Pupillometry: Cutting Edge Biometrics for Early Intervention in Increased Intracranial Pressure.

PubMed

John, Jennilee St

2015-10-01

The pupillometer, a cutting-edge biometric device, is a valuable assessment tool that can aid in the early detection and prompt treatment of neurological abnormalities. Pupil assessment is a critical component of the neurological examination, and manual pupil assessment leaves much room for error. Automated pupillometry improves the quality and reliability of pupillary and neurological assessments, ultimately improving patient outcomes. Copyright 2015, SLACK Incorporated.

Relative adrenal insufficiency in severe congestive heart failure with preserved systolic function: a case report.

PubMed

Lovelock, Joshua D; Coslet, Sandra; Johnson, Marie; Rich, Stuart; Gomberg-Maitland, Mardi

2007-09-01

Relative adrenal insufficiency in critically ill patients is an important syndrome in septic shock. The insufficient stress response of the hypothalamic-pituitary-adrenal axis in acute illness contributes to hemodynamic instability. Treatment of this state in septic shock improves patient outcomes. In this report, we describe the case of a patient with severe diastolic dysfunction who presented in cardiogenic shock associated with relative adrenal insufficiency and had a complete recovery with corticosteroid replacement. Alteration of the hypothalamic-pituitary-adrenal axis may be more prevalent than suspected in end-stage heart failure, and the diagnosis and treatment of this syndrome may ultimately improve outcomes in a subgroup of heart failure patients.

You have an idea, now what?

PubMed

Gertner, Michael

2006-11-01

The innovation process is often more important than the original idea, particularly when the ultimate goal is to improve patient care through technologically advanced products. Many physicians have great ideas; unfortunately, many of these great ideas are never translated to patient care improvements because of a misunderstanding of "the next step." In many cases, the next step is a step backward to understand the real clinical problem: "the clinical need." With the clinical need in hand, the most efficient path to a product for improved patient care can then be derived. Often, the most efficient pathway involves an appreciation of many issues, including intellectual property, regulatory pathways, finance, and clinical trial strategies. The integration of these issues underlies innovation in biomedical technology.

Understanding and preventing contrast-induced acute kidney injury.

PubMed

Fähling, Michael; Seeliger, Erdmann; Patzak, Andreas; Persson, Pontus B

2017-03-01

Contrast-induced acute kidney injury (CIAKI) occurs in up to 30% of patients who receive iodinated contrast media and is generally considered to be the third most common cause of hospital-acquired AKI. Accurate assessment of the incidence of CIAKI is obscured, however, by the use of various definitions for diagnosis, the different populations studied and the prophylactic measures put in place. A deeper understanding of the mechanisms that underlie CIAKI is required to enable reliable risk assessment for individual patients, as their medical histories will determine the specific pathways by which contrast media administration might lead to kidney damage. Here, we highlight common triggers that prompt the development of CIAKI and the subsequent mechanisms that ultimately cause kidney damage. We also discuss effective protective measures, such as rapidly acting oral hydration schemes and loop diuretics, in the context of CIAKI pathophysiology. Understanding of how CIAKI arises in different patient groups could enable a marked reduction in incidence and improved outcomes. The ultimate goal is to shape CIAKI prevention strategies for individual patients.

A proposal for health care management and leadership education within the UK undergraduate medical curriculum.

PubMed

Mafe, Cecilia; Menyah, Effie; Nkere, Munachi

2016-01-01

Health care management and leadership education is an important gap in the undergraduate medical curriculum. Lack of training promotes poor decision making and may lead to inadequate health services, adversely affecting patients. We propose an integrated approach to health care management and leadership education at undergraduate level, to enable doctors to be effective leaders and manage resources appropriately and to ultimately improve patient care.

Recurrence of conversion disorder symptoms in a successfully treated 16-year-old female.

PubMed

Shapiro, Michael; Mehta, Anuja; Avila, Jorge; Nguyen, Mathew

2015-01-01

We present a case of a 16-year-old Caucasian female with a history of major depressive disorder and post-traumatic stress disorder who was admitted to an inpatient adolescent psychiatric unit with symptoms of conversion disorder, including non-epileptic seizures, an inability to speak or walk, and not eating on her own. She has a history of multiple previous medical and psychiatric hospitalizations without any significant resolution of symptoms, and extensive medical workups have all been negative. Treatment ultimately involved reassuring the patient and family that there was no underlying medical condition and emphasizing the conversion disorder diagnosis. The patient participated daily in physical therapy to improve mobility, deconditioning, and functioning. Hospital staff was instructed on the nature of the non-epileptic seizures, which continued to occur during the hospitalization. After one month, the patient was discharged home fully functional: walking, speaking, and eating on her own. One week after discharge, the patient presented with the same symptoms and was readmitted to the psychiatric facility. She subsequently never regained her previous level of functioning, and she was ultimately transferred to a residential treatment facility. We will discuss factors that led to the initial improvement and the factors that led to recurrence and persistence of symptoms. © The Author(s) 2015.

Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective.

PubMed

Han, MeiLan K; Martinez, Carlos H; Au, David H; Bourbeau, Jean; Boyd, Cynthia M; Branson, Richard; Criner, Gerard J; Kalhan, Ravi; Kallstrom, Thomas J; King, Angela; Krishnan, Jerry A; Lareau, Suzanne C; Lee, Todd A; Lindell, Kathleen; Mannino, David M; Martinez, Fernando J; Meldrum, Catherine; Press, Valerie G; Thomashow, Byron; Tycon, Laura; Sullivan, Jamie Lamson; Walsh, John; Wilson, Kevin C; Wright, Jean; Yawn, Barbara; Zueger, Patrick M; Bhatt, Surya P; Dransfield, Mark T

2016-06-01

The burden of chronic obstructive pulmonary disease (COPD) in the USA continues to grow. Although progress has been made in the the development of diagnostics, therapeutics, and care guidelines, whether patients' quality of life is improved will ultimately depend on the actual implementation of care and an individual patient's access to that care. In this Commission, we summarise expert opinion from key stakeholders-patients, caregivers, and medical professionals, as well as representatives from health systems, insurance companies, and industry-to understand barriers to care delivery and propose potential solutions. Health care in the USA is delivered through a patchwork of provider networks, with a wide variation in access to care depending on a patient's insurance, geographical location, and socioeconomic status. Furthermore, Medicare's complicated coverage and reimbursement structure pose unique challenges for patients with chronic respiratory disease who might need access to several types of services. Throughout this Commission, recurring themes include poor guideline implementation among health-care providers and poor patient access to key treatments such as affordable maintenance drugs and pulmonary rehabilitation. Although much attention has recently been focused on the reduction of hospital readmissions for COPD exacerbations, health systems in the USA struggle to meet these goals, and methods to reduce readmissions have not been proven. There are no easy solutions, but engaging patients and innovative thinkers in the development of solutions is crucial. Financial incentives might be important in raising engagement of providers and health systems. Lowering co-pays for maintenance drugs could result in improved adherence and, ultimately, decreased overall health-care spending. Given the substantial geographical diversity, health systems will need to find their own solutions to improve care coordination and integration, until better data for interventions that are universally effective become available. Copyright © 2016 Elsevier Ltd. All rights reserved.

Finding common ground to achieve a "good death": family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study.

PubMed

Tan, Amy; Manca, Donna

2013-01-22

Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a "bad death" experience for the patient and family. We aim to describe Canadian family physicians' experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients. Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged. Eleven family physicians with a range of 3 to 40 years in clinical practice participated.The family physicians expressed a desire to achieve a "good death" and described their role in positively influencing the experience of death.Finding Common Ground to Achieve a "Good Death" for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described. A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a "good death". These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths.

Medical School Hotline: Developing communication skills for leading family meetings.

PubMed

Inaba, Michiko; Bell, Christina; Tamura, Bruce; Kasuya, Richard; Masaki, Kamal

2011-06-01

Good clinician-family communication is essential for the provision of high-quality patient care. Families rate the communication skills of clinicians as critical clinical skills. However, there has been no structured training of fellow communication skills while leading family meetings in the University of Hawai'i Geriatric Medicine Fellowship Program. Effective training to develop communication skills with families will better prepare Geriatric Medicine fellows for this important task, and ultimately improve the quality of care they provide to these patients and patients' families.

[Controlled weight bearing after osteosynthesis].

PubMed

Perren, T; Matter, P

1993-01-01

Patient compliance with postoperative partial weight bearing can be a difficult management problem. The problem may be intentional or unintentional. There is no objective way to assess the amount of weight placed on the lower extremity by the patient. It is our clinical suspicion that patients place more weight than is desirable on the effected limb. There are few reports in the literature on this topic. One study has confirmed our suspicion of poor patient compliance with postoperative weight bearing. Our goal is to develop a system to accurately assess weight bearing and to improve this aspect of postoperative fracture care. Through an active feedback device we hope to improve patient education and understanding. We plan to study the clinical applications of using a pressure sensitive shoe insert device. Our ultimate goal is to improve upon the present device and to study the clinical application of there use.

Improving Patient Outcomes With Oral Heart Failure Medications.

PubMed

Sherrod, Melissa M; Cheek, Dennis J; Seale, Ashlie

2016-05-01

Hospitals are under immense pressure to reduce heart failure readmissions that occur within 30 days of discharge, and to improve the quality of care for these patients. Penalties mandated by the Affordable Care Act decrease hospital reimbursement and ultimately the overall cost of caring for these patients increases if they are not well managed. Approximately 25% of patients hospitalized for heart failure are at high risk for readmission and these rates have not changed over the past decade. As a result of an aging population, the incidence of heart failure is expected to increase to one in five Americans over the age of 65. Pharmacologic management can reduce the risk of death and help prevent unnecessary hospitalizations. Healthcare providers who have knowledge of heart failure medications and drug interactions and share this information with their patients contribute to improved long-term survival and physical functioning as well as fewer hospitalizations and a delay of progressive worsening of heart failure.

The effectiveness of policy changes designed to increase the attendance rate for outpatient retinopathy of prematurity (ROP) screening examinations.

PubMed

Barry, Gerard P; Tauber, Kate; Emmanuel, Gregory; Horgan, Michael J; Simon, John W

2013-06-01

To determine the effectiveness of a series of policy changes designed to increase the attendance rate for outpatient retinopathy of prematurity (ROP) screening examinations. We retrospectively reviewed the records of consecutive neonatal intensive care unit patients before and after the implementation of policy changes. Policy changes included parent education forms, streamlined scheduling, and creation of a log for all patients seen. The primary outcome measure was attendance rates for the first outpatient appointment after discharge. The Fisher exact test was used to compare rates between the two groups. Before the policy was implemented, 22 of 52 (42%) neonates and their caregivers attended their first outpatient ROP screening examination on the recommended date. This rate improved significantly after policy implementation, when 46 of 57 (81%) neonates and their caregivers were seen on the recommended date (P < 0.01). The number of patients who ultimately met the criteria for conclusion of acute retinal screening examinations also significantly improved, from 47 of 52 (90%) of neonates in the pre-implementation group to 57 of 57 (100%) in the post-implementation group (P = 0.02). The attendance rates for initial outpatient ROP examinations and the number of patients who ultimately met criteria for conclusion of acute retinal screening examinations significantly improved after the implementation of new policies. Copyright © 2013 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.

Mechanisms of Transendothelial Migration of Primary Human Invasive Ductal Carcinoma Cells from ER+, Her2+, and Triple-Negative Disease

DTIC Science & Technology

2016-09-01

cell dissem- ination and, ultimately, patient death (1). The outcome of breast cancer patients with metastatic disease has not improved in the past 30...breast cancer is a heterogeneous disease consisting of several distinct subtypes with substantially different responses to therapy and clinical...and Triple-Negative Disease PRINCIPAL INVESTIGATOR: Jeanine Pignatelli CONTRACTING ORGANIZATION: Albert Einstein College of Medicine Bronx, NY 10461

Simultaneous improvement and worsening of vitiligo lesions during the course of NB-UVB phototherapy; vitiligo may not act as one unit.

PubMed

Anbar, Tag; Abdel-Rahman, Amal; Hegazy, Rehab; El-Khayyat, Mohamed; Ragaie, Maha

2017-01-01

Re-pigmentation and stabilization are the two ultimate goals of any re-pigmenting plan designed for vitiligo management. Furthermore, whether the improvement of some vitiligo lesions could be considered a guarantee for a similar response and/or stabilization of the rest of the lesions or not, remains to be clarified. To evaluate the behavior of non-segmental vitiligo (NSV), while on narrow band-ultraviolet B (NB-UVB) phototherapy. 25 patients with stable generalized NSV were included and received NB-UVB twice weekly. For the sake of ensuring accuracy of follow up, up to four lesions were randomly chosen in each patient and regularly measured using the point counting technique. The over-all point counting technique of all included patients showed a significant reduction (18.5 ± 8.4 cm 2 to 8.2± 3.1 cm 2 ) after 6 months of therapy (p < .001). Nine patients (36%), showed mixed response in the different lesions. Improvement was documented in some lesions, while other lesions showed no response or even worsening. No significant correlations were detected between the behavior of vitiligo during NB-UVB and any of the demographic or clinical data of the patients. NB-UVB is a pillar in the management of vitiligo, however close follow-up of the patient as a whole and his lesions, by both subjective and objective measures are mandatory to detect activity as early as possible, as vitiligo at many times may not act as one unit. This early detection of activity and the subsequent change in the treatment policy may ultimately change the final outcome of treatment. © 2016 Wiley Periodicals, Inc.

Current approaches to the management of idiopathic pulmonary fibrosis.

PubMed

Raghu, Ganesh; Richeldi, Luca

2017-08-01

Idiopathic pulmonary fibrosis (IPF) is a progressive and ultimately fatal lung disease associated with dyspnoea, cough and impaired quality of life. Currently, the aims of patient care are to improve outcomes for patients by slowing the progression of the disease, extending life, and improving quality of life. A prompt, accurate diagnosis is important to enable patients to receive treatment early in the course of the disease and to be considered for lung transplantation. Two anti-fibrotic drugs, nintedanib and pirfenidone, have been shown to reduce decline in lung function in patients with IPF. In addition to pharmacological therapy, optimal management of IPF includes treatment of comorbidities, symptom relief, pulmonary rehabilitation, and palliative care. Patient education is important to enable patients to make decisions about their care and to help them manage their disease and the side-effects of anti-fibrotic drugs. Research continues into new treatments and combinations of treatments that may improve outcomes for patients with this devastating disease. Copyright © 2017. Published by Elsevier Ltd.

Improving the Working Relationship between Doctors and Pharmacists: Is Inter-Professional Education the Answer?

ERIC Educational Resources Information Center

Gallagher, Ruth M.; Gallagher, Helen C.

2012-01-01

Despite their common history, there are many cultural, attitudinal and practical differences between the professions of medicine and pharmacy that ultimately influence patient care and health outcomes. While poor communication between doctors and pharmacists is a major cause of medical errors, it is clear that effective, deliberate…

Understanding common statistical methods, Part I: descriptive methods, probability, and continuous data.

PubMed

Skinner, Carl G; Patel, Manish M; Thomas, Jerry D; Miller, Michael A

2011-01-01

Statistical methods are pervasive in medical research and general medical literature. Understanding general statistical concepts will enhance our ability to critically appraise the current literature and ultimately improve the delivery of patient care. This article intends to provide an overview of the common statistical methods relevant to medicine.

Symptom management in HIV-infected patients.

PubMed

Hughes, Anne

2004-01-01

Symptom management has always been a focus of nursing care. Assessing and managing symptoms is an important component of HIV nursing practice. When effective, interventions to relieve symptoms may improve quality of life (QoL), potentially increase adherence to highly active antiretroviral therapy, and improve other outcomes such as functional status. Common underrecognized and/or undertreated symptoms that may influence the QoL of persons living with HIV include fatigue, pain, anxiety/depression, and sleep disturbances. These symptoms may also contribute to the difficulty of adhering to HAART When evaluating a patient's symptoms, the nurse attempts to understand the symptom experience from the patient's perspective because symptoms are subjective experiences. Together, the nurse and patient work to determine feasible interventions. Symptom management plans are evaluated frequently. Fundamentally, symptom management aims to decrease the frequency, intensity, and distress of symptoms, with the ultimate goal of improving QoL.

Impact of a bronchial genomic classifier on clinical decision making in patients undergoing diagnostic evaluation for lung cancer.

