril/valsartan vs olmesartan (P < .014). A greater proportion of patients achieved BP control with sacubitril/valsartan vs olmesartan. The overall incidence of adverse events was comparable between the groups. Compared with continued olmesartan, sacubitril/valsartan was more effective and generally safe in patients with hypertension uncontrolled with olmesartan 20 mg. ©2018 Wiley Periodicals, Inc.

Impact of Surface Type, Wheelchair Weight, and Axle Position on Wheelchair Propulsion by Novice Older Adults

PubMed Central

Cowan, Rachel E.; Nash, Mark S.; Collinger, Jennifer L.; Koontz, Alicia M.; Boninger, Michael L.

2009-01-01

Objective To examine the impact of surface type, wheelchair weight, and rear axle position on older adult propulsion biomechanics. Design Crossover trial. Setting Biomechanics laboratory. Participants Convenience sample of 53 ambulatory older adults with minimal wheelchair experience (65−87y); men = 20, women = 33. Intervention Participants propelled 4 different wheelchair configurations over 4 surfaces; tile, low carpet, high carpet, and an 8% grade ramp (surface, chair order randomized). Chair configurations included: (1) unweighted chair with an anterior axle position, (2) 9.05kg weighted chair with an anterior axle position, (3) unweighted chair with a posterior axle position (Δ0.08m), and (4) 9.05kg weighted chair with a posterior axle position (Δ0.08m). Weight was added to a titanium folding chair, simulating the weight difference between very light and depot wheelchairs. Instrumented wheels measured propulsion kinetics. Main Outcome Measures Average self-selected velocity, push-frequency, stroke length, peak resultant and tangential force. Results Velocity decreased as surface rolling resistance or chair weight increased. Peak resultant and tangential forces increased as chair weight increased, surface resistance increased, and with a posterior axle position. The effect of a posterior axle position was greater on high carpet and the ramp. The effect of weight was constant, but more easily observed on high carpet and ramp. The effects of axle position and weight were independent of one another. Conclusion Increased surface resistance decreases self-selected velocity and increases peak forces. Increased weight decreases self-selected velocity and increases forces. Anterior axle positions decrease forces, more so on high carpet. Effects of weight and axle position are independent. Greatest reductions in peak forces occur in lighter chairs with anterior axle positions. PMID:19577019

Controllable continuous sub-tenon drug delivery of dexamethasone disodium phosphate to ocular posterior segment in rabbit.

PubMed

Huang, Xuetao; Liu, Shaogang; Yang, Yezhen; Duan, Yiqin; Lin, Ding

2017-11-01

Corticosteroids have been used for treatment of posterior segment eye diseases, but the delivery of drug to the posterior segments is still a problem to resolve. In our study, we explore the feasibility of Sub-tenon's Controllable Continuous Drug Delivery to ocular posterior segment. Controllable continuous sub-tenon drug delivery (CCSDD) system, intravenous injections (IV) and sub-conjunctival injections (SC) were used to deliver dexamethasone disodium phosphate (DEXP) in rabbits, the dexamethasone concentration was measured in the ocular posterior segment tissue by Shimadzu LC-MS 2010 system at different time points in 24 h after first dose injection. Levels of dexamethasone were significantly higher at 12, 24 h in CCSDD than two other approaches, and at 3, 6 h in CCSDD than IV in vitreous body (p < 0.01); at 6, 12, 24 h in CCSDD than two other approaches, and at 1, 3 h in CCSDD than IV in retinal/choroidal compound (p < 0.01); at 3, 6, 12, 24 h in CCSDD than two other approaches, and at 1 h in CCSDD than IV in sclera (p < 0.05). The AUC 0-24 in CCSDD group is higher than two other groups in all ocular posterior segment tissue. Our results demonstrated that dexamethasone concentration could be sustained moderately higher in the posterior segment by CCSDD than SC and IV, indicating that CCSDD might be a therapeutic alternative to treat a variety of intractable posterior segment diseases.

Predictors of At-Home Arterial Oxygen Desaturation Events in Ambulatory Surgical Patients.

PubMed

Biddle, Chuck; Elam, Charles; Lahaye, Laura; Kerr, Gordon; Chubb, Laura; Verhulst, Brad

2016-11-02

Little is known about the early recovery phase occurring at-home after anesthesia and surgery in ambulatory surgical patients. We studied quantitative oximetry and quality-of-life metrics in the first 48 hours after same-day orthopedic surgery examining the association between the recovery metrics and specific patient and procedural factors. We used the STOP-Bang score to quantify patient risk for obstructive sleep apnea in 50 adult patients at 2 centers using continuous portable oximetry and patient journaling. Parametric statistical procedures were used to assess relationships among patient and procedural factors and desaturation events. Higher STOP-Bang scores were predictive of the number and duration of desaturation events below mild and severe thresholds for arterial oxygen saturation during their first 48 hours after discharge from ambulatory surgery. Older patients and patients with higher BMI in particular were at an increased risk of mild and severe arterial oxygen desaturation. Using a home CPAP reduced the number of desaturation events. Of interest, taking opiate analgesics decreased the number of desaturation events. Given the absence of systematic research of early ambulatory anesthesia/surgery recovery at home and concerns of postoperative respiratory events, our results have clear implications for patient safety. Our results imply that screening based on noninvasive STOP-Bang scores may allow for suggestions for recovery from ambulatory surgery, such as encouraging patients with high scores to use home CPAP and aggressive education regarding use of opiates.

Pleural Effusion Developing in Two Patients on Continuous Ambulatory Peritoneal Dialysis.

PubMed

Asim, Muhammad

2016-11-01

Two patients with end-stage-renal-disease on continuous ambulatory peritoneal dialysis (CAPD) presented with pleural effusions. The aspirated fluid was categorised as transudate, based on alkaline pH, low protein and lactic dehydrogenase level. A striking feature of the pleural fluid was, its very high glucose content that resulted from translocation of dextrose containing peritoneal dialysate into the pleural space via a pleuroperitoneal connection. One patient was transferred to hemodialysis, which led to complete resolution of pleural effusion. The other patient was switched to automated peritoneal dialysis, using small dwell volumes with consequent reduction in size of the pleural effusion. Pleuroperitoneal leak should always be considered in the differential diagnosis of pleural effusion in CAPD patients. Although isotopic peritoneography can demonstrate reflux of the tracer in the pleural space, measurement of pleural fluid glucose is a simpler and reliable way of diagnosing pleuroperitoneal communication.

Non Candida albicans fungal peritonitis in continuous ambulatory peritoneal dialysis patients.

PubMed

Kleinpeter, M A; Butt, A A

2001-01-01

We report four episodes of non Candida albicans peritonitis (NCAP) in 3 patients on continuous ambulatory peritoneal dialysis (CAPD). Risk factors for NCAP included diabetes mellitus and prior antibiotic use in half of the cases. The antibiotic treatment was prescribed for exit-site infection (ESI) or peritonitis in the patient. Treatment for NCAP included antifungal therapy with oral fluconazole or intravenous amphotericin B. The NCAP resulted in catheter loss in 100% of the patients over time. Initial catheter salvage in one patient was followed 6 months later by catheter loss following treatment of a bacterial peritonitis that was complicated by the development of Candida (Torulopsis) glabrata peritonitis unresponsive to treatment with intravenous amphotericin B. Although the literature suggests that Candida peritonitis responds to oral fluconazole with and without catheter removal, this series suggests that the treatment of NCAP includes removal of the peritoneal dialysis catheter with appropriate antifungal agents.

Paecilomyces variotii peritonitis in a patient on continuous ambulatory peritoneal dialysis.

PubMed

Uzunoglu, E; Sahin, A M

2017-06-01

Paecilomyces variotii (P. variotii) is an extremely rare cause of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. When diagnosed, it usually portends poor prognosis. Patient's survival depends on early laboratory diagnosis and proper treatment. We herein report a P. variotii peritonitis in a patient on CAPD which is a quite rare clinical entity. Laboratory diagnosis was confirmed via both morphological analysis and DNA sequencing. Antifungal susceptibility tests were performed and interpreted according to the Clinical Laboratory Standards Institute M38-A2 guidelines. After laboratory diagnosis, the patient was treated succesfully with liposomal amphotericin B and itraconazole combination and the peritoneal catheter was removed. This case is worthy of reporting since P. variotii is an uncommon cause of peritonitis and leads to dilemmas in both laboratory diagnosis and treatment strategies. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare.

PubMed

Amjad, Halima; Carmichael, Donald; Austin, Andrea M; Chang, Chiang-Hua; Bynum, Julie P W

2016-09-01

Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.

[Residual renal function and nutritional status in patients on continuous ambulatory peritoneal dialysis].

PubMed

Jovanović, Natasa; Lausević, Mirjana; Stojimirović, Biljana

2005-01-01

During the last years, an increasing number of patients with end-stage renal failure caused by various underlying diseases, all over the world, is treated by renal replacement therapy. NUTRITIONAL STATUS: Malnutrition is often found in patients affected by renal failure; it is caused by reduced intake of nutritional substances due to anorexia and dietary restrictions hormonal and metabolic disorders, comorbid conditions and loss of proteins, amino-acids, and vitamins during the dialysis procedure itself. Nutritional status significantly affects the outcome of patients on chronic dialysis treatment. Recent epiodemiological trials have proved that survival on chronic continuous ambulatory peritoneal dialysis program depends more on residual renal function (RRF) than on peritoneal clearances of urea and creatinine. The aim of the study was to analyze the influence of RRF on common biochemical and anthropometric markers of nutrition in 32 patients with end-stage renal failure with various underlying diseases during the first 6 months on continuous ambulatory peritoneal dialysis (CAPD). The mean residual creatinine clearance was 8,3 ml/min and the mean RRF was 16,24 l/week in our patients at the beginning of the chronic peritoneal dialysis treatment. During the follow-up, the RRF slightly decreased, while the nutritional status of patients significantly improved. Gender and age, as well as the leading disease and peritonitis didn't influence the RRF during the first 6 months of CAPD treatment. We found several positive correlations between RRF and laboratory and anthropometric markers of nutrition during the follow-up, proving the positive influence of RRF on nutritional status of patients on chronic peritoneal dialysis.

Anticoagulation management in the ambulatory surgical setting.

PubMed

Eisenstein, Diana Hill

2012-04-01

Many people receiving maintenance anticoagulation therapy require surgery each year in ambulatory surgery centers. National safety organizations focus attention toward improving anticoagulation management, and the American College of Chest Physicians has established guidelines for appropriate anticoagulation management to balance the risk of thromboembolism when warfarin is discontinued with the risk of bleeding when anticoagulation therapy is maintained. The guidelines recommend that patients at high or moderate risk for thromboembolism should be bridged with subcutaneous low-molecular-weight heparin or IV unfractionated heparin with the interruption of warfarin, and low-risk patients may require subcutaneous low-molecular-weight heparin or no bridging with the interruption of warfarin. The guidelines recommend the continuation of warfarin for patients who are undergoing minor dermatologic or dental procedures or cataract removal. The literature reveals, however, that there is not adequate adherence to these recommendations and guidelines. Management of anticoagulation therapy by a nurse practitioner may improve compliance and safety in ambulatory surgery centers. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Use of continuous ambulatory infusions of concentrated subcutaneous (s.q.) hydromorphone versus intravenous (i.v.) morphine: cost implications for palliative care.

PubMed

Fudin, J; Smith, H S; Toledo-Binette, C S; Kenney, E; Yu, A B; Boutin, R

2000-01-01

Health care practitioners are increasingly under pressure to curtail spending while trying to deliver excellent patient care. These issues are also affecting palliative care, particularly now that palliative care programs are expanding. A comparison of cost-effectiveness and feasibility of using continuous subcutaneous (s.q.) ambulatory infusion of hydromorphone versus intravenous (i.v.) ambulatory morphine is illustrated in this study. With the high doses of morphine required in chronic cancer pain, the use of subcutaneous morphine is not feasible due to the volume of solution required to be delivered. Hydromorphone can be prepared in concentrated solutions enabling it to be delivered by the subcutaneous route. Morphine stability data are available. However, hydromorphone stability has only been verified for seven days; thus, stability data were needed post-seven days. Concentrations of 10 mg/ml, 20 mg/ml, 50 mg/ml, and 100 mg/ml, in 0.9 percent normal saline or dextrose 5 percent water, were analyzed via high-performance liquid chromatography (HPLC) at seven and 28 days. Cost comparisons of supplies and associated costs with subcutaneous versus intravenous solutions were obtained. Hydromorphone was found to be stable for 28 days in both dilutants. Cost analysis of a hydromorphone 28-day supply resulted in substantial savings over the equivalent costs of morphine infusions.

Ambulatory heart rate of professional taxi drivers while driving without their typical psychosocial work stressors: a pilot study.

PubMed

Choi, BongKyoo; Choi, SangJun; Jeong, JeeYeon; Lee, JiWon; Shu, Shi; Yu, Nu; Ko, SangBaek; Zhu, Yifang

2016-01-01

Few studies have examined ambulatory cardiovascular physiological parameters of taxi drivers while driving in relation to their occupational hazards. This study aims to investigate and quantify the impact of worksite physical hazards as a whole on ambulatory heart rate of professional taxi drivers while driving without their typical worksite psychosocial stressors. Ambulatory heart rate (HR driving ) of 13 non-smoking male taxi drivers (24 to 67 years old) while driving was continuously assessed on their 6-hour experimental on-road driving in Los Angeles. Percent maximum HR range (PMHR driving ) of the drivers while driving was estimated based on the individual HR driving values and US adult population resting HR (HR rest ) reference data. For analyses, the HR driving and PMHR driving data were split and averaged into 5-min segments. Five physical hazards inside taxi cabs were also monitored while driving. Work stress and work hours on typical work days were self-reported. The means of the ambulatory 5-min HR driving and PMHR driving values of the 13 drivers were 80.5 bpm (11.2 bpm higher than their mean HR rest ) and 10.7 % (range, 5.7 to 19.9 %), respectively. The means were lower than the upper limits of ambulatory HR and PMHR for a sustainable 8-hour work (35 bpm above HR rest and 30 % PMHR), although 15-27 % of the 5-min HR driving and PMHR driving values of one driver were higher than the limits. The levels of the five physical hazards among the drivers were modest: temperature (26.4 ± 3.0 °C), relative humidity (40.7 ± 10.4 %), PM 2.5 (21.5 ± 7.9  μg /m 3 ), CO 2 (1,267.1 ± 580.0 ppm) and noise (69.7 ± 3.0 dBA). The drivers worked, on average, 72 h per week and more than half of them reported that their job were often stressful. The impact of physical worksite hazards alone on ambulatory HR of professional taxi drivers in Los Angeles generally appeared to be minor. Future ambulatory heart rate studies including both physical and psychosocial hazards of professional taxi drivers are warranted.

Multiclass Posterior Probability Twin SVM for Motor Imagery EEG Classification.

PubMed

She, Qingshan; Ma, Yuliang; Meng, Ming; Luo, Zhizeng

2015-01-01

Motor imagery electroencephalography is widely used in the brain-computer interface systems. Due to inherent characteristics of electroencephalography signals, accurate and real-time multiclass classification is always challenging. In order to solve this problem, a multiclass posterior probability solution for twin SVM is proposed by the ranking continuous output and pairwise coupling in this paper. First, two-class posterior probability model is constructed to approximate the posterior probability by the ranking continuous output techniques and Platt's estimating method. Secondly, a solution of multiclass probabilistic outputs for twin SVM is provided by combining every pair of class probabilities according to the method of pairwise coupling. Finally, the proposed method is compared with multiclass SVM and twin SVM via voting, and multiclass posterior probability SVM using different coupling approaches. The efficacy on the classification accuracy and time complexity of the proposed method has been demonstrated by both the UCI benchmark datasets and real world EEG data from BCI Competition IV Dataset 2a, respectively.

Severe kyphoscoliosis after primary Echinococcus granulosus infection of the spine

PubMed Central

Gabl, M.; Lechner, R.; Gstöttner, M.; Bach, C. M.

2010-01-01

A primary Echinococcus granulosus infection of the spine involving the vertebrae T8 and T9 of a 6-year-old child was treated elsewhere by thoracotomy, partial corporectomy, multiple laminectomies and uninstrumented fusion. Owing to inappropriate stabilization, severe deformity developed secondary to these surgeries. X-rays, CT and MRI scans of the spine revealed a severe thoracic kyphoscoliosis of more than 100° (Fig. 1) and recurrence of Echinococcus granulosus infection. The intraspinal cyst formation was located between the stretched dural sac and the vertebral bodies of the kyphotic apex causing significant compression of the cord (Figs. 2, 3, 4). A progressive neurologic deficit was reported by the patient. At the time of referral, the patient was wheelchair bound and unable to walk by herself (Frankel Grade C). Standard antiinfectious therapy of Echinococcus granulosus requires a minimum treatment period of 3 months. This should be done before any surgical intervention because in case of a rupture of an active cyst, the delivered lipoprotein antigens of the parasite may cause a potentially lethal anaphylactic shock. Owing to the critical neurological status, we decided to perform surgery without full length preoperative antiinfectious therapy. Surgical treatment consisted in posterior vertebral column resection technique with an extensive bilateral costotransversectomy over three levels, re-decompression with cyst excision around the apex and multilevel corporectomy of the apex of the deformity. Stabilisation and correction of the spinal deformity were done by insertion of a vertebral body replacement cage anteriorly and posterior shortening by compression and by a multisegmental pedicle screw construct. After the surgery, antihelminthic therapy was continued. The patients neurological deficits resolved quickly: 4 weeks after surgery, the patient had Frankel Grade D and was ambulatory without any assistance. After an 18-month follow-up, the patient is free of recurrence of infection and free of neurologically deficits (Frankel E). This case demonstrates that inappropriate treatment—partial resection of the cyst, inappropriate anterior stabilization and posterior multilevel laminectomies without posterior stabilization—may lead to severe progressive kyphoscoliotic deformity and recurrence of infection, both leading to significant neurological injury presenting as a very difficult to treat pathology.Fig. 1X-rays of the patient showing a kyhoscoliotic deformity. a ap view, b lateral viewFig. 2CT reconstruction of the whole spine showing the apex of the deformity is located in the area of the previous surgeriesFig. 3Sagittal CT-cut showing the bone bloc at the apex with a translation deformityFig. 4Sagittal T2-weighted MRI image showing the cystic formation at the apex PMID:20514501

A Multicenter, Randomized, Triple-Masked, Placebo-Controlled Trial of The Effect of Ambulatory Continuous Femoral Nerve Blocks on Discharge-Readiness Following Total Knee Arthroplasty In Patients on General Orthopaedic Wards

PubMed Central

Ilfeld, Brian M.; Mariano, Edward R.; Girard, Paul J.; Loland, Vanessa J.; Meyer, R. Scott; Donovan, John F.; Pugh, George A.; Le, Linda T.; Sessler, Daniel I.; Shuster, Jonathan J.; Theriaque, Douglas W.; Ball, Scott T.

2010-01-01

A continuous femoral nerve block (cFNB) involves the percutaneous insertion of a catheter adjacent to the femoral nerve, followed by a local anesthetic infusion, improving analgesia following total knee arthroplasty (TKA). Portable infusion pumps allow infusion continuation following hospital discharge, raising the possibility of decreasing hospitalization duration. We therefore used a multicenter, randomized, triple-masked, placebo-controlled study design to test the primary hypothesis that a four-day ambulatory cFNB decreases the time until each of three predefined readiness-for-discharge criteria (adequate analgesia, independence from intravenous opioids, and ambulation ≥ 30 meters) are met following TKA compared with an overnight inpatient-only cFNB. Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomized to either continue perineural ropivacaine (n=39) or switch to normal saline (n=38). Patients were discharged with their cFNB and portable infusion pump as early as postoperative day three. Patients given four days of perineural ropivacaine attained all three criteria in a median (25th–75th percentiles) of 47 (29–69) hours, compared with 62 (45–79) hours for those of the control group (Estimated ratio=0.80, 95% confidence interval: 0.66–1.00; p=0.028). Compared with controls, patients randomized to ropivacaine met the discharge criterion for analgesia in 20 (0–38) vs. 38 (15–64) hours (p=0.009), and intravenous opioid independence in 21 (0–37) vs. 33 (11–50) hours (p=0.061). We conclude that a four-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 20% following TKA compared with an overnight cFNB, primarily by improving analgesia. PMID:20573448

Impact of Volume Management on Volume Overload and Rehospitalization in CAPD Patients.

PubMed

Xu, Yi; Yang, Shen-Min; Wang, Xiao-Hua; Wang, Hai-Fang; Niu, Mei-E; Yang, Yi-Qun; Lu, Guo-Yuan; Pang, Jian-Hong; Wang, Fei; Li, Lin

2018-05-01

Heart failure due to volume overload is a major reason for rehospitalization in continuous ambulatory peritoneal dialysis patients. Strict volume control provides better cardiac functions and blood pressure in this population. Volume management, which is a volume control strategy, may decrease volume overload and related complications. Using a quasi-experimental design, 66 continuous ambulatory peritoneal dialysis patients were randomly assigned to the intervention group ( n = 34) and control group ( n = 32). The patients were followed up for 6 months with scheduled clinic and/or telephone visits; the intervention group adopted volume management strategy, while the control group adopted conventional care. Volume overload and cardiac function were compared between the two groups at the baseline and at 6 months. At Month 6, the intervention group resulted in significant improvement in volume overloaded status, cardiac function, and volume-overload-related rehospitalization. Volume management strategy allows for better control of volume overload and is associated with fewer volume-related readmissions.

Validation of a Wireless, Self-Application, Ambulatory Electroencephalographic Sleep Monitoring Device in Healthy Volunteers.

PubMed

Finan, Patrick H; Richards, Jessica M; Gamaldo, Charlene E; Han, Dingfen; Leoutsakos, Jeannie Marie; Salas, Rachel; Irwin, Michael R; Smith, Michael T

2016-11-15

To evaluate the validity of an ambulatory electroencephalographic (EEG) monitor for the estimation of sleep continuity and architecture in healthy adults. Healthy, good sleeping participants (n = 14) were fit with both an ambulatory EEG monitor (Sleep Profiler) and a full polysomnography (PSG) montage. EEG recordings were gathered from both devices on the same night, during which sleep was permitted uninterrupted for eight hours. The study was set in an inpatient clinical research suite. PSG and Sleep Profiler records were scored by a neurologist board certified in sleep medicine, blinded to record identification. Agreement between the scored PSG record, the physician-scored Sleep Profiler record, and the Sleep Profiler record scored by an automatic algorithm was evaluated for each sleep stage, with the PSG record serving as the reference. Results indicated strong percent agreement across stages. Kappa was strongest for Stage N3 and REM. Specificity was high for all stages; sensitivity was low for Wake and Stage N1, and high for Stage N2, Stage N3, and REM. Agreement indices improved for the manually scored Sleep Profiler record relative to the autoscore record. Overall, the Sleep Profiler yields an EEG record with comparable sleep architecture estimates to PSG. Future studies should evaluate agreement between devices with a clinical sample that has greater periods of wake in order to better understand utility of this device for estimating sleep continuity indices, such as sleep onset latency and wake after sleep onset. © 2016 American Academy of Sleep Medicine

Pro: Ambulatory blood pressure should be used in all patients on hemodialysis

PubMed Central

Agarwal, Rajiv

2015-01-01

In the adult population in general and among people with chronic kidney disease in particular, it is now well established that hypertension is a major driver of renal disease progression and cardiovascular morbidity and mortality [1–4]. Although the contribution of hypertension to cardiovascular morbidity and mortality among patients on long-term dialysis continues to be debated [5–8], a major barrier to detect hypertension as a risk factor for cardiovascular events in these patients has been the inability to diagnose hypertension [9]. Largely to blame has been the easy availability of pre-dialysis and post-dialysis blood pressure recordings in stark contrast to ambulatory blood pressure measurements in dialysis patients to accurately diagnose the presence or control of hypertension [10]. It is increasingly becoming clear that out-of-office blood pressure recordings are superior to clinic recordings in making a diagnosis, assessing target organ damage, evaluating prognosis and managing patients with hypertension [11–15]. In this debate, I have been asked to defend the position that ambulatory blood pressure recordings should be systematically applied to all patients on hemodialysis. PMID:26022728

Low-complexity R-peak detection in ECG signals: a preliminary step towards ambulatory fetal monitoring.

PubMed

Rooijakkers, Michiel; Rabotti, Chiara; Bennebroek, Martijn; van Meerbergen, Jef; Mischi, Massimo

2011-01-01

Non-invasive fetal health monitoring during pregnancy has become increasingly important. Recent advances in signal processing technology have enabled fetal monitoring during pregnancy, using abdominal ECG recordings. Ubiquitous ambulatory monitoring for continuous fetal health measurement is however still unfeasible due to the computational complexity of noise robust solutions. In this paper an ECG R-peak detection algorithm for ambulatory R-peak detection is proposed, as part of a fetal ECG detection algorithm. The proposed algorithm is optimized to reduce computational complexity, while increasing the R-peak detection quality compared to existing R-peak detection schemes. Validation of the algorithm is performed on two manually annotated datasets, the MIT/BIH Arrhythmia database and an in-house abdominal database. Both R-peak detection quality and computational complexity are compared to state-of-the-art algorithms as described in the literature. With a detection error rate of 0.22% and 0.12% on the MIT/BIH Arrhythmia and in-house databases, respectively, the quality of the proposed algorithm is comparable to the best state-of-the-art algorithms, at a reduced computational complexity.

Fluid and electrolyte shifts in women during +Gz acceleration after 15 days' bed rest

NASA Technical Reports Server (NTRS)

Greenleaf, J. E.; Stinnett, H. O.; Davis, G. L.; Kollias, J.; Bernauer, E. M.

1977-01-01

Experiments were conducted on twelve women aged 23-34 yr - a bed rest (BR) group of eight subjects and an ambulatory (AMB) group of four subjects - to determine the effect of bed rest on shifts in plasma volume, electrolytes, and erythrocyte volume during +Gz acceleration on a centrifuge. The BR group underwent the +Gz acceleration during a two-week ambulatory control period, after 15 days of a 17-day BR period, and on the third day of ambulatory recovery. The AMB group underwent the same experimental procedures, but continued their normal daily routine during the BR period without additional prescribed physical exercise. Major conclusions are that (1) the higher the mean control tolerance, the greater the tolerance decline after BR; (2) relative confinement and reduced activity contribute as much to reduction in tolerance as does the horizontal body position during BR; (3) BR deconditioning has no effect on the erythrocyte volume during +3.0 Gz; and (4) about one-half the loss in tolerance after BR can be attributed to plasma volume and electrolyte shifts.

Motion analysis of wheelchair propulsion movements in hemiplegic patients: effect of a wheelchair cushion on suppressing posterior pelvic tilt.

PubMed

Kawada, Kyohei; Matsuda, Tadamitsu; Takanashi, Akira; Miyazima, Shigeki; Yamamoto, Sumiko

2015-03-01

[Purpose] This study sought to ascertain whether, in hemiplegic patients, the effect of a wheelchair cushion to suppress pelvic posterior tilt when initiating wheelchair propulsion would continue in subsequent propulsions. [Subjects] Eighteen hemiplegic patients who were able to propel a wheelchair in a seated position participated in this study. [Methods] An adjustable wheelchair was fitted with a cushion that had an anchoring function, and a thigh pad on the propulsion side was removed. Propulsion movements from the seated position without moving through three propulsion cycles were measured using a three-dimensional motion analysis system, and electromyography was used to determine the angle of pelvic posterior tilt, muscle activity of the biceps femoris long head, and propulsion speed. [Results] Pelvic posterior tilt could be suppressed through the three propulsion cycles, which served to increase propulsion speed. Muscle activity of the biceps femoris long head was highest when initiating propulsion and decreased thereafter. [Conclusion] The effect of the wheelchair cushion on suppressing pelvic posterior tilt continued through three propulsion cycles.

Motion analysis of wheelchair propulsion movements in hemiplegic patients: effect of a wheelchair cushion on suppressing posterior pelvic tilt

PubMed Central

Kawada, Kyohei; Matsuda, Tadamitsu; Takanashi, Akira; Miyazima, Shigeki; Yamamoto, Sumiko

2015-01-01

[Purpose] This study sought to ascertain whether, in hemiplegic patients, the effect of a wheelchair cushion to suppress pelvic posterior tilt when initiating wheelchair propulsion would continue in subsequent propulsions. [Subjects] Eighteen hemiplegic patients who were able to propel a wheelchair in a seated position participated in this study. [Methods] An adjustable wheelchair was fitted with a cushion that had an anchoring function, and a thigh pad on the propulsion side was removed. Propulsion movements from the seated position without moving through three propulsion cycles were measured using a three-dimensional motion analysis system, and electromyography was used to determine the angle of pelvic posterior tilt, muscle activity of the biceps femoris long head, and propulsion speed. [Results] Pelvic posterior tilt could be suppressed through the three propulsion cycles, which served to increase propulsion speed. Muscle activity of the biceps femoris long head was highest when initiating propulsion and decreased thereafter. [Conclusion] The effect of the wheelchair cushion on suppressing pelvic posterior tilt continued through three propulsion cycles. PMID:25931688

Rectus sheath catheters for continuous analgesia after upper abdominal surgery.

PubMed

Cornish, Philip; Deacon, Alf

2007-01-01

The segmental nerves T6-T11 pass through and innervate the rectus abdominis muscle and overlying skin. The arcuate lines compartmentalize the rectus, but they are deficient posteriorly and hence a catheter tunnelled into the posterior sheath can be used to achieve an effective continuous analgesic block. Volume is important to fill the compartment. It is a simple surgical procedure that has several advantages and appears a viable alternative to epidural analgesia.

[Upper Age Limit in Outpatient Anesthesia: Opportunities and Risks].

PubMed

Hüppe, Tobias; Kneller, Nicole; Raddatz, Alexander

2018-05-01

Ambulatory surgery in elderly patients continues to increase - avoiding hospitalization and thus postoperative cognitive dysfunction in older patients being its major objectives. An upper age limit in outpatient anesthesia does not exist to date. However, functional rather than chronological age is crucial in patient selection. In consensus discussion, baseline functional status should be evaluated regularly - defined as everyday behaviors necessary to maintain daily life and encompassing areas of physical, cognitive, and social functioning. Moreover, frailty in elderly patients can be quantified objectively and is associated with increased perioperative morbidity in ambulatory general surgery. The decision for or against outpatient anesthesia therefore remains a case-by-case decision which should be discussed within a team. Georg Thieme Verlag KG Stuttgart · New York.

Marketing strategy adjustments in the ambulatory care center industry: implications for community pharmacy.

PubMed

Phillips, J H

1989-01-01

Each stage of a product's life cycle requires marketing strategy modifications in response to changing demand levels. The purpose of this study was to investigate changes in ambulatory care center (ACC) operational characteristics indicative of product, market, and distribution channel adjustments that could have a competitive impact upon community pharmacy practice. A questionnaire was mailed to a national sample of 325 ACC managers. Evidence of new product feature additions includes increased emphasis on continued care and increased prevalence of prescription drug dispensing. Expansion into new market segments and distribution channels was demonstrated by increased participation in HMO and employer relationships. The observed adjustments in ACC marketing strategies present obvious challenges as well as less obvious opportunities for community pharmacy practice.

42 CFR 416.40 - Condition for coverage-Compliance with State licensure law.

Code of Federal Regulations, 2010 CFR

2010-10-01

... licensure law. 416.40 Section 416.40 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM AMBULATORY SURGICAL SERVICES Specific Conditions for Coverage § 416.40 Condition for coverage—Compliance with State licensure law. The ASC must comply...

[MRSA and ESBL in outpatient: development from 2008 up to 2012 and socio demographic differences].

PubMed

Eckmanns, Tim; Richter, Doreen; Feig, Marcel

2014-01-01

Data on resistance from ambulatory care are rarely available, since surveillance systems cover mostly isolates come from inpatient care. The outpatient setting is of interest, however, since it is where hospitalized patients with resistant pathogens are also treated as outpatients, and where patients are seen who have resistant pathogens from other sources, such as food. In addition, 85% of the antibiotics used in human medicine, are used in ambulatory care. Using data from the Antibiotic Resistance Surveillance System (ARS), we show the development of resistance of Staphylococcus aureus to oxacillin and of Escherichia coli and Klebsiella pneumoniae to cefotaxime in outpatient care between 2008 and 2012 and corresponding socio-demographic differences in the resistance rate. According to our analyses, the proportion of MRSA in S. aureus since 2009 in the outpatient sector decreased (all materials: 2009 11.5%, 2012 9.8%), which is similar to inpatient care, while the proportion of ESBL in E. coli (2008 2.7%, 2012 5.6%), and K. pneumoniae (2008 2.7%, 2012 6.6%) increased over the total period. At the same time resistance for the three pathogens in both sexes over the age groups continuously increased, women still hold a lower proportion of resistance than men. The resistance levels of S. aureus and K. pneumoniae in ambulatory care are reflected at a lower level than in hospital care. In contrast, the high proportion of resistant E. coli in children suggests another source in ambulatory care.

Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: results of a randomised clinical trial.

PubMed

Kumagai, Koshi; Kjellin, Ann; Tsai, Jon A; Thorell, Anders; Granqvist, Staffan; Lundell, Lars; Håkanson, Bengt

2014-01-01

The optimal anti-reflux procedure after Heller cardiomyotomy for oesophageal achalasia remains unclear. The most commonly used procedure is the anterior partial fundoplication according to Dor, although during recent years the posterior counterpart (Toupet) has become popular. Patients with newly diagnosed achalasia and referred for cardiomyotomy were randomised to receive either an anterior or partial posterior fundoplication following a classical cardiomyotomy. The effect of surgery was assessed during the first postoperative year by Eckardt scores, EORTC QLQ-OES18 scores and HRQL questionnaires. Timed barium oesophagogram (TBO) and ambulatory 24-h pH monitoring were performed to determine oesophageal emptying and the degree of reflux control, respectively. Forty-two patients were randomised into Dor (n = 20) and Toupet (n = 22) groups. Eckardt scores improved dramatically with both procedures, but the EORTC QLQ-OES18 (functional scales) scores revealed significantly better relative improvements in the Toupet group compared to the Dor repair (P = 0.044). Corresponding advantages in favour of Toupet were observed postoperatively in the percentage of oesophageal emptying at TBO (P = 0.011 in height and P = 0.018 in area), an effect not observed in the Dor group. There were no other significant differences recorded between the study groups concerning HRQL evaluations and objective assessment of gastro-oesophageal acid reflux. A partial posterior fundoplication after cardiomyotomy seems to achieve more improvement in oesophageal emptying and EORTC QLQ-OES18 functional scale scores than the anterior fundoplication. Otherwise no differences between the two anti-reflux repairs were noted. ClinicalTrials.gov Identifier: NCT01933373. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Adolescent medicine training in pediatric residency programs.

PubMed

Fox, Harriette B; McManus, Margaret A; Klein, Jonathan D; Diaz, Angela; Elster, Arthur B; Felice, Marianne E; Kaplan, David W; Wibbelsman, Charles J; Wilson, Jane E

2010-01-01

The aim of this study was to provide an assessment of pediatric residency training in adolescent medicine. We conducted 2 national surveys: 1 of pediatric residency program directors and the other of faculty who are responsible for the adolescent medicine block rotation for pediatric residents to elicit descriptive and qualitative information concerning the nature of residents' ambulatory care training experience in adolescent medicine and the workforce issues that affect the experience. Required adolescent medicine topics that are well covered pertain to normal development, interviewing, and sexual issues. Those least well covered concern the effects of violence, motor vehicle safety, sports medicine, and chronic illness. Shortages of adolescent medicine specialists, addictions counselors, psychiatrists, and other health professionals who are knowledgeable about adolescents frequently limit pediatric residency training in adolescent medicine. Considerable variation exists in the timing of the mandatory adolescent medicine block rotation, the clinic sites used for ambulatory care training, and the range of services offered at the predominant training sites. In addition, residents' continuity clinic experience often does not include adolescent patients; thus, pediatric residents do not have opportunities to establish ongoing therapeutic relationships with adolescents over time. Both program and rotation directors had similar opinions about adolescent medicine training. Significant variation and gaps exist in adolescent medicine ambulatory care training in pediatric residency programs throughout the United States. For addressing the shortcomings in many programs, the quality of the block rotation should be improved and efforts should be made to teach adolescent medicine in continuity, general pediatric, and specialty clinics. In addition, renewed attention should be given to articulating the core competencies needed to care for adolescents.

Care of the Patient with Renal Disease: Peritoneal Dialysis and Transplants, Nursing 321A.

ERIC Educational Resources Information Center

Hulburd, Kimberly

A description is provided of a course, "Care of the Patient with Renal Disease," offered at the community college level to prepare licensed registered nurses to care for patients with renal disease, including instruction in performing the treatments of peritoneal dialysis and continuous ambulatory peritoneal dialysis (CAPD). The first…

77 FR 59616 - Medicare and Medicaid Programs; Approval of the American Osteopathic Association/Healthcare...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-28

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-3264-FN... Accreditation Program (AOA/HFAP) Application for Continuing CMS-Approval of Its Ambulatory Surgical Center (ASC... 6 years or sooner as determined by CMS. AOA/HFAP's current term of approval for their ASC...

Evaluation of continuous ambulatory peritoneal dialysis fluid C-reactive protein in patients with peritonitis.

PubMed

Ramanathan, Kumaresan; Padmanabhan, Giri; Vijayaraghavan, Bhooma

2016-05-01

Severe peritonitis causing death is one of the most devastating complications of peritoneal dialysis (PD). Since the predictive value of C-reactive protein (CRP) in PD fluid has not been assessed, the objective of the present study is to evaluate its predictive value and clinical correlation in patients on PD with peritonitis. One hundred and twenty patients on continuous ambulatory PD (CAPD) were enrolled and their serum and fluid CRP (Fl. CRP) were evaluated at the start of CAPD. All patients who developed peritonitis were further evaluated for serum and fluid CRP. The patients were categorized into four groups, namely: normal patients (control group), patients with peritonitis, patients with peritonitis leading to catheter removal, and death due to peritonitis. Sixty-five patients developed peritonitis of whom, catheter removal was performed in eight patients. Five patients died due to peritonitis-related complications. Fl. CRP showed a significant difference among the three groups, unlike S. CRP. Estimation of CRP in the peritoneal fluid may be a useful marker to monitor the onset of peritonitis.

Laboratory diagnosis of peritonitis in patients on continuous ambulatory peritoneal dialysis.

PubMed Central

Ludlam, H A; Price, T N; Berry, A J; Phillips, I

1988-01-01

The clinical course and laboratory diagnosis of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis was studied in 32 consecutive episodes. Peritonitis was associated with a failure in aseptic technique in eight episodes and with an exit-site infection in four episodes. Intraperitoneal vancomycin and ceftazidime were safe, effective, and convenient. Most patients administered their antibiotics at home, and symptoms usually resolved by day 4. Culture of the deposit obtained by centrifugation of 50 ml of effluent after leukocyte lysis provided the best rate of recovery (84% culture positive) but was technically demanding. Filtration of the same volume without leukocyte lysis was simple to perform and almost as effective. Enrichment was less satisfactory (65% culture positive) owing to the presence of antibiotic or infection with fastidious microorganisms. Culture of 50 ml of effluent after concentration by a commonly used laboratory technique, centrifugation without leukocyte lysis, performed poorly (59% culture positive at 48 h), as this method caused sequestration and death of microorganisms within the leukocytes. Culture of nearly 1 liter of effluent from 33 asymptomatic patients by the same techniques yielded no microorganisms. PMID:3183023

Fatal Hormonema dematioides Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis: Criteria for Organism Identification and Review of Other Known Fungal Etiologic Agents

PubMed Central

Shin, Jong Hee; Lee, Sang Ku; Suh, Soon Pal; Ryang, Dong Wook; Kim, Nam Ho; Rinaldi, Michael G.; Sutton, Deanna A.

1998-01-01

We report a fatal case a fungal peritonitis caused by the yeast-like dematiaceous mould Hormonema dematioides in a 45-year-old woman. The woman had a 13-year history of insulin-dependent diabetes mellitus and had been on continuous ambulatory peritoneal dialysis for chronic renal failure. H. dematioides was repeatedly isolated from the dialysate culture specimens collected on days 3, 9, 16, and 20 of her hospital stay. Preliminary culture reports on day 7 of the growth of a yeast-like fungus, a probable Candida species, prompted the administration of fluconazole (FLU). Intraperitoneal and intravenous FLU failed to eliminate the mould, and the patient expired on day 21 of her hospital stay. We use this case to present what appears to be the first report of fungal peritonitis due to H. dematioides, to provide laboratorians with criteria for differentiating this organism from the similar mould Aureobasidium pullulans and from various yeast genera, and to provide a review of known fungal taxa inciting peritonitis. PMID:9650991

Wearable PWV technologies to measure Blood Pressure: eliminating brachial cuffs.

PubMed

Solá, J; Proença, M; Chételat, O

2013-01-01

The clinical demand for technologies to monitor Blood Pressure (BP) in ambulatory scenarios with minimal use of inflation cuffs is strong: new generation of BP monitors are expected to be not only accurate, but also non-occlusive. In this paper we review recent advances on the use of the so-called Pulse Wave Velocity (PWV) technologies to estimate BP in a beat-by-beat basis. After introducing the working principle and underlying methodological limitations, two implementation examples are provided. Pilot studies have demonstrated that novel PWV-based BP monitors depict accuracy scores falling within the limits of the British Hypertensive Society (BHS) Grade A standard. The reported techniques pave the way towards ambulatory-compliant, continuous and non-occlusive BP monitoring devices, where the use of inflation cuffs is drastically reduced.

Activity and heart rate-based measures for outpatient cardiac rehabilitation.

PubMed

Bidargaddi, N P; Sarela, A

2008-01-01

Derive activity and heart rate (HR) monitor-based clinically relevant measures for outpatient cardiac rehabilitation (CR). We are currently collecting activity/ECG data from patients undergoing cardiac rehabilitation over duration of six weeks. From these data sets, we a) derive various measures which can be used in assessing home-based CR patients remotely and b) investigate the usefulness of continuous ambulatory HR and heart rate variability (HRV) for various core components of CR. The information provided by these measures is interpreted according to the CR guidelines framework by American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), thus showing how these tools can be used in assessing the progress of patients' condition. The usefulness and significance of these measures from a health care professional perspective is also presented by evaluating them against the existing hospital-based measures through examples. Hospital-based CR programs, despite their clinical benefits are severely under-utilized and resource-demanding. Ambulatory monitoring technologies, which provide a means for continuous physiological monitoring of patients at home compared to hospital-based tools, can enable home-based CR. The clinically relevant measures derived from these tools not only reflect patients' condition in a similar way as conventional tools but also show the continuous status of functional capacity (FC).

Age-Dependency of Location of Epileptic Foci in "Continuous Spike-and-Waves during Sleep": A Parallel to the Posterior-Anterior Trajectory of Slow Wave Activity.

PubMed

Bölsterli Heinzle, Bigna Katrin; Bast, Thomas; Critelli, Hanne; Huber, Reto; Schmitt, Bernhard

2017-02-01

Epileptic encephalopathy with continuous spike-and-waves during sleep (CSWS) occurs during childhood and is characterized by an activation of spike wave complexes during slow wave sleep. The location of epileptic foci is variable, as is etiology. A relationship between the epileptic focus and age has been shown in various focal epilepsies following a posterior-anterior trajectory, and a link to brain maturation has been proposed. We hypothesize that in CSWS, maximal spike wave activity, corresponding to the epileptic focus, is related to age and shows a posterior-anterior evolution. In a retrospective cross-sectional study on CSWS (22 EEGs of 22 patients aged 3.1–13.5 years), the location of the epileptic focus is related to age and follows a posterior-anterior course. Younger patients are more likely to have posterior foci than older ones. We propose that the posterior-anterior trajectory of maximal spike waves in CSWS might reflect maturational changes of maximal expression of sleep slow waves, which follow a comparable course. Epileptic spike waves, that is, “hyper-synchronized slow waves” may occur at the place where the highest and therefore most synchronized slow waves meet brain tissue with an increased susceptibility to synchronization. Georg Thieme Verlag KG Stuttgart · New York.

The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis.

PubMed

Lam, Lai Wah; Lee, Diana T F; Shiu, Ann T Y

2014-06-01

The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored. To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis. This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study. The study was conducted at a renal unit of an acute hospital in Hong Kong. Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews. Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously. Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life. The process of adherence was dynamic as there were fluctuations at each stage of the participants' adherence. With reference to each stage identified, nursing interventions can be developed to help patients achieve smooth transition throughout all the stages. Copyright © 2013 Elsevier Ltd. All rights reserved.

Postnatal hypothermia and cold stress among newborn infants in Nepal monitored by continuous ambulatory recording.

PubMed

Ellis, M; Manandhar, N; Shakya, U; Manandhar, D S; Fawdry, A; Costello, A M

1996-07-01

To describe the pattern of hypothermia and cold stress after delivery among a normal neonatal population in Nepal; to provide practical advice for improving thermal care in a resource limited maternity hospital. The principal government funded maternity hospital in Kathmandu, Nepal, with an annual delivery rate of 15,000 (constituting 40% of all Kathmandu Valley deliveries), severe resource limitations (annual budget Pounds 250,000), and a cold winter climate provided the setting. Thirty five healthy term neonates not requiring special care were enrolled for study within 90 minutes of birth. Continuous ambulatory temperature monitoring, using microthermistor skin probes for forehead and axilla, a flexible rectal probe, and a black ball probe placed next to the infant for ambient temperature, was carried out. All probes were connected to a compact battery powered Squirrel Memory Logger, giving a temperature reading to 0.2 degree C at five minute intervals for 24 hours. Severity and duration of hypothermia, using cutoff values of core temperature less than 36 degrees C, 34 degrees C, and 32 degrees C; and cold stress, using cutoff values of skin-core (forehead-axilla) temperature difference greater than 3 degrees C and 4 degrees C were the main outcome measures. Twenty four hour mean ambient temperatures were generally lower than the WHO recommended level of 25 degrees C (median 22.3 degrees C, range 15.1-27.5 degrees C). Postnatal hypothermia was prolonged, with axillary core temperatures only reaching 36 degrees C after a mean of 6.4 hours (range 0-21.1; SD 4.6). There was persistent and increasing cold stress over the first 24 hours with the core-skin (axillary-forehead) temperature gap exceeding 3 degrees C for more than half of the first 24 hours. Continuous ambulatory recording identifies weak links in the "warm chain" for neonates. The severity and duration of thermal problems was greater than expected even in a hospital setting where some of the WHO recommendations had already been implemented.

Continuous monitoring of blood pressure in children and adolescents,a review of the literature.

PubMed

Mercado, Arlene B

2008-08-01

Continuous or ambulatory blood pressure monitoring (CBPM or ABPM) is becoming a useful tool in the early detection of hypertension in children and adolescents. With increased obesity in pediatrics, chronic diseases such as hypertension, diabetes, dyslipidemia and metabolic syndrome which was more commonly seen in adults in the early years, can now be seen in this population. This review provides the clinical reports of the use of CBPM for diagnosis and management of hypertension in the pediatric population.

Decompression sickness during simulated extravehicular activity: ambulation vs. non-ambulation.

PubMed

Webb, James T; Beckstrand, Devin P; Pilmanis, Andrew A; Balldin, Ulf I

2005-08-01

Extravehicular activity (EVA) is required from the International Space Station on a regular basis. Because of the weightless environment during EVA, physical activity is performed using mostly upper-body movements since the lower body is anchored for stability. The adynamic model (restricted lower-body activity; non-ambulation) was designed to simulate this environment during earthbound studies of decompression sickness (DCS) risk. DCS symptoms during ambulatory (walking) and non-ambulatory high altitude exposure activity were compared. The objective was to determine if symptom incidences during ambulatory and non-ambulatory exposures are comparable and provide analogous estimates of risk under otherwise identical conditions. A retrospective analysis was accomplished on DCS symptoms from 2010 ambulatory and 330 non-ambulatory exposures. There was no significant difference between the overall incidence of DCS or joint-pain DCS in the ambulatory (49% and 40%) vs. the non-ambulatory exposures (53% and 36%; p > 0.1). DCS involving joint pain only in the lower body was higher during ambulatory exposures (28%) than non-ambulatory exposures (18%; p < 0.01). Non-ambulatory exposures terminated more frequently with non-joint-pain DCS (17%) or upper-body-only joint pain (18%) as compared with ambulatory exposures, 9% and 11% (p < 0.01), respectively. These findings show that lower-body, weight-bearing activity shifts the incidence of joint-pain DCS from the upper body to the lower body without altering the total incidence of DCS or joint-pain DCS. Use of data from previous and future subject exposures involving ambulatory activity while decompressed appears to be a valid analogue of non-ambulatory activity in determining DCS risk during simulated EVA studies.

Ambulatory urodynamic studies (UDS) in children using a Bluetooth-enabled device.

PubMed

Deshpande, Aniruddh V; Craig, Jonathan C; Caldwell, Patrina H Y; Smith, Grahame H H

2012-12-01

• To report the early observations of using ambulatory urodynamic studies (UDS) using a Bluetooth-enabled device in children • To evaluate the incremental value of ambulatory over conventional UDS. • Ambulatory UDS were performed in selected children with voiding dysfunction between August 2009 and October 2010. • Conventional UDS were concurrently performed wherever possible. • The test results and treatment consequences of the two tests were compared. • In all, 12 ambulatory and seven conventional UDS were performed on 10 children (five boys, median [range] age 7 [4-16] years). • Six of the seven children had a normal conventional UDS. Ambulatory UDS detected phasic detrusor overactivity (DO) in five children and generalised DO in one. • Direct correlation of symptoms to DO was possible in two children during ambulatory UDS. Pressure rise during filling, seen in two children on conventional UDS, was not seen during ambulatory UDS. • Five children showed clinical improvement when therapy was guided by ambulatory UDS results. • Ambulatory UDS was generally well tolerated in eight children, with two complaining of discomfort. Inadequate information was obtained in two children who underwent ambulatory UDS due to technical problems in one and distress induced by the UDS in the other. • Ambulatory UDS provides useful additional information over conventional UDS and can be used to guide further therapy in selected children with voiding dysfunction. • It is safe and well tolerated in children. • There is a need for explicit guidance for the technical delivery and interpretation of ambulatory UDS in children. © 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.

[Face-lift surgery in ambulatory].

PubMed

Soulhiard, F

2017-10-01

The proposal is to demonstrate that facelift surgery is particularly suitable for the care in ambulatory. Between 2010 and 2016, 246 patients were operated for a facelift in ambulatory. No major complication arose in this series (241). Among the patients, 98% expressed their satisfaction and would accept again this intervention in ambulatory. The facelift can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

76 FR 6572 - Non-Ambulatory Disabled Veal Calves and Other Non-Ambulatory Disabled Livestock at Slaughter...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-07

... Service 9 CFR Part 309 [Docket No. FSIS-2010-0041] Non-Ambulatory Disabled Veal Calves and Other Non... the disposition of non-ambulatory disabled veal calves and other non-ambulatory disabled livestock at... after being warmed or rested. The HSUS has petitioned FSIS to amend the regulations to require that non...

Salvage of tibial pilon fractures using fusion of the ankle with a 90 degrees cannulated blade-plate: a preliminary report.

PubMed

Morgan, S J; Thordarson, D B; Shepherd, L E

1999-06-01

Six patients with ankle joint destruction and delayed metaphyseal union after tibial plafond fracture were surgically treated with tibiotalar arthrodesis and metaphyseal reconstruction, using a fixed-angle cannulated blade-plate. The procedure was performed through a posterior approach in five cases and a lateral approach in one case. The subtalar joint was preserved in all cases. Metaphyseal union and a stable arthrodesis were obtained in all cases without loss of fixation and with no mechanical failure of the blade-plate. Union was obtained in an average of 26 weeks. No secondary procedures were required to obtain union. All six patients were ambulatory at last follow-up. Stable internal fixation for simultaneous tibiotalar fusion and metaphyseal reconstruction can be achieved with a cannulated blade-plate while preserving the subtalar joint in complex plafond fractures.

Outpatients' Knowledge About and Attitude Toward Randomised Clinical Trials

ClinicalTrials.gov

2017-03-23

Ambulatory Patients in the Dep. of Medical Gastroenterology; Ambulatory Patients in the Dep. of Gynecology; Ambulatory Patients in the Dep. of Orthopedic Surgery; Ambulatory Patients in the Dep. of Urology

Active ambulatory care management supported by short message services and mobile phone technology in patients with arterial hypertension.

PubMed

Kiselev, Anton R; Gridnev, Vladimir I; Shvartz, Vladimir A; Posnenkova, Olga M; Dovgalevsky, Pavel Ya

2012-01-01

The use of short message services and mobile phone technology for ambulatory care management is the most accessible and most inexpensive way to transition from traditional ambulatory care management to active ambulatory care management in patients with arterial hypertension (AH). The aim of this study was to compare the clinical efficacy of active ambulatory care management supported by short message services and mobile phone technology with traditional ambulatory care management in AH patients. The study included 97 hypertensive patients under active ambulatory care management and 102 patients under traditional ambulatory care management. Blood pressure levels, body mass, and smoking history of patients were analyzed in the study. The duration of study was 1 year. In the active ambulatory care management group, 36% of patients were withdrawn from the study within a year. At the end of the year, 77% of patients from the active care management group had achieved the goal blood pressure level. That was more than 5 times higher than that in the traditional ambulatory care management group (P < .001). The risk ratio of achieving and maintaining the goal blood pressure in patients of active care management group was 5.44, CI (3.2-9.9; P = .005). Implementation of active ambulatory care management supported by short message services and mobile phone improves the quality of ambulatory care of hypertensive patients. Copyright © 2012 American Society of Hypertension. Published by Elsevier Inc. All rights reserved.

Relationships between developmental profiles and ambulatory ability in A follow-up study of preschool children with spastic quadriplegic cerebral palsy.

PubMed

Chen, Chia-Ling; Chen, Chung-Yao; Lin, Keh-Chung; Chen, Kai-Hua; Wu, Ching-Yi; Lin, Chu-Hsu; Liu, Wen-Yu; Hsu, Hung-Chih

2010-01-01

To investigate the follow-up course of developmental profiles in preschool children with spastic quadriplegic (SQ) cerebral palsy (CP) who had varying ambulatory abilities. Forty-eight children with SQ CP between 1 and 5 years old were classified into 2 groups, the ambulatory and non-ambulatory groups, based on Gross Motor Function Classification System (GMFCS) levels during the initial assessment. The developmental profiles, consisting of development quotients (DQs) of 8 domains, were evaluated during the initial assessment and the final assessment one year later. The DQ change index (%) was calculated as 100% X (final DQ-initial DQ)/initial DQ. The DQs of all developmental domains in the non-ambulatory group were lower than those in the ambulatory group on both initial and final assessments (p<0.01). As indicated by the DQ change indices, most DQs in the ambulatory group decreased slightly, whereas those in the non-ambulatory group decreased considerably (p<0.05). Furthermore, fine motor function increased proportionally with age in the ambulatory group, but not in the non-ambulatory group. The DQs of the developmental profiles varied in preschool CP children with different ambulatory abilities. The course of developmental profiles in preschool children with SQ CP evolves with age and relates to the degree of ambulatory function. Knowledge of these developmental profiles may be helpful in understanding, predicting, and managing the developmental problems of these children.

42 CFR 23.21 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... meet the needs of patients treated and to assure continuity of care. The 40 hours per week must be performed in no less than 4 days per week with no more than 12 hours of work being performed in any 24-hour... clinical practice means the provision of ambulatory clinical services for a minimum of 40 hours per week...

Measuring hot flash phenomenonology using ambulatory prospective digital diaries

PubMed Central

Fisher, William I.; Thurston, Rebecca C.

2016-01-01

Objective This study provides the description, protocol, and results from a novel prospective ambulatory digital hot flash phenomenon diary. Methods This study included 152 midlife women with daily hot flashes who completed an ambulatory electronic hot flash diary continuously for the waking hours of 3 consecutive days. In this diary, women recorded their hot flashes and accompanying characteristics and associations as the hot flashes occurred. Results Self-reported hot flash severity on the digital diaries indicated that the majority of hot flashes were rated as mild (41.3%) or moderate (43.7%). Severe (13.1%) and very severe (1.8%) hot flashes were less common. Hot flash bother ratings were rated as mild (43%), or moderate (33.5%), with fewer hot flashes reported bothersome (17.5%) or very bothersome (6%). The majority of hot flashes were reported as occurring on the on the face (78.9%), neck (74.7%), and chest (61.3%). Prickly skin was reported concurrently with 32% of hot flashes, 7% with anxiety and 5% with nausea. A novel finding, 38% of hot flashes were accompanied by a premonitory aura. Conclusion A prospective electronic digital hot flash diary allows for a more precise quantitation of hot flashes while overcoming many of the limitations of commonly employed retrospective questionnaires and paper diaries. Unique insights into the phenomenology, loci and associated characteristics of hot flashes were obtained using this device. The digital hot flash phenomenology diary is recommended for future ambulatory studies of hot flashes as a prospective measure of the hot flash experience. PMID:27404030

Measuring hot flash phenomenonology using ambulatory prospective digital diaries.

PubMed

Fisher, William I; Thurston, Rebecca C

2016-11-01

This study provides the description, protocol, and results from a novel prospective ambulatory digital hot flash phenomenon diary. This study included 152 midlife women with daily hot flashes who completed an ambulatory electronic hot flash diary continuously for the waking hours of three consecutive days. In this diary, women recorded their hot flashes and accompanying characteristics and associations as the hot flashes occurred. Self-reported hot flash severity on the digital diaries indicated that the majority of hot flashes were rated as mild (41.3%) or moderate (43.7%). Severe (13.1%) and very severe (1.8%) hot flashes were less common. Hot flash bother ratings were rated as mild (43%), or moderate (33.5%), with fewer hot flashes reported bothersome (17.5%) or very bothersome (6%). The majority of hot flashes were reported as occurring on the face (78.9%), neck (74.7%), and chest (61.3%). Of all reported hot flashes, 32% occurred concurrently with prickly skin, 7% with anxiety, and 5% with nausea. A novel finding from the study was that 38% of hot flashes were accompanied by a premonitory aura. A prospective electronic digital hot flash diary allows for a more precise quantitation of hot flashes while overcoming many of the limitations of commonly used retrospective questionnaires and paper diaries. Unique insights into the phenomenology, loci, and associated characteristics of hot flashes were obtained using this device. The digital hot flash phenomenology diary is recommended for future ambulatory studies of hot flashes as a prospective measure of the hot flash experience.

Disenrollment from Medicare HMOs.

PubMed

Call, K T; Dowd, B E; Feldman, R; Lurie, N; McBean, M A; Maciejewski, M

2001-01-01

Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. Cross-sectional analysis of 1994 Medicare data. Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Developing Staffing Models to Support Population Health Management And Quality Oucomes in Ambulatory Care Settings.

PubMed

Haas, Sheila A; Vlasses, Frances; Havey, Julia

2016-01-01

There are multiple demands and challenges inherent in establishing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high-performing interprofessional teams and staffing models and electronic documentation systems that track performance, patients will have more opportunities to receive safe, high-quality evidence-based care that encourages patient participation in decision making, as well as provision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully invested in population health management, and continuously scanning the environment for competitive, regulatory, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collaborative practice among the interprofessional team including the patient.

To ventricular assist devices or not: When is implantation of a ventricular assist device appropriate in advanced ambulatory heart failure?

PubMed Central

Cerier, Emily; Lampert, Brent C; Kilic, Arman; McDavid, Asia; Deo, Salil V; Kilic, Ahmet

2016-01-01

Advanced heart failure has been traditionally treated via either heart transplantation, continuous inotropes, consideration for hospice and more recently via left ventricular assist devices (LVAD). Heart transplantation has been limited by organ availability and the futility of other options has thrust LVAD therapy into the mainstream of therapy for end stage heart failure. Improvements in technology and survival combined with improvements in the quality of life have made LVADs a viable option for many patients suffering from heart failure. The question of when to implant these devices in those patients with advanced, yet still ambulatory heart failure remains a controversial topic. We discuss the current state of LVAD therapy and the risk vs benefit of these devices in the treatment of heart failure. PMID:28070237

Posterior composite restoration update: focus on factors influencing form and function

PubMed Central

Bohaty, Brenda S; Ye, Qiang; Misra, Anil; Sene, Fabio; Spencer, Paulette

2013-01-01

Restoring posterior teeth with resin-based composite materials continues to gain popularity among clinicians, and the demand for such aesthetic restorations is increasing. Indeed, the most common aesthetic alternative to dental amalgam is resin composite. Moderate to large posterior composite restorations, however, have higher failure rates, more recurrent caries, and increased frequency of replacement. Investigators across the globe are researching new materials and techniques that will improve the clinical performance, handling characteristics, and mechanical and physical properties of composite resin restorative materials. Despite such attention, large to moderate posterior composite restorations continue to have a clinical lifetime that is approximately one-half that of the dental amalgam. While there are numerous recommendations regarding preparation design, restoration placement, and polymerization technique, current research indicates that restoration longevity depends on several variables that may be difficult for the dentist to control. These variables include the patient’s caries risk, tooth position, patient habits, number of restored surfaces, the quality of the tooth–restoration bond, and the ability of the restorative material to produce a sealed tooth–restoration interface. Although clinicians tend to focus on tooth form when evaluating the success and failure of posterior composite restorations, the emphasis must remain on advancing our understanding of the clinical variables that impact the formation of a durable seal at the restoration–tooth interface. This paper presents an update of existing technology and underscores the mechanisms that negatively impact the durability of posterior composite restorations in permanent teeth. PMID:23750102

Single-shot pectoral plane (PECs I and PECs II) blocks versus continuous local anaesthetic infusion analgesia or both after non-ambulatory breast-cancer surgery: a prospective, randomised, double-blind trial.