PubMed

Ferguson, J Scott; Van Wert, Ryan; Choi, Yoonha; Rosenbluth, Michael J; Smith, Kate Porta; Huang, Jing; Spira, Avrum

2016-05-17

Bronchoscopy is frequently used for the evaluation of suspicious pulmonary lesions found on computed tomography, but its sensitivity for detecting lung cancer is limited. Recently, a bronchial genomic classifier was validated to improve the sensitivity of bronchoscopy for lung cancer detection, demonstrating a high sensitivity and negative predictive value among patients at intermediate risk (10-60 %) for lung cancer with an inconclusive bronchoscopy. Our objective for this study was to determine if a negative genomic classifier result that down-classifies a patient from intermediate risk to low risk (<10 %) for lung cancer would reduce the rate that physicians recommend more invasive testing among patients with an inconclusive bronchoscopy. We conducted a randomized, prospective, decision impact survey study assessing pulmonologist recommendations in patients undergoing workup for lung cancer who had an inconclusive bronchoscopy. Cases with an intermediate pretest risk for lung cancer were selected from the AEGIS trials and presented in a randomized fashion to pulmonologists either with or without the patient's bronchial genomic classifier result to determine how the classifier results impacted physician decisions. Two hundred two physicians provided 1523 case evaluations on 36 patients. Invasive procedure recommendations were reduced from 57 % without the classifier result to 18 % with a negative (low risk) classifier result (p < 0.001). Invasive procedure recommendations increased from 50 to 65 % with a positive (intermediate risk) classifier result (p < 0.001). When stratifying by ultimate disease diagnosis, there was an overall reduction in invasive procedure recommendations in patients with benign disease when classifier results were reported (54 to 41 %, p < 0.001). For patients ultimately diagnosed with malignant disease, there was an overall increase in invasive procedure recommendations when the classifier results were reported (50 to 64 %, p = 0.003). Our findings suggest that a negative (low risk) bronchial genomic classifier result reduces invasive procedure recommendations following an inconclusive bronchoscopy and that the classifier overall reduces invasive procedure recommendations among patients ultimately diagnosed with benign disease. These results support the potential clinical utility of the classifier to improve management of patients undergoing bronchoscopy for suspect lung cancer by reducing additional invasive procedures in the setting of benign disease.

A Consensus Set of Outcomes for Parkinson’s Disease from the International Consortium for Health Outcomes Measurement

PubMed Central

de Roos, Paul; Bloem, Bastiaan R.; Kelley, Thomas A.; Antonini, Angelo; Dodel, Richard; Hagell, Peter; Marras, Connie; Martinez-Martin, Pablo; Mehta, Shyamal H.; Odin, Per; Chaudhuri, Kallol Ray; Weintraub, Daniel; Wilson, Bil; Uitti, Ryan J.

2017-01-01

Background Parkinson’s disease (PD) is a progressive neurodegenerative condition that is expected to double in prevalence due to demographic shifts. Value-based healthcare is a proposed strategy to improve outcomes and decrease costs. To move towards an actual value-based health care system, condition-specific outcomes that are meaningful to patients are essential. Objective Propose a global consensus standard set of outcome measures for PD. Methods Established methods for outcome measure development were applied, as outlined and used previously by the International Consortium for Health Outcomes Measurement (ICHOM). An international group, representing both patients and experts from the fields of neurology, psychiatry, nursing, and existing outcome measurement efforts, was convened. The group participated in six teleconferences over a six-month period, reviewed existing data and practices, and ultimately proposed a standard set of measures by which patients should be tracked, and how often data should be collected. Results The standard set applies to all cases of idiopathic PD, and includes assessments of motor and non-motor symptoms, ability to work, PD-related health status, and hospital admissions. Baseline demographic and clinical variables are included to enable case mix adjustment. Conclusions The Standard Set is now ready for use and pilot testing in the clinical setting. Ultimately, we believe that using the set of outcomes proposed here will allow clinicians and scientists across the world to document, report, and compare PD-related outcomes in a standardized fashion. Such international benchmarks will improve our understanding of the disease course and allow for identification of ‘best practices’, ultimately leading to better informed treatment decisions. PMID:28671140

Resolution of Tachyarrhythmia Following Posterior Fossa Decompression Surgery for Chiari Malformation Type I.

PubMed

Elia, Christopher; Brazdzionis, James; Tashjian, Vartan

2018-03-01

Chiari malformation (CM) type I commonly presents with symptoms such as tussive headaches, paresthesias, and, in severe cases, corticobulbar dysfunction. However, patients may present with atypical symptoms lending to the complexity in this patient population. We present a case of a CM patient presenting with atypical cardiac symptoms and arrhythmias, all of which resolved after surgical decompression. A 31-year-old female presented with atypical chest pain, palpitations, tachycardia, headaches, and dizziness for 2 years. Multiple antiarrhythmics and ultimately cardiac ablation procedure proved to be ineffective. Magnetic resonance imaging revealed CM, and the patient ultimately underwent surgical decompression with subsequent resolution of her symptoms. The surgical management of CM patients presenting with atypical symptoms can be challenging and often lead to delays in intervention. To our knowledge this is the only reported case of a patient presenting with tachyarrhythmia and atypical chest pain with resolution after Chiari decompression. We believe the dramatic improvement documented in the present case should serve to advance Chiari decompression in CM patients presenting with refractory tachyarrhythmia in whom no other discernable cause has been elucidated. Further studies are needed to better correlate the findings and to hopefully establish a criteria for patients that will likely benefit from surgical decompression. Copyright © 2017 Elsevier Inc. All rights reserved.

Care of the family in the surgical intensive care unit.

PubMed

Tyrie, Leslie Steele; Mosenthal, Anne Charlotte

2011-04-01

In the surgical intensive care unit (SICU), the stress of having a critically ill loved one creates significant bereavement and emotional needs for family members. Surgical palliative care has expanded; clinicians do not just treat the patient, but now include the family within the scope of care. Understanding and treating complicated grief, and the emotional and educational needs of the family improves family outcome, improves the surrogate family's ability to act as decision makers, and ultimately may positively affect patient survivor outcome. Care of families in the SICU requires interdisciplinary teams and palliative care processes to appropriately address their needs. Copyright © 2011 Elsevier Inc. All rights reserved.

Personalized diagnostics and biosensors: a review of the biology and technology needed for personalized medicine.

PubMed

Ahmed, Minhaz Uddin; Saaem, Ishtiaq; Wu, Pae C; Brown, April S

2014-06-01

Exploiting the burgeoning fields of genomics, proteomics and metabolomics improves understanding of human physiology and, critically, the mutations that signal disease susceptibility. Through these emerging fields, rational design approaches to diagnosis, drug development and ultimately personalized medicine are possible. Personalized medicine and point-of-care testing techniques must fulfill a host of constraints for real-world applicability. Point-of-care devices (POCDs) must ultimately provide a cost-effective alternative to expensive and time-consuming laboratory tests in order to assist health care personnel with disease diagnosis and treatment decisions. Sensor technologies are also expanding beyond the more traditional classes of biomarkers--nucleic acids and proteins--to metabolites and direct detection of pathogens, ultimately increasing the palette of available techniques for the use of personalized medicine. The technologies needed to perform such diagnostics have also been rapidly evolving, with each generation being increasingly sensitive and selective while being more resource conscious. Ultimately, the final hurdle for all such technologies is to be able to drive consumer adoption and achieve a meaningful medical outcome for the patient.

Three patients with hemophagocytic syndrome who developed acute organic brain syndrome.

PubMed

Shinno, Hideto; Hikasa, Satoshi; Matsuoka, Tatsuo; Fujita, Hidekazu; Yamamoto, Osamu; Takebayashi, Minoru; Uchida, Youzou; Nishiura, Tetsuo; Horiguchi, Jun

2006-01-01

We describe three patients with hemophagocytic syndrome (HPS) who developed acute organic brain syndrome. All three presented with high-grade fever and twilight state, and were admitted to our hospital. After admission, delirium developed in all three. As delirium improved, various other psychiatric symptoms, including hallucinations, agitation, hypoactivity, affective lability and insomnia, were noted. When treated with steroid hormones, immunoglobulin and neuroleptics, all patients demonstrated improvement in their psychiatric symptoms, as well as in their general condition and laboratory findings. Ultimately, they all recovered and were discharged. It needs to be noted that organic brain syndrome might be observed at the onset of HPS. Consequently, early diagnosis and treatment for psychiatric symptoms, as well as for HPS, are crucial.

Current Management of Calcific Aortic Stenosis

PubMed Central

Lindman, Brian R.; Bonow, Robert O.; Otto, Catherine M.

2014-01-01

Calcific aortic stenosis (AS) is a progressive disease with no effective medical therapy that ultimately requires aortic valve replacement (AVR) for severe valve obstruction. Echocardiography is the primary diagnostic approach to define valve anatomy, measure AS severity and evaluate the left ventricular (LV) response to chronic pressure overload. In asymptomatic patients, markers of disease progression include the degree of leaflet calcification, hemodynamic severity of stenosis, adverse LV remodeling, reduced LV longitudinal strain, myocardial fibrosis and pulmonary hypertension. The onset of symptoms portends a predictably high mortality rate unless AVR is performed. In symptomatic patients, AVR improves symptoms, improves survival and, in patients with LV dysfunction, improves systolic function. Poor outcomes after AVR are associated with low-flow low-gradient AS, severe ventricular fibrosis, oxygen dependent lung disease, frailty, advanced renal dysfunction and a high comorbidity score. However, in most patients with severe symptoms, AVR is lifesaving. Bioprosthetic valves are recommended for patients over the age of 65 years. Transcatheter AVR is now available for patients with severe comorbidities, is recommended in patients who are deemed inoperable and is a reasonable alternative to surgical AVR in high risk patients. PMID:23833296

Finding common ground to achieve a “good death”: family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study

PubMed Central

2013-01-01

Background Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a “bad death” experience for the patient and family. We aim to describe Canadian family physicians’ experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients. Methods Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged. Results Eleven family physicians with a range of 3 to 40 years in clinical practice participated. The family physicians expressed a desire to achieve a “good death” and described their role in positively influencing the experience of death. Finding Common Ground to Achieve a “Good Death” for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described. Conclusions A novel framework for developing Common Ground to manage conflicts during end-of-life decision-making discussions may assist in achieving a “good death”. These results could aid in educating physicians, learners, and the public on how to achieve productive collaborative relationships during end-of-life decision-making for dying patients, and ultimately improve their deaths. PMID:23339822

A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope.

PubMed

Fehlings, Michael G; Tetreault, Lindsay A; Wilson, Jefferson R; Kwon, Brian K; Burns, Anthony S; Martin, Allan R; Hawryluk, Gregory; Harrop, James S

2017-09-01

Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

Curidium Medica, plc.

PubMed

Caffo, Nathan A

2008-05-01

Curidium Medica, plc is a personalized medicine company intent on developing targeted medicines and their associated companion diagnostics to treat patients more effectively and safely. Through the use of its proprietary gene-expression analysis tool, Homomatrix ® , Curidium aims to reveal different patient subgroups characterized by distinct underlying disease mechanisms. This is anticipated to lead to the identification of diagnostics to subclassify patients within heterogeneous disease populations and improved therapies for different patient subgroups, ultimately resulting in the development of personalized medicines using companion diagnostics and targeted treatments. The company's initial focus on diseases of the CNS has resulted in the identification of a blood diagnostic tool, PsychINDx™, which classifies patients with schizophrenia/bipolar disorder into four subgroups. PsychINDx may have the potential to improve the treatment of patients with schizophrenia/bipolar disorder. Curidium aims to continue to use this approach to improve patient treatments in a variety of therapeutic areas and heterogeneous diseases. The first such additional application using Homomatrix has been initiated within a strategic research alliance with Takeda (Osaka, Japan) in the area of major depressive disorder.

A manual physical therapy intervention for symptoms of knee osteoarthritis and associated fall risk: A case series of four patients.

PubMed

Allen, Chris; Sheehan, Riley; Deyle, Gail; Wilken, Jason; Gill, Norman

2018-02-26

Patients with knee osteoarthritis (OA) are at an increased risk of falling. Further, the symptoms associated with knee OA are correlated with fall risk. A manual physical therapy (MPT) approach consisting of mobilizing techniques and reinforcing exercise improves the symptoms and functional limitations associated with knee OA. The purpose of this case series is to evaluate an MPT intervention of mobilization techniques and exercise for knee OA on improving symptoms and quantify the secondary benefit of improving stumble recovery. Four patients with symptomatic knee OA and four matched controls completed a fall risk assessment. Following 4 weeks of intervention, patients were reevaluated. Initial Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores indicated notable symptoms and functional limitations in all patients. In addition, all patients displayed elevated fall risk and/or impaired stumble responses. Following 4 weeks of intervention, all patients reported meaningful reductions in all three WOMAC subscales and demonstrated improvements in at least two of the three fall risk measures. We identified potential connections between symptom relief in patients with knee OA, stumble response, and ultimately fall risk. The results suggest that MPT intervention designed to improve the signs and symptoms of knee OA may lead to a secondary benefit of improved gait stability and stumble response.

Neoadjuvant chemotherapy in soft tissue sarcomas: latest evidence and clinical implications

PubMed Central

Pasquali, Sandro; Gronchi, Alessandro

2017-01-01

Soft tissue sarcomas are a rare and multifaceted group of solid tumours. Neoadjuvant chemotherapy is increasingly used to limit loss of function after wide surgical excision with the ultimate aim of improving patient survival. Recently, advances in the identification of effective treatment strategies and improvements in patient risk stratification have been reached. A randomized trial demonstrated that neoadjuvant epirubicin and ifosfamide improves survival of patients affected by five high-risk soft tissue sarcoma histologies of trunk and extremities, including undifferentiated pleomorphic sarcoma, myxoid liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumours, and leiomyosarcoma. Selection of patients for these treatments is expected to be improved by the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system, as it tailors T-stage categories on primary tumour site and considers a prognostic nomogram for retroperitoneal sarcoma, which also includes soft tissue sarcoma histology and other patient and tumour features not directly included in the TNM staging. Within this framework, this article will present neoadjuvant treatment strategies for high-risk soft tissue sarcoma, emphasizing the most recent advances and discussing the need for further research to improve the effectiveness of neoadjuvant treatments. PMID:28607580

Xeroderma pigmentosum with melanoma of face and its prosthetic management.

PubMed

Sadaf, Ayesha; Yazdanie, Nazia

2013-10-01

Xeroderma pigmentosum is a rare genetic disorder, characterized by cutaneous, ocular and neurological symptoms. Squamous cell carcinoma and melanoma are also its secondary characters. This case report is about maxillofacial prosthetic management of a 10 years old child presented with xeroderma pigmentosum. The nose of the patient was excised surgically due to melanoma. This case report elaborates the role of prosthodontist and the whole procedure of constructing the nasal prosthesis via conventional technique by using the patient's sibling nasal form as template. Regular follow up revealed marked improvement in esthetics, function and ultimately patient's quality of life.

Three-Dimensional Printing: An Aid to Epidural Access for Neuromodulation.

PubMed

Taverner, Murray G; Monagle, John P

2017-08-01

The case report details to use of three-dimensional (3D) printing as an aid to neuromodulation. A patient is described in whom previous attempts at spinal neuromodulation had failed due to lack of epidural or intrathecal access, and the use of a 3D printed model allowed for improved planning and ultimately, success. Successful spinal cord stimulation was achieved with the plan developed by access to a 3D model of the patient's spine. Neuromodulation techniques can provide the optimal analgesic techniques for individual patients. At times these can fail due to lack of access to the site for intervention, in this case epidural access. 3D printing may provide additional information to improve the likelihood of access when anatomy is distorted and standard approaches prove difficult. © 2017 International Neuromodulation Society.

Improving patient care. The cognitive psychology of missed diagnoses.

PubMed

Redelmeier, Donald A

2005-01-18

Cognitive psychology is the science that examines how people reason, formulate judgments, and make decisions. This case involves a patient given a diagnosis of pharyngitis, whose ultimate diagnosis of osteomyelitis was missed through a series of cognitive shortcuts. These errors include the availability heuristic (in which people judge likelihood by how easily examples spring to mind), the anchoring heuristic (in which people stick with initial impressions), framing effects (in which people make different decisions depending on how information is presented), blind obedience (in which people stop thinking when confronted with authority), and premature closure (in which several alternatives are not pursued). Rather than trying to completely eliminate cognitive shortcuts (which often serve clinicians well), becoming aware of common errors might lead to sustained improvement in patient care.

Improving operating room safety

PubMed Central

2009-01-01

Despite the introduction of the Universal Protocol, patient safety in surgery remains a daily challenge in the operating room. This present study describes one community health system's efforts to improve operating room safety through human factors training and ultimately the development of a surgical checklist. Using a combination of formal training, local studies documenting operating room safety issues and peer to peer mentoring we were able to substantially change the culture of our operating room. Our efforts have prepared us for successfully implementing a standardized checklist to improve operating room safety throughout our entire system. Based on these findings we recommend a multimodal approach to improving operating room safety. PMID:19930577

State-of-the-art and emerging technologies for atrial fibrillation ablation.

PubMed

Dewire, Jane; Calkins, Hugh

2010-03-01

Catheter ablation is an important treatment modality for patients with atrial fibrillation (AF). Although the superiority of catheter ablation over antiarrhythmic drug therapy has been demonstrated in middle-aged patients with paroxysmal AF, the role the procedure in other patient subgroups-particularly those with long-standing persistent AF-has not been well defined. Furthermore, although AF ablation can be performed with reasonable efficacy and safety by experienced operators, long-term success rates for single procedures are suboptimal. Fortunately, extensive ongoing research will improve our understanding of the mechanisms of AF, and considerable funds are being invested in developing new ablation technologies to improve patient outcomes. These technologies include ablation catheters designed to electrically isolate the pulmonary veins with improved safety, efficacy, and speed, catheters designed to deliver radiofrequency energy with improved precision, robotic systems to address the technological demands of the procedure, improved imaging and electrical mapping systems, and MRI-guided ablation strategies. The tools, technologies, and techniques that will ultimately stand the test of time and become the standard approach to AF ablation in the future remain unclear. However, technological advances are sure to result in the necessary improvements in the safety and efficacy of AF ablation procedures.

Future Directions for the Early Detection of Colorectal Cancer Recurrence

PubMed Central

Walker, Avery S.; Johnson, Eric K.; Maykel, Justin A.; Stojadinovic, Alex; Nissan, Aviram; Brucher, Bjorn; Champagne, Bradley J.; Steele, Scott R.

2014-01-01

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence. PMID:24790655

Market-Based Health Care in Specialty Surgery: Finding Patient-Centered Shared Value.

PubMed

Smith, Timothy R; Rambachan, Aksharananda; Cote, David; Cybulski, George; Laws, Edward R

2015-10-01

: The US health care system is struggling with rising costs, poor outcomes, waste, and inefficiency. The Patient Protection and Affordable Care Act represents a substantial effort to improve access and emphasizes value-based care. Value in health care has been defined as health outcomes for the patient per dollar spent. However, given the opacity of health outcomes and cost, the identification and quantification of patient-centered value is problematic. These problems are magnified by highly technical, specialized care (eg, neurosurgery). This is further complicated by potentially competing interests of the 5 major stakeholders in health care: patients, doctors, payers, hospitals, and manufacturers. These stakeholders are watching with great interest as health care in the United States moves toward a value-based system. Market principles can be harnessed to drive costs down, improve outcomes, and improve overall value to patients. However, there are many caveats to a market-based, value-driven system that must be identified and addressed. Many excellent neurosurgical efforts are already underway to nudge health care toward increased efficiency, decreased costs, and improved quality. Patient-centered shared value can provide a philosophical mooring for the development of health care policies that utilize market principles without losing sight of the ultimate goals of health care, to care for patients.

Management of pediatric patients with refractory constipation who fail cecostomy.

PubMed

Bonilla, Silvana F; Flores, Alejandro; Jackson, Carl-Christian A; Chwals, Walter J; Orkin, Bruce A

2013-09-01

Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking. To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients. Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed. 76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up. Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues. Copyright © 2013 Elsevier Inc. All rights reserved.

Low Cryptococcus Antigen Titers as Determined by Lateral Flow Assay Should Be Interpreted Cautiously in Patients without Prior Diagnosis of Cryptococcal Infection.

PubMed

Dubbels, Marie; Granger, Dane; Theel, Elitza S

2017-08-01

Detection of Cryptococcus antigen (CrAg) is invaluable for establishing cryptococcal disease. Multiple different methods for CrAg detection are available, including a lateral flow assay (LFA). Despite excellent performance of the CrAg LFA, we have observed multiple cases of low-titer (≤1:5) positive CrAg LFA results in patients for whom cryptococcosis was ultimately excluded. To investigate the accuracy of low-titer positive CrAg LFA results, we performed chart reviews for all patients with positive CrAg LFA results between June 2014 and December 2016. During this period, serum and/or cerebrospinal fluid (CSF) samples from 3,969 patients were tested with the CrAg LFA, and 55 patients (1.5%) tested positive. Thirty-eight of those patients lacked a history of cryptococcal disease and were the focus of this study. Fungal culture or histopathology confirmed Cryptococcus infection for 20 patients (52.6%), and CrAg LFA titers in serum and CSF samples ranged from 1:5 to ≥1:2,560. For the 18 patients (47.4%) without culture or histopathological confirmation, the CrAg LFA results were considered true-positive results for 5 patients (titer range, 1:10 to ≥1:2,560), due to clinical improvement with targeted therapy and decreasing CrAg LFA titers. The remaining 13 patients had CrAg LFA titers of 1:2 ( n = 11) or 1:5 ( n = 2) and were ultimately diagnosed with an alternative condition ( n = 11) or began therapy for possible cryptococcosis without improvement ( n = 2), leading to an overall CrAg LFA false-positive rate of 34%. We recommend careful clinical correlation prior to establishing a diagnosis of cryptococcal infection for patients with first-time positive CrAg LFA titers of 1:2. Copyright © 2017 American Society for Microbiology.

Barriers to Care for Persons With Sickle Cell Disease: The Case Manager's Opportunity to Improve Patient Outcomes.

PubMed

Brennan-Cook, Jill; Bonnabeau, Emily; Aponte, Ravenne; Augustin, Christina; Tanabe, Paula

The purpose of this discussion is to review the barriers to care for patients with sickle cell disease (SCD). Chronic pain and the perception of addiction, implicit bias, frequent hospitalizations and emergency department visits, clinician and patient knowledge deficits, and SCD stigma all impede the ability to provide evidence-based care for patients with SCD. Case managers can coordinate and advocate for appropriate care that improves patient outcomes. This discussion is relevant to case managers working with patients with SCD in the clinic, hospital, and emergency department. Case managers can serve an important advocacy role and intervene to improve the coordination of services and efficient use of resources. This will lead to improved quality of life and optimal health care utilization for persons with SCD. As a constant member of the health care team, the case manager may be the only health care team member who has a broad knowledge of the patient's experience of acute and chronic pain, usual state of health, social behavioral health needs, and how these factors may affect both inpatient and outpatient health care use and health outcomes. This article explores the barriers to care and suggests specific interventions within the role of the case manager that can improve care delivered and ultimately contribute to improved patient outcomes. Specifically, these interventions can improve communication among members of the health care team. Case manager interventions can guide coordination, prevent hospital readmissions, reduce health care utilization, and contribute to overall improved patient quality of life and health outcomes.

Why might people donate tissue for cancer research? Insights from organ/tissue/blood donation and clinical research.

PubMed

Axler, Renata E; Irvine, Rob; Lipworth, Wendy; Morrell, Bronwen; Kerridge, Ian H

2008-01-01

Little is known about why patients with cancer do or do not donate their biopsied/cancerous tissue to research. A review of the literature on motivations to participate in clinical research and to donate tissues/organs for therapeutic use may provide some insights relevant to tumour banking research. While more research is necessary, a better understanding of the factors that motivate patients to give or refuse consent to tumour banking may ultimately improve consent practices, public trust and donation rates. Copyright 2008 S. Karger AG, Basel.

Minimal acceptable care as a vital component to Missouri's trauma system.

PubMed

Helling, Thomas S

2002-07-01

Immediate attention to life-threatening injuries and expeditious transfer of major and complex wounds to tertiary care trauma centers are the cornerstones of any trauma system. Rapid assessment and "minimalization" of care should be the buzz-word of rural (Level III) and suburban (Level II) trauma centers in order to provide quickest treatment of injuries by timely referral of patients for definitive attention. This concept is called minimal acceptable care and may serve to improve patient outcome by reducing the interval to ultimate treatment and avoidance of duplication of services.

Automated generation of individually customized visualizations of diagnosis-specific medical information using novel techniques of information extraction

NASA Astrophysics Data System (ADS)

Chen, Andrew A.; Meng, Frank; Morioka, Craig A.; Churchill, Bernard M.; Kangarloo, Hooshang

2005-04-01

Managing pediatric patients with neurogenic bladder (NGB) involves regular laboratory, imaging, and physiologic testing. Using input from domain experts and current literature, we identified specific data points from these tests to develop the concept of an electronic disease vector for NGB. An information extraction engine was used to extract the desired data elements from free-text and semi-structured documents retrieved from the patient"s medical record. Finally, a Java-based presentation engine created graphical visualizations of the extracted data. After precision, recall, and timing evaluation, we conclude that these tools may enable clinically useful, automatically generated, and diagnosis-specific visualizations of patient data, potentially improving compliance and ultimately, outcomes.

Haemodynamic coherence - The relevance of fluid therapy.

PubMed

Arnemann, Philip; Seidel, Laura; Ertmer, Christian

2016-12-01

The ultimate goal of fluid therapy is to improve the oxygenation of cells by improving the cardiac output, thus improving microcirculation by optimizing macrocirculation. This haemodynamic coherence is often altered in patients with haemorrhagic shock and sepsis. The loss of haemodynamic coherence is associated with adverse outcomes. It may be influenced by the mechanisms of the underlying disease and properties of different fluids used for resuscitation in these critically ill patients. Monitoring microcirculation and haemodynamic coherence may be an additional tool to predict the response to fluid administration. In addition, microcirculatory analysis may support the clinician in his decision to not administer fluids when microcirculatory blood flow is preserved. In future, the indication, guidance and termination of fluid therapy may be assessed by bedside microvascular analysis in combination with standard haemodynamic monitoring. Copyright © 2016 Elsevier Ltd. All rights reserved.

Improving HCAHPS Scores with Advances in Digital Radiography.

PubMed

Matthews, Marianne; Cretella, Gregg; Nicholas, William

2016-01-01

The imaging department can be instrumental in contributing to a healthcare facility's ability to succeed in this new era of competition. Advances in DR technology can improve patient perceptions in the imaging department by improving efficiencies and outcomes which, in turn, can ultimately bolster overall HCAHPS scores. Specific areas for improved scores by utilization of DR include nurse communication, doctor communication, pain management, and communication about medication. Value based purchasing brought with it a mandate for hospitals to track key metrics, which requires an investment in time, tools, and human resources. However, this mandate also presents hospitals and imaging departments, with an opportunity to leverage those very metrics to better market their facilities.

Quality of Life in Glaucoma: A Review of the Literature.

PubMed

Quaranta, Luciano; Riva, Ivano; Gerardi, Chiara; Oddone, Francesco; Floriano, Irene; Konstas, Anastasios G P

2016-06-01

The ultimate goal of glaucoma management is the preservation of patients' visual function and quality of life (QoL). The disease itself as well as the medical or surgical treatment can have an enormous impact on a patient's QoL. Even the mere diagnosis of a chronic, irreversible, potentially blinding disorder can adversely affect the patient's sense of well-being and QoL by eliciting significant anxiety. Patients with primary open-angle glaucoma rarely present with visual symptoms, at least early in the course of the disease. A better understanding of patient-reported QoL can improve patient-physician interaction and enhance treatment adherence by customizing treatment options based on individual patient profile, thus optimizing long-term prognosis. These aspects are summarized and critically appraised in this article.

Business process study simulation for resource management in an emergency department.

PubMed

Poomkothammal, Velusamy

2006-01-01

Alexandra Hospital conducted a business process reengineering exercise for all its main processes in order to further improve on their efficiencies with the ultimate aim to provide a higher level of services to patients. The goal of the DEM is to manage an anticipated increase in the volume of patients without much increase in resources. As a start, the Department of Emergency (DEM) medicine studied its AS-IS process and has designed and implemented the new TO-BE process. As part of this continuous improvement effort, staff from Nanyang Polytechnic (NYP) has been assigned the task of applying engineering and analytical techniques to simulate the new process. The simulations were conducted to show on process management and resource planning.

Dosimetric quality assurance of highly conformal external beam treatments: from 2D phantom comparisons to 4D patient dose reconstruction

NASA Astrophysics Data System (ADS)

Feygelman, V.; Nelms, B.

2013-06-01

As IMRT technology continues to evolve, so do the dosimetric QA methods. A historical review of those is presented, starting with longstanding techniques such as film and ion chamber in a phantom and progressing towards 3D and 4D dose reconstruction in the patient. Regarding patient-specific QA, we envision that the currently prevalent limited comparison of dose distributions in the phantom by γ-analysis will be eventually replaced by clinically meaningful patient dose analyses with improved sensitivity and specificity. In a larger sense, we envision a future of QA built upon lessons from the rich history of "quality" as a science and philosophy. This future will aim to improve quality (and ultimately reduce cost) via advanced commissioning processes that succeed in detecting and rooting out systematic errors upstream of patient treatment, thus reducing our reliance on, and the resource burden associated with, per-beam/per-plan inspection.

Complementary and Alternative Medicine and Osteoarthritis.

PubMed

Wang, Chenchen

2013-01-01

Patients with osteoarthritis experience high levels of pain, psychological distress and have limited therapeutic options. Emerging evidence from clinical trials suggests that both acupuncture and Tai Chi mind-body therapies are safe and effective treatments for osteoarthritis. Acupuncture has effects over and above those of 'sham acupuncture' and the most robust evidence to date demonstrates that acupuncture does have short-term benefits and is a reasonable referral option for patients with symptomatic osteoarthritis. Tai Chi is a mind-body exercise that enhances cardiovascular fitness, muscular strength, balance, and physical function. It also appears to be associated with reduced stress and anxiety and depression, as well as improved quality of life. Thus, Tai Chi may be safely recommended to patients with osteoarthritis as a complementary and alternative medical approach to affect patient well-being. Integrative approaches combine the best of conventional medicine and complementary and alternative medicine to ultimately improve patient care. These modalities may lead to the development of better disease modifying strategies that could improve symptoms and decrease the progression of osteoarthritis. This overview synthesizes the current body of knowledge about Chinese mind-body medicine to better inform clinical decision-making for our rheumatic patients.

How health systems could avert 'triple fail' events that are harmful, are costly, and result in poor patient satisfaction.

PubMed

Lewis, Geraint; Kirkham, Heather; Duncan, Ian; Vaithianathan, Rhema

2013-04-01

Health care systems in many countries are using the "Triple Aim"--to improve patients' experience of care, to advance population health, and to lower per capita costs--as a focus for improving quality. Population strategies for addressing the Triple Aim are becoming increasingly prevalent in developed countries, but ultimately success will also require targeting specific subgroups and individuals. Certain events, which we call "Triple Fail" events, constitute a simultaneous failure to meet all three Triple Aim goals. The risk of experiencing different Triple Fail events varies widely across people. We argue that by stratifying populations according to each person's risk and anticipated response to an intervention, health systems could more effectively target different preventive interventions at particular risk strata. In this article we describe how such an approach could be planned and operationalized. Policy makers should consider using this stratified approach to reduce the incidence of Triple Fail events, thereby improving outcomes, enhancing patient experience, and lowering costs.

Feasibility study of using statistical process control to customized quality assurance in proton therapy.

PubMed

Rah, Jeong-Eun; Shin, Dongho; Oh, Do Hoon; Kim, Tae Hyun; Kim, Gwe-Ya

2014-09-01

To evaluate and improve the reliability of proton quality assurance (QA) processes and, to provide an optimal customized tolerance level using the statistical process control (SPC) methodology. The authors investigated the consistency check of dose per monitor unit (D/MU) and range in proton beams to see whether it was within the tolerance level of the daily QA process. This study analyzed the difference between the measured and calculated ranges along the central axis to improve the patient-specific QA process in proton beams by using process capability indices. The authors established a customized tolerance level of ±2% for D/MU and ±0.5 mm for beam range in the daily proton QA process. In the authors' analysis of the process capability indices, the patient-specific range measurements were capable of a specification limit of ±2% in clinical plans. SPC methodology is a useful tool for customizing the optimal QA tolerance levels and improving the quality of proton machine maintenance, treatment delivery, and ultimately patient safety.

A systematic review of best practices in teaching ophthalmology to medical students.

PubMed

Succar, Tony; Grigg, John; Beaver, Hilary A; Lee, Andrew G

2016-01-01

Ophthalmic medical student education is a cornerstone to improving eye health care globally. We review the current state of the literature, listing barriers to potential best practices for undergraduate ophthalmology teaching and learning within medical curricula. We describe recent advances and pedagogical approaches in ophthalmic education and propose specific recommendations for further improvements and research. Future research should concentrate on developing teaching and learning innovations that may result in a more time- and resource-effective models for interactive and integrated learning. As well as demonstrating that a competency-based approach results not just in better eye health, but also improvements in patient care, education, and medical care in general. By optimizing teaching available through improved evidence-based education, the ultimate goal is to increase medical students' knowledge and produce graduates who are highly trained in eye examination skills, resulting in improved patient eye care through timely diagnosis, referrals, and treatment. Copyright © 2016 Elsevier Inc. All rights reserved.

Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome?