PubMed

O'Scanaill, P; Keane, S; Wall, V; Flood, G; Buggy, D J

2018-04-01

Pectoral plane blocks (PECs) are increasingly used in analgesia for patients undergoing breast surgery, and were recently found to be at least equivalent to single-shot paravertebral anaesthesia. However, there are no data comparing PECs with the popular practice of continuous local anaesthetic wound infusion (LA infusion) analgesia for breast surgery. Therefore, we compared the efficacy and safety of PECs blocks with LA infusion, or a combination of both in patients undergoing non-ambulatory breast-cancer surgery. This single-centre, prospective, randomised, double-blind trial analysed 45 women to receive either PECs blocks [levobupivacaine 0.25%, 10 ml PECs I and levobupivacaine 0.25%, 20 ml PECs II (PECs group); LA infusion catheter (levobupivacaine 0.1% at 10 ml h -1 for 24 h (LA infusion group); or both (PECs and LA infusion)]. The primary outcome measure was area under the curve of the pain verbal rating score whilst moving vs time (AUC) over 24 h. Secondary outcomes included total opioid consumption at 24 h. AUC moving was mean (SD) 71 (34) mm h -1 vs 58 (41) vs 23 (20) in PECs, LA infusion, and both, respectively; P=0.002. AUC at rest was also significantly lower in patients receiving both. The total 24 h opioid consumption [median (25-75%)] was 14 mg (9-26) vs 11 (8-24) vs 9 (5-11); P=0.4. No adverse events were observed. The combination of both pre-incisional PECs blocks and postoperative LA infusion provides better analgesia over 24 h than either technique alone after non-ambulatory breast-cancer surgery. NCT 03024697. Copyright © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Left ventricular hypertrophy and blood pressure control in automated and continuous ambulatory peritoneal dialysis patients.

PubMed

Ataş, Nuh; Erten, Yasemin; Okyay, Gülay Ulusal; Inal, Salih; Topal, Salih; Öneç, Kürşad; Akyel, Ahmet; Çelik, Bülent; Tavil, Yusuf; Bali, Musa; Arınsoy, Turgay

2014-06-01

Hypertension, non-dipper blood pressure (BP) pattern and decrease in daily urine output have been associated with left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. However, there is lack of data regarding the impact of different PD regimens on these factors. We aimed to investigate the impact of circadian rhythm of BP on LVH in end-stage renal disease patients using automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD) modalities. Twenty APD (7 men, 13 women) and 28 CAPD (16 men, 12 women) patients were included into the study. 24-h ambulatory blood pressure monitoring (ABPM) and transthoracic echocardiography besides routine blood examinations were performed. Two groups were compared with each other for ABPM measurements, BP loads, dipping patterns, left ventricular mass index (LVMI) and daily urine output. Mean systolic and diastolic BP measurements, BP loads, LVMI, residual renal function (RRF) and percentage of non-dippers were found to be similar for the two groups. There were positive correlations of LVMI with BP measurements and BP loads. LVMI was found to be significantly higher in diastolic non-dippers compared to dippers (140.4 ± 35.3 vs 114.5 ± 29.7, respectively, P = 0.02). RRF and BP were found to be independent predictors of LVMI. Non-dipping BP pattern was a frequent finding among all PD patients without an inter-group difference. Additionally, higher BP measurements, decrease in daily urine output and non-dipper diastolic BP pattern were associated with LVMI. In order to avoid LVH, besides correction of anemia and volume control, circadian BP variability and diastolic dipping should also be taken into consideration in PD patients. © 2014 The Authors. Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis.

NATIONAL SURVEY FOR AMBULATORY SURGERY (NSAS)

EPA Science Inventory

The National Survey of Ambulatory Surgery (NSAS), which was initiated by the National Center for Health Statistics in 1994, is a national survey designed to meet the need for information about the use of ambulatory surgery services in the United States. For NSAS, ambulatory surge...

Relationship Between 24-Hour Ambulatory Central Systolic Blood Pressure and Left Ventricular Mass: A Prospective Multicenter Study.

PubMed

Weber, Thomas; Wassertheurer, Siegfried; Schmidt-Trucksäss, Arno; Rodilla, Enrique; Ablasser, Cornelia; Jankowski, Piotr; Lorenza Muiesan, Maria; Giannattasio, Cristina; Mang, Claudia; Wilkinson, Ian; Kellermair, Jörg; Hametner, Bernhard; Pascual, Jose Maria; Zweiker, Robert; Czarnecka, Danuta; Paini, Anna; Salvetti, Massimo; Maloberti, Alessandro; McEniery, Carmel

2017-12-01

We investigated the relationship between left ventricular mass and brachial office as well as brachial and central ambulatory systolic blood pressure in 7 European centers. Central systolic pressure was measured with a validated oscillometric device, using a transfer function, and mean/diastolic pressure calibration. M-mode images were obtained by echocardiography, and left ventricular mass was determined by one single reader blinded to blood pressure. We studied 289 participants (137 women) free from antihypertensive drugs (mean age: 50.8 years). Mean office blood pressure was 145/88 mm Hg and mean brachial and central ambulatory systolic pressures were 127 and 128 mm Hg, respectively. Mean left ventricular mass was 93.3 kg/m 2 , and 25.6% had left ventricular hypertrophy. The correlation coefficient between left ventricular mass and brachial office, brachial ambulatory, and central ambulatory systolic pressure was 0.29, 0.41, and 0.47, respectively ( P =0.003 for comparison between brachial office and central ambulatory systolic pressure and 0.32 for comparison between brachial and central ambulatory systolic pressure). The results were consistent for men and women, and young and old participants. The areas under the curve for prediction of left ventricular hypertrophy were 0.618, 0.635, and 0.666 for brachial office, brachial, and central ambulatory systolic pressure, respectively ( P =0.03 for comparison between brachial and central ambulatory systolic pressure). In younger participants, central ambulatory systolic pressure was superior to both other measurements. Central ambulatory systolic pressure, measured with an oscillometric cuff, shows a strong trend toward a closer association with left ventricular mass and hypertrophy than brachial office/ambulatory systolic pressure. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01278732. © 2017 American Heart Association, Inc.

Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors.

PubMed

Rinke, Michael L; Milstone, Aaron M; Chen, Allen R; Mirski, Kara; Bundy, David G; Colantuoni, Elizabeth; Pehar, Miriana; Herpst, Cynthia; Miller, Marlene R

2013-11-01

To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs. We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs. We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17). In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts. Copyright © 2013 Wiley Periodicals, Inc.

Posterior medial meniscus-femoral insertion into the anterior cruciate ligament. A case report.

PubMed

Bhargava, A; Ferrari, D A

1998-03-01

Medial meniscal anomalies are rare. The anterior horn insertion into the anterior cruciate ligament is the most common. In the course of an arthroscopy for torn lateral meniscus, an anomalous band in continuity with the posterior horn of the medial meniscus was observed to insert into the anterior cruciate ligament. Although the tibial portion of the anterior cruciate was redundant, the anomalous band provided tension to the anterior cruciate ligament and a negative pivot shift. A previously unreported posterior medial meniscal femoral insertion is described.

Fungal peritonitis in patients undergoing continuous ambulatory peritoneal dialysis in Qatar.

PubMed

Khan, Fahmi Yousef; Elsayed, Mohammed; Anand, Deshmukh; Abu Khattab, Mohammed; Sanjay, Doiphode

2011-09-14

This study was conducted at Hamad General Hospital to determine the incidence of fungal peritonitis and to describe its clinical and microbiological findings in patients undergoing continuous ambulatory peritoneal dialysis in Qatar. The medical records of these patients between 1 January 2005 and 31 December 2008 were retrospectively reviewed and the collected data were analysed. During the study period, 141 episodes of peritonitis were observed among 294 patients. In 14 of these episodes (9.9%), fungal peritonitis was reported in 14 patients with a rate of 0.05 episodes per patient year, while the bacterial peritonitis rate was 0.63 per patient year. Thirteen (93%) patients had one or more previous episodes of bacterial peritonitis that was treated with multiple broad-spectrum antibiotics, 11 (85%) had received broad-spectrum antibiotics within the preceding month, 12 (92%) within three months, and 8 (62%) within six months. Candida species were the only fungal species isolated from the dialysate with predominance of non-albicans Candida species (especially Candida parapsilosis). Therapeutic approach was immediate catheter removal, followed by systemic antifungal therapy and temporary haemodialysis. Nine patients (64.3%) were continued on haemodialysis, whereas five patients (35.7%) died. Prior antibiotic use was an important risk factor predisposing patients to the development of fungal peritonitis. Early detection of fungal peritonitis would lead to early institution of appropriate therapy and prevention of complications.

[Left ventricular dysfunction measured in diabetic patients with chronic renal failure on continuous ambulatory peritoneal dialysis].

PubMed

Díaz-Arrieta, Gustavo; Mendoza-Hernández, María Elsa; Pacheco-Aranda, Erika; Rivas-Duro, Miguel; Robles-Parra, Héctor Manuel; Espinosa-Vázquez, Raúl Arturo; Hernández-Cabrera, Jorge

2010-01-01

In diabetic patients with chronic renal failure (CRF) treated with dialysis, the diastolic and systolic left ventricular dysfunction is frequent. The aim was to assess by echocardiography the prevalence of diastolic and systolic ventricular dysfunction in diabetic patients with CRF treated with continuous ambulatory peritoneal dialysis (CAPD). Sixty diabetic patients with CRF in CAPD were studied. The mean age was 54.5 +/- 12 years (27-78 years). The left ventricular filling pattern (LVFP) as a diastolic function parameter and left ventricular ejection fraction (LVEF) as a systolic function parameter were measured by transthoracic echocardiography. Descriptive statistical analysis was used. 27 (45 %) patients were women and 33 (55 %) were men. In 55 (91.7 %) left ventricular concentric hypertrophy was observed. Fifty-two patients (86.7 %) showed LVFP type I; three (5 %) had the type II; two (3.3 %) showed pseudonormal pattern and three (5 %) had a normal LVFP. The LVEF was 0.63 +/- 0.09 (CI = 0.41-0.82). Forty nine (81.7 %) patients had LVEF equal or greater than 0.55. The prevalence of diastolic left ventricular dysfunction was 95 % and the prevalence of systolic left ventricular dysfunction was 18.3%.

Effect of glucose concentration on peritoneal inflammatory cytokines in continuous ambulatory peritoneal dialysis patients.

PubMed Central

Sayarlioglu, Hayriye; Topal, Cevat; Sayarlioglu, Mehmet; Dulger, Haluk; Dogan, Ekrem; Erkoc, Reha

2004-01-01

OBJECTIVE: It is known that glucose concentrations of peritoneal dialysis solutions are detrimental to the peritoneal membrane. In order to determine the effect of glucose concentration on cytokine levels of peritoneal fluid of continuous ambulatory peritoneal dialysis (CAPD) patients, a cross-sectional study was performed. METHODS: Nine non-diabetic CAPD patients participated in two 8-h dwell sessions of overnight exchanges in consecutive days, with 1.36% and 3.86% glucose containing peritoneal dialysis solutions (Baxter-Eczacibas). Peritoneal dialysis fluid tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 levels were measured. RESULTS: TNF-alpha levels after 1.36% and 3.86% glucose used dwells were 23+/-14 pg/ml and 28+/-4 pg/ml, respectively (p=0.78). The IL-6 levels were 106+/-57 pg/ml and 115+/-63 pg/ml (p=0.81), respectively. CONCLUSION: In our in vivo study we found that the glucose concentration of the conventional lactate-based CAPD solution has no effect on basal IL-6 and TNF-alpha levels of peritoneal fluid. Further in vivo studies with non-lactate-based CAPD solutions are needed in order to determine the effect of glucose concentration per se on cytokine release. PMID:15203553

Ambulatory surgery: is the liability risk lower?

PubMed

Metzner, Julia; Kent, Christopher D

2012-12-01

To summarize the currently available data on malpractice claims related to ambulatory anesthesia and provide an insight into the emerging patterns of anesthesia liability in this practice setting. At present, studies are mixed about how the continued growth of outpatient surgery will impact liability for anesthesiologists. Data derived from the ASA Closed Claims Project suggests that malpractice claims for major damaging events are less common in the outpatient settings than in inpatient settings. Correspondingly, the payment amounts for outpatient claims are significantly lower than those for inpatients. Nevertheless, nondisabling adverse events are common and involve respiratory, cardiac, equipment-related, and drug errors. In addition, the vast majority of injuries in outpatient claims was the result of substandard care and judged preventable by better monitoring. Although major incidents leading to malpractice suits are less, new liability exposure may be on the horizon, due to the changing landscape of ambulatory practice that permits care for sicker patients who require more complex surgeries. The areas of potential concern include postoperative discharge criteria, care for the obstructive sleep apnea patient, and the choice of anesthetic techniques such as neuraxial blocks and monitored anesthesia care. With steady increase in outpatient surgery, anesthesiologists are confronted with new areas of liability. More data are needed to identify these risks and reduce exposure to malpractice claims.

[Ambulatory anesthesia in pediatric surgery].

PubMed

Ben Khalifa, S; Hila, S; Hamzaoui, M; el Cadhi, A; Jlidi, S; Nouira, F; Hellal, Y; Houissa, T; Chaouachi, B

2000-04-01

Child is an ideal patient for day care surgery. So more than 60% of paediatric surgery could benefit by ambulatory surgery. Preoperative visit may select patients for ambulatory surgery. Medical exam may lead to choose pre operative screening. The ideal ambulatory anesthesia is locoregional technic or inhalatory one. Tracheal intubation don't contre indicate ambulatory surgery. Recovery of mental abilities following general anesthesia has not the same significance as in adult. Many studies confirm the safety of paediatric outpatients anesthesia.

Identifying opportunities to advance practice at a large academic medical center using the ASHP Ambulatory Care Self-Assessment Tool.

PubMed

Martirosov, Amber Lanae; Michael, Angela; McCarty, Melissa; Bacon, Opal; DiLodovico, John R; Jantz, Arin; Kostoff, Diana; MacDonald, Nancy C; Mikulandric, Nancy; Neme, Klodiana; Sulejmani, Nimisha; Summers, Bryant B

2018-05-29

The use of the ASHP Ambulatory Care Self-Assessment Tool to advance pharmacy practice at 8 ambulatory care clinics of a large academic medical center is described. The ASHP Ambulatory Care Self-Assessment Tool was developed to help ambulatory care pharmacists assess how their current practices align with the ASHP Practice Advancement Initiative. The Henry Ford Hospital Ambulatory Care Advisory Group (ACAG) opted to use the "Practitioner Track" sections of the tool to assess pharmacy practices within each of 8 ambulatory care clinics individually. The responses to self-assessment items were then compiled and discussed by ACAG members. The group identified best practices and ways to implement action items to advance ambulatory care practice throughout the institution. Three recommended action items were common to most clinics: (1) identify and evaluate solutions to deliver financially viable services, (2) develop technology to improve patient care, and (3) optimize the role of pharmacy technicians and support personnel. The ACAG leadership met with pharmacy administrators to discuss how action items that were both feasible and deemed likely to have a medium-to-high impact aligned with departmental goals and used this information to develop an ambulatory care strategic plan. This process informed and enabled initiatives to advance ambulatory care pharmacy practice within the system. The ASHP Ambulatory Care Self-Assessment Tool was useful in identifying opportunities for practice advancement in a large academic medical center. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Relationship of Office and Ambulatory Blood Pressure With Left Ventricular Global Longitudinal Strain.

PubMed

Sera, Fusako; Jin, Zhezhen; Russo, Cesare; Lee, Edward S; Schwartz, Joseph E; Rundek, Tatjana; Elkind, Mitchell S V; Homma, Shunichi; Sacco, Ralph L; Di Tullio, Marco R

2016-11-01

Left ventricular (LV) global longitudinal strain (GLS) is an early indicator of subclinical cardiac dysfunction, even when LV ejection fraction (LVEF) is normal, and is an independent predictor of cardiovascular events. Ambulatory blood pressure (BP) is a better predictor of cardiovascular events, including heart failure, than office BP. We investigated the association of office and ambulatory BP measurements with subclinical LV systolic dysfunction in a community-based cohort with normal LVEF. Two-dimensional speckle-tracking echocardiography and 24-hour ambulatory BP monitoring were performed in 577 participants (mean age 70±9 years; 60% women) with LVEF ≥50% from the Cardiovascular Abnormalities and Brain Lesions (CABL) study. Univariable and multivariable linear regression analyses were used to assess the associations of BP measures with GLS. Higher ambulatory and office BP values were consistently associated with impaired GLS. After adjustment for pertinent covariates (age, sex, race/ethnicity, body mass index, diabetes mellitus, coronary artery disease, LV mass index, and antihypertensive medication), office diastolic BP and ambulatory systolic and diastolic BPs (24-hour, daytime and nighttime) were independently associated with GLS (P = 0.003 for office DBP, P ≤ 0.001 for all ambulatory BPs). When ambulatory and office BP values were included in the same model, all ambulatory BP measures remained significantly associated with GLS (all P < 0.01), whereas office BP values were not. Ambulatory BP values are significantly associated with impaired GLS and the association is stronger than for office BP. Ambulatory BP monitoring might have a role in the risk stratification of hypertensive patients for early LV dysfunction.

77 FR 70783 - Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-27

...] Medicare and Medicaid Programs; Approval of the Accreditation Association for Ambulatory Health Care (AAAHC... announces our decision to approve the Accreditation Association for Ambulatory Health Care (AAAHC) for... Ambulatory Health Care's (AAAHC) current term of approval for their ASC accreditation program expires on...

Pediatric outcomes data collection instrument scores in ambulatory children with cerebral palsy: an analysis by age groups and severity level.

PubMed

Barnes, Douglas; Linton, Judith L; Sullivan, Elroy; Bagley, Anita; Oeffinger, Donna; Abel, Mark; Damiano, Diane; Gorton, George; Nicholson, Diane; Romness, Mark; Rogers, Sarah; Tylkowski, Chester

2008-01-01

The Pediatric Outcomes Data Collection Instrument (PODCI) was developed in 1994 as a patient-based tool for use across a broad age range and wide array of musculoskeletal disorders, including children with cerebral palsy (CP). The purpose of this study was to establish means and SDs of the Parent PODCI measures by age groups and Gross Motor Function Classification System (GMFCS) levels for ambulatory children with CP. This instrument was one of several studied in a prospective, multicenter project of ambulatory patients with CP between the aged 4 and 18 years and GMFCS levels I through III. Participants included 338 boys and 221 girls at a mean age of 11.1 years, with 370 diplegic, 162 hemiplegic, and 27 quadriplegic. Both baseline and follow-up data sets of the completed Parent PODCI responses were statistically analyzed. Age was identified as a significant predictor of the PODCI measures of Upper Extremity Function, Transfers and Basic Mobility, Global Function, and Happiness With Physical Condition. Gross Motor Function Classification System levels was a significant predictor of Transfers and Basic Mobility, Sports and Physical Function, and Global Function. Pattern of involvement, sex, and prior orthopaedic surgery were not statistically significant predictors for any of the Parent PODCI measures. Mean and SD scores were calculated for age groups stratified by GMFCS levels. Analysis of the follow-up data set validated the findings derived from the baseline data. Linear regression equations were derived, with age as a continuous variable and GMFCS levels as a categorical variable, to be used for Parent PODCI predicted scores. The results of this study provide clinicians and researchers with a set of Parent PODCI values for comparison to age- and severity-matched populations of ambulatory patients with CP.

METABOLIC SYNDROME AND DAILY AMBULATION IN CHILDREN, ADOLESCENTS, AND YOUNG ADULTS

PubMed Central

Gardner, Andrew W.; Parker, Donald E.; Krishnan, Sowmya; Chalmers, Laura J.

2012-01-01

Purposes To compare daily ambulatory measures in children, adolescents, and young adults with and without metabolic syndrome, and to assess which metabolic syndrome components, demographic measures, and body composition measures are associated with daily ambulatory measures. Methods Two-hundred fifty subjects between the ages of 10 and 30 years were assessed on metabolic syndrome components, demographic and clinical measures, body fat percentage, and daily ambulatory strides, durations, and cadences during seven consecutive days. Forty-five of the 250 subjects had metabolic syndrome, as defined by the International Diabetes Federation. Results Subjects with metabolic syndrome ambulated at a slower daily average cadence than those without metabolic syndrome (13.6 ± 2.2 strides/min vs. 14.9 ± 3.2 strides/min; p=0.012), and they had slower cadences for continuous durations of 60 minutes (p=0.006), 30 minutes (p=0.005), 20 minutes (p=0.003), 5 minutes (p=0.002), and 1 minute (p=0.001). However, the total amount of time spent ambulating each day was not different (p=0.077). After adjustment for metabolic syndrome status, average cadence is linearly associated with body fat percentage (p<0.001) and fat mass (p<0.01). Group difference in average cadence was no longer significant after adjusting for body fat percentage (p=0.683) and fat mass (p=0.973). Conclusion Children, adolescents, and young adults with metabolic syndrome ambulate more slowly and take fewer strides throughout the day than those without metabolic syndrome, even though the total amount of time spent ambulating is not different. Furthermore, the detrimental influence of metabolic syndrome on ambulatory cadence is primarily a function of body fatness. PMID:22811038

[Profile and tasks of a medical university polyclinic in the past and present using as example the Medical Polyclinical Institutes of the Karl Marx University of Leipzig].

PubMed

Hambsch, K; Treutler, H; Pietruschka, W D

1981-03-15

After a short survey of the historical development of the Medico-Policlinical Institute of the Karl Marx University Leipzig tasks and developmental tendencies of university medical policlinics are described, evaluating hereby the results of the Vth conference of higher education. They are understood as a university representation of ambulatorily working internists and to a large extent of the specialists for general medicine. Their main tasks consist in education and continued professional training of this group of physicians under integrative description of the whole subject internal medicine, a research oriented to practice as well as a guiding and coordination function for the ambulatory internistic care, taking into particular consideration the early recognition of a disease, in primary and secondary prevention as well as in a scientifically based ambulatory therapy of epidemiologically important diseases.

Adaptive downhill skiing in children with cerebral palsy: effect on gross motor function.

PubMed

Sterba, John A

2006-01-01

The study was designed to examine the effect of adaptive downhill skiing (ADS) on gross motor function in children with spastic cerebral palsy. One girl and four boys participated (mean age = eight years, five months). All were ambulatory. Participants' Gross Motor Function Measure (GMFM) classifications were: Level I (n = 2); Level II (n = 2); Level III (n = 1). ADS was conducted for a 10-week period at one ski resort. Each participant had the same ski instructor. GMFM was obtained every five weeks: beginning five weeks before ADS instruction and continuing to 10 weeks after ADS instruction. After 10 weeks of ADS GMFM-D, and GMFM-Total Score increased 5.4% (p = 0.022) and 3.2% (p = 0.035), respectively, and remained increased 10 weeks after ADS. ADS could be recommended by clinicians as a recreational activity for the gross motor rehabilitation of ambulatory children with spastic cerebral palsy.

Vertical integration strategies: revenue effects in hospital and Medicare markets.

PubMed

Cody, M

1996-01-01

The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post-hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue.

[A guide to good practice for information security in the handling of personal health data by health personnel in ambulatory care facilities].

PubMed

Sánchez-Henarejos, Ana; Fernández-Alemán, José Luis; Toval, Ambrosio; Hernández-Hernández, Isabel; Sánchez-García, Ana Belén; Carrillo de Gea, Juan Manuel

2014-04-01

The appearance of electronic health records has led to the need to strengthen the security of personal health data in order to ensure privacy. Despite the large number of technical security measures and recommendations that exist to protect the security of health data, there is an increase in violations of the privacy of patients' personal data in healthcare organizations, which is in many cases caused by the mistakes or oversights of healthcare professionals. In this paper, we present a guide to good practice for information security in the handling of personal health data by health personnel, drawn from recommendations, regulations and national and international standards. The material presented in this paper can be used in the security audit of health professionals, or as a part of continuing education programs in ambulatory care facilities. Copyright © 2013 Elsevier España, S.L. All rights reserved.

[Ambulatory continuous intravenous infusion of fluorouracil: a feasible palliative form of chemotherapy].

PubMed

van Hoef, M E; Zonnenberg, B A; de Graeff, A; van Milligen de Wit, A W; Tjia, P; Neijt, J P

1991-03-30

A study to evaluate the feasibility and toxicity of outpatient continuous intravenous infusion of fluorouracil (5-FU) was initiated at the department of Medical Oncology of the University Hospital of Utrecht. To this purpose a subcutaneous drug delivery system (Port-a-Cath) was implanted in 36 patients with various advanced cancers. Of these patients 83% had received prior chemotherapy (including 5-FU in 62%). Ambulatory continuous-infusion pumps were used to administer 5-FU in a dosage of 300 mg/m2/24 h. The treatment was continued until tumour progression was seen, and it was interrupted in case of toxicity grade 2 or more (WHO criteria). A Port-a-Cath was implanted 37 times in the 36 patients. The main complications of this infusion system were pneumothorax (2/37), arrhythmia (1/37), catheter sepsis (2/37) and thrombosis (2/37); they were easily managed. The toxicity and feasibility of this treatment were evaluable in 30 patients. They received a median of 44 g 5-FU (range 11-136, 5 g, mean 281 mg/m2/24 h) during a median infusion time of 12 weeks (range 4-32 w). Side effects were encountered in 70% of the patients and consisted of the hand-foot syndrome (14/30), nausea and vomiting (8/30), diarrhoea (8/30) and stomatitis (7/30). The toxicity was completely reversible after a short interruption of the chemotherapy. The treatment was tolerated well, and good palliation was attained in 22 of 30 patients. The best response was seen in patients with colon and breast cancer. We conclude that continuous infusion of 5-FU is a reliable outpatient chemotherapy even in this category of patients.

Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

ERIC Educational Resources Information Center

Singh, Hardeep; Weingart, Saul N.

2009-01-01

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may…

[Structural development of ambulatory surgical care in the United States of America. What can we learn or apply?].

PubMed

Kraus, T; Wolkener, F; Mieth, M; Möller, J; Büchler, M W

2002-10-01

Expansion of ambulatory surgical care is a major focus in United States health politics. In 1996 a total of 31.5 million ambulatory operations were performed, currently accounting for 45% of yearly procedures. Operations in ophthalmology and gastroenterology are predominant. Ambulatory surgery is organized in different forms: "office-based surgery," "hospital outpatient departments," and "ambulatory surgery centers" (ASC). The numbers of ASCs are rapidly increasing. The current proportion of ASCs is 16% of all operations. The type of ambulatory surgery is primarily defined by payors. Medicare standards are the benchmark for private organizations. Recovery care centers now offer postoperative care beyond the former 23-h threshold. This may lead to a further expanded ASC access. Revenues for ambulatory surgery were so far mostly based on fees for service. The implementation of an outpatient prospective payment system ("OPPS") is planned by Medicare, using fixed package prices within a newly defined ambulatory payment classification ("APC"). The dimension of structural changes could be enormous and possibly be compared with the implementation of DRGs in 1983.

The association between the availability of ambulatory care and non-emergency treatment in emergency medicine departments: a comprehensive and nationwide validation.

PubMed

Chan, Chien-Lung; Lin, Wender; Yang, Nan-Ping; Huang, Hsin-Tsung

2013-05-01

To quantify dynamic availability of ambulatory care, and to examine possible associations with non-emergency treatments in emergency departments (EDs). Longitudinal data from the Taiwan National health Insurance Research Database were used to evaluate 749,584 emergency-medicine cases occurring between 2005 and 2010 according to a modified New York University algorithm. Multivariable-cumulative-logistic-regression analysis with generalized estimating-equation methods was used to determine associations between availability of ambulatory care and the urgency of patients' medical needs during ED visits. More than half (53.04%) of the ED visits that were evaluated in our study were classified as non-emergencies, and over half of these occurred despite a high availability of ambulatory care facilities (median > 96%). Compared with patients in areas with a low availability of ambulatory care, patients in areas of medium to high availability showed approximately 0.8 times lower odds ratios for associations with non-emergency ED visits. Non-emergency ED visits may be reduced by increasing the availability of ambulatory care facilities in areas with deficits in the availability of such facilities. However, increasing the availability of ambulatory care by raising the number of available ambulatory care physicians or the number of ambulatory care facilities may not reduce non-emergency ED visits in areas with medium to high availability of ambulatory care facilities. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Comparison of ambulatory and inpatient cleft lip surgery for adults.

PubMed

Sohail, Muhammad; Khan, Farid Ahmad; Mir, Zameer Abbas

2010-01-01

Ambulatory cleft lip repair after its acceptance in developed countries is also becoming popular in developing world. This study was performed to compares the outcomes of ambulatory cleft lip repair with the inpatient group for adult patients. Objectives were to compare outcome after ambulatory and inpatient cleft lip surgery for adults with respect to perioperative complications (Early: pain, oedema of upper lip, bleeding, nausea or vomiting, infection, dehiscence; Late: visible scar and white roll discrepancy), to compare the economic benefits, and evaluate patient satisfaction in terms of acceptance for ambulatory surgery. This comparative study is carried out in Plastic Surgery Department, King Edward Medical University, Mayo Hospital, Lahore. The study included 80 adult patients fulfilling inclusion criteria and were randomly divided into two groups, i.e., Ambulatory (Group-A, n=40) and Inpatient (Group-B, n=40). Those belonging to ambulatory group were worked up on OPD basis, advised to report on morning of surgery, operated under loco-regional anaesthesia and were discharged on same day. Patients of inpatient group were admitted two days before surgery, worked up in ward, operated under general anaesthesia and were discharged on 2nd day. Ambulatory cleft lip surgery can be easily performed under loco-regional anaesthesia. Perioperative complications between these groups were comparable. Hospital stay was significantly reduced in ambulatory surgery. The patients felt more satisfied after ambulatory than inpatient surgery. Ambulatory cleft lip repair for adults is as safe as inpatient surgery. It is dependable option and can be successfully performed in our setup. It should be considered whenever possible due to cost effectiveness, reduction of waiting lists, earlier discharge and better utilisation of hospital resources.

Concept of the Ambulatory Pain Physician.

PubMed

Thomas, Donna-Ann; Chang, Daniel; Zhu, Richard; Rayaz, Hassan; Vadivelu, Nalini

2017-01-01

Given the growing number of ambulatory surgeries being performed and the variability in postoperative pain requirements, early discharge, and inconsistent follow-up, ambulatory surgery presents a unique challenge for this patient population and warrants the presence of an ambulatory pain specialist to evaluate a patient preoperatively and postoperatively to optimize patient safety and satisfaction. This article explores the crucial role that a dedicated pain physician would have in the ambulatory surgery setting. The prevalence of chronic pain, opioid use, and substance abuse is growing in this country, while ambulatory and same-day surgery have also experienced considerable growth. Inevitably, more patients with challenging chronic pain or substance abuse are having ambulatory surgery. Increased BMI, advanced age, more comorbidities warranting a higher ASA physical status classification, and longer surgeries are now all components of ambulatory surgery that contribute to increased risk too. Certain surgeries including breast surgery, inguinal hernia repair, and thoracotomy are at higher risk for the conversion of acute to chronic pain, and an ambulatory pain specialist would be beneficial for added focus on these patients. Multimodal pain control with non-opioids and regional anesthesia adjuvants are beneficial, while emphasis on a patient's functional capacity may be more useful than quantifying the severity of pain. Despite the best efforts of patients' primary care providers or surgeons, patients often are discharged with more chronic opioid therapy than they presented with, and an ambulatory pain specialist can help manage the complications and prevent further escalation of this opioid epidemic. An onsite anesthesiologist with interest in pain management in each ambulatory surgery center administering anesthesia and available onsite to deal with immediate preoperative, intraoperative, and recovery room would be ideal to curb and manage complication from uncontrolled pain and related pain issues.

The internal medicine clerkship and ambulatory learning experiences: results of the 2010 clerkship directors in internal medicine survey.

PubMed

Shaheen, Amy; Papp, Klara K; Torre, Dario

2013-01-01

Education in the ambulatory setting should be an integral part of undergraduate medical education. However, previous studies have shown education in this setting has been lacking in medical school. Ambulatory education occurs on some internal medicine clerkships. The extent of this education is unclear. The purpose of this survey was to assess the structure, curriculum, assessment methods, and barriers to implementation of ambulatory education on the internal medicine clerkship. An annual survey of institutional members of the Clerkship Directors in Internal Medicine (CDIM) was done in April 2010. The data were anonymous and descriptive statistics were used to summarize responses. Free text results were analyzed using qualitative techniques. The response rate was 75%. The majority of respondents had a required ambulatory component to the clerkship. Ambulatory experiences distinct from the inpatient internal medicine experience were common (46%). Integration with either the inpatient experiences or other departmental clerkships also occurred. The majority of ambulatory educational experiences were with generalists (74%) and/or subspecialists (45%). The most common assessment tool was the National Board of Medical Examiners (NBME) ambulatory shelf exam. Thematic analysis of the question about how practice based learning was taught elicited four major themes: Not taught; taught in the context of learning evidence based medicine; taught while learning chronic disease management with quality improvement; taught while learning about health care finance. Barriers to implementation included lack of faculty and financial resources. There have been significant increases in the amount of time dedicated to ambulatory internal medicine. The numbers of medical schools with ambulatory internal medicine education has increased. Integration of the ambulatory experiences with other clerkships such as family medicine occurs. Curriculum was varied but difficulties with dissemination and assessment in these disparate settings was noted. Overall, the results of this study demonstrate increased implementation and recognition of the importance of ambulatory education in internal medicine.

A cost analysis of orthopedic foot surgery: can outpatient continuous regional analgesia provide the same standard of care for postoperative pain control at home without shifting costs?

PubMed

Saporito, Andrea; Calciolari, Stefano; Ortiz, Laura Gonzalez; Anselmi, Luciano; Borgeat, Alain; Aguirre, José

2016-11-01

Same-day surgery is common for foot surgery. Continuous regional anesthesia for outpatients has been shown effective but the economic impact on the perioperative process-related healthcare costs remains unclear. One hundred twenty consecutive patients were included in this assessor-blinded, prospective cohort study and allocated according to inclusion criteria in the day-care or in the in-patient group. Standardized continuous popliteal sciatic nerve block was performed in both groups for 48 h using an elastomeric pump delivering ropivacaine 0.2 % at a rate of 5 ml/h with an additional 5 ml bolus every 60 min. Outpatients were discharged the day of surgery and followed with standardized telephone interviews. The total direct health costs of both groups were compared. Moreover, the difference in treatment costs and the difference in terms of quality of care and effectiveness between the groups were compared. Total management costs were significantly reduced in the day-care group. There was no difference between the groups regarding pain at rest and with motion, persistent pain after catheter removal and the incidence of PONV. Persistent motor block and catheter inflammation/infection were comparable in both groups. There was neither a difference in the number of unscheduled ambulatory visits nor in the number of readmissions. Day-care continuous regional analgesia leads to an overall positive impact on costs by decreasing the incidence of unplanned ambulatory visits and unscheduled readmissions, without compromising on the quality of analgesia, patients' satisfaction, and safety.

Competency-based learning in an ambulatory care setting: Implementation of simulation training in the Ambulatory Care Rotation during the final year of the MaReCuM model curriculum.

PubMed

Dusch, Martin; Narciß, Elisabeth; Strohmer, Renate; Schüttpelz-Brauns, Katrin

2018-01-01

Aim: As part of the MaReCuM model curriculum at Medical Faculty Mannheim Heidelberg University, a final year rotation in ambulatory care was implemented and augmented to include ambulatory care simulation. In this paper we describe this ambulatory care simulation, the designated competency-based learning objectives, and evaluate the educational effect of the ambulatory care simulation training. Method: Seventy-five final year medical students participated in the survey (response rate: 83%). The control group completed the ambulatory rotation prior to the implementation of the ambulatory care simulation. The experimental group was required to participate in the simulation at the beginning of the final year rotation in ambulatory care. A survey of both groups was conducted at the beginning and at the end of the rotation. The learning objectives were taken from the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). Results: The ambulatory care simulation had no measurable influence on students' subjectively perceived learning progress, the evaluation of the ambulatory care rotation, or working in an ambulatory care setting. At the end of the rotation participants in both groups reported having gained better insight into treating outpatients. At the beginning of the rotation members of both groups assessed their competencies to be at the same level. The simulated ambulatory scenarios were evaluated by the participating students as being well structured and easy to understand. The scenarios successfully created a sense of time pressure for those confronted with them. The ability to correctly fill out a narcotic prescription form as required was rated significantly higher by those who participated in the simulation. Participation in the ambulatory care simulation had no effect on the other competencies covered by the survey. Discussion: The effect of the four instructional units comprising the ambulatory care simulation was not measurable due to the current form or the measurement point at the end of the 12-week rotation. The reasons for this could be the many and statistically elusive factors relevant to the individual and the wide variety among final year rotation placements, the late point in time of the final survey, and the selection of simulated scenarios. The course is slated to undergo specific further development and should be supplemented with additional learning opportunities to ensure that the main learning objectives are covered. The description of the teaching format is meant to contribute to the ongoing development of medical education with an emphasis on competency in the areas of ambulatory care, communication, prevention and health promotion.

Efficacy and safety of mini-dose glucagon for treatment of nonsevere hypoglycemia in adults with type 1 diabetes

USDA-ARS?s Scientific Manuscript database

The purpose of this study was to evaluate low-dose glucagon to treat mild hypoglycemia in ambulatory adults with type 1 diabetes (T1D). This was a randomized crossover trial (two 3-week periods) conducted at five U.S. diabetes clinics. Twenty adults with T1D using an insulin pump and continuous gluc...

Attribute correlates of hospital outpatient satisfaction.

PubMed

Krueckeberg, H F; Hubbert, A

1995-01-01

Customer satisfaction (patient satisfaction) with hospital outpatient or ambulatory services is an important factor in influencing patient patronage and loyalty. Based on an empirical study, this article examines the attributes of the ambulatory care experience which were significantly associated with the level of satisfaction resulting from the most recent hospital ambulatory visit. This study focuses on identifying attributes of ambulatory services. This article brings to the health care marketing literature information on ambulatory satisfaction comparable to that which has been contributed to the literature regarding satisfaction with physician and hospital experiences.

Posterior shoulder instability in the athletic population: Variations in assessment, clinical outcomes, and return to sport.

PubMed

DeLong, Jeffrey M; Bradley, James P

2015-12-18

Posterior instability of the shoulder is becoming an increasingly recognized shoulder injury in the athletic population. Diagnostic elements, such as etiology, directionality, and degree of instability are essential factors to assess in the unstable athletic shoulder. Concomitant injuries and associated pathologic lesions continue to be a significant challenge in the surgical management of posterior shoulder instability. Return to sport and previous level of play is ultimately the goal for every committed athlete and surgeon, thus subpopulations of athletes should be recognized as distinct entities requiring unique diagnostic, functional outcome measures, and surgical approaches.

Ambulatory versus home versus clinic blood pressure: the association with subclinical cerebrovascular diseases: the Ohasama Study.

PubMed

Hara, Azusa; Tanaka, Kazushi; Ohkubo, Takayoshi; Kondo, Takeo; Kikuya, Masahiro; Metoki, Hirohito; Hashimoto, Takanao; Satoh, Michihiro; Inoue, Ryusuke; Asayama, Kei; Obara, Taku; Hirose, Takuo; Izumi, Shin-Ichi; Satoh, Hiroshi; Imai, Yutaka

2012-01-01

The usefulness of ambulatory, home, and casual/clinic blood pressure measurements to predict subclinical cerebrovascular diseases (silent cerebrovascular lesions and carotid atherosclerosis) was compared in a general population. Data on ambulatory, home, and casual/clinic blood pressures and brain MRI to detect silent cerebrovascular lesions were obtained in 1007 subjects aged ≥55 years in a general population of Ohasama, Japan. Of the 1007 subjects, 583 underwent evaluation of the extent of carotid atherosclerosis. Twenty-four-hour, daytime, and nighttime ambulatory and home blood pressure levels were closely associated with the risk of silent cerebrovascular lesions and carotid atherosclerosis (all P<0.05). When home and one of the ambulatory blood pressure values were simultaneously included in the same regression model, each of the ambulatory blood pressure values remained a significant predictor of silent cerebrovascular lesions, whereas home blood pressure lost its predictive value. Of the ambulatory blood pressure values, nighttime blood pressure was the strongest predictor of silent cerebrovascular lesions. The home blood pressure value was more closely associated with the risk of carotid atherosclerosis than any of the ambulatory blood pressure values when home and one of the ambulatory blood pressure values were simultaneously included in the same regression model. The casual/clinic blood pressure value had no significant association with the risk of subclinical cerebrovascular diseases. Although the clinical indications for ambulatory blood pressure monitoring and home blood pressure measurements may overlap, the clinical significance of each method for predicting target organ damage may differ for different target organs.

Heritability and Temporal Stability of Ambulatory Autonomic Stress Reactivity in Unstructured 24-Hour Recordings.

PubMed

Neijts, Melanie; van Lien, Rene; Kupper, Nina; Boomsma, Dorret; Willemsen, Gonneke; de Geus, Eco J C

2015-10-01

Measurements of ambulatory autonomic reactivity can help with our understanding of the long-term health consequences of exposure to psychosocial stress in real-life settings. In this study, unstructured 24-hour ambulatory recordings of cardiac parasympathetic and sympathetic control were obtained in 1288 twins and siblings, spanning both work time and leisure time. These data were used to define two ambulatory baseline (sleep, leisure) and four stress conditions (wake, work, work_sitting, work_peak) from which six ambulatory stress reactivity measures were derived. The use of twin families allowed for estimation of heritability and testing for the amplification of existing or emergence of new genetic variance during stress compared with baseline conditions. Temporal stability of ambulatory reactivity was assessed in 62 participants and was moderate to high over a 3-year period (0.36 < r < 0.91). Depending on the definition of ambulatory reactivity used, significant heritability was found, ranging from 29% to 40% for heart rate, 34% to 47% for cardiac parasympathetic control (indexed as respiratory sinus arrhythmia), and 10% to 19% for cardiac sympathetic control (indexed as the preejection period). Heritability of ambulatory reactivity was largely due to newly emerging genetic variance during stress compared with periods of rest. Interestingly, reactivity to short standardized stressors was poorly correlated with the ambulatory reactivity measures implying poor laboratory-real-life correspondence. Ambulatory autonomic reactivity extracted from an unstructured real-life setting shows reliable, stable, and heritable individual differences. Real-life situations uncover a new and different genetic variation compared with that seen in resting baseline conditions, including sleep.

Alternative approaches to ambulatory training: internal medicine residents' and program directors' perspectives.

PubMed

Thomas, Kris G; West, Colin P; Popkave, Carol; Bellini, Lisa M; Weinberger, Steven E; Kolars, Joseph C; Kogan, Jennifer R

2009-08-01

Internal medicine ambulatory training redesign, including recommendations to increase ambulatory training, is a focus of national discussion. Residents' and program directors' perceptions about ambulatory training models are unknown. To describe internal medicine residents' and program directors' perceptions regarding ambulatory training duration, alternative ambulatory training models, and factors important for ambulatory education. National cohort study. Internal medicine residents (N = 14,941) and program directors (N = 222) who completed the 2007 Internal Medicine In-Training Examination (IM-ITE) Residents Questionnaire or Program Directors Survey, representing 389 US residency programs. A total of 58.4% of program directors and 43.7% of residents preferred one-third or more training time in outpatient settings. Resident preferences for one-third or more outpatient training increased with higher levels of training (48.3% PGY3), female sex (52.7%), primary care program enrollment (64.8%), and anticipated outpatient-focused career, such as geriatrics. Most program directors (77.3%) and residents (58.4%) preferred training models containing weekly clinic. Although residents and program directors reported problems with competing inpatient-outpatient responsibilities (74.9% and 88.1%, respectively) and felt that absence of conflict with inpatient responsibilities is important for good outpatient training (69.4% and 74.2%, respectively), only 41.6% of residents and 22.7% of program directors supported models eliminating ambulatory sessions during inpatient rotations. Residents' and program directors' preferences for outpatient training differ from recommendations for increased ambulatory training. Discordance was observed between reported problems with conflicting inpatient-outpatient responsibilities and preferences for models maintaining longitudinal clinic during inpatient rotations. Further study regarding benefits and barriers of ambulatory redesign is needed.

Differentiation of lower urinary tract dysfunctions: The role of ambulatory urodynamic monitoring.

PubMed

Rademakers, Kevin L J; Drossaerts, Jamie M A F L; Rahnama'i, Mohammad S; van Koeveringe, Gommert A

2015-05-01

To determine the value of ambulatory urodynamic monitoring in the assessment of patients with lower urinary tract symptoms. This was a cross-sectional study including patients who underwent both conventional urodynamic and ambulatory urodynamic assessment at our Center between December 2002 and February 2013. The ambulatory urodynamic studies were interpreted in a standardized way by a resident experienced with urodynamic measurements, and one staff member who specialized in incontinence and urodynamics. A total of 239 patients (71 male and 168 female) were included in the present study. The largest subgroup of patients, 79 (33%), underwent ambulatory urodynamic monitoring based on suspicion of an acontractile bladder. However, 66 of these patients (83.5%) still showed contractions on ambulatory urodynamics. Other groups that were analyzed were patients with suspected storage dysfunction (47 patients), inconclusive conventional urodynamic studies (68 patients) and incontinence of unclear origin (45 patients). Particularly in this last group, ambulatory urodynamics appeared to be useful for discrimination between different causes of incontinence. Ambulatory urodynamic monitoring is a valuable discriminating diagnostic tool in patients with lower urinary tract symptoms who have already undergone conventional urodynamics, particularly in the case of patients with suspected bladder acontractility and incontinence of unclear origin during ambulatory urodynamics. Further study is required to determine the clinical implications of the findings and their relationship with treatment outcome. © 2015 The Japanese Urological Association.

Electrocortical activity distinguishes between uphill and level walking in humans.

PubMed

Bradford, J Cortney; Lukos, Jamie R; Ferris, Daniel P

2016-02-01

The objective of this study was to determine if electrocortical activity is different between walking on an incline compared with level surface. Subjects walked on a treadmill at 0% and 15% grades for 30 min while we recorded electroencephalography (EEG). We used independent component (IC) analysis to parse EEG signals into maximally independent sources and then computed dipole estimations for each IC. We clustered cortical source ICs and analyzed event-related spectral perturbations synchronized to gait events. Theta power fluctuated across the gait cycle for both conditions, but was greater during incline walking in the anterior cingulate, sensorimotor and posterior parietal clusters. We found greater gamma power during level walking in the left sensorimotor and anterior cingulate clusters. We also found distinct alpha and beta fluctuations, depending on the phase of the gait cycle for the left and right sensorimotor cortices, indicating cortical lateralization for both walking conditions. We validated the results by isolating movement artifact. We found that the frequency activation patterns of the artifact were different than the actual EEG data, providing evidence that the differences between walking conditions were cortically driven rather than a residual artifact of the experiment. These findings suggest that the locomotor pattern adjustments necessary to walk on an incline compared with level surface may require supraspinal input, especially from the left sensorimotor cortex, anterior cingulate, and posterior parietal areas. These results are a promising step toward the use of EEG as a feed-forward control signal for ambulatory brain-computer interface technologies.

Metadata - National Hospital Ambulatory Medical Care Survey (NHAMCS)

EPA Pesticide Factsheets

The National Hospital Ambulatory Medical Care Survey (NHAMCS) is designed to collect information on the services provided in hospital emergency and outpatient departments and in ambulatory surgery centers.

The effect of complete radial lateral meniscus posterior root tear on the knee contact mechanics: a finite element analysis.

PubMed

Bao, H R C; Zhu, D; Gong, H; Gu, G S

2013-03-01

In recent years, with technological advances in arthroscopy and magnetic resonance imaging and improved biomechanical studies of the meniscus, there has been some progress in the diagnosis and treatment of injuries to the roots of the meniscus. However, the biomechanical effect of posterior lateral meniscus root tears on the knee has not yet become clear. The purpose of this study was to determine the effect of a complete radial posterior lateral meniscus root tear on the knee contact mechanics and the function of the posterior meniscofemoral ligament on the knee with tear in the posterior root of lateral meniscus. A finite element model of the knee was developed to simulate different cases for intact knee, a complete radial posterior lateral meniscus root tear, a complete radial posterior lateral meniscus root tear with posterior meniscofemoral ligament deficiency, and total meniscectomy of the lateral meniscus. A compressive load of 1000 N was applied in all cases to calculate contact areas, contact pressure, and meniscal displacements. The complete radial posterior lateral meniscus root tear decreased the contact area and increased the contact pressure on the lateral compartment under compressive load. We also found a decreased contact area and increased contact pressure in the medial compartment, but it was not obvious compared to the lateral compartment. The lateral meniscus was radially displaced by compressive load after a complete radial posterior lateral meniscus root tear, and the displacement took place mainly in the body and posterior horn of lateral meniscus. There were further decrease in contact area and increases in contact pressure and raidial displacement of the lateral meniscus in the case of the complete posterior lateral meniscus root tear in combination with posterior meniscofemoral ligament deficiency. Complete radial posterior lateral meniscus root tear is not functionally equivalent to total meniscectomy. The posterior root torn lateral meniscus continues to provide some load transmission and distribution functions across the joint. The posterior meniscofemoral ligament prevents excessive radial displacement of the posterior root torn lateral meniscus and assists the torn lateral meniscus in transmitting a certain amount of stress in the lateral compartment.

Developments in ambulatory surgery in orthopedics in France in 2016.

PubMed

Hulet, C; Rochcongar, G; Court, C

2017-02-01

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

The '6W' multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions.

PubMed

Vanasse, A; Courteau, M; Ethier, J-F

2018-04-01

To synthesize concepts and approaches related to the analysis of patterns or processes of care and patient's outcomes into a comprehensive model of care trajectories, focusing on hospital readmissions for patients with chronic ambulatory care sensitive conditions (ACSCs). Narrative literature review. Published studies between January 2000 and November 2017, using the concepts of 'continuity', 'pathway', 'episode', and 'trajectory', and focused on readmissions and chronic ACSCs, were collected in electronic databases. Qualitative content analysis was performed with emphasis on key constituents to build a comprehensive model. Specific common constituents are shared by the concepts reviewed: they focus on the patient, aim to measure and improve outcomes, follow specific periods of time and consider other factors related to care providers, care units, care settings, and treatments. Using these common denominators, the comprehensive '6W' multidimensional model of care trajectories was created. Considering patients' attributes and their chronic ACSCs illness course ('who' and 'why' dimensions), this model reflects their patterns of health care use across care providers ('which'), care units ('where'), and treatments ('what'), at specific periods of time ('when'). The '6W' model of care trajectories could provide valuable information on 'missed opportunities' to reduce readmission rates and improve quality of both ambulatory and inpatient care. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

Cost sharing and hospitalizations for ambulatory care sensitive conditions.

PubMed

Arrieta, Alejandro; García-Prado, Ariadna

2015-01-01

During the last decade, Chile's private health sector has experienced a dramatic increase in hospitalization rates, growing at four times the rate of ambulatory visits. Such evolution has raised concern among policy-makers. We studied the effect of ambulatory and hospital co-insurance rates on hospitalizations for ambulatory care sensitive conditions (ACSC) among individuals with private insurance in Chile. We used a large administrative dataset of private insurance claims for the period 2007-8 and a final sample of 2,792,662 individuals to estimate a structural model of two equations. The first equation was for ambulatory visits and the second for future hospitalizations for ACSC. We estimated the system by Two Stage Least Squares (2SLS) corrected by heteroskedasticity via Generalized Method of Moments (GMM) estimation. Results show that increased ambulatory visits reduced the probability of future hospitalizations, and increased ambulatory co-insurance decreased ambulatory visits for the adult population (19-65 years-old). Both findings indicate the need to reduce ambulatory co-insurance as a way to reduce hospitalizations for ACSC. Results also showed that increasing hospital co-insurance does have a statistically significant reduction on hospitalizations for the adult group, while it does not seem to have a significant effect on hospitalizations for the children (1-18 years-old) group. This paper's contribution is twofold: first, it shows how the level of co-insurance can be a determinant in avoiding unnecessary hospitalizations for certain conditions; second, it highlights the relevance for policy-making of using data on ACSC to improve the efficiency of health systems by promoting ambulatory care as well as population health. Copyright © 2014 Elsevier Ltd. All rights reserved.

Ambulatory blood pressure and cardiovascular events in chronic kidney disease

PubMed Central

Agarwal, Rajiv

2007-01-01

Purpose of review Hypertension is an important risk factor for adverse cardiovascular and renal outcomes particularly in patients with chronic kidney disease. This review compares blood pressure measurements obtained in the clinic with those obtained outside the clinic to predict cardiovascular and renal injury and outcomes. Recent findings Data are accumulating that suggest that ambulatory blood pressure monitoring is a superior prognostic marker compared to blood pressures obtained in the clinic. Use of ambulatory blood pressure monitoring can detect white coat hypertension and masked hypertension which results in less misclassification of blood pressures. Ambulatory blood pressure monitoring is a marker of cardiovascular end points in CKD. Non dipping is associated with proteinuria and lower GFR. Although non-dipping is associated with more ESRD and cardiovascular events, adjustment for other risk factors removes the prognostic significance of non-dipping. For patients with CKD, not on dialysis, 24 hour ambulatory BP of <125/75 mm Hg, daytime ambulatory of <130/85 mm Hg and nighttime ambulatory BP of <110/70 mm Hg appear to be reasonable goal BP targets. In the management of hypertension in patients with CKD, control of hypertension is important. Ambulatory BP monitoring may be useful to assign more aggressive treatment to patients with masked hypertension and withdraw antihypertensive therapy in patients with white-coat hypertension. Summary Ambulatory blood pressure monitoring can refine cardiovascular and renal risk assessment in all stages of chronic kidney disease. The independent prognostic role of non-dipping is unclear. PMID:17868791

Reproducibility of blood pressure variation in older ambulatory and bedridden subjects.

PubMed

Tsuchihashi, Takuya; Kawakami, Yasunobu; Imamura, Tsuyoshi; Abe, Isao

2002-06-01

We investigated the influence of ambulation on the reproducibility of circadian blood pressure variation in older nursing home residents. Ambulatory blood pressure monitoring was performed twice in 37 older nursing home residents. Nursing home in Japan. Subjects included 18 ambulatory nursing home residents who had no limitation on physical activity and 19 bedridden residents who did not participate in physical activity. Twenty-four-hour, daytime, and nighttime blood pressure levels and their variability. The 24-hour and daytime variability of systolic blood pressure (SBP) was significantly greater in ambulatory than in bedridden subjects, whereas nighttime variability was similar. Significant correlations in SBP averaged for the whole day, daytime, and nighttime were observed between the two examinations in ambulatory (r =.80-.83) and bedridden (r =.83-.91) subjects, but the variabilities of SBP for the whole day and during the daytime of the first measurement were correlated with those of the second measurement in bedridden (r =.67 and r =.47, respectively) but not in ambulatory (r =.39 and r =.28, respectively) subjects. Significant correlations were found between the nocturnal SBP changes at two occasions in both ambulatory (r =.50) and bedridden (r =.51) subjects, but the dipper versus nondipper profiles, defined as reduction in SBP of greater than 10% versus not, showed low reproducibility in ambulatory subjects; five ambulatory (28%) and one bedridden (5%) subjects showed divergent profiles between the two examinations. The reproducibility of blood pressure variation in nursing home residents is influenced by ambulation.

Medical Surveillance Monthly Report (MSMR). Volume 9, Number 6, September/October 2003

DTIC Science & Technology

2003-10-01

October 2003Vol. 9 No. 6 Contents Incidence, severity, and trends of pneumonia/influenza and acute respiratory failure/pulmonary insufficiency, US...high risk of acute respiratory illnesses.1-3 In the US military, acute respiratory illnesses continue to be leading causes of hospitalizations and...ambulatory visits of servicemembers.4,5 The most frequent acute respiratory illnesses of US servicemembers are upper respiratory infections (URIs) that

Close association of vascular and valvular calcification and prognosis of patients on continuous ambulatory peritoneal dialysis.

PubMed

Gen, Shikou; Inoue, Tsutomu; Nodaira, Yuka; Ikeda, Naofumi; Kobayashi, Kazuhiro; Watanabe, Yusuke; Kanno, Yoshihiko; Nakamoto, Hidetomo; Suzuki, Hiromichi

2008-01-01

In the present study, we examined the association between vascular and valvular calcification and the prognosis of patients on continuous ambulatory peritoneal dialysis (CAPD). Data were collected from the records of patients introduced onto CAPD therapy during 1999 - 2006 at the Department of Nephrology, Saitama Medical University. At the start of CAPD, cardiac and vascular echography were used to examine 162 patients (average age: 56 +/- 5 years; 58 men, 104 women; 43 with and 119 without diabetes) for evaluation of vascular and valvular calcification. Both vascular and valvular calcification were found in 32 patients. Vascular calcification was found in 16, and valvular calcification in 11. Over 5 years, 11 patients suffered from cardiovascular disease (7 with stroke, 4 with myocardial infarction). All of these patients had vascular or valvular calcification at the start of CAPD therapy. We also used Cox hazard analysis to examine values for Ca, P, Ca x P, intact parathyroid hormone (iPTH), and lipids. None of these values were independent contributory factors for incidence of cardiovascular disease in patients on CAPD. These data suggest the importance of vascular and valvular echography to evaluate patients on CAPD, especially at the start of CAPD therapy. Vascular and valvular calcification are important factors for determining the prognosis of patients on CAPD.

Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period.

PubMed

2012-11-15

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2013 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).

An Examination of the Likelihood of Home Discharge After General Hospitalizations Among Medicaid Recipients

PubMed Central

Mkanta, William N.; Chumbler, Neale R.; Yang, Kai; Saigal, Romesh; Abdollahi, Mohammad; Mejia de Grubb, Maria C.; Ezekekwu, Emmanuel U.

2017-01-01

Ability to predict discharge destination would be a useful way of optimizing posthospital care. We conducted a cross-sectional, multiple state study of inpatient services to assess the likelihood of home discharges in 2009 among Medicaid enrollees who were discharged following general hospitalizations. Analyses were conducted using hospitalization data from the states of California, Georgia, Michigan, and Mississippi. A total of 33 160 patients were included in the study among which 13 948 (42%) were discharged to their own homes and 19 212 (58%) were discharged to continue with institutional-based treatment. A multiple logistic regression model showed that gender, age, race, and having ambulatory care-sensitive conditions upon admission were significant predictors of home-based discharges. Females were at higher odds of home discharges in the sample (odds ratio [OR] = 1.631; 95% confidence interval [CI], 1.520-1.751), while patients with ambulatory care-sensitive conditions were less likely to get home discharges (OR = 0.739; 95% CI, 0.684-0.798). As the nation engages in the continued effort to improve the effectiveness of the health care system, cost savings are possible if providers and systems of care are able to identify admission factors with greater prospects for in-home services after discharge.

Continuous ambulatory peritoneal dialysis is better than automated peritoneal dialysis as first-line treatment in renal replacement therapy.

PubMed

Li, Philip Kam-Tao; Chung, Kwok Yi; Chow, Kai Ming

2007-06-01

This article examines the roles of continuous ambulatory peritoneal dialysis (CAPD) versus automated peritoneal dialysis (APD) as first-line renal replacement therapy. To date, no high-quality large-scale randomized controlled studies have compared CAPD with APD as first-line therapy. However, a discussion on this issue is important so that nephrologists can decide and patients can have a choice of modality on which to start dialysis, especially in the context of health care economics. We review the literature and present Hong Kong as the model of a "CAPD first" policy, an appealing, cost-effective approach for any country. An ideal renal replacement therapy should provide optimal survival, lowest possible risk for comorbidity, highest level of quality of life, and equally important, acceptable cost to society. When we consider this subject in the context that all patients should be started on one first-line modality, the data suggest that a "CAPD first" policy has all these advantages, with APD probably having the edge only with regard to patient preference. The present review highlights preservation of residual renal function, removal and balancing of sodium, incidence of peritonitis, peritoneal membrane transport status, patient rehabilitation, and financial issues in demonstrating that a "CAPD first" policy is the model that should be adopted.

Office blood pressure measurement alone often misclassifies treatment status in children with primary hypertension.

PubMed

Samuel, Joyce P; Bell, Cynthia S; Hebert, Sean A; Varughese, Arun; Samuels, Joshua A; Tyson, Jon E

2017-12-01

Clinicians frequently rely on office blood pressure (BP) measurements alone to assess hypertension control, despite widespread acceptance of 24-h ambulatory blood pressure monitoring (ABPM) as the reference standard in the initial diagnosis of hypertension. This study was designed to investigate how often the hypertensive status differed between concurrent office BP versus ABPM measurements, and whether any patient-specific characteristics predict the risk for misclassification by office BP. This study evaluated 42 children with primary hypertension who underwent repeated ambulatory monitoring (190 total recordings) with concurrent office BP measurement as part of their participation in n-of-1 trials. In nearly 40% of the visits, the treatment status by office measurement was opposite to the status by ambulatory monitoring. Office BP underestimated the ambulatory hypertensive status (masked uncontrolled hypertension) in 25% of visits and overestimated ambulatory BP (white coat effect) in 14% of visits. The difference between office BP and ambulatory monitoring was consistent within patients across repeated visits. Patients whose office measurement underestimated or overestimated the ambulatory BP at the first visit were more likely to show persistent discrepancy at subsequent visits. The underuse of ambulatory monitoring in management decisions of children treated for primary hypertension may result in systematic misclassification of hypertension control.

Back to Normal! Gaussianizing posterior distributions for cosmological probes

NASA Astrophysics Data System (ADS)

Schuhmann, Robert L.; Joachimi, Benjamin; Peiris, Hiranya V.

2014-05-01

We present a method to map multivariate non-Gaussian posterior probability densities into Gaussian ones via nonlinear Box-Cox transformations, and generalizations thereof. This is analogous to the search for normal parameters in the CMB, but can in principle be applied to any probability density that is continuous and unimodal. The search for the optimally Gaussianizing transformation amongst the Box-Cox family is performed via a maximum likelihood formalism. We can judge the quality of the found transformation a posteriori: qualitatively via statistical tests of Gaussianity, and more illustratively by how well it reproduces the credible regions. The method permits an analytical reconstruction of the posterior from a sample, e.g. a Markov chain, and simplifies the subsequent joint analysis with other experiments. Furthermore, it permits the characterization of a non-Gaussian posterior in a compact and efficient way. The expression for the non-Gaussian posterior can be employed to find analytic formulae for the Bayesian evidence, and consequently be used for model comparison.

Gluteo-vaginal sinus formation complicating posterior intravaginal slingplasty followed by successful IVS removal. A case report and review of the literature.

PubMed

Mikos, Themistoklis; Tsalikis, Tryfon; Papanikolaou, Alexios; Pournaropoulos, Fotios; Bontis, John N

2008-03-01

Posterior intravaginal slingplasty (IVS) is a technique used for the treatment of apical prolapse. Type III meshes have been mostly used with this technique. In this article, a case of bilateral gluteo-vaginal sinus tract formation that complicated a posterior vaginal slingplasty with a type III mesh is presented. At 3 months follow-up, the patient complained for bulking through the vagina, continuous offensive vaginal discharge, and constant pain at the buttocks. She had prolapse recurrence, and there was defective healing at the gluteal entry points of the posterior IVS. Ten months after the initial surgery, she underwent a laparotomic subtotal hysterectomy and sacrocervicopexy with prolene type I mesh. At the same time, the posterior mesh was removed allowing the surgeon to discover communication of the canal of the mesh extending from gluteal incisions to the vagina epithelium. The sinus tract was managed surgically with excision of the surrounding tissues. There was no recurrence or other complications at 2 months follow-up.