PubMed

Hagerman, Nancy S; Varughese, Anna M; Kurth, C Dean

2014-06-01

Cognitive aids are tangible or intangible instruments that guide users in decision-making and in the completion of a complex series of tasks. Common examples include mnemonics, checklists, and algorithms. Cognitive aids constitute very effective approaches to achieve well tolerated, high quality healthcare because they promote highly reliable processes that reduce the likelihood of failure. This review describes recent advances in quality improvement for pediatric anesthesiology with emphasis on application of cognitive aids to impact patient safety and outcomes. Quality improvement encourages the examination of systems to create stable processes and ultimately high-value care. Quality improvement initiatives in pediatric anesthesiology have been shown to improve outcomes and the delivery of efficient and effective care at many institutions. The use of checklists, in particular, improves adherence to evidence-based care in crisis situations, decreases catheter-associated bloodstream infections, reduces blood product utilization, and improves communication during the patient handoff process. Use of this simple tool has been associated with decreased morbidity, fewer medical errors, improved provider satisfaction, and decreased mortality in nonanesthesia disciplines as well. Successful quality improvement initiatives utilize cognitive aids such as checklists and have been shown to optimize pediatric patient experience and anesthesia outcomes and reduce perioperative complications.

Evidence-based therapies for upper extremity dysfunction.

PubMed

Liepert, Joachim

2010-12-01

The diversity of interventions aimed at improving upper extremity dysfunction is increasing. This article reviews the effectiveness of different therapeutic approaches that have been published in 2009 and 2010. Evidence is based on randomized controlled trials, systematic reviews, and meta-analyses. Application of constraint-induced movement therapy in acute stroke patients was not more effective than a control intervention, and a more intense therapy may even be harmful. Botulinum toxin injections do not only reduce spasticity but, in children, also improve motor functions if combined with occupational therapy. Strength training improves arm function but not necessarily activities of daily living. Bilateral arm training is as effective as other interventions. Extrinsic feedback and sensory training may further improve motor functions. Mirror therapy was particularly effective for patients with initial hand plegia. For some interventions (e.g. constraint-induced movement therapy, botulinum toxin), efficacy is evident, for others (e.g. mental practice, virtual reality), well designed studies with sufficient numbers of patients are needed. The ultimate goal still is to develop evidence-based therapies for all different degrees of motor impairment.

The patient experience: measuring the quality of care in the Defence Medical Services.

PubMed

Piper, Neale; Lamb, D

2014-06-01

Healthcare provided by the Defence Medical Services (DMS) is acknowledged to be of a high standard but patients' experiences of it has not been measured and collated in a consistent and meaningful way, which has limited strategic quality improvement initiatives. Responsibility for implementing and delivering a programme of healthcare governance and assurance for the DMS rests with the Inspector General (IG). An important aspect of this role is to nurture a culture of continuous improvement in the DMS and under this leadership the IG team has prioritised a number of projects to address this. The project to improve patient experience data capture was prioritised in the work schedule as it incorporated initiatives that would lead to improved quality in DMS healthcare, information exploitation and ultimately patient safety. This is the first in a series of articles that will document this important work and describe the methodological considerations associated with the initial questionnaire design, collaboration with NHS partners, the pilot study and progress towards the introduction of the definitive DMS tool later this year. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Synchronous Pulmonary Malignancies: Atypical Presentation of Mantle Cell Lymphoma Masking a Lung Malignancy

PubMed Central

Masha, Luke; Zinchuk, Andrey; Boosalis, Valia

2015-01-01

We present a case of a pleural space malignancy masked by an atypical presentation of mantle cell lymphoma. Our patient presented with a large pleural effusion and right sided pleural studding, initially attributed to a new diagnosis of mantle cell lymphoma. Rare atypical epithelial cells were also seen amongst the clonal population of lymphocytes. The patient lacked systemic manifestations of mantle cell lymphoma and did not improve with chemotherapy. A pleural biopsy ultimately revealed the presence of an undifferentiated carcinoma, favoring a lung primary. A discussion of synchronous pleural space malignancies involving lymphomas is given. PMID:26500732

Synchronous Pulmonary Malignancies: Atypical Presentation of Mantle Cell Lymphoma Masking a Lung Malignancy.

PubMed

Masha, Luke; Zinchuk, Andrey; Boosalis, Valia

2015-09-07

We present a case of a pleural space malignancy masked by an atypical presentation of mantle cell lymphoma. Our patient presented with a large pleural effusion and right sided pleural studding, initially attributed to a new diagnosis of mantle cell lymphoma. Rare atypical epithelial cells were also seen amongst the clonal population of lymphocytes. The patient lacked systemic manifestations of mantle cell lymphoma and did not improve with chemotherapy. A pleural biopsy ultimately revealed the presence of an undifferentiated carcinoma, favoring a lung primary. A discussion of synchronous pleural space malignancies involving lymphomas is given.

Pathophysiology and Prevention of Intraoperative Atelectasis: A Review of the Literature.

PubMed

Randtke, Mark A; Andrews, Benjamin P; Mach, William J

2015-12-01

Atelectasis is a common problem in the perioperative setting, affecting a significant number of surgical patients receiving general anesthesia. Absorption, compression, and reduced surfactant are the three mechanisms implicated in the etiology of atelectasis. Interventions designed to minimize the risk of intraoperative atelectasis such as positioning, positive end-expiratory pressure, and administration of the least amount of fraction of inspired oxygen can be used to maintain patency of small airways and ultimately improve gas exchange in the surgical patient. Copyright © 2015 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Case Studies in Tremor.

PubMed

Shanker, Vicki L

2016-08-01

Tremor is a frequent patient complaint in the neurologist's office. Nevertheless, despite the routine nature of this office presentation, misdiagnosis of common tremors is not an infrequent practice. In addition, there are less common causes of tremor that can be missed if the clinician is not aware of key features. An organized and methodical history and neurologic examination are essential in developing the differential diagnosis in tremor patients and ultimately in achieving the correct diagnosis. Awareness of key historical features associated with tremor and knowledge of the movement disorders examination will improve tremor assessment. Copyright © 2016 Elsevier Inc. All rights reserved.

Addressing the coming radiology crisis-the Society for Computer Applications in Radiology transforming the radiological interpretation process (TRIP) initiative.

PubMed

Andriole, Katherine P; Morin, Richard L; Arenson, Ronald L; Carrino, John A; Erickson, Bradley J; Horii, Steven C; Piraino, David W; Reiner, Bruce I; Seibert, J Anthony; Siegel, Eliot

2004-12-01

The Society for Computer Applications in Radiology (SCAR) Transforming the Radiological Interpretation Process (TRIP) Initiative aims to spearhead research, education, and discovery of innovative solutions to address the problem of information and image data overload. The initiative will foster interdisciplinary research on technological, environmental and human factors to better manage and exploit the massive amounts of data. TRIP will focus on the following basic objectives: improving the efficiency of interpretation of large data sets, improving the timeliness and effectiveness of communication, and decreasing medical errors. The ultimate goal of the initiative is to improve the quality and safety of patient care. Interdisciplinary research into several broad areas will be necessary to make progress in managing the ever-increasing volume of data. The six concepts involved are human perception, image processing and computer-aided detection (CAD), visualization, navigation and usability, databases and integration, and evaluation and validation of methods and performance. The result of this transformation will affect several key processes in radiology, including image interpretation; communication of imaging results; workflow and efficiency within the health care enterprise; diagnostic accuracy and a reduction in medical errors; and, ultimately, the overall quality of care.

Management of Respiratory Infections with Use of Procalcitonin: Moving toward More Personalized Antibiotic Treatment Decisions.

PubMed

Wirz, Yannick; Branche, Angela; Wolff, Michel; Welte, Tobias; Nobre, Vandack; Reinhart, Konrad; Falsey, Ann R; Damas, Pierre; Beishuizen, Albertus; Deliberato, Rodrigo O; Shehabi, Yahya; Jensen, Jens-Ulrik S; Mueller, Beat; Schuetz, Philipp

2017-12-08

Due to overlap of clinical findings and low sensitivity of bacterial diagnostic tests, differentiation between bacterial and viral respiratory tract infections remains challenging, ultimately leading to antibiotic overuse in this population of patients. Addition of procalcitonin, a blood biomarker expressed by epithelial cells in response to bacterial infections, to the clinical assessment leads to a reduction in inappropriate antibiotic initiation. Procalcitonin also provides prognostic information about the resolution of illness, and significant decreases over time are a strong signal for the discontinuation of antibiotics. Current evidence from randomized trials indicates that procalcitonin-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side effects, which importantly translates into improved survival of patients with respiratory infections. Inclusion of procalcitonin into antibiotic stewardship algorithms thus improves the diagnostic and therapeutic management of patients presenting with respiratory illnesses and holds great promise to mitigate the global bacterial resistance crisis.

Sexual Assault Simulation Course for Healthcare Providers: Enhancing Sexual Assault Education Using Simulation.

PubMed

Scannell, Meredith; Lewis-O'Connor, Annie; Barash, Ashley

2015-01-01

Patients who have been sexually assaulted disproportionately experience gaps in healthcare delivery. Ensuring that healthcare providers who care for this population are adequately prepared is one way of addressing this gap. At the Brigham and Women's Hospital, a 4-hour long interprofessional Sexual Assault Simulation Course for Healthcare Providers (SASH) was developed and conducted at the hospital's Simulation, Training, Research, & Technology Utilization System Center. The SASH is offered using a variety of teaching methodologies including didactics, skill stations comprising how to collect forensic evidence, simulation experience with standardized patient, and debriefing. Using simulation as an educational method allows healthcare professionals to gain hands-on skills in a safe environment. Ultimately, the goal of the SASH is to enhance collaborative practice between healthcare professionals and to improve knowledge, with the purpose of improving care for patients who have been sexually assaulted.

The art and science of interprofessional education.

PubMed

Graybeal, Clay; Long, Richard; Scalise-Smith, Dale; Zeibig, Elizabeth

2010-01-01

Interprofessional education (IPE) is increasingly accepted as a core element of health professions education. Its primary function is to prepare health professions students to engage in and deliver interprofessional, team-based healthcare, with the ultimate goal of improving the health and well-being of patients and clients. This paper summarizes findings from 10 interviews with institutional leaders in the field. The goal was to discover core themes than contribute to the art and science of IPE. Thematic challenges and successes are reviewed, and recommendations are provided for further research and for those interested in developing or improving IPE in their own institutions.

Student-oriented learning outlines: a valuable supplement to traditional instruction.

PubMed

VanArsdale, S K; Hammons, J O

1998-01-01

In a time of changing health care and funding restraints in institutions, continuing education and staff development departments are being challenged to produce better prepared nurses at reduced costs per employee. Improvements in how nurses are prepared are needed to ensure higher levels of competence without increasing the cost. This article describes the development and use of a practical strategy for mastery learning known as Student-Oriented Learning Outlines or SOLOs. This approach has been found to be effective in producing improvements in learning and ultimately patient care while reducing cost to the institution.

Comparative Analysis of Vitamin A (Retinol) Regulated Genes in African-American and Caucasian Prostate Cancer Patients

DTIC Science & Technology

2007-03-01

chemoprevention strategies and to the development of novel therapies for this disease. 14. SUBJECT TERMS 15. NUMBER OF PAGES 13Retinoids, Vitamin A...the TRAMP model will ultimately lead to improved chemoprevention strategies and to the development of novel therapies for prostate cancer...Selective retinoids and rexinoids in cancer therapy and chemoprevention. Drug Discov Today, 7: 1165-1174, 2002. 5. Wei, L. N. Retinoid receptors and

Standard-Fractionated Radiotherapy for Optic Nerve Sheath Meningioma: Visual Outcome Is Predicted by Mean Eye Dose

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

Abouaf, Lucie; Girard, Nicolas; Claude Bernard University, Lyon

2012-03-01

Purpose: Radiotherapy has shown its efficacy in controlling optic nerve sheath meningiomas (ONSM) tumor growth while allowing visual acuity to improve or stabilize. However, radiation-induced toxicity may ultimately jeopardize the functional benefit. The purpose of this study was to identify predictive factors of poor visual outcome in patients receiving radiotherapy for ONSM. Methods and Materials: We conducted an extensive analysis of 10 patients with ONSM with regard to clinical, radiologic, and dosimetric aspects. All patients were treated with conformal radiotherapy and subsequently underwent biannual neuroophthalmologic and imaging assessments. Pretreatment and posttreatment values of visual acuity and visual field were comparedmore » with Wilcoxon's signed rank test. Results: Visual acuity values significantly improved after radiotherapy. After a median follow-up time of 51 months, 6 patients had improved visual acuity, 4 patients had improved visual field, 1 patient was in stable condition, and 1 patient had deteriorated visual acuity and visual field. Tumor control rate was 100% at magnetic resonance imaging assessment. Visual acuity deterioration after radiotherapy was related to radiation-induced retinopathy in 2 patients and radiation-induced mature cataract in 1 patient. Study of radiotherapy parameters showed that the mean eye dose was significantly higher in those 3 patients who had deteriorated vision. Conclusions: Our study confirms that radiotherapy is efficient in treating ONSM. Long-term visual outcome may be compromised by radiation-induced side effects. Mean eye dose has to be considered as a limiting constraint in treatment planning.« less

Shared Decision-Making and Patient Empowerment in Preventive Cardiology.

PubMed

Kambhampati, Swetha; Ashvetiya, Tamara; Stone, Neil J; Blumenthal, Roger S; Martin, Seth S

2016-05-01

Shared decision-making, central to evidence-based medicine and good patient care, begins and ends with the patient. It is the process by which a clinician and a patient jointly make a health decision after discussing options, potential benefits and harms, and considering the patient's values and preferences. Patient empowerment is crucial to shared decision-making and occurs when a patient accepts responsibility for his or her health. They can then learn to solve their own problems with information and support from professionals. Patient empowerment begins with the provider acknowledging that patients are ultimately in control of their care and aims to increase a patient's capacity to think critically and make autonomous, informed decisions about their health. This article explores the various components of shared decision-making in scenarios such as hypertension and hyperlipidemia, heart failure, and diabetes. It explores barriers and the potential for improving medication adherence, disease awareness, and self-management of chronic disease.

Robotics in Arthroplasty: A Comprehensive Review.

PubMed

Jacofsky, David J; Allen, Mark

2016-10-01

Robotic-assisted orthopedic surgery has been available clinically in some form for over 2 decades, claiming to improve total joint arthroplasty by enhancing the surgeon's ability to reproduce alignment and therefore better restore normal kinematics. Various current systems include a robotic arm, robotic-guided cutting jigs, and robotic milling systems with a diversity of different navigation strategies using active, semiactive, or passive control systems. Semiactive systems have become dominant, providing a haptic window through which the surgeon is able to consistently prepare an arthroplasty based on preoperative planning. A review of previous designs and clinical studies demonstrate that these robotic systems decrease variability and increase precision, primarily focusing on component positioning and alignment. Some early clinical results indicate decreased revision rates and improved patient satisfaction with robotic-assisted arthroplasty. The future design objectives include precise planning and even further improved consistent intraoperative execution. Despite this cautious optimism, many still wonder whether robotics will ultimately increase cost and operative time without objectively improving outcomes. Over the long term, every industry that has seen robotic technology be introduced, ultimately has shown an increase in production capacity, improved accuracy and precision, and lower cost. A new generation of robotic systems is now being introduced into the arthroplasty arena, and early results with unicompartmental knee arthroplasty and total hip arthroplasty have demonstrated improved accuracy of placement, improved satisfaction, and reduced complications. Further studies are needed to confirm the cost effectiveness of these technologies. Copyright © 2016 Elsevier Inc. All rights reserved.

Optimizing quality of life in patients with idiopathic pulmonary fibrosis

PubMed Central

van Manen, Mirjam J. G.; Geelhoed, J. J. Miranda.; Tak, Nelleke C.; Wijsenbeek, Marlies S.

2017-01-01

Idiopathic pulmonary fibrosis (IPF) is a devastating, progressive and ultimately fatal lung disease. The combination of poor prognosis, uncertainty of disease course and severe symptom burden heavily impacts patients’ and their families’ quality of life. Though new antifibrotic drugs have been shown to decrease disease progression, the effect on health-related quality of life (HRQOL) has not been convincingly demonstrated. In a relentless disease such as IPF, striving to optimize HRQOL should complement the endeavour to prolong life. Unfortunately, there is a paucity of interventions improving symptoms and functionality for patients with IPF, and research focusing on symptom improvement, and assessing and optimizing HRQOL, is limited. This review summarizes the most recent insights into measuring and improving quality of life for patients with IPF, and discusses challenges in the management of this devastating disease. Moreover, we postulate a new model for continuous care in IPF – ‘the ABCDE of IPF care’: Assessing patients’ needs; Backing patients by giving information and support; delivering Comfort care by focusing on treating symptoms and taking into account Comorbidities; striving to prolong life by Disease modification; helping and preparing patients and their caregivers for the eventual End-of-life events that are likely to occur. PMID:28134007

Training professionals' communication and motivation skills to improve spinal cord injury patients' satisfaction and clinical outcomes: Study protocol of the ESPELMA trial.

PubMed

Lusilla-Palacios, Pilar; Castellano-Tejedor, Carmina; Lucrecia-Ramírez-Garcerán; Navarro-Sanchís, José A; Rodríguez-Urrutia, Amanda; Parramon-Puig, Gemma; Valero-Ventura, Sergi; Cuxart-Fina, Ampar

2015-10-01

Acute spinal cord injury leaves patients severely impaired and generates high levels of psychological distress among them and their families, which can cause a less active role in rehabilitation, worse functional recovery, and less perceived satisfaction with the results. Additionally, rehabilitation professionals who deal with this psychological distress could ultimately experience higher stress and more risk of burnout. This article presents the study protocol of the ESPELMA project, aimed to train rehabilitation professionals in the clinical management of acute spinal cord injury-associated psychological distress, and to measure the impact of this training on the patients' perceived satisfaction with treatment. © The Author(s) 2013.

A Strategic Planning Tool for Increasing African American Blood Donation.

PubMed

Singleton, Ashley; Spratling, Regena

2018-05-01

Historically, African Americans (AAs) have been underrepresented as blood donors. Having a lack of racially diverse blood donors contributes to transfusion complications, particularly in patients with sickle cell disease, who are both disproportionately AA and the recipients of frequent transfusions. Increasing AA blood donation is a complex public health issue. This review article serves to fill a gap in translating research regarding known hindrances and facilitators of AA blood donation to improve real-world donation practice and ultimately, patient outcomes. We incorporate findings from a literature review to develop a tool that blood centers, provider organizations, and patient advocacy groups can use to aid strategic planning efforts aimed at increasing AA blood donation.

Harnessing person-generated health data to accelerate patient-centered outcomes research: the Crohn’s and Colitis Foundation of America PCORnet Patient Powered Research Network (CCFA Partners)

PubMed Central

Sandler, Robert S; Long, Millie D; Ahrens, Sean; Burris, Jessica L; Martin, Christopher F; Anton, Kristen; Robb, Amber; Caruso, Thomas P; Jaeger, Elizabeth L; Chen, Wenli; Clark, Marshall; Myers, Kelly; Dobes, Angela; Kappelman, Michael D

2016-01-01

The Crohn’s and Colitis Foundation of America Partners Patient-Powered Research Network (PPRN) seeks to advance and accelerate comparative effectiveness and translational research in inflammatory bowel diseases (IBDs). Our IBD-focused PCORnet PPRN has been designed to overcome the major obstacles that have limited patient-centered outcomes research in IBD by providing the technical infrastructure, patient governance, and patient-driven functionality needed to: 1) identify, prioritize, and undertake a patient-centered research agenda through sharing person-generated health data; 2) develop and test patient and provider-focused tools that utilize individual patient data to improve health behaviors and inform health care decisions and, ultimately, outcomes; and 3) rapidly disseminate new knowledge to patients, enabling them to improve their health. The Crohn’s and Colitis Foundation of America Partners PPRN has fostered the development of a community of citizen scientists in IBD; created a portal that will recruit, retain, and engage members and encourage partnerships with external scientists; and produced an efficient infrastructure for identifying, screening, and contacting network members for participation in research. PMID:26911821

A systematic review of surgeon-patient communication: strengths and opportunities for improvement.

PubMed

Levinson, Wendy; Hudak, Pamela; Tricco, Andrea C

2013-10-01

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon-patient communication. Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits. 2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy. Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills. These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Palliative care for adolescents and young adults with cancer

PubMed Central

Rosenberg, Abby R; Wolfe, Joanne

2017-01-01

Adolescents and young adults (AYAs) with cancer represent a unique and challenging group of patients with distinct developmental and psychosocial needs that may be unrecognized or unmet during their cancer experience. Palliative care refers to the total care of a patient, regardless of his or her disease status, and aims to improve quality of life by controlling symptoms and alleviating physical, social, psychological, and spiritual suffering. Integrating palliative care into standard oncology practice for AYAs is therefore valuable, if not imperative, in improving their overall cancer experience. In this review, we aimed to describe the scope, benefits, and challenges of palliative care for AYA oncology patients. We provide a broad impression of the existing literature describing or investigating palliative care in this population. Put together, the evidence suggests that palliative care is not only needed, but can also be critically beneficial to patients, families, and health care professionals alike. As we increase public and professional awareness of the needs and applications of palliative care for AYA patients with cancer, we will ultimately enable better psychosocial outcomes of the AYA patients and their larger communities. PMID:21523753

Mitomycin-C: 'a ray of hope' in refractory corrosive esophageal strictures.

PubMed

Nagaich, N; Nijhawan, S; Katiyar, P; Sharma, R; Rathore, M

2014-04-01

Increasingly frequent dilation may become a self-defeating cycle in refractory stricture as recurrent trauma enhance, scar formation, and ultimately recurrence and potential worsening of the stricture. In 12 patients of caustic induced esophageal stricture, who failed to respond despite rigorous dilatation regimen for more than one year, a trial of topical mitomycin-C application to improve dilatation results was undertaken, considering the recently reported efficacy and safety of this agent. Mitomycin-C was applied for 2-3 minutes at the strictured esophageal segment after dilation with wire-guided Savary-Gilliard dilator. Patient was kept nil by mouth for 2-3 hours. After 4-6 sessions of mitomycin-C treatment, resolution of symptoms and significant improvement in dysphagia score and periodic dilatation index was seen in all 12 patients. Mitomycin-C topical application may be a useful strategy in refractory corrosive esophageal strictures and salvage patients from surgery. © 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Spousal Involvement and CPAP Adherence: A Dyadic Perspective

PubMed Central

Ye, Lichuan; Malhotra, Atul; Kayser, Karen; Willis, Danny G.; Horowitz, June; Aloia, Mark; Weaver, Terri E.

2014-01-01

Summary Poor adherence to continuous positive airway pressure (CPAP) treatment is associated with substantial health care costs, morbidity and mortality, and has been a leading obstacle in the effective management of obstructive sleep apnea (OSA). Successful interventions to improve CPAP adherence may ultimately include a variety of components. For patients living with spouses (refers to all domestic partners), the spouse will likely be an integral component to any successful intervention. Developing understanding of the role of spouses in adherence to CPAP has been identified to be a critical research need. This review expands the investigation of CPAP adherence to a broader context, from an exclusive focus on individual patients to a dyadic perspective encompassing both patients and their spouses. A conceptual framework based on social support and social control theories is proposed to understand spousal involvement in CPAP adherence. Methodologies for future investigations are discussed, along with implications for developing interventions that engage both patients and their spouses to improve CPAP use. PMID:24906222

Mentalising skills in generic mental healthcare settings: can we make our day-to-day interactions more therapeutic?

PubMed

Welstead, H J; Patrick, J; Russ, T C; Cooney, G; Mulvenna, C M; Maclean, C; Polnay, A

2018-06-01

Aims and methodCaring for patients with personality disorder is one of the biggest challenges in psychiatric work. We investigated whether mentalisation-based treatment skills (MBT-S) teaching improves clinicians' understanding of mentalising and attitudes towards personality disorder. Self-report questionnaires (Knowledge and Application of MBT (KAMQ) and Attitudes to Personality Disorder (APDQ)) were completed at baseline and after a 2-day MBT-S workshop. Ninety-two healthcare professionals completed questionnaires before and after training. The mean within-participant increase in scores from baseline to end-of-programme was 11.6 points (95% CI 10.0-13.3) for the KAMQ and 4.0 points (1.8-6.2) for the APDQ.Clinical implicationsMBT-S is a short intervention that is effective in improving clinicians' knowledge of personality disorder and mentalisation. That attitudes to personality disorder improved overall is encouraging in relation to the possibility of deeper learning in staff and, ultimately, improved care for patients with personality disorder.Declaration of interestNone.

Quantum Limits of Space-to-Ground Optical Communications

NASA Technical Reports Server (NTRS)

Hemmati, H.; Dolinar, S.

2012-01-01

For a pure loss channel, the ultimate capacity can be achieved with classical coherent states (i.e., ideal laser light): (1) Capacity-achieving receiver (measurement) is yet to be determined. (2) Heterodyne detection approaches the ultimate capacity at high mean photon numbers. (3) Photon-counting approaches the ultimate capacity at low mean photon numbers. A number of current technology limits drive the achievable performance of free-space communication links. Approaching fundamental limits in the bandwidth-limited regime: (1) Heterodyne detection with high-order coherent-state modulation approaches ultimate limits. SOA improvements to laser phase noise, adaptive optics systems for atmospheric transmission would help. (2) High-order intensity modulation and photon-counting can approach heterodyne detection within approximately a factor of 2. This may have advantages over coherent detection in the presence of turbulence. Approaching fundamental limits in the photon-limited regime (1) Low-duty cycle binary coherent-state modulation (OOK, PPM) approaches ultimate limits. SOA improvements to laser extinction ratio, receiver dark noise, jitter, and blocking would help. (2) In some link geometries (near field links) number-state transmission could improve over coherent-state transmission

The break-even point: when medical advances are less important than improving the fidelity with which they are delivered.

PubMed

Woolf, Steven H; Johnson, Robert E

2005-01-01

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fidelity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in efficacy to do more good than could be accomplished by improving fidelity. In 2 examples (the development of anti-platelet agents and statins), we show that enhanced efficacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve efficacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care.

Applying adult learning practices in medical education.

PubMed

Reed, Suzanne; Shell, Richard; Kassis, Karyn; Tartaglia, Kimberly; Wallihan, Rebecca; Smith, Keely; Hurtubise, Larry; Martin, Bryan; Ledford, Cynthia; Bradbury, Scott; Bernstein, Henry Hank; Mahan, John D

2014-07-01

The application of the best practices of teaching adults to the education of adults in medical education settings is important in the process of transforming learners to become and remain effective physicians. Medical education at all levels should be designed to equip physicians with the knowledge, clinical skills, and professionalism that are required to deliver quality patient care. The ultimate outcome is the health of the patient and the health status of the society. In the translational science of medical education, improved patient outcomes linked directly to educational events are the ultimate goal and are best defined by rigorous medical education research efforts. To best develop faculty, the same principles of adult education and teaching adults apply. In a systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education, the use of experiential learning, feedback, effective relationships with peers, and diverse educational methods were found to be most important in the success of these programs. In this article, we present 5 examples of applying the best practices in teaching adults and utilizing the emerging understanding of the neurobiology of learning in teaching students, trainees, and practitioners. These include (1) use of standardized patients to develop communication skills, (2) use of online quizzes to assess knowledge and aid self-directed learning, (3) use of practice sessions and video clips to enhance significant learning of teaching skills, (4) use of case-based discussions to develop professionalism concepts and skills, and (5) use of the American Academy of Pediatrics PediaLink as a model for individualized learner-directed online learning. These examples highlight how experiential leaning, providing valuable feedback, opportunities for practice, and stimulation of self-directed learning can be utilized as medical education continues its dynamic transformation in the years ahead. Copyright © 2014 Mosby, Inc. All rights reserved.

Technology Advances to Improve Response to Cardiac Resynchronization Therapy: What Clinicians Should Know.

PubMed

Auricchio, Angelo; Heggermont, Ward A

2018-06-01

Cardiac resynchronization therapy (CRT) is a well-established treatment for symptomatic heart failure patients with reduced left ventricular ejection fraction, prolonged QRS duration, and abnormal QRS morphology. The ultimate goals of modern CRT are to improve the proportion of patients responding to CRT and to maximize the response to CRT in patients who do respond. While the rate of CRT nonresponders has moderately but progressively decreased over the last 20 years, mostly in patients with left bundle branch block, in patients without left bundle branch block the response rate is almost unchanged. A number of technological advances have already contributed to achieve some of the objectives of modern CRT. They include novel lead design (the left ventricular quadripolar lead, and multipoint pacing), or the possibility to go beyond conventional delivery of CRT (left ventricular endocardial pacing, His bundle pacing). Furthermore, to improve CRT response, a triad of actions is paramount: reducing the burden of atrial fibrillation, reducing the number of appropriate and inappropriate interventions, and adequately predicting heart failure episodes. As in other fields of cardiology, technology and innovations for CRT delivery have been at the forefront in transforming-improving-patient care; therefore, these innovations are discussed in this review. Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis.

PubMed

Francis, David O; Williamson, Kelly; Hovis, Kristen; Gelbard, Alexander; Merati, Albert L; Penson, David F; Netterville, James L; Garrett, C Gaelyn

2016-01-01

To determine whether injection augmentation reduces the likelihood of ultimately needing definitive framework surgery in unilateral vocal fold paralysis (UVFP) patients. Retrospective cohort study. All patients diagnosed with UVFP (2008-2012) at the academic center were identified. The time from symptom onset to presentation to either community otolaryngologist and/or academic center, as well as any directed treatment(s), were recorded. Stepwise, multivariate logistic regression analysis was used to determine whether injection augmentation independently affected odds of needing definitive, framework surgery among patients who were seen within 9 months of symptom onset and had not undergone any prior rehabilitative procedures. Cohort consisted of 633 patients (55% female, 80% Caucasian, median age 60 years) with UVFP. The majority of etiologies were either surgery (48%) or idiopathic (37%). Duration to presentation at community otolaryngologist was shorter than to the academic center (median 2 vs. 6 months). Overall, less than half of UVFP patients had any operation (46%). Multivariate logistic regression found that earlier injection augmentation did not affect odds of ultimately undergoing framework surgery (odds ratio 1.13; confidence interval, 0.92-1.40; P = 0.23). Nearly half of UVFP patients do not require any rehabilitative procedure. When indicated, early injection augmentation is effective at temporarily alleviating associated symptoms but does not reduce likelihood of needing a definitive framework operation in patients with UVFP. Understanding practice patterns and fostering early detection and treatment may improve quality of life in this patient population. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Futile Interhospital Transfer for Endovascular Treatment in Acute Ischemic Stroke: The Madrid Stroke Network Experience.

PubMed

Fuentes, Blanca; Alonso de Leciñana, María; Ximénez-Carrillo, Alvaro; Martínez-Sánchez, Patricia; Cruz-Culebras, Antonio; Zapata-Wainberg, Gustavo; Ruiz-Ares, Gerardo; Frutos, Remedios; Fandiño, Eduardo; Caniego, Jose L; Fernández-Prieto, Andrés; Méndez, Jose C; Bárcena, Eduardo; Marín, Begoña; García-Pastor, Andrés; Díaz-Otero, Fernando; Gil-Núñez, Antonio; Masjuán, Jaime; Vivancos, Jose; Díez-Tejedor, Exuperio

2015-08-01

The complexity of endovascular revascularization treatment (ERT) in acute ischemic stroke and the small number of patients eligible for treatment justify the development of stroke center networks with interhospital patient transfers. However, this approach might result in futile transfers (ie, the transfer of patients who ultimately do not undergo ERT). Our aim was to analyze the frequency of these futile transfers and the reasons for discarding ERT and to identify the possible associated factors. We analyzed an observational prospective ERT registry from a stroke collaboration ERT network consisting of 3 hospitals. There were interhospital transfers from the first attending hospital to the on-call ERT center for the patients for whom this therapy was indicated, either primarily or after intravenous thrombolysis (drip and shift). The ERT protocol was activated for 199 patients, 129 of whom underwent ERT (64.8%). A total of 120 (60.3%) patients required a hospital transfer, 50 of whom (41%) ultimately did not undergo ERT. There were no differences in their baseline characteristics, the times from stroke onset, or in the delays in interhospital transfers between the transferred patients who were treated and those who were not treated. The main reasons for rejecting ERT after the interhospital transfer were clinical improvement/arterial recanalization (48%) and neuroimaging criteria (32%). Forty-one percent of the ERT transfers were futile, but none of the baseline patient characteristics predicted this result. Futility could be reduced if repetition of unnecessary diagnostic tests was avoided. © 2015 American Heart Association, Inc.

Operational research in malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV

PubMed Central

2011-01-01

Background In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. Discussion District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. Summary Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not. PMID:21794154

I need to know! Timely accessing of perioperative user manuals.

PubMed

Landreneau, Raphael

2010-12-01

Ready access to equipment or product information is essential for the safe operation of the many items that a perioperative nurse is asked to use, troubleshoot, or maintain. One institution's solution for making manufacturer information available in the practice setting was to create a facility intranet site dedicated to OR equipment manuals. This site provides information access to perioperative nurses and support staff members and, ultimately, helps improve patient care. Published by Elsevier Inc. All rights reserved.