The fraud and abuse statute and investor-owned ambulatory surgery centers.

PubMed

Becker, Scott; Harned, Nicholas

2002-04-01

The growth in the number of ambulatory surgery centers, coupled with the unique guidance provided by the OIG in this area, provide a fascinating legal and regulatory environment for ambulatory surgery centers.

Ambulatory intravenous ceftriaxone in paediatric A&E: a useful alternative to hospital admission?

PubMed

Smith, Jennifer K; Alexander, Saji; Abrahamson, Ed

2011-10-01

Treatment of children with intravenous ceftriaxone on an ambulatory basis is described. This allows a child to remain at home, but also be reviewed regularly when attending the Emergency Department for antibiotics. Indications for, and length of, treatment and laboratory parameters were recorded. Also, a survey of children's parents was undertaken to ascertain opinions regarding ambulatory treatment. 36 patients were treated with ambulatory ceftriaxone over 4 months. Indications included fever without focus, tonsillitis, periorbital cellulitis, urinary tract infection, petechial rash and lymphadenitis. Median duration of treatment was 2.3 days. There was no occult bacteraemia but five positive urine cultures. There was one failure of treatment with subsequent admission for alternative intravenous antibiotics. Parental opinion favours ambulatory treatment, with 94% of parents acknowledging they would choose it again in similar circumstances. Cost analysis favours ambulatory treatment based on predicted costs of a similar length of inpatient stay.

Helping You Choose Quality Ambulatory Care

MedlinePlus

Helping you choose: Quality ambulatory care When you need ambulatory care, you should find out some information to help you choose the best ... the center follows rules for patient safety and quality. Go to Quality Check ® at www. qualitycheck. org ...

Use of hospital-based ambulatory care in New York City's Health Manpower Shortage Areas.

PubMed Central

Stager, D F; Krasner, M I; Goodwin, E J

1987-01-01

The development of a comprehensive data base for hospital-based ambulatory care has made possible the accurate determination of each community's use of hospitals in New York City and permits a reliable estimation of all ambulatory care received by residents of Health Manpower Shortage Areas (HMSAs). In spite of the city's abundant supply of private practitioners and widespread Medicaid coverage, residents of HMSAs in New York City are heavily dependent on hospital-based ambulatory care. Contrary to commonly held notions, however, HMSA residents do not appear to overuse hospital-based ambulatory care. Rather, that use appears to be quite modest, given their poorer health status. PMID:3101118

Continuous Blood Pressure Monitoring in Daily Life

NASA Astrophysics Data System (ADS)

Lopez, Guillaume; Shuzo, Masaki; Ushida, Hiroyuki; Hidaka, Keita; Yanagimoto, Shintaro; Imai, Yasushi; Kosaka, Akio; Delaunay, Jean-Jacques; Yamada, Ichiro

Continuous monitoring of blood pressure in daily life could improve early detection of cardiovascular disorders, as well as promoting healthcare. Conventional ambulatory blood pressure monitoring (ABPM) equipment can measure blood pressure at regular intervals for 24 hours, but is limited by long measuring time, low sampling rate, and constrained measuring posture. In this paper, we demonstrate a new method for continuous real-time measurement of blood pressure during daily activities. Our method is based on blood pressure estimation from pulse wave velocity (PWV) calculation, which formula we improved to take into account changes in the inner diameter of blood vessels. Blood pressure estimation results using our new method showed a greater precision of measured data during exercise, and a better accuracy than the conventional PWV method.

[Some behavioral characteristics of physicians desired by ambulatory patients. A pilot survey].

PubMed

Tambone, V; De Virgilio, A; Paolini, A; Paviglianiti, A; Picconi, F; Pietrapertosa, G; Rega, D; Ricciardi, R; Spada, A

2007-01-01

We must pay attention to character formation of Medical Doctors because it could build a good or bad relationship with colleagues and patients: it is not a merely "humanistic" goal but a necessary component of professional excellence. The first endpoint of this study is to identify how to improve the quality of the outpatient visit. We tested a user-friendly questionnaire, distributed to 100 patients. The most important behavioral characteristics desired by patients from physicians are: 1. to have the physician's attention without feeling hurried (such as without the physician answering a phone call during the office visit); 2. to have continuity of care even in the ambulatory setting; 3. to find a relationship of empathy, participation and sharing; 4. to have a peaceful relationship of collaboration with the nurses and other health care personnel; 5. to find the physician appropriately groomed and dressed; 6. to receive the full diagnosis with clarity and at the most appropriate moment of communication.

Usability Testing of Two Ambulatory EHR Navigators.

PubMed

Hultman, Gretchen; Marquard, Jenna; Arsoniadis, Elliot; Mink, Pamela; Rizvi, Rubina; Ramer, Tim; Khairat, Saif; Fickau, Keri; Melton, Genevieve B

2016-01-01

Despite widespread electronic health record (EHR) adoption, poor EHR system usability continues to be a significant barrier to effective system use for end users. One key to addressing usability problems is to employ user testing and user-centered design. To understand if redesigning an EHR-based navigation tool with clinician input improved user performance and satisfaction. A usability evaluation was conducted to compare two versions of a redesigned ambulatory navigator. Participants completed tasks for five patient cases using the navigators, while employing a think-aloud protocol. The tasks were based on Meaningful Use (MU) requirements. The version of navigator did not affect perceived workload, and time to complete tasks was longer in the redesigned navigator. A relatively small portion of navigator content was used to complete the MU-related tasks, though navigation patterns were highly variable across participants for both navigators. Preferences for EHR navigation structures appeared to be individualized. This study demonstrates the importance of EHR usability assessments to evaluate group and individual performance of different interfaces and preferences for each design.

Wireless behind-the-ear EEG recording device with wireless interface to a mobile device (iPhone/iPod touch).

PubMed

Do Valle, Bruno G; Cash, Sydney S; Sodini, Charlie G

2014-01-01

EEG remains the mainstay test for the diagnosis and treatment of patients with epilepsy. Unfortunately, ambulatory EEG systems are far from ideal for patients that have infrequent seizures. The systems only last up to 3 days and if a seizure is not captured during the recordings, the doctor cannot give a definite diagnosis of the patient's condition. The ambulatory systems also suffers from being too bulky and posing some constraints on the patient, such as not being able to shower during the recordings. This paper presents a novel behind-the-ear EEG recording device that uses an iPhone or iPod Touch to continuously upload the patient's data to a secure server. This device not only gives the doctors access to the EEG data in real time but it can be easily removed and re-applied by the patient at any time, thus reducing the interference with quality of life.

Treating Intractable Post-Amputation Phantom Limb Pain with Ambulatory Continuous Peripheral Nerve Blocks

DTIC Science & Technology

2016-01-01

Upper ☐Lower Side of amputation: ☐Right ☐Left Level of original amputation (distal to…): ☐wrist/ ankle ☐elbow/knee...Right ☐Left Level of original amputation (distal to…): ☐wrist/ ankle ☐elbow/knee ☐shoulder/hip Initial Amputation Etiology...extremity: ☐Upper ☐Lower Side of amputation: ☐Right ☐Left Level of original amputation (distal to…): ☐wrist/ ankle ☐elbow/knee

Organization of ambulatory care provision: a critical determinant of health system performance in developing countries.

PubMed Central

Berman, P.

2000-01-01

Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision of services to improve performance. To do this wisely, much better information on ambulatory care organization is needed, as well as more experience with diverse approaches to improve performance. PMID:10916916

Tooth replacement and putative odontogenic stem cell niches in pharyngeal dentition of medaka (Oryzias latipes).

PubMed

Abduweli, Dawud; Baba, Otto; Tabata, Makoto J; Higuchi, Kazunori; Mitani, Hiroshi; Takano, Yoshiro

2014-04-01

The small-sized teleost fish medaka, Oryzias latipes, has as many as 1000 pharyngeal teeth undergoing continuous replacement. In this study, we sought to identify the tooth-forming units and determine its replacement cycles, and further localize odontogenic stem cell niches in the pharyngeal dentition of medaka to gain insights into the mechanisms whereby continuous tooth replacement is maintained. Three-dimensional reconstruction of pharyngeal epithelium and sequential fluorochrome labeling of pharyngeal bones and teeth indicated that the individual functional teeth and their successional teeth were organized in families, each comprising up to five generations of teeth and successional tooth germs, and that the replacement cycle of functional teeth was approximately 4 weeks. BrdU label/chase experiments confirmed the existence of clusters of label-retaining epithelial cells at the posterior end of each tooth family where the expression of pluripotency marker Sox2 was confirmed by in situ hybridization. Label-retaining cells were also identified in the mesoderm immediately adjacent to the posterior end of each tooth family. These data suggest the importance of existence of slow-cycling dental epithelial cells and Sox2 expressions at the posterior end of each tooth family to maintain continuous tooth formation and replacement in the pharyngeal dentition of medaka.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Duncan, I.C., E-mail: docdunc@iafrica.com; Santos, C. Dos

A patient with intractable posterior epistaxis was treated with embolization of the ipsilateral sphenopalatine and facial arteries and contralateral sphenopalatine artery. She continued to bleed despite a seemingly adequate embolization procedure. A second angiogram revealed a significant collateral blood supply to the posterior nasal cavity from the accessory meningeal artery not identified during the first procedure. This was then embolized with no further epistaxis encountered. This case demonstrates yet another collateral arterial pathway that might account for a failed embolization.

Continuous recording of pulmonary artery pressure in unrestricted subjects.

PubMed Central

Ikram, H; Richards, A M; Hamilton, E J; Nicholls, M G

1984-01-01

Continuous ambulatory pulmonary artery pressures were recorded using a conventional No 5 French Goodale-Lubin filled catheter linked to the Oxford Medilog system of a portable transducer-perfusion unit and miniaturised recorder. Data retrieval and analysis were performed using a PB2 Medilog playback unit linked to a PDP 11 computer system. The total system has a frequency response linear to 8 Hz allowing accurate pressure recording over the full range of heart rates. Ten recordings in 10 patients yielded artefact free data for 80% or more of the recorded period. This inexpensive reliable method allows pulmonary artery pressures to be recorded in unrestricted subjects. Images PMID:6704262

Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure – results from the SPRINT ambulatory blood pressure study

PubMed Central

Drawz, Paul; Pajewski, Nicholas M.; Bates, Jeffrey T.; Bello, Natalie A.; Cushman, William C.; Dwyer, Jamie P.; Fine, Lawrence J.; Goff, David C.; Haley, William E.; Krousel-Wood, Marie; McWilliams, Andrew; Rifkin, Dena E.; Slinin, Yelena; Taylor, Addison; Townsend, Raymond; Wall, Barry; Wright, Jackson T.; Rahman, Mahboob

2016-01-01

The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the Systolic Blood Pressure Intervention Trial (SPRINT) Ambulatory BP Ancillary Study was to evaluate the effect of intensive versus standard clinic-based BP targets on ambulatory BP. Ambulatory BP was obtained within 3 weeks of the 27 month study visit in 897 SPRINT participants. Intensive treatment resulted in lower clinic systolic BP (mean difference between groups = 16.0 mmHg (95% CI: 14.1 to 17.8 mmHg)), nighttime systolic BP (mean difference = 9.6 mmHg (95% CI: 7.7 to 11.5 mmHg)), daytime systolic BP (mean difference = 12.3 mmHg (95% CI: 10.6 to 13.9 mmHg)), and 24 hour systolic BP (mean difference = 11.2 mmHg (95% CI: 9.7 to 12.8 mmHg)). The night/day systolic BP ratio was similar between the intensive (0.92 ± 0.09) and standard treatment groups (0.91 ± 0.09). There was considerable lack of agreement within participants between clinic systolic BP and daytime ambulatory systolic BP with wide limits of agreement on Bland-Altman plots. In conclusion, targeting a systolic BP of less than 120 mmHg, as compared with less than 140 mmHg, resulted in lower nighttime, daytime, and 24 hour systolic BP, but did not change the night/day systolic BP ratio. Ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP improves clinical outcomes. PMID:27849563

Effect of Intensive Versus Standard Clinic-Based Hypertension Management on Ambulatory Blood Pressure: Results From the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study.

PubMed

Drawz, Paul E; Pajewski, Nicholas M; Bates, Jeffrey T; Bello, Natalie A; Cushman, William C; Dwyer, Jamie P; Fine, Lawrence J; Goff, David C; Haley, William E; Krousel-Wood, Marie; McWilliams, Andrew; Rifkin, Dena E; Slinin, Yelena; Taylor, Addison; Townsend, Raymond; Wall, Barry; Wright, Jackson T; Rahman, Mahboob

2017-01-01

The effect of clinic-based intensive hypertension treatment on ambulatory blood pressure (BP) is unknown. The goal of the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory BP ancillary study was to evaluate the effect of intensive versus standard clinic-based BP targets on ambulatory BP. Ambulatory BP was obtained within 3 weeks of the 27-month study visit in 897 SPRINT participants. Intensive treatment resulted in lower clinic systolic BP (mean difference between groups=16.0 mm Hg; 95% confidence interval, 14.1-17.8 mm Hg), nighttime systolic BP (mean difference=9.6 mm Hg; 95% confidence interval, 7.7-11.5 mm Hg), daytime systolic BP (mean difference=12.3 mm Hg; 95% confidence interval, 10.6-13.9 mm Hg), and 24-hour systolic BP (mean difference=11.2 mm Hg; 95% confidence interval, 9.7-12.8 mm Hg). The night/day systolic BP ratio was similar between the intensive (0.92±0.09) and standard-treatment groups (0.91±0.09). There was considerable lack of agreement within participants between clinic systolic BP and daytime ambulatory systolic BP with wide limits of agreement on Bland-Altman plots. In conclusion, targeting a systolic BP of <120 mm Hg, when compared with <140 mm Hg, resulted in lower nighttime, daytime, and 24-hour systolic BP, but did not change the night/day systolic BP ratio. Ambulatory BP monitoring may be required to assess the effect of targeted hypertension therapy on out of office BP. Further studies are needed to assess whether targeting hypertension therapy based on ambulatory BP improves clinical outcomes. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01835249. © 2016 American Heart Association, Inc.

Ambulatory Medication Reconciliation in Dialysis Patients: Benefits and Community Practitioners’ Perspectives

PubMed Central

Wilson, Jo-Anne S; Ladda, Matthew A; Tran, Jaclyn; Wood, Marsha; Poyah, Penelope; Soroka, Steven; Rodrigues, Glenn; Tennankore, Karthik

2017-01-01

Background Ambulatory medication reconciliation can reduce the frequency of medication discrepancies and may also reduce adverse drug events. Patients receiving dialysis are at high risk for medication discrepancies because they typically have multiple comorbid conditions, are taking many medications, and are receiving care from many practitioners. Little is known about the potential benefits of ambulatory medication reconciliation for these patients. Objectives To determine the number, type, and potential level of harm associated with medication discrepancies identified through ambulatory medication reconciliation and to ascertain the views of community pharmacists and family physicians about this service. Methods This retrospective cohort study involved patients initiating hemodialysis who received ambulatory medication reconciliation in a hospital renal program over the period July 2014 to July 2016. Discrepancies identified on the medication reconciliation forms for study patients were extracted and categorized by discrepancy type and potential level of harm. The level of harm was determined independently by a pharmacist and a nurse practitioner using a defined scoring system. In the event of disagreement, a nephrologist determined the final score. Surveys were sent to 52 community pharmacists and 44 family physicians involved in the care of study patients to collect their opinions and perspectives on ambulatory medication reconciliation. Results Ambulatory medication reconciliation was conducted 296 times for a total of 147 hemodialysis patients. The mean number of discrepancies identified per patient was 1.31 (standard deviation 2.00). Overall, 30% of these discrepancies were deemed to have the potential to cause moderate to severe patient discomfort or clinical deterioration. Survey results indicated that community practitioners found ambulatory medication reconciliation valuable for providing quality care to dialysis patients. Conclusions This study has provided evidence that ambulatory medication reconciliation can increase patient safety and potentially prevent adverse events associated with medication discrepancies. PMID:29299004

Sensor and software use for the glycaemic management of insulin-treated type 1 and type 2 diabetes patients.

PubMed

Ajjan, Ramzi A; Abougila, Kamal; Bellary, Srikanth; Collier, Andrew; Franke, Bernd; Jude, Edward B; Rayman, Gerry; Robinson, Anthony; Singh, Baldev M

2016-05-01

Lowering glucose levels, while avoiding hypoglycaemia, can be challenging in insulin-treated patients with diabetes. We evaluated the role of ambulatory glucose profile in optimising glycaemic control in this population. Insulin-treated patients with type 1 and type 2 diabetes were recruited into a prospective, multicentre, 100-day study and randomised to control (n = 28) or intervention (n = 59) groups. The intervention group used ambulatory glucose profile, generated by continuous glucose monitoring, to assess daily glucose levels, whereas the controls relied on capillary glucose testing. Patients were reviewed at days 30 and 45 by the health care professional to adjust insulin therapy. Comparing first and last 2 weeks of the study, ambulatory glucose profile-monitored type 2 diabetes patients (n = 28) showed increased time in euglycaemia (mean ± standard deviation) by 1.4 ± 3.5 h/day (p = 0.0427) associated with reduction in HbA1c from 77 ± 15 to 67 ± 13 mmol/mol (p = 0.0002) without increased hypoglycaemia. Type 1 diabetes patients (n = 25) showed reduction in hypoglycaemia from 1.4 ± 1.7 to 0.8 ± 0.8 h/day (p = 0.0472) associated with a marginal HbA1c decrease from 75 ± 10 to 72 ± 8 mmol/mol (p = 0.0508). Largely similar findings were observed comparing intervention and control groups at end of study. In conclusion, ambulatory glucose profile helps glycaemic management in insulin-treated diabetes patients by increasing time spent in euglycaemia and decreasing HbA1c in type 2 diabetes patients, while reducing hypoglycaemia in type 1 diabetes patients. © The Author(s) 2016.

Delegation of GP-home visits to qualified practice assistants: assessment of economic effects in an ambulatory healthcare centre

PubMed Central

2010-01-01

Background Against the background of a decreasing number of general practitioners (GPs) in rural regions in Germany, the AGnES-concept (AGnES = GP-supporting, community-based, e-health-assisted, systemic intervention) supports the delegation of regular GP-home visits to qualified practice assistants. The concept was implemented and evaluated in different model projects in Germany. To explore the economic effects of this concept, the development of the number of home visits in an ambulatory healthcare centre was analysed and compared with the number of home visits in the surrounding county. Methods Information about GP-home visits was derived from reimbursement data of the ambulatory healthcare centre and a statutory health insurance. Information about home visits conducted by AGnES-practice assistants was collected from the project documentation over a time period of 12 consecutive quarter years, four quarter years before the beginning of the project and 8 quarter years while the project was implemented, considering background temporal trends on the population level in the study region. Results Within the ambulatory healthcare centre, the home visits by the GPs significantly decreased, especially the number of medically urgent home visits. However, the overall rate of home visits (conducted by the GPs and the AGnES-practice assistants together) did not change significantly after implementation of the AGnES-concept. In the surrounding county, the home visit rates of the GPs were continuous; the temporal patterns were approximately equal for both usual and urgent home visits. Conclusion The results of the analyses show that the support by AGnES-practice assistants led to a decrease of GP-home visits rather than an induction of additional home visits by the AGnES-practice assistants. The most extended effect is related to the medically urgent home visits rather than to the usual home visits. PMID:20529307

Effects of a sensory branch to the posterior external ear canal: coughing, pain, Ramsay Hunt's syndrome and Hitselberger's sign.

PubMed

Mulazimoglu, S; Flury, R; Kapila, S; Linder, T

2017-04-01

A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve. In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed. Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.

Defining and evaluating quality for ambulatory care educational programs.

PubMed

Bowen, J L; Stearns, J A; Dohner, C; Blackman, J; Simpson, D

1997-06-01

As the training of medical students and residents increasingly moves to ambulatory care settings, clerkship and program directors must find a way to use their limited resources to guide the development and evaluation of the quality of these ambulatory-based learning experiences. To evaluate quality, directors must first define, in operational and measurable terms, what is meant by the term "quality" as it is applied to ambulatory-based education. Using educational theories and the definition of quality used by health care systems, the authors propose an operational definition of quality for guiding the planning, implementation, and evaluation of ambulatory care educational programs. They assert that quality is achieved through the interaction of an optimal learning environment, defined educational goals and positive outcomes, participant satisfaction, and cost-effectiveness. By describing the components of quality along with examples of measurable indicators, the authors provide a foundation for the evaluation and improvement of instructional innovations in ambulatory care education for the benefit of teachers, learners, and patients.

[Establishing an Ambulatory Health-Care Centre (AHCC) at a University Hospital].

PubMed

Krüll, A; Debatin, J F

2013-02-01

Since January 2004 hospitals have the opportunity to establish an ambulatory health-care centre (Medizinisches Versorgungszentrum - MVZ) as a result of the introduction of the Health-care Modernisation Act (Gesetz zur Modernisierung der gesetzlichen Krankenversicherung - GMG). After about a half-year preparatory phase, the UKE, in September 2004, began operation of the "Ambulanzzentrum des UKE GmbH" (a limited liability company) as the first MVZ at a university hospital in Germany. We report here on the establishment of the MVZ and the experience made. In the initial phase, only the medical fields of radiation therapy and nuclear medicine were represented. Both disciplines, especially radiation therapy, were existentially threatened by the extensive loss of ambulatory patients. The central motive for the establishment of the ambulatory health-care centre was to secure the survival of both disciplines and to preserve existing jobs. After it was put into operation, the referrals from practice-based colleagues to both radiation therapy and nuclear medicine increased quickly. The positive developments caused other departments of the UKE to express their interest in supplementing their outpatient activities with facilities in the MVZ. Over the following years, the ambulance centre grew steadily. Now 24 departments are represented in the MVZ, and the centre has a total of 49 positions for physicians contracted by and registered within the German public health insurance system. The number of salaried doctors has risen to 85, although many of these only work part time in the MVZ. Also more than 83 non-medical staff members were hired over the years. These were mostly physiotherapists, radiographers, and medical assistants. With the growing number of departments in the MVZ, the number of treated cases grew steadily. Currently approximately 20 000 cases are treated in each quarter of a year. The experience made while establishing an ambulatory health-care centre is very positive. Better cross-sectoral medicine, support of referring practice-based colleagues, content of centre-physicians and a strengthening of research and teaching summarise the experience of the last 7 years accurately. The outpatient centre of UKE GmbH will strive to continue to expand its range of medical services into other medical fields whenever it makes sense. © Georg Thieme Verlag KG Stuttgart · New York.

Ambulatory surgery in orthopedics: experience of over 10,000 patients.

PubMed

Martín-Ferrero, M A; Faour-Martín, O; Simon-Perez, C; Pérez-Herrero, M; de Pedro-Moro, J A

2014-03-01

The concept of day surgery is becoming an increasingly important part of elective surgery worldwide. Relentless pressure to cut costs may constrain clinical judgment regarding the most appropriate location for a patient's surgical care. The aim of this study was to determine clinical and quality indicators relating to our experience in orthopedic day durgery, mainly in relation to unplanned overnight admission and readmission rates. Additionally, we focused on describing the main characteristics of the patients that experienced complications, and compared the patient satisfaction rates following ambulatory and non-ambulatory procedures. We evaluated 10,032 patients who underwent surgical orthopedic procedures according to the protocols of our Ambulatory Surgery Unit. All complications that occurred were noted. A quality-of-life assessment (SF-36 test) was carried out both pre- and postoperatively. Ambulatory substitution rates and quality indicators for orthopedic procedures were also determined. The major complication rate was minimal, with no mortal cases, and there was a high rate of ambulatory substitution for the procedures studied. Outcomes of the SF-36 questionnaire showed significant improvement postoperatively. An unplanned overnight admission rate of 0.14 % was achieved. Our institution has shown that it is possible to provide good-quality ambulatory orthopedic surgery. There still appears to be the potential to increase the proportion of these procedures. Surgeons and anesthesiologists must strongly adhere to strict patient selection criteria for ambulatory orthopedic surgery in order to reduce complications in the immediate postoperative term.

Acute and Chronic Effects of Aerobic and Resistance Exercise on Ambulatory Blood Pressure

PubMed Central

Cardoso, Crivaldo Gomes; Gomides, Ricardo Saraceni; Queiroz, Andréia Cristiane Carrenho; Pinto, Luiz Gustavo; da Silveira Lobo, Fernando; Tinucci, Tais; Mion, Décio; de Moraes Forjaz, Claudia Lucia

2010-01-01

Hypertension is a ubiquitous and serious disease. Regular exercise has been recommended as a strategy for the prevention and treatment of hypertension because of its effects in reducing clinical blood pressure; however, ambulatory blood pressure is a better predictor of target-organ damage than clinical blood pressure, and therefore studying the effects of exercise on ambulatory blood pressure is important as well. Moreover, different kinds of exercise might produce distinct effects that might differ between normotensive and hypertensive subjects. The aim of this study was to review the current literature on the acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure in normotensive and hypertensive subjects. It has been conclusively shown that a single episode of aerobic exercise reduces ambulatory blood pressure in hypertensive patients. Similarly, regular aerobic training also decreases ambulatory blood pressure in hypertensive individuals. In contrast, data on the effects of resistance exercise is both scarce and controversial. Nevertheless, studies suggest that resistance exercise might acutely decrease ambulatory blood pressure after exercise, and that this effect seems to be greater after low-intensity exercise and in patients receiving anti-hypertensive drugs. On the other hand, only two studies investigating resistance training in hypertensive patients have been conducted, and neither has demonstrated any hypotensive effect. Thus, based on current knowledge, aerobic training should be recommended to decrease ambulatory blood pressure in hypertensive individuals, while resistance exercise could be prescribed as a complementary strategy. PMID:20360924

Lessons From Analyzing the Medical Costs of Civilian Terror Victims: Planning Resources Allocation for a New Era of Confrontations.

PubMed

Ellenberg, Eytan; Taragin, Mark I; Hoffman, Jay R; Cohen, Osnat; Luft-Afik, Daniella; Bar-On, Zvia; Ostfeld, Ishay

2017-12-01

Policy Points: Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror. Across the globe, the threat from terrorist attacks is rising, which requires a careful assessment of long-term medical support. Based on an 18-month follow-up of the Israeli civilian population following the 2014 war in Gaza, we describe and analyze the medical costs associated with rocket attacks and review the demography of the victims who filed claims for disability compensation. We then propose practical lessons to help health care authorities prepare for future confrontations. Using the National Insurance Institute of Israel's (NII) database, we conducted descriptive and comparative analyses using statistical tests (Fisher's Exact Test, chi-square test, and students' t-tests). The costs were updated until March 30, 2016, and are presented in US dollars. We included only civilian expenses in our analysis. We identified 5,189 victims, 3,236 of whom presented with acute stress reactions during the conflict. Eighteen months after the conflict, the victims' total medical costs reached $4.4 million. The NII reimbursed $2,541,053 for associated medical costs and $1,921,792 for associated mental health costs. A total of 709 victims filed claims with the NII for further support, including rehabilitation, medical devices, and disability pensions. We found 3 major sources of costs: hospital expenditures, mental health services dedicated to acute stress reactions, and ambulatory follow-up. During the first year, most of the costs were related to hospitalization and support for stress relief. During the second year, ambulatory and rehabilitation costs continued to grow. Public health specialists should consider these major components of costs and their evolution over time to properly advise the medical and social authorities on allocating resources for the medical and nonmedical support of civilian casualties resulting from war or terror. © 2017 Milbank Memorial Fund.

Superior perioperative analgesia with combined femoral-obturator-sciatic nerve block in comparison with posterior lumbar plexus and sciatic nerve block for ACL reconstructive surgery.

PubMed

Bareka, Metaxia; Hantes, Michael; Arnaoutoglou, Eleni; Vretzakis, George

2018-02-01

The purpose of this randomized controlled study is to compare and evaluate the intraoperative and post-operative outcome of PLPS nerve block and that of femoral, obturator and sciatic (FOS) nerve block as a method of anaesthesia, in performing ACL reconstruction. Patients referred for elective arthroscopic ACL reconstruction using hamstring autograft were divided in two groups. The first group received combined femoral-obturator-sciatic nerve block (FOS Group) under dual guidance, whereas the second group received posterior lumbar plexus block under neurostimulation and sciatic nerve block (PLPS Group) under dual guidance. The two groups were comparable in terms of age, sex, BMI and athletic activity. The time needed to perform the nerve blocks was significantly shorter for the FOS group (p < 0.005). Similarly, VAS scores during tourniquet inflation and autograft harvesting were significantly higher (p < 0.005) in the PLPS group and this is also reflected in the intraoperative fentanyl consumption and conversion to general anaesthesia. Finally, patients in this group also reported higher post-operative VAS scores and consumed more morphine. Peripheral nerve blockade of FOS nerve block under dual guidance for arthroscopic ACL reconstructive surgery is a safe and tempting anaesthetic choice. The success rate of this technique is higher in comparison with PLPS and results in less peri- and post-operative pain with less opioid consumption. This study provides support for the use of peripheral nerve blocks as an exclusive method for ACL reconstructive surgery in an ambulatory setting with almost no complications. I.

Longitudinal relationships among posturography and gait measures in multiple sclerosis.

PubMed

Fritz, Nora E; Newsome, Scott D; Eloyan, Ani; Marasigan, Rhul Evans R; Calabresi, Peter A; Zackowski, Kathleen M

2015-05-19

Gait and balance dysfunction frequently occurs early in the multiple sclerosis (MS) disease course. Hence, we sought to determine the longitudinal relationships among quantitative measures of gait and balance in individuals with MS. Fifty-seven ambulatory individuals with MS (28 relapsing-remitting, 29 progressive) were evaluated using posturography, quantitative sensorimotor and gait measures, and overall MS disability with the Expanded Disability Status Scale at each session. Our cohort's age was 45.8 ± 10.4 years (mean ± SD), follow-up time 32.8 ± 15.4 months, median Expanded Disability Status Scale score 3.5, and 56% were women. Poorer performance on balance measures was related to slower walking velocity. Two posturography measures, the anterior-posterior sway and sway during static eyes open, feet apart conditions, were significant contributors to walk velocity over time (approximate R(2) = 0.95), such that poorer performance on the posturography measures was related to slower walking velocity. Similarly, the anterior-posterior sway and sway during static eyes closed, feet together conditions were also significant contributors to the Timed 25-Foot Walk performance over time (approximate R(2) = 0.83). This longitudinal cohort study establishes a strong relationship between clinical gait measures and posturography. The data show that increases in static posturography and reductions in dynamic posturography are associated with a decline in walk velocity and Timed 25-Foot Walk performance over time. Furthermore, longitudinal balance measures predict future walking performance. Quantitative walking and balance measures are important additions to clinical testing to explore longitudinal change and understand fall risk in this progressive disease population. © 2015 American Academy of Neurology.

78 FR 22880 - Agency Information Collection Activities; Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-17

... between Health IT and Ambulatory Care Workflow Redesign.'' In accordance with the Paperwork Reduction Act... Understand the Relationship between Health IT and Ambulatory Care Workflow Redesign. The Agency for... Methods to Better Understand the Relationship between Health IT and Ambulatory Care Workflow Redesign...

Development of a practice-based research program.

PubMed

Hawk, C; Long, C R; Boulanger, K

1998-01-01

To establish an infrastructure to collect accurate data from ambulatory settings. The program was developed through an iterative model governed by a process of formative evaluation. The three iterations were a needs assessment, feasibility study and pilot project. Necessary program components were identified as infrastructure, practitioner-researcher partnership, centralized data management and standardized quality assurance measures. Volunteer chiropractors and their staff collected data on patients in their practices in ambulatory settings in the U.S. and Canada. Evaluative measures were counts of participants, patients and completed forms. Standardized, validated and reliable measures collected by patient self-report were used to assess treatment outcomes. These included the SF-36 or SF-12 Health Survey, the Pain Disability Index, and the Global Well-Being Scale. For characteristics for which appropriate standardized instruments were not available, questionnaires were designed and and pilot-tested before use. Information was gathered on practice and patient characteristics and treatment outcomes, but for this report, only those data concerning process evaluation are reported. Through the three program iterations, 65 DCs collected data on 1360 patients, 663 of whom were new patients. Follow-up data recorded by doctors were obtained for more than 70% of patients; a maximum of 50% of patient-completed follow-up forms were collected in the three iterations. This program is capable of providing data for descriptive epidemiology of ambulatory patients, and, with continued effort to maximize follow-up, may have utility in providing insight into utilization patterns and patient outcomes.

The zebrafish tailbud contains two independent populations of midline progenitor cells that maintain long-term germ layer plasticity and differentiate in response to local signaling cues

PubMed Central

Row, Richard H.; Tsotras, Steve R.; Goto, Hana; Martin, Benjamin L.

2016-01-01

Vertebrate body axis formation depends on a population of bipotential neuromesodermal cells along the posterior wall of the tailbud that make a germ layer decision after gastrulation to form spinal cord and mesoderm. Despite exhibiting germ layer plasticity, these cells never give rise to midline tissues of the notochord, floor plate and dorsal endoderm, raising the question of whether midline tissues also arise from basal posterior progenitors after gastrulation. We show in zebrafish that local posterior signals specify germ layer fate in two basal tailbud midline progenitor populations. Wnt signaling induces notochord within a population of notochord/floor plate bipotential cells through negative transcriptional regulation of sox2. Notch signaling, required for hypochord induction during gastrulation, continues to act in the tailbud to specify hypochord from a notochord/hypochord bipotential cell population. Our results lend strong support to a continuous allocation model of midline tissue formation in zebrafish, and provide an embryological basis for zebrafish and mouse bifurcated notochord phenotypes as well as the rare human congenital split notochord syndrome. We demonstrate developmental equivalency between the tailbud progenitor cell populations. Midline progenitors can be transfated from notochord to somite fate after gastrulation by ectopic expression of msgn1, a master regulator of paraxial mesoderm fate, or if transplanted into the bipotential progenitors that normally give rise to somites. Our results indicate that the entire non-epidermal posterior body is derived from discrete, basal tailbud cell populations. These cells remain receptive to extracellular cues after gastrulation and continue to make basic germ layer decisions. PMID:26674311

Near-Fatal Gastrointestinal Hemorrhage in a Child with Medulloblastoma on High Dose Dexamethasone.

PubMed

Yecies, Derek; Tawfik, Daniel; Damman, Jennifer; Thorson, Chad; Hong, David S; Grant, Gerald A; Bensen, Rachel; Damian, Mihaela

2017-07-07

A four-year-old female was admitted to a university-based children's hospital with a newly-diagnosed posterior fossa tumor. She was started on famotidine and high-dose dexamethasone and underwent gross total resection of a medulloblastoma. She was continued on dexamethasone and famotidine. She exhibited postoperative posterior fossa syndrome and was started on enteral feeds via the nasoduodenal tube. She had small gastrointestinal bleeds on postoperative days eight, 11, and 18, and was found to have a well-circumscribed posterior duodenal ulcer. On postoperative day 19, she suffered a massive life-threatening gastrointestinal bleed requiring aggressive resuscitation with blood products. She required an emergent laparotomy due to ongoing blood loss and she was found to have posterior duodenal wall erosion into her gastroduodenal artery. She recovered and subsequently began delayed chemotherapy. This case demonstrates a rare and life-threatening complication of high-dose dexamethasone therapy in the setting of posterior fossa pathology despite stress ulcer prophylaxis. We present a historical perspective with the review of the association between duodenal and intracranial pathology and the usage of high-dose dexamethasone in such cases.

A Marketing Analysis to Determine the Consumer Demand for Ambulatory Surgery at Darnall Army Community Hospital, Fort Hood, Texas

DTIC Science & Technology

1982-08-01

8 Marketing Research ...... ................................9 The Marketing Audit...9 A Marketing Research Model .... ..........................10 An Ambulatory Marketing Model. .... ......................12 Stage 1. Internal...14 Stage 4. Modifications of Internal Projecttons. .. ......14 Marketing Research on Ambulatory Surgical Centers .. ........15 Research

[Successful transcatheter ablation of fascicular potential in pediatric patients with left posterior fascicular tachycardia].

PubMed

Zeng, Shao-ying; Shi, Ji-jun; Li, Hong; Zhang, Zhi-wei; Li, Yu-fen

2010-08-01

To simplify the methods of transcatheter mapping and ablation in the pediatric patients with left posterior fascicular tachycardia. While in sinus rhythm, the fascicular potential can be mapped at the posterior septal region (1 - 2 cm below inferior margin of orifice of coronary sinus vein), which display a biphasic wave before ventricular wave, and exist equipotential lines between them. When the fascicular potential occurs 20 ms later than the bundle of His' potential, radiofrequency was applied. Before applying radiofrequency, catheter position must be observed using double angle viewing (LAO 45°RAO 30°), and it should be made sure that the catheter is not at His' bundle. If the electrocardiogram displays left posterior fascicular block, the correct region is identified and ablation can continue for 60 s. Electrocardiogram monitoring should continue for 24 - 48 hours after operation, and notice abnormal repolarization after termination of ventricular tachycardia. Aspirin [2 - 3 mg/(kg·d)] was used for 3 months, and antiarrhythmic drug was discontinued. Surface electrocardiogram, chest X-ray and ultrasound cardiography were rechecked 1 d after operation. Follow-up was made at 1 month and 3 months post-discharge. Recheck was made half-yearly or follow-up was done by phone from then on. Fifteen pediatric patients were ablated successfully, and their electrocardiograms all displayed left posterior fascicular block after ablation. None of the patients had recurrences during the 3 to 12 months follow-up period. In one case, the electrocardiogram did not change after applying radiofrequency ablation and the ventricular tachycardia remained; however, on second attempt after remapping, the electrocardiogram did change. The radiofrequency lasted for 90 seconds and ablation was successful. This case had no recurrences at 6 months follow-up. Transcatheter ablation of the fascicular potential in pediatric patients with left posterior fascicular tachycardia can simplify mapping, reduce operative difficulty and produce a distinct endpoint for ablation.

Peritonitis due to Curvularia inaequalis in an elderly patient undergoing peritoneal dialysis and a review of six cases of peritonitis associated with other Curvularia spp.

PubMed

Pimentel, Jason D; Mahadevan, Kumar; Woodgyer, Alan; Sigler, Lynne; Gibas, Connie; Harris, Owen C; Lupino, Michael; Athan, Eugene

2005-08-01

Fungal peritonitis due to Curvularia species in patients undergoing peritoneal dialysis is a very rare problem. We report a case of peritonitis caused by Curvularia inaequalis. This is the first report in the English literature of this species causing human infection. We also review the six previously reported cases of continuous ambulatory peritoneal dialysis peritonitis caused by other Curvularia species.

Treating Intractable Post Amputation Phantom Limb Pain with Ambulatory Continuous Peripheral Nerve Blocks

DTIC Science & Technology

2018-01-01

author(s) and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation...hurricane that hit Puerto Rico this last summer knocked out the factory that makes the local anesthetic used in this study—ropivacaine—and, so our enrollment...was halted because ropivacaine cannot be purchased in the United States. It is unclear when the factory will begin producing ropivacaine again; but

Restless legs syndrome in dialysis patients: a comparison between hemodialysis and continuous ambulatory peritoneal dialysis.

PubMed

Merlino, Giovanni; Lorenzut, Simone; Romano, Giulio; Sommaro, Martina; Fontana, Augusto; Montanaro, Domenico; Valente, Mariarosaria; Gigli, Gian Luigi

2012-12-01

Restless legs syndrome (RLS) is common in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). A few studies so far have investigated RLS prevalence in ESRD patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The aim of this study was to compare the prevalence, characteristics, consequences and predictors of RLS between HD and CAPD patients. We recruited 58 HD and 28 CAPD patients. A neurologist expert in sleep medicine performed RLS diagnosis during a face-to-face interview. The prevalence of RLS was slightly higher in HD than in CAPD patients (19 vs. 10.7%). RLS appeared after the onset of kidney complaint in HD patients; in contrast, in CAPD patients RLS preceded the occurrence of renal disease. Five HD patients reported that RLS symptoms occurred throughout the dialysis session. HD patients with RLS(+) had a higher mean number of HD sessions per week and a longer mean duration of HD session than the RLS(-) ones. Prevalence of females was significantly higher in CAPD patients with RLS(+) than in the RLS(-) ones. RLS frequently affects both HD and CAPD patients. RLS impaired sleep in both groups, but use of dopaminergic agents was uncommon in our sample. Dialysis schedule was associated with RLS in HD patients, while female sex was related to RLS in CAPD patients. Awareness concerning RLS identification and treatment in HD and CAPD patients is recommended.

Educating nurses about research ethics and practices with a self-directed practice-based learning program.

PubMed

Cibulka, Nancy J

2011-11-01

Learner-driven and practice-based education programs are recommended for integration of learning. A continuing education program on research ethics was introduced to five nurses in an ambulatory care setting at a Magnet® hospital, using a commercially available web-based course followed by a research practicum. The seasoned nurses reported little previous education in this area. Working with a nurse researcher, three nurses participated in a research project for improving clinic care delivery. The success of the continuing education program was determined by knowledge acquisition, satisfaction with learning activities, and perceived confidence in research participation. This continuing education program was effective in providing for knowledge and skill development in research ethics. The integrative learning format was well received. Copyright 2011, SLACK Incorporated.

Diagnostic yield of 24-hour esophageal manometry in non-cardiac chest pain.

PubMed

Barret, M; Herregods, T V K; Oors, J M; Smout, A J P M; Bredenoord, A J

2016-08-01

In the past, ambulatory 24-h manometry has been shown useful for the evaluation of patients with non-cardiac chest pain (NCCP). With the diagnostic improvements brought by pH-impedance monitoring and high-resolution manometry (HRM), the contribution of ambulatory 24-h manometry to the diagnosis of esophageal hypertensive disorders has become uncertain. Our aim was to assess the additional diagnostic yield of ambulatory manometry to HRM and ambulatory pH-impedance monitoring in this patient population. All patients underwent 24-h ambulatory pressure-pH-impedance monitoring and HRM. Patients had retrosternal pain as a predominant symptom and no explanation after cardiologic and digestive endoscopic evaluations. Diagnostic measurements were analyzed by two independent physicians. Fifty-nine patients met the inclusion criteria; 37.3% of the patients had their symptoms explained by abnormalities on pH-impedance monitoring and 6.8% by ambulatory manometry. Functional chest pain was diagnosed in 52.5% of the patients. High-resolution manometry, using the Chicago Classification v3.0 criteria alone, did not identify any of the four patients with esophageal spasm on ambulatory manometry. However, taking into account other abnormalities, such as simultaneous (rapid) or repetitive contractions, HRM had a sensitivity of 75% and a specificity of 98.2% for the diagnosis of esophageal spasm. In the work-up of NCCP, ambulatory 24-h manometry has a low additional diagnostic yield. However, it remains the best technique to identify esophageal spasm as the cause of symptoms. This is particularly useful when an unequivocal diagnosis is needed before treatment. © 2016 John Wiley & Sons Ltd.

Performance measurement for ambulatory care: moving towards a new agenda.

PubMed

Roski, J; Gregory, R

2001-12-01

Despite a shift in care delivery from inpatient to ambulatory care, performance measurement efforts for the different levels in ambulatory care settings such as individual physicians, individual clinics and physician organizations have not been widely instituted in the United States (U.S.). The Health Plan Employer Data and Information Set (HEDIS), the most widely used performance measurement set in the U.S., includes a number of measures that evaluate preventive and chronic care provided in ambulatory care facilities. While HEDIS has made important contributions to the tracking of ambulatory care quality, it is becoming increasingly apparent that the measurement set could be improved by providing quality of care information at the levels of greatest interest to consumers and purchasers of care, namely for individual physicians, clinics and physician organizations. This article focuses on the improvement opportunities for quality performance measurement systems in ambulatory care. Specific challenges to creating a sustainable performance measurement system at the level of physician organizations, such as defining the purpose of the system, the accountability logic, information and reporting needs and mechanisms for sustainable implementation, are discussed.

[Intensive care anaesthesia practice in the prison environment. Can a prisoner benefit from ambulatory anaesthesia].

PubMed

Manaouil, C; Montpellier, D; Sannier, O; Defouilloy, C; Radji, M; Jardé, O; Dupont, H

2010-01-01

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France. Copyright 2009 Elsevier Masson SAS. All rights reserved.

[Incidence of surgical site infection in ambulatory surgery: results of the INCISCO surveillance network in 1999-2000].

PubMed

Sewonou, A; Rioux, C; Golliot, F; Richard, L; Massault, P P; Johanet, H; Cherbonnel, G; Botherel, A H; Farret, D; Astagneau, P

2002-04-01

To estimate the incidence of surgical-site infections (SSI) in ambulatory surgery and to identify risk factors based on the surveillance network INCISO in 1999-2000. Annually, during a three-month period, each surgical ward had to include 200 consecutive operations. Patients were surveyed over the month following surgery. For each patient, data including peri-operative factors, type of procedure and SSI occurrence were collected on a standardized form by a surgical staff committed for the study. Of the 5,183 patients who underwent an ambulatory surgery, the SSI incidence ratio was 0.4% (95% CI [0.3-0.7]). Orthopedic, gynecologic/obstetrics, head and neck, skin and soft tissues surgery accounted for 83% of all ambulatory procedures. 93% of patients belonged to the 0 risk category of the National Nosocomial Infections Surveillance system (NNIS) index. Emergency, age, american anesthesia risk score (ASA), Altemeier wound class, and procedure duration were not found to be risk factors for SSI in ambulatory surgery. Based on these surveillance data, infectious risk was low in ambulatory surgery and was not associated with known SSI risk factors.

[The health care structure law as a political public health reform in ambulatory and day surgery].

PubMed

Sorgatz, H

1994-01-01

The statutory opening of hospitals for ambulatory surgery can't without more ado be derived from the health-care reform which came into force on the 1st of January 1993. From the genesis of this reform it can be understood that the field of ambulatory surgery has been integrated just shortly before its legislation into the outlines of the health-care reform. As a consequence the hospitals are obliged to follow the principle "ambulatory before stationary" even in the stationary field. In this way the strict separation between the two fields (ambulatory and stationary) will be overcome to a great extent. Taking into consideration the further changes brought by the health-care reform in the stationary field new ranges of action for hospitals, with their chances but also their risks, have to be expected.

Hospital-based, acute care after ambulatory surgery center discharge.

PubMed

Fox, Justin P; Vashi, Anita A; Ross, Joseph S; Gross, Cary P

2014-05-01

As a measure of quality, ambulatory surgery centers have begun reporting rates of hospital transfer at discharge. This process, however, may underestimate the acute care needs of patients after care. We conducted this study to determine rates and evaluate variation in hospital transfer and hospital-based, acute care within 7 days among patients discharged from ambulatory surgery centers. Using data from the Healthcare Cost and Utilization Project, we identified adult patients who underwent a medical or operative procedure between July 2008 and September 2009 at ambulatory surgery centers in California, Florida, and Nebraska. The primary outcomes were hospital transfer at the time of discharge and hospital-based, acute care (emergency department visits or hospital admissions) within 7-days expressed as the rate per 1,000 discharges. At the ambulatory surgery center level, rates were adjusted for age, sex, and procedure-mix. We studied 3,821,670 patients treated at 1,295 ambulatory surgery centers. At discharge, the hospital transfer rate was 1.1 per 1,000 discharges (95% confidence interval 1.1-1.1). Among patients discharged home, the hospital-based, acute care rate was 31.8 per 1,000 discharges (95% confidence interval 31.6-32.0). Across ambulatory surgery centers, there was little variation in adjusted hospital transfer rates (median = 1.0/1,000 discharges [25th-75th percentile = 1.0-2.0]), whereas substantial variation existed in adjusted, hospital-based, acute care rates (28.0/1,000 [21.0-39.0]). Among adult patients undergoing ambulatory care at surgery centers, hospital transfer at time of discharge from the ambulatory care center is a rare event. In contrast, the rate of need for hospital-based, acute care in the first week afterwards is nearly 30-fold greater, varies across centers, and may be a more meaningful measure for discriminating quality. Published by Mosby, Inc.

Ambulatory cleft lip surgery: A value analysis.

PubMed

Arneja, Jugpal S; Mitton, Craig

2013-01-01

Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost. To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced. A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair. On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada. The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.

Ambulatory vital signs in the workup of pulmonary embolism using a standardized 3-minute walk test.

PubMed

Amin, Qamar; Perry, Jeffrey J; Stiell, Ian G; Mohapatra, Subhra; Alsadoon, Abdulaziz; Rodger, Marc

2015-05-01

Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism. This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism. We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0). In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.

Comparison of laboratory and ambulatory measures of central blood pressure and pulse wave reflection: hitting the target or missing the mark?

PubMed

Burns, Matthew J; Seed, Jeremy D; Incognito, Anthony V; Doherty, Connor J; Notay, Karambir; Millar, Philip J

2018-04-01

Prior studies demonstrating clinical significance of noninvasive estimates of central blood pressure (BP) and pulse wave reflection have relied primarily on discrete resting measures. The aim of this study was to compare central BP and pulse wave reflection measures sampled during a single resting laboratory visit against those obtained under ambulatory conditions. The secondary aim was to investigate the reproducibility of ambulatory central BP and pulse wave reflection measurements. Forty healthy participants (21 males; 24 ± 3 years) completed three measurements of brachial artery pulse wave analysis (Oscar 2 with SphygmoCor Inside) in the laboratory followed by 24 hours of ambulatory monitoring. Seventeen participants repeated the 24-hour ambulatory monitoring visit after at least 1 week. Ambulatory measures were divided into daytime (9 AM-9 PM), nighttime (1 AM-6 AM), and 24-hour periods. Compared with laboratory measurements, central systolic BP, augmentation pressure, and augmentation index (with and without heart rate normalization) were higher (all P < .01) during daytime and 24-hour periods but lower during the nighttime period (all P < .001). The drop in nighttime brachial systolic BP was larger than central systolic pressure (Δ -20 ± 6 vs. -15 ± 6 mm Hg; P < .0001). Repeat ambulatory measurements of central BP and pulse wave reflection displayed good-to-excellent intraclass correlation coefficients (r = 0.58-0.86; all P < .01), although measures of pulse wave reflection had higher coefficients of variation (14%-41%). The results highlight absolute differences in central BP and pulse wave reflection between discrete laboratory and ambulatory conditions. The use of ambulatory measures of central BP and pulse wave reflection warrant further investigation for clinical prognostic value. Copyright © 2018 American Heart Association. Published by Elsevier Inc. All rights reserved.

Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality.

PubMed

Banegas, José R; Ruilope, Luis M; de la Sierra, Alejandro; Vinyoles, Ernest; Gorostidi, Manuel; de la Cruz, Juan J; Ruiz-Hurtado, Gema; Segura, Julián; Rodríguez-Artalejo, Fernando; Williams, Bryan

2018-04-19

Evidence for the influence of ambulatory blood pressure on prognosis derives mainly from population-based studies and a few relatively small clinical investigations. This study examined the associations of blood pressure measured in the clinic (clinic blood pressure) and 24-hour ambulatory blood pressure with all-cause and cardiovascular mortality in a large cohort of patients in primary care. We analyzed data from a registry-based, multicenter, national cohort that included 63,910 adults recruited from 2004 through 2014 in Spain. Clinic and 24-hour ambulatory blood-pressure data were examined in the following categories: sustained hypertension (elevated clinic and elevated 24-hour ambulatory blood pressure), "white-coat" hypertension (elevated clinic and normal 24-hour ambulatory blood pressure), masked hypertension (normal clinic and elevated 24-hour ambulatory blood pressure), and normotension (normal clinic and normal 24-hour ambulatory blood pressure). Analyses were conducted with Cox regression models, adjusted for clinic and 24-hour ambulatory blood pressures and for confounders. During a median follow-up of 4.7 years, 3808 patients died from any cause, and 1295 of these patients died from cardiovascular causes. In a model that included both 24-hour and clinic measurements, 24-hour systolic pressure was more strongly associated with all-cause mortality (hazard ratio, 1.58 per 1-SD increase in pressure; 95% confidence interval [CI], 1.56 to 1.60, after adjustment for clinic blood pressure) than the clinic systolic pressure (hazard ratio, 1.02; 95% CI, 1.00 to 1.04, after adjustment for 24-hour blood pressure). Corresponding hazard ratios per 1-SD increase in pressure were 1.55 (95% CI, 1.53 to 1.57, after adjustment for clinic and daytime blood pressures) for nighttime ambulatory systolic pressure and 1.54 (95% CI, 1.52 to 1.56, after adjustment for clinic and nighttime blood pressures) for daytime ambulatory systolic pressure. These relationships were consistent across subgroups of age, sex, and status with respect to obesity, diabetes, cardiovascular disease, and antihypertensive treatment. Masked hypertension was more strongly associated with all-cause mortality (hazard ratio, 2.83; 95% CI, 2.12 to 3.79) than sustained hypertension (hazard ratio, 1.80; 95% CI, 1.41 to 2.31) or white-coat hypertension (hazard ratio, 1.79; 95% CI, 1.38 to 2.32). Results for cardiovascular mortality were similar to those for all-cause mortality. Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension. (Funded by the Spanish Society of Hypertension and others.).

Losing the struggle to stay awake: divergent thalamic and cortical activity during microsleeps.

PubMed

Poudel, Govinda R; Innes, Carrie R H; Bones, Philip J; Watts, Richard; Jones, Richard D

2014-01-01

Maintaining alertness is critical for safe and successful performance of most human activities. Consequently, microsleeps during continuous visuomotor tasks, such as driving, can be very serious, not only disrupting performance but sometimes leading to injury or death due to accidents. We have investigated the neural activity underlying behavioral microsleeps--brief (0.5-15 s) episodes of complete failure to respond accompanied by slow eye-closures--and EEG theta activity during drowsiness in a continuous task. Twenty healthy normally-rested participants performed a 50-min continuous tracking task while fMRI, EEG, eye-video, and responses were simultaneously recorded. Visual rating of performance and eye-video revealed that 70% of the participants had frequent microsleeps. fMRI analysis revealed a transient decrease in thalamic, posterior cingulate, and occipital cortex activity and an increase in frontal, posterior parietal, and parahippocampal activity during microsleeps. The transient activity was modulated by the duration of the microsleep. In subjects with frequent microsleeps, power in the post-central EEG theta was positively correlated with the BOLD signal in the thalamus, basal forebrain, and visual, posterior parietal, and prefrontal cortices. These results provide evidence for distinct neural changes associated with microsleeps and with EEG theta activity during drowsiness in a continuous task. They also suggest that the occurrence of microsleeps during an active task is not a global deactivation process but involves localized activation of fronto-parietal cortex, which, despite a transient loss of arousal, may constitute a mechanism by which these regions try to restore responsiveness. Copyright © 2012 Wiley Periodicals, Inc.

Military Health Service System Ambulatory Work Unit (AWU).

DTIC Science & Technology

1988-04-01

E-40 BBC-4 Ambulatory Work Unit Distribution Screen Passes BBC - Neurosurgery Clinic .... ............. . E-40 BBD -I Initial Record...Screen Failures BBD - Ophthalmology Clinic ... ............ E-41 BBD -2 Distribution Screen Failures BBD - Ophthalmology Clinic ............ E-41 BBD -3...Descriptive Statistics Distribution Screen Passes BBD - Ophthalmology Clinic ............ E-42 BBD -4 Ambulatory Work Unit Distribution Screen Passes BBD

Anchorage condition during canine retraction using transpalatal arch with continuous and segmented arch mechanics.

PubMed

Alhadlaq, Adel; Alkhadra, Thamer; El-Bialy, Tarek

2016-05-01

To compare anchorage condition in cases in which transpalatal arch was used to enhance anchorage in both continuous and segmented arch techniques. Twenty cases that required first premolar extraction for orthodontic treatment and transpalatal arch to enhance anchorage were included in this study. Ten cases were treated using the continuous arch technique, while the other 10 cases were treated using 0.019 × 0.025-inch TMA T-loops with posterior anchorage bend according to the Burstone and Marcotte description. Lateral cephalometric analysis of before and after canine retraction was performed using Ricketts analysis to measure the anteroposterior position of the upper first molar to the vertical line from the Pt point. Data were analyzed using an independent sample t-test. There was a statistically significant forward movement of the upper first molar in cases treated by continuous arch mechanics (4.5 ± 3.0 mm) compared with segmented arch mechanics (-0.7 ± 1.4 mm; P  =  .01). The posterior anchorage bend to T-loop used to retract the maxillary canine can enhance anchorage during maxillary canine retraction.

The Influence of Ambulatory Aid on Lower-Extremity Muscle Activation During Gait.

PubMed

Sanders, Michael; Bowden, Anton E; Baker, Spencer; Jensen, Ryan; Nichols, McKenzie; Seeley, Matthew K

2018-05-10

Foot and ankle injuries are common and often require a nonweight-bearing period of immobilization for the involved leg. This nonweight-bearing period usually results in muscle atrophy for the involved leg. There is a dearth of objective data describing muscle activation for different ambulatory aids that are used during the aforementioned nonweight-bearing period. To compare activation amplitudes for 4 leg muscles during (1) able-bodied gait and (2) ambulation involving 3 different ambulatory aids that can be used during the acute phase of foot and ankle injury care. Within-subject, repeated measures. University biomechanics laboratory. Sixteen able-bodied individuals (7 females and 9 males). Each participant performed able-bodied gait and ambulation using 3 different ambulatory aids (traditional axillary crutches, knee scooter, and a novel lower-leg prosthesis). Muscle activation amplitude quantified via mean surface electromyography amplitude throughout the stance phase of ambulation. Numerous statistical differences (P < .05) existed for muscle activation amplitude between the 4 observed muscles, 3 ambulatory aids, and able-bodied gait. For the involved leg, comparing the 3 ambulatory aids: (1) knee scooter ambulation resulted in the greatest vastus lateralis activation, (2) ambulation using the novel prosthesis and traditional crutches resulted in greater biceps femoris activation than knee scooter ambulation, and (3) ambulation using the novel prosthesis resulted in the greatest gastrocnemius activation (P < .05). Generally speaking, muscle activation amplitudes were most similar to able-bodied gait when subjects were ambulating using the knee scooter or novel prosthesis. Type of ambulatory aid influences muscle activation amplitude. Traditional axillary crutches appear to be less likely to mitigate muscle atrophy during the nonweighting, immobilization period that often follows foot or ankle injuries. Researchers and clinicians should consider these results when recommending ambulatory aids for foot or ankle injuries.

Surgical Site Infections Following Pediatric Ambulatory Surgery: An Epidemiologic Analysis.

PubMed

Rinke, Michael L; Jan, Dominique; Nassim, Janelle; Choi, Jaeun; Choi, Steven J

2016-08-01

OBJECTIVE To identify surgical site infection (SSI) rates following pediatric ambulatory surgery, SSI outcomes and risk factors, and sensitivity and specificity of SSI administrative billing codes. DESIGN Retrospective chart review of pediatric ambulatory surgeries with International Classification of Disease, Ninth Revision (ICD-9) codes for SSI, and a systematic random sampling of 5% of surgeries without SSI ICD-9 codes, all adjudicated for SSI on the basis of an ambulatory-adapted National Healthcare Safety Network definition. SETTING Urban pediatric tertiary care center April 1, 2009-March 31, 2014. METHODS SSI rates and sensitivity and specificity of ICD-9 codes were estimated using sampling design, and risk factors were analyzed in case-rest of cohort, and case-control, designs. RESULTS In 15,448 pediatric ambulatory surgeries, 34 patients had ICD-9 codes for SSI and 25 met the adapted National Healthcare Safety Network criteria. One additional SSI was identified with systematic random sampling. The SSI rate following pediatric ambulatory surgery was 2.9 per 1,000 surgeries (95% CI, 1.2-6.9). Otolaryngology surgeries demonstrated significantly lower SSI rates compared with endocrine (P=.001), integumentary (P=.001), male genital (P<.0001), and respiratory (P=.01) surgeries. Almost half of patients with an SSI were admitted, 88% received antibiotics, and 15% returned to the operating room. No risk factors were associated with SSI. The sensitivity of ICD-9 codes for SSI following ambulatory surgery was 55.31% (95% CI, 12.69%-91.33%) and specificity was 99.94% (99.89%-99.97%). CONCLUSIONS SSI following pediatric ambulatory surgery occurs at an appreciable rate and conveys morbidity on children. Infect Control Hosp Epidemiol 2016;37:931-938.

[Pre-hospital adverse events: a way to go].

PubMed

Alvarez-Ortiz, Nancy Jezzi; Aranaz Andrés, Jesús María; Gea Velázquez De Castro, María Teresa; Miralles Bueno, Juan José

2010-01-01

The occurrence of adverse events is a problem at all levels of care and creates a significant burden of morbidity and mortality. In Spain there have been significant investigations of adverse effects (AE) in hospitals and primary care, however, studies of pre-hospital care are not yet developed. The aim of this study was to determine the frequency, type, preventability, severity and impact of "pre-hospital" adverse events, which were detected in the hospitalization index and the comparing those that occurred in ambulatory and non-ambulatory care. Case Series Study, with analytical components, of a sample of subjects included in the "National study of adverse events related to hospitalization (ENEAS). Qualitative data are presented as proportions with confidence intervals. For comparative analysis of qualitative data, we used the chi-square test. Of a total of 5624 patients, 2.3% (N=131) ((95%)CI: 1.94-2.72) had an AE that occurred prior to hospitalization or "pre-hospital", and 40.5% of these (N=53) ((95%)CI: 32.05-48.86) were preventable. In 44 patients the AE had its origin in ambulatory care and 85 patients in non-ambulatory care. The characteristic of patients with ambulatory AE are men and older women (median 76 years) who consulted for medical problems (84.1%) and the AE were related to medication in 77.8%. The characteristic of patients with non-ambulatory AE, were men (median 73 years), consulting for medical and surgical problems (44,7-55,3%) and the EA is related to medications, infections and procedures. The characteristics of patients with AE and undesirable effects that occurred during pre-hospitalization period depended on whether they originated during ambulatory care or non-ambulatory care. Therefore prevention strategies should take these differences into account. Copyright 2009 SECA. Published by Elsevier Espana. All rights reserved.