Clinical importance of achieving biochemical control with medical therapy in adult patients with acromegaly

PubMed Central

Christofides, Elena A

2016-01-01

In acromegaly, achieving biochemical control (growth hormone [GH] level <1.0 ng/mL and age- and sex-normalized levels of insulin-like growth factor 1 [IGF-1]) through timely diagnosis and appropriate treatment provides an opportunity to improve patient outcomes. Diagnosis of acromegaly is challenging because it is rooted in observing subtle clinical manifestations, and it is typical for acromegaly to evolve for up to 10 years before it is recognized. This results in chronic exposure to elevated levels of GH and IGF-1 and delay in patients receiving appropriate treatment, which consequently increases mortality risk. In this review, the clinical impact of elevated GH and IGF-1 levels, the effectiveness of current therapies, and the potential role of novel treatments for acromegaly will be discussed. Clinical burden of acromegaly and benefits associated with management of GH and IGF-1 levels will be reviewed. Major treatment paradigms in acromegaly include surgery, medical therapy, and radiotherapy. With medical therapies, such as somatostatin analogs, dopamine agonists, and GH receptor antagonists, a substantial proportion of patients achieve reduced GH and normalized IGF-1 levels. In addition, signs and symptoms, quality of life, and comorbidities have also been reported to improve to varying degrees in patients who achieve biochemical control. Currently, there are several innovative therapies in development to improve patient outcomes, patient use, and access. Timely biochemical control of acromegaly ensures that the patient can ultimately improve morbidity and mortality from this disease and its extensive consequences. PMID:27471378

Assessing the Effects of Financial Literacy on Patient Engagement.

PubMed

Meyer, Melanie A; Hudak, Ronald P

2016-07-01

We investigated the relationship between financial literacy and patient engagement while considering the possible interaction effects due to patient financial responsibility and patient-physician shared decision making, and the impact of personal attributes. Participants consisted of an Internet-based sample of American adults (N = 160). Hierarchical multiple linear regression analysis was conducted to examine the relationship of the study variables on patient engagement. We found that patient financial responsibility (β = -.19, p < .05) and patient-physician shared decision-making (β = .17, p < .05) predicted patient engagement. However, there was no statistically significant relationship between patient financial literacy and patient engagement; moreover, the moderation effects of patient financial responsibility and shared decision making with financial literacy also were not statistically significant. Increasing patient financial responsibility and patient-physician shared decision making can impact patient engagement. Understanding the predictors of patient engagement and the factors that influence financial behaviors may allow for the development of interventions to enable patients to make better healthcare decisions, and ultimately, improve health outcomes.

78 FR 8444 - Energy Efficiency and Conservation Loan Program Programmatic Environmental Assessment

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-06

... Recipients' service territories (Ultimate Recipients) for EE improvements at the Ultimate Recipients... area of previous disturbance, but a review of National Resources Conservation Service (NRCS) soils maps shows that the Ultimate Recipient's premises is not within a hydric soil unit which is one of the three...

Workplace engagement and workers' compensation claims as predictors for patient safety culture.

PubMed

Thorp, Jonathon; Baqai, Waheed; Witters, Dan; Harter, Jim; Agrawal, Sangeeta; Kanitkar, Kirti; Pappas, James

2012-12-01

Demonstrate the relationship between employee engagement and workplace safety for predicting patient safety culture. Patient safety is an issue for the U.S. health-care system, and health care has some of the highest rates of nonfatal workplace injuries. Understanding the types of injuries sustained by health-care employees, the type of safety environment employees of health-care organizations work in, and how employee engagement affects patient safety is vital to improving the safety of both employees and patients. The Gallup Q survey and an approved, abbreviated, and validated subset of questions from the Hospital Survey on Patient Safety Culture were administered to staff at a large tertiary academic medical center in 2007 and 2009. After controlling for demographic variables, researchers conducted a longitudinal, hierarchical linear regression analysis to study the unique contributions of employee engagement, changes in employee engagement, and employee safety in predicting patient safety culture. Teams with higher baseline engagement, more positive change in engagement, fewer workers' compensation claims, and fewer part-time associates in previous years had stronger patient safety cultures in 2009. Baseline engagement and change in engagement were the strongest independent predictors of patient safety culture in 2009. Engagement and compensation claims were additive and complimentary predictors, independent of other variables in the analysis, including the demographic composition of the workgroups in the study. A synergistic effect exists between employee engagement and decreased levels of workers' compensation claims for improving patient safety culture. Organizations can improve engagement and implement safety policies, procedures, and devices for employees with an ultimate effect of improving patient safety culture.

Implications of Direct Patient Online Access to Radiology Reports Through Patient Web Portals.

PubMed

Lee, Christoph I; Langlotz, Curtis P; Elmore, Joann G

2016-12-01

In an era of increasing health information transparency and informed decision making, more patients are being provided with direct online access to their medical records, including radiology reports, via web-based portals. Although radiologists' narrative reports have previously been the purview of referring physicians, patients are now reading these on their own. Many potential benefits may result from patients reviewing their radiology reports, including improvements in patients' own understanding of their health, promotion of shared decision making and patient-physician communication, and, ultimately, improvements in patient outcomes. However, there may also be negative consequences, including confusion and anxiety among patients and longer patient-physician interactions. The rapid adoption of this new technology has led to major questions regarding ethics and professionalism for radiologists, including the following: Who is the intended audience of radiology reports? How should content be presented or worded? How will open access influence radiologists' relationships with patients and referring physicians? What legal ramifications may arise from increased patient access? The authors describe the current practices and research findings associated with patient online access to medical records, including radiology reports, and discuss several implications of this growing trend for the radiology profession. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Normal pressure hydrocephalus: how often does the diagnosis hold water?

PubMed

Klassen, Bryan T; Ahlskog, J Eric

2011-09-20

To determine our community's incidence of clinically suspected normal pressure hydrocephalus (NPH), the rate of shunting for NPH, and short- and long-term outcomes of shunting. A retrospective query of the Mayo Clinic medical records linkage system was conducted to identify residents of Olmsted County, Minnesota, undergoing an invasive diagnostic procedure for evaluation of suspected NPH from 1995 through 2003. Among patients with shunts, early- and long-term outcomes were determined via a review of available medical records. Forty-one patients underwent an invasive diagnostic procedure for evaluation of suspected NPH; 13 ultimately received shunts, representing an incidence of 1.19/100,000/year. The incidence of sustained definite improvements at 3 years after shunting was only 0.36/100,000/year. Definite gait improvement was documented in 75% at 3-6 months after shunt placement, although it dropped to 50% at 1 year and to 33% at 3 years. Only 1 of 8 patients with cognitive impairment and 1 of 6 patients with urinary incontinence had definite improvement in these symptoms at 3 years. No patient with moderate to severe postural instability experienced sustained definite improvement in any symptom. Complications occurred in 33% of patients including one perioperative death. Additional or alternative neurologic diagnoses later surfaced in 5 of 12 patients. In this community, NPH is relatively rare with an incidence approximating that of progressive supranuclear palsy in this population. Whereas early gait improvement was common, only one-third of patients enjoyed continued improvement by 3 years; cognition or urinary incontinence was even less responsive long term. Baseline postural instability predicted poor outcome. Clinicians should balance potential benefits of shunting against the known risks.

Normal pressure hydrocephalus

PubMed Central

Ahlskog, J. Eric

2011-01-01

Objective: To determine our community's incidence of clinically suspected normal pressure hydrocephalus (NPH), the rate of shunting for NPH, and short- and long-term outcomes of shunting. Methods: A retrospective query of the Mayo Clinic medical records linkage system was conducted to identify residents of Olmsted County, Minnesota, undergoing an invasive diagnostic procedure for evaluation of suspected NPH from 1995 through 2003. Among patients with shunts, early- and long-term outcomes were determined via a review of available medical records. Results: Forty-one patients underwent an invasive diagnostic procedure for evaluation of suspected NPH; 13 ultimately received shunts, representing an incidence of 1.19/100,000/year. The incidence of sustained definite improvements at 3 years after shunting was only 0.36/100,000/year. Definite gait improvement was documented in 75% at 3–6 months after shunt placement, although it dropped to 50% at 1 year and to 33% at 3 years. Only 1 of 8 patients with cognitive impairment and 1 of 6 patients with urinary incontinence had definite improvement in these symptoms at 3 years. No patient with moderate to severe postural instability experienced sustained definite improvement in any symptom. Complications occurred in 33% of patients including one perioperative death. Additional or alternative neurologic diagnoses later surfaced in 5 of 12 patients. Conclusions: In this community, NPH is relatively rare with an incidence approximating that of progressive supranuclear palsy in this population. Whereas early gait improvement was common, only one-third of patients enjoyed continued improvement by 3 years; cognition or urinary incontinence was even less responsive long term. Baseline postural instability predicted poor outcome. Clinicians should balance potential benefits of shunting against the known risks. PMID:21849644

Laparoscopic Ultrasound-Guided Radiofrequency Ablation of Uterine Fibroids

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

Milic, Andrea; Asch, Murray R.; Hawrylyshyn, Peter A.

Four patients with symptomatic uterine fibroids measuring less than 6 cm underwent laparoscopic ultrasound-guided radiofrequency ablation (RFA) using multiprobe-array electrodes. Follow-up of the treated fibroids was performed with gadolinium-enhanced magnetic resonance imaging (MRI) and patients' symptoms were assessed by telephone interviews. The procedure was initially technically successful in 3 of the 4 patients and MRI studies at 1 month demonstrated complete fibroid ablation. Symptom improvement, including a decrease in menstrual bleeding and pain, was achieved in 2 patients at 3 months. At 7 months, 1 of these 2 patients experienced symptom worsening which correlated with recurrent fibroid on MRI. Themore » third, initially technically successfully treated patient did not experience any symptom relief after the procedure and was ultimately diagnosed with adenomyosis. Our preliminary results suggest that RFA is a technically feasible treatment for symptomatic uterine fibroids in appropriately selected patients.« less

Application of Six Sigma towards improving surgical outcomes.

PubMed

Shukla, P J; Barreto, S G; Nadkarni, M S

2008-01-01

Six Sigma is a 'process excellence' tool targeting continuous improvement achieved by providing a methodology for improving key steps of a process. It is ripe for application into health care since almost all health care processes require a near-zero tolerance for mistakes. The aim of this study is to apply the Six Sigma methodology into a clinical surgical process and to assess the improvement (if any) in the outcomes and patient care. The guiding principles of Six Sigma, namely DMAIC (Define, Measure, Analyze, Improve, Control), were used to analyze the impact of double stapling technique (DST) towards improving sphincter preservation rates for rectal cancer. The analysis using the Six Sigma methodology revealed a Sigma score of 2.10 in relation to successful sphincter preservation. This score demonstrates an improvement over the previous technique (73% over previous 54%). This study represents one of the first clinical applications of Six Sigma in the surgical field. By understanding, accepting, and applying the principles of Six Sigma, we have an opportunity to transfer a very successful management philosophy to facilitate the identification of key steps that can improve outcomes and ultimately patient safety and the quality of surgical care provided.

Case Report: Use of Sports and Performance Vision Training to Benefit a Low-vision Patient's Function.

PubMed

Laby, Daniel M

2018-05-17

Despite our inability to attenuate the course of many ocular diseases that can ultimately lead to loss or significantly decreased visual function, this report describes a potential technique to aid such patients in maximizing the use of the vision that remains. The aim of this study was to demonstrate the applicability of utilizing sports vision training to improve objective and subjective visuomotor function in a low-vision patient. A 37-year-old woman with Usher syndrome presented with reduced central visual acuity and visual field. Although we were unable to reverse the damage resulting from her diagnosis, we were able to improve the use of the remaining vision. A 27 to 31% improvement in hand-eye coordination was achieved along with a 41% improvement in object tracking and visual concentration. Most importantly, following the 14-week training period, there was also a subjective improvement in the patient's appreciation of her visual ability. The sports vision literature cites many examples in which sports vision training is useful in improving visuomotor and on-field performance. We hypothesized that these techniques may be used to aid not only athletes but also patients with low vision. Despite suffering from reduced acuity and a limited visual field, these patients often still have a significant amount of vision ability that can be used to guide motor actions. Using techniques to increase the efficient use of this remaining vision may reduce the impact of the reduced visual function and aid in activities of daily living.

Stakeholders’ Perspectives on Postmastectomy Breast Reconstruction: Recognizing Ways to Improve Shared Decision Making

PubMed Central

Hasak, Jessica M.; Myckatyn, Terence M.; Grabinski, Victoria F.; Philpott, Sydney E.; Parikh, Rajiv P.

2017-01-01

Background: Postmastectomy breast reconstruction (PMBR) is an elective, preference-sensitive decision made during a stressful, time-pressured period after a cancer diagnosis. Shared decision making (SDM) can improve decision quality about preference-sensitive choices. Stakeholders’ perspectives on ways to support PMBR decision-making were explored. Methods: Forty semi-structured interviews with stakeholders (20 postmastectomy patients, 10 PMBR surgeons, 10 PMBR nurses) were conducted. Clinicians were recruited from diverse practices across the United States. Patients were recruited using purposive sampling with varying PMBR experiences, including no reconstruction. The interview guide was based on an implementation research framework. Themes were identified using grounded theory approach, based on frequency and emotive force conveyed. Results: Engagement in SDM was variable. Some patients wanted more information about PMBR from clinicians, particularly about risks. Some clinicians acknowledged highlighting benefits and downplaying risks. Many patients felt pressured to make a choice by their clinicians. Clinicians who successfully engaged patients through decisions often used outside resources to supplement conversations. Conclusions: Patient–clinician trust was critical to high-quality decisions, and many patients expressed decision regret when they were not engaged in PMBR discussions. Patients often perceived a race- or age-related bias in clinician information sharing. Interventions to support SDM may enhance decision quality and reduce decision regret about PMBR, ultimately improving patient-centered care for women with breast cancer. PMID:29263969

European Society of Cardiology smartphone and tablet applications for patients with atrial fibrillation and their health care providers

PubMed Central

Kotecha, Dipak; Chua, Winnie W L; Fabritz, Larissa; Hendriks, Jeroen; Casadei, Barbara; Schotten, Ulrich; Vardas, Panos; Heidbuchel, Hein; Dean, Veronica; Kirchhof, Paulus

2018-01-01

Abstract We are in the midst of a digital revolution in health care, although the application of new and useful technology in routine clinical practice is variable. The Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly (CATCH ME) Consortium, in collaboration with the European Society of Cardiology (ESC), has funded the creation of two applications (apps) in atrial fibrillation (AF) for use in smartphones and tablets. The patient app aims to enhance patient education, improve communication between patients and health care professionals, and encourage active patient involvement in the management of their condition. The health care professional app is designed as an interactive management tool incorporating the new ESC Practice Guidelines on AF and supported by the European Heart Rhythm Association (EHRA), with the aim of improving best practice approaches for the care of patients with AF. Both stand-alone apps are now freely available for Android and iOS devices though the Google Play, Amazon, and Apple stores. In this article, we outline the rationale for the design and implementation of these apps. Our objective is to demonstrate the value of integrating novel digital technology into clinical practice, with the potential for patient engagement, optimization of pharmacological and interventional therapy in AF, and ultimately to improve patient outcomes. PMID:29040548

[New drugs in the treatment of multiple myeloma].

PubMed

Oriol, Albert; Motlló, Cristina

2014-09-15

Progress in the treatment of multiple myeloma in the last decade has been able to delay, but ultimately not to prevent, the development of resistances and most patients still die of the disease or its related complications. New drugs have been developed including new alkylating agents, proteasome inhibitors and immunomodulators but also monoclonal antibodies and drugs with new mechanisms of action. Hopefully, this new generation of targeted agents will improve the results of the initial therapy, avoid relapses and development of resistances and provide better and less toxic options for the relapsed and refractory patient. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Feasibility study of using statistical process control to customized quality assurance in proton therapy

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

Rah, Jeong-Eun; Oh, Do Hoon; Shin, Dongho

Purpose: To evaluate and improve the reliability of proton quality assurance (QA) processes and, to provide an optimal customized tolerance level using the statistical process control (SPC) methodology. Methods: The authors investigated the consistency check of dose per monitor unit (D/MU) and range in proton beams to see whether it was within the tolerance level of the daily QA process. This study analyzed the difference between the measured and calculated ranges along the central axis to improve the patient-specific QA process in proton beams by using process capability indices. Results: The authors established a customized tolerance level of ±2% formore » D/MU and ±0.5 mm for beam range in the daily proton QA process. In the authors’ analysis of the process capability indices, the patient-specific range measurements were capable of a specification limit of ±2% in clinical plans. Conclusions: SPC methodology is a useful tool for customizing the optimal QA tolerance levels and improving the quality of proton machine maintenance, treatment delivery, and ultimately patient safety.« less

Data-Mining Technologies for Diabetes: A Systematic Review

PubMed Central

Marinov, Miroslav; Mosa, Abu Saleh Mohammad; Yoo, Illhoi; Boren, Suzanne Austin

2011-01-01

Background The objective of this study is to conduct a systematic review of applications of data-mining techniques in the field of diabetes research. Method We searched the MEDLINE database through PubMed. We initially identified 31 articles by the search, and selected 17 articles representing various data-mining methods used for diabetes research. Our main interest was to identify research goals, diabetes types, data sets, data-mining methods, data-mining software and technologies, and outcomes. Results The applications of data-mining techniques in the selected articles were useful for extracting valuable knowledge and generating new hypothesis for further scientific research/experimentation and improving health care for diabetes patients. The results could be used for both scientific research and real-life practice to improve the quality of health care diabetes patients. Conclusions Data mining has played an important role in diabetes research. Data mining would be a valuable asset for diabetes researchers because it can unearth hidden knowledge from a huge amount of diabetes-related data. We believe that data mining can significantly help diabetes research and ultimately improve the quality of health care for diabetes patients. PMID:22226277

The use of recombinant factor VIIa in a patient with Noonan syndrome and life-threatening bleeding.

PubMed

Tofil, Nancy M; Winkler, Margaret K; Watts, Raymond G; Noonan, Jacqueline

2005-05-01

To present a case report of a patient with Noonan syndrome who developed life-threatening gastrointestinal bleeding shortly after cardiac surgery that was successfully treated with recombinant factor VIIa. Case report. Pediatric intensive care unit of a children's hospital. Ten-month-old with Noonan syndrome and massive gastrointestinal bleeding resulting in severe hypovolemic shock. Recombinant factor VIIa was used in this patient's severe bleeding associated with Noonan syndrome after no other supportive measures were successful. Recombinant Factor VIIa significantly decreased the patient's bleeding and allowed his hypovolemic shock to improve. Ultimately, the patient made a complete recovery. Noonan syndrome has a constellation of both cardiac and noncardiac malformations including an increased risk of bleeding, and recombinant factor VIIa is an important agent in the treatment of significant bleeding.

A guide to wound managment in palliative care.

PubMed

Naylor, Wayne A

2005-11-01

Wound management in palliative patients is often a very challenging area of care. There are many unique issues that can combine to produce complicated wound management scenarios, including the types of wounds and wound symptoms most commonly affecting palliative care patients, as well as the presence of concurrent disease and associated treatment. Problems exist with the availability of suitable dressings and balancing life expectancy with the goals of wound care. A significant, and possibly under-recognized, issue is the emotional and social distress experienced by these patients, which can be directly attributed to their wound. These problems must all be recognized and addressed in order to manage wounds effectively in this patient population. This article aims to explore these issues and offer advice on the management of wound-related symptoms, with the ultimate goal of improving patients' quality of life.

Patient-centeredness and quality management in Dutch diabetes care organizations after a 1-year intervention.

PubMed

Campmans-Kuijpers, Marjo Je; Lemmens, Lidwien C; Baan, Caroline A; Rutten, Guy Ehm

2016-01-01

More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention. This before-after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization's quality management program. Patient-centeredness (0%-100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients' access to medical files, patient education policy, safeguarding patients' interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests. Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P =0.002), and on its subdomains "access to medical files" (from 42.0% to 49.4%), and "safeguarding patients' interests" (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P =0.54) or its subdomains. "Formal patient involvement" remained low in both care groups (23.2%) and outpatient clinics (33.9%). After a simple intervention, care groups significantly improved their quality management on patient-centeredness, but outpatient clinics did not. Interventions to improve quality management on patient-centeredness in diabetes care organizations should differ between primary and secondary care.

A Standardized Framework for Transplant-Specific Competencies for Dietitians.

PubMed

Pieloch, Daniel; Friedman, Golnaz G; DiCecco, Sara; Ulerich, Linda; Beer, Stacey; Hasse, Jeanette

2017-09-01

Dietitians have extensive training and are considered the experts in medical nutrition therapy (MNT). Although dietitian competencies for MNT are well established, competencies that account for the expanded roles of dietitians working in transplantation have not been developed. These expanded roles require a better understanding of transplant processes, regulations, and even the business side of transplant, novel concepts to most dietitians. Therefore, we proposed a standardized framework of transplant-specific competencies for dietitians practicing in transplantation. These competencies can help improve and standardize initial and ongoing training for transplant dietitians moving forward, ultimately leading to improved patient care for transplant candidates, recipients, and donors.

Background and Epidemiology

PubMed Central

Sanders, Don B.; Fink, Aliza

2016-01-01

SYNOPSIS Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians. Significant advances in therapies and outcomes have occurred for people with CF over the past 30 years. Many of these improvements have come about through the concerted efforts of the US CF Foundation and international CF societies, networks of CF care centers, and the worldwide community of care providers, researchers, and patients and families. Despite these gains, there are still hurdles to overcome to continue to improve the quality of life, reduce CF complications, prolong survival, and ultimately cure CF. This article reviews the epidemiology of CF, including trends in incidence and prevalence, clinical characteristics, common complications, and survival. PMID:27469176

Revisiting perceptions of quality of hospice care: managing for the ultimate referral.

PubMed

Churchman, Richard; York, Grady S; Woodard, Beth; Wainright, Charles; Rau-Foster, Mary

2014-08-01

Hospice services provided in the final months of life are delivered through complex interpersonal relationships between caregivers, patients, and families. Often, service value and quality are defined by these interpersonal interactions. This understanding provides hospice leaders with an enormous opportunity to create processes that provide the optimal level of care during the last months of life. The authors argue that the ultimate referral is attained when a family member observes the care of a loved one, and the family member conveys a desire to receive the same quality of services their loved one received at that facility. The point of this article is to provide evidence that supports the methods to ultimately enhance the patient's and family's experience and increase the potential for the ultimate referral. © The Author(s) 2013.

The peer review system (PRS) for quality assurance and treatment improvement in radiation therapy

NASA Astrophysics Data System (ADS)

Le, Anh H. T.; Kapoor, Rishabh; Palta, Jatinder R.

2012-02-01

Peer reviews are needed across all disciplines of medicine to address complex medical challenges in disease care, medical safety, insurance coverage handling, and public safety. Radiation therapy utilizes technologically advanced imaging for treatment planning, often with excellent efficacy. Since planning data requirements are substantial, patients are at risk for repeat diagnostic procedures or suboptimal therapeutic intervention due to a lack of knowledge regarding previous treatments. The Peer Review System (PRS) will make this critical radiation therapy information readily available on demand via Web technology. The PRS system has been developed with current Web technology, .NET framework, and in-house DICOM library. With the advantages of Web server-client architecture, including IIS web server, SOAP Web Services and Silverlight for the client side, the patient data can be visualized through web browser and distributed across multiple locations by the local area network and Internet. This PRS will significantly improve the quality, safety, and accessibility, of treatment plans in cancer therapy. Furthermore, the secure Web-based PRS with DICOM-RT compliance will provide flexible utilities for organization, sorting, and retrieval of imaging studies and treatment plans to optimize the patient treatment and ultimately improve patient safety and treatment quality.

Physicians' Preferences for Communication of Pharmacist-Provided Medication Therapy Management in Community Pharmacy.

PubMed

Guthrie, Kendall D; Stoner, Steven C; Hartwig, D Matthew; May, Justin R; Nicolaus, Sara E; Schramm, Andrew M; DiDonato, Kristen L

2017-02-01

(1) To identify physicians' preferences in regard to pharmacist-provided medication therapy management (MTM) communication in the community pharmacy setting; (2) to identify physicians' perceived barriers to communicating with a pharmacist regarding MTM; and (3) to determine whether Missouri physicians feel MTM is beneficial for their patients. A cross-sectional prospective survey study of 2021 family and general practice physicians registered with MO HealthNet, Missouri's Medicaid program. The majority (52.8%) of physicians preferred MTM data to be communicated via fax. Most physicians who provided care to patients in long-term care (LTC) facilities (81.0%) preferred to be contacted at their practice location as opposed to the LTC facility. The greatest barriers to communication were lack of time and inefficient communication practices. Improved/enhanced communication was the most common suggestion for improvement in the MTM process. Approximately 67% of respondents reported MTM as beneficial or somewhat beneficial for their patients. Survey respondents saw value in the MTM services offered by pharmacists. However, pharmacists should use the identified preferences and barriers to improve their currently utilized communication practices in hopes of increasing acceptance of recommendations. Ultimately, this may assist MTM providers in working collaboratively with patients' physicians.

The application of a "6S Lean" initiative to improve workflow for emergency eye examination rooms.

PubMed

Nazarali, Samir; Rayat, Jaspreet; Salmonson, Hilary; Moss, Theodora; Mathura, Pamela; Damji, Karim F

2017-10-01

Ophthalmology residents on call at the Royal Alexandra Hospital identified workplace disorganization and lack of standardization in emergency eye examination rooms as an impediment to efficient patient treatment. The aim of the study was to use the "6S Lean" model to improve workflow in eye examination rooms at the Royal Alexandra Hospital. With the assistance of quality improvement consultants, the "6S Lean" model was applied to the current operation of the emergency eye clinic examination rooms. This model, considering 8 waste categories, was then used to recommend and implement changes to the examination rooms and to workplace protocols to enhance efficiency and safety. Eye examination rooms were improved with regards to setup, organization of supplies, inventory control, and maintenance. All targets were achieved, and the 5S audit checklist score increased by 33 points from 44 to 77. Implementation of the 6S methodology is a simple approach that removes inefficiencies from the workplace. The ophthalmology clinic removed waste from all 8 waste categories, increased audit results, mitigated patient and resident safety risks, and ultimately redirected resident time back to patient care delivery. Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

Employee Engagement and a Culture of Safety in the Intensive Care Unit.

PubMed

Collier, Susan L; Fitzpatrick, Joyce J; Siedlecki, Sandra L; Dolansky, Mary A

2016-01-01

A descriptive, retrospective design was used to explore the relationship between employee engagement and culture of safety in ICUs within a large Midwestern healthcare system. Results demonstrated a strong positive relationship between total engagement score and total patient safety score (r = 0.645, P < .01) and positive relationships between total engagement score and the 12 safety culture dimensions. These findings have implications for improving managerial strategies relative to employee engagement that may ultimately impact perceptions of a safety culture.

A psychodynamic model of behavior after acute central nervous system damage.

PubMed

Groswasser, Z; Stern, M J

1998-02-01

This article describes a conceptual psychodynamic model for understanding the neurobehavioral manifestations of acute central nervous system damage (ACNSD) displayed by patients during the rehabilitation process. According to the proposed model, patientsO behavioral responses are viewed as their only means of emotional expression and therefore may not be considered entirely abnormal when viewed from the perspective of patientsO interpersonal contexts. An improved understanding of the dynamic processes through which recovering patients with ACNSD journey may lead to better interaction between the patient and the therapeutic environment, the interdisciplinary team, and family members. Combining this proposed psychodynamic model with an emerging understanding of the neurobehavioral foundations of aggression and depression may also lead to a more rational approach to intervention with various psychopharmacologic agents. During the rehabilitation process, understanding patients' cognitive deficits, motivational drives, and emotional needs and proper implementation of medical and environmental treatment can ultimately lead to a better psychosocial outcome.

'Moral distress'--time to abandon a flawed nursing construct?

PubMed

Johnstone, Megan-Jane; Hutchinson, Alison

2015-02-01

Moral distress has been characterised in the nursing literature as a major problem affecting nurses in all healthcare systems. It has been portrayed as threatening the integrity of nurses and ultimately the quality of patient care. However, nursing discourse on moral distress is not without controversy. The notion itself is conceptually flawed and suffers from both theoretical and practical difficulties. Nursing research investigating moral distress is also problematic on account of being methodologically weak and disparate. Moreover, the ultimate purpose and significance of the research is unclear. In light of these considerations, it is contended that the notion of moral distress ought to be abandoned and that concerted attention be given to advancing inquiries that are more conducive to improving the quality and safety of moral decision-making, moral conduct and moral outcomes in nursing and healthcare domains. © The Author(s) 2013.

Ribose in the heart.

PubMed

Herrick, James; St Cyr, John

2008-01-01

Every cell needs energy, i.e., adenosine triphosphate (ATP), to carry out its function. Decreased oxygen levels, decreased blood flow, and other stressful conditions can drastically effect the intracellular concentrations of these energy compounds. Skeletal muscle, unlike the heart, can address this drop in ATP by employing the myokinase reaction, ultimately producing ATP with a subsequent elevation in adenosine monophosphate (AMP). Ribose, a naturally occurring 5-carbon monosaccharide, is a key component of RNA, DNA (which has deoxyribose), acetyl coenzyme A, and ATP. Each cell produces its own ribose, involved in the pentose phosphate pathway (PPP), to aid in ATP production. States of ischemia and/or hypoxia can severely lower levels of cellular energy compounds in the heart, with an associated compromise in cellular processes, ultimately reflected in altered function. Ribose appears to provide a solution to the problem in replenishing the depressed ATP levels and improving functional status of patients afflicted with cardiovascular diseases.

Professionals learning together with patients: An exploratory study of a collaborative learning Fellowship programme for healthcare improvement.

PubMed

Myron, Rowan; French, Catherine; Sullivan, Paul; Sathyamoorthy, Ganesh; Barlow, James; Pomeroy, Linda

2018-05-01

Improving the quality of healthcare involves collaboration between many different stakeholders. Collaborative learning theory suggests that teaching different professional groups alongside each other may enable them to develop skills in how to collaborate effectively, but there is little literature on how this works in practice. Further, though it is recognised that patients play a fundamental role in quality improvement, there are few examples of where they learn together with professionals. To contribute to addressing this gap, we review a collaborative fellowship in Northwest London, designed to build capacity to improve healthcare, which enabled patients and professionals to learn together. Using the lens of collaborative learning, we conducted an exploratory study of six cohorts of the year long programme (71 participants). Data were collected using open text responses from an online survey (n = 31) and semi-structured interviews (n = 34) and analysed using an inductive open coding approach. The collaborative design of the Fellowship, which included bringing multiple perspectives to discussions of real world problems, was valued by participants who reflected on the safe, egalitarian space created by the programme. Participants (healthcare professionals and patients) found this way of learning initially challenging yet ultimately productive. Despite the pedagogical and practical challenges of developing a collaborative programme, this study indicates that opening up previously restricted learning opportunities as widely as possible, to include patients and carers, is an effective mechanism to develop collaborative skills for quality improvement.

The American College of Surgeons: an enduring commitment to quality and patient care.

PubMed

Hoyt, David B; Schneidman, Diane S

2015-03-01

This paper describes the American College of Surgeons' 100-plus-year commitment to improving quality and patient care. It summarizes programs that the College established a century ago to improve patient care, including the Hospital Standardization Program, and new initiatives, such as the ACS National Surgical Quality Improvement Program. The College's longstanding experience with quality improvement programs is enabling the organization to play a critical and influential role in helping to ensure that health care reforms, including those in the Affordable Care Act, are implemented in a way that best serves that interests of the surgical patient. Through a combination of these data analysis systems and the application of a finely tuned set of values, the College has become a respected voice in quality and patient safety. The ultimate goal is to create an environment where high value and high reliability take precedence over high volume and where all health care professionals play an active leadership role in delivering optimal, coordinated care. This article further describes how the surgical culture can be reshaped to meet these evolving needs and demands. The American College of Surgeons (ACS) has a longstanding commitment to improving the quality of surgical care through outcome measurement, standards setting, accreditation, and educational activities. This legacy has enabled the ACS to play an influential role in recent developments related to implementation of the Affordable Care Act (ACA) and Medicare physician payment reform. Copyright © 2015 Elsevier Inc. All rights reserved.

Harnessing person-generated health data to accelerate patient-centered outcomes research: the Crohn's and Colitis Foundation of America PCORnet Patient Powered Research Network (CCFA Partners).

PubMed

Chung, Arlene E; Sandler, Robert S; Long, Millie D; Ahrens, Sean; Burris, Jessica L; Martin, Christopher F; Anton, Kristen; Robb, Amber; Caruso, Thomas P; Jaeger, Elizabeth L; Chen, Wenli; Clark, Marshall; Myers, Kelly; Dobes, Angela; Kappelman, Michael D

2016-05-01

The Crohn's and Colitis Foundation of America Partners Patient-Powered Research Network (PPRN) seeks to advance and accelerate comparative effectiveness and translational research in inflammatory bowel diseases (IBDs). Our IBD-focused PCORnet PPRN has been designed to overcome the major obstacles that have limited patient-centered outcomes research in IBD by providing the technical infrastructure, patient governance, and patient-driven functionality needed to: 1) identify, prioritize, and undertake a patient-centered research agenda through sharing person-generated health data; 2) develop and test patient and provider-focused tools that utilize individual patient data to improve health behaviors and inform health care decisions and, ultimately, outcomes; and 3) rapidly disseminate new knowledge to patients, enabling them to improve their health. The Crohn's and Colitis Foundation of America Partners PPRN has fostered the development of a community of citizen scientists in IBD; created a portal that will recruit, retain, and engage members and encourage partnerships with external scientists; and produced an efficient infrastructure for identifying, screening, and contacting network members for participation in research. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Developing a Continuous Quality Improvement Assessment Using a Patient-Centered Approach in Optimizing Systemic Lupus Erythematosus Disease Control.