Benzodiazepine Prescribing in Older Adults in U.S. Ambulatory Clinics and Emergency Departments (2001-10).

PubMed

Marra, Erin M; Mazer-Amirshahi, Maryann; Brooks, Gillian; van den Anker, John; May, Larissa; Pines, Jesse M

2015-10-01

To assess trends in benzodiazepine use from 2001 to 2010 in older adults in U.S. ambulatory clinics and emergency departments (EDs). Retrospective analysis. 2001 to 2010 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Individuals aged 65 and older for whom the reason for visit might prompt a physician to use a benzodiazepine (e.g., anxiety, detoxification, back sprain). The NAMCS and NHAMCS were used to evaluate U.S. ambulatory clinic and ED visits. Encounters involving individuals aged 65 and older for whom a benzodiazepine might be prescribed were analyzed. Trends in benzodiazepine use in these visits were explored, and predictors of use were assessed using survey-weighted chi-square tests and logistic regression. From 2001 to 2010, benzodiazepines were used in 16.6 million of 133.3 million ambulatory clinic visits and 1.9 million of 18.1 million ED visits with the selected reasons for the visits. There was no change in benzodiazepine use in either setting over the study period, although benzodiazepine use for those aged 85 and older increased from 8.9% to 19.3% in ambulatory clinics and 10.1% to 17.2% in EDs. Individuals visiting clinics with anxiety were five times as likely to receive benzodiazepines (odds ratio (OR) = 4.8), and those in EDs were twice as likely (OR = 2.3). Despite safety concerns, benzodiazepine use in older adults in U.S. ambulatory clinics and EDs did not change from 2001 to 2010. In the oldest individuals, who are at higher risk of adverse events, a greater increase was seen than in those aged 65 to 84. Additional measures may be needed to promote alternatives to benzodiazepines. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

Design of a wearable bio-patch for monitoring patient's temperature.

PubMed

Vicente, Jose M; Avila-Navarro, Ernesto; Juan, Carlos G; Garcia, Nicolas; Sabater-Navarro, Jose M

2016-08-01

New communication technologies allow us developing useful and more practical medical applications, in particular for ambulatory monitoring. NFC communication has the advantages of low powering and low influence range area, what makes this technology suitable for health applications. This work presents an explanation of the design process of planar NFC antennas in a wearable biopatch. The problem of optimizing the communication distance is addressed. Design of a biopatch for continuous temperature monitoring and experimental results obtained wearing this biopatch during daily activities are presented.

Coleman during ICV Assessment in the Kibo JPM during Expedition 26

NASA Image and Video Library

2011-01-07

ISS026-E-015923 (7 Jan. 2011) --- NASA astronaut Catherine (Cady) Coleman, Expedition 26 flight engineer, participates in the ambulatory monitoring part of the Integrated Cardiovascular (ICV) assessment research experiment in the Kibo laboratory of the International Space Station. Coleman is wearing electrodes, a Holter Monitor 2 (HM2) for recording Electrocardiogram (ECG), a European Space Agency (ESA) Cardio pressure / Blood Pressure unit to continuously monitor blood pressure and two Actiwatches (hip/waist and ankle) for monitoring activity levels.

Caseload management skills for improved efficiency.

PubMed

Ervin, Naomi E

2008-03-01

This article provides information about caseload management, which was one of a group of six competencies identified by nurse administrators as needed by new baccalaureate graduates. Caseload management is an important skill for nurses who work with caseloads of patients or clients (e.g., home health nurses, public health nurses, case managers, ambulatory care nurses). Because inadequate information about caseload management is contained in community health nursing textbooks, continuing education and staff development programs need to include caseload management skills to improve the efficiency and quality of nursing care.

The value of registered nurses in ambulatory care settings: a survey.

PubMed

Mastal, Margaret; Levine, June

2012-01-01

Ambulatory care settings employ 25% of the three million registered nurses in the United States. The American Academy of Ambulatory Care Nursing (AAACN) is committed to improving the quality of health care in ambulatory settings, enhancing patient outcomes, and realizing greater health care efficiencies. A survey of ambulatory care registered nurses indicates they are well positioned to lead and facilitate health care reform activities with organizational colleagues. They are well schooled in critical thinking, triage, advocating for patients, educating patients and families, collaborating with medical staff and other professionals, and care coordination. The evolving medical home concept and other health care delivery models reinforces the critical need for registered nurses to provide chronic disease management, care coordination, health risk appraisal, care transitions, health promotion, and disease prevention services. Recommendations are offered for organizational leaders, registered nurses, and AAACN to utilize nursing knowledge and skills in the pursuit of leading change and advancing health.

Development of Quality Metrics in Ambulatory Pediatric Cardiology.

PubMed

Chowdhury, Devyani; Gurvitz, Michelle; Marelli, Ariane; Anderson, Jeffrey; Baker-Smith, Carissa; Diab, Karim A; Edwards, Thomas C; Hougen, Tom; Jedeikin, Roy; Johnson, Jonathan N; Karpawich, Peter; Lai, Wyman; Lu, Jimmy C; Mitchell, Stephanie; Newburger, Jane W; Penny, Daniel J; Portman, Michael A; Satou, Gary; Teitel, David; Villafane, Juan; Williams, Roberta; Jenkins, Kathy

2017-02-07

The American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Section had attempted to create quality metrics (QM) for ambulatory pediatric practice, but limited evidence made the process difficult. The ACPC sought to develop QMs for ambulatory pediatric cardiology practice. Five areas of interest were identified, and QMs were developed in a 2-step review process. In the first step, an expert panel, using the modified RAND-UCLA methodology, rated each QM for feasibility and validity. The second step sought input from ACPC Section members; final approval was by a vote of the ACPC Council. Work groups proposed a total of 44 QMs. Thirty-one metrics passed the RAND process and, after the open comment period, the ACPC council approved 18 metrics. The project resulted in successful development of QMs in ambulatory pediatric cardiology for a range of ambulatory domains. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Benefits of a Continuous Ambulatory Peritoneal Dialysis (CAPD) Technique with One Icodextrin-Containing and Two Biocompatible Glucose-Containing Dialysates for Preservation of Residual Renal Function and Biocompatibility in Incident CAPD Patients

PubMed Central

2014-01-01

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Δ1.2±2.9 mL/min/1.73 m2, P=0.027) and urine volume (-Δ363.6±543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Δ0.5±2.7 mL/min/1.73 m2, P=0.266; -Δ108.6±543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, β2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549] Graphical Abstract PMID:25246739

Continuous ambulatory peritoneal dialysis: perspectives on patient selection in low- to middle-income countries

PubMed Central

Wearne, Nicola; Kilonzo, Kajiru; Effa, Emmanuel; Davidson, Bianca; Nourse, Peter; Ekrikpo, Udeme; Okpechi, Ikechi G

2017-01-01

Chronic kidney disease is a major public health problem that continues to show an unrelenting global increase in prevalence. The prevalence of chronic kidney disease has been predicted to grow the fastest in low- to middle-income countries (LMICs). There is evidence that people living in LMICs have the highest need for renal replacement therapy (RRT) despite the lowest access to various modalities of treatment. As continuous ambulatory peritoneal dialysis (CAPD) does not require advanced technologies, much infrastructure, or need for dialysis staff support, it should be an ideal form of RRT in LMICs, particularly for those living in remote areas. However, CAPD is scarcely available in many LMICs, and even where available, there are several hurdles to be confronted regarding patient selection for this modality. High cost of CAPD due to unavailability of fluids, low patient education and motivation, low remuneration for nephrologists, lack of expertise/experience for catheter insertion and management of complications, presence of associated comorbid diseases, and various socio-demographic factors contribute significantly toward reduced patient selection for CAPD. Cost of CAPD fluids seems to be a major constraint given that many countries do not have the capacity to manufacture fluids but instead rely heavily on fluids imported from developed countries. There is need to invest in fluid manufacturing (either nationally or regionally) in LMICs to improve uptake of patients treated with CAPD. Workforce training and retraining will be necessary to ensure that there is coordination of CAPD programs and increase the use of protocols designed to improve CAPD outcomes such as insertion of catheters, treatment of peritonitis, and treatment of complications associated with CAPD. Training of nephrology workforce in CAPD will increase workforce experience and make CAPD a more acceptable RRT modality with improved outcomes. PMID:28115864

Return on Investment for the Baccalaureate-Prepared RN in Ambulatory Care.

PubMed

Zolotorofe, Irene; Fortini, Robert; Hash, Pam; Daniels, Angel; Orsolini, Liana; Mazzoccoli, Andrea; Gerardi, Tina

2018-03-01

Evidence supports the return on investment for an RN in ambulatory care. Utilizing RNs to their fullest potential in ambulatory practices is essential to effectively manage population health. Bon Secours Health System launched a new role, patient navigator RNs, to ensure seamless transitions of complex patients across care settings, resulting in better patient outcomes and a financial return.

Ambulatory Voice Biofeedback: Relative Frequency and Summary Feedback Effects on Performance and Retention of Reduced Vocal Intensity in the Daily Lives of Participants with Normal Voices

ERIC Educational Resources Information Center

Van Stan, Jarrad H.; Mehta, Daryush D.; Sternad, Dagmar; Petit, Robert; Hillman, Robert E.

2017-01-01

Purpose: Ambulatory voice biofeedback has the potential to significantly improve voice therapy effectiveness by targeting carryover of desired behaviors outside the therapy session (i.e., retention). This study applies motor learning concepts (reduced frequency and delayed, summary feedback) that demonstrate increased retention to ambulatory voice…

[Considerations on local-regional anesthesia for ambulatory tooth extractions in patients with heart disease].

PubMed

Debernardi, G; Borgogna, E

1975-01-01

Ambulatory dental extraction was performed on 150 patients with various forms of heart disease. No serious complications were noted with an anaesthetic without vasoconstriction (plain 3% carbocaine). The prior history was carefully studied and pressure values were determined. It is felt that heart disease does not form an absolute contraindication to ambulatory dental extraction.

Contact Kinematics Correlates to Tibial Component Migration Following Single Radius Posterior Stabilized Knee Replacement.

PubMed

Teeter, Matthew G; Perry, Kevin I; Yuan, Xunhua; Howard, James L; Lanting, Brent A

2018-03-01

Contact kinematics between total knee arthroplasty components is thought to affect implant migration; however, the interaction between kinematics and tibial component migration has not been thoroughly examined in a modern implant system. A total of 24 knees from 23 patients undergoing total knee arthroplasty with a single radius, posterior stabilized implant were examined. Patients underwent radiostereometric analysis at 2 and 6 weeks, 3 and 6 months, and 1 and 2 years to measure migration of the tibial component in all planes. At 1 year, patients also had standing radiostereometric analysis examinations acquired in 0°, 20°, 40°, and 60° of flexion, and the location of contact and magnitude of any condylar liftoff was measured for each flexion angle. Regression analysis was performed between kinematic variables and migration at 1 year. The average magnitude of maximum total point motion across all patients was 0.671 ± 0.270 mm at 1 year and 0.608 ± 0.359 mm at 2 years (P = .327). Four implants demonstrated continuous migration of >0.2 mm between the first and second year of implantation. There were correlations between the location of contact and tibial component anterior-posterior tilt, varus-valgus tilt, and anterior-posterior translation. The patients with continuous migration demonstrated atypical kinematics and condylar liftoff in some instances. Kinematics can influence tibial component migration, likely through alterations of force transmission. Abnormal kinematics may play a role in long-term implant loosening. Copyright © 2017 Elsevier Inc. All rights reserved.

What Ambulatory Care Managers Need to Know About Examination Room Utilization Measurement and Analysis.

PubMed

Klarich, Mark J; Rea, Ronald W; Lal, Tarun Mohan; Garcia, Angel L; Steffens, Fay L

2016-01-01

Demand for ambulatory care visits is projected to increase 22% between 2008 and 2025. Given this growth, ambulatory care managers need to proactively plan for efficient use of scarce resources (ie, space, equipment, and staff). One important component of ambulatory care space (the number of examination rooms) is dependent on multiple factors, including variation in demand, hours of operation, scheduling, and staff. The authors (1) outline common data collection methods, (2) highlight analysis and reporting considerations for examination room utilization, and (3) provide a strategic framework for short- and long-term decision making for facility design or renovation.

Ambulatory surgery and anaesthesia in HUKM, a teaching hospital in Malaysia: the first two years experience.

PubMed

Norsidah, A M; Yahya, N; Adeeb, N; Lim, A L

2001-03-01

Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.

The use of ambulatory blood pressure monitoring to confirm a diagnosis of high blood pressure by primary-care physicians in Oregon.

PubMed

Carter, Brittany U; Kaylor, Mary Beth

2016-04-01

Hypertension is the most commonly diagnosed medical condition in the USA. Unfortunately, patients are misdiagnosed in primary care because of inaccurate office-based blood pressure measurements. Several US healthcare organizations currently recommend confirming an office-based hypertension diagnosis with ambulatory blood pressure monitoring to avoid overtreatment; however, its use for the purpose of confirming an office-based hypertension diagnosis is relatively unknown. This descriptive study surveyed 143 primary-care physicians in Oregon with regard to their current use of ambulatory blood pressure monitoring. Nineteen percent of the physicians reported that they would use ambulatory blood pressure monitoring to confirm an office-based hypertension diagnosis, although over half had never ordered it. The most frequent indication for ordering ambulatory blood pressure monitoring was to investigate suspected white-coat hypertension (37.3%). In addition, many of the practices did not own an ambulatory blood pressure monitoring device (79.7%) and, therefore, had to refer patients to other clinics or departments for testing. Many primary-care physicians will need to change their current clinical practice to align with the shift toward a confirmation process for office-based hypertension diagnoses to improve population health.

Automated recording of home cage activity and temperature of individual rats housed in social groups: The Rodent Big Brother project

PubMed Central

Tse, Karen; Grant, Claire; Keerie, Amy; Simpson, David J.; Pedersen, John C.; Rimmer, Victoria; Leslie, Lauren; Klein, Stephanie K.; Karp, Natasha A.; Sillito, Rowland; Chartsias, Agis; Lukins, Tim; Heward, James; Vickers, Catherine; Chapman, Kathryn; Armstrong, J. Douglas

2017-01-01

Measuring the activity and temperature of rats is commonly required in biomedical research. Conventional approaches necessitate single housing, which affects their behavior and wellbeing. We have used a subcutaneous radiofrequency identification (RFID) transponder to measure ambulatory activity and temperature of individual rats when group-housed in conventional, rack-mounted home cages. The transponder location and temperature is detected by a matrix of antennae in a baseplate under the cage. An infrared high-definition camera acquires side-view video of the cage and also enables automated detection of vertical activity. Validation studies showed that baseplate-derived ambulatory activity correlated well with manual tracking and with side-view whole-cage video pixel movement. This technology enables individual behavioral and temperature data to be acquired continuously from group-housed rats in their familiar, home cage environment. We demonstrate its ability to reliably detect naturally occurring behavioral effects, extending beyond the capabilities of routine observational tests and conventional monitoring equipment. It has numerous potential applications including safety pharmacology, toxicology, circadian biology, disease models and drug discovery. PMID:28877172

The APA/HRSA Faculty Development Scholars Program: introduction to the supplement.

PubMed

Osborn, Lucy M; Roberts, Kenneth B; Greenberg, Larrie; DeWitt, Tom; Devries, Jeffrey M; Wilson, Modena; Simpson, Deborah E

2004-01-01

The purpose of this project was to improve pediatric primary care medical education by providing faculty development for full-time and community-based faculty who teach general pediatrics to medical students and/or residents in ambulatory pediatric community-based settings. Funding for the program came through an interagency agreement with the Health Resources and Services Administration (HRSA) and the Agency for Healthcare Research and Quality (AHRQ). A train-the-trainer model was used to train 112 scholars who could teach skills to general pediatric faculty across the nation. The three scholar groups focused on community-based ambulatory teaching; educational scholarship; and executive leadership. Scholars felt well prepared to deliver faculty development programs in their home institutions and regions. They presented 599 workshops to 7989 participants during the course of the contract. More than 50% of scholars assumed positions of leadership, and most reported increased support for medical education in their local and regional environments. This national pediatric faculty development program pioneered in the development of a new training model and should guide training of new scholars and advanced and continuing training for those who complete a basic program.

An ultra low energy biomedical signal processing system operating at near-threshold.

PubMed

Hulzink, J; Konijnenburg, M; Ashouei, M; Breeschoten, A; Berset, T; Huisken, J; Stuyt, J; de Groot, H; Barat, F; David, J; Van Ginderdeuren, J

2011-12-01

This paper presents a voltage-scalable digital signal processing system designed for the use in a wireless sensor node (WSN) for ambulatory monitoring of biomedical signals. To fulfill the requirements of ambulatory monitoring, power consumption, which directly translates to the WSN battery lifetime and size, must be kept as low as possible. The proposed processing platform is an event-driven system with resources to run applications with different degrees of complexity in an energy-aware way. The architecture uses effective system partitioning to enable duty cycling, single instruction multiple data (SIMD) instructions, power gating, voltage scaling, multiple clock domains, multiple voltage domains, and extensive clock gating. It provides an alternative processing platform where the power and performance can be scaled to adapt to the application need. A case study on a continuous wavelet transform (CWT)-based heart-beat detection shows that the platform not only preserves the sensitivity and positive predictivity of the algorithm but also achieves the lowest energy/sample for ElectroCardioGram (ECG) heart-beat detection publicly reported today.

Automated recording of home cage activity and temperature of individual rats housed in social groups: The Rodent Big Brother project.

PubMed

Redfern, William S; Tse, Karen; Grant, Claire; Keerie, Amy; Simpson, David J; Pedersen, John C; Rimmer, Victoria; Leslie, Lauren; Klein, Stephanie K; Karp, Natasha A; Sillito, Rowland; Chartsias, Agis; Lukins, Tim; Heward, James; Vickers, Catherine; Chapman, Kathryn; Armstrong, J Douglas

2017-01-01

Measuring the activity and temperature of rats is commonly required in biomedical research. Conventional approaches necessitate single housing, which affects their behavior and wellbeing. We have used a subcutaneous radiofrequency identification (RFID) transponder to measure ambulatory activity and temperature of individual rats when group-housed in conventional, rack-mounted home cages. The transponder location and temperature is detected by a matrix of antennae in a baseplate under the cage. An infrared high-definition camera acquires side-view video of the cage and also enables automated detection of vertical activity. Validation studies showed that baseplate-derived ambulatory activity correlated well with manual tracking and with side-view whole-cage video pixel movement. This technology enables individual behavioral and temperature data to be acquired continuously from group-housed rats in their familiar, home cage environment. We demonstrate its ability to reliably detect naturally occurring behavioral effects, extending beyond the capabilities of routine observational tests and conventional monitoring equipment. It has numerous potential applications including safety pharmacology, toxicology, circadian biology, disease models and drug discovery.

Collecting Practice-level Data in a Changing Physician Office-based Ambulatory Care Environment: A Pilot Study Examining the Physician induction interview Component of the National Ambulatory Medical Care Survey.

PubMed

Halley, Meghan C; Rendle, Katharine A; Gugerty, Brian; Lau, Denys T; Luft, Harold S; Gillespie, Katherine A

2017-11-01

Objective This report examines ways to improve National Ambulatory Medical Care Survey (NAMCS) data on practice and physician characteristics in multispecialty group practices. Methods From February to April 2013, the National Center for Health Statistics (NCHS) conducted a pilot study to observe the collection of the NAMCS physician interview information component in a large multispecialty group practice. Nine physicians were randomly sampled using standard NAMCS recruitment procedures; eight were eligible and agreed to participate. Using standard protocols, three field representatives conducted NAMCS physician induction interviews (PIIs) while trained ethnographers observed and audio recorded the interviews. Transcripts and field notes were analyzed to identify recurrent issues in the data collection process. Results The majority of the NAMCS items appeared to have been easily answered by the physician respondents. Among the items that appeared to be difficult to answer, three themes emerged: (a) physician respondents demonstrated an inconsistent understanding of "location" in responding to questions; (b) lack of familiarity with administrative matters made certain questions difficult for physicians to answer; and (c) certain primary care‑oriented questions were not relevant to specialty care providers. Conclusions Some PII survey questions were challenging for physicians in a multispecialty practice setting. Improving the design and administration of NAMCS data collection is part of NCHS' continuous quality improvement process. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.

Impact of pharmacist interventions on cost avoidance in an ambulatory cancer center.

PubMed

Randolph, Laura A; Walker, Cheri K; Nguyen, Ann T; Zachariah, Subi R

2018-01-01

Objective To provide a foundation to justify the presence of a full-time clinical pharmacist in the ambulatory cancer center in addition to an existing centralized pharmacist through cost avoidance calculation and patient and staff satisfaction surveys. Methods The prospective, pilot study took place in an ambulatory cancer center over four weeks in 2014. Cost avoidance values were assigned to interventions performed by a pharmacy resident, who was present in the ambulatory cancer center during clinic hours, along with a centralized oncology pharmacist routinely working with the cancer center. Anonymous patient and staff satisfaction surveys based on a 5-point Likert scale were distributed to assess the perceived benefit of a pharmacist located in the ambulatory cancer center. Results Data collection took place over approximately one month. After evaluation of 962 interventions from both pharmacists, the estimated cost avoidance was US$282,741 per pharmacist per year, yielding a net benefit of US$138,441. The most common interventions made by the resident included chemotherapy regimen review (n = 290, 69%) and patient counseling (n = 102, 24%), while the majority of the centralized pharmacist's interventions was chemotherapy regimen review (n = 525, 97%). Results from the anonymous patient and staff surveys revealed an overall positive perception of the pharmacy resident while in the ambulatory cancer center. Conclusion A full-time clinical pharmacist in an ambulatory cancer center is both financially beneficial and positively perceived by patients and staff.

Unanticipated hospital admission in pediatric patients with congenital heart disease undergoing ambulatory noncardiac surgical procedures.

PubMed

Yuki, Koichi; Koutsogiannaki, Sophia; Lee, Sandra; DiNardo, James A

2018-05-18

An increasing number of surgical and nonsurgical procedures are being performed on an ambulatory basis in children. Analysis of a large group of pediatric patients with congenital heart disease undergoing ambulatory procedures has not been undertaken. The objective of this study was to characterize the profile of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis at our institution, to determine the incidence of adverse cardiovascular and respiratory adverse events, and to determine the risk factors for unscheduled hospital admission. This is a retrospective study of children with congenital heart disease who underwent noncardiac procedures on an ambulatory basis in a single center. Using the electronic preoperative anesthesia evaluation form, we identified 3010 patients with congenital heart disease who underwent noncardiac procedures of which 1028 (34.1%) were scheduled to occur on an ambulatory basis. Demographic, echocardiographic and functional status data, cardiovascular and respiratory adverse events, and reasons for postprocedure admission were recorded. Univariable analysis was conducted. The unplanned hospital admission was 2.7% and univariable analysis demonstrated that performance of an echocardiogram within 6 mo of the procedure and procedures performed in radiology were associated with postoperative admission. Cardiovascular adverse event incidence was 3.9%. Respiratory adverse event incidence was 1.8%. Ambulatory, noncomplex procedures can be performed in pediatric patients with congenital heart disease and good functional status with a relatively low unanticipated hospital admission rate. © 2018 John Wiley & Sons Ltd.

Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study.

PubMed

Gaillard, M; Tranchart, H; Lainas, P; Tzanis, D; Franco, D; Dagher, I

2015-11-01

Over the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS. Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. Twenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10). This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Current state of continuous ambulatory peritoneal dialysis in Egypt.

PubMed

Elzorkany, Khaled Mohamed Amin

2017-01-01

Patients with end-stage renal disease (ESRD) continue to increase in number worldwide, especially in developing countries. Although continuous ambulatory peritoneal dialysis (CAPD) has comparable survival advantages as hemodialysis (HD), it is greatly underutilized in many regions worldwide. The prevalence of use of CAPD in Egypt is 0.29/million population in 2017. The aim of this study is to describe the current state and practice of CAPD in Egypt and included 22 adult patients who were treated by CAPD. All the study patients were switched to CAPD after treatment with HD failed due to vascular access problems. Patients were mainly female (68.2 %) with the mean age of 49.77 ± 11.41 years. The average duration on CAPD was 1.76 ± 1.30 years. Hypertension was the main cause of end-stage renal disease (ESRD) constituting 36.4%, followed by diabetes (27.3 %), and toxic nephropathy (4.5%). Of importance is that about 31.8% of patients had ESRD of unknown etiology. The mean weekly Kt/V urea of patients on PD was 1.92 ± 0.18. The mean hemoglobin, serum calcium, phosphorus, parathormone, and albumin levels were 10.27 ± 1.98 g/dL, 8.36 ± 1.19 mg/dL, 5.70 ± 1.35 mg/dL, 541.18 ± 230.12 pg/mL, and 2.98 ± 0.73 g/dL, respectively. There was no significant difference between diabetic and nondiabetic CAPD patients regarding demographic and laboratory data. Our data indicate that there is continuing underutilization of CAPD in Egypt which may be related to nonavailability of CAPD fluid, patient factors (education and motivation), gradual decline of the efficiency of health-care professionals, and lack of a national program to start PD as the first modality for renal replacement therapy. It is advised to start an organized program to make CAPD widespread and encourage local production of PD fluids to reduce the cost of CAPD.

Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study.

PubMed

Whippey, Amanda; Kostandoff, Greg; Paul, James; Ma, Jinhui; Thabane, Lehana; Ma, Heung Kan

2013-07-01

The primary objectives of this historical case-control study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery. A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists' (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions. The incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] 16.70; 95% confidence interval [CI] 4.10 to 67.99) and length of surgery more than three hours (OR 4.26; 95% CI 2.40 to 7.55); ASA class III (OR 4.60; 95% CI 1.81 to 11.68); ASA class IV (OR 6.51; 95% CI 1.66 to 25.59); advanced age (> 80 yr) (OR 5.41; 95% CI 1.54 to 19.01); and body mass index (BMI) of 30-35 (OR 2.81; 95% CI 1.31 to 6.04). Current smoking status was found to be associated with a decreased likelihood of unanticipated admission (OR 0.44; 95% CI 0.23 to 0.83), as was monitored anesthesia care when compared with general anesthesia (OR 0.17; 95% CI 0.04 to 0.68) and plastic (OR 0.18; 95% CI 0.07 to 0.50), orthopedic (OR 0.16; 95% CI 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact unanticipated admission. Unanticipated admission after ambulatory surgery occurs mainly due to surgical, anesthetic, and medical complications. Length of surgery more than one hour, high ASA class, advanced age, and increased BMI were all predictors. No specific comorbid illness was associated with an increased likelihood of unanticipated admission. These findings support continued use of the ASA classification as a marker of patient perioperative risk rather than attributing risk to a specific disease process.

Diurnal and menstrual cycles in body temperature are regulated differently: a 28-day ambulatory study in healthy women with thermal discomfort of cold extremities and controls.

PubMed

Kräuchi, Kurt; Konieczka, Katarzyna; Roescheisen-Weich, Corina; Gompper, Britta; Hauenstein, Daniela; Schoetzau, Andreas; Fraenkl, Stephan; Flammer, Josef

2014-02-01

Diurnal cycle variations in body-heat loss and heat production, and their resulting core body temperature (CBT), are relatively well investigated; however, little is known about their variations across the menstrual cycle under ambulatory conditions. The main purpose of this study was to determine whether menstrual cycle variations in distal and proximal skin temperatures exhibit similar patterns to those of diurnal variations, with lower internal heat conductance when CBT is high, i.e. during the luteal phase. Furthermore, we tested these relationships in two groups of women, with and without thermal discomfort of cold extremities (TDCE). In total, 19 healthy eumenorrheic women with regular menstrual cycles (28-32 days), 9 with habitual TDCE (ages 29 ± 1.5 year; BMI 20.1 ± 0.4) and 10 controls without these symptoms (CON: aged 27 ± 0.8 year; BMI 22.7 ± 0.6; p < 0.004 different to TDCE) took part in the study. Twenty-eight days continuous ambulatory skin temperature measurements of distal (mean of hands and feet) and proximal (mean of sternum and infraclavicular regions) skin regions, thighs, and calves were carried out under real-life, ambulatory conditions (i-Buttons® skin probes, sampling rate: 2.5 min). The distal minus proximal skin temperature gradient (DPG) provided a valuable measure for heat redistribution from the core to the shell, and, hence, for internal heat conduction. Additionally, basal body temperature was measured sublingually directly after waking up in bed. Mean diurnal amplitudes in skin temperatures increased from proximal to distal skin regions and the 24-h mean values were inversely related. TDCE compared to CON showed significantly lower hand skin temperatures and DPG during daytime. However, menstrual cycle phase did not modify these diurnal patterns, indicating that menstrual and diurnal cycle variations in skin temperatures reveal additive effects. Most striking was the finding that all measured skin temperatures, together with basal body temperature, revealed a similar menstrual cycle variation (independent of BMI), with highest and lowest values during the luteal and follicular phases, respectively. These findings lead to the conclusion that in contrast to diurnal cycle, variations in CBT variation across the menstrual cycle cannot be explained by changes in internal heat conduction under ambulatory conditions. Although no measurements of metabolic heat production were carried out increased metabolic heat generation during the luteal phase seems to be the most plausible explanation for similar body temperature increases.

Cost-Utility of Evaluation for Posterior Vitreous Detachment and Prophylaxis of Retinal Detachment.

PubMed

Yannuzzi, Nicolas A; Chang, Jonathan S; Brown, Gary C; Smiddy, William E

2018-01-01

To evaluate the costs and cost-utility of examination for posterior vitreous detachment (PVD) and treatment of associated pathology, and of managing various other peripheral retinal disorders to prevent retinal detachment (RD). A decision analysis model of cost-utility. There were no participants. Published retrospective data on the natural course of PVD, retinal tears, and lattice degeneration were used to quantitate the visual benefits of examination and treatment. Center for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility/ambulatory surgical center (ASC)-based setting. Published standards of utility for a given level of visual acuity were used to derive costs and quality-adjusted life years (QALYs). Cost of evaluation and treatment, utility of defined health states, QALY, and cost per QALY. The modeled cost of evaluation of a patient with PVD and treatment of associated pathology in the facility/hospital (nonfacility/ASC)-based setting was $65 to $190 ($25-$71) depending on whether a single or 2-examination protocol was used. The cost per QALY saved was $255 to $638/QALY ($100-$239/QALY). Treatment of a symptomatic horseshoe tear resulted in a net cost savings of $1749 ($1314) and improved utility, whereas treatment of an asymptomatic horseshoe tear resulted in $2981/QALY ($1436/QALY). Treatment of asymptomatic lattice degeneration in an eye in which the fellow eye had a history of RD resulted in $4414/QALY ($2187/QALY). Evaluation and management of incident acute PVD (and symptomatic horseshoe tears) offer a low cost and a favorable cost-utility (low $/QALY) as a result of the minimization of the cost and morbidity associated with the development of RD, thus justifying current practice standards. Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

The new look in rehabilitation.

PubMed

Eazell, D E

1987-01-01

In the 1990s, operational strategies to assure survival will be crucial for all healthcare providers. All will face an accelerating rate of change, and the paramount change will be an intensified competitive marketplace. How does this impact rehabilitation? Like acute care hospitals, rehabilitation facilities will diversify into alternative delivery systems. This paper examines the course one provider--Casa Colina, Inc.--has taken, the pitfalls and problems along the way, and the implications for other rehabilitation providers. Strategies used to strengthen various areas of rehabilitation are considered, including ambulatory care, skilled nursing, traumatic brain injury, medical and vocational rehabilitation, residential programs, joint ventures, rehabilitation hospitals and outpatient services. A strong consensus exists today among healthcare experts concerning where we are headed and operational strategies for survival in 1990. How does this consensus impact rehabilitation? Before dealing with rehabilitation, let us review essential agreements. For HOSPITALS, the experts agree that: multi-hospital systems will continue to grow and will be best positioned to implement and take advantage of the strategies of choice in the new competitive market; money spent nationally on healthcare services will continue to grow; new types of providers will erode acute care inpatient hospitals' share of healthcare expenditures; emphasis in healthcare will shift to ambulatory services and delivery systems; and hospitals may be at a disadvantage in attracting capital financing and many will have to create new corporate structures and business ventures to compete in the capital market.(ABSTRACT TRUNCATED AT 250 WORDS)

ECG-derived Cheyne-Stokes respiration and periodic breathing in healthy and hospitalized populations.

PubMed

Tinoco, Adelita; Drew, Barbara J; Hu, Xiao; Mortara, David; Cooper, Bruce A; Pelter, Michele M

2017-11-01

Cheyne-Stokes respiration (CSR) has been investigated primarily in outpatients with heart failure. In this study we compare CSR and periodic breathing (PB) between healthy and cardiac groups. We compared CSR and PB, measured during 24 hr of continuous 12-lead electrocardiographic (ECG) Holter recording, in a group of 90 hospitalized patients presenting to the emergency department with symptoms suggestive of acute coronary syndrome (ACS) to a group of 100 healthy ambulatory participants. We also examined CSR and PB in the 90 patients presenting with ACS symptoms, divided into a group of 39 (43%) with confirmed ACS, and 51 (57%) with a cardiac diagnosis but non-ACS. SuperECG software was used to derive respiration and then calculate CSR and PB episodes from the ECG Holter data. Regression analyses were used to analyze the data. We hypothesized SuperECG software would differentiate between the groups by detecting less CSR and PB in the healthy group than the group of patients presenting to the emergency department with ACS symptoms. Hospitalized patients with suspected ACS had 7.3 times more CSR episodes and 1.6 times more PB episodes than healthy ambulatory participants. Patients with confirmed ACS had 6.0 times more CSR episodes and 1.3 times more PB episodes than cardiac non-ACS patients. Continuous 12-lead ECG derived CSR and PB appear to differentiate between healthy participants and hospitalized patients. © 2017 Wiley Periodicals, Inc.

Hospitalizations owing to ambulatory care sensitive conditions in Florianopolis, Santa Catarina - an ecological study, 2001-2011.

PubMed

Brasil, Vinicius Paim; Costa, Juvenal Soares Dias da

2016-01-01

to evaluate trends in rates of hospitalizations owing to ambulatory care sensitive conditions in the municipality of Florianópolis, Santa Catarina, Brazil, from 2001 to 2011, and to assess correlation with the public health expendutures Family Health Strategy (FHS) population coverage. this was an ecological study using Ministry of Health secondary data; data were analyzed using Poisson Regression. the regression coefficient was 0.97, showing a decrease of 3% per year in hospitalizations owing to ambulatory care sensitive conditions, a three-fold increase in FHS coverage and seven times more financial investment per capita in health services, from R$67.65 in 2001 to R$471.03 in 2011; FHS investments per capita in health and population coverage were negatively correlated to the rate of hospitalizations owing to ambulatory care sensitive conditions. financial investment and FHS expansion had led to major reductions in the rate of hospitalizations owing to ambulatory care sensitive conditions.

Transcranial Doppler-determined change in posterior cerebral artery blood flow velocity does not reflect vertebral artery blood flow during exercise.

PubMed

Washio, Takuro; Sasaki, Hiroyuki; Ogoh, Shigehiko

2017-04-01

We examined whether a change in posterior cerebral artery flow velocity (PCAv) reflected the posterior cerebral blood flow in healthy subjects during both static and dynamic exercise. PCAv and vertebral artery (VA) blood flow, as an index of posterior cerebral blood flow, were continuously measured during an exercise trial using transcranial Doppler (TCD) ultrasonography and Doppler ultrasound, respectively. Static handgrip exercise significantly increased both PCAv and VA blood flow. Increasing intensity of dynamic exercise further increased VA blood flow from moderate exercise, while PCAv decreased to almost resting level. During both static and dynamic exercise, the PCA cerebrovascular conductance (CVC) index significantly decreased from rest (static and high-intensity dynamic exercise, -11.5 ± 12.2% and -18.0 ± 16.8%, means ± SD, respectively) despite no change in the CVC of VA. These results indicate that vasoconstriction occurred at PCA but not VA during exercise-induced hypertension. This discrepancy in vascular response to exercise between PCA and VA may be due to different cerebral arterial characteristics. Therefore, to determine the effect of exercise on posterior cerebral circulation, at least, we need to carefully consider which cerebral artery to measure, regardless of exercise mode. NEW & NOTEWORTHY We examined whether transcranial Doppler-determined flow velocity in the posterior cerebral artery can be used as an index of cerebral blood flow during exercise. However, the changes in posterior cerebral artery flow velocity during exercise do not reflect vertebral artery blood flow. Copyright © 2017 the American Physiological Society.

Comparison of analgesic efficacy of four-quadrant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing laparoscopic colorectal surgery: an open-label, randomised, non-inferiority trial.

PubMed

Niraj, G; Kelkar, A; Hart, E; Horst, C; Malik, D; Yeow, C; Singh, B; Chaudhri, S

2014-04-01

Posterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received four-quadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1.0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery. © 2013 The Association of Anaesthetists of Great Britain and Ireland.

Pros and cons of the ambulatory surgery center joint venture.

PubMed

Giannini, Deborah

2008-01-01

If a physician group has determined that it has a realistic patient base to establish an ambulatory surgery center, it may be beneficial to consider a partner to share the costs and risks of this new joint venture. Joint ventures can be a benefit or liability in the establishment of an ambulatory surgery center. This article discusses the advantages and disadvantages of a hospital physician-group joint venture.

Knee Muscle Strength at Varying Angular Velocities and Associations with Gross Motor Function in Ambulatory Children with Cerebral Palsy

ERIC Educational Resources Information Center

Hong, Wei-Hsien; Chen, Hseih-Ching; Shen, I-Hsuan; Chen, Chung-Yao; Chen, Chia-Ling; Chung, Chia-Ying

2012-01-01

The aim of this study was to evaluate the relationships of muscle strength at different angular velocities and gross motor functions in ambulatory children with cerebral palsy (CP). This study included 33 ambulatory children with spastic CP aged 6-15 years and 15 children with normal development. Children with CP were categorized into level I (n =…

Ultrasound assessment of hamstring muscle size using posterior thigh muscle thickness.

PubMed

Abe, Takashi; Loenneke, Jeremy P; Thiebaud, Robert S

2016-05-01

Several studies have investigated the relationship between ultrasound-measured muscle thickness (MT) and individual muscle cross-sectional area (CSA) and muscle volume (MV) in extremity and trunk muscles; however, the hamstring muscle has not been studied. The purpose of this study was to examine the relationship between posterior thigh MT by ultrasound and the muscle CSA and MV of the hamstring obtained by magnetic resonance imaging (MRI). Ten young women aged 20-31 had MT measured by ultrasound at three sites on the medial anterior (50% of thigh length; TL) and posterior (50% and 70% of TL) aspects of the thigh. On the same day, a series of continuous muscle CSA along the thigh was measured by MRI. In each slice, the anatomical CSA of the hamstring (biceps femoris, semitendinosus and semimembranosus) and quadriceps muscle was analysed, and the CSAs at 50% and 70% of TL and maximal CSA of the hamstring (CSAmax ) were determined. MV was calculated by multiplying CSA by slice thickness. A significant correlation was observed between posterior 50% MT and 50% hamstring CSA (r = 0·848, P = 0·002) and between posterior 70% MT and 70% hamstring CSA (r = 0·679, P = 0·031). Posterior 50% MT (r = 0·732, P = 0·016) and 50% MTxTL (r = 0·873, P = 0·001) were also correlated to hamstring MV. Anterior:posterior 50% thigh MT ratio was correlated to MV ratio of quadriceps and hamstring muscles (r = 0·803, P = 0·005). Our results suggest that posterior thigh MT reflects hamstring muscle CSA and MV. The anterior:posterior MT ratio may serve as a surrogate for MV ratio of quadriceps and hamstring. © 2014 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.

Ambulatory oral surgery: 1-year experience with 11 680 patients from Zagreb district, Croatia

PubMed Central

Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor

2013-01-01

Aim To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Methods Sociodemographic and clinical data on 11 680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. Results The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P < 0.001) and intraoral incisions (P < 0.001) were performed among male patients, whereas significantly more alveolectomies and apicoectomies were performed among female patients (P < 0.001). A greater prevalence of periodontal disease was found in patients residing in Zagreb than in patients residing in rural areas. Conclusion The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients’ awareness of the importance of oral health. PMID:23444246

Ambulatory oral surgery: 1-year experience with 11680 patients from Zagreb district, Croatia.

PubMed

Jokić, Dražen; Macan, Darko; Perić, Berislav; Tadić, Marinka; Biočić, Josip; Đanić, Petar; Brajdić, Davor

2013-02-01

To examine the types and frequencies of oral surgery diagnoses and ambulatory oral surgical treatments during one year period at the Department of Oral Surgery, University Hospital Dubrava in Zagreb, Croatia. Sociodemographic and clinical data on 11680 ambulatory patients, treated between January 1 and of December 31, 2011 were retrieved from the hospital database using a specific protocol. The obtained data were subsequently analyzed in order to assess the frequency of diagnoses and differences in sex and age. The most common ambulatory procedure was tooth extraction (37.67%) and the most common procedure in ambulatory operating room was alveolectomy (57.25%). The test of proportions showed that significantly more extractions (P<0.001) and intraoral incisions (P<0.001) were performed among male patients, whereas significantly more alveolectomies and apicoectomies were performed among female patients (P<0.001). A greater prevalence of periodontal disease was found in patients residing in Zagreb than in patients residing in rural areas. The data from this study may be useful for planning of ambulatory oral surgery services, budgeting, and sustaining quality improvement, enhancing oral surgical curricula, training and education of primary health care doctors and oral surgery specialists, and promoting patients' awareness of the importance of oral health.

Relationship Between 24-Hour Ambulatory Blood Pressure and Cognitive Function in Community-Living Older Adults: The UCSD Ambulatory Blood Pressure Study.

PubMed

Conway, Kyle S; Forbang, Nketi; Beben, Tomasz; Criqui, Michael H; Ix, Joachim H; Rifkin, Dena E

2015-12-01

Twenty-four-hour ambulatory blood pressure (BP) patterns have been associated with diminished cognitive function in hypertensive and very elderly populations. The relationship between ambulatory BP patterns and cognitive function in community-living older adults is unknown. We conducted a cross-sectional study in which 24-hour ambulatory BP, in-clinic BP, and cognitive function measures were obtained from 319 community-living older adults. The mean age was 72 years, 66% were female, and 13% were African-American. We performed linear regression with performance on the Montreal Cognitive Assessment (MoCA) as the primary outcome and 24-hour BP patterns as the independent variable, adjusting for age, sex, race/ethnicity, education, and comorbidities. Greater nighttime systolic dipping (P = 0.046) and higher 24-hour diastolic BP (DBP; P = 0.015) were both significantly associated with better cognitive function, whereas 24-hour systolic BP (SBP), average real variability, and ambulatory arterial stiffness were not. Higher 24-hour DBP and greater nighttime systolic dipping were significantly associated with improved cognitive function. Future studies should examine whether low 24-hour DBP and lack of nighttime systolic dipping predict future cognitive impairment. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Sustainable business models: systematic approach toward successful ambulatory care pharmacy practice.

PubMed

Sachdev, Gloria

2014-08-15

This article discusses considerations for making ambulatory care pharmacist services at least cost neutral and, ideally, generate a margin that allows for service expansion. The four pillars of business sustainability are leadership, staffing, information technology, and compensation. A key facet of leadership in ambulatory care pharmacy practice is creating and expressing a clear vision for pharmacists' services. Staffing considerations include establishing training needs, maximizing efficiencies, and minimizing costs. Information technology is essential for efficiency in patient care delivery and outcomes assessment. The three domains of compensation are cost savings, pay for performance, and revenue generation. The following eight steps for designing and implementing an ambulatory care pharmacist service are discussed: (1) prepare a needs assessment, (2) analyze existing strengths, weaknesses, opportunities, and threats, (3) analyze service gaps and feasibility, (4) consider financial opportunities, (5) consider stakeholders' interests, (6) develop a business plan, (7) implement the service, and (8) measure outcomes. Potential future changes in national healthcare policy (such as pharmacist provider status and expanded pay for performance) could enhance the opportunities for sustainable ambulatory care pharmacy practice. The key challenges facing ambulatory care pharmacists are developing sustainable business models, determining which services yield a positive return on investment, and demanding payment for value-added services. Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Building a dream: creating an oncology day/evening hospital.

PubMed

Fletcher, K; Painter, V

2002-01-01

The demand for inpatient beds has reached and often exceeds capacity producing waiting lists for cancer care. There is a need to explore alternative approaches to oncology treatment. The Oncology Day/Evening Hospital (ODEH), originally envisioned in 1995 as a joint project between an ambulatory cancer centre and a large teaching hospital, is an important cancer treatment initiative offering extended hours of ambulatory oncology treatment on days, evenings, weekends and statutory holidays. A review of current inpatient treatment modalities revealed that many patients receiving inpatient therapy could be safely and effectively managed in the ambulatory setting if treatment regimens were modified and if ambulatory hours of operation were extended. Healthcare improvements expected were: appropriate movement of inpatient activity to the ambulatory setting; more opportunities for patient choice in treatment time thereby allowing for maintenance of normal living; better quality of life for patients through prevention of hospitalization; decrease in treatment waiting times; consolidation of patients into an ambulatory oncology treatment setting as opposed to utilization of adult medicine units; and more rational inpatient bed utilization with reduction of admissions and intra-treatment transfers. This article describes our experience in building a dream, the challenges and lessons learned in implementing a better way to deliver oncology care in an environment of rapid change and staff shortages.

[Importance of ambulatory blood pressure monitoring in adolescent hypertension].

PubMed

Páll, Dénes; Juhász, Mária; Katona, Eva; Lengyel, Szabolcs; Komonyi, Eva; Fülesdi, Béla; Paragh, György

2009-12-06

The prevalence of adolescent hypertension is increasing. The national epidemiological study found 2.5% prevalence, while it is 4.5% according to the newest international survey. Repeated casual blood pressure measurements, but not ambulatory blood pressure monitoring is needed for the diagnosis of adolescent hypertension on the basis of the presently available European guideline. At the last decade growing evidence came into light for ambulatory blood pressure monitoring in adolescence. These data show better correlation with end-organ damages than casual measurements. In patients with hypertension diagnosed based on repeated casual blood pressure measurements, 24-hour monitoring showed normal blood pressure in 21-47%, so this is the rate of white coat hypertension. Masked hypertension can also be diagnosed with the help of this method, which has a prevalence of 7-11%. We can also get useful data for secondary forms of hypertension. Until the appearance of the new European guidelines, more frequent use of ambulatory blood pressure monitoring is affordable. The confirmation of the diagnosis based on elevated casual blood pressure data is important. Ambulatory blood pressure monitoring is suggested in cases suspicious for white coat or masked hypertension, in cases of target organ damages or therapy resistant hypertension. Before administration of pharmaceutical therapy in adolescence hypertension - according to author's opinion - ambulatory blood pressure monitoring is absolutely necessary.

Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre.

PubMed

Teh, Benjamin W; Brown, Christine; Joyce, Trish; Worth, Leon J; Slavin, Monica A; Thursky, Karin A

2018-03-01

Neutropenic fever (NF) is a common complication of cancer chemotherapy. Patients at low risk of medical complications from NF can be identified using a validated risk assessment and managed in an outpatient setting. This is a new model of care for Australia. This study described the implementation of a sustainable ambulatory program for NF at a tertiary cancer centre over a 12-month period. Peter MacCallum Cancer Centre introduced an ambulatory care program in 2014, which identified low-risk NF patients, promoted early de-escalation to oral antibiotics, and early discharge to a nurse-led ambulatory program. Patients prospectively enrolled in the ambulatory program were compared with a historical-matched cohort of patients from 2011 for analysis. Patient demographics, clinical variables (cancer type, recent chemotherapy, treatment intent, site of presentation) and outcomes were collected and compared. Total cost of inpatient admissions was determined from diagnosis-related group (DRG) codes and applied to both the prospective and historical cohorts to allow comparisons. Twenty-five patients were managed in the first year of this program with a reduction in hospital median length of stay from 4.0 to 1.1 days and admission cost from Australian dollars ($AUD) 8580 to $AUD2360 compared to the historical cohort. Offsetting salary costs, the ambulatory program had a net cost benefit of $AUD 71895. Readmission for fever was infrequent (8.0%), and no deaths were reported. Of relevance to hospitals providing cancer care, feasibility, safety, and cost benefits of an ambulatory program for low-risk NF patients have been demonstrated.

Ambulatory measurement of ankle kinetics for clinical applications.

PubMed

Rouhani, H; Favre, J; Crevoisier, X; Aminian, K

2011-10-13

This study aimed to design and validate the measurement of ankle kinetics (force, moment, and power) during consecutive gait cycles and in the field using an ambulatory system. An ambulatory system consisting of plantar pressure insole and inertial sensors (3D gyroscopes and 3D accelerometers) on foot and shank was used. To test this system, 12 patients and 10 healthy elderly subjects wore shoes embedding this system and walked many times across a gait lab including a force-plate surrounded by seven cameras considered as the reference system. Then, the participants walked two 50-meter trials where only the ambulatory system was used. Ankle force components and sagittal moment of ankle measured by ambulatory system showed correlation coefficient (R) and normalized RMS error (NRMSE) of more than 0.94 and less than 13% in comparison with the references system for both patients and healthy subjects. Transverse moment of ankle and ankle power showed R>0.85 and NRMSE<23%. These parameters also showed high repeatability (CMC>0.7). In contrast, the ankle coronal moment of ankle demonstrated high error and lower repeatability. Except for ankle coronal moment, the kinetic features obtained by the ambulatory system could distinguish the patients with ankle osteoarthritis from healthy subjects when measured in 50-meter trials. The proposed ambulatory system can be easily accessible in most clinics and could assess main ankle kinetics quantities with acceptable error and repeatability for clinical evaluations. This system is therefore suggested for field measurement in clinical applications. Copyright © 2011 Elsevier Ltd. All rights reserved.

Sarcopenia Is Highly Prevalent in Older Medical Patients With Mobility Limitation.

PubMed

Maeda, Keisuke; Shamoto, Hiroshi; Wakabayashi, Hidetaka; Akagi, Junji

2017-02-01

The association of sarcopenia with disability with ambulatory status is uncertain because most studies have targeted people who could walk independently. This study explored the prevalence of sarcopenia regardless of ambulatory status and the impact of ambulatory status on sarcopenia. In total, 778 consecutive patients, aged ≥65 years and admitted to a hospital, were enrolled. Ambulatory status was divided into 4 grades according to mobility as described in the Barthel index. Sarcopenia was defined as a loss of appendicular muscle mass index (AMI) with bioelectrical impedance and decreased muscle strength with handgrip strength (HGS); cutoff values were adopted from the Asian Working Group for Sarcopenia. The mean patient age was 83.2 ± 8.3 years; 37.8% were male patients. Mobility limitation was associated with higher age, underweight body mass index, malnourishment, and comorbidities (all P < .001). AMI and HGS gradually decreased with declining ambulatory status ( P < .001). The prevalence of sarcopenia in the independent walk, walk with help, wheelchair, and immobile groups was 57.9%, 76.1%, 89.4%, and 91.7%, respectively. AMI prevalence declined and sarcopenia drastically increased in patients who were unable to walk independently compared with those who could walk independently ( P < .001). Multivariate regression analyses showed that mobility limitation was an independent indicator of decreasing AMI and sarcopenia after adjustment for confounders. Patients with dependent ambulatory status experienced a higher prevalence of sarcopenia compared with those with ambulation; in addition, decline in ambulatory status was an independent indicator for the presence of sarcopenia after adjustment for potential confounders.

Continuous lumbar hemilaminectomy for intervertebral disc disease in an Amur tiger (Panthera tigris altaica).

PubMed

Flegel, Thomas; Böttcher, Peter; Alef, Michaele; Kiefer, Ingmar; Ludewig, Eberhard; Thielebein, Jens; Grevel, Vera

2008-09-01

A 13-yr-old Amur tiger (Panthera tigris altaica) was presented for an acute onset of paraplegia. Spinal imaging that included plain radiographs, myelography, and computed tomography performed under general anesthesia revealed lateralized spinal cord compression at the intervertebral disc space L4-5 caused by intervertebral disc extrusion. This extrusion was accompanied by an extensive epidural hemorrhage from L3 to L6. Therefore, a continuous hemilaminectomy from L3 to L6 was performed, resulting in complete decompression of the spinal cord. The tiger was ambulatory again 10 days after the surgery. This case suggests that the potential benefit of complete spinal cord decompression may outweigh the risk of causing clinically significant spinal instability after extensive decompression.

Evaluation of a stereoscopic camera-based three-dimensional viewing workstation for ophthalmic surgery.

PubMed

Bhadri, Prashant R; Rowley, Adrian P; Khurana, Rahul N; Deboer, Charles M; Kerns, Ralph M; Chong, Lawrence P; Humayun, Mark S

2007-05-01

To evaluate the effectiveness of a prototype stereoscopic camera-based viewing system (Digital Microsurgical Workstation, three-dimensional (3D) Vision Systems, Irvine, California, USA) for anterior and posterior segment ophthalmic surgery. Institutional-based prospective study. Anterior and posterior segment surgeons performed designated standardized tasks on porcine eyes after training on prosthetic plastic eyes. Both anterior and posterior segment surgeons were able to complete tasks requiring minimal or moderate stereoscopic viewing. The results indicate that the system provides improved ergonomics. Improvements in key viewing performance areas would further enhance the value over a conventional operating microscope. The performance of the prototype system is not at par with the planned commercial system. With continued development of this technology, the three- dimensional system may be a novel viewing system in ophthalmic surgery with improved ergonomics with respect to traditional microscopic viewing.

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients.

PubMed

Lampkin, Stacie J; Gildon, Brooke; Benavides, Sandra; Walls, Kelly; Briars, Leslie

2018-01-01

Pediatric clinical pharmacists are an integral part of the health care team. By practicing in an ambulatory care clinic, they can reduce the risk of medication errors, improve health outcomes, and enhance patient care. Unfortunately, because of limited data, misconceptions surrounding the role of pharmacists, and reimbursement challenges, there may be difficulty in establishing or expanding pediatric clinical pharmacy services to an ambulatory care setting. The purpose of this paper is to provide an overview of considerations for establishing or expanding pharmacy services in a pediatric ambulatory care clinic. The primer will discuss general and pediatric-specific pharmacy practice information, as well as potential barriers, and recommendations for identifying a practice site, creating a business plan, and integrating these services into a clinic setting.

The Cramér-Rao Bounds and Sensor Selection for Nonlinear Systems with Uncertain Observations.

PubMed

Wang, Zhiguo; Shen, Xiaojing; Wang, Ping; Zhu, Yunmin

2018-04-05

This paper considers the problems of the posterior Cramér-Rao bound and sensor selection for multi-sensor nonlinear systems with uncertain observations. In order to effectively overcome the difficulties caused by uncertainty, we investigate two methods to derive the posterior Cramér-Rao bound. The first method is based on the recursive formula of the Cramér-Rao bound and the Gaussian mixture model. Nevertheless, it needs to compute a complex integral based on the joint probability density function of the sensor measurements and the target state. The computation burden of this method is relatively high, especially in large sensor networks. Inspired by the idea of the expectation maximization algorithm, the second method is to introduce some 0-1 latent variables to deal with the Gaussian mixture model. Since the regular condition of the posterior Cramér-Rao bound is unsatisfied for the discrete uncertain system, we use some continuous variables to approximate the discrete latent variables. Then, a new Cramér-Rao bound can be achieved by a limiting process of the Cramér-Rao bound of the continuous system. It avoids the complex integral, which can reduce the computation burden. Based on the new posterior Cramér-Rao bound, the optimal solution of the sensor selection problem can be derived analytically. Thus, it can be used to deal with the sensor selection of a large-scale sensor networks. Two typical numerical examples verify the effectiveness of the proposed methods.

[Acute epidural hematoma of the posterior fossa caused by forehead impact].

PubMed

Abe, S; Furukawa, K; Endo, S; Hoshi, S; Kanaya, H

1988-03-01

A rare case of acute epidural hematoma of the posterior fossa caused by forehead impact is reported. This 36-year-old man fell from a truck and hit his face. He was conscious and was brought to our center 30 minutes after the injury. On admission, a contused wound of the right forehead was noticed. He was restless and had severe pain in the neck and upper extremities. Skull X-ray showed a linear fracture of the frontal bone and computed tomography (CT) scan was normal. He continued to be restless and sudden respiratory arrest and pupillary dilation occurred 10 hours after the admission. A CT scan revealed a lenticular high density area in the left posterior fossa which extended to the supratentorial region. The 4th ventricle was compressed and displaced to the right and also the quadrigeminal and ambient cisterns were not visualized at all. Immediate surgery disclosed a 30 g epidural hematoma of the left posterior fossa and the supratentorium and the clot was completely evacuated. The source of bleeding could not be identified. Opening of the dura revealed contusion in the occipital lobe. He died on the 17th postoperative day. The possible mechanism in the production of the posterior fossa hematoma in this case is discussed.

[Chronic pain and syringomyelic slit of the posterior horns of the spinal cord].

PubMed

Rémillard, G M; Robitaille, Y; Bertrand, G

1985-01-01

Two male patients 46 and 44 y.o. respectively, were admitted for a syndrome of chronic pain characterized by: sudden onset, spontaneous or following spasmodic coughing, of an anterior hemithoracic pain slowly progressing to involve several unilateral cervicothoracic dermatomes, a continuous burning sensation made worse by light touch, limb movements and cold water, and partially relieved by warm water or deep palpation. On examination, patient 1 revealed no sensorimotor deficit after repeated observations during 8 years. At autopsy, a syrinx localized at the cord segments corresponding to the symptoms was found without documentation of specific causal factors. It involved the posterior horn of the cord selectively. In patient 2, pain was associated with slight hypesthesia to pinprick and heat from C2 to T5 on the left without motor deficit since 18 months. A high resolution C.A.T. scan showed an intramedullary cavity 0.3 cm from the midline in the projection of the posterior horn without anomalies at the cervicomedullary junction. These observations link chronic pain syndromes with predominantly posterior horn lesions, which so far have failed to respond to conventional therapeutic measures.

Tissue-Informative Mechanism for Wearable Non-invasive Continuous Blood Pressure Monitoring

NASA Astrophysics Data System (ADS)

Woo, Sung Hun; Choi, Yun Young; Kim, Dae Jung; Bien, Franklin; Kim, Jae Joon

2014-10-01

Accurate continuous direct measurement of the blood pressure is currently available thru direct invasive methods via intravascular needles, and is mostly limited to use during surgical procedures or in the intensive care unit (ICU). Non-invasive methods that are mostly based on auscultation or cuff oscillometric principles do provide relatively accurate measurement of blood pressure. However, they mostly involve physical inconveniences such as pressure or stress on the human body. Here, we introduce a new non-invasive mechanism of tissue-informative measurement, where an experimental phenomenon called subcutaneous tissue pressure equilibrium is revealed and related for application in detection of absolute blood pressure. A prototype was experimentally verified to provide an absolute blood pressure measurement by wearing a watch-type measurement module that does not cause any discomfort. This work is supposed to contribute remarkably to the advancement of continuous non-invasive mobile devices for 24-7 daily-life ambulatory blood-pressure monitoring.

A Study to Determine the Feasibility of Establishing an Ambulatory Surgery Program at Keller Army Community Hospital, West Point, New York

DTIC Science & Technology

1987-05-01

18.79 Other plastic repair of external ear Otoplasty; Postauricular skin graft ; Repair of lop ear 19.4 Myringoplasty Epitympanic, type I; Myringoplasty...of lip 27.53 Closure of fistula of mouth * 27.54 Repair of cleft lip * 27.55 Bill-thickness skin graft to lip and mouth * 27.56 Other skin graft to...structure 86.60 Free skin graft , not otherwise specified *d :935 Empire Blue Cross and Blue Shield- New York Dvisior 56 INTEGUMENTARY SYSTIA continued

Posterior capsule opacification.

PubMed

Wormstone, I Michael; Wang, Lixin; Liu, Christopher S C

2009-02-01

Posterior Capsule Opacification (PCO) is the most common complication of cataract surgery. At present the only means of treating cataract is by surgical intervention, and this initially restores high visual quality. Unfortunately, PCO develops in a significant proportion of patients to such an extent that a secondary loss of vision occurs. A modern cataract operation generates a capsular bag, which comprises a proportion of the anterior and the entire posterior capsule. The bag remains in situ, partitions the aqueous and vitreous humours, and in the majority of cases, houses an intraocular lens. The production of a capsular bag following surgery permits a free passage of light along the visual axis through the transparent intraocular lens and thin acellular posterior capsule. However, on the remaining anterior capsule, lens epithelial cells stubbornly reside despite enduring the rigours of surgical trauma. This resilient group of cells then begin to re-colonise the denuded regions of the anterior capsule, encroach onto the intraocular lens surface, occupy regions of the outer anterior capsule and most importantly of all begin to colonise the previously cell-free posterior capsule. Cells continue to divide, begin to cover the posterior capsule and can ultimately encroach on the visual axis resulting in changes to the matrix and cell organization that can give rise to light scatter. This review will describe the biological mechanisms driving PCO progression and discuss the influence of IOL design, surgical techniques and putative drug therapies in regulating the rate and severity of PCO.

Antimicrobial usage in ambulatory patients with respiratory infections in Taiwan, 2001.

PubMed

Ho, Monto; Hsiung, Chao Agnes; Yu, Hui-Tzu; Chi, Cheng-Liang; Yin, Hsiao-Chuan; Chang, Hong-Jen

2004-02-01

Excess use of antimicrobials by ambulatory patients is a determinant of antimicrobial resistance. This study investigated the types of illnesses for which antimicrobials were prescribed and the amounts prescribed with special emphasis on respiratory infections for the year in which the Bureau of National Health Insurance (BNHI) enforced a policy to restrict antimicrobials for upper respiratory infections. The number of ambulatory patients seen and the types of ambulatory facilities in Taiwan were also described. Raw data were obtained from the BNHI database on every 500 th visit in 2001. Medical diagnoses were categorized according to the ICD-9-CM system. Antimicrobial consumption was expressed in defined daily doses per 1000 population per day (DDD/1000/day). Among the population of 22.3 million in Taiwan, there were 285.8 million ambulatory patient visits (12.8 per person), including 108.9 million visits (4.9 per person) for respiratory infections, of which 62.7 million (2.8 per person) were for upper respiratory infections (URI). Antimicrobial consumption was 19.83 DDD/1000/day [standard error (SE), 0.00055], of which 9.97 DDD/1000/day (SE, 0.00047) were for respiratory infections and 4.03 DDD/1000/day (0.00055) were for URI. 23.6% of visits for URI entailed a prescription for antimicrobials. About two-thirds (66.5%) of ambulatory patients were seen in clinics, mostly private ones, and 67.6% of all antimicrobials were received there. Aminopenicillins and cephalosporins constituted 35.2% and 19.5%, respectively, of antimicrobials prescribed. Despite the new BNHI rule restricting antimicrobial usage for URI, Taiwan still has an excessive number of ambulatory patient visits, especially for respiratory infections and URI. The majority of antimicrobials used were for URI. They were mostly prescribed in private clinics rather than hospital outpatient departments.

Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the HARMONY randomized controlled trial.

PubMed

Blom, Kimberly; Baker, Brian; How, Maxine; Dai, Monica; Irvine, Jane; Abbey, Susan; Abramson, Beth L; Myers, Martin G; Kiss, Alex; Perkins, Nancy J; Tobe, Sheldon W

2014-01-01

The HARMONY study was a randomized, controlled trial examining the efficacy of an 8-week mindfulness-based stress reduction (MBSR) program for blood pressure (BP) lowering among unmedicated stage 1 hypertensive participants. Participants diagnosed with stage 1 hypertension based on ambulatory BP were randomized to either immediate treatment of MBSR for 8 weeks or wait-list control. Primary outcome analysis evaluated whether change in awake and 24-hour ambulatory BP from baseline to week 12 was significantly different between the 2 groups. A within-group before and after MBSR analysis was also performed. The study enrolled 101 adults (38% male) with baseline average 24-hour ambulatory BP of 135±7.9/82±5.8mm Hg and daytime ambulatory BP of 140±7.7/87±6.3 mmHg. At week 12, the change from baseline in 24-hour ambulatory BP was 0.4±6.7/0.0±4.9mm Hg for the immediate intervention and 0.4±7.8/-0.4±4.6mm Hg for the wait-list control. There were no significant differences between intervention and wait-list control for all ambulatory BP parameters. The secondary within-group analysis found a small reduction in BP after MBSR compared with baseline, a finding limited to female subjects in a sex analysis. MBSR did not lower ambulatory BP by a statistically or clinically significant amount in untreated, stage 1 hypertensive patients when compared with a wait-list control group. It leaves untested whether MBSR might be useful for lowering BP by improving adherence in treated hypertensive participants. NCT00825526.

Comparison of ambulatory blood pressure monitoring and office blood pressure measurements in obese children and adolescents.

PubMed

Renda, Rahime

2018-04-01

Obesity in adults has been related to hypertension and abnormal nocturnal dipping of blood pressure, which are associated with poor cardiovascular and renal outcomes. Here, we aimed to resolve the relationship between the degree of obesity, the severity of hypertension and dipping status on ambulatory blood pressure in obese children. A total 72 patients with primary obesity aged 7 to 18 years (mean: 13.48 ± 3.25) were selected. Patients were divided into three groups based on body mass index (BMİ) Z-score. Diagnosis and staging of ambulatory hypertension based on 24-h blood pressure measurements, obtained from ambulatory blood pressure monitoring. Based on our ambulatory blood pressure data, 35 patients (48.6%) had hypertension, 7 (20%) had ambulatory prehypertension, 21 (60%) had hypertension, and 7 patients (20%) had severe ambulatory hypertension. There was a significant relationship between severity of hypertension and the degree of obesity (p < 0.05). Thirty-one patients (88.6%) had isolated nighttime hypertension, and 53 patients (73.6%) were non-dippers. All systolic blood pressure results and loads were similar between groups. Diastolic and mean arterial blood pressure levels during the night, diastolic blood pressure loads, and heart rate during the day were significantly higher in Group 3 (p < 0.05). Nocturnal non-dipping was not associated with severity of obesity. Obesity was associated with severity of hypertension, higher diastolic blood pressure at night, mean arterial pressure at night, diastolic blood pressure loads and heart rate at day. Increase in BMI Z-score does not a significant impact on daytime blood pressure and nocturnal dipping status.

Left ventricular mass predicted by a single reading of ambulatory blood pressure in essential hypertension.

PubMed

Ohmori, S; Matsumura, K; Kajioka, T; Fukuhara, M; Abe, I; Fujishima, M

2000-07-01

The spectral power of heart rate variability has been shown to be negatively correlated with left ventricular mass (LVM), suggesting the contribution of left ventricular hypertrophy to autonomic dysfunction in essential hypertension. However, a simultaneous assessment of autonomic function and ambulatory blood pressure in relation to LVM has not been carried out. The objective of the present study was to elucidate the synergistic effects of ambulatory blood pressure and autonomic nerve activity on the heart. We enrolled 25 ambulant patients with untreated essential hypertension (9 men and 16 women; mean age 50.6 +/- 2.0 years). The ambulatory blood pressure and heart rate variability were simultaneously monitored every 30 min for 24 h. The spectral power of high-frequency (HF: 0.15 to 0.4 Hz) and low-frequency (LF: 0.05 to 0.15 Hz) bands were measured, and the ratio of LF to HF (LF/HF) was calculated. LF/HF and HF were used as indexes of sympathetic and parasympathetic activities, respectively. LVM was determined by echocardiography. Both the average daytime and nighttime systolic ambulatory blood pressures significantly correlated with the LVM index (r= 0.644, p< 0.001; and r= 0.428, p< 0.05; respectively), although there was no such correlation with the clinic blood pressures. In contrast, a single reading of ambulatory systolic blood pressure measured when LF/HF reached a maximum value was significantly correlated with the LVM index independently of age and sex (partial r= 0.484, p< 0.05). These results suggest that the ambulatory systolic blood pressure during increases in the activity of the sympathetic nervous system is able to infer LVM in essential hypertension.

Effects of an isocaloric healthy Nordic diet on ambulatory blood pressure in metabolic syndrome: a randomized SYSDIET sub-study.

PubMed

Brader, L; Uusitupa, M; Dragsted, L O; Hermansen, K

2014-01-01

Dietary pattern is central in the prevention of hypertension and blood pressure (BP)-related diseases. A diet based on healthy Nordic foods may have a favourable impact on BP. The objective was to clarify whether a Nordic alternative for a healthy food pattern would have beneficial effects on ambulatory BP in subjects with metabolic syndrome (MetS). In total, 37 subjects were randomized to either a healthy Nordic diet or a control diet. A healthy Nordic diet embraced whole grains, rapeseed oil, berries, fruits, vegetables, fish, nuts and low-fat dairy products of Nordic origin. The mean nutrient intake in the Nordic countries formed the control diet, embracing wheat products, dairy fat-based spread and a lower intake of fruits, vegetables and fish. Diets were isoenergetic. Ambulatory BP was monitored and 24-h urine was collected before and after 12 weeks of intervention. After 12 weeks, ambulatory diastolic BP (-4.4 mm Hg; P=0.001) and mean arterial pressure (-4.2 mm Hg; P=0.006) were lowered by the healthy Nordic diet compared with the control diet, whereas changes in ambulatory systolic BP did not differ significantly between diets (-3.5 mm Hg; P=0.122). Heart rate tended to be lower in those on the healthy Nordic diet (P=0.057). Urinary sodium and potassium excretions were unaffected by diets and consequently not associated with the healthy Nordic diet-induced lowering of BP. Consumption of Nordic varieties of health-enhancing foods for 12 weeks decreased diastolic ambulatory BP and mean arterial pressure in subjects with features of MetS during weight-stable condition, suggesting beneficial effects of a healthy Nordic dietary pattern on ambulatory BP.

Emergent risk factors associated with eyeball loss and ambulatory vision loss after globe injuries.

PubMed

Hyun Lee, Seung; Ahn, Jae Kyoun

2010-07-01

The objective of this study was to evaluate risk factors associated with eyeball loss and ambulatory vision loss on emergent examination of patients with ocular trauma. We reviewed the medical records of 1,875 patients hospitalized in a single tertiary referral center between January 2003 and December 2007. Emergent examinations included a history of trauma, elapsed time between injury and hospital arrival, visible intraocular tissues, and initial visual acuity (VA) using a penlight. The main outcome measures were ocular survival and ambulatory vision survival (>20/200) at 1 year after trauma using univariate and multivariate regression analysis. The ocular trauma scores were significantly higher in open globe injuries than in closed globe injuries (p < 0.01). In open globe injuries, initial VA less than light perception (LP) and a history of golf ball injury were the significant risk factors associated with eyeball loss. Elapsed time more than 12 hours and visible intraocular tissues were the significant risk factors associated with ambulatory vision loss. The most powerful predictor of eyeball loss and ambulatory vision loss was eyeball rupture. In closed globe injuries, there were no significant risk factors of eyeball loss, whereas initial vision less than LP and the presence of relative afferent pupillary defect were the significant risk factors associated with ambulatory vision loss. An initial VA less than LP using a penlight, a history of golf ball injury, and elapsed time more than 12 hours between ocular trauma and hospital arrival were associated with eyeball loss and ambulatory vision loss. Physicians should bear these factors in mind so that they can more effectively counsel patients with such injuries.

A systematic review of risk factors associated with accidental falls, outcome measures and interventions to manage fall risk in non-ambulatory adults.

PubMed

Rice, Laura A; Ousley, Cherita; Sosnoff, Jacob J

2015-01-01

To systematically review peer-reviewed literature pertaining to risk factors, outcome measures and interventions managing fall risk in non-ambulatory adults. Twenty-one papers were selected for inclusion from databases including PubMed/Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Scopus, Consumer Health Complete and Web of Science. Selected studies involved a description of fall related risk factors, outcomes to assess fall risk and intervention studies describing protocols to manage fall risk in non-ambulatory adults. Studies were selected by two reviewers and consultation provided by a third reviewer. The most frequently cited risk factors/characteristics associated with falls included: wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. The majority of the outcomes were found to evaluate seated postural control. One intervention study was identified describing a protocol targeting specific problems of individual participants. A global fall prevention program was not identified. Several risk factors associated with falls were identified and must be understood by clinicians to better serve their clients. To improve objective assessment, a comprehensive outcome assessment specific to non-ambulatory adults is needed. Finally, additional research is needed to examine the impact of structured protocols to manage fall risk in non-ambulatory adults. Falls are a common health concern for non-ambulatory adults. Risk factors commonly associated with falls include wheelchair related characteristics, transfer activities, impaired seated balance and environmental factors. Limited outcome measures are available to assess fall risk in non-ambulatory adults. Clinicians must be aware of the known risk factors and provide comprehensive education to their clients on the potential for falls. Additional research is needed to develop and evaluate protocols to clinically manage fall risk.

How reproducible is home-based 24-hour ambulatory monitoring of motor activity in patients with multiple sclerosis?

PubMed

Rietberg, Marc B; van Wegen, Erwin E; Uitdehaag, Bernard M; de Vet, Henrica C; Kwakkel, Gert

2010-10-01

To determine the reproducibility of 24-hour monitoring of motor activity in patients with multiple sclerosis (MS). Test-retest design; 6 research assistants visited the participants twice within 1 week in the home situation. General community. A convenience sample of ambulatory patients (N=43; mean age ± SD, 48.7±7.0y; 30 women; median Expanded Disability Status Scale scores, 3.5; interquartile range, 2.5) were recruited from the outpatient clinic of a university medical center. Not applicable. Dynamic activity and static activity parameters were recorded by using a portable data logger and classified continuously for 24 hours. Reproducibility was determined by calculating intraclass correlation coefficients (ICCs) for test-retest reliability and by applying the Bland-Altman method for agreement between the 2 measurements. The smallest detectable change (SDC) was calculated based on the standard error of measurement. Test-retest reliability expressed by the ICC(agreement) was .72 for dynamic activity, .74 for transitions, .77 for walking, .71 for static activity, .67 for sitting, .62 for standing, and .55 for lying. Bland and Altman analysis indicated no systematic differences between the first and second assessment for dynamic and static activity. Measurement error expressed by the SDC was 1.23 for dynamic activity, 66 for transitions, .99 for walking, 1.52 for static activity, 4.68 for lying, 3.95 for sitting, and 3.34 for standing. The current study shows that with 24-hour monitoring, a reproducible estimate of physical activity can be obtained in ambulatory patients with MS. Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Association of sleep disordered breathing symptoms with early postoperative analgesic requirement in pediatric ambulatory surgical patients

PubMed Central

Yang, Kamie; Baetzel, Anne; Chimbira, Wilson T; Yermolina, Yuliya; Reynolds, Paul I; Nafiu, Olubukola O

2017-01-01

Introduction Sleep disordered breathing (SDB) symptoms are associated with increased rates of opioid-induced respiratory depression as well as enhanced nociception. Consequently, practitioners often withhold or administer lower intraoperative doses of opioids out of concern for postoperative respiratory depression. Therefore, SDB may be a critical determinant of analgesic requirement in the post-anesthesia care unit (PACU). We investigated whether preoperative SDB classification was independently associated with need for PACU analgesic intervention in a cross-sectional sample of 985 children who underwent elective, painful ambulatory surgical procedures. Methods Using prospectively collected data, children aged 4–17yr were grouped into two categories based on whether or not they had symptoms of SDB. Perioperative variables were compared between the exposed and control groups using Chi-squared test for categorical or t-test for continuous variables. Logistic regression analysis was used to assess the association between SDB and the odds of requiring PACU IV opioids. Results Children with preoperative SDB symptoms (N=325) compared with the reference group of children who did not have these symptoms had higher rates of PACU analgesic intervention (47.1% vs. 37.4%; p=0.004) and higher mean arousal pain scores (3.7±3.5 vs.1.9±2.9; p<0.001). In our primary multivariable logistic regression model adjusted for a number of variables, preoperative SDB symptoms was associated with a two-fold increased odds of receiving PACU intravenous opioid (OR = 2.01, 95%CI, 1.29–3.12; p=0.002). Conclusion These results suggest that preoperative SDB symptoms in children undergoing ambulatory surgery, exerts a significant influence on PACU pain behavior and analgesic requirement. Mechanisms underlying this enhanced pain experience deserve further elucidation. PMID:28390605

Evaluating the implementation of RxNorm in ambulatory electronic prescriptions

PubMed Central

Ward-Charlerie, Stacy; Rupp, Michael T; Kilbourne, John; Amin, Vishal P; Ruiz, Joshua

2016-01-01

Objective RxNorm is a standardized drug nomenclature maintained by the National Library of Medicine that has been recommended as an alternative to the National Drug Code (NDC) terminology for use in electronic prescribing. The objective of this study was to evaluate the implementation of RxNorm in ambulatory care electronic prescriptions (e-prescriptions). Methods We analyzed a random sample of 49 997 e-prescriptions that were received by 7391 locations of a national retail pharmacy chain during a single day in April 2014. The e-prescriptions in the sample were generated by 37 801 ambulatory care prescribers using 519 different e-prescribing software applications. Results We found that 97.9% of e-prescriptions in the study sample could be accurately represented by an RxNorm identifier. However, RxNorm identifiers were actually used as drug identifiers in only 16 433 (33.0%) e-prescriptions. Another 431 (2.5%) e-prescriptions that used RxNorm identifiers had a discrepancy in the corresponding Drug Database Code qualifier field or did not have a qualifier (Term Type) at all. In 10 e-prescriptions (0.06%), the free-text drug description and the RxNorm concept unique identifier pointed to completely different drug concepts, and in 7 e-prescriptions (0.04%), the NDC and RxNorm drug identifiers pointed to completely different drug concepts. Discussion The National Library of Medicine continues to enhance the RxNorm terminology and expand its scope. This study illustrates the need for technology vendors to improve their implementation of RxNorm; doing so will accelerate the adoption of RxNorm as the preferred alternative to using the NDC terminology in e-prescribing. PMID:26510879

Central Iliac Arteriovenous Anastomosis for Uncontrolled Hypertension: One-Year Results From the ROX CONTROL HTN Trial.

PubMed

Lobo, Melvin D; Ott, Christian; Sobotka, Paul A; Saxena, Manish; Stanton, Alice; Cockcroft, John R; Sulke, Neil; Dolan, Eamon; van der Giet, Markus; Hoyer, Joachim; Furniss, Stephen S; Foran, John P; Witkowski, Adam; Januszewicz, Andrzej; Schoors, Danny; Tsioufis, Konstantinos; Rensing, Benno J; Scott, Benjamin; Ng, G André; Schmieder, Roland E

2017-12-01

Creation of a central iliac arteriovenous anastomosis using a novel nitinol coupler device results in an immediate, significant reduction of blood pressure (BP). We present efficacy and safety findings at 12 months post-coupler insertion. This open-label, multicenter, prospective, randomized trial enrolled patients with a baseline office systolic BP ≥140 mm Hg and average daytime ambulatory BP ≥135/85 mm Hg. Subjects were randomly allocated to coupler implantation and continuing previous pharmacotherapy or to maintain previous treatment alone. At 12 months, 39 patients who had coupler therapy were included in the intention-to-treat analysis. Office-based systolic BP reduced by 25.1±23.3 mm Hg (baseline, 174±18 mm Hg; P <0.0001) post-coupler placement, and office diastolic BP reduced by 20.8±13.3 mm Hg (baseline, 100±13 mm Hg; P <0.0001). Mean 24-hour ambulatory BP reduced by 12.6±17.4/15.3±9.7 mm Hg ( P <0.0001 for both). In a prespecified subset of patients who failed to respond adequately to prior renal denervation, coupler therapy led to highly significant reduction in office systolic/diastolic BP (30.7/24.1 mm Hg) and significant reduction in 24-hour ambulatory systolic/diastolic BP (12.4/14.4 mm Hg) at 12 months (n=9). After coupler therapy, 14 patients (33%) developed ipsilateral venous stenosis; all were treated successfully with venous stenting. These findings confirm the importance of arterial mechanics in the pathophysiology of hypertension and support the clinical use of a central iliac arteriovenous anastomosis. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01642498. © 2017 American Heart Association, Inc.

Automated ambulatory assessment of cognitive performance, environmental conditions, and motor activity during military operations

NASA Astrophysics Data System (ADS)

Lieberman, Harris R.; Kramer, F. Matthew; Montain, Scott J.; Niro, Philip; Young, Andrew J.

2005-05-01

Until recently scientists had limited opportunities to study human cognitive performance in non-laboratory, fully ambulatory situations. Recently, advances in technology have made it possible to extend behavioral assessment to the field environment. One of the first devices to measure human behavior in the field was the wrist-worn actigraph. This device, now widely employed, can acquire minute-by-minute information on an individual"s level of motor activity. Actigraphs can, with reasonable accuracy, distinguish sleep from waking, the most critical and basic aspect of human behavior. However, rapid technologic advances have provided the opportunity to collect much more information from fully ambulatory humans. Our laboratory has developed a series of wrist-worn devices, which are not much larger then a watch, which can assess simple and choice reaction time, vigilance and memory. In addition, the devices can concurrently assess motor activity with much greater temporal resolution then the standard actigraph. Furthermore, they continuously monitor multiple environmental variables including temperature, humidity, sound and light. We have employed these monitors during training and simulated military operations to collect information that would typically be unavailable under such circumstances. In this paper we will describe various versions of the vigilance monitor and how each successive version extended the capabilities of the device. Samples of data from several studies are presented, included studies conducted in harsh field environments during simulated infantry assaults, a Marine Corps Officer training course and mechanized infantry (Stryker) operations. The monitors have been useful for documenting environmental conditions experienced by wearers, studying patterns of sleep and activity and examining the effects of nutritional manipulations on warfighter performance.

Intensive versus conventional blood pressure monitoring in a general practice population. The Blood Pressure Reduction in Danish General Practice trial: a randomized controlled parallel group trial.

PubMed

Klarskov, Pia; Bang, Lia E; Schultz-Larsen, Peter; Gregers Petersen, Hans; Benee Olsen, David; Berg, Ronan M G; Abrahamsen, Henrik; Wiinberg, Niels

2018-01-17

To compare the effect of a conventional to an intensive blood pressure monitoring regimen on blood pressure in hypertensive patients in the general practice setting. Randomized controlled parallel group trial with 12-month follow-up. One hundred and ten general practices in all regions of Denmark. One thousand forty-eight patients with essential hypertension. Conventional blood pressure monitoring ('usual group') continued usual ad hoc blood pressure monitoring by office blood pressure measurements, while intensive blood pressure monitoring ('intensive group') supplemented this with frequent home blood pressure monitoring and 24-hour ambulatory blood pressure monitoring. Mean day- and night-time systolic and diastolic 24-hour ambulatory blood pressure. Change in systolic and diastolic office blood pressure and change in cardiovascular risk profile. Of the patients, 515 (49%) were allocated to the usual group, and 533 (51%) to the intensive group. The reductions in day- and night-time 24-hour ambulatory blood pressure were similar (usual group: 4.6 ± 13.5/2.8 ± 82 mmHg; intensive group: 5.6 ± 13.0/3.5 ± 8.2 mmHg; P = 0.27/P = 0.20). Cardiovascular risk scores were reduced in both groups at follow-up, but more so in the intensive than in the usual group (P = 0.02). An intensive blood pressure monitoring strategy led to a similar blood pressure reduction to conventional monitoring. However, the intensive strategy appeared to improve patients' cardiovascular risk profile through other effects than a reduction of blood pressure. Clinical Trials NCT00244660. © The Author 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment.

PubMed

Overholt, Bergein F; Brooks-Belli, Linda; Grace, Michael; Rankin, Kristin; Harrell, Royce; Turyk, Mary; Rosenberg, Fred B; Barish, Robert W; Gilinsky, Norman H

2010-04-01

To evaluate the use and impact of the recommended withdrawal time of at least 6 minutes from the cecum in colonoscopy in multiple gastroenterology endoscopy ambulatory surgery centers serving a wide geographical area. An observational prospective multicenter quality assurance review was conducted in 49 ambulatory surgery centers in 17 states with 315 gastroenterologists. There was no intervention with this quality assessment program as care of patients and the routine of gastroenterologists continued as standard practice. Multivariable analysis was applied to the database to examine factors affecting withdrawal time and polyp detection. There were 15,955 consecutive qualified patients receiving colonoscopies in a designated 4-week period. Gastroenterologists with average withdrawal times of 6 minutes or more in patients with no polyps were 1.8 times more likely to detect 1 or more polyps and had a significantly higher rate (P<0.0001) of polyp detection in patients with findings of polyps compared to gastroenterologists with average withdrawal times of less than 6 minutes in patients with no polyps. For patients with no pathology, the mean time of withdrawal was 6.98 (SD=4.34) minutes and for patients with pathology mean time of withdrawal was 11.27 (SD=6.71) minutes. Strongest predictors of withdrawal time of 6 minutes or more were presence of carcinoma (3.7 times more likely than those with no pathology), adenoma (2.0 times more likely than those with no pathology), and number of polyps visualized (1.7 times more likely for each polyp). This quality assurance assessment from standard colonoscopy practices of 315 gastroenterologists in 49 endoscopic ambulatory surgery centers serving a wide geographical area provides support for the merits of a colonoscopy withdrawal time from the cecum of 6 minutes or more to improve the detection of polyps.

Increasing ambulatory pulse pressure predicts the development of left ventricular hypertrophy during long-term follow-up.

PubMed

Pääkkö, Tero J W; Perkiömäki, Juha S; Kesäniemi, Y Antero; Ylitalo, Antti S; Lumme, Jarmo A; Huikuri, Heikki V; Ukkola, Olavi H

2018-03-01

Ambulatory blood pressure (ABP) has been shown to have an association with left ventricular hypertrophy (LVH). We evaluated the association between ABP characteristics and the development of LVH during long-term follow-up (20 years) in 420 middle-aged subjects from OPERA cohort. ABP measurements (ABPM) were recorded and echocardiographic examinations were performed at baseline and revisit. Anthropometrics were measured and laboratory analyses performed at visit. The questionnaire presented to all participants elicited detailed information about their habits. Left ventricular mass index (LVMI) was calculated according to Troys method. Baseline LVMI was a significant independent predictor of LVMI change (p < 0.001). None of the baseline continuous ABPM predicted the change in LVMI. A greater increase in daytime and night-time systolic blood pressure (BP) (p from 0.006 to 0.048) and 24 h, daytime and night-time pulse pressure (PP) (p from 0.005 to 0.034) predicted a greater increase in LVMI. Especially the increase in night-time SBP (p = 0.006) and PP (p = 0.005) predicted a greater increase in LVMI. We also considered circadian BP profiles among subjects, whose ABPM at baseline and echocardiographic measurements both at baseline and follow-up were available. Diastolic non-dippers were observed to show a greater increase in LVMI compared to diastolic dippers (10.6 ± 33.0 g/m 2 vs. 7.0 ± 28.8 g/m 2 , p = 0.032), when baseline LVMI and in-office DBP were taken account. These findings suggest that an increasing ambulatory PP increases and a diastolic non-dipping status may increase the risk for the development of LVH during later life course.

A Study to Develop a Model for the Allocation of Medical Supply Funds to the Various Clinical Services at Keller Army Community Hospital Based Upon Inpatient Weighted Units and Ambulatory Weighted Units

DTIC Science & Technology

1989-05-11

zDiagnosis Related Groups (DRGs), as developed by ther Mz researchers at Yale University in the late 1960s, were a m mmeans of classifying patients by...the group’s recalibration of the Rickard 19 ambulatory portion of the HCU was most important. This was because it resulted in, "an ambulatory

Watsu approach for improving spasticity and ambulatory function in hemiparetic patients with stroke.

PubMed

Chon, Seung Chul; Oh, Duck Won; Shim, Jae Hun

2009-06-01

This study reports the effect of Watsu as rehabilitation method for hemiparetic patients with stroke. Watsu consisted of 40 treatment sessions for 8 weeks, delivered underwater or at water surface level, it applied in three patients. Outcome measures included tools for assessing spasticity and ambulatory function. All patients showed decreased scores in the TAS and RVGA after Watsu application. Watsu was helpful in controlling spasticity and improving ambulatory function of the patients with hemiparesis.

Ambulatory care pavilion takes its place out front by solving multiple needs.

PubMed

Saukaitis, C A

1994-09-01

In sum, this structure exemplifies the fact that high-tech tertiary care medical centers can be user-friendly to the ambulatory health care consumer by serving their routine needs conveniently and efficiently. Says Gerald Miller, president of Crozer-Chester: "The ambulatory care pavilion has enabled Crozer to successfully and efficiently merge physicians' offices with institutional-based services and inpatient services. We are pleased with how the pavilion positions our medical center for the next century.

Using internal communication as a marketing strategy: gaining physician commitment.

PubMed

Heine, R P

1990-01-01

In the ambulatory care industry, increased competition and promotional costs are pressuring managers to design more creative and effective marketing strategies. One largely overlooked strategy is careful monitoring of the daily communication between physicians and ambulatory care staff providing physician services. Satisfying physician communication needs is the key to increasing physician commitment and referrals. This article outlines the steps necessary to first monitor, then improve the quality of all communication provided to physicians by ambulatory care personnel.

Successful Semi-Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation Bridge to Heart-Lung Transplantation in a Very Small Child.

PubMed

Wong, J Y W; Buchholz, H; Ryerson, L; Conradi, A; Adatia, I; Dyck, J; Rebeyka, I; Lien, D; Mullen, J

2015-08-01

Lung transplantation (LTx) may be denied for children on extracorporeal membrane oxygenation (ECMO) due to high risk of cerebral hemorrhage. Rarely has successful LTx been reported in children over 10 years of age receiving awake or ambulatory veno-venous ECMO. LTx following support with ambulatory veno-arterial ECMO (VA ECMO) in children has never been reported to our knowledge. We present the case of a 4-year-old, 12-kg child with heritable pulmonary artery hypertension and refractory right ventricular failure. She was successfully bridged to heart-lung transplantation (HLTx) using ambulatory VA ECMO. Initial resuscitation with standard VA ECMO was converted to an ambulatory circuit using Berlin heart cannulae. She was extubated and ambulating around her bed while on VA ECMO for 40 days. She received an HLTx from an oversized marginal lung donor. Despite a cardiac arrest and Grade 3 primary graft dysfunction, she made a full recovery without neurological deficits. She achieved 104% force expiratory volume in 1 s 33 months post-HLTx. Ambulatory VA ECMO may be a useful strategy to bridge very young children to LTx or HLTx. Patient tailored ECMO cannulation, minimization of hemorrhage, and thrombosis risks while on ECMO contributed to a successful HLTx in our patient. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

[Evaluation of a teaching ambulatory module of respiratory diseases in the undergraduate medical curriculum].

PubMed

Leiva R, Isabel; Bitran C, Marcela; Saldías P, Fernando

2012-05-01

As the focus of healthcare provision shifts towards ambulatory care, increasing attention must now be given to develop opportunities for clinical teaching in this setting. To assess teacher and students' views about the strengths and weaknesses of real and simulated patient interactions for teaching undergraduate students clinical skills in the ambulatory setting. Fourth-year medical students were exposed in a systematic way, during two weeks, to real and simulated patients in an outpatient clinic, who presented common respiratory problems, such as asthma, chronic obstructive pulmonary disease, smoking and sleep apnea syndrome. After the clinical interview, students received feedback from the tutor and their peers. The module was assessed interviewing the teachers and evaluating the results qualitatively. Students evaluated the contents and quality of teaching at the end of the rotation. Tutors identified the factors that facilitate ambulatory teaching. These depended on the module design, resources and patient care, of characteristics of students and their participation, leadership and interaction with professors. They also identified factors that hamper teaching activities such as availability of resources, student motivation and academic recognition. Most students evaluated favorably the interaction with real and simulated patients in the ambulatory setting. Teaching in the ambulatory setting was well evaluated by students and teachers. The use of qualitative methodology allowed contrasting the opinions of teachers and students.

Task demands and the pressures of everyday life: associations between cardiovascular reactivity and work blood pressure and heart rate.

PubMed

Steptoe, A; Cropley, M; Joekes, K

2000-01-01

Associations between cardiovascular stress reactivity and blood pressure and heart rate recorded in everyday life were hypothesized to depend on the stressfulness of the ambulatory monitoring period relative to standardized tasks and on activity levels at the time of measurement. One hundred two female and 60 male school teachers carried out high- and low-demand tasks under standardized conditions and ambulatory monitoring during the working day. Stress ratings during the day were close to those recorded during the low-demand task. Reactions to the low-demand task were significant predictors of ambulatory blood pressure and heart rate independent of baseline, age, gender, and body mass. Associations were more consistent for ambulatory recordings taken when participants were seated than when they were standing and when the ambulatory monitoring day was considered to be as stressful as usual or more stressful than usual, and not less stressful than usual. Laboratory-field associations of cardiovascular activity depend in part on the congruence of stressfulness and physical activity level in the 2 situations.

Ambulatory Blood Pressure Monitoring in Clinical Practice: A Review

PubMed Central

Viera, Anthony J.; Shimbo, Daichi

2016-01-01

Ambulatory blood pressure monitoring offers the ability to collect blood pressure readings several times an hour across a 24-hour period. Ambulatory blood pressure monitoring facilitates the identification of white-coat hypertension, the phenomenon whereby certain individuals who are not on antihypertensive medication show elevated blood pressure in a clinical setting but show non-elevated blood pressure averages when assessed by ambulatory blood pressure monitoring. Additionally, readings can be segmented into time windows of particular interest, e.g., mean daytime and nighttime values. During sleep, blood pressure typically decreases, or dips, such that mean sleep blood pressure is lower than mean awake blood pressure. A non-dipping pattern and nocturnal hypertension are strongly associated with increased cardiovascular morbidity and mortality. Approximately 70% of individuals dip ≥10% at night, while 30% have non-dipping patterns, when blood pressure remains similar to daytime average, or occasionally rises above daytime average. The various blood pressure categorizations afforded by ambulatory blood pressure monitoring are valuable for clinical management of high blood pressure since they increase accuracy for diagnosis and the prediction of cardiovascular risk. PMID:25107387

[Ambulatory pediatric surgery: 25 years of experience].

PubMed

González Landa, G; Sánchez-Ruiz, I; Prado, C; Azcona, I; Sánchez, C

2000-10-01

The objectives of this study are: collect 25 years of experience with ambulatory pediatric surgery in The Pediatric Surgery Service of Hospital de Cruces, present the results of a parents-patient satisfaction survey and show the estimated money savings in the last five years. In the period 1973-1997, 19,934 children (56% of the total surgical cases) were operated with ambulatory surgery, and have been grouped in five quinquenia, showing a constant increase of the percentage of ambulatory surgery. General surgery and ENT are the specialities that more frequently uses this type of surgery (72.4% and 68.6% of the surgical cases of each speciality, respectively, in the last ten years). In general surgery inguinal hernia is the most frequent diagnosis with an increase of orchidopexy in the last five years. ENT is doing ambulatory tonsilectomies in the last ten years. The prolonged recovery stay and unanticipated admissions are rare, usually due to vomiting. The parents satisfaction survey shows great acceptancy, although 13% preferred an overnight postoperative stay. The estimated money saved in the last quinquenia has been important.

Effective Online Bayesian Phylogenetics via Sequential Monte Carlo with Guided Proposals

PubMed Central

Fourment, Mathieu; Claywell, Brian C; Dinh, Vu; McCoy, Connor; Matsen IV, Frederick A; Darling, Aaron E

2018-01-01

Abstract Modern infectious disease outbreak surveillance produces continuous streams of sequence data which require phylogenetic analysis as data arrives. Current software packages for Bayesian phylogenetic inference are unable to quickly incorporate new sequences as they become available, making them less useful for dynamically unfolding evolutionary stories. This limitation can be addressed by applying a class of Bayesian statistical inference algorithms called sequential Monte Carlo (SMC) to conduct online inference, wherein new data can be continuously incorporated to update the estimate of the posterior probability distribution. In this article, we describe and evaluate several different online phylogenetic sequential Monte Carlo (OPSMC) algorithms. We show that proposing new phylogenies with a density similar to the Bayesian prior suffers from poor performance, and we develop “guided” proposals that better match the proposal density to the posterior. Furthermore, we show that the simplest guided proposals can exhibit pathological behavior in some situations, leading to poor results, and that the situation can be resolved by heating the proposal density. The results demonstrate that relative to the widely used MCMC-based algorithm implemented in MrBayes, the total time required to compute a series of phylogenetic posteriors as sequences arrive can be significantly reduced by the use of OPSMC, without incurring a significant loss in accuracy. PMID:29186587

On the relationship between lower extremity muscles activation and peak vertical and posterior ground reaction forces during single leg drop landing.

PubMed

Mahaki, M; Mi'mar, R; Mahaki, B

2015-10-01

Anterior cruciate ligament (ACL) injury continues to be an important medical issue for athletes participating in sports. Vertical and posterior ground reaction forces have received considerable attention for their potential influence on ACL injuries. The purpose of this study was to examine the relationship between electromyographic activity of lower extremity muscles and the peak vertical and posterior ground reaction forces during single leg drop landing. Thirteen physical education male students participated in this correlation study. Electromyographic activities of gluteus medius, biceps femoris, medial gastrocnemius, soleus as well as anterior tibialis muscles along with ground reaction forces were measured. Participants performed single-leg landing from a 0.3 m height on to a force platform. Landing was divided into two phases: 100 ms preceding ground contact and 100 ms proceeding ground contact. Pearson correlation test was used to determine the relationships between these muscles activity and peak vertical and posterior ground reaction forces. The results of the study indicated that the activity of soleus and tibialis anterior in pre-landing phase were positively correlated with peak vertical ground reaction force ([P≤0.04], [P≤0.008], respectively). However, no significant correlation was found between the activities of other muscles in pre-landing phase and peak vertical as well as peak posterior ground reaction forces. Also, no significant correlation was found between the activities of muscles in post-landing phase and peak vertical as well as peak posterior ground reaction forces. Soleus loading shifts the proximal tibia posterior at the knee joint and tibialis anterior prevent hyperporonation of the ankle, a mechanisms of ACL injury. Hence, neuromuscular training promoting preparatory muscle activity in these muscles may reduce the incidence of ACL injuries.

Ambulatory orthopaedic surgery patients' emotions when using different patient education methods.

PubMed

Heikkinen, Katja; Salanterä, Sanna; Leppänen, Tiina; Vahlberg, Tero; Leino-Kilpi, Helena

2012-07-01

A randomised controlled trial was used to evaluate elective ambulatory orthopaedic surgery patients' emotions during internet-based patient education or face-to-face education with a nurse. The internet-based patient education was designed for this study and patients used websites individually based on their needs. Patients in the control group participated individually in face-to-face patient education with a nurse in the ambulatory surgery unit. The theoretical basis for both types of education was the same. Ambulatory orthopaedic surgery patients scored their emotions rather low at intervals throughout the whole surgical process, though their scores also changed during the surgical process. Emotion scores did not decrease after patient education. No differences in patients' emotions were found to result from either of the two different patient education methods.

[Patient safety and a culture of responsibility in ambulatory care: strategies for improving practice].

PubMed

Lichte, Thomas; Klement, Andreas; Herrmann, Markus

2009-01-01

The development of a medical safety culture is spreading beyond the hospital into the ambulatory setting. Patient safety defined as "absence of unwanted events" (primum non nocere) can serve as a starting point for the advancement of our ambulatory medical care system. Error analyses conducted in GP and specialist practices will identify gaps and traps in the system and provide ideas for the development and implementation of new safety strategies in ambulatory patient care. In the light of the structures and processes of GP medical care aspects of patient safety will be correlated to the outcome quality and examples will be discussed. Possible strategies for the improvement of patient safety in GP practice will be presented from the perspective of both patient- and practice individuality.

[Development of a portable ambulatory ECG monitor based on embedded microprocessor unit].

PubMed

Wang, Da-xiong; Wang, Guo-jun

2005-06-01

To develop a new kind of portable ambulatory ECG monitor. The hardware and software were designed based on RCA-CDP1802. New methods of ECG data compression and feature extraction of QRS complexes were applied to software design. A model for automatic arrhythmia analysis was established for real-time ambulatory ECG Data analysis. Compact, low power consumption and low cost were emphasized in the hardware design. This compact and light-weight monitor with low power consumption and high intelligence was capable of real-time monitoring arrhythmia for more than 48 h. More than ten types of arrhythmia could be detected, only the compressed abnormal ECG data was recorded and could be transmitted to the host if required. The monitor meets the design requirements and can be used for ambulatory ECG monitoring.

A Study of CAP-1002 in Ambulatory and Non-Ambulatory Patients With Duchenne Muscular Dystrophy

ClinicalTrials.gov

2018-06-16

Muscular Dystrophies; Muscular Dystrophy, Duchenne; Muscular Disorders, Atrophic; Muscular Diseases; Neuromuscular Diseases; Nervous System Diseases; Genetic Diseases, X-Linked; Genetic Diseases, Inborn

85. INTERIOR VIEW, DETAIL, HEAD HOUSE, FIRST FLOOR AMBULATORY, WOOD ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

85. INTERIOR VIEW, DETAIL, HEAD HOUSE, FIRST FLOOR AMBULATORY, WOOD FLOOR SHOWING ORIGINAL AND REPLACED PANELS, LOOKING SOUTHWEST - Timberline Lodge, Timberline Trail, Government Camp, Clackamas County, OR

Ear Acupuncture for Post-Operative Pain Associated with Ambulatory Arthroscopic Knee Surgery: A Randomized Controlled Trial

DTIC Science & Technology

2014-01-14

E7(/(3+21(180%(5 ,QFOXGHDUHDFRGH 14 Jan 2014 Final Report Ear acupuncture for post-operative pain associated with ambulatory arthroscopic...DISTRIBUTION A. Approved for public release: distribution unlimited. The purpose of this study is to compare ear acupuncture plus standard therapy versus...3298 Ear Acupuncture for Post-operative Pa111 Assoc1ated With Ambulatory Arthroscopic Knee Surgery A Randomized Controlled Trial ’• V ’’ ’-’ I

Utilization of lean management principles in the ambulatory clinic setting.

PubMed

Casey, Jessica T; Brinton, Thomas S; Gonzalez, Chris M

2009-03-01

The principles of 'lean management' have permeated many sectors of today's business world, secondary to the success of the Toyota Production System. This management method enables workers to eliminate mistakes, reduce delays, lower costs, and improve the overall quality of the product or service they deliver. These lean management principles can be applied to health care. Their implementation within the ambulatory care setting is predicated on the continuous identification and elimination of waste within the process. The key concepts of flow time, inventory and throughput are utilized to improve the flow of patients through the clinic, and to identify points that slow this process -- so-called bottlenecks. Nonessential activities are shifted away from bottlenecks (i.e. the physician), and extra work capacity is generated from existing resources, rather than being added. The additional work capacity facilitates a more efficient response to variability, which in turn results in cost savings, more time for the physician to interact with patients, and faster completion of patient visits. Finally, application of the lean management principle of 'just-in-time' management can eliminate excess clinic inventory, better synchronize office supply with patient demand, and reduce costs.

Ambulatory recording of physiological variables during an ascent of Mt Aconcagua.

PubMed

Wagner, Dale R

2011-03-01

The aim of this descriptive case study was to use an ambulatory biosensor system to capture data in real time in a harsh environment and to obtain continuous physiological measurements during an ascent of Argentina's Mt Aconcagua, the highest point in the Western Hemisphere. Between the 5800-m-high camp and the 6962-m summit, a 41-year-old male with previous high-altitude mountaineering experience was measured for minute-by-minute heart rate (60-154 beats/min), respiration rate (2-42 breaths/min), skin temperature (11.7-36.1°C), and core temperature (36.9-38.7°C) (1240 min of data: 417 min rest/sleep; 643 min ascent; 180 min descent). All of the measured variables were significantly correlated with each other (p < 0.01). There were incidences of "open leads" and "recovered data," indicating the potential for some aberrant data; however, data exist for each minute of the 1240 minutes of collection, and the values are within the expected physiological ranges. This study demonstrates the potential application of telemetry to monitor physiological variables during high altitude mountaineering. Copyright © 2011 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.

Addressing outpatient continuity for ambulatory training: A novel tool for longitudinal primary care sign out.

PubMed

Long, Theodore; Uradu, Andrea; Castillo, Ronald; Brienza, Rebecca

2016-01-01

We created a tool to improve communication among health professional trainees in the ambulatory setting. The tool was devised to both inform practice partner teams about high-risk patients and assign patient follow-up issues to team members. Team members were internal medicine residents and nurse practitioner fellows in the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE), an interprofessional training model in primary care. We used a combination of Likert scale response questions and open ended questions to evaluate trainee attitudes before and after the implementation of the tool, as well as solicited feedback to improve the tool. After using the primary care sign out tool, trainees expressed greater confidence that they could identify high-risk patients that had been cared for by other trainees and that important patient care issues would be followed up by others when they were not in clinic. In terms of areas for improvement, respondents wanted to have the sign out tool posted online. Our sign out tool offers a strategy that others can use to improve communication and knowledge of shared patients within teams comprised of interprofessional trainees.

Development of motion resistant instrumentation for ambulatory near-infrared spectroscopy

PubMed Central

Zhang, Quan; Yan, Xiangguo; Strangman, Gary E.

2011-01-01

Ambulatory near-infrared spectroscopy (aNIRS) enables recording of systemic or tissue-specific hemodynamics and oxygenation during a person's normal activities. It has particular potential for the diagnosis and management of health problems with unpredictable and transient hemodynamic symptoms, or medical conditions requiring continuous, long-duration monitoring. aNIRS is also needed in conditions where regular monitoring or imaging cannot be applied, including remote environments such as during spaceflight or at high altitude. One key to the successful application of aNIRS is reducing the impact of motion artifacts in aNIRS recordings. In this paper, we describe the development of a novel prototype aNIRS monitor, called NINscan, and our efforts to reduce motion artifacts in aNIRS monitoring. Powered by 2 AA size batteries and weighting 350 g, NINscan records NIRS, ECG, respiration, and acceleration for up to 14 h at a 250 Hz sampling rate. The system's performance and resistance to motion is demonstrated by long term quantitative phantom tests, Valsalva maneuver tests, and multiparameter monitoring during parabolic flight and high altitude hiking. To the best of our knowledge, this is the first report of multiparameter aNIRS monitoring and its application in parabolic flight. PMID:21895335

The Changing Impact of Gastroesophageal Reflux Disease in Clinical Practice.

PubMed

Akst, Lee M; Haque, Omar J; Clarke, John O; Hillel, Alexander T; Best, Simon R A; Altman, Kenneth W

2017-03-01

The National Ambulatory Medical Care Survey (NAMCS) database was utilized to understand evolving national trends in diagnosis and management of reflux. The NAMCS database was queried for visits related to gastroesophageal reflux diagnosis and management. Analysis performed for time periods 1998-2001, 2002-2005, and 2006-2009 was weighted to provide national estimates of care. Results were compared to previously reported time periods from 1990 to 2001 to evaluate patterns in overall visits, age and ethnicity of patients, provider type, and prescriptions provided. The number of ambulatory visits for reflux increased from 8 684 000 in 1998-2001 to 15 750 000 in 2006-2009. Visits increased across each time period for internal medicine, family, and gastroenterology physicians. Among otolaryngologists, absolute visits increased from 1998-2001 to 2002-2005 but decreased in 2006-2009; difference between these time periods did not reach statistical significance. From 1998-2001 to 2006-2009, reflux medication use increased 233%, with continuing trends toward increased proton pump inhibitor use. Reflux visits have increased across all demographic subgroups studied. Knowledge of these trends may inform further paradigm shifts in diagnosis and management of reflux.

Recent advances in diagnostic testing for gastroesophageal reflux disease.

PubMed

Naik, Rishi D; Vaezi, Michael F

2017-06-01

Gastroesophageal reflux disease (GERD) has a large economic burden with important complications that include esophagitis, Barrett's esophagus, and adenocarcinoma. Despite endoscopy, validated patient questionnaires, and traditional ambulatory pH monitoring, the diagnosis of GERD continues to be challenging. Areas covered: This review will explore the difficulties in diagnosing GERD with a focus on new developments, ranging from basic fundamental changes (histology and immunohistochemistry) to direct patient care (narrow-band imaging, impedance, and response to anti-reflux surgery). We searched PubMed using the noted keywords. We included data from full-text articles published in English. Further relevant articles were identified from the reference lists of review articles. Expert commentary: Important advances in novel parameters in intraluminal impedance monitoring such as baseline impedance monitoring has created some insight into alternative diagnostic strategies in GERD. Recent advances in endoscopic assessment of esophageal epithelial integrity via mucosal impedance measurement is questioning the paradigm of prolonged ambulatory testing for GERD. The future of reflux diagnosis may very well be without the need for currently employed technologies and could be as simple as assessing changes in epithelia integrity as a surrogate marker for GERD. However, future studies must validate such an approach.

Strategic response by providers to specialty hospitals, ambulatory surgery centers, and retail clinics.

PubMed

Burns, Lawton R; David, Guy; Helmchen, Lorens A

2011-04-01

Radical innovation and disruptive technologies are frequently heralded as a solution to delivering higher quality, lower cost health care. According to the literature on disruption, local hospitals and physicians (incumbent providers) may be unable to competitively respond to such "creative destruction" and alter their business models for a host of reasons, thus threatening their future survival. However, strategic management theory and research suggest that, under certain conditions, incumbent providers may be able to weather the discontinuities posed by the disrupters. This article analyzes 3 disruptive innovations in service delivery: single-specialty hospitals, ambulatory surgical centers, and retail clinics. We first discuss the features of these innovations to assess how disruptive they are. We then draw on the literature on strategic adaptation to suggest how incumbents develop competitive responses to these disruptive innovations that assure their continued survival. These arguments are then evaluated in a field study of several urban markets based on interviews with both incumbents and entrants. The interviews indicate that entrants have failed to disrupt incumbent providers primarily as a result of strategies pursued by the incumbents. The findings cast doubt on the prospects for these disruptive innovations to transform health care.

Overview of a pharmacist anticoagulation certificate program.

PubMed

Kirk, Julienne K; Edwards, Rebecca; Brewer, Andrew; Miller, Cathey; Bray, Bryan; Groce, James B

2017-07-01

To describe the design of an ongoing anticoagulation certificate program and annual renewal update for pharmacists. Components of the anticoagulation certificate program include home study, pre- and posttest, live sessions, case discussions with evaluation and presentation, an implementation plan, and survey information (program evaluation and use in practice). Clinical reasoning skills were assessed through case work-up and evaluation prior to live presentation. An annual renewal program requires pharmacists to complete home study and case evaluations. A total of 361 pharmacists completed the anticoagulation certificate program between 2002 and 2015. Most (62%) practiced in ambulatory care and 38% in inpatient care settings (8% in both). In the past four years, 71% were working in or starting anticoagulation clinics in ambulatory and inpatient settings. In their evaluations of the program, an average of 90% of participants agreed or strongly agreed the lecture material was relevant and objectives were met. Pharmacists are able to apply knowledge and skills in management of anticoagulation. This structured practice-based continuing education program was intended to enhance pharmacy practice and has achieved that goal. The certificate program in anticoagulation was relevant to pharmacists who attended the program. Copyright © 2017. Published by Elsevier Inc.

Comparison of peritonitis rates and patient survival in automated and continuous ambulatory peritoneal dialysis: a 10-year single center experience.

PubMed

El-Reshaid, Wael; Al-Disawy, Hanan; Nassef, Hossameldeen; Alhelaly, Usama

2016-09-01

Peritonitis is a common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). In this retrospective study, peritonitis rates and patient survival of 180 patients on CAPD and 128 patients on APD were compared in the period from January 2005 to December 2014 at Al-Nafisi Center in Kuwait. All patients had prophylactic topical mupirocin at catheter exit site. Patients on CAPD had twin bag system with Y transfer set. The peritonitis rates were 1 in 29 months in CAPD and 1 in 38 months in APD (p < 0.05). Percentage of peritonitis free patients over 10-year period in CAPD and APD were 49 and 60%, respectively (p < 0.05). Time to develop peritonitis was 10.25 ± 3.1 months in CAPD compared to 16.1 ± 4 months in APD (p < 0.001). Relapse and recurrence rates were similar in both groups. Median patient survival in CAPD and APD groups with peritonitis was 13.1 ± 1 and 14 ± 1.4 months respectively (p = 0.3) whereas in peritonitis free patients it was 15 ± 1.4 months in CAPD and 23 ± 3.1 months in APD (p = 0.025). APD had lower incidence rate of peritonitis than CAPD. Patient survival was better in APD than CAPD in peritonitis free patients but was similar in patients who had peritonitis.

Effect of continuous positive airway pressure therapy on hypothalamic-pituitary-adrenal axis function and 24-h blood pressure profile in obese men with obstructive sleep apnea syndrome.

PubMed

Carneiro, Gláucia; Togeiro, Sônia Maria; Hayashi, Lílian F; Ribeiro-Filho, Fernando Flexa; Ribeiro, Artur Beltrame; Tufik, Sérgio; Zanella, Maria Teresa

2008-08-01

Obstructive sleep apnea syndrome (OSAS) increases the risk of cardiovascular events. Sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis activation may be the mechanism of this relationship. The aim of this study was to evaluate HPA axis and ambulatory blood pressure monitoring in obese men with and without OSAS and to determine whether nasal continuous positive airway pressure therapy (nCPAP) influenced responses. Twenty-four-hour ambulatory blood pressure monitoring and overnight cortisol suppression test with 0.25 mg of dexamethasone were performed in 16 obese men with OSAS and 13 obese men controls. Nine men with severe apnea were reevaluated 3 mo after nCPAP therapy. Body mass index and blood pressure of OSAS patients and obese controls were similar. In OSAS patients, the percentage of fall in systolic blood pressure at night (P = 0.027) and salivary cortisol suppression postdexamethasone (P = 0.038) were lower, whereas heart rate (P = 0.022) was higher compared with obese controls. After nCPAP therapy, patients showed a reduction in heart rate (P = 0.036) and a greater cortisol suppression after dexamethasone (P = 0.001). No difference in arterial blood pressure (P = 0.183) was observed after 3 mo of nCPAP therapy. Improvement in cortisol suppression was positively correlated with an improvement in apnea-hypopnea index during nCPAP therapy (r = 0.799, P = 0.010). In conclusion, men with OSAS present increased postdexamethasone cortisol levels and heart rate, which were recovered by nCPAP.

Evaluation of DNA extraction methods and their clinical application for direct detection of causative bacteria in continuous ambulatory peritoneal dialysis culture fluids from patients with peritonitis by using broad-range PCR.

PubMed

Kim, Si Hyun; Jeong, Haeng Soon; Kim, Yeong Hoon; Song, Sae Am; Lee, Ja Young; Oh, Seung Hwan; Kim, Hye Ran; Lee, Jeong Nyeo; Kho, Weon-Gyu; Shin, Jeong Hwan

2012-03-01

The aims of this study were to compare several DNA extraction methods and 16S rDNA primers and to evaluate the clinical utility of broad-range PCR in continuous ambulatory peritoneal dialysis (CAPD) culture fluids. Six type strains were used as model organisms in dilutions from 10(8) to 10(0) colony-forming units (CFU)/mL for the evaluation of 5 DNA extraction methods and 5 PCR primer pairs. Broad-range PCR was applied to 100 CAPD culture fluids, and the results were compared with conventional culture results. There were some differences between the various DNA extraction methods and primer sets with regard to the detection limits. The InstaGene Matrix (Bio-Rad Laboratories, USA) and Exgene Clinic SV kits (GeneAll Biotechnology Co. Ltd, Korea) seem to have higher sensitivities than the others. The results of broad-range PCR were concordant with the results from culture in 97% of all cases (97/100). Two culture-positive cases that were broad-range PCR-negative were identified as Candida albicans, and 1 PCR-positive but culture-negative sample was identified as Bacillus circulans by sequencing. Two samples among 54 broad-range PCR-positive products could not be sequenced. There were differences in the analytical sensitivity of various DNA extraction methods and primers for broad-range PCR. The broad-range PCR assay can be used to detect bacterial pathogens in CAPD culture fluid as a supplement to culture methods.

Non-compliance to the continuous ambulatory peritoneal dialysis procedure increases the risk of peritonitis.

PubMed

Mawar, Shashi; Gupta, Sanjay; Mahajan, Sandeep

2012-08-01

Peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) is the leading cause of technique failure. Information on the impact of non-compliance in performing CAPD exchange on peritonitis is limited. We aimed to find the prevalence of non-compliance to the CAPD procedure and its influence on the incidence of peritonitis. This observational study included 30 adult patients undergoing CAPD. The CAPD exchange procedure was observed at home and assessed as per the structured checklist and categorized into poor, average and good compliance. The compliance was correlated with the episodes of peritonitis in previous 1 year. The patients' mean age was 52 ± 13 years and the mean duration of CAPD was 2.1 ± 0.9 years. Only 16.5% of patients were good performers, while 67% were average performers, and 16.5% were poor performers. The technique skill was similar across all the steps of the procedure. The most common improperly performed steps were: not putting on a face mask in 68%, not flushing the tubing system in 60%, and not washing hands in 24%. Poor adherence to procedure was independent of age, gender, education and duration of dialysis. Ten episodes of peritonitis occurred in 5 patients over 1-year period. Peritonitis occurred in 60% of poor performers, whereas fully compliant patients had no peritonitis. Also 40% of the poorly compliant patients had multiple episodes of peritonitis. Poor compliance in performing the CAPD procedure is a modifiable risk factor for peritonitis. Adherence to recommended aseptic technique is the cornerstone of peritonitis prevention.

Self-reported adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.

PubMed

Lam, Lai Wah; Twinn, Sheila F; Chan, Sally W C

2010-04-01

This paper is a report of a study conducted to examine self-reported adherence to a therapeutic regimen for continuous ambulatory peritoneal dialysis. Studies of patients' adherence during dialysis have primarily focused on haemodialysis and have frequently yielded inconsistent results, which are attributed to the inconsistent tools used to measure adherence. Levels of adherence to all four components of the therapeutic regimen (i.e. dietary and fluid restrictions, medication, and the dialysis regimen) among patients receiving peritoneal dialysis have not been examined, especially from a patient perspective. A total population sample was used. A cross-sectional survey was carried out by face-to-face interviews in 2005 in one renal clinic in Hong Kong. A total of 173 patients undergoing peritoneal dialysis (56% of the total population) participated in the study. Patients perceived themselves as more adherent to medication (83%; 95% confidence interval 77-88%) and dialysis (93%; 95% confidence interval 88-96%) prescriptions than to fluid (64%; 95% confidence interval 56-71%) and dietary (38%; 95% confidence interval 30-45%) restrictions. Those who were male, younger or had received dialysis for 1-3 years saw themselves as more non-adherent compared with other patients. Healthcare professionals should take cultural issues into consideration when setting dietary and fluid restriction guidelines. Additional attention and support are required for patients who identify themselves as more non-adherent. To help patients live with end-stage renal disease and its treatment, qualitative research is required to understand how they go through the dynamic process of adherence.

Office-based surgery: embracing patient safety strategies.

PubMed

Shapiro, Fred E; Punwani, Nathan; Urman, Richard D

2013-01-01

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

Ambulatory tuberculosis treatment in post-Semashko health care systems needs supportive financing mechanisms.

PubMed

Kohler, S; Asadov, D A; Bründer, A; Healy, S; Khamraev, A K; Sergeeva, N; Tinnemann, P

2014-12-01

The tuberculosis (TB) control strategy in the Republic of Karakalpakstan, Uzbekistan, is being changed to decentralised out-patient care for most TB patients by the Government of Uzbekistan, in collaboration with the international medical humanitarian organisation Médecins Sans Frontières. Ambulatory treatment of both drug-susceptible and drug-resistant TB from the first day of treatment has been recommended since 2011. Out-patient treatment of TB from the beginning of treatment was previously prohibited. However, the current Uzbek health financing system, which evolved from the Soviet Semashko model, offers incentives that work against the adoption of ambulatory TB treatment. Based on the 'Comprehensive TB Care for All' programme implemented in Karakalpakstan, we describe how existing policies for the allocation of health funds complicate the scale-up of ambulatory-based management of TB.

Physician ownership of ambulatory surgery centers and practice patterns for urological surgery: Evidence from the State of Florida

PubMed Central

Strope, Seth A.; Daignault, Stephanie; Hollingsworth, John M.; Ze, Zaujun; Wei, John T.; Hollenbeck, Brent K.

2009-01-01

Objective To evaluate the relationship between ownership and use of ambulatory surgical centers (ASCs). Methods From 1998 through 2002, ambulatory surgical discharges for procedures within the genitourinary system were abstracted from the Florida State Ambulatory Surgery Database. State-wide utilization rates for ambulatory surgery were calculated by physician-level ownership (using an empirically-derived, externally-validated method) and financial incentives. A surgeon level Poisson regression model was fit to compare the rates of surgery by year, ownership, and their interaction. Results Rates of ambulatory surgery increased from 607 per 100,000 in 1998 to 702 per 100,000 in 2002 (p < 0.01 for trend). While rates at the hospital increased only slightly (0.9%), those at the ASC were up by 53% (p < 0.01). Physician ownership was associated with this greater utilization as new owners increased their use from 9 per 100,000 to 94 per 100,000 (p < 0.01) in the first full year as owners. In the first year of ownership, the proportion of a new owner’s surgeries comprised of financially lucrative procedures increased to 61% compared to 50% in the year preceding ownership (p < 0.01). Conclusions Physician ownership is associated with the increasing use of ASCs, although the extent to which this is attributable to previously unmet demand is unclear. However, new owners appear to alter their procedure-mix after establishing ownership to include a greater share of financially lucrative procedures. PMID:19330889

Wait watchers: the application of a waiting list active management program in ambulatory care.

PubMed

de Belvis, Antonio Giulio; Marino, Marta; Avolio, Maria; Pelone, Ferruccio; Basso, Danila; Dei Tos, Gian Antonio; Cinquetti, Sandro; Ricciardi, Walter

2013-04-01

This study describes and evaluates the application of a waiting list management program in ambulatory care. Waiting list active management survey (telephone call and further contact); before and after controlled trial. Local Health Trust in Veneto Region (North-East of Italy) in 2008-09. Five hundred and one people on a 554 waiting list for C Class ambulatory care diagnostic and/or clinical investigations (electrocardiography plus cardiology ambulatory consultation, eye ambulatory consultation, carotid vessels Eco-color-Doppler, legs Eco-color-Doppler or colonoscopy, respectively). Active list management program consisting of a telephonic interview on 21 items to evaluate socioeconomic features, self-perceived health status, social support, referral physician, accessibility and patients' satisfaction. A controlled before-and-after study was performed to evaluate anonymously the overall impact on patients' self-perceived quality of care. The rate of patients with deteriorating healthcare conditions; rate of dropout; interviewed degree of satisfaction about the initiative; overall impact on citizens' perceived quality of care. 95.4% patients evaluated the initiative as useful. After the intervention, patients more likely to have been targeted with the program showed a statistically significant increase in self-reported quality of care. Positive impact of the program on some dimensions of ambulatory care quality (health status, satisfaction, willingness to remain in the queue), thus confirming the outstanding value of 'not to leave people alone' and 'not to leave them feeling themselves alone' in healthcare delivery.

Ambulatory estimation of foot placement during walking using inertial sensors.

PubMed

Martin Schepers, H; van Asseldonk, Edwin H F; Baten, Chris T M; Veltink, Peter H

2010-12-01

This study proposes a method to assess foot placement during walking using an ambulatory measurement system consisting of orthopaedic sandals equipped with force/moment sensors and inertial sensors (accelerometers and gyroscopes). Two parameters, lateral foot placement (LFP) and stride length (SL), were estimated for each foot separately during walking with eyes open (EO), and with eyes closed (EC) to analyze if the ambulatory system was able to discriminate between different walking conditions. For validation, the ambulatory measurement system was compared to a reference optical position measurement system (Optotrak). LFP and SL were obtained by integration of inertial sensor signals. To reduce the drift caused by integration, LFP and SL were defined with respect to an average walking path using a predefined number of strides. By varying this number of strides, it was shown that LFP and SL could be best estimated using three consecutive strides. LFP and SL estimated from the instrumented shoe signals and with the reference system showed good correspondence as indicated by the RMS difference between both measurement systems being 6.5 ± 1.0 mm (mean ± standard deviation) for LFP, and 34.1 ± 2.7 mm for SL. Additionally, a statistical analysis revealed that the ambulatory system was able to discriminate between the EO and EC condition, like the reference system. It is concluded that the ambulatory measurement system was able to reliably estimate foot placement during walking. Copyright © 2010 Elsevier Ltd. All rights reserved.

Effect of losartan on ambulatory short-term blood pressure variability and cardiovascular remodeling in hypertensive patients on hemodialysis.

PubMed

Mitsuhashi, Hiroshi; Tamura, Kouichi; Yamauchi, Junji; Ozawa, Motoko; Yanagi, Mai; Dejima, Toru; Wakui, Hiromichi; Masuda, Shin-ichiro; Azuma, Koichi; Kanaoka, Tomohiko; Ohsawa, Masato; Maeda, Akinobu; Tsurumi-Ikeya, Yuko; Okano, Yasuko; Ishigami, Tomoaki; Toya, Yoshiyuki; Tokita, Yasuo; Ohnishi, Toshimasa; Umemura, Satoshi

2009-11-01

Previous studies have shown increases in ambulatory short-term blood pressure (BP) variability to be related to cardiovascular disease. In this study, we examined whether an angiotensin II type 1 receptor blocker losartan would improve ambulatory short-term BP variability in hypertensive patients on hemodialysis. Forty hypertensive patients on hemodialysis therapy were randomly assigned to the losartan treatment group (n=20) or the control treatment group (n=20). At baseline and 6 and 12 months after the treatment, 24-h ambulatory BP monitoring was performed. Echocardiography and measurements of brachial-ankle pulse wave velocity (baPWV) and biochemical parameters were also performed before and after therapy. After 6- and 12-months of treatment, nighttime short-term BP variability, assessed on the basis of the coefficient of variation of ambulatory BP, was significantly decreased in the losartan group, but remained unchanged in the control group. Compared with the control group, losartan significantly decreased left ventricular mass index (LVMI), baPWV, and the plasma levels of brain natriuretic peptide and advanced glycation end products (AGE). Furthermore, multiple regression analysis showed significant correlations between changes in LVMI and changes in nighttime short-term BP variability, as well as between changes in LVMI and changes in the plasma levels of AGE. These results suggest that losartan is beneficial for the suppression of pathological cardiovascular remodeling though its inhibitory effect on ambulatory short-term BP variability during nighttime.

Prescription Drug Shortages: Implications for Ambulatory Pediatrics.

PubMed

Donnelly, Katie A; Zocchi, Mark S; Katy, Tamara A; Fox, Erin R; van den Anker, John N; Mazer-Amirshahi, Maryann E

2018-05-08

To describe contemporary drug shortages affecting general ambulatory pediatrics. Data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Service. Two pediatricians reviewed drug shortages and identified agents used in ambulatory pediatrics. Shortage data were analyzed by the type of drug, formulation, reason for shortage, duration, marketing status, if a pediatric friendly-formulation was available, or if it was a single-source product. The availability of an alternative, and whether that alternative was affected by a shortage, also was noted. Of 1883 products in shortage during the study period, 314 were determined to be used in ambulatory pediatrics. The annual number of new pediatric shortages decreased initially but then increased to a high of 38 in 2011. Of the 314 pediatric shortages, 3.8% were unresolved at the end of the study. The median duration of resolved shortages was 7.6 months. The longest shortage was for ciprofloxacin 500-mg tablets. The most common class involved was infectious disease drugs. Pediatric-friendly dosage forms were affected in 19.1% of shortages. An alternative agent was available for 86% drugs; however, 29% of these also were affected. The most common reason for shortage was manufacturing problems. Drug shortages affected a substantial number of agents used in general ambulatory pediatrics. Shortages for single-source products are a concern if a suitable alternative is unavailable. Providers working in the ambulatory setting must be aware of current shortages and implement mitigation strategies to optimize patient care. Copyright © 2018 Elsevier Inc. All rights reserved.

Evolving vendor market for HITECH-certified ambulatory EHR products.

PubMed

Gold, Marsha; Hossain, Mynti; Charles, Dustin R; Furukawa, Michael F

2013-11-01

The ambitious goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act require rapid development and certification of new ambulatory electronic health record (EHR) products. To examine where the vendor market for EHR products stands now and the policy issues emerging from the market's evolution. Descriptive study with policy analysis. We had 3 main sources of information: (1) documents describing this evolving market, which is not well represented in peer-reviewed literature; (2) operational data on certified ambulatory EHR products and their use by Medicareeligible professionals attesting for meaningful use payments from January 2011 to October 2012; and (3) telephone interviews with 10 vendors that account for 57% of the market. Those attesting for Medicare meaningful use payments used ambulatory EHRs from 353 different vendors, although 16 firms accounted for 75% of the market. The Herfindahl-Hirschman Index showed the ambulatory EHR market to be highly competitive, particularly for practices of 50 or fewer professionals. The interviewed vendors and the external analysts agreed that stage 1 requirements set a relatively low bar for market entry, but that likely will change as requirements get more demanding. The HITECH Act met its initial goals to motivate growth of diverse ambulatory EHR products. A market shakeout may emerge, though current data reveal no signs of it. Policy makers can influence the shape and value of such a shakeout, and the extent of disruption, through their approach to certification and "usability" and "interoperability" strategies and requirements.

Ambulatory (24 hour) blood pressure monitoring in police officers.

PubMed

Tomei, Francesco; Rosati, Maria Valeria; Baccolo, Tiziana Paola; Cherubini, Emilia; Ciarrocca, Manuela; Caciari, Tiziana; Tomao, Enrico

2004-05-01

The aim of the study is to evaluate, by ambulatory (24 h) blood pressure monitoring (ABPM), whether police officers exposed to urban pollutants and possible psycho-social stressors could be at risk of changes in ambulatory systolic blood pressure (SBP), and ambulatory diastolic blood pressure (DBP) compared to controls. After excluding the principal confounding factors, police officers and controls have been subdivided into non-smoker and smoker subjects. Police officers were compared by sex, age, length of service, family history of cardiovascular disease, serum total cholesterol, serum HDL cholesterol, serum LDL cholesterol, plasma triglyceride, body mass index (BMI kg/m (2)) and drinking habits with controls. Smoker police officers were compared with controls also by the smoking habit. In the non smoker group 77 police officers with outdoor activity (38 men and 39 women) and 87 controls with indoor activity (43 men and 44 women) were studied. In the smoker group 43 police officers (21 men and 22 women) and 29 controls (15 men and 14 women) were studied. In non smoker male police officers ambulatory SBP mean values during 24 h, during day-time and during night-time were significantly higher than controls. In the same group ambulatory DBP values during 24 h and between 6 AM and 11 AM and between 10 PM and 6 AM were significantly higher in police officers than controls. The results suggest that occupational exposure to urban pollutants and possible psycho-social stressors could cause changes in ABPM values in male police officers compared to controls.

Preliminary study of percutaneous nephrolithotomy on an ambulatory basis.

PubMed

El-Tabey, Magdy Ahmed; Abd-Allah, Osama Abdel-Wahab; Ahmed, Ahmed Sebaey; El-Barky, Ehab Mohammed; Noureldin, Yasser Abdel-Sattar

2013-02-01

Preliminary study to assess the feasibility and safety of percutaneous nephrolithotomy (PCNL) as an ambulatory procedure. Between February 2011 and September 2012, 84 patients with renal calculi fulfilling the inclusion criteria were admitted to the Urology Department of Benha University Hospitals for PCNL. All patients were subjected to a full medical history, clinical, laboratory and radiological examinations. Tubeless PCNLs were done in the supine position, and an antegrade double-J stent was inserted. Operative time and intraoperative complications were recorded. Postoperatively, the hematocrit value, postoperative pain and analgesics, need of blood transfusion, stone-free rate, and length of hospital stay were recorded. Stable patients that could be safely discharged within 24 hours after surgery were considered ambulatory. All cases of tubeless PCNL were successfully done and no cases converted to open surgery. The overall stone-free rate was 91.7%, the mean postoperative pain score measured by the visual analog scale was 4.4 ± 1.2, the mean overall hematocrit deficit was 4.8 ± 2.2% and the mean hospital stay was 33.4 ± 17.5 hours. Ambulatory PCNL was accomplished in 60 out of 84 patients (71.4%) and double-J stents were removed 7-10 days postoperatively. In the non-ambulatory cases, double-J stents were removed after auxillary procedures were done according to each case. PCNL can be safely done on an ambulatory basis under strict criteria, but further studies are needed to confirm and expand these findings.

Spermiogenesis and spermatozoon ultrastructure in basal polyopisthocotylean monogeneans, Hexabothriidae and Chimaericolidae, and their significance for the phylogeny of the Monogenea

PubMed Central

Justine, Jean-Lou; Poddubnaya, Larisa G.

2018-01-01

Sperm ultrastructure provides morphological characters useful for understanding phylogeny; no study was available for two basal branches of the Polyopisthocotylea, the Chimaericolidea and Diclybothriidea. We describe here spermiogenesis and sperm in Chimaericola leptogaster (Chimaericolidae) and Rajonchocotyle emarginata (Hexabothriidae), and sperm in Callorhynchocotyle callorhynchi (Hexabothriidae). Spermiogenesis in C. leptogaster and R. emarginata shows the usual pattern of most Polyopisthocotylea with typical zones of differentiation and proximo-distal fusion of the flagella. In all three species, the structure of the spermatozoon is biflagellate, with two incorporated trepaxonematan 9 + “1” axonemes and a posterior nucleus. However, unexpected structures were also seen. An alleged synapomorphy of the Polyopisthocotylea is the presence of a continuous row of longitudinal microtubules in the nuclear region. The sperm of C. leptogaster has a posterior part with a single axoneme, and the part with the nucleus is devoid of the continuous row of microtubules. The spermatozoon of R. emarginata has an anterior region with membrane ornamentation, and posterior lateral microtubules are absent. The spermatozoon of C. callorhynchi has transverse sections with only dorsal and ventral microtubules, and its posterior part shows flat sections containing a single axoneme and the nucleus. These findings have important implications for phylogeny and for the definition of synapomorphies in the Neodermata. We point out a series of discrepancies between actual data and interpretation of character states in the matrix of a phylogeny of the Monogenea. Our main conclusion is that the synapomorphy “lateral microtubules in the principal region of the spermatozoon” does not define the Polyopisthocotylea but is restricted to the Mazocraeidea. PMID:29436366

Surfing-related ocular injuries.

PubMed

Kim, J W; McDonald, H R; Rubsamen, P E; Luttrull, J K; Drouilhet, J H; Frambach, D A; Boyer, D S; Lambrou, F H; Hendrick, A; Weiss, J N; Engstrom, R E; Ing, M

1998-01-01

This report evaluates the clinical characteristics of surfing-related ocular trauma to learn the nature of such injuries and propose possible preventive measures. The authors reviewed 11 cases of surfing-related eye injuries caused by direct trauma from the surfboard, studying their mechanism of injury, the associated ocular complications, and the anatomic and visual outcomes of surgical repair. Surfing-related ocular injuries occurred exclusively in young males (mean age, 24.8 years; range, 14-37 years). The mechanism of injury most frequently responsible was impact with the sharp nose of the surfboard following a fall. Serious posterior segment complications were observed in all 11 patients, with nine patients suffering ruptured globes. Despite immediate medical attention, five patients did not recover ambulatory levels of visual acuity (>5/200). Surfing-related ocular trauma presenting to the retinal specialist typically leaves the patient with a permanent visual disability. Important factors contributing to these high-velocity injuries include the sharply pointed nose of the surfboard and the leash keeping the surfer in close proximity to the board following a fall. A simple modification in surfboard design such as blunting the sharp nose of the surfboard, or appropriate protective guards fitted over the surfboard nose, should lessen the severity of such injuries.

Intramuscular pressures in antigravity muscles using gravity-independent, pneumatic hardware.

PubMed

Macias, Brandon R; Minocha, Ranjeet; Cutuk, Adnan A; Hill, James; Shiau, Jonathon; Hargens, Alan R

2008-08-01

Resistive exercise helps prevent muscle atrophy in microgravity, but better exercise equipment is needed. Therefore, the purpose of this study was to determine if a pneumatic, gravity-independent leg-press device (LPD) provides sufficient force to leg musculature. We hypothesized that intramuscular pressure (IMP), a quantitative index of muscle force, is greater in the antigravity superficial posterior and deep posterior compartments than in the non-antigravity anterior compartment during bilateral leg-press exercise. Millar pressure transducers were inserted into the anterior, lateral, superficial posterior, and deep posterior muscle compartments of the left leg of eight healthy subjects (three women, five men). Subjects were supine on the Keiser SX-1, a pneumatic LPD. Then maximal voluntary contraction (MVC) was determined; each subject performed three consecutive voluntary contractions at approximately 18%, 50%, and 100% MVC while continuously measuring IMP. Repeated measures ANOVA were used to determine differences of IMPs between compartments and loads. The magnitudes of IMP (mean +/- SEM) at 18 - 3% (abbreviated approximately 18%), 50%, and 100% MVC in the superficial and deep posterior compartments were significantly greater than that in the anterior compartment during exercise (P < 0.05). Additionally, IMPs in all four compartments significantly rose as resistance increased at approximately 18%, 50%, and 100% MVC (P < 0.05). The LPD provides significantly increased resistance to all four compartments, but with greater loading of the antigravity compartments as compared to the non-antigravity compartment. Since antigravity muscles of the leg are contained primarily in the superficial and deep posterior compartments, the LPD may help prevent muscle atrophy associated with microgravity.

Meta-synthesis on nurse practitioner autonomy and roles in ambulatory care.

PubMed

Wang-Romjue, Pauline

2018-04-01

Many healthcare stakeholders view nurse practitioners (NPs) as an important workforce resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is expected by 2020. Multiple quantitative studies revealed the attributes of NPs' practice autonomy and roles. However, there is no qualitative meta-synthesis that describes the experiences of NPs' practice autonomy and roles. To describe and understand the experiences of NPs regarding their practice autonomy and roles in various ambulatory settings through the exploration of existing qualitative studies: meta-synthesis. A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs' practice autonomy and roles through content analysis and reciprocal translation. Articles published between 2000 and 2017 were retrieved by searching 7 databases using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambulatory care, NP autonomy, and outpatient care. Autonomy, NPs' roles and responsibilities, practice relationships, and organizational work environment pressures are the four main themes that emerged from the content analysis of the nine selected qualitative studies. Within and between states, NPs' experiences with autonomy and NPs' roles are multifaceted depending on state regulations, practice relationships, and organizational work environments. © 2017 Wiley Periodicals, Inc.

Ambulatory diffuse optical tomography and multimodality physiological monitoring system for muscle and exercise applications

NASA Astrophysics Data System (ADS)

Hu, Gang; Zhang, Quan; Ivkovic, Vladimir; Strangman, Gary E.

2016-09-01

Ambulatory diffuse optical tomography (aDOT) is based on near-infrared spectroscopy (NIRS) and enables three-dimensional imaging of regional hemodynamics and oxygen consumption during a person's normal activities. Although NIRS has been previously used for muscle assessment, it has been notably limited in terms of the number of channels measured, the extent to which subjects can be ambulatory, and/or the ability to simultaneously acquire synchronized auxiliary data such as electromyography (EMG) or electrocardiography (ECG). We describe the development of a prototype aDOT system, called NINscan-M, capable of ambulatory tomographic imaging as well as simultaneous auxiliary multimodal physiological monitoring. Powered by four AA size batteries and weighing 577 g, the NINscan-M prototype can synchronously record 64-channel NIRS imaging data, eight channels of EMG, ECG, or other analog signals, plus force, acceleration, rotation, and temperature for 24+ h at up to 250 Hz. We describe the system's design, characterization, and performance characteristics. We also describe examples of isometric, cycle ergometer, and free-running ambulatory exercise to demonstrate tomographic imaging at 25 Hz. NINscan-M represents a multiuse tool for muscle physiology studies as well as clinical muscle assessment.

Ambulatory cardiovascular activity and hostility ratings in women with chronic posttraumatic stress disorder.

PubMed

Beckham, Jean C; Flood, Amanda M; Dennis, Michelle F; Calhoun, Patrick S

2009-02-01

The objective of the current study is to evaluate the relationship between hostility and ambulatory cardiovascular activity in women with and without posttraumatic stress disorder (PTSD). One hundred and one women completed 24 hours of ambulatory monitoring and standardized diagnostic and hostility measures. Generalized estimating equations analysis was used to examine the effects of group and hostility factor scores (hostile beliefs, overt hostility, and covert hostility) on ambulatory heart rate (AHR) and ambulatory systolic (ASBP) and diastolic (ADBP) blood pressure. After controlling for covariates, there was an interaction between PTSD and both hostile beliefs and overt hostility for AHR. Increases in hostility were associated with greater increases in heart rate among women with PTSD relative to those without PTSD. There was a similar interaction between hostile beliefs and group for ADBP. Increased AHR and blood pressure have been linked to poor cardiovascular outcomes in nonpsychiatric populations. Individuals with PTSD display increased hostility, a construct that has also been linked to poorer cardiovascular outcomes. Increases in hostile beliefs were associated with a greater increase in ADBP among women with PTSD as compared with control subjects. These data suggest that PTSD might in part moderate the relationship between hostility and cardiovascular outcomes.

Factors Associated with Mobility Outcomes in a National Spina Bifida Patient Registry

PubMed Central

Dicianno, Brad E.; Karmarkar, Amol; Houtrow, Amy; Crytzer, Theresa M.; Cushanick, Katelyn M.; McCoy, Andrew; Wilson, Pamela; Chinarian, James; Neufeld, Jacob; Smith, Kathryn; Collins, Diane M.

2017-01-01

Objective To provide descriptive data on ambulatory ability and muscle strength in a large cohort of individuals with spina bifida enrolled in a National Spina Bifida Patient Registry (NSBPR) and to investigate factors associated with ambulatory status. Design Cross-sectional analysis of data from a multi-site patient registry Results Descriptive analysis of mobility variables for 2604 individuals with spina bifida age 5 and above are presented from 19 sites in the United States. Analysis of a subset of NSBPR data from 380 individuals from three sites accompanied by data from a specialized spina bifida electronic medical record revealed that those with no history of a shunt, lower motor level, and no history of hip or knee contracture release surgery were more likely to be ambulatory at the community level than at the household or wheelchair level. Conclusion This study is the first to examine factors associated with ambulatory status in a large sample of individuals with myelomeningocele and non-myelomeningocele subtypes of SB. Results of this study delineate the breadth of strength and functional abilities within the different age groups and subtypes of SB. The results may inform clinicians of the characteristics of those with varying ambulatory abilities. PMID:26488146

Control of an Ambulatory Exoskeleton with a Brain-Machine Interface for Spinal Cord Injury Gait Rehabilitation.

PubMed

López-Larraz, Eduardo; Trincado-Alonso, Fernando; Rajasekaran, Vijaykumar; Pérez-Nombela, Soraya; Del-Ama, Antonio J; Aranda, Joan; Minguez, Javier; Gil-Agudo, Angel; Montesano, Luis

2016-01-01

The closed-loop control of rehabilitative technologies by neural commands has shown a great potential to improve motor recovery in patients suffering from paralysis. Brain-machine interfaces (BMI) can be used as a natural control method for such technologies. BMI provides a continuous association between the brain activity and peripheral stimulation, with the potential to induce plastic changes in the nervous system. Paraplegic patients, and especially the ones with incomplete injuries, constitute a potential target population to be rehabilitated with brain-controlled robotic systems, as they may improve their gait function after the reinforcement of their spared intact neural pathways. This paper proposes a closed-loop BMI system to control an ambulatory exoskeleton-without any weight or balance support-for gait rehabilitation of incomplete spinal cord injury (SCI) patients. The integrated system was validated with three healthy subjects, and its viability in a clinical scenario was tested with four SCI patients. Using a cue-guided paradigm, the electroencephalographic signals of the subjects were used to decode their gait intention and to trigger the movements of the exoskeleton. We designed a protocol with a special emphasis on safety, as patients with poor balance were required to stand and walk. We continuously monitored their fatigue and exertion level, and conducted usability and user-satisfaction tests after the experiments. The results show that, for the three healthy subjects, 84.44 ± 14.56% of the trials were correctly decoded. Three out of four patients performed at least one successful BMI session, with an average performance of 77.6 1 ± 14.72%. The shared control strategy implemented (i.e., the exoskeleton could only move during specific periods of time) was effective in preventing unexpected movements during periods in which patients were asked to relax. On average, 55.22 ± 16.69% and 40.45 ± 16.98% of the trials (for healthy subjects and patients, respectively) would have suffered from unexpected activations (i.e., false positives) without the proposed control strategy. All the patients showed low exertion and fatigue levels during the performance of the experiments. This paper constitutes a proof-of-concept study to validate the feasibility of a BMI to control an ambulatory exoskeleton by patients with incomplete paraplegia (i.e., patients with good prognosis for gait rehabilitation).

Control of an Ambulatory Exoskeleton with a Brain–Machine Interface for Spinal Cord Injury Gait Rehabilitation

PubMed Central

López-Larraz, Eduardo; Trincado-Alonso, Fernando; Rajasekaran, Vijaykumar; Pérez-Nombela, Soraya; del-Ama, Antonio J.; Aranda, Joan; Minguez, Javier; Gil-Agudo, Angel; Montesano, Luis

2016-01-01

The closed-loop control of rehabilitative technologies by neural commands has shown a great potential to improve motor recovery in patients suffering from paralysis. Brain–machine interfaces (BMI) can be used as a natural control method for such technologies. BMI provides a continuous association between the brain activity and peripheral stimulation, with the potential to induce plastic changes in the nervous system. Paraplegic patients, and especially the ones with incomplete injuries, constitute a potential target population to be rehabilitated with brain-controlled robotic systems, as they may improve their gait function after the reinforcement of their spared intact neural pathways. This paper proposes a closed-loop BMI system to control an ambulatory exoskeleton—without any weight or balance support—for gait rehabilitation of incomplete spinal cord injury (SCI) patients. The integrated system was validated with three healthy subjects, and its viability in a clinical scenario was tested with four SCI patients. Using a cue-guided paradigm, the electroencephalographic signals of the subjects were used to decode their gait intention and to trigger the movements of the exoskeleton. We designed a protocol with a special emphasis on safety, as patients with poor balance were required to stand and walk. We continuously monitored their fatigue and exertion level, and conducted usability and user-satisfaction tests after the experiments. The results show that, for the three healthy subjects, 84.44 ± 14.56% of the trials were correctly decoded. Three out of four patients performed at least one successful BMI session, with an average performance of 77.6 1 ± 14.72%. The shared control strategy implemented (i.e., the exoskeleton could only move during specific periods of time) was effective in preventing unexpected movements during periods in which patients were asked to relax. On average, 55.22 ± 16.69% and 40.45 ± 16.98% of the trials (for healthy subjects and patients, respectively) would have suffered from unexpected activations (i.e., false positives) without the proposed control strategy. All the patients showed low exertion and fatigue levels during the performance of the experiments. This paper constitutes a proof-of-concept study to validate the feasibility of a BMI to control an ambulatory exoskeleton by patients with incomplete paraplegia (i.e., patients with good prognosis for gait rehabilitation). PMID:27536214

77 FR 17068 - Medicare and Medicaid Programs; Approval of the Application by the American Association for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-23

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Fast and Accurate Learning When Making Discrete Numerical Estimates.

PubMed

Sanborn, Adam N; Beierholm, Ulrik R

2016-04-01

Many everyday estimation tasks have an inherently discrete nature, whether the task is counting objects (e.g., a number of paint buckets) or estimating discretized continuous variables (e.g., the number of paint buckets needed to paint a room). While Bayesian inference is often used for modeling estimates made along continuous scales, discrete numerical estimates have not received as much attention, despite their common everyday occurrence. Using two tasks, a numerosity task and an area estimation task, we invoke Bayesian decision theory to characterize how people learn discrete numerical distributions and make numerical estimates. Across three experiments with novel stimulus distributions we found that participants fell between two common decision functions for converting their uncertain representation into a response: drawing a sample from their posterior distribution and taking the maximum of their posterior distribution. While this was consistent with the decision function found in previous work using continuous estimation tasks, surprisingly the prior distributions learned by participants in our experiments were much more adaptive: When making continuous estimates, participants have required thousands of trials to learn bimodal priors, but in our tasks participants learned discrete bimodal and even discrete quadrimodal priors within a few hundred trials. This makes discrete numerical estimation tasks good testbeds for investigating how people learn and make estimates.

Fast and Accurate Learning When Making Discrete Numerical Estimates

PubMed Central

Sanborn, Adam N.; Beierholm, Ulrik R.

2016-01-01

Many everyday estimation tasks have an inherently discrete nature, whether the task is counting objects (e.g., a number of paint buckets) or estimating discretized continuous variables (e.g., the number of paint buckets needed to paint a room). While Bayesian inference is often used for modeling estimates made along continuous scales, discrete numerical estimates have not received as much attention, despite their common everyday occurrence. Using two tasks, a numerosity task and an area estimation task, we invoke Bayesian decision theory to characterize how people learn discrete numerical distributions and make numerical estimates. Across three experiments with novel stimulus distributions we found that participants fell between two common decision functions for converting their uncertain representation into a response: drawing a sample from their posterior distribution and taking the maximum of their posterior distribution. While this was consistent with the decision function found in previous work using continuous estimation tasks, surprisingly the prior distributions learned by participants in our experiments were much more adaptive: When making continuous estimates, participants have required thousands of trials to learn bimodal priors, but in our tasks participants learned discrete bimodal and even discrete quadrimodal priors within a few hundred trials. This makes discrete numerical estimation tasks good testbeds for investigating how people learn and make estimates. PMID:27070155

Joint-venture proposals strengthen hospital-physician relationship.

PubMed

Rovinsky, M

2000-12-01

By proposing the joint-venture development of an ambulatory surgery center and medical office space with a group practice, one hospital succeeded in enhancing its relationship with the practice and paved the way for future collaboration. Although the hospital's proposal to jointly develop an ambulatory surgery center was not accepted, the hospital was able to dissuade the group practice from developing a competing ambulatory surgery facility while increasing the group's trust in and loyalty to the hospital. As a result, the hospital potentially will benefit from increased inpatient admissions.

Relationships of muscle strength and bone mineral density in ambulatory children with cerebral palsy.

PubMed

Chen, C-L; Lin, K-C; Wu, C-Y; Ke, J-Y; Wang, C-J; Chen, C-Y

2012-02-01

This work explores the relationships of muscle strength and areal bone mineral density (aBMD) in ambulatory children with cerebral palsy (CP). The knee extensor strength, but not motor function, was related to aBMD. Thus, muscle strength, especially antigravity muscle strength, was more associated with aBMD in these children than motor function. Muscle strength is related to bone density in normal children. However, no studies have examined these relationships in ambulatory children with CP. This work explores the relationships of muscle strength and aBMD in ambulatory children with CP. Forty-eight ambulatory children with spastic CP, aged 5-15 years, were classified into two groups based on Gross Motor Function Classification System levels: I (n = 28) and II (n = 20). Another 31 normal development (ND) children were recruited as the comparison group for the aBMD. Children with CP underwent assessments of growth, lumbar and distal femur aBMD, Gross Motor Function Measure-66 (GMFM-66), and muscle strength of knee extensor and flexor by isokinetic dynamometer. The distal femur aBMD, but not lumbar aBMD, was lower in children with CP than in ND children (p < 0.05). Children with level I had greater knee flexor strength and GMFM-66 scores than those with level II (p < 0.001). However, the knee extensor strength and distal femur and lumbar aBMD did not differ between two groups. Regression analysis revealed the weight and knee extensor strength, but not GMFM-66 scores, were related positively to the distal femur and lumbar aBMD (adjusted r (2) = 0.56-0.65, p < 0.001). These results suggest the muscle strength, especially antigravity muscle strength, were more associated with the bone density of ambulatory children with CP than motor function. The data may allow clinicians for early identifying the ambulatory CP children of potential low bone density.

Office blood pressure or ambulatory blood pressure for the prediction of cardiovascular events.

PubMed

Mortensen, Rikke Nørmark; Gerds, Thomas Alexander; Jeppesen, Jørgen Lykke; Torp-Pedersen, Christian

2017-11-21

To determine the added value of (i) 24-h ambulatory blood pressure relative to office blood pressure and (ii) night-time ambulatory blood pressure relative to daytime ambulatory blood pressure for 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. A total of 7927 participants were included from the International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes. We used cause-specific Cox regression to predict 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. Discrimination of 10-year outcomes was assessed by time-dependent area under the receiver operating characteristic curve (AUC). No differences in predicted risks were observed when comparing office blood pressure and ambulatory blood pressure. The median difference in 10-year risks (1st; 3rd quartile) was -0.01% (-0.3%; 0.1%) for cardiovascular mortality and -0.1% (-1.1%; 0.5%) for cardiovascular events. The difference in AUC (95% confidence interval) was 0.65% (0.22-1.08%) for cardiovascular mortality and 1.33% (0.83-1.84%) for cardiovascular events. Comparing daytime and night-time blood pressure, the median difference in 10-year risks was 0.002% (-0.1%; 0.1%) for cardiovascular mortality and -0.01% (-0.5%; 0.2%) for cardiovascular events. The difference in AUC was 0.10% (-0.08 to 0.29%) for cardiovascular mortality and 0.15% (-0.06 to 0.35%) for cardiovascular events. Ten-year predictions obtained from ambulatory blood pressure are similar to predictions from office blood pressure. Night-time blood pressure does not improve 10-year predictions obtained from daytime measurements. For an otherwise healthy population sufficient prognostic accuracy of cardiovascular risks can be achieved with office blood pressure. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

PubMed

Kabré, Yvette B; Traoré, Idriss S S; Kaboré, Flavien A R; Ki, Bertille; Traoré, Alain I; Ouédraogo, Isso; Bandré, Emile; Wandaogo, Albert; Ouédraogo, Nazinigouba

2017-02-01

Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain. The family had to live within 1 hour of the hospital and be available by telephone. During the study period, a total of 1250 patients underwent surgery, of whom 515 were elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average age of 59.74 ± 41.57 months, actually underwent surgery. The principal indications for surgery were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review.

PubMed

Mus-Peters, Cindy T R; Huisstede, Bionka M A; Noten, Suzie; Hitters, Minou W M G C; van der Slot, Wilma M A; van den Berg-Emons, Rita J G

2018-05-22

Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.

Solute clearance measurement in the assessment of dialysis adequacy among African continuous ambulatory peritoneal dialysis patients.

PubMed

Abdu, Aliyu; Naidoo, Sagren; Malgas, Shirin; Naicker, Jocelyn T; Paget, Graham; Naicker, Saraladevi

2015-01-01

Solute clearance measurement is an objective means of quantifying the dose of peritoneal dialysis (PD). Despite continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients, guidelines based on solute clearance values are common in clinical practice. There is limited information on the solute clearance indices and PD adequacy parameters among this predominantly low socioeconomic status PD population. We investigated the solute clearance among continuous ambulatory peritoneal dialysis (CAPD) patients at the Charlotte Maxeke Johannesburg Academic Hospital and its relationship with other parameters of PD adequacy. Seventy patients on CAPD were studied in this cross-sectional study. Solute clearance was assessed using urea clearance (Kt/V). Linear regression analysis was used to determine factors associated with solute clearance, while analysis of variance was used to test the influence of weekly Kt/V on blood pressure (BP), hemoglobin (Hb) and other biochemical parameters. The mean age of the study population was 37.9 ± 12.4 years, 43% were females and 86% were black Africans. The mean duration on CAPD was 19.7 ± 20.8 months. Mean systolic and diastolic BP were 144 ± 28 and 92 ± 17 mm Hg, respectively. The mean Hb was 11.1 ± 2.2 g/dL and the mean weekly Kt/V was 1.7 ± 0.3. Factors like systolic BP, Hb level, serum levels of cholesterol, calcium, phosphate, parathyroid hormone and albumin were not significantly associated with the weekly Kt/V. We conclude that the dose of PD received by the majority of our patients in terms of the weekly Kt/V is within the recommended values and that this finding is significant considering the low socioeconomic background of our patients. There is no significant association between Kt/V and other indices of dialysis adequacy.

Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients: A retrospective study.

PubMed

Tian, Yuanshi; Xie, Xishao; Xiang, Shilong; Yang, Xin; Zhang, Xiaohui; Shou, Zhangfei; Chen, Jianghua

2016-12-01

Peritonitis remains a major complication of peritoneal dialysis (PD). A high peritonitis rate (HPR) affects continuous ambulatory peritoneal dialysis (CAPD) patients' technique survival and mortality. Predictors and outcomes of HPR, rather than the first peritonitis episode, were rarely studied in the Chinese population. In this study, we examined the risk factors associated with HPR and its effects on clinical outcomes in CAPD patients.This is a single center, retrospective, observational cohort study. A total of 294 patients who developing at least 1 episode of peritonitis were followed up from March 1st, 2002, to July 31, 2014, in our PD center. Multivariate logistic regression was used to determine the factors associated with HPR, and the Cox proportional hazard model was conducted to assess the effects of HPR on clinical outcomes.During the study period of 2917.5 patient-years, 489 episodes of peritonitis were recorded, and the total peritonitis rate was 0.168 episodes per patient-year. The multivariate analysis showed that factors associated with HPR include a quick occurrence of peritonitis after CAPD initiation (shorter than 12 months), and a low serum albumin level at the start of CAPD. In the Cox proportional hazard model, HPR was a significant predictor of technique failure. There were no differences between HPR and low peritonitis rate (LPR) group for all-cause mortality. However, when the peritonitis rate was considered as a continuous variable, a positive correlation was observed between the peritonitis rate and mortality.We found the quick peritonitis occurrence after CAPD and the low serum albumin level before CAPD were strongly associated with an HPR. Also, our results verified that HPR was positively correlated with technique failure. More importantly, the increase in the peritonitis rate suggested a higher risk of all-cause mortality.These results may help to identify and target patients who are at higher risk of HPR at the start of CAPD and to take interventions to reduce peritonitis incidence and improve clinical outcomes.

Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients

PubMed Central

Tian, Yuanshi; Xie, Xishao; Xiang, Shilong; Yang, Xin; Zhang, Xiaohui; Shou, Zhangfei; Chen, Jianghua

2016-01-01

Abstract Peritonitis remains a major complication of peritoneal dialysis (PD). A high peritonitis rate (HPR) affects continuous ambulatory peritoneal dialysis (CAPD) patients’ technique survival and mortality. Predictors and outcomes of HPR, rather than the first peritonitis episode, were rarely studied in the Chinese population. In this study, we examined the risk factors associated with HPR and its effects on clinical outcomes in CAPD patients. This is a single center, retrospective, observational cohort study. A total of 294 patients who developing at least 1 episode of peritonitis were followed up from March 1st, 2002, to July 31, 2014, in our PD center. Multivariate logistic regression was used to determine the factors associated with HPR, and the Cox proportional hazard model was conducted to assess the effects of HPR on clinical outcomes. During the study period of 2917.5 patient-years, 489 episodes of peritonitis were recorded, and the total peritonitis rate was 0.168 episodes per patient-year. The multivariate analysis showed that factors associated with HPR include a quick occurrence of peritonitis after CAPD initiation (shorter than 12 months), and a low serum albumin level at the start of CAPD. In the Cox proportional hazard model, HPR was a significant predictor of technique failure. There were no differences between HPR and low peritonitis rate (LPR) group for all-cause mortality. However, when the peritonitis rate was considered as a continuous variable, a positive correlation was observed between the peritonitis rate and mortality. We found the quick peritonitis occurrence after CAPD and the low serum albumin level before CAPD were strongly associated with an HPR. Also, our results verified that HPR was positively correlated with technique failure. More importantly, the increase in the peritonitis rate suggested a higher risk of all-cause mortality. These results may help to identify and target patients who are at higher risk of HPR at the start of CAPD and to take interventions to reduce peritonitis incidence and improve clinical outcomes. PMID:27930566

Ambulatory blood pressure response to a bout of HIIT in metabolic syndrome patients.

PubMed

Ramirez-Jimenez, M; Morales-Palomo, F; Pallares, J G; Mora-Rodriguez, Ricardo; Ortega, J F

2017-07-01

The effectiveness of exercise to lower blood pressure may depend on the type and intensity of exercise. We study the short-term (i.e., 14-h) effects of a bout of high-intensity aerobic interval training (HIIT) on blood pressure in metabolic syndrome (MetS) patients. Nineteen MetS patients (55.2 ± 7.3 years, 6 women) entered the study. Eight of them were normotensive and eleven hypertensive according to MetS threshold (≥130 mmHg for SBP and/or ≥85 mmHg for DBP). In the morning of 3 separated days, they underwent a cycling exercise bout of HIIT (>90% of maximal heart rate, ~85% VO 2max ), or a bout of isocaloric moderate-intensity continuous training (MICT; ~70% of maximal heart rate, ~60% VO 2max ), or a control no-exercise trial (REST). After exercise, ambulatory blood pressure (ABP; 14 h) was monitored, while subjects continued their habitual daily activities wearing a wrist-band activity monitor. No ABP differences were found for normotensive subjects. In hypertensive subjects, systolic ABP was reduced by 6.1 ± 2.2 mmHg after HIIT compared to MICT and REST (130.8 ± 3.9 vs. 137.4 ± 5.1 and 136.4 ± 3.8 mmHg, respectively; p < 0.05). However, diastolic ABP was similar in all three trials (77.2 ± 2.6 vs. 78.0 ± 2.6 and 78.9 ± 2.8 mmHg, respectively). Motion analysis revealed no differences among trials during the 14-h. This study suggests that the blood pressure reducing effect of a bout of exercise is influence by the intensity of exercise. A HIIT exercise bout is superior to an equivalent bout of continuous exercise when used as a non-pharmacological aid in the treatment of hypertension in MetS.

Optimising postoperative pain management in the ambulatory patient.

PubMed

Shang, Allan B; Gan, Tong J

2003-01-01

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation. Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner. While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the treatment of acute pain.Non-pharmacological methods for the management of postoperative pain include acupuncture, electromagnetic millimetre waves, hypnosis and the use of music during surgery. However, further research of these techniques is warranted to elucidate their effectiveness in this indication. Pain is a multifactorial experience, not just a sensation. Emotion, perception and past experience all affect an individual's response to noxious stimuli. Improved postoperative pain control through innovation and creativity may improve compliance, ease of delivery, reduce length of hospital stay and improve patient satisfaction. Patient education, early diagnosis of symptoms and aggressive treatment of pain using an integrative approach, combining pharmacotherapy as well as complementary technique, should serve us well in dealing with this complex problem.

An Ambulatory Medical Education Program for Internal Medicine Residents.

ERIC Educational Resources Information Center

Wones, Robert G.; And Others

1987-01-01

An ambulatory medicine program for university hospital clinic residents was found to be effective in improving students' knowledge, enhancing attitudes toward the clinic, and improving performance of influenza vaccinations. No adverse program effects were found. (MSE)

Patient Safety Threat - Syringe Reuse

MedlinePlus

... Fingerstick Devices Clinical Reminder: Insulin Pens Publications Infection Control Assessment of Ambulatory Surgical Centers Meetings Insurance Stakeholders Meeting – December 2011 Ambulatory Surgical Centers – October 2010 Safety by Design – May 2010 Sticking with Safety – May 2010 Injection ...

Influence of Patient Characteristics on Success of Ambulatory Blood Pressure Monitoring

PubMed Central

Fravel, Michelle A.; Ernst, Michael E.; Weber, Cynthia A.; Dawson, Jeffrey D.; Carter, Barry L.; Bergus, George R.

2014-01-01

Study Objective To examine the influence of specific patient characteristics on the success of ambulatory blood pressure monitoring (ABPM). Design Retrospective analysis. Setting University-affiliated family care center. Patients Five hundred thirty patients (mean age 52.7 yrs, range 14–90 yrs) who were undergoing ABPM between January 1, 2001, and July 1, 2007. Measurement and Main Results Specific patient characteristics were identified through an electronic medical record review and then examined for association with ABPM session success rate. These patient characteristics included age, sex, weight, height, body mass index (BMI), occupation, clinic blood pressure, travel distance to clinic, and presence of diabetes mellitus or renal disease. The percentage of valid readings obtained during an ABPM session was analyzed continuously (0–100%), whereas overall session success was analyzed dichotomously (0–79% or 80–100%). Univariate and multivariate regression analyses were performed to examine the influence of patient characteristics on the percentage of valid readings and the overall likelihood of achieving a successful session. In the 530 patients, the average percentage of valid readings was 90%, and a successful ABPM session (≥ 80% valid readings) was obtained in 84.7% (449 patients). A diagnosis of diabetes was found to negatively predict ABPM session success (continuous variable analysis, p=0.019; dichotomous variable analysis, odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23–0.87, p=0.019), as did renal disease (continuous variable analysis, p=0.006; dichotomous variable analysis, OR 0.39, 95% CI 0.17–0.90, p=0.027) and increasing BMI (continuous variable analysis, p<0.001; dichotomous variable analysis, OR 0.78, 95% CI 0.65–0.93, p=0.005). Renal disease and BMI remained significant predictors in adjusted analyses. Conclusion For most patients, ABPM was successful; however, elevated BMI and renal disease were associated with less complete ABPM session results. Adaptation and individualization of the ABPM process may be necessary to improve results in these patients. PMID:18956994

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences

PubMed Central

Pereira, Chrystian R.; Harris, Ila M.; Moon, Jean Y.; Westberg, Sarah M.; Kolar, Claire

2016-01-01

Objective. To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). Design. Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students’ competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. Assessment. Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. Conclusions. Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs. PMID:26941440

Reliability and Validity of Ambulatory Cognitive Assessments

PubMed Central

Sliwinski, Martin J.; Mogle, Jacqueline A.; Hyun, Jinshil; Munoz, Elizabeth; Smyth, Joshua M.; Lipton, Richard B.

2017-01-01

Mobile technologies are increasingly used to measure cognitive function outside of traditional clinic and laboratory settings. Although ambulatory assessments of cognitive function conducted in people’s natural environments offer potential advantages over traditional assessment approaches, the psychometrics of cognitive assessment procedures have been understudied. We evaluated the reliability and construct validity of ambulatory assessments of working memory and perceptual speed administered via smartphones as part of an ecological momentary assessment (EMA) protocol in a diverse adult sample (N=219). Results indicated excellent between-person reliability (≥.97) for average scores, and evidence of reliable within-person variability across measurement occasions (.41–.53). The ambulatory tasks also exhibited construct validity, as evidence by their loadings on working memory and perceptual speed factors defined by the in-lab assessments. Our findings demonstrate that averaging across brief cognitive assessments made in uncontrolled naturalistic settings provide measurements that are comparable in reliability to assessments made in controlled laboratory environments. PMID:27084835

Hypertension and arterial stiffness in heart transplantation patients

PubMed Central

de Souza-Neto, João David; de Oliveira, Ítalo Martins; Lima-Rocha, Hermano Alexandre; Oliveira-Lima, José Wellington; Bacal, Fernando

2016-01-01

OBJECTIVES: Post-transplantation hypertension is prevalent and is associated with increased cardiovascular morbidity and subsequent graft dysfunction. The present study aimed to identify the factors associated with arterial stiffness as measured by the ambulatory arterial stiffness index. METHODS: The current study used a prospective, observational, analytical design to evaluate a group of adult heart transplantation patients. Arterial stiffness was obtained by monitoring ambulatory blood pressure and using the ambulatory arterial stiffness index as the surrogate outcome. Multivariate logistic regression analyses were performed to control confounding. RESULTS: In a group of 85 adult heart transplantation patients, hypertension was independently associated with arterial stiffness (OR 4.98, CI 95% 1.06-23.4) as well as systolic and diastolic blood pressure averages and nighttime descent. CONCLUSIONS: Measurement of ambulatory arterial stiffness index is a new, non-invasive method that is easy to perform, may contribute to better defining arterial stiffness prognosis and is associated with hypertension. PMID:27652829

Participation restrictions in ambulatory amyotrophic lateral sclerosis patients: Physical and psychological factors.

PubMed

Van Groenestijn, Annerieke C; Schröder, Carin D; Kruitwagen-Van Reenen, Esther T; Van Den Berg, Leonard H; Visser-Meily, Johanna M A

2017-11-01

The aim of this study was to assess the prevalence of participation restrictions in ambulatory patients with amyotrophic lateral sclerosis (ALS) and to identify physical and psychological contributory factors. In this cross-sectional study, self-reported participation restrictions of 72 ambulatory ALS patients were assessed using the social health status dimension (SIPSOC) of the Sickness Impact Profile (SIP-68). Associations between SIPSOC and physical functioning, psychological factors, and demographic factors were analyzed using hierarchical regression analyses. Ninety-two percent of the patients reported participation restrictions; 54.9% could be explained by physical functioning; psychological factors accounted for 8.1% of the variance. Lung capacity, functional mobility, fatigue, and helplessness were independently associated with participation restrictions. Ambulatory ALS patients have participation restrictions, which may be influenced if early ALS care is directed toward lung capacity, functional mobility, fatigue, and feelings of helplessness. Muscle Nerve 56: 912-918, 2017. © 2017 Wiley Periodicals, Inc.

[The scope and structure of ambulatory polyclinic visits of physicians in the Russian Federation in 2009-2011].

PubMed

Schepin, V O; Mirgorodskaya, O V

2013-01-01

The article presents the results of structural functional analysis of public statistic data concerning the appealability of population the Russian Federation for ambulatory polyclinic care in health institutions of Minzdrav of Russia in 2009-2011. The study was targeted to identify the institutions, the volume, the specialists, the groups of population and purpose of provided medical care. It is demonstrated that during three years the significant differences in volume and structure of ambulatory polyclinic care used per capita between adults and children, urban and rural residents still are present. This is an indication of different degree of need and availability of this kind of medical care. It is noted that in ambulatory polyclinic institutions the specialized medical care is provided mainly on the occasion of diseases. This situation is not fully in line with present conceptions of targets of this stage of medical care provision.

Support Vector Machines to improve physiologic hot flash measures: application to the ambulatory setting.

PubMed

Thurston, Rebecca C; Hernandez, Javier; Del Rio, Jose M; De La Torre, Fernando

2011-07-01

Most midlife women have hot flashes. The conventional criterion (≥2 μmho rise/30 s) for classifying hot flashes physiologically has shown poor performance. We improved this performance in the laboratory with Support Vector Machines (SVMs), a pattern classification method. We aimed to compare conventional to SVM methods to classify hot flashes in the ambulatory setting. Thirty-one women with hot flashes underwent 24 h of ambulatory sternal skin conductance monitoring. Hot flashes were quantified with conventional (≥2 μmho/30 s) and SVM methods. Conventional methods had low sensitivity (sensitivity=.57, specificity=.98, positive predictive value (PPV)=.91, negative predictive value (NPV)=.90, F1=.60), with performance lower with higher body mass index (BMI). SVMs improved this performance (sensitivity=.87, specificity=.97, PPV=.90, NPV=.96, F1=.88) and reduced BMI variation. SVMs can improve ambulatory physiologic hot flash measures. Copyright © 2010 Society for Psychophysiological Research.

Exploring the link between ambulatory care and avoidable hospitalizations at the Veteran Health Administration.

PubMed

Pracht, Etienne E; Bass, Elizabeth

2011-01-01

This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable. © 2011 National Association for Healthcare Quality.

Biomedical Wireless Ambulatory Crew Monitor

NASA Technical Reports Server (NTRS)

Chmiel, Alan; Humphreys, Brad

2009-01-01

A compact, ambulatory biometric data acquisition system has been developed for space and commercial terrestrial use. BioWATCH (Bio medical Wireless and Ambulatory Telemetry for Crew Health) acquires signals from biomedical sensors using acquisition modules attached to a common data and power bus. Several slots allow the user to configure the unit by inserting sensor-specific modules. The data are then sent real-time from the unit over any commercially implemented wireless network including 802.11b/g, WCDMA, 3G. This system has a distributed computing hierarchy and has a common data controller on each sensor module. This allows for the modularity of the device along with the tailored ability to control the cards using a relatively small master processor. The distributed nature of this system affords the modularity, size, and power consumption that betters the current state of the art in medical ambulatory data acquisition. A new company was created to market this technology.

MRI appearance of posterior cruciate ligament tears.

PubMed

Rodriguez, William; Vinson, Emily N; Helms, Clyde A; Toth, Alison P

2008-10-01

There is little in the radiology literature regarding the MRI appearance of a torn posterior cruciate ligament (PCL). The purpose of this study was to describe the MRI appearance of surgically proven PCL tears and to emphasize previously unreported signs. The PCL is usually injured as the result of stretching deformation; on MRI, the ligament maintains continuity as a single structure with apparent thickening. On sagittal T2-weighted images, an anteroposterior diameter of 7 mm or more is highly suggestive of a torn PCL. Increased intrasubstance signal intensity in the PCL on proton-density images with lower signal intensity on T2-weighted images is another common feature.

Continuing Versus New Prescriptions for Sedative-Hypnotic Medications: United States, 2005–2012

PubMed Central

Spira, Adam P.; Depp, Colin A.; Mojtabai, Ramin

2016-01-01

Objectives. To assess trends in continuing and new prescriptions for sedative-hypnotic medications, including benzodiazepines (BZDs) and non-BZD receptor agonists (nBZRAs). Methods. Data came from the National Ambulatory Medical Care Survey and comprised 287 288 randomly sampled patient visits. Physicians reported medications prescribed and whether they were “continuing” or “new” prescriptions. We assessed trends in continuing BZD, new BZD, continuing nBZRA, and new nBZRA prescriptions from 2005 to 2012. Results. Proportions of visits with continuing prescriptions increased from 3.4% in 2005 to 4.7% in 2012 (P < .01) for BZDs, and from 1.0% to 1.7% (P < .01) for nBZRAs. We noted no changes in new prescriptions. We observed the same patterns across patient age and physician specialties, except psychiatry. Despite no growth over time, the prevalence of visits involving continuing and new BZD and nBZRA prescriptions was much higher in psychiatry than in primary care and other specialties. Conclusions. Increased sedative-hypnotic prescribing in recent years may be attributable to long-term growth in continuing prescriptions, rather than new prescriptions. Public Health Implications. Findings call for renewed efforts to limit continuing prescribing of sedative-hypnotics to reduce their use in the population. PMID:27631754

Real-Time Management of Multimodal Streaming Data for Monitoring of Epileptic Patients.

PubMed

Triantafyllopoulos, Dimitrios; Korvesis, Panagiotis; Mporas, Iosif; Megalooikonomou, Vasileios

2016-03-01

New generation of healthcare is represented by wearable health monitoring systems, which provide real-time monitoring of patient's physiological parameters. It is expected that continuous ambulatory monitoring of vital signals will improve treatment of patients and enable proactive personal health management. In this paper, we present the implementation of a multimodal real-time system for epilepsy management. The proposed methodology is based on a data streaming architecture and efficient management of a big flow of physiological parameters. The performance of this architecture is examined for varying spatial resolution of the recorded data.

Physician-executives past, present, and future.

PubMed

Smallwood, K G; Wilson, C N

1992-08-01

The dramatic changes in the United States' health care system during the last decade have sparked increasing interest in physician-executives. These executives, skilled in both clinical medicine and health care management, can be found in hospitals, managed care organizations, group practices, and government institutions. This paper outlines the physician-executive's roles and the development process. The remarkable growth in the number of physician-executives is expected to continue as they demonstrate their abilities to help health care providers expand ambulatory services, facilitate provider-physician relationships and physician recruitment, and lend expertise in quality improvement and risk management issues.

Manpower Substitution and Productivity in Medical Practice

PubMed Central

Reinhardt, Uwe E.

1973-01-01

Probably in response to the often alleged physician shortage in this country, concerted research efforts are under way to identify technically feasible opportunities for manpower substitution in the production of ambulatory health care. The approaches range from descriptive studies of the effect of task delegation on output of medical services to rigorous mathematical modeling of health care production by means of linear or continuous production functions. In this article the distinct methodological approaches underlying mathematical models are presented in synopsis, and their inherent strengths and weaknesses are contrasted. The discussion includes suggestions for future research directions. Images Fig. 2 PMID:4586735

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review.

PubMed

Keller, Sara C; Tamma, Pranita D; Cosgrove, Sara E; Miller, Melissa A; Sateia, Heather; Szymczak, Julie; Gurses, Ayse P; Linder, Jeffrey A

2018-01-01

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS. © Copyright 2018 by the American Board of Family Medicine.

Assessing patient safety in Canadian ambulatory surgery facilities: A national survey

PubMed Central

Ahmad, Jamil; Ho, Olivia A; Carman, Wayne W; Thoma, Achilles; Lalonde, Donald H; Lista, Frank

2014-01-01

BACKGROUND: There has been increased interest regarding patient safety and standards of care in Canadian ambulatory surgery facilities where surgical procedures are performed. The Canadian Association for Accreditation of Ambulatory Surgical Facilities (CAAASF) is a national organization formed to establish and maintain standards to ensure that surgical procedures conducted outside of public hospitals are performed safely. OBJECTIVE: To determine how many procedures are performed annually at CAAASF member sites, and to examine complication rates and several key patient safety practices. METHODS: All 69 facilities accredited by the CAAASF were surveyed. The survey focused on procedural data, complication rates and patient safety interventions. RESULTS: In 2010, 40,240 estimated procedures were performed. A total of 263 (0.007%) complications were reported. Sixteen (0.0004%) patients required reoperations in hospital and 19 (0.0004%) patients required transfer to hospital on the day of surgery. There were only two mortalities within 30 days of surgery reported in the past five years. With regard to patient safety practices, 93% used antimicrobial prophylaxis, 100% used strategies to maintain normothermia and 82% used measures for venous thromboembolism prevention. CONCLUSION: The present study is the first to report on the Canadian experience in ambulatory surgery facilities and provides insight into current practices at these facilities. Appropriate accreditation of ambulatory surgery facilities, well-established patient safety-related standards of care, careful patient selection and procedures performed by qualified health care professionals with appropriate certification practicing within the scope of their practice form the basis for safe and effective ambulatory surgery. PMID:25152645

Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors.

PubMed

Rosero, Eric B; Joshi, Girish P

2017-11-01

The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical Assessment Applications of Ambulatory Biosensors

ERIC Educational Resources Information Center

Haynes, Stephen N.; Yoshioka, Dawn T.

2007-01-01

Ambulatory biosensor assessment includes a diverse set of rapidly developing and increasingly technologically sophisticated strategies to acquire minimally disruptive measures of physiological and motor variables of persons in their natural environments. Numerous studies have measured cardiovascular variables, physical activity, and biochemicals…

Predictors of exercise participation in ambulatory and non-ambulatory older people with multiple sclerosis

PubMed Central

Harris, Chelsea; Wallack, Elizabeth M.; Drodge, Olivia; Beaulieu, Serge; Mayo, Nancy

2015-01-01

Background. Exercise at moderate intensity may confer neuroprotective benefits in multiple sclerosis (MS), however it has been reported that people with MS (PwMS) exercise less than national guideline recommendations. We aimed to determine predictors of moderate to vigorous exercise among a sample of older Canadians with MS who were divided into ambulatory (less disabled) and non-ambulatory (more disabled) groups. Methods. We analysed data collected as part of a national survey of health, lifestyle and aging with MS. Participants (n = 743) were Canadians over 55 years of age with MS for 20 or more years. We identified ‘a priori’ variables (demographic, personal, socioeconomic, physical health, exercise history and health care support) that may predict exercise at moderate to vigorous intensity (>6.75 metabolic equivalent hours/week). Predictive variables were entered into stepwise logistic regression until best fit was achieved. Results. There was no difference in explanatory models between ambulatory and non-ambulatory groups. The model predicting exercise included the ability to walk independently (OR 1.90, 95% CI [1.24–2.91]); low disability (OR 1.50, 95% CI [1.34–1.68] for each 10 point difference in Barthel Index score), perseverance (OR 1.17, 95% CI [1.08–1.26] for each additional point on the scale of 0–14), less fatigue (OR 2.01, 95% CI [1.32–3.07] for those in the lowest quartile), fewer years since MS diagnosis (OR 1.58, 95% CI [1.11–2.23] below the median of 23 years) and fewer cardiovascular comorbidities (OR 1.55 95% CI [1.02–2.35] one or no comorbidities). It was also notable that the factors, age, gender, social support, health care support and financial status were not predictive of exercise. Conclusions. This is the first examination of exercise and exercise predictors among older, more disabled PwMS. Disability is a major predictor of exercise participation (at moderate to vigorous levels) in both ambulatory and non-ambulatory groups suggesting that more exercise options must be developed for people with greater disability. Perseverance, fatigue, and cardiovascular comorbidities are predictors that are modifiable and potential targets for exercise adherence interventions. PMID:26339540

Agreement between ambulatory, home, and office blood pressure variability.

PubMed

Juhanoja, Eeva P; Niiranen, Teemu J; Johansson, Jouni K; Puukka, Pauli J; Jula, Antti M

2016-01-01

Ambulatory, home, and office blood pressure (BP) variability are often treated as a single entity. Our aim was to assess the agreement between these three methods for measuring BP variability. Twenty-four-hour ambulatory BP monitoring, 28 home BP measurements, and eight office BP measurements were performed on 461 population-based or hypertensive participants. Five variability indices were calculated for all measurement methods: SD, coefficient of variation, maximum-minimum difference, variability independent of the mean, and average real variability. Pearson's correlation coefficients were calculated for indices measured with different methods. The agreement between different measurement methods on the diagnoses of extreme BP variability (participants in the highest decile of variability) was assessed with kappa (κ) coefficients. SBP/DBP variability was greater in daytime (coefficient of variation: 9.8 ± 2.9/11.9 ± 3.6) and night-time ambulatory measurements (coefficient of variation: 8.6 ± 3.4/12.1 ± 4.5) than in home (coefficient of variation: 4.4 ± 1.8/4.7 ± 1.9) and office (coefficient of variation: 4.6 ± 2.4/5.2 ± 2.6) measurements (P < 0.001/0.001 for all). Pearson's correlation coefficients for systolic/diastolic daytime or night-time ambulatory-home, ambulatory-office, and home-office variability indices ranged between 0.07-0.25/0.12-0.23, 0.13-0.26/0.03-0.22 and 0.13-0.24/0.10-0.19, respectively, indicating, at most, a weak positive (r < 0.3) relationship. The agreement between measurement methods on diagnoses of extreme SBP/DBP variability was only slight (κ < 0.2), with the κ coefficients for daytime and night-time ambulatory-home, ambulatory-office, and home-office agreement varying between-0.014-0.20/0.061-0.15, 0.037-0.18/0.082-0.15, and 0.082-0.13/0.045-0.15, respectively. Shorter-term and longer-term BP variability assessed by different methods of BP measurement seem to correlate only weakly with each other. Our study suggests that BP variability measured by different methods and timeframes may reflect different phenomena, not a single entity.

Interspecialty communication supported by health information technology associated with lower hospitalization rates for ambulatory care-sensitive conditions.

PubMed

O'Malley, Ann S; Reschovsky, James D; Saiontz-Martinez, Cynthia

2015-01-01

Practice tools such as health information technology (HIT) have the potential to support care processes, such as communication between health care providers, and influence care for "ambulatory care-sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization. To date, associations between such primary care practice capabilities and hospitalizations for ambulatory care-sensitive conditions have been primarily limited to smaller, local studies or unique delivery systems rather than nationally representative studies of primary care physicians in the United States. We analyzed a nationally representative sample of 1,819 primary care physicians who responded to the Center for Studying Health System Change's Physician Survey. We linked 3 years of Medicare claims (2007 to 2009) with these primary care physician survey respondents. This linkage resulted in the identification of 123,760 beneficiaries with one or more of 4 ambulatory care-sensitive chronic conditions (diabetes, chronic obstructive pulmonary disease, asthma, and congestive heart failure) for whom these physicians served as the usual provider. Key independent variables of interest were physicians' practice capabilities, including communication with specialists, use of care managers, participation in quality and performance measurement, use of patient registries, and HIT use. The dependent variable was a summary measure of ambulatory care-sensitive hospitalizations for one or more of these 4 conditions. Higher provider-reported levels of communication between primary care and specialist physicians were associated with lower rates of potentially avoidable hospitalizations. While there was no significant main effect between HIT use and ACSC hospitalizations, the associations between interspecialty communication and ACSC hospitalizations were magnified in the presence of higher HIT use. For example, patients in practices with both the highest level of interspecialty communication and the highest level of HIT use had lower odds of ambulatory care-sensitive hospitalizations than did those in practices with lower interspecialty communication and high HIT use (adjusted odds ratio, 0.70; 95% confidence limits, 0.59, 0.82). Greater primary care and specialist communication is associated with reduced hospitalizations for ambulatory care-sensitive conditions. This effect was magnified in the presence of higher provider-reported HIT use, suggesting that coordination of care with support from HIT is important in the treatment of ambulatory care-sensitive conditions. © Copyright 2015 by the American Board of Family Medicine.

Morphological patterns of the collateral sulcus in the human brain.

PubMed

Huntgeburth, Sonja C; Petrides, Michael

2012-04-01

The collateral sulcal complex is an important landmark on the medial surface of the temporal lobe. Anteriorly, it delineates the limbic regions of the parahippocampal gyrus from the visual-processing areas of the fusiform gyrus. Posteriorly, it continues into the occipital lobe, bearing no relationship to the memory-related limbic regions. Given the considerable extent of the sulcus and functional heterogeneity of the surrounding cortex, an investigation of the morphology of this sulcus was carried out to examine whether it is continuous or a series of sulcal parts, i.e. independent sulci classified together under the name collateral sulcus. We investigated the collateral sulcal complex using magnetic resonance images taking into account the three-dimensional nature of the brain. Our examination demonstrated three separate sulcal segments: (i) an anterior segment, the rhinal sulcus, delineating the uncus from the adjacent temporal neocortex, (ii) a middle segment, the collateral sulcus proper, forming the lateral border of the posterior parahippocampal cortex, and (iii) a caudal segment, the occipital extent of the collateral sulcus, within the occipital lobe. Three relationships exist between the rhinal sulcus and collateral sulcus proper, only one being clearly identifiable from the surface. Posteriorly, the collateral sulcus proper and the occipital collateral sulcus, although appearing continuous on the brain surface, can be separated in the depth of the sulcus in all cases. These results provide quantification of the location and variability within standard stereotaxic space for the three collateral sulcus segments that could be used to aid accurate identification of functional activation peaks derived from neuroimaging studies. © 2012 The Authors. European Journal of Neuroscience © 2012 Federation of European Neuroscience Societies and Blackwell Publishing Ltd.