PubMed

Updyke, Katelyn Mariko; Urso, Brittany; Beg, Shazia; Solomon, James

2017-10-09

Systemic lupus erythematosus (SLE) is a multi-organ, autoimmune disease in which patients lose self-tolerance and develop immune complexes which deposit systemically causing multi-organ damage and inflammation. Patients often experience unpredictable flares of symptoms with poorly identified triggers. Literature suggests exogenous exposures may contribute to flares in symptoms. An online pilot survey was marketed globally through social media to self-reported SLE patients with the goal to identify specific subpopulations who are susceptible to disease state changes based on analyzed exogenous factors. The pilot survey was promoted for two weeks, 80 respondents fully completed the survey and were included in statistical analysis. Descriptive statistical analysis was performed on de-identified patient surveys and compared to previous literature studies reporting known or theorized triggers in the SLE disease state. The pilot survey identified similar exogenous triggers compared to previous literature, including antibiotics, increasing beef intake, and metal implants. The goal of the pilot survey is to utilize similar questions to develop a detailed internet-based patient interactive form that can be edited and time stamped as a method to promote continuous quality improvement assessments. The ultimate objective of the platform is to interact with SLE patients from across the globe longitudinally to optimize disease control and improve quality of care by allowing them to avoid harmful triggers.

Developing a Continuous Quality Improvement Assessment Using a Patient-Centered Approach in Optimizing Systemic Lupus Erythematosus Disease Control

PubMed Central

Urso, Brittany; Beg, Shazia; Solomon, James

2017-01-01

Systemic lupus erythematosus (SLE) is a multi-organ, autoimmune disease in which patients lose self-tolerance and develop immune complexes which deposit systemically causing multi-organ damage and inflammation. Patients often experience unpredictable flares of symptoms with poorly identified triggers. Literature suggests exogenous exposures may contribute to flares in symptoms. An online pilot survey was marketed globally through social media to self-reported SLE patients with the goal to identify specific subpopulations who are susceptible to disease state changes based on analyzed exogenous factors. The pilot survey was promoted for two weeks, 80 respondents fully completed the survey and were included in statistical analysis. Descriptive statistical analysis was performed on de-identified patient surveys and compared to previous literature studies reporting known or theorized triggers in the SLE disease state. The pilot survey identified similar exogenous triggers compared to previous literature, including antibiotics, increasing beef intake, and metal implants. The goal of the pilot survey is to utilize similar questions to develop a detailed internet-based patient interactive form that can be edited and time stamped as a method to promote continuous quality improvement assessments. The ultimate objective of the platform is to interact with SLE patients from across the globe longitudinally to optimize disease control and improve quality of care by allowing them to avoid harmful triggers. PMID:29226052

Reform Doesn't Work: Grassroots Efforts Can Provide Answers to School Improvement

ERIC Educational Resources Information Center

Babbage, Keen

2012-01-01

Where does education happen? In classrooms. Teachers can provide the ultimate reform of education and teachers can be the ultimate reformers of education. Still, teachers cannot create all of the needed improvements in education alone. Input from, involvement from, ideas from, and participation from many other people can combine with what only…

Development and Evaluation of a Pilot Nurse Case Management Model to Address Multidrug-Resistant Tuberculosis (MDR-TB) and HIV in South Africa

PubMed Central

Farley, Jason E.; Kelly, Ana M.; Reiser, Katrina; Brown, Maria; Kub, Joan; Davis, Jeane G.; Walshe, Louise; Van der Walt, Martie

2014-01-01

Setting Multidrug-resistant tuberculosis (MDR-TB) unit in KwaZulu-Natal, South Africa. Objective To develop and evaluate a nurse case management model and intervention using the tenets of the Chronic Care Model to manage treatment for MDR-TB patients with a high prevalence of human immunodeficiency virus (HIV) co-infection. Design A quasi-experimental pilot programme utilizing a nurse case manager to manage care for 40 hospitalized MDR-TB patients, 70% HIV co-infected, during the intensive phase of MDR-TB treatment. Patients were followed for six months to compare proximal outcomes identified in the model between the pre- and post-intervention period. Results The greatest percent differences between baseline and six-month MDR-TB proximal outcomes were seen in the following three areas: baseline symptom evaluation on treatment initiation (95% improvement), baseline and monthly laboratory evaluations completed per guidelines (75% improvement), and adverse drug reactions acted upon by medical and/or nursing intervention (75% improvement). Conclusion Improvements were identified in guideline-based treatment and monitoring of adverse drug reactions following implementation of the nurse case management intervention. Further study is required to determine if the intervention introduced in this model will ultimately result in improvements in final MDR-TB treatment outcomes. PMID:25405988

Social Medicine: Twitter in Healthcare.

PubMed

Pershad, Yash; Hangge, Patrick T; Albadawi, Hassan; Oklu, Rahmi

2018-05-28

Social media enables the public sharing of information. With the recent emphasis on transparency and the open sharing of information between doctors and patients, the intersection of social media and healthcare is of particular interest. Twitter is currently the most popular form of social media used for healthcare communication; here, we examine the use of Twitter in medicine and specifically explore in what capacity using Twitter to share information on treatments and research has the potential to improve care. The sharing of information on Twitter can create a communicative and collaborative atmosphere for patients, physicians, and researchers and even improve quality of care. However, risks involved with using Twitter for healthcare discourse include high rates of misinformation, difficulties in verifying the credibility of sources, overwhelmingly high volumes of information available on Twitter, concerns about professionalism, and the opportunity cost of using physician time. Ultimately, the use of Twitter in healthcare can allow patients, healthcare professionals, and researchers to be more informed, but specific guidelines for appropriate use are necessary.

Virtual Communities for Diabetes Chronic Disease Healthcare

PubMed Central

Chorbev, Ivan; Sotirovska, Marija; Mihajlov, Dragan

2011-01-01

Diabetes is classified as the world's fastest-growing chronic illness that affects millions of people. It is a very serious disease, but the bright side is that it is treatable and can be managed. Proper education in this view is necessary to achieve essential control and prevent the aggregation of this chronic sickness. We have developed a healthcare social network that provides methods for distance learning; opportunities for creation of virtual self-help groups where patients can get information and establish interactions among each other in order to exchange important healthcare-related information; discussion forums; patient-to-healthcare specialist communication. The mission of our virtual community is to increase the independence of people with diabetes, self-management, empower them to take care of themselves, make their everyday activities easier, enrich their medical knowledge, and improve their health condition, make them more productive, and improve their communication with other patients with similar diagnoses. The ultimate goal is to enhance the quality of their life. PMID:22121358

Chronic myelogenous leukemia: laboratory diagnosis and monitoring.

PubMed

Wang, Y L; Bagg, A; Pear, W; Nowell, P C; Hess, J L

2001-10-01

Rapid developments have occurred both in laboratory medicine and in therapeutic interventions for the management of patients with chronic myelogenous leukemia (CML). With a wide array of laboratory tests available, selecting the appropriate test for a specific diagnostic or therapeutic setting has become increasingly difficult. In this review, we first discuss, from the point of view of laboratory medicine, the advantages and disadvantages of several commonly used laboratory assays, including cytogenetics, fluorescence in situ hybridization (FISH), and qualitative and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). We then discuss, from the point of view of clinical care, the test(s) of choice for the most common clinical scenarios, including diagnosis and monitoring of the therapeutic response and minimal residual disease in patients treated with different therapies. The purpose of this review is to help clinicians and laboratory physicians select appropriate tests for the diagnosis and monitoring of CML, with the ultimate goal of improving the cost-effective usage of clinical laboratories and improving patient care. Copyright 2001 Wiley-Liss, Inc.

Patient Blood Management: An International Perspective.

PubMed

Eichbaum, Quentin; Murphy, Michael; Liu, Yu; Kajja, Isaac; Hajjar, Ludhmila Abrahao; Smit Sibinga, Cees Th; Shan, Hua

2016-12-01

This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country's PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety.

Facing the dilemma of patient-centred psoriasis care: a qualitative study identifying patient needs in dermatological outpatient clinics.

PubMed

Khoury, L R; Skov, L; Møller, T

2017-08-01

Caregivers must be aware of patients' current needs by providing care responsive to patients' values and preferences and by identifying what approach improves and encourages patients to participate in their treatment and disease management. Patients with psoriasis healthcare needs perhaps change as medical knowledge improves, new drugs emerge and the healthcare system improves its efficiency as a result of constant structural development. To explore the unmet needs and health perceptions of people with psoriasis, regarding interaction with clinicians and the structure inherent to consultations in a hospital outpatient dermatological clinic. A qualitative investigation with data generated from semi-structured interviews. Transcriptions were subsequently analysed using the template analysis method. Sixteen patients with psoriasis were interviewed. Challenges and dilemmas of patient-centred psoriasis care were identified. Patients have a strong need to be met as individuals as the burden of living with psoriasis goes beyond the skin. Patients strive for efficient treatment and ultimately dream of being cured of psoriasis. They prefer individualized health education in order to adjust their knowledge and self-management skills. These central issues are as yet rarely addressed in clinical consultations. Consultations with a standardized structure do not match the individual challenges and healthcare needs of patients with psoriasis. In order to achieve a more patient-centred approach, health professionals should implement minor structural changes to dermatological services to meet patients' current needs and invite dialogue about the patients' emotional well-being and concerns that go beyond biomedical factors, as well as offer individualized health education. © 2016 British Association of Dermatologists.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction.

PubMed

Chandrasegaram, Manju D; Eslick, Guy D; Mansfield, Clare O; Liem, Han; Richardson, Mark; Ahmed, Sulman; Cox, Michael R

2012-02-01

Malignant gastric outlet obstruction represents a terminal stage in pancreatic cancer. Between 5% and 25% of patients with pancreatic cancer ultimately experience malignant gastric outlet obstruction. The aim in palliating patients with malignant gastric outlet obstruction is to reestablish an oral intake by restoring gastrointestinal continuity. This ultimately improves their quality of life in the advanced stages of cancer. The main drawback to operative bypass is the high incidence of delayed gastric emptying, particularly in this group of patients with symptomatic obstruction. This study aimed to compare surgical gastrojejunostomy and endoscopic stenting in palliation of malignant gastric outlet obstruction, acknowledging the diversity and heterogeneity of patients with this presentation. This retrospective study investigated patients treated for malignant gastric outlet obstruction from December 1998 to November 2008 at Nepean Hospital, Sydney, Australia. Endoscopic duodenal stenting was performed under fluoroscopic guidance for placement of the stent. The operative patients underwent open surgical gastrojejunostomy. The outcomes assessed included time to diet, hospital length of stay (LOS), biliary drainage procedures, morbidity, and mortality. Of the 45 participants in this study, 26 underwent duodenal stenting and 19 had operative bypass. Comparing the stenting and operative patients, the median time to fluid intake was respectively 0 vs. 7 days (P < 0.001), and the time to intake of solids was 2 vs. 9 days (P = 0.004). The median total LOS was shorter in the stenting group (11 vs. 25 days; P < 0.001), as was the median postprocedure LOS (5 vs. 10 days; P = 0.07). Endoscopic stenting is preferable to operative gastrojejunostomy in terms of shorter LOS, faster return to fluids and solids, and reduced morbidity and in-hospital mortality for patients with a limited life span.

Teleophthalmology: improving patient outcomes?

PubMed

Sreelatha, Omana Kesary; Ramesh, Sathyamangalam VenkataSubbu

2016-01-01

Teleophthalmology is gaining importance as an effective eye care delivery modality worldwide. In many developing countries, teleophthalmology is being utilized to provide quality eye care to the underserved urban population and the unserved remote rural population. Over the years, technological innovations have led to improvement in evidence and teleophthalmology has evolved from a research tool to a clinical tool. The majority of the current teleophthalmology services concentrate on patient screening and appropriate referral to experts. Specialty care using teleophthalmology services for the pediatric group includes screening as well as providing timely care for retinopathy of prematurity (ROP). Among geriatric eye diseases, specialty teleophthalmology care is focused toward screening and referral for diabetic retinopathy (DR), glaucoma, age-related macular degeneration (ARMD), and other sight-threatening conditions. Comprehensive vision screening and refractive error services are generally covered as part of most of the teleophthalmology methods. Over the past decades, outcome assessment of health care system includes patients' assessments on their health, care, and services they receive. Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care. Teleophthalmology produces the same desired clinical outcome as the traditional system. Remote portals allow specialists to provide care over a larger region, thereby improving health outcomes and increasing accessibility of specialty care to a larger population. A high satisfaction level and acceptance is reported in the majority of the studies because of increased accessibility and reduced traveling cost and time. Considering the improved quality of patient care and patient satisfaction reported for these telemedicine services, this review explores how teleophthalmology helps to improve patient outcomes.

Results from a Community-Wide Pilot Program to Standardize COPD Education for Patients Across Healthcare Settings in Rhode Island.

PubMed

Pelland, Kimberly; Youssef, Rouba; Calandra, Kathleen; Cellar, Jennifer; Thiesen, Jennifer; Gardner, Rebekah

2017-07-05

Chronic obstructive pulmonary disease (COPD) is associated with significant morbidity, decreased quality of life, and burdensome hospital admissions. Therefore, patients with COPD interact with clinicians in a number of healthcare settings. A coalition of healthcare practitioners in Rhode Island, in partnership with the local Quality Improvement Organization, designed and implemented a standardized, COPD education program for use across multiple healthcare settings. More than 60 organizations participated, producing 140 Master Trainers, who trained 634 staff members at their facilities from October 2015 through June 2016. Master Trainers were satisfied with the training, and we observed significant increases in knowledge scores post-training among all participants, which remained significant when stratified by setting. These results demonstrate that implementation of a community-based program to disseminate patient-centered, standardized COPD education in multiple healthcare settings is feasible. We hope this program will ultimately improve patient outcomes and serve as the foundation for expanding standardized education for other chronic conditions. [Full article available at http://rimed.org/rimedicaljournal-2017-07.asp].

The PEREGRINETM program: using physics and computer simulation to improve radiation therapy for cancer

NASA Astrophysics Data System (ADS)

Hartmann Siantar, Christine L.; Moses, Edward I.

1998-11-01

When using radiation to treat cancer, doctors rely on physics and computer technology to predict where the radiation dose will be deposited in the patient. The accuracy of computerized treatment planning plays a critical role in the ultimate success or failure of the radiation treatment. Inaccurate dose calculations can result in either insufficient radiation for cure, or excessive radiation to nearby healthy tissue, which can reduce the patient's quality of life. This paper describes how advanced physics, computer, and engineering techniques originally developed for nuclear weapons and high-energy physics research are being used to predict radiation dose in cancer patients. Results for radiation therapy planning, achieved in the Lawrence Livermore National Laboratory (LLNL) 0143-0807/19/6/005/img2 program show that these tools can give doctors new insights into their patients' treatments by providing substantially more accurate dose distributions than have been available in the past. It is believed that greater accuracy in radiation therapy treatment planning will save lives by improving doctors' ability to target radiation to the tumour and reduce suffering by reducing the incidence of radiation-induced complications.

A mobile phone based remote patient monitoring system for chronic disease management.

PubMed

Trudel, Mathieu; Cafazzo, Joseph A; Hamill, Melinda; Igharas, Walter; Tallevi, Kevin; Picton, Peter; Lam, Jack; Rossos, Peter G; Easty, Anthony C; Logan, Alexander

2007-01-01

Rising concern over the poor state of chronic disease management led to the user-informed design and development of a home tele-monitoring system. Focus groups with patients and primary care providers guided the research team towards a design that would accommodate the workflow and concerns of the healthcare providers and the low use and comfort with technology found among the patient population. The system was trialed in a before-and-after pilot study of 34 patients with diabetes and hypertension. Findings demonstrate a significant improvement in systolic and diastolic blood pressure. An RCT beginning in 2007 is being conducted to confirm these findings. It is hypothesized that this user-centred approach, utilizing focus groups, iterative design and human factors methods of evaluation, will lead to the next-generation of home tele-monitoring applications that are more intuitive, less cumbersome, and ultimately bring about greater patient compliance and better physician management.

Proximal muscular atrophy and weakness: An unusual adverse effect of deferasirox iron chelation therapy.

PubMed

Vill, K; Müller-Felber, W; Teusch, V; Blaschek, A; Gerstl, L; Huetker, S; Albert, M H

2016-01-01

Deferasirox is a standard treatment for chronic transfusional iron overload. Adverse effects of deferasirox have been reported in large prospective studies. We report two cases of monozygotic twins manifesting with proximal muscular atrophy and weakness under deferasirox. Discontinuation of deferasirox resulted in symptom improvement and ultimately in complete remission five months after successful haematopoietic stem cell transplantation. Broad diagnostic work-up could not bring evidence of another aetiology of muscular weakness. Iron overload or beta thalassemia itself as a cause is considered unlikely