MAP Estimators for Piecewise Continuous Inversion

DTIC Science & Technology

2016-08-08

MAP estimators for piecewise continuous inversion M M Dunlop1 and A M Stuart Mathematics Institute, University of Warwick, Coventry, CV4 7AL, UK E...Published 8 August 2016 Abstract We study the inverse problem of estimating a field ua from data comprising a finite set of nonlinear functionals of ua...then natural to study maximum a posterior (MAP) estimators. Recently (Dashti et al 2013 Inverse Problems 29 095017) it has been shown that MAP

State-of-the-art techniques in operative dentistry: contemporary teaching of posterior composites in UK and Irish dental schools.

PubMed

Lynch, C D; Frazier, K B; McConnell, R J; Blum, I R; Wilson, N H F

2010-08-14

Advances of composite systems and their application have revolutionised the management of posterior teeth affected by caries, facilitating a minimally invasive approach. Previous surveys have indicated that the teaching of posterior composites within dental schools was developing, albeit not keeping pace with clinical evidence and the development of increasingly predictable techniques and materials. Concurrently, surveys of dental practice indicate that dental amalgam still predominates as the 'material of choice' for the restoration of posterior teeth within UK general dental practice. In light of such considerations, the aim of this study was to investigate current teaching of posterior composites in Irish and UK dental schools. An online questionnaire which sought information in relation to the current teaching of posterior composites was developed and distributed to the 17 established Irish and UK dental schools with undergraduate teaching programmes in late 2009. Completed responses were received from all 17 schools (response rate = 100%). All 17 schools taught the placement of occlusal and two-surface occlusoproximal composites in premolar and permanent molar teeth. Two schools did not teach placement of three-surface occlusoproximal composites in either premolars or molars. In their preclinical courses, ten schools taught posterior composites before teaching dental amalgams. Fifty-five percent of posterior restorations placed by dental students were of composite (range = 10-90%) and 44% amalgam (range = 10-90%), indicating an increase of 180% in the numbers of posterior composites placed over the past five years. Diversity was noted in the teaching of clinical techniques and students at different schools are trained with different composites and bonding systems. Some cause for concern was noted in the teaching of certain techniques that were not in keeping with existing best evidence, such as the teaching of transparent matrix bands and light-transmitting wedges for occluso-proximal composites (eight schools) and the teaching of bevels on the cavosurface enamel margins of both the occlusal and proximal box margins (three schools). The teaching of posterior composites in the Irish and UK dental schools has substantially increased over the last five years. Dental students in these schools often gain more experience in the placement of posterior composites than amalgam. However, practice trends indicate that a majority of GDPs continue to place amalgam in preference to composite, thereby suggesting a source of tension as current dental students emerge into the dental workforce over the coming years. There is, as a consequence, a challenge to the dental profession and its funding agencies in the UK to encourage more of a shift towards the minimally interventive use of composite systems in the restoration of posterior teeth, in particular among established practitioners.

[GPs' self-perception of their own role compared with hospital, ambulatory, academic, and health organisation physicians].

PubMed

Daghio, Maria Monica; Gaglianò, Giuseppe; Bevini, Massimo; Cadioli, Tiziano; Delvecchio, Carlo; Guidetti, Patrizia; Lorenzetti, Manuela; Fattori, Giuseppe; Ciardullo, Anna Vittoria

2005-05-01

Aim of the present study was to explore how the 76 general practitioners (GPs) - serving Carpi district (90,000 residents) - value their own role compared with the hospital, ambulatory, academic, and health organisation physicians'. GPs had a positive self-image only in comparison with health organisation doctors (7 vs 7 grades). GPs disappointed with themselves when comparing their role with ambulatory (-1.6 grades), academic (-1.9 grades) and hospital doctors (-2.2 grades). Secondarily, GPs perceived patients' valuing their professional role mostly 'subordinate' to the other physicians', except health organisation colleagues'.

Accounting for the move to ambulatory patient groups.

PubMed

Boyagian, H R; Dessingue, R F

1998-07-01

This article focuses on the cost accounting challenge an ambulatory patient group (APG)-like-based prospective payment system presents to providers and the issues associated with that challenge. In particular, how can costs be identified, how can the differences in costs be associated with alternative settings, and how do costs identified through a detailed resource costing methodology compare to estimates using alternative measures? The results presented suggest that decisions made based on current measures of ambulatory cost (i.e., charge-based measures) need to be reexamined. These decisions could include which services to provide, what setting is appropriate, and where marketshare opportunities exist.

New approaches to ambulatory care facilities in the United Kingdom--an investor developer's perspective.

PubMed

Eminson, C; Dawson, D

1999-01-01

The purpose of this article is to describe the strategic context within which ambulatory care facilities are being developed, to consider a range of models of care facilities available, and, by drawing on the experience of the authors, to comment on some of the investment and development issues arising from two projects in progress--the community hospitals in Richmond, Yorkshire, in rural north England, and Thames Ditton on the borders of outer south London. In the final section, we consider the possible future of ambulatory care development in the light of government policy.

Challenges of ambulatory physiological sensing.

PubMed

Healey, Jennifer

2004-01-01

Applications for ambulatory monitoring span the spectrum from fitness optimization to cardiac defibrillation. This range of applications is associated with a corresponding range of required detection accuracies and a range of inconvenience and discomfort that wearers are willing to tolerate. This paper describes a selection of physiological sensors and how they might best be worn in the unconstrained ambulatory environment to provide the most robust measurements and the greatest comfort to the wearer. Using wireless mobile computing devices, it will be possible to record, analyze and respond to changes in the wearers' physiological signals in real time using these sensors.

Variability in opioid prescribing for children undergoing ambulatory surgery in the United States.

PubMed

Van Cleve, William C; Grigg, Eliot B

2017-09-01

We attempted to describe the opioid prescribing patterns for ambulatory pediatric surgery in the United States from 2007 to 2014. Retrospective database review. Operating room ambulatory encounters as determined by the Truven Health Marketscan Commercial Claims and Encounters database. A total of 929,874 ambulatory surgical encounters were identified in patients <18years of age and, of these, 439,286 encounters generated an analgesic prescription. N/A MEASUREMENTS: The analgesic prescription was described in terms of the type of opioid along with the inclusion of acetaminophen and/or NSAIDs. The probability of receiving a post-operative analgesic prescription increased with age, ranging from 18.2% of infants to 71.7% of teens. Acetaminophen with codeine (APAP/C) was the most common drug for infants (63.8%), while acetaminophen with hydrocodone (APAP/H) was the most common analgesic prescription for teens (53.6%). APAP/C and APAP/H were the predominant drugs used for all procedure types. Substantial variability in analgesic prescribing at the level of the procedure performed, both in terms of the probability of receiving a prescription and in which drugs were prescribed. We observed significant age and procedure-based variability in opioid prescribing following pediatric ambulatory surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

A validation of the Mobil O Graph (version 12) ambulatory blood pressure monitor.

PubMed

Jones, C R; Taylor, K; Chowienczyk, P; Poston, L; Shennan, A H

2000-08-01

To assess the clinical accuracy of the Mobil O Graph (version 12) ambulatory blood pressure monitor in an adult population. The accuracy of the device was assessed by predefined criteria (British Hypertension Society, BHS) in 85 subjects recruited from the patients and staff in a teaching hospital. A series of same-arm sequential blood pressure measurements were taken: first two observers taking simultaneous mercury readings, followed by a reading with the Mobil O Graph ambulatory monitor. A total of seven readings were taken from each subject in the sitting position. The data were then analysed according to the BHS protocol and the criteria of the Association for the Advancement of Medical Instrumentation (AAMI). The Mobil O Graph ambulatory monitor fulfilled the criteria of the BHS protocol, achieving a grade B for systolic blood pressure (SBP) and a grade A for diastolic blood pressure (DBP). The mean differences were -2+/-8 mmHg for SBP and -2+/-7 mmHg for DBP. The device therefore also passed the AAMI standard (the mean to be within 5+/-8 mmHg). The Mobil O Graph ambulatory monitor performed in a satisfactory manner according to the BHS and the AAMI criteria and can therefore be recommended for clinical use in the general population.

Burden of norovirus gastroenteritis in the ambulatory setting--United States, 2001-2009.

PubMed

Gastañaduy, Paul A; Hall, Aron J; Curns, Aaron T; Parashar, Umesh D; Lopman, Benjamin A

2013-04-01

Gastroenteritis remains an important cause of morbidity in the United States. The burden of norovirus gastroenteritis in ambulatory US patients is not well understood. Cause-specified and cause-unspecified gastroenteritis emergency department (ED) and outpatient visits during July 2001-June 2009 were extracted from MarketScan insurance claim databases. By using cause-specified encounters, time-series regression models were fitted to predict the number of unspecified gastroenteritis visits due to specific pathogens other than norovirus. Model residuals were used to estimate norovirus visits. MarketScan rates were extrapolated to the US population to estimate national ambulatory visits. During 2001-2009, the estimated annual mean rates of norovirus-associated ED and outpatient visits were 14 and 57 cases per 10 000 persons, respectively, across all ages. Rates for ages 0-4, 5-17, 18-64, and ≥65 years were 38, 10, 12, and 15 ED visits per 10 000 persons, respectively, and 233, 85, 35, and 54 outpatient visits per 10 000 persons, respectively. Norovirus was estimated to cause 13% of all gastroenteritis-associated ambulatory visits, with ~50% of such visits occurring during November-February. Nationally, norovirus contributed to approximately 400 000 ED visits and 1.7 million office visits annually, resulting in $284 million in healthcare charges. Norovirus is a substantial cause of gastroenteritis in the ambulatory setting.

A pilot audit of a protocol for ambulatory investigation of predicted low-risk patients with possible pulmonary embolism.

PubMed

McDonald, A H; Murphy, R

2011-09-01

Patients with possible pulmonary embolism (PE) commonly present to acute medical services. Research has led to the identification of low-risk patients suitable for ambulatory management. We report on a protocol designed to select low-risk patients for ambulatory investigation if confirmatory imaging is not available that day. The protocol was piloted in the Emergency Department and Medical Assessment Area at the Royal Infirmary of Edinburgh. We retrospectively analysed electronic patient records in an open observational audit of all patients managed in the ambulatory arm over five months of use. We analysed 45 patients' records. Of these, 91.1% required imaging to confirm or refute PE, 62.2% received a computed tomography pulmonary angiogram (CTPA). In 25% of patients, PE was confirmed with musculoskeletal pain (22.7%), and respiratory tract infection (15.9%) the next most prevalent diagnoses. Alternative diagnoses was provided by CTPA in 32% of cases. We identified no adverse events or readmissions but individualised follow-up was not attempted. The data from this audit suggests this protocol can be applied to select and manage low-risk patients suitable for ambulatory investigation of possible PE. A larger prospective comparative study would be required to accurately define the safety and effectiveness of this protocol.

Vascular Glucose Sensor Symposium: Continuous Glucose Monitoring Systems (CGMS) for Hospitalized and Ambulatory Patients at Risk for Hyperglycemia, Hypoglycemia, and Glycemic Variability.

PubMed

Joseph, Jeffrey I; Torjman, Marc C; Strasma, Paul J

2015-07-01

Hyperglycemia, hypoglycemia, and glycemic variability have been associated with increased morbidity, mortality, length of stay, and cost in a variety of critical care and non-critical care patient populations in the hospital. The results from prospective randomized clinical trials designed to determine the risks and benefits of intensive insulin therapy and tight glycemic control have been confusing; and at times conflicting. The limitations of point-of-care blood glucose (BG) monitoring in the hospital highlight the great clinical need for an automated real-time continuous glucose monitoring system (CGMS) that can accurately measure the concentration of glucose every few minutes. Automation and standardization of the glucose measurement process have the potential to significantly improve BG control, clinical outcome, safety and cost. © 2015 Diabetes Technology Society.

An Ambulatory System for Gait Monitoring Based on Wireless Sensorized Insoles.

PubMed

González, Iván; Fontecha, Jesús; Hervás, Ramón; Bravo, José

2015-07-09

A new gait phase detection system for continuous monitoring based on wireless sensorized insoles is presented. The system can be used in gait analysis mobile applications, and it is designed for real-time demarcation of gait phases. The system employs pressure sensors to assess the force exerted by each foot during walking. A fuzzy rule-based inference algorithm is implemented on a smartphone and used to detect each of the gait phases based on the sensor signals. Additionally, to provide a solution that is insensitive to perturbations caused by non-walking activities, a probabilistic classifier is employed to discriminate walking forward from other low-level activities, such as turning, walking backwards, lateral walking, etc. The combination of these two algorithms constitutes the first approach towards a continuous gait assessment system, by means of the avoidance of non-walking influences.

Light and scanning electron microscopy of the ecdysis of Haemonchus contortus infective larvae.

PubMed

Gamble, H R; Lichtenfels, J R; Purcell, J P

1989-04-01

During the second ecdysis of ruminant trichostrongyles, a region of the second molt cuticle is digested by a 44-kDa Zn-metalloprotease. We have examined this digestion process by light and scanning electron microscopy (SEM). The substrate region of the cuticle appeared, during the ecdysis process, as an indented ring at the 20th cuticular annulus coincident with the anterior terminus of the lateral alae. Continued digestion of the cuticle resulted in holes in the ring region that expanded until they became continuous and separation occurred between the anterior and posterior portions of the cuticle. Mechanical movements of the L3 forced aside the cuticle cap that generally remained attached on one side to the posterior portion as the larva escaped from the sheath. The site of secretion of the 44-kDa ecdysing enzyme causing cuticle digestion was not clear from morphological observations; however, existing evidence strongly points to the release of enzyme from the esophageal (pharyngeal) glands through the mouth.

Analysis of age-dependence of the anterior and posterior cornea with scheimpflug imaging.

PubMed

Nemeth, Gabor; Hassan, Ziad; Szalai, Eszter; Berta, Andras; Modis, Laszlo

2013-05-01

To assess keratometric and higher-order aberrations of the anterior and posterior cornea and their age-related changes. This study investigated one healthy eye of 227 patients (mean age: 55.15 ± 21.2 years; range: 16 to 90 years; 135 right eyes, 92 left eyes). Images were captured from each eye with Pentacam HR (Oculus Optikgeräte GmbH, Wetzlar, Germany) using automatic mode. Keratometric, astigmatism data, and corneal higher-order aberrations were analyzed. With respect to laterality, no deviance was found in any of the parameters (P > .05). Mean refractive error was 0.52 ± 0.23 diopters. The level of astigmatism decreased significantly with advancing age for both the anterior and posterior corneal surfaces (P < .05). The overall root mean square of the higher-order aberration increased continuously with age (r = 0.517; P < .01), which can be explained by the combined effect of the increased in both the anterior and posterior corneal root mean square higher-order aberrations. Of the higher-order aberrations, the constant increase of the primary and secondary spherical aberration with aging (P < .01) is caused by the spherical aberration growth of the anterior surface. Apart from these, only the vertical coma aberration of the posterior surface and the vertical trefoil aberrations of both the anterior and posterior surfaces showed a significantly positive correlation with aging (P < .05). Corneal astigmatism showed a significant decrease with aging. Of the higher-order aberrations, primary and secondary spherical aberrations, vertical coma, and vertical trefoil significantly increase with age, whereas other higher-order aberrations show no correlation with aging. Copyright 2013, SLACK Incorporated.

Development of the posterior neural tube in human embryos.

PubMed

Saitsu, Hirotomo; Yamada, Shigehito; Uwabe, Chigako; Ishibashi, Makoto; Shiota, Kohei

2004-12-01

Development of the posterior neural tube (PNT) in human embryos is a complicated process that involves both primary and secondary neurulation. Because normal development of the PNT is not fully understood, pathogenesis of spinal neural tube defects remains elusive. To clarify the mechanism of PNT development, we histologically examined 20 human embryos around the stage of posterior neuropore closure and found that the developing PNT can be divided into three parts: 1) the most rostral region, which corresponds to the posterior part of the primary neural tube, 2) the junctional region of the primary and secondary neural tubes, and 3) the caudal region, which emerges from the neural cord. In the junctional region, the axially-condensed mesenchyme (AM) intervened between the neural plate/tube and the notochord at the stage of posterior neuropore closure, while the notochord was directly attached to the neural plate/tube in the most rostral region. A single cavity was found to be formed in the AM as the presumptive luminal surface cells were radially aligned in the junctional region prior to the formation of the neural cord. The single cavity was continuous with the central cavity of the primary neural tube. In contrast, multiple or isolated cavities were frequently observed in the caudal region of the PNT. Our observation suggests that the junctional region of the PNT is distinct from other regions in terms of the relationship with the notochord and the mode of cavitation during secondary neurulation.

Impact of vitreomacular adhesion on ranibizumab mono- and combination therapy for neovascular age-related macular degeneration.

PubMed

Waldstein, Sebastian M; Ritter, Markus; Simader, Christian; Mayr-Sponer, Ulrike; Kundi, Michael; Schmidt-Erfurth, Ursula

2014-08-01

To investigate the influence of vitreomacular adhesion on the efficacy of pro re nata (PRN) ranibizumab monotherapy and verteporfin photodynamic therapy (PDT) combination therapy for neovascular age-related macular degeneration. Post hoc analysis of prospective randomized 12-month multicenter clinical trial data. Total of 255 treatment-naïve patients with subfoveal choroidal neovascularization. Assessment of the vitreomacular interface on monthly optical coherence tomography with division of patients into the following categories according to continuous 1-year grading: posterior vitreous detachment (n=154), dynamic release of vitreomacular adhesion (n=32), stable vitreomacular adhesion (n=51). Mean best-corrected visual acuity (BCVA) letter and central retinal thickness changes at month 12 in the vitreomacular interface groups. Mean BCVA changes at month 12 were +3.5 (posterior vitreous detachment), +4.3 (release of vitreomacular adhesion), and +6.3 (vitreomacular adhesion) in patients receiving monotherapy (P=.767), and +0.1 (posterior vitreous detachment), +6.6 (release of vitreomacular adhesion), and +9.2 (vitreomacular adhesion) in patients receiving combination therapy (P=.009). Mean central retinal thickness changes were -113 μm (posterior vitreous detachment), -89 μm (release of vitreomacular adhesion), and -122 μm (vitreomacular adhesion) in monotherapy (P=.725) and -121 μm (posterior vitreous detachment), -113 μm (release of vitreomacular adhesion), and -113 μm (vitreomacular adhesion) in combination therapy (P=.924). Mean ranibizumab retreatments during 12 months were 4.9 (posterior vitreous detachment), 6.6 (release of vitreomacular adhesion), and 5.3 (vitreomacular adhesion) in monotherapy (P=.018) and 4.7 (posterior vitreous detachment), 5.2 (release of vitreomacular adhesion), and 5.8 (vitreomacular adhesion) in combination therapy (P=.942). This study adds evidence that the vitreomacular interface status impacts functional outcomes and retreatment requirements. Patients with posterior vitreous detachment achieve acceptable results with fewer injections in PRN monotherapy, but lose potential vision gain with PDT. Patients with other vitreomacular interface configurations may potentially achieve optimized vision outcomes by combination of antiangiogenic treatment and vaso-occlusive PDT. Copyright © 2014 Elsevier Inc. All rights reserved.

42 CFR 416.180 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) MEDICARE PROGRAM AMBULATORY SURGICAL SERVICES Adjustment in Payment Amounts for New Technology Intraocular... technology intraocular lenses (IOLs) furnished at ambulatory surgical centers (ASCs). (b) Scope. This subpart sets forth— (1) The process for interested parties to request that CMS review the appropriateness of...

A rare type of ankle fracture: Syndesmotic rupture combined with a high fibular fracture without medial injury.

PubMed

van Wessem, K J P; Leenen, L P H

2016-03-01

High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior. In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury. Copyright © 2016 Elsevier Ltd. All rights reserved.

Role of the vitreous in age-related macular degeneration.

PubMed

Ondeş, F; Yilmaz, G; Acar, M A; Unlü, N; Kocaoğlan, H; Arsan, A K

2000-01-01

To investigate the relationship between posterior vitreous detachment (PVD) and age-related macular degeneration (AMD). The condition of the vitreous was examined by slit-lamp funduscopy and ultrasonography in 93 eyes of 50 patients with AMD (exudative or dry) and 100 eyes of 50 controls. There was complete PVD in 31 of the 93 eyes (33.3%) of 50 patients with AMD and the posterior vitreous was attached in 62 of these eyes (66.6%). In the control group, in 50 eyes (50%) of 50 subjects there was posterior vitreous detachment. The prevalence of PVD in eyes with macular degeneration was significantly lower (P < .05). There was no statistically significant difference between the exudative and the nonexudative groups in respect to PVD. PVD may have a protective role against the development of AMD. Chronic vitreomacular traction and/or continuous exposure to free radicals and cytokines may possibly be one of the causes of AMD in eyes with attached vitreous.

Posterior consistency in conditional distribution estimation

PubMed Central

Pati, Debdeep; Dunson, David B.; Tokdar, Surya T.

2014-01-01

A wide variety of priors have been proposed for nonparametric Bayesian estimation of conditional distributions, and there is a clear need for theorems providing conditions on the prior for large support, as well as posterior consistency. Estimation of an uncountable collection of conditional distributions across different regions of the predictor space is a challenging problem, which differs in some important ways from density and mean regression estimation problems. Defining various topologies on the space of conditional distributions, we provide sufficient conditions for posterior consistency focusing on a broad class of priors formulated as predictor-dependent mixtures of Gaussian kernels. This theory is illustrated by showing that the conditions are satisfied for a class of generalized stick-breaking process mixtures in which the stick-breaking lengths are monotone, differentiable functions of a continuous stochastic process. We also provide a set of sufficient conditions for the case where stick-breaking lengths are predictor independent, such as those arising from a fixed Dirichlet process prior. PMID:25067858

Serial corneal endothelial cell loss with lathe-cut and injection-molded posterior chamber intraocular lenses.

PubMed

Kraff, M C; Sanders, D R; Lieberman, H L

1983-01-01

We compared endothelial cell loss of patients implanted with lathe-cut posterior chamber lenses and those implanted with injection-molded lenses over a three-year postoperative period. Results were based on more than 2,500 measurements of corneal endothelial density. Although the technique of cataract extraction (anterior chamber phacoemulsification, posterior chamber phacoemulsification, or planned extracapsular extraction) significantly affected cell loss (P less than .01), the type of implant (lathe-cut or injection-molded) did not. Significant continuing endothelial cell loss did not occur during the first three postoperative years with injection-molded lenses. There was, however, a statistically significant 7% to 15% additional cell loss after surgery over the first two to three postoperative years with lathe-cut implants. There have been no cases of corneal endothelial decompensation developing after implantation of injection-molded or lathe-cut lenses. Because a standard field clinical specular microscope was used in this study, cell counting errors cannot be ruled out as a cause of these findings.

Ambulatory glucose profile analysis of the juvenile diabetes research foundation continuous glucose monitoring dataset-Applications to the pediatric diabetes population.

PubMed

Forlenza, Gregory P; Pyle, Laura L; Maahs, David M; Dunn, Timothy C

2017-11-01

Increased continuous glucose monitor (CGM) use presents both the benefit and burden of increased data for clinicians to rapidly analyze. The ambulatory glucose profile (AGP) is an evolving a universal software report for CGM data analysis. We utilized the Juvenile Diabetes Research Foundation-CGM dataset to evaluate the AGP across a broad spectrum of patients to show how AGP can be used clinically to assist with CGM-related decision making. We hypothesized that AGP metrics would be different across age and HbA1c strata. AGPs were generated from the JDRF-CGM trial dataset for all periods during which there were ≥10 days of CGM coverage in the 2 weeks adjacent to an HbA1c measurement yielding 1101 AGPs for 393 unique subjects. AGPs were stratified by age group (8-14, 15-24, and ≥25 years) and HbA1c (within or above target for age) and compared for between group differences in AGP metrics via two-factor ANOVA. Glycemic differences between time periods were analyzed via segmented regression analysis. Glucose exposure (average and estimated A1c) and variability (standard deviation and interquartile range) were different between the low and high HbA1c levels. Within a given HbA1c level all age groups were significantly different from each other with older patients having lower averages with less variability than younger patients. AGP analysis of the JDRF-CGM data highlights significant differences in glycemic profiles between pediatric and adult age groups and between well and less well-controlled patient populations. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

MISSED WELL-CHILD CARE VISITS, LOW CONTINUITY OF CARE, AND RISK FOR AMBULATORY CARE SENSITIVE HOSPITALIZATIONS IN YOUNG CHILDREN

PubMed Central

Tom, Jeffrey; Tseng, Chien-Wen; Davis, James; Solomon, Cam; Zhou, Chuan; Mangione-Smith, Rita

2013-01-01

Objectives To determine if adherence to the recommended well-child care (WCC) visit schedule, independent of continuity of care (COC), is associated with lower risk for Ambulatory Care Sensitive Hospitalizations (ACSH) and whether this association varies by chronic disease status. Design Population-based, retrospective cohort study Setting Hawaii’s largest health plan from 1999 to 2006 Patients/Participants 36,944 children ≤ 3.5 years-old who were eligible if they were enrolled prior to 2 months-old, had ≥ 4 outpatient visits during the study period, and had an enrollment period that overlapped with ≥ 1 WCC visit interval. Main Exposure(s) WCC visit adherence and COC Index Main Outcome Measure(s) Risk for ACSH (Hazard Ratio [HR]) Results Overall, 8,921 (24%) children had ≥ 1 chronic disease. The proportions of ACSH among healthy children versus those with ≥ 1 chronic disease were 3% (n= 751) and 7% (n= 645), respectively. For children with chronic disease, those with the lowest WCC visit adherence (0–25%) had 1.9 times (HR: 1.9, 95% Confidence Interval [CI]: 1.5–2.5) the risk of ACSH compared to those in the highest category (75–100%). The risk of ACSH for children with chronic disease who fell into the lowest COC category (0–0.25) was 2.4 times (HR 2.4, 95% CI: 1.7–3.5) higher than for those who fell into the highest category (0.75–1.0). Conclusions For children with chronic disease, both low WCC visit adherence and COC are independently associated with an increased risk of ACSH. Providing access to a consistent source of primary care appears important for this vulnerable population. PMID:21041598

Topical oxygen therapy promotes the healing of chronic diabetic foot ulcers: a pilot study.

PubMed

Hayes, P D; Alzuhir, N; Curran, G; Loftus, I M

2017-11-02

Interventions that can heal or reduce diabetic foot ulcer (DFU) size may reduce the incidence of infection and amputation, and reduce associated social and economic costs. Many chronic wounds exhibit a degree of hypoxia and this leads to a reduction in healing processes including cell division and differentiation, angiogenesis, infection prevention, and collagen production. The aim of this pilot study was to assess the effects of a device supplying continuous oxygen ambulatory therapy on healing in chronic DFUs. Patients with chronic DFUs from two tertiary referral hospitals in the UK received treatment with the device. Data were prospectively obtained on wound size using standardised digital images measured by a clinician blinded to the study. Data on device satisfaction and pain were also obtained. We recruited 10 patients, with a mean ulcer duration of 43 weeks (median: 43 weeks) before treatment. By week eight, mean ulcer size had decreased by 51% (median: 53%). Seven of the 10 ulcers were in a healing trajectory, one ulcer present for 56 weeks healed completely, a two-year old ulcer was reduced by more than 50%, and a third, present for 88 weeks, was down to 10% of its original size by the end of the eight-week study. There was also a non-significant trend towards reduction in pain and the device was extremely well tolerated. The ambulatory topical oxygen delivery device showed a significant beneficial effect on wound size. This poses practical advantages over currently existing oxygen-based wound therapies such as hyperbaric oxygen therapy due to its continuous oxygen delivery, ease of use, safety and lower cost. The results of this study warrant further review of the device in comparison to standard wound therapies.

Patient-Doctor Contact Interval and Clinical Outcomes in Continuous Ambulatory Peritoneal Dialysis Patients.

PubMed

Yi, Chunyan; Guo, Qunying; Lin, Jianxiong; Li, Jianying; Yu, Xueqing; Yang, Xiao

2017-01-01

The optimal patient-doctor contact (PDC) interval remains unknown in peritoneal dialysis (PD) patients. The aim was to investigate the association between PDC interval and clinical outcomes in continuous ambulatory PD (CAPD) patients. In this retrospective cohort study, CAPD patients who resided in Guangzhou city between January 2006 and December 2012 were included. According to receiver operating characteristic curve analysis, all patients were classified as high (PDC interval ≤2 months) and low (PDC interval >2 months) PDC frequency groups. Biochemical data, clinical events, and clinical outcomes during the follow-up period were compared. Of 433 CAPD patients, the mean age was 51.3 ± 15.7 years, 54.3% of patients were male, and 29.1% with diabetes. The median vintage of PD was 45.8 (26.3-69.1) months. Patients with high PDC frequency (n = 233) had better patient-survival rates (99.6, 87.7, and 76.5% vs. 92.7, 76.5, and 58.7% at 1, 3, and 5 years; p < 0.001), lower peritonitis rate (0.17 vs. 0.23 episodes per patient-year; p < 0.001), and hospitalization rate (0.49 vs. 0.67 episodes per patient-year; p < 0.001) than those in the low PDC frequency group (n = 200). After adjustment for confounders, PDC interval of no more than 2 months was independently associated with better patient survival (hazard ratio 0.60, 95% CI 0.42-0.86, p = 0.006). A PDC interval of 2 months or less was associated with better clinical outcomes in CAPD patients. This indicates that a shorter PDC interval should be encouraged for them to achieve better clinical outcomes. © 2017 S. Karger AG, Basel.

76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-18

...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. These proposed changes would be applicable to services furnished on or after January 1, 2012. In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we set forth the proposed relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other proposed ratesetting information for the CY 2012 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2012. We are proposing to revise the requirements for the Hospital Outpatient Quality Reporting (IQR) Program, add new requirements for ASC Quality Reporting System, and make additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are proposing to allow eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. In addition, we are proposing to make changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

Effect of pyrazinamide and probenecid on peritoneal urate transport kinetics during continuous ambulatory peritoneal dialysis.

PubMed

Spaia, S; Magoula, I; Tsapas, G; Vayonas, G

2000-01-01

We administered pyrazinamide (PZA) and probenecid (PB) --two well-known modulators of urate transport via the proximal tubules - to evaluate their impact on urate transport through the peritoneal membrane and to clarify mechanisms affecting peritoneal transport. A continuous ambulatory peritoneal dialysis (CAPD) unit in 2nd Hospital of IKA (Social Services Institute), Greece. In 20 stable CAPD patients, on the study day, a 4-hour, 2-L, 1.36% glucose exchange was performed (control exchange). Pyrazinamide 3 g was given orally and another identical exchange was performed (study exchange). The same protocol was repeated with 2 g PB. KtN, peritoneal clearances of urea, creatinine, and urate for each exchange, and mass transfer area coefficients (MTAC) for the three solutes and their dialysate-to-plasma concentration (D/P) ratios were used to estimate peritoneal transport. Administration of PZA resulted in decreased clearances and MTAC values for the three solutes. The D/P ratio decreased significantly only for urate, indicating a more intense influence of PZA on urate. After PB administration, clearances of urea, creatinine, and urate were increased. MTAC and DIP ratio increased significantly only for urate (p < 0.05), demonstrating an action similar to that exerted on renal tubules. These findings provide evidence that unrestricted diffusion is not the only transport mechanism in the case of urate, and demonstrate the existence of an active mechanism in peritoneal urate transport with a reabsorptive and, probably, a secretive component that resembles that of renal tubule urate transport. Attention should be given in the case of CAPD patients undergoing antituberculous (PZA) treatment: it might have a negative impact on urea, creatinine, and urate peritoneal transport rates.

Effects of a magnesium-free dialysate on magnesium metabolism during continuous ambulatory peritoneal dialysis.

PubMed

Shah, G M; Winer, R L; Cutler, R E; Arieff, A I; Goodman, W G; Lacher, J W; Schoenfeld, P Y; Coburn, J W; Horowitz, A M

1987-10-01

While the use of magnesium-containing compounds is usually contraindicated in dialysis patients, the risk of toxicity from hypermagnesemia can be reduced by lowering the magnesium concentration in dialysate. We examined the effects of a magnesium-free dialysate on both serum magnesium level and the peritoneal removal rate of magnesium over 12 weeks in 25 stable patients undergoing continuous ambulatory peritoneal dialysis (CAPD). After 2 weeks, the serum magnesium level decreased from 2.2 to 1.9 mg/dL (0.9 to 0.8 mmol/L) (P less than .02) and the peritoneal removal rate increased from 66 to 83 mg/d (2.8 to 3.5 mmol/d) (P less than .05), with both values remaining stable thereafter. There was a strong association between these parameters (r = -0.62, P less than .05), suggesting that the serum magnesium level decreased as a result of the initial increased peritoneal removal rate. For an additional 4-week period, a subgroup of nine patients received magnesium-containing, phosphate binding agents instead of those containing only aluminum. During this phase, serum inorganic phosphorus was well controlled. The serum magnesium level increased only from 1.8 to 2.5 mg/dL (0.7 to 1.0 mmol/L) (P less than .05), due in great part to the concomitant 41% rise in peritoneal magnesium removal from 91 to 128 mg/d (3.8 to 5.3 mmol/d) (P less than .05). No toxicity was noted during the entire 16-week study period, nor did serum calcium change. Thus, serum magnesium levels remained within an acceptable range as magnesium-containing phosphate binders were given through the use of magnesium-free peritoneal dialysate.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of peritonitis and mortality in patients treated with continuous ambulatory peritoneal dialysis (CAPD) in Africa: a protocol for a systematic review and meta-analysis.

PubMed

Moloi, Mothusi Walter; Kajawo, Shepherd; Noubiap, Jean Jacques; Mbah, Ikechukwu O; Ekrikpo, Udeme; Kengne, Andre Pascal; Bello, Aminu K; Okpechi, Ikechi G

2018-05-24

Continuous ambulatory peritoneal dialysis (CAPD) is the ideal modality for renal replacement therapy in most African settings given that it is relatively cheaper than haemodialysis (HD) and does not require in-centre care. CAPD is, however, not readily utilised as it is often complicated by peritonitis leading to high rates of technique failure. The objective of this study is to assess the prevalence of CAPD-related peritonitis and all-cause mortality in patients treated with CAPD in Africa. We will search PubMed, EMBASE, SCOPUS, Africa Journal Online and Google Scholar for studies conducted in Africa from 1 January 1980 to 30 June 2017 with no language restrictions. Eligible studies will include cross-sectional, prospective observational and cohort studies of patients treated with CAPD. Two authors will independently screen, select studies, extract data and conduct risk of bias assessment. Data consistently reported across studies will be pooled using random-effects meta-analysis. Heterogeneity will be evaluated using Cochrane's Q statistic and quantified using I 2 statistics. Graphical and formal statistical tests will be used to assess for publication bias. Ethical approval will not be needed for this study as data used will be extracted from already published studies. Results of this review will be published in a peer-reviewed journal and presented at conferences. The Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015) framework guided the development of this protocol. CRD42017072966. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring.

PubMed

Ibe, O E; Austin, T; Sullivan, K; Fabanwo, O; Disu, E; Costello, A M de L

2004-09-01

Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.03-0.25). More cases of hyperthermia (> 37.5 degrees C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9 degrees C (RR 1.3, 0.9-1.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants, although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants. Copyright 2004 Liverpool School of Tropical Medicine

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate, clinical, and laboratory outcomes: A 1-year retrospective observation study.

PubMed

Li, John Wing; Wong, Joseph Ho Sing; Chak, Wai Leung; Chau, Ka Foon

2017-10-18

While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed. A 1-year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin). NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age-adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77-20.99, P = 0.04). They consumed less aluminum-based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol 2 /L 2 , P < 0.01), with similar hemoglobin levels. NHHD appeared to offer higher employment rate, lower dosage of aluminum-based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong. © 2017 International Society for Hemodialysis.

Predictors of Peritonitis and the Impact of Peritonitis on Clinical Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients in Taiwan—10 Years’ Experience in a Single Center

PubMed Central

Hsieh, Yao-Peng; Chang, Chia-Chu; Wen, Yao-Ko; Chiu, Ping-Fang; Yang, Yu

2014-01-01

♦ Objective: Peritoneal dialysis (PD) has become more prevalent as a treatment modality for end-stage renal disease, and peritonitis remains one of its most devastating complications. The aim of the present investigation was to examine the frequency and predictors of peritonitis and the impact of peritonitis on clinical outcomes. ♦ Methods: Our retrospective observational cohort study enrolled 391 patients who had been treated with continuous ambulatory PD (CAPD) for at least 90 days. Relevant demographic, biochemical, and clinical data were collected for an analysis of CAPD-associated peritonitis, technique failure, drop-out from PD, and patient mortality. ♦ Results: The peritonitis rate was 0.196 episodes per patient-year. Older age (>65 years) was the only identified risk factor associated with peritonitis. A multivariate Cox regression model demonstrated that technique failure occurred more often in patients experiencing peritonitis than in those free of peritonitis (p < 0.001). Kaplan-Meier analysis revealed that the group experiencing peritonitis tended to survive longer than the group that was peritonitis-free (p = 0.11). After multivariate adjustment, the survival advantage reached significance (hazard ratio: 0.64; 95% confidence interval: 0.46 to 0.89; p = 0.006). Compared with the peritonitis-free group, the group experiencing peritonitis also had more drop-out from PD (p = 0.03). ♦ Conclusions: The peritonitis rate was relatively low in the present investigation. Elderly patients were at higher risk of peritonitis episodes. Peritonitis independently predicted technique failure, in agreement with other reports. However, contrary to previous studies, all-cause mortality was better in patients experiencing peritonitis than in those free of peritonitis. The underlying mechanisms of this presumptive “peritonitis paradox” remain to be clarified. PMID:24084840

Risk Factors for the First Episode of Peritonitis in Southern Chinese Continuous Ambulatory Peritoneal Dialysis Patients

PubMed Central

Fan, Xiaoguang; Huang, Rong; Wang, Juan; Ye, Hongjian; Guo, Qunying; Yi, Chunyan; Lin, Jianxiong; Zhou, Qian; Shao, Fengmin; Yu, Xueqing; Yang, Xiao

2014-01-01

Background The first episode of peritonitis affects survival of the peritoneal membrane as a medium for dialysis as well as survival of patients. The aim of this study is to investigate risk factors associated with the first episode of peritonitis in Southern Chinese continuous ambulatory peritoneal dialysis (CAPD) patients. Methods This is a single-center, retrospective, cohort study. All incident CAPD patients from 1 January 2006 to 31 December 2010 were recruited, and followed up until their first episode of peritonitis or 31 December, 2012. Baseline demographic, socioeconomic, clinical and laboratory data were collected. Cox proportional model was used to determine the factors associated with the first episode of peritonitis. Results In a cumulative 30756.5 patient-months follow-up (the median vintage 26.1 months) of 1117 CAPD patients, 309(27.7%) patients presented the first episodes of peritonitis. The cumulative peritonitis-free survival was 86.2%, 78.1%, 71.4% and 57.8% at 1, 2, 3 and 5 year, respectively. The multivariate analysis showed that factors associated with risk for the first episode of peritonitis were elderly patients (>65 years) [hazard ratio (HR) = 1.427, 95% confidence interval (CI) = 1.051 to 1.938, P = 0.023], male(HR = 1.315, 95% CI = 1.028 to 1.684, P = 0.030), lower education level (HR = 1.446, 95% CI: 1.127 to 1.855, P = 0.004) and albumin <38g/L (HR = 1.425, 95% CI: 1.112 to 1.825, P = 0.005). Conclusions Older age, male, lower educational level and hypoalbuminemia at the commencement of PD were the risk factors associated with the first episode of peritonitis in Southern Chinese CAPD patients. PMID:25222609

The effect of low-GDP solution on ultrafiltration and solute transport in continuous ambulatory peritoneal dialysis patients.

PubMed

Cho, Kyu-Hyang; Do, Jun-Young; Park, Jong-Won; Yoon, Kyung-Woo; Kim, Yong-Lim

2013-01-01

Several studies have reported benefits for human peritoneal mesothelial cell function of a neutral-pH dialysate low in glucose degradation products (GDPs). However, the effects of low-GDP solution on ultrafiltration (UF), transport of solutes, and control of body water remain elusive. We therefore investigated the effect of low-GDP solution on UF, solute transport, and control of body water. Among 79 new continuous ambulatory peritoneal dialysis (CAPD) patients, 60 completed a 12-month protocol (28 in a lactate-based high-GDP solution group, 32 in a lactate-based low-GDP solution group). Clinical indices--including 24-hour UF volume (UFV), 24-hour urine volume (UV), residual renal function, and dialysis adequacy--were measured at months 1, 6, and 12. At months 1, 6, and 12, UFV, glucose absorption, 4-hour dialysate-to-plasma (D/P) creatinine, and 1-hour D/P Na(+) were assessed during a modified 4.25% peritoneal equilibration test (PET). Body composition by bioelectric impedance analysis was measured at months 1 and 12 in 26 CAPD patients. Daily UFV was lower in the low-GDP group. Despite similar solute transport and aquaporin function, the low-GDP group also showed lower UFV and higher glucose absorption during the PET. Factors associated with UFV during the PET were lactate-based high-GDP solution and 1-hour D/P Na(+). No differences in volume status and obesity at month 12 were observed, and improvements in hypervolemia were equal in both groups. Compared with the high-GDP group, the low-GDP group had a lower UFV during a PET and a lower daily UFV during the first year after peritoneal dialysis initiation. Although the low-GDP group had a lower daily UFV, no difficulties in controlling edema were encountered.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis.

PubMed

Cortés-Sanabria, Laura; Paredes-Ceseña, Carlos A; Herrera-Llamas, Rebeca M; Cruz-Bueno, Yolanda; Soto-Molina, Herman; Pazarín, Leonardo; Cortés, Margarita; Martínez-Ramírez, Héctor R

2013-11-01

The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs. This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL. One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD. A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group. Copyright © 2013 IMSS. Published by Elsevier Inc. All rights reserved.

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period.

PubMed

2011-11-30

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

Predictors of Residual Renal Function Decline in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

PubMed Central

Szeto, Cheuk-Chun; Kwan, Bonnie Ching-Ha; Chow, Kai-Ming; Chung, Sebastian; Yu, Vincent; Cheng, Phyllis Mei-Shan; Leung, Chi-Bon; Law, Man-Ching; Li, Philip Kam-Tao

2015-01-01

♦ Background: Residual renal function (RRF) is an important prognostic indicator in continuous ambulatory peritoneal dialysis (CAPD) patients. We determined the predictors of RRF loss in a cohort of incident CAPD patients. ♦ Methods: We reviewed the record of 645 incident CAPD patients. RRF loss is represented by the slope of decline of residual glomerular filtration rate (GFR) as well as the time to anuria. ♦ Results: The average rate of residual GFR decline was -0.083 ± 0.094 mL/min/month. The rate of residual GFR decline was faster with a higher proteinuria (r = -0.506, p < 0.0001) and baseline residual GFR (r = -0.560, p < 0.0001). Multivariate analysis showed that proteinuria, baseline residual GFR, and the use of diuretics were independent predictors of residual GFR decline. Cox proportional hazard model showed that proteinuria, glucose exposure, and the number of peritonitis episodes were independent predictors of progression to anuria, while a higher baseline GFR was protective. Each 1 g/day of proteinuria is associated with a 13.2% increase in the risk of progressing to anuria, each 10 g/day higher glucose exposure is associated with a 2.5% increase in risk, while each peritonitis episode confers a 3.8% increase in risk. ♦ Conclusions: Our study shows that factors predicting the loss of residual solute clearance and urine output are different. Proteinuria, baseline residual GFR, and the use of diuretics are independently related to the rate of RRF decline in CAPD patients, while proteinuria, glucose exposure, and the number of peritonitis episodes are independent predictors for the development of anuria. The role of anti-proteinuric therapy and measures to prevent peritonitis episodes in the preservation of RRF should be tested in future studies. PMID:24497594

Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience.

PubMed

Lalezari, Sepehr; Musielak, Matthew C; Broun, Lisa A; Curry, Trace W

2018-06-01

We present our experience with same-day discharge (without an overnight stay) after laparoscopic sleeve gastrectomy (SG) in 821 consecutive patients from 2011 to 2015. This is the largest series published to date of patients undergoing ambulatory surgery for such a procedure. To review our outcomes from ambulatory SG over 52 months to determine if SG can be safely performed in the ambulatory setting. Ambulatory surgery center. Retrospective review of all consecutive patients undergoing ambulatory SG from January 2011 to April 2015. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and admission to the hospital after discharge was reviewed up to 30 days from surgery. From January 2011 to April 2015, 821 consecutive patients underwent SG. Nineteen 30-day complications occurred in the series, 17 of them requiring admission to the hospital. Of the 19 cases, gastric leaks accounted for 7, intr-aabdominal abscess for 4, and dehydration/nausea/vomiting for 4; 4 were due to other causes. Complication and readmission rates at 30 days were 2.3% and 2.1%, respectively. Follow-up at 30 days was 98.4%. With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that SG may be suitable for the outpatient setting. Experience and comfort with bariatric surgery is essential on the part of the operating surgeon to ensure good outcomes. Our low overall readmission and complication rate portends to the feasibility of laparoscopic SG as a safe outpatient procedure. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

The contribution of viral hepatitis to the burden of chronic liver disease in the United States.

PubMed

Roberts, Henry W; Utuama, Ovie A; Klevens, Monina; Teshale, Eyasu; Hughes, Elizabeth; Jiles, Ruth

2014-03-01

Chronic liver disease (CLD) is increasingly recognized as a major public health problem. However, in the United States, there are few nationally representative data on the contribution of viral hepatitis as an etiology of CLD. We applied a previously used International Classification of Diseases, Ninth Revision, Clinical Modification-based definition of CLD cases to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases for 2006-2010. We estimated the mean number of CLD visits per year, prevalence ratio of visits by patient characteristics, and the percentage of CLD visits attributed to viral hepatitis and other selected etiologies. An estimated 6.0 billion ambulatory care visits occurred in the United States from 2006 to 2010, of which an estimated 25.8 million (0.43%) were CLD-related. Among adults aged 45-64 years, Medicaid and Medicare recipients were 3.9 (prevalence ratio (PR)=3.9, 95% confidence limit (CL; 2.8, 5.4)) and 2.3 (PR=2.3, 95% CL (1.6, 3.4)) times more likely to have a CLD-related ambulatory visit than those with private insurance, respectively. In the United States, from 2006 to 2010, an estimated 49.6% of all CLD-related ambulatory visits were attributed solely to viral hepatitis B and C diagnoses. In this unique application of health-care utilization data, we confirm that viral hepatitis is an important etiology of CLD in the United States, with hepatitis B and C contributing approximately one-half of the CLD burden. CLD ambulatory visits in the United States disproportionately occur among adults, aged 45-64 years, who are primarily minorities, men, and Medicare or Medicaid recipients.

Where the United States Spends its Spine Dollars: Expenditures on different ambulatory services for the management of back and neck conditions

PubMed Central

Davis, Matthew A.

2012-01-01

Study Design Serial, cross-sectional, nationally representative surveys of non-institutionalized adults. Objective To examine expenditures on common ambulatory health services for the management of back and neck conditions. Summary of Background Data Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. Methods We used the Medical Expenditure Panel Survey (MEPS) to examine adult (age ≥ 18 years) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Results Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; while physical therapy was the most costly service overall, in recent years those costs have contracted. Conclusion Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions. PMID:22433497

Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions.

PubMed

Davis, Matthew A; Onega, Tracy; Weeks, William B; Lurie, Jon D

2012-09-01

Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults. To examine expenditures on common ambulatory health services for the management of back and neck conditions. Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted. Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

A strategy utilizing ambulatory monitoring and home and clinic blood pressure measurements to optimize the safety evaluation of noncardiovascular drugs with potential for hemodynamic effects: a report from the SYNERGY trial.

PubMed

Weber, Michael A; Chapple, Christopher R; Gratzke, Christian; Herschorn, Sender; Robinson, Dudley; Frankel, Jeffrey M; Ridder, Arwin M; Stoelzel, Matthias; Paireddy, Asha; van Maanen, Robert; White, William B

2018-06-01

The aim of this study was to perform a blood pressure (BP) safety evaluation in patients with an overactive bladder receiving solifenacin (an antimuscarinic agent), mirabegron (a β3-adrenoceptor agonist), or both compared with placebo in the SYNERGY trial. Patients were randomized to receive solifenacin 5 mg+mirabegron 50 mg (combination 5+50 mg); solifenacin 5 mg+mirabegron 25 mg (combination 5+25 mg); solifenacin 5 mg; mirabegron 50 mg; mirabegron 25 mg; or placebo for a double-blind 12-week treatment period. Systolic BP, diastolic BP, and heart rate were measured by ambulatory BP monitoring, and in the clinic or home. A total of 715 patients were analyzed in an ambulatory BP monitoring substudy. At the end of treatment, ambulatory BP monitoring measurements showed no consistent increases from baseline in the mean 24-h systolic BP or diastolic BP for combination versus monotherapy groups or for monotherapy groups versus placebo. Analysis of 1-h BP averages during the 6 h range that included the Tmax values of both study drugs showed no significant BP effects. Shift analysis (switch between different normotension/hypertension stages) did not show differences among the active and placebo groups, nor did outlier analysis of major BP changes differ between placebo and active treatment. Similarly, there were no significant signals in the 24-h heart rate. Office and home measurements were consistent with ambulatory BP monitoring findings. A paradigm of ambulatory BP monitoring analysis designed to test BP safety of noncardiovascular drugs showed that solifenacin plus mirabegron combination therapy during 12 weeks produced no meaningful changes in BP or heart rate.

[Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids].

PubMed

Zaragozá, Cristóbal; García Fadrique, Alfonso; Castaño, Sergio; Villalba, Raúl; Bruna Esteban, Marcos; Redondo Cano, Carlos

2007-03-01

We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81+/- 12 minutes with a mean length of hospital stay of 168.88 +/- 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder.

Separate aftereffects of morning and evening exercise on ambulatory blood pressure in prehypertensive men.

PubMed

Brito, Leandro C; Rezende, Rafael A; Mendes, Caroline; Silva-Junior, Natan D; Tinucci, Taís; Cipolla-Neto, José; de Moraes Forjaz, Cláudia L

2018-01-01

Clinic postexercise hypotension (PEH) is different after aerobic exercise performed in the morning and in the evening. Thus, ambulatory PEH should also differ after exercises conducted at different times of day. However, because of the circadian pattern of blood pressure (BP), ambulatory PEH should be assessed considering a control condition. Thus, this study was designed to verify the effects of morning and evening exercises on postexercise ambulatory BP averages and circadian parameters by comparing responses obtained at each time of day after an exercise and a control session. Thirteen prehypertensive men underwent four sessions (randomized order): two in the morning (9 am) and two in the evening (6:30 pm). At each time of day, a control (C) and an exercise (E: cycle ergometer 45 min, 50% VO2peak) sessions were performed. After the sessions, an ambulatory BP and heart rate (HR) monitoring was started for 24 h. Paired t-test or Wilcoxon Signed Rank Test were used to compare the E and the C sessions at each time of day. In the morning, 24 h, daytime and nighttime HR were higher after the E than the C session. In the evening, nighttime systolic BP (116±11 vs. 120±10 mmHg, P=0.04) and rate pressure product (7981±1294 vs. 8583±1523 mmHg.bpm, P=0.04), as well as MESOR (128±11 vs. 130±10 mmHg, P=0.03) were lower in the E than the C session. In prehypertensive men, morning exercise increased ambulatory HR, while evening exercise decreased nighttime BP and cardiac work, reducing the MESOR of systolic BP.

Ambulatory Aortic Stiffness Is Associated With Narrow Retinal Arteriolar Caliber in Hypertensives: The SAFAR Study.

PubMed

Aissopou, Evaggelia K; Argyris, Antoniοs A; Nasothimiou, Efthimia G; Konstantonis, George D; Tampakis, Kostas; Tentolouris, Nikolaos; Papathanassiou, Miltiadis; Theodossiadis, Panagiotis G; Papaioannou, Theodoros G; Stehouwer, Coen D A; Sfikakis, Petros P; Protogerou, Athanassios D

2016-05-01

Arterial stiffness measured under static conditions reclassifies significantly cardiovascular (CV) risk and associates with narrower retinal arterioles. However, arterial stiffness exhibits circadian variation, thus single static stiffness recordings do not correspond to the "usual" 24 hr, awake, and asleep average arterial stiffness. We aimed to test the hypothesis that ambulatory 24 hr, awake, and asleep aortic (a) pulse wave velocity (PWV) associate with retinal vessel calibers, independently of confounders and of static arterial stiffness, in hypertensive individuals free from diabetes and CV disease. Digital retinal images were obtained (181 individuals, age: 53.9±10.7 years, 55.2% men) and retinal vessel calibers were measured with validated software to determine central retinal arteriolar and venular equivalents (CRAE and CRVE, respectively); ambulatory (24 hr, awake, asleep) and static office aPWV were estimated by Mobil-O-Graph; and static office carotid to femoral (cf) PWV by SphygmoCor. Regression analysis performed in 320 gradable retinal images showed that, after adjustment for confounders: (i) ambulatory aPWV was significantly associated with narrower retinal arterioles but not with venules; (ii) asleep aPWV had stronger associations with CRAE than awake aPWV; (iii) both ambulatory aPWV and cfPWV were associated mutually independently with narrower retinal arterioles; aPWV introduction in the model of cfPWV, improved model's R2 (P = 0.012). Similar discriminatory ability of 24 hr aPWV and of cfPWV to detect the presence of retinal arteriolar narrowing was found. Ambulatory aPWV, estimated by an operator-independent method, provides additional information to cfPWV regarding the associations of arterial stiffness with the retinal vessel calibers. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Out-of-office blood pressure and target organ damage in children and adolescents: a systematic review and meta-analysis.

PubMed

Kollias, Anastasios; Dafni, Maria; Poulidakis, Emmanouil; Ntineri, Angeliki; Stergiou, George S

2014-12-01

In children, out-of-office blood pressure (BP) assessment (especially ambulatory monitoring) is regarded as indispensable for accurate hypertension diagnosis. This article reviewed the evidence on the association between out-of-office BP measurements and preclinical organ damage indices in children. A systematic review and meta-analysis of 93 relevant articles (1974-2012) was performed. Analysis of 10 studies (n = 480, pooled age 14.4 years, with hypertension 33%, renal disease 27%, type 1 diabetes 10%) revealed a significant association between systolic ambulatory BP and left ventricular mass index (LVMI), with pooled correlation coefficient r = 0.40 [95% confidence interval (CI) 0.30-0.50]. Eleven studies reported data on LVMI differences between normotensive (n = 428) and hypertensive children (n = 432), with higher values in the latter group by 6.53 g/m(2.7) (95% CI 4.73-8.33). A moderate association was found between systolic ambulatory BP and carotid intima-media thickness (three studies, n = 231, age 13.3 years, pooled r = 0.32, 95% CI 0.21-0.44), as well as between diastolic ambulatory BP and urine albumin excretion (five studies, n = 355, age 13.1 years, type 1 diabetes 42%, reflux nephropathy 28%, pooled r = 0.32, 95% CI 0.05-0.58). Two studies reported on the association between home BP and LVMI, with one of them showing comparable coefficients as for ambulatory monitoring. The available evidence suggests a moderate but significant association between ambulatory BP and preclinical organ damage, mainly based on studies in nephropathy and/or diabetes. More data are needed in essential hypertension without nephropathy or diabetes, as well as with home measurements.

[The determination of arterial pressure by the physician or the nurse: its relation to ambulatory pressure and left ventricular mass. The MAPA-Madrid Group. Monitorización Ambulatoria de la Presión Arterial (Ambulatory Monitoring of Arterial Pressure)].

PubMed

Martínez, M A; Aguirre, A; Sánchez, M; Nevado, A; Laguna, I; Torre, A; Manuel, E; Villar, C; García-Puig, J

1999-12-11

In the present study we evaluated the influence of the observer's status--physician or nurse--on blood pressure levels and the relationship among clinic blood pressure measurement with ambulatory blood pressure and left ventricle mass. Cross sectional study performed in seven primary care centers. Participating physicians and nurses were trained for blood pressure measurement prior to the study and subsequently retrained at 3 month intervals during the study. Patients included in the study were 122 subjects with mild to moderate hypertension who underwent the following study protocol: a) measurement of clinic blood pressure by physician and nurse, in an independent fashion, on 3 visits; b) clinic-epidemiologic questionnaire; c) conventional hematological and biochemical study; d) electrocardiogram; e) 24-hour ambulatory blood pressure monitoring, f) M-mode and Doppler echocardiography (only in 58 subjects). Nurse-measured blood pressure levels were higher than those determined by physicians (mean differences: 3.9 [6.7] mmHg in systolic blood pressure and 2.6 [5.4] mmHg in diastolic blood pressure). The blood pressure level differences between the two observers were higher in female patients and subjects with low educational level, independently of the observer's gender. Nurse-measured blood pressure was more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. Nurse-measured blood pressure levels are lower than those determined by physicians and more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. These data support that nurses, instead of doctors, should routinely measure blood pressure in primary care centers.

Opening ambulatory surgery centers and stone surgery rates in health care markets.

PubMed

Hollingsworth, John M; Krein, Sarah L; Birkmeyer, John D; Ye, Zaojun; Kim, Hyungjin Myra; Zhang, Yun; Hollenbeck, Brent K

2010-09-01

Ambulatory surgery centers deliver surgical care more efficiently than hospitals but may increase overall procedure use and adversely affect competing hospitals. Motivated by these concerns we evaluated how opening of an ambulatory surgery center impacts stone surgery use in a health care market and assessed the effect of its opening on the patient mix at nearby hospitals. In a 100% sample of outpatient surgery from Florida we measured annual stone surgery use between 1998 and 2006. We used multiple regression to determine if the rate of change in use differed between markets, defined by the hospital service area, without and with a recently opened ambulatory surgery center. Stone surgery use increased an average of 11 procedures per 100,000 individuals per year (95% CI 1-20, p <0.001) after an ambulatory surgery center opened in a hospital service area. Four years after opening the relative increase in the stone surgery rate was approximately 64% higher (95% CI 27 to 102) in hospital service areas where a center opened vs hospital service areas without a center. These market level increases in surgery were not associated with decreased surgical volume at competing hospitals and the absolute change in patient disease severity treated at nearby hospitals was small. While opening of an ambulatory surgery center did not appear to have an overly detrimental effect on competing hospitals, it led to a significant increase in the population based rate of stone surgery in the hospital service area. Possible explanations are the role of physician financial incentives and unmet surgical demand. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

PubMed

Ware, Chelsea E; Ajabnoor, Yasser; Mullins, Peter M; Mazer-Amirshahi, Maryann; Pines, Jesse M; May, Larissa

2016-09-01

Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured. Copyright © 2016 Elsevier Inc. All rights reserved.

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States.

PubMed

Rosero, Eric B; Joshi, Girish P

2014-05-01

To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. Retrospective, propensity-matched cohort study. Academic medical center. The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese. Copyright © 2014 Elsevier Inc. All rights reserved.

Trends in physician referrals in the United States, 1999-2009.

PubMed

Barnett, Michael L; Song, Zirui; Landon, Bruce E

2012-01-23

Physician referrals play a central role in ambulatory care in the United States; however, little is known about national trends in physician referrals over time. The objective of this study was to assess changes in the annual rate of referrals to other physicians from physician office visits in the United States from 1999 to 2009. We analyzed nationally representative cross-sections of ambulatory patient visits in the United States, using a sample of 845 243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2009, focusing on the decade from 1999 to 2009. The main outcome measures were survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.8% to 9.3% (P < .001), a 94% increase. The absolute number of visits resulting in a physician referral increased 159% nationally during this time, from 41 million to 105 million. This trend was consistent across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice (P = .02) or those with the majority of income from managed care contracts (P = .007). Changes in referral rates varied according to the principal symptoms accounting for patients' visits, with significant increases noted for visits to primary care physicians from patients with cardiovascular, gastrointestinal, orthopedic, dermatologic, and ear/nose/throat symptoms. The percentage and absolute number of ambulatory visits resulting in a referral in the United States grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.

Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients.

PubMed

Sisante, Jason-Flor V; Abraham, Michael G; Phadnis, Milind A; Billinger, Sandra A; Mittal, Manoj K

2016-10-01

Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate. A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84). Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Evaluating ambulatory care training in Firoozgar hospital based on Iranian national standards of undergraduate medical education

PubMed Central

Sabzghabaei, Foroogh; Salajeghe, Mahla; Soltani Arabshahi, Seyed Kamran

2017-01-01

Background: In this study, ambulatory care training in Firoozgar hospital was evaluated based on Iranian national standards of undergraduate medical education related to ambulatory education using Baldrige Excellence Model. Moreover, some suggestions were offered to promote education quality in the current condition of ambulatory education in Firoozgar hospital and national standards using the gap analysis method. Methods: This descriptive analytic study was a kind of evaluation research performed using the standard check lists published by the office of undergraduate medical education council. Data were collected through surveying documents, interviewing, and observing the processes based on the Baldrige Excellence Model. After confirming the validity and reliability of the check lists, we evaluated the establishment level of the national standards of undergraduate medical education in the clinics of this hospital in the 4 following domains: educational program, evaluation, training and research resources, and faculty members. Data were analyzed according to the national standards of undergraduate medical education related to ambulatory education and the Baldrige table for scoring. Finally, the quality level of the current condition was determined as very appropriate, appropriate, medium, weak, and very weak. Results: In domains of educational program 62%, in evaluation 48%, in training and research resources 46%, in faculty members 68%, and in overall ratio, 56% of the standards were appropriate. Conclusion: The most successful domains were educational program and faculty members, but evaluation and training and research resources domains had a medium performance. Some domains and indicators were determined as weak and their quality needed to be improved, so it is suggested to provide the necessary facilities and improvements by attending to the quality level of the national standards of ambulatory education PMID:29951400

The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study.

PubMed

Tu, Jack V; Maclagan, Laura C; Ko, Dennis T; Atzema, Clare L; Booth, Gillian L; Johnston, Sharon; Tu, Karen; Lee, Douglas S; Bierman, Arlene; Hall, Ruth; Bhatia, R Sacha; Gershon, Andrea S; Tobe, Sheldon W; Sanmartin, Claudia; Liu, Peter; Chu, Anna

2017-04-25

High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. Copyright 2017, Joule Inc. or its licensors.

Electronic medical records for otolaryngology office-based practice.

PubMed

Chernobilsky, Boris; Boruk, Marina

2008-02-01

Pressure is mounting on physicians to adopt electronic medical records. The field of health information technology is evolving rapidly with innovations and policies often outpacing science. We sought to review research and discussions about electronic medical records from the past year to keep abreast of these changes. Original scientific research, especially from otolaryngologists, is lacking in this field. Adoption rates are slowly increasing, but more of the burden is shouldered by physicians despite policy efforts and the clear benefits to third-party payers. Scientific research from the past year suggests lack of improvements and even decreasing quality of healthcare with electronic medical record adoption in the ambulatory care setting. The increasing prevalence and standardization of electronic medical record systems results in a new set of problems including rising costs, audits, difficulties in transition and public concerns about security of information. As major players in healthcare continue to push for adoption, increased effort must be made to demonstrate actual improvements in patient care in the ambulatory care setting. More scientific studies are needed to demonstrate what features of electronic medical records actually improve patient care. Otolaryngologists should help each other by disseminating research about improvement in patient outcomes with their systems since current adoption and outcomes policies do not apply to specialists.

Transcutaneous sacral neurostimulation for irritative voiding dysfunction.

PubMed

Walsh, I K; Johnston, R S; Keane, P F

1999-01-01

Patients with irritative voiding dysfunction are often unresponsive to standard clinical treatment. We evaluated the response of such individuals to transcutaneous electrical stimulation of the third sacral nerve. 32 patients with refractory irritative voiding dysfunction (31 female and 1 male; mean age 47 years) were recruited to the study. Ambulatory transcutaneous electrical neurostimulation was applied bilaterally to the third sacral dermatomes for 1 week. Symptoms of frequency, nocturia, urgency, and bladder pain were scored by each patient throughout and up to 6 months following treatment. The mean daytime frequency was reduced from 11.3 to 7.96 (p = 0.01). Nocturia episodes were reduced from a mean of 2.6 to 1.8 (p = 0.01). Urgency and bladder pain mean symptom scores were reduced from 5.97 to 4.89 and from 1.48 to 0.64, respectively. After stopping therapy, symptoms returned to pretreatment levels within 2 weeks in 40% of the patients and within 6 months in 100%. Three patients who continued with neurostimulation remained satisfied with this treatment modality at 6 months. Transcutaneous third sacral nerve stimulation may be an effective and noninvasive ambulatory technique for the treatment of patients with refractory irritative voiding dysfunction. Following an initial response, patients may successfully apply this treatment themselves to ensure long-term relief.

Hindlimb unloading alters ligament healing

NASA Technical Reports Server (NTRS)

Provenzano, Paolo P.; Martinez, Daniel A.; Grindeland, Richard E.; Dwyer, Kelley W.; Turner, Joanne; Vailas, Arthur C.; Vanderby, Ray Jr

2003-01-01

We investigated the hypothesis that hindlimb unloading inhibits healing in fibrous connective tissue such as ligament. Male rats were assigned to 3- and 7-wk treatment groups with three subgroups each: sham control, ambulatory healing, and hindlimb-suspended healing. Ambulatory and suspended animals underwent surgical rupture of their medial collateral ligaments, whereas sham surgeries were performed on control animals. After 3 or 7 wk, mechanical and/or morphological properties were measured in ligament, muscle, and bone. During mechanical testing, most suspended ligaments failed in the scar region, indicating the greatest impairment was to ligament and not to bone-ligament insertion. Ligament testing revealed significant reductions in maximum force, ultimate stress, elastic modulus, and low-load properties in suspended animals. In addition, femoral mineral density, femoral strength, gastrocnemius mass, and tibialis anterior mass were significantly reduced. Microscopy revealed abnormal scar formation and cell distribution in suspended ligaments with extracellular matrix discontinuities and voids between misaligned, but well-formed, collagen fiber bundles. Hence, stress levels from ambulation appear unnecessary for formation of fiber bundles yet required for collagen to form structurally competent continuous fibers. Results support our hypothesis that hindlimb unloading impairs healing of fibrous connective tissue. In addition, this study provides compelling morphological evidence explaining the altered structure-function relationship in load-deprived healing connective tissue.

An ambulatory recording system for the assessment of autonomic changes across multiple days

NASA Astrophysics Data System (ADS)

Sollers, John J., III; Yonezawa, Yoshiharu; Silver, Rebecca A.; Merritt, Marcellus M.; Thayer, Julian F.

2005-05-01

Recent evidence indicates that poor autonomic regulation, indexed by decreased heart period variability (HPV), is associated with decreased working memory. HPV analyses are computed on the interbeat interval time series derived from the electrocardiogram (EKG). Unfortunately, the duration of the data collection and the issue of the size of ambulatory monitors with sufficient storage capacity for multi-day records is somewhat problematic. In the present paper we describe a system that allows for the collection of large amounts of high quality data using a small data collection device. The recording system consists of a miniature, single-module electrocardiogram-recording device. This module consists of an integrated three-electrode device that is attached to the chest of the subject. A low power 8-bit micro-controller detects the R-spike and stores the time between R-spikes in milliseconds on a 512 KB EEPROM. This system can record continuously for over four days. This system will allow the recording of cardio-dynamics in the field and provide highly reliable data across multiple days. The use of this device to assess physiological function in military operations would allow researchers to examine longer data records across several contexts and to understand the role of changes in autonomic function as they relate to performance.

Quantifying weight bearing while in passive standers and a comparison of standers.

PubMed

Kecskemethy, Heidi H; Herman, Daniel; May, Ryan; Paul, Kathleen; Bachrach, Steven J; Henderson, Richard C

2008-07-01

Mechanical loading plays an important role in skeletal health, and this is a major reason standing devices are widely used with non-ambulatory persons. However, little is known about the true axial loading that occurs while in a stander, or the factors which may impact loading. The purpose of this study was to quantify weight borne while in a stander, and to directly compare different standers. Load measuring footplate adaptors were designed and fabricated specifically for this study. Weight bearing loads in 20 non-ambulatory persons with quadriplegic cerebral palsy aged 6 to 21 years (median 14 y) were continuously monitored during routine 30-minute standing sessions. Fourteen participants were female, six were male; one was Gross Motor Function Classification System (GMFCS) Level IV, and 19 were GMFCS Level V. Each participant was monitored on four to six occasions over an 8-week period, two to three times in each of two different standers (total 108 standing sessions). Weight bearing loads ranged widely from 37 to 101% of body weight. The difference between standers was as much as 29% body weight. There is wide variance in the actual weight borne while in passive standers. The type of stander utilized is one factor which can significantly affect the amount of weight borne.

The French health care system: liberal universalism.

PubMed

Steffen, Monika

2010-06-01

This article analyzes the reforms introduced over the last quarter century into the French health care system. A particular public-private combination, rooted in French history and institutionalized through a specific division of the policy field between private doctors and public hospitals, explains the system's core characteristics: universal access, free choice, high quality, and a weak capacity for regulation. The dual architecture of this unique system leads to different reform strategies and outcomes in its two main parts. While the state has leverage in the hospital sector, it has failed repeatedly in attempts to regulate the ambulatory care sector. The first section of this article sets out the main characteristics and historical landmarks that continue to affect policy framing and implementation. Section 2 focuses on the evolution in financing and access, section 3 on management and governance in the (private) ambulatory care sector, and section 4 on the (mainly public) hospital sector. The conclusion compares the French model with those developed in the comparative literature and sets out the terms of the dilemma: a state-run social health insurance that lacks both the legitimacy of Bismarckian systems and the leverages of state-run systems. The French system therefore pursues contradictory policy goals, simultaneously developing universalism and liberalism, which explains both the direct state intervention and its limits.

Physician-based transactions: the sale of medical practices, ambulatory surgery centers, and dialysis facilities.

PubMed

Becker, S; Pristave, R J

1995-01-01

This article provides an overview of the critical business and legal issues encountered in sales of practices, ambulatory surgery centers, and dialysis facilities. Specifically, it discusses prototypical valuations, transaction structures, and the principal legal issues that must be addressed.

Estimating Treatment and Treatment Times for Special and Nonspecial Patients in Hospital Ambulatory Dental Clinics.

ERIC Educational Resources Information Center

Rosenberg, Dara J.; And Others

1986-01-01

A study compared the treatments and the amount of time needed for treatment of the dental needs of developmentally disabled, severely compromised, and moderately compromised patients with those of nondisabled patients in a hospital ambulatory dental clinic. (MSE)

Teaching Interdisciplinary Geriatrics Ambulatory Care: A Case Study

ERIC Educational Resources Information Center

Williams, Brent C.; Remington, Tami L.; Foulk, Mariko A.; Whall, Ann L.

2006-01-01

Interdisciplinary health care training is advocated by numerous government and philanthropic organizations. Educators in the health professions are increasingly offering training in interdisciplinary health care in a variety of contexts, including ambulatory settings. This paper describes a three-year program to teach skills in interdisciplinary…

78 FR 40740 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-08

... proposed information collection project: ``Pretest of the Ambulatory Surgery/Procedure Survey on [email protected] . SUPPLEMENTARY INFORMATION: Proposed Project Pretest of the Ambulatory Surgery... to improve their practices and their culture of patient safety. This survey is designed for use in...

Latissimus dorsi free flap for coverage of sacral radiodermatitis in the ambulatory patient

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stark, D.; Tofield, J.J.; Terranova, W.

1987-07-01

Ambulatory patients with large sacral ulcers can represent extremely challenging coverage problems. Technical options become fewer when sacral ulcers are coupled with radiation dermatitis. Latissimus dorsi free flap transfer, with direct anastomoses to sacral vessels, is described in 2 patients.

Impact of an Elective Course in Community and Ambulatory Care Pharmacy Practices on Student Perception of Patient Care

PubMed Central

Maguire, Michelle; Bennett, Marialice S.

2015-01-01

Objective. To determine the impact of an elective course on students’ perception of opportunities and of their preparedness for patient care in community and ambulatory pharmacy settings. Design. Each course meeting included a lecture and discussion to introduce concepts and active-learning activities to apply concepts to patient care or practice development in a community or ambulatory pharmacy setting. Assessment. A survey was administered to students before and after the course. Descriptive statistics were used to assess student responses to survey questions, and Wilcoxon signed rank tests were used to analyze the improvement in student responses with an alpha level set at 0.05. Students felt more prepared to provide patient care, develop or improve a clinical service, and effectively communicate recommendations to other health care providers after course completion. Conclusion. This elective course equipped students with the skills necessary to increase their confidence in providing patient care services in community and ambulatory settings. PMID:27168617

The effect of depression on sleep quality and the circadian rhythm of ambulatory blood pressure in older patients with hypertension.

PubMed

Ma, Lina; Li, Yun

2017-05-01

To explore the effect of depression on the sleep quality, and the circadian rhythm of ambulatory blood pressure in patients with essential hypertension. A total of 73 older patients with hypertension were screened for depression and divided into two groups. The Pittsburgh Sleep Quality Index (PSQI) and the circadian rhythm of ambulatory blood pressure were compared between the non-depressed (control) and depressed (case) group. In the case group, 24h ambulatory SBP and DBP, and nocturnal SBP and DBP were higher than in the control group, and the circadian rhythm of non-dipper was higher (67.22% vs 40.13%，P<0.01). There was a positive correlation between PSQI and depression (r=0.432, P<0.01). There was a significant correlation between sleep quality and depression in older patients with hypertension. Depression increases the circadian rhythm of non-dipper in older patients with hypertension. Copyright © 2017 Elsevier Ltd. All rights reserved.

Determining suitability for home versus community-based ambulatory therapy services for adults with arthritis.

PubMed

Rothman, L M; Badley, E M

1996-02-01

A survey of clients seen by a community-based arthritis therapy service was conducted to investigate how characteristics of clients might provide information to assist in the development of guidelines for services delivered in the home versus in a community-based ambulatory setting. Clients completed a self-administered questionnaire, which included the Health Assessment Questionnaire, and a mobility handicap measure. Two indicator variables selected as criteria for suitability for ambulatory therapy were the therapists' rating of client suitability and the clients' report of going out more than once weekly. Based on these indicator variables, 60-76% of clients currently receiving home therapy by this service could potentially receive services in a community-based ambulatory setting. The results demonstrate the usefulness of considering client characteristics when deciding whether clients need to be seen at home. This study emphasizes the need to determine the most efficient and effective methods of providing services to people in the community with chronic conditions.

Health professionals' beliefs related to parental involvement in ambulatory care: an international inquiry.

PubMed

Tourigny, Jocelyne; Chartrand, Julie; Massicotte, Julie

2008-01-01

Changes in health care delivery in Canada and Europe, especially the shift to ambulatory care, have modified the care that children and parents receive and have prompted the need for a partnership alliance. The objectives of this exploratory study were to identify Canadian and Belgian health professionals' beliefs and attitudes towards parental involvement in their child's ambulatory care and to determine if these beliefs varied according to cultural background. Health professionals from both countries generally were in favor of parental involvement in their child's care, but are uncertain about its advantages and disadvantages. Facilitators and barriers mentioned by the health care providers were related to parents' abilities or their attitudes toward partnership, and they also expressed a need for more education on the subject. Results of this study indicate that health professionals working in ambulatory care are not fully ready to utilize parents as true partners in their interventions with children and families. Staff education is an important step towards the establishment and maintenance of a real partnership.

Effective Learning in an Ambulatory Family Medicine Clerkship: A Qualitative Study of Medical Student Midpoint Feedback.

PubMed

Bradner, Melissa K; Flores, Sharon Kaufer; Gary, Judy S; Zumbrunn, Sharon

2017-09-01

There is substantial research on the effectiveness of ambulatory medical preceptors' teaching skills, but less is known about the student perspective on what contributes most to effective learning in a busy clinical practice. As part of a formative midpoint assessment during the third-year clerkship in family medicine, students were asked to respond to the following open-ended reflective prompt: "My preceptor contributed to my learning by..." A qualitative assessment of student responses was conducted to identify themes describing effective learning in the ambulatory setting. Responses for all clerkship students from the years 2012-2014 were examined (N=314). The most common characteristic of effective learning identified by respondents was Autonomy in Practice. Other prominent themes included Stimulating Critical Thinking and Feedback. Understanding student perceptions of the critical components of learning in ambulatory settings will allow medical educators to design meaningful student learning experiences and coach community teachers on effective teaching practices.

Ambulatory (24 h) blood pressure and arterial stiffness measurement in Marfan syndrome patients: a case control feasibility and pilot study.

PubMed

Hillebrand, Matthias; Nouri, Ghazaleh; Hametner, Bernhard; Parragh, Stephanie; Köster, Jelena; Mortensen, Kai; Schwarz, Achim; von Kodolitsch, Yskert; Wassertheurer, Siegfried

2016-05-06

The aim of this work is the investigation of measures of ambulatory brachial and aortic blood pressure and indices of arterial stiffness and aortic wave reflection in Marfan patients. A case-control study was conducted including patients with diagnosed Marfan syndrome following Ghent2 nosology and healthy controls matched for sex, age and daytime brachial systolic blood pressure. For each subject a 24 h ambulatory blood pressure and 24 h pulse wave analysis measurement was performed. All parameters showed a circadian pattern whereby pressure dipping was more pronounced in Marfan patients. During daytime only Marfan patients with aortic root surgery showed increased pulse wave velocity. In contrast, various nighttime measurements, wave reflection determinants and circadian patterns showed a significant difference. The findings of our study provide evidence that ambulatory measurement of arterial stiffness parameters is feasible and that these determinants are significantly different in Marfan syndrome patients compared to controls in particular at nighttime. Further investigation is therefore indicated.

Collaborative Care in Ambulatory Psychiatry: Content Analysis of Consultations to a Psychiatric Pharmacist.

PubMed

Gotlib, Dorothy; Bostwick, Jolene R; Calip, Seema; Perelstein, Elizabeth; Kurlander, Jacob E; Fluent, Thomas

2017-09-15

To determine the volume and nature (or topic) of consultations submitted to a psychiatric pharmacist embedded in an ambulatory psychiatry clinic, within a tertiary care academic medical center and to increase our understanding about the ways in which providers consult with an available psychiatric pharmacist. Authors analyze and describe the ambulatory psychiatric pharmacist consultation log at an academic ambulatory clinic. All consultation questions were submitted between July 2012 and October 2014. Psychiatry residents, attending physicians, and advanced practice nurse practitioners submitted 280 primary questions. The most common consultation questions from providers consulted were related to drug-drug interactions (n =70), drug formulations/dosing (n =48), adverse effects (n =43), and pharmacokinetics/lab monitoring/cross-tapering (n =36). This is a preliminary analysis that provides information about how psychiatry residents, attending physicians, and advanced practice nurse practitioners at our health system utilize a psychiatric pharmacist. This collaborative relationship may have implications for the future of psychiatric care delivery.

Secondary conditions among males with Duchenne or Becker muscular dystrophy

PubMed Central

Latimer, Rebecca; Street, Natalie; Conway, Kristin Caspers; James, Kathy; Cunniff, Christopher; Oleszek, Joyce; Fox, Deborah; Ciafaloni, Emma; Westfield, Christina; Paramsothy, Pangaja

2017-01-01

Duchenne and Becker muscular dystrophy are X-linked neuromuscular disorders characterized by progressive muscle degeneration. Despite the involvement of multiple systems, secondary conditions among affected males have not been comprehensively described. Two hundred and nine caregivers of affected males (aged 3–31 years) identified by the Muscular Dystrophy Surveillance, Tracking, and Research Network completed a mailed survey that included questions about secondary conditions impacting multiple body functions. The five most commonly reported conditions in males with Duchenne were cognitive deficits (38.4%), constipation (31.7%), anxiety (29.3%), depression (27.4%), and obesity (19.5%). Higher frequencies of anxiety, depression, and kidney stones, were found among non-ambulatory males compared to ambulatory males. Attention deficit hyperactivity disorder was more common in ambulatory than non-ambulatory males. These data support clinical care recommendations for monitoring of patients with Duchenne or Becker muscular dystrophy by a multidisciplinary team to prevent and treat conditions that may be secondary to the diagnosis. PMID:28393671

Gait speed using powered robotic exoskeletons after spinal cord injury: a systematic review and correlational study.

PubMed

Louie, Dennis R; Eng, Janice J; Lam, Tania

2015-10-14

Powered robotic exoskeletons are an emerging technology of wearable orthoses that can be used as an assistive device to enable non-ambulatory individuals with spinal cord injury (SCI) to walk, or as a rehabilitation tool to improve walking ability in ambulatory individuals with SCI. No studies to date have systematically reviewed the literature on the efficacy of powered exoskeletons on restoring walking function. Our objective was to systematically review the literature to determine the gait speed attained by individuals with SCI when using a powered exoskeleton to walk, factors influencing this speed, and characteristics of studies involving a powered exoskeleton (e.g. inclusion criteria, screening, and training processes). A systematic search in computerized databases was conducted to identify articles that reported on walking outcomes when using a powered exoskeleton. Individual gait speed data from each study was extracted. Pearson correlations were performed between gait speed and 1) age, 2) years post-injury, 3) injury level, and 4) number of training sessions. Fifteen articles met inclusion criteria, 14 of which investigated the powered exoskeleton as an assistive device for non-ambulatory individuals and one which used it as a training intervention for ambulatory individuals with SCI. The mean gait speed attained by non-ambulatory participants (n = 84) while wearing a powered exoskeleton was 0.26 m/s, with the majority having a thoracic-level motor-complete injury. Twelve articles reported individual data for the non-ambulatory participants, from which a positive correlation was found between gait speed and 1) age (r = 0.27, 95 % CI 0.02-0.48, p = 0.03, 63 participants), 2) injury level (r = 0.27, 95 % CI 0.02-0.48, p = 0.03, 63 participants), and 3) training sessions (r = 0.41, 95 % CI 0.16-0.61, p = 0.002, 55 participants). In conclusion, powered exoskeletons can provide non-ambulatory individuals with thoracic-level motor-complete SCI the ability to walk at modest speeds. This speed is related to level of injury as well as training time.

Ambulatory Pulse Wave Velocity Is a Stronger Predictor of Cardiovascular Events and All-Cause Mortality Than Office and Ambulatory Blood Pressure in Hemodialysis Patients.

PubMed

Sarafidis, Pantelis A; Loutradis, Charalampos; Karpetas, Antonios; Tzanis, Georgios; Piperidou, Alexia; Koutroumpas, Georgios; Raptis, Vasilios; Syrgkanis, Christos; Liakopoulos, Vasilios; Efstratiadis, Georgios; London, Gérard; Zoccali, Carmine

2017-07-01

Arterial stiffness and augmentation of aortic blood pressure (BP) measured in office are known cardiovascular risk factors in hemodialysis patients. This study examines the prognostic significance of ambulatory brachial BP, central BP, pulse wave velocity (PWV), and heart rate-adjusted augmentation index [AIx(75)] in this population. A total of 170 hemodialysis patients underwent 48-hour ambulatory monitoring with Mobil-O-Graph-NG during a standard interdialytic interval and followed-up for 28.1±11.2 months. The primary end point was a combination of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Secondary end points included: (1) all-cause mortality; (2) cardiovascular mortality; and (3) a combination of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, coronary revascularization, or hospitalization for heart failure. During follow-up, 37(21.8%) patients died and 46(27.1%) had cardiovascular events. Cumulative freedom from primary end point was similar for quartiles of predialysis-systolic BP (SBP), 48-hour peripheral-SBP, and central-SBP, but was progressively longer for increasing quartiles for 48-hour peripheral-diastolic BP and central-diastolic BP and shorter for increasing quartiles of 48-hour central pulse pressure (83.7%, 71.4%, 69.0%, 62.8% [log-rank P =0.024]), PWV (93.0%, 81.0%, 57.1%, 55.8% [log-rank P <0.001]), and AIx(75) (88.4%, 66.7%, 69.0%, 62.8% [log-rank P =0.014]). The hazard ratios for all-cause mortality, cardiovascular mortality, and the combined outcome were similar for quartiles of predialysis-SBP, 48-hour peripheral-SBP, and central-SBP, but were increasing with higher ambulatory PWV and AIx(75). In multivariate analysis, 48-hour PWV was the only vascular parameter independently associated with the primary end point (hazard ratios, 1.579; 95% confidence intervals, 1.187-2.102). Ambulatory PWV, AIx(75), and central pulse pressure are associated with increased risk of cardiovascular events and mortality, whereas office and ambulatory SBP are not. These findings further support that arterial stiffness is the prominent cardiovascular risk factor in hemodialysis. © 2017 American Heart Association, Inc.

A comparison study of brachial blood pressure recorded with Spacelabs 90217A and Mobil-O-Graph NG devices under static and ambulatory conditions.

PubMed

Sarafidis, P A; Lazaridis, A A; Imprialos, K P; Georgianos, P I; Avranas, K A; Protogerou, A D; Doumas, M N; Athyros, V G; Karagiannis, A I

2016-12-01

Ambulatory blood pressure monitoring is an important tool in hypertension diagnosis and management. Although several ambulatory devices exist, comparative studies are scarce. This study aimed to compare for the first time brachial blood pressure levels of Spacelabs 90217A and Mobil-O-Graph NG, under static and ambulatory conditions. We examined 40 healthy individuals under static (study A) and ambulatory (study B) conditions. In study A, participants were randomized into two groups that included blood pressure measurements with mercury sphygmomanometer, Spacelabs and Mobil-O-Graph devices with reverse order of recordings. In study B, simultaneous 6-h recordings with both devices were performed with participants randomized in two sequences of device positioning with arm reversal at 3 h. Finally, all the participants filled in a questionnaire rating their overall preference for a device. In study A, brachial systolic blood pressure (117.2±10.3 vs 117.1±9.8 mm Hg, P=0.943) and diastolic blood pressure (73.3±9.4 mm Hg vs 74.1±9.4 mm Hg, P=0.611) did not differ between Spacelabs and Mobil-O-Graph or vs sphygmomanometer (117.8±11.1 mm Hg, P=0.791 vs Spacelabs, P=0.753 vs Mobil-O-Graph). Similarly, no differences were found in ambulatory systolic blood pressure (117.9±11.4 vs 118.3±11.0 mm Hg, P=0.864), diastolic blood pressure (73.7±7.4 vs 74.7±8.0 mm Hg, P=0.571), mean blood pressure and heart rate between Spacelabs and Mobil-O-Graph. Correlation analyses and Bland-Altman plots showed agreement between the monitors. Overall, the participants showed a preference for the Mobil-O-Graph. Spacelabs 90217A and Mobil-O-Graph NG provide practically identical measurements during the static and ambulatory conditions in healthy individuals and can be rather used interchangeably in clinical practice.

Home monitoring after ambulatory implanted primary cardiac implantable electronic devices: The home ambulance pilot study.

PubMed

Parahuleva, Mariana S; Soydan, Nedim; Divchev, Dimitar; Lüsebrink, Ulrich; Schieffer, Bernhard; Erdogan, Ali

2017-11-01

The Home Monitoring (HM) system of cardiac implantable electronic devices (CIEDs) permits early detection of arrhythmias or device system failures. The aim of this pilot study was to examine how the safety and efficacy of the HM system in patients after ambulatory implanted primary CIEDs compare to patients with a standard procedure and hospitalization. We hypothesized that HM and their modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs. This retrospective analysis evaluates telemetric data obtained from 364 patients in an ambulatory single center over 6 years. Patients were assigned to an active group (n = 217), consisting of those who were discharged early on the day of implantation of the primary CIED, or to a control group (n = 147), consisting of those discharged and followed up with the HM system according to usual medical practices. The mean duration of hospitalization was 73.2% shorter in the active group than in the control group, corresponding to 20.5 ± 13 fewer hours (95% confidence interval [CI]: 6.3-29.5; P < 0.01) spent in the hospital (7.5 ± 1.5 vs 28 ± 4.5 h). This shorter mean hospital stay was attributable to a 78.8% shorter postoperative period in the active group. The proportion of patients with treatment-related adverse events was 11% (n = 23) in the active group and 17% (n = 25) in the control group (95% CI: 5.5-8.3; P = 0.061). This 6% absolute risk reduction (95% CI: 3.3-9.1; P = 0.789) confirmed the noninferiority of the ambulatory implanted CIED when compared with standard management of these patients. Early discharge with the HM system after ambulatory CIED implantation was safe and not inferior to the classic medical procedure. Thus, together with lower costs, HM and its modifications would be a useful extension of the present concepts for ambulatory implanted CIEDs. © 2017 Wiley Periodicals, Inc.

Aortic Stiffness, Ambulatory Blood Pressure, and Predictors of Response to Antihypertensive Therapy in Hemodialysis.

PubMed

Georgianos, Panagiotis I; Agarwal, Rajiv

2015-08-01

Arterial stiffness is associated with elevated blood pressure (BP), but it is unclear whether it also makes hypertension more resistant to treatment. Among hypertensive dialysis patients, this study investigated whether aortic stiffness determines ambulatory BP and predicts its improvement with therapy. Post hoc analysis of the Hypertension in Hemodialysis Patients Treated With Atenolol or Lisinopril (HDPAL) trial. 179 hypertensive hemodialysis patients with echocardiographic left ventricular hypertrophy. Baseline aortic pulse wave velocity (PWV). Baseline and treatment-induced change in 44-hour ambulatory BP at 3, 6, and 12 months. Aortic PWV was assessed with an echocardiographic-Doppler technique (ACUSON Cypress, Siemens Medical), and 44-hour interdialytic ambulatory BP monitoring was performed with a Spacelabs 90207 monitor. Mean baseline aortic PWV was 7.6±2.7 (SD) m/s. Overall treatment-induced changes in ambulatory systolic BP (SBP) were -15.6±20.4, -18.9±22.5, and -20.0±19.7 mmHg at 3, 6, and 12 months. Changes in SBP were no different among tertiles of baseline PWV. Aortic PWV was associated directly with baseline ambulatory SBP and pulse pressure (PP) and inversely with diastolic BP (DBP). After adjustment for several cardiovascular risk factors, each 1-m/s higher PWV was associated with 1.34-mm Hg higher baseline SBP (β=1.34±0.46; P=0.004) and 1.02-mm Hg higher PP (β=1.02±0.33; P=0.002), whereas the association with DBP was no longer significant. Baseline PWV did not predict treatment-induced changes in SBP (Wald test, P=0.3) and DBP (Wald test, P=0.7), but was a predictor of an overall improvement in PP during follow-up (Wald test, P=0.03). Observational design; predominantly black patients were studied. Because aortic PWV is not a predictor of treatment-induced change in ambulatory BP among hypertensive dialysis patients, it indicates that among these patients, hypertension can be controlled successfully regardless of aortic stiffness. Published by Elsevier Inc.

Use of ECT in the presence of acute bilateral posterior vitreous detachmanet.

PubMed

Taye, Tesema; Dobranici, Letitia; Fisher, Mark; Cullum, Sarah

2018-04-01

We describe a case of acute bilateral posterior vitreous detachment (PVD) in a 71-year-old female, which developed during a course of electroconvulsive therapy (ECT) for treatment-resistant depression. The risks and benefits of continuing ECT were assessed and the patient completed the full course of 16 ECT treatments without further ophthalmic complications. As the incidence of PVD increases with age, and ECT is used more frequently in elderly people with depression, we recommend paying attention to ophthalmic symptoms as part of the routine clinical monitoring of ECT side effects. If ophthalmic symptoms occur, the risks and benefits of ECT need to be weighed up including consultation with an ophthalmologist.

Greater efficacy of aldosterone blockade and diuretic reinforcement vs. dual renin-angiotensin blockade for left ventricular mass regression in patients with resistant hypertension.

PubMed

Azizi, Michel; Perdrix, Ludivine; Bobrie, Guillaume; Frank, Michael; Chatellier, Gilles; Ménard, Joël; Plouin, Pierre-François

2014-10-01

We report the results of an echocardiographic substudy carried out in a trial comparing the effects of two different treatment strategies - mineralocorticoid receptor blockade (MRB) and dual renin-angiotensin system blockade (RASB) - in patients with resistant hypertension. Both strategies reduce left ventricular mass index (LVMI), but they have not been compared in patients with resistant hypertension. After 4-week treatment with 300 mg irbesartan + 12.5 mg hydrochorothiazide + 5 mg amlodipine, 86 patients with resistant hypertension were randomized to the add-on 25 mg spironolactone (MRB group, n = 46) or 5 mg ramipril (RASB group, n = 40) groups for 12 weeks. Treatment intensity was increased at week 4, 8 or 10 if home blood pressure (BP) was equal to or above 135/85 mmHg, by sequentially adding 20-40 mg furosemide and 5 mg amiloride (MRB group), or 10 mg ramipril and 5-10 mg bisoprolol (RASB group). Transthoracic echography was performed at baseline and week 12. Daytime ambulatory BP decreased by 19 ± 12/11 ± 8 mmHg in the MRB group and by 8 ± 13/7 ± 7 mmHg in the RASB group (P = 0.0003/0.03). LVMI decreased by 8.2 ± 18.9 g/m in the MRB group, whereas it increased by 1.8 ± 19.1 g/m in the RASB group (P = 0.03). The decreases in posterior wall thickness, left ventricular (LV) end-systolic diameter, E/e' ratio and left atrial area were significantly greater with MRB than with RASB. The difference between groups remained significant after adjustment for the decrease in ambulatory BP. In patients with resistant hypertension, MRB-based treatment decreased both BP and LVMI more efficiently than a strategy based on dual RASB.

Developing from within: ensuring the ambulatory emergency care workforce is fit for purpose.

PubMed

Thurgate, Claire; Holmes, Sue

2015-11-01

Emergency healthcare provision is changing, and services need to respond to evolving health economies while providing safe, effective, patient-centred care. Ambulatory care is developing to meet these needs, but workforce planners need to ensure that staff are fit for purpose. To address this, one trust, in partnership with a local university, designed a bespoke in-house, work-based learning package on ambulatory care, which was delivered to registered nurses by practice experts. This article describes the project and discusses the evaluation, which highlighted the benefits of this way of learning for the nurses, the trust and the university, and identified some areas that require development.

The Anxiolytic Effect of Aromatherapy on Patients Awaiting Ambulatory Surgery: A Randomized Controlled Trial

PubMed Central

Ni, Cheng-Hua; Hou, Wen-Hsuan; Kao, Ching-Chiu; Chang, Ming-Li; Yu, Lee-Fen; Wu, Chia-Che; Chen, Chiehfeng

2013-01-01

The aim of this study was to determine if aromatherapy could reduce preoperative anxiety in ambulatory surgery patients. A total of 109 preoperative patients were randomly assigned to experimental (bergamot essential oil) and control (water vapor) conditions and their responses to the State Trait Anxiety Inventory and vital signs were monitored. Patients were stratified by previous surgical experience, but that did not influence the results. All those exposed to bergamot essential oil aromatherapy showed a greater reduction in preoperative anxiety than those in the control groups. Aromatherapy may be a useful part of a holistic approach to reducing preoperative anxiety before ambulatory surgery. PMID:24454517

Ambulatory surgery centers--current business and legal issues.

PubMed

Becker, S; Biala, M

2000-01-01

This article explores a handful of critical trends that have broad implications for ambulatory surgery centers and health care entities as a whole. As of the year 2000, the health care delivery system is experiencing broad changes and reconstruction in a variety of manners. One of the largest changes revolves around the accelerating movement of patient care from inpatient models to outpatient models, and the commensurate investment and development in outpatient systems and outpatient bricks and mortar. This metamorphosis is particularly evident as it relates to freestanding ambulatory surgery centers. This change in health care delivery will prove to have severe economic impacts on many of the nation's hospital systems.

A Comprehensive Computer Package for Ambulatory Surgical Facilities

PubMed Central

Kessler, Robert R.

1980-01-01

Ambulatory surgical centers are a cost effective alternative to hospital surgery. Their increasing popularity has contributed to heavy case loads, an accumulation of vast amounts of medical and financial data and economic pressures to maintain a tight control over “cash flow”. Computerization is now a necessity to aid ambulatory surgical centers to maintain their competitive edge. An on-line system is especially necessary as it allows interactive scheduling of surgical cases, immediate access to financial data and rapid gathering of medical and statistical information. This paper describes the significant features of the computer package in use at the Salt Lake Surgical Center, which processes 500 cases per month.

Frontal-posterior coherence and cognitive function in older adults.

PubMed

Fleck, Jessica I; Kuti, Julia; Brown, Jessica; Mahon, Jessica R; Gayda-Chelder, Christine

2016-12-01

The reliable measurement of brain health and cognitive function is essential in mitigating the negative effects associated with cognitive decline through early and accurate diagnosis of change. The present research explored the relationship between EEG coherence for electrodes within frontal and posterior regions, as well as coherence between frontal and posterior electrodes and performance on standard neuropsychological measures of memory and executive function. EEG coherence for eyes-closed resting-state EEG activity was calculated for delta, theta, alpha, beta, and gamma frequency bands. Participants (N=66; mean age=67.15years) had their resting-state EEGs recorded and completed a neuropsychological battery that assessed memory and executive function, two cognitive domains that are significantly affected during aging. A positive relationship was observed between coherence within the frontal region and performance on measures of memory and executive function for delta and beta frequency bands. In addition, an inverse relationship was observed for coherence between frontal and posterior electrode pairs, particularly within the theta frequency band, and performance on Digit Span Sequencing, a measure of working memory. The present research supports a more substantial link between EEG coherence, rather than spectral power, and cognitive function. Continued study in this area may enable EEG to be applied broadly as a diagnostic measure of cognitive ability. Copyright © 2016 Elsevier B.V. All rights reserved.

Repetition Suppression and Reactivation in Auditory–Verbal Short-Term Recognition Memory

PubMed Central

D'Esposito, Mark

2009-01-01

The neural response to stimulus repetition is not uniform across brain regions, stimulus modalities, or task contexts. For instance, it has been observed in many functional magnetic resonance imaging (fMRI) studies that sometimes stimulus repetition leads to a relative reduction in neural activity (repetition suppression), whereas in other cases repetition results in a relative increase in activity (repetition enhancement). In the present study, we hypothesized that in the context of a verbal short-term recognition memory task, repetition-related “increases” should be observed in the same posterior temporal regions that have been previously associated with “persistent activity” in working memory rehearsal paradigms. We used fMRI and a continuous recognition memory paradigm with short lags to examine repetition effects in the posterior and anterior regions of the superior temporal cortex. Results showed that, consistent with our hypothesis, the 2 posterior temporal regions consistently associated with working memory maintenance, also show repetition increases during short-term recognition memory. In contrast, a region in the anterior superior temporal lobe showed repetition suppression effects, consistent with previous research work on perceptual adaptation in the auditory–verbal domain. We interpret these results in light of recent theories of the functional specialization along the anterior and posterior axes of the superior temporal lobe. PMID:18987393

Repetition suppression and reactivation in auditory-verbal short-term recognition memory.

PubMed

Buchsbaum, Bradley R; D'Esposito, Mark

2009-06-01

The neural response to stimulus repetition is not uniform across brain regions, stimulus modalities, or task contexts. For instance, it has been observed in many functional magnetic resonance imaging (fMRI) studies that sometimes stimulus repetition leads to a relative reduction in neural activity (repetition suppression), whereas in other cases repetition results in a relative increase in activity (repetition enhancement). In the present study, we hypothesized that in the context of a verbal short-term recognition memory task, repetition-related "increases" should be observed in the same posterior temporal regions that have been previously associated with "persistent activity" in working memory rehearsal paradigms. We used fMRI and a continuous recognition memory paradigm with short lags to examine repetition effects in the posterior and anterior regions of the superior temporal cortex. Results showed that, consistent with our hypothesis, the 2 posterior temporal regions consistently associated with working memory maintenance, also show repetition increases during short-term recognition memory. In contrast, a region in the anterior superior temporal lobe showed repetition suppression effects, consistent with previous research work on perceptual adaptation in the auditory-verbal domain. We interpret these results in light of recent theories of the functional specialization along the anterior and posterior axes of the superior temporal lobe.

Serial measures of cardiac troponin T levels by a highly sensitive assay and incident atrial fibrillation in a prospective cohort of ambulatory older adults.

PubMed

Hussein, Ayman A; Bartz, Traci M; Gottdiener, John S; Sotoodehnia, Nona; Heckbert, Susan R; Lloyd-Jones, Donald; Kizer, Jorge R; Christenson, Robert; Wazni, Oussama; deFilippi, Christopher

2015-05-01

Various mechanisms in cardiac remodeling related to atrial fibrillation (AF) lead to elevated circulating cardiac troponin levels, but little is known about such elevations upstream to AF onset. The purpose of this study was to study the association between circulating troponin levels as assessed by a highly sensitive cardiac troponin T (hs-cTnT) assay and incident atrial fibrillation (AF). In a large prospective cohort of ambulatory older adults [the Cardiovascular Health Study (CHS)], hs-cTnT levels were measured in sera that were collected at enrollment from 4262 participants without AF (2871 with follow-up measurements). Incident AF was identified by electrocardiograms during CHS visits, hospital discharge diagnoses, and Medicare files, including outpatient and physician claims diagnoses. Over median follow-up of 11.2 years (interquartile range 6.1-16.5), 1363 participants (32.0%) developed AF. Higher baseline levels of hs-cTnT were associated with incident AF in covariate-adjusted analyses accounting for demographics, traditional risk factors, and incident heart failure in time-dependent analyzes (hazard ratio for 3rd tertile vs undetectable 1.75, 95% confidence interval 1.48-2.08). This association was statistically significant in analyses that additionally adjusted for biomarkers of inflammation and hemodynamic strain (hazard ratio for 3rd tertile vs undetectable 1.38, 95% confidence interval 1.16-1.65). Significant associations were also found when hs-cTnT levels were treated as a continuous variable and when examining change from baseline of hs-cTnT levels and incident AF. The findings show a significant association of circulating troponin levels in ambulatory older adults with incident AF beyond that of traditional risk factors, incident heart failure, and biomarkers of inflammation and hemodynamic strain. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Catheter-based renal denervation for resistant hypertension: 12-month results of the EnligHTN I first-in-human study using a multielectrode ablation system.

PubMed

Papademetriou, Vasilios; Tsioufis, Costas P; Sinhal, Ajay; Chew, Derek P; Meredith, Ian T; Malaiapan, Yuvi; Worthley, Matthew I; Worthley, Stephen G

2014-09-01

Renal denervation has emerged as a novel approach for the treatment of patients with drug-resistant hypertension. To date, only limited data have been published using multielectrode radiofrequency ablation systems. In this article, we present the 12-month data of EnligHTN I, a first-in-human study using a multielectrode ablation catheter. EnligHTN I enrolled 46 patients (average age, 60±10 years; on average 4.7±1.0 medications) with drug-resistant hypertension. Eligible patients were on ≥3 antihypertensive medications and had a systolic blood pressure (BP) ≥160 mm Hg (≥150 mm Hg for diabetics). Bilateral renal artery ablation was performed using a percutaneous femoral approach and standardized techniques. The average baseline office BP was 176/96 mm Hg, average 24-hour ambulatory BP was 150/83 mm Hg, and average home BP was 158/90 mm Hg. The average reductions (mm Hg) at 1, 3, 6, and 12 months were as follows: office: -28/-10, -27/-10, -26/-10, and -27/-11 mm Hg (P<0.001 for all); 24-hour ambulatory: -10/-5, -10/-5, -10/-6 (P<0.001 for all), and -7/-4 for 12 months (P<0.0094). Reductions in home measurements (based on 2-week average) were -9/-4, -8/-5,-10/-7, and -11/-6 mm Hg (P<0.001 at 12 months). At 12 months, there were no signals of worsening renal function and no new serious or life-threatening adverse events. One patient with baseline nonocclusive renal artery stenosis progressed to 75% diameter stenosis, requiring renal artery stenting. The 12-month data continue to demonstrate safety and efficacy of the EnligHTN ablation system in patients with drug-resistant hypertension. Home BP measurements parallel measurements obtained with 24-hour ambulatory monitoring. © 2014 American Heart Association, Inc.

Inappropriate usage of dietary supplements in patients by miscommunication with physicians in Japan.

PubMed

Chiba, Tsuyoshi; Sato, Yoko; Nakanishi, Tomoko; Yokotani, Kaori; Suzuki, Sachina; Umegaki, Keizo

2014-11-26

Recently, people have used dietary supplements not only for nutritional supplementation, but also for treatment of their diseases. However, use of dietary supplements to treat diseases, especially with medications, may cause health problems in patients. In this study, we investigated use of dietary supplements in patients in Japan. This survey was conducted from January to December 2012, and was completed by 2732 people, including 599 admitted patients, 1154 ambulatory patients, and 979 healthy subjects who attended a seminar about dietary supplements. At the time of the questionnaire, 20.4% of admitted patients, 39.1% of ambulatory patients, and 30.7% of healthy subjects were using dietary supplements, which including vitamin/mineral supplements, herbal extracts, its ingredients, or food for specified health uses. The primary purpose for use in all groups was health maintenance, whereas 3.7% of healthy subjects, 10.0% of ambulatory patients, and 13.2% of admitted patients used dietary supplements to treat diseases. In addition, 17.7% of admitted patients and 36.8% of ambulatory patients were using dietary supplements concomitantly with their medications. However, among both admitted patients and ambulatory patients, almost 70% did not mention dietary supplement use to their physicians. Overall, 3.3% of all subjects realized adverse effects associated with dietary supplements. Communication between patients and physicians is important to avoid health problems associated with the use of dietary supplements.

Salivary cortisol in ambulatory assessment--some dos, some don'ts, and some open questions.

PubMed

Kudielka, Brigitte M; Gierens, Andrea; Hellhammer, Dirk H; Wüst, Stefan; Schlotz, Wolff

2012-05-01

The impact of stress on health and disease is an important research topic in psychosomatic medicine. Because research on hypothalamic-pituitary-adrenal (HPA) axis regulation under controlled laboratory studies lacks ecological validity, it needs to be complemented by a research program that includes momentary ambulatory assessment. The measurement of salivary cortisol offers the possibility to trace the free steroid hormone concentrations in ambulant settings. Therefore, in this article, we first discuss the role of salivary cortisol in ambulatory monitoring. We start with a brief description of HPA axis regulation, and we then consider cortisol assessments in other organic materials, followed by a presentation of common salivary markers of HPA axis regulation suitable for ambulatory assessment. We further provide an overview on assessment designs and sources of variability within and between subjects (intervening variables), acknowledge the issue of (non)compliance, and address statistical aspects. We further give an overview of associations with psychosocial and health-related variables relevant for ambulatory assessment. Finally, we deal with preanalytical aspects of laboratory salivary cortisol analysis. The relative simplicity of salivary cortisol assessment protocols may lead to an overoptimistic view of the robustness of this method. We thus discuss several important issues related to the collection and storage of saliva samples and present empirical data on the stability of salivary cortisol measurements over time.

Inappropriate Usage of Dietary Supplements in Patients by Miscommunication with Physicians in Japan

PubMed Central

Chiba, Tsuyoshi; Sato, Yoko; Nakanishi, Tomoko; Yokotani, Kaori; Suzuki, Sachina; Umegaki, Keizo

2014-01-01

Recently, people have used dietary supplements not only for nutritional supplementation, but also for treatment of their diseases. However, use of dietary supplements to treat diseases, especially with medications, may cause health problems in patients. In this study, we investigated use of dietary supplements in patients in Japan. This survey was conducted from January to December 2012, and was completed by 2732 people, including 599 admitted patients, 1154 ambulatory patients, and 979 healthy subjects who attended a seminar about dietary supplements. At the time of the questionnaire, 20.4% of admitted patients, 39.1% of ambulatory patients, and 30.7% of healthy subjects were using dietary supplements, which including vitamin/mineral supplements, herbal extracts, its ingredients, or food for specified health uses. The primary purpose for use in all groups was health maintenance, whereas 3.7% of healthy subjects, 10.0% of ambulatory patients, and 13.2% of admitted patients used dietary supplements to treat diseases. In addition, 17.7% of admitted patients and 36.8% of ambulatory patients were using dietary supplements concomitantly with their medications. However, among both admitted patients and ambulatory patients, almost 70% did not mention dietary supplement use to their physicians. Overall, 3.3% of all subjects realized adverse effects associated with dietary supplements. Communication between patients and physicians is important to avoid health problems associated with the use of dietary supplements. PMID:25431879

[Hospitalizations for ambulatory care-sensitive conditions: validation study at a Hospital Information System (SIH) in the Federal District, Brazil, in 2012].

PubMed

Cavalcante, Danyelle Monteiro; de Oliveira, Maria Regina Fernandes; Rehem, Tânia Cristina Morais Santa Bárbara

2016-03-01

This study analyzes hospitalizations due to ambulatory care-sensitive conditions with a focus on infectious and parasitic diseases (IPDs) and validates the Hospital Information System, Brazilian Unified National Health System (SIH/SUS) for recording hospitalizations due to ambulatory care-sensitive conditions in a hospital in the Federal District, Brazil, in 2012. The study estimates the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the SIH for recording hospitalizations due to ambulatory care-sensitive conditions, with the patient's medical file as the gold standard. There were 1,604 hospitalizations for hospitalizations due to ambulatory care-sensitive conditions (19.6%, 95%CI: 18.7-20.5), and the leading IPDs were renal and urinary tract infection, infection of the skin and subcutaneous tissue, and infectious gastroenteritis. IPDs were the leading cause of hospitalization in the 20 to 29-year age bracket and caused 28 deaths. Sensitivity was 70.1% (95%CI: 60.5-79.7), specificity 88.4% (95%CI: 85.6-91.2), PPV = 51.7% (95%CI: 42.7-60.7), and NPV = 94.3% (95%CI: 92.2-96.4). The findings for admissions due to ACSCs in this hospital were similar to those of other studies, featuring admissions for IPDs. The SIH/SUS database was more specific than sensitive.

Adverse Drug Events in U.S. Adult Ambulatory Medical Care

PubMed Central

Sarkar, Urmimala; López, Andrea; Maselli, Judith H; Gonzales, Ralph

2011-01-01

Objective To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. Data Source We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. Study Design Secondary data analysis. Principal Findings An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). Conclusions Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices. PMID:21554271

Sequential steps of macroautophagy and chaperone-mediated autophagy are involved in the irreversible process of posterior silk gland histolysis during metamorphosis of Bombyx mori.

PubMed

Shiba, Hajime; Yabu, Takeshi; Sudayama, Makoto; Mano, Nobuhiro; Arai, Naoto; Nakanishi, Teruyuki; Hosono, Kuniaki

2016-04-15

To elucidate the degradation process of the posterior silk gland during metamorphosis of the silkworm ITALIC! Bombyx mori, tissues collected on the 6th day after entering the 5th instar (V6), prior to spinning (PS), during spinning (SP) and after cocoon formation (CO) were used to analyze macroautophagy, chaperone-mediated autophagy (CMA) and the adenosine triphosphate (ATP)-dependent ubiquitin proteasome. Immediately after entering metamorphosis stage PS, the levels of ATP and phosphorylated p70S6 kinase protein decreased spontaneously and continued to decline at SP, followed by a notable restoration at CO. In contrast, phosphorylated AMP-activated protein kinase α (AMPKα) showed increases at SP and CO. Most of the Atg8 protein was converted to form II at all stages. The levels of ubiquitinated proteins were high at SP and CO, and low at PS. The proteasome activity was high at V6 and PS but low at SP and CO. In the isolated lysosome fractions, levels of Hsc70/Hsp70 protein began to increase at PS and continued to rise at SP and CO. The lysosomal cathepsin B/L activity showed a dramatic increase at CO. Our results clearly demonstrate that macroautophagy occurs before entering the metamorphosis stage and strongly suggest that the CMA pathway may play an important role in the histolysis of the posterior silk gland during metamorphosis. © 2016. Published by The Company of Biologists Ltd.

Bayesian Retrieval of Complete Posterior PDFs of Oceanic Rain Rate From Microwave Observations

NASA Technical Reports Server (NTRS)

Chiu, J. Christine; Petty, Grant W.

2005-01-01

This paper presents a new Bayesian algorithm for retrieving surface rain rate from Tropical Rainfall Measurements Mission (TRMM) Microwave Imager (TMI) over the ocean, along with validations against estimates from the TRMM Precipitation Radar (PR). The Bayesian approach offers a rigorous basis for optimally combining multichannel observations with prior knowledge. While other rain rate algorithms have been published that are based at least partly on Bayesian reasoning, this is believed to be the first self-contained algorithm that fully exploits Bayes Theorem to yield not just a single rain rate, but rather a continuous posterior probability distribution of rain rate. To advance our understanding of theoretical benefits of the Bayesian approach, we have conducted sensitivity analyses based on two synthetic datasets for which the true conditional and prior distribution are known. Results demonstrate that even when the prior and conditional likelihoods are specified perfectly, biased retrievals may occur at high rain rates. This bias is not the result of a defect of the Bayesian formalism but rather represents the expected outcome when the physical constraint imposed by the radiometric observations is weak, due to saturation effects. It is also suggested that the choice of the estimators and the prior information are both crucial to the retrieval. In addition, the performance of our Bayesian algorithm is found to be comparable to that of other benchmark algorithms in real-world applications, while having the additional advantage of providing a complete continuous posterior probability distribution of surface rain rate.

78 FR 77470 - Health Insurance Exchanges; Approval of an Application by the Accreditation Association for...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-23

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS-9953-FN] Health Insurance Exchanges; Approval of an Application by the Accreditation Association for Ambulatory...\\ Health Insurance Exchanges; Application by the Accreditation Association for Ambulatory Health Care To Be...

Educational Strategies in Ambulatory Care

ERIC Educational Resources Information Center

Barker, Lee R.

1978-01-01

In 1974 an ambulatory practice was developed for the house staff in the Department of Medicine at Baltimore City Hospital and integrated into the traditional residency program, which is based upon block rotations in inpatient services, emergency service, and subspeciality electives. The goals and strategies of this program are described. (LB H)

An Analysis of Ambulatory Teaching Situations for Faculty Development.

ERIC Educational Resources Information Center

Simpson, Deborah E.; And Others

1990-01-01

A study identified variables perceived by clinical medical faculty (n=20) to influence the ease or difficulty of teaching in the ambulatory care setting. Characteristics affecting the teaching situation included teacher, student, and patient characteristics. Implications for faculty development on teaching in the clinical setting are discussed.…

Evaluation of The Products of Ambulatory Care and Products of Ambulatory Surgery Classification System For the Military Health Care System.

DTIC Science & Technology

1992-09-14

Paranoid Disorder, Atypical 29830 2983 Paranoid Disorder, Acute 29889 2988 Psychosis, Brief Reactive 29890 2989 Psychosis, Atypical 2990 29900 Autism ...Complication, Hemodialysis 99892 9999 Complication, Peritoneal Dialysis 999 9999 Compli,:ation, Medical Care 99901 9999 Complication, Vaccination , Nos 84

76 FR 31339 - Agency Information Collection Activities: Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-31

... extension of the currently approved tool for the collection of ambulatory care clinical performance measure...: Medicare Demonstration Ambulatory Care Quality Measure Performance Assessment Tool (``PAT''); Use: This... based system. This system will also provide a platform for developing tools to collect clinical quality...

Memo to: Ambulatory Health Care Planners.

ERIC Educational Resources Information Center

Educational Facilities Labs., Inc., New York, NY.

Planning for changing types of health professions and a changing clientele necessitates designing flexible facilities. Findings from a recently completed analysis of ambulatory care facilities are directed to planners in the form of 16 memos. Approaches to planning and design considerations are made that attempt to humanize these facilities.…

77 FR 19290 - Medicare and Medicaid Programs; Renewal of Deeming Authority of the Accreditation Association for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-30

... Ambulatory Health Care, Inc. for Medicare Advantage Health Maintenance Organizations and Local Preferred... Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) for Health Maintenance Organizations and....165(b). AOs that apply for MA deeming authority are generally recognized by the health care industry...

Validating hyperbilirubinemia and gut mucosal atrophy with a novel ultramobile ambulatory total parenteral nutrition piglet model

USDA-ARS?s Scientific Manuscript database

Total parenteral nutrition (TPN) provides all nutrition intravenously. Although TPN therapy has grown enormously, it causes significant complications, including gut and hepatic dysfunction. Current models use animal tethering which is unlike ambulatory human TPN delivery and is cost prohibitive. We ...

The Ambulatory Experience for Junior Medical Students at the Medical College of Georgia.

ERIC Educational Resources Information Center

Fincher, Ruth-Marie E.; Albritton, T. Andrew

1993-01-01

The Medical College of Georgia's third-year medicine clerkship includes a one-month ambulatory care block rotation in internal medicine, medicine, and dermatology. Students present topics and participate in case discussions in daily and weekly conferences. Program success is resulting in expansion. (MSE)

A Hot-Line Emergency Service for the Ambulatory Frail Elderly.

ERIC Educational Resources Information Center

Wolf-Klein, Gisele P.; Silverstone, Felix A.

1987-01-01

Surveyed patients and families who used hotline emergency service in ambulatory day treatment center for frail elderly. Results revealed appropriate use of service: Most calls required medical intervention, including hospitalization in 31 percent of cases. Findings suggest that 24-hour medical coverage is necessary and cost efficient. (Author/NB)

78 FR 25450 - Agency Information Collection Activities; Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-01

... observe the physical layout and computer work stations, clarify the purpose of the study and the site... others involved in care delivery. However, few studies have examined how health IT can change workflow in ambulatory physician practices. Further, in most studies that address health IT in ambulatory settings...

Implications of an emerging EHR monoculture for hospitals and healthcare systems.

PubMed

Koppel, Ross; Lehmann, Christoph U

2015-03-01

In many hospitals and health systems, a 'new' electronic health record means a shift to one vendor: Epic, a vendor that dominates in large and medium hospital markets and continues its success with smaller institutions and ambulatory practices. Our paper examines the implications of this emerging monoculture: its advantages and disadvantages for physicians and hospitals and its role in innovation, professional autonomy, implementation difficulties, workflow, flexibility, cost, data standards, interoperability, and interactions with other information technology (IT) systems. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

[Infections due to Kocuria kristinae: case reports of two patients and review of the literature].

PubMed

Chávez Valencia, Venice; Orizaga de la Cruz, Citlalli; Aguilar Bixano, Omar; Huerta Ruíz, Marilyn Karla; Sánchez Estrada, Erik Emilio

2014-12-01

Kocuria kristinae is a gram-positive coccus of the family of Micrococcaceae. It inhabits the skin and mucous and human oropharynx and some mammals. Clinical cases of proven infections are scarce, affecting patients with indwelling devices and severe underlying diseases. We report two unusual case of a K. kristinae infection in a hemodialysis. First is a case of bacteremia associated with permanent hemodialysis catheter in a 20-year-old female; and second is a case of acute peritonitis in a 68-year-old male patient on continuous ambulatory peritoneal dialysis. A review of other reported K. kristinae infections is provided.

Department of Defense CHAMPUS Ambulatory Professional Services Summary Analysis, Fiscal Year 1991

DTIC Science & Technology

1991-11-21

CONTINUED) CPT4 TOTAL AD RET/ RET/DEC CODE CPT4 NAME (SHORT) PROC DEP PCT DEC PCT DEP PCT 97520 PROSTHETIC TRAINING 40 11 27.5% 8 20.0% 21 52.5% 93510...219 27.8% 491 62.2% 51726 COMPLEX CYSTOMETROGRAM 782 207 26.5% 146 18.7% 429 54.9% 25600 TREAT FRACTURE RADIUS/ULN 754 509 67.5% 25 3.3% 220 29.2...11701 SURGICAL CLEANSING OF NAI 483 19 3.9. 146 30.2% 318 65.8% 25605 TREAT FRACTURE RADIUS/ULN 482 254 52.7% 26 5.4% 202 41.9% 51720 TREATMENT OF

Letter to editor: Blood pressure, hypertension and lead exposure.

PubMed

Yang, Wen-Yi; Staessen, Jan A

2018-02-19

A significant association of office diastolic blood pressure with low-level blood lead exposure was reported in a Brazilian adult population. However, caution should be taken to interpret these results. The multivariable-adjusted association with blood pressure was positive for diastolic blood pressure, but inverse for systolic blood pressure. The association sizes were infinitesimal without clinical relevance. The outcome measures, i.e. blood pressure and the prevalence of hypertension were analysed across categories of the blood lead distribution - not in relation to blood lead as continuous variable. Blood pressure was the average of two oscillometric office readings, whereas ambulatory monitoring is the state-of-the-art.

Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial

PubMed Central

Godwin, Marshall; Dawes, Martin; Kiss, Alexander; Tobe, Sheldon W; Grant, F Curry; Kaczorowski, Janusz

2011-01-01

Objective To compare the quality and accuracy of manual office blood pressure and automated office blood pressure using the awake ambulatory blood pressure as a gold standard. Design Multi-site cluster randomised controlled trial. Setting Primary care practices in five cities in eastern Canada. Participants 555 patients with systolic hypertension and no serious comorbidities under the care of 88 primary care physicians in 67 practices in the community. Interventions Practices were randomly allocated to either ongoing use of manual office blood pressure (control group) or automated office blood pressure (intervention group) using the BpTRU device. The last routine manual office blood pressure (mm Hg) was obtained from each patient’s medical record before enrolment. Office blood pressure readings were compared before and after enrolment in the intervention and control groups; all readings were also compared with the awake ambulatory blood pressure. Main outcome measure Difference in systolic blood pressure between awake ambulatory blood pressure minus automated office blood pressure and awake ambulatory blood pressure minus manual office blood pressure. Results Cluster randomisation allocated 31 practices (252 patients) to manual office blood pressure and 36 practices (303 patients) to automated office blood pressure measurement. The most recent routine manual office blood pressure (149.5 (SD 10.8)/81.4 (8.3)) was higher than automated office blood pressure (135.6 (17.3)/77.7 (10.9)) (P<0.001). In the control group, routine manual office blood pressure before enrolment (149.9 (10.7)/81.8 (8.5)) was reduced to 141.4 (14.6)/80.2 (9.5) after enrolment (P<0.001/P=0.01), but the reduction in the intervention group from manual office to automated office blood pressure was significantly greater (P<0.001/P=0.02). On the first study visit after enrolment, the estimated mean difference for the intervention group between the awake ambulatory systolic/diastolic blood pressure and automated office blood pressure (−2.3 (95% confidence interval −0.31 to −4.3)/−3.3 (−2.7 to −4.4)) was less (P=0.006/P=0.26) than the difference in the control group between the awake ambulatory blood pressure and the manual office blood pressure (−6.5 (−4.3 to −8.6)/−4.3 (−2.9 to −5.8)). Systolic/diastolic automated office blood pressure showed a stronger (P<0.001) within group correlation (r=0.34/r=0.56) with awake ambulatory blood pressure after enrolment compared with manual office blood pressure versus awake ambulatory blood pressure before enrolment (r=0.10/r= 0.40); the mean difference in r was 0.24 (0.12 to 0.36)/0.16 (0.07 to 0.25)). The between group correlation comparing diastolic automated office blood pressure and awake ambulatory blood pressure (r=0.56) was stronger (P<0.001) than that for manual office blood pressure versus awake ambulatory blood pressure (r=0.30); the mean difference in r was 0.26 (0.09 to 0.41). Digit preference with readings ending in zero was substantially reduced by use of automated office blood pressure. Conclusion In compliant, otherwise healthy, primary care patients with systolic hypertension, introduction of automated office blood pressure into routine primary care significantly reduced the white coat response compared with the ongoing use of manual office blood pressure measurement. The quality and accuracy of automated office blood pressure in relation to the awake ambulatory blood pressure was also significantly better when compared with manual office blood pressure. Trial registration Clinical trials NCT 00214053. PMID:21300709

An Ambulatory System for Gait Monitoring Based on Wireless Sensorized Insoles

PubMed Central

González, Iván; Fontecha, Jesús; Hervás, Ramón; Bravo, José

2015-01-01

A new gait phase detection system for continuous monitoring based on wireless sensorized insoles is presented. The system can be used in gait analysis mobile applications, and it is designed for real-time demarcation of gait phases. The system employs pressure sensors to assess the force exerted by each foot during walking. A fuzzy rule-based inference algorithm is implemented on a smartphone and used to detect each of the gait phases based on the sensor signals. Additionally, to provide a solution that is insensitive to perturbations caused by non-walking activities, a probabilistic classifier is employed to discriminate walking forward from other low-level activities, such as turning, walking backwards, lateral walking, etc. The combination of these two algorithms constitutes the first approach towards a continuous gait assessment system, by means of the avoidance of non-walking influences. PMID:26184199

A multiparameter wearable physiologic monitoring system for space and terrestrial applications

NASA Technical Reports Server (NTRS)

Mundt, Carsten W.; Montgomery, Kevin N.; Udoh, Usen E.; Barker, Valerie N.; Thonier, Guillaume C.; Tellier, Arnaud M.; Ricks, Robert D.; Darling, Robert B.; Cagle, Yvonne D.; Cabrol, Nathalie A.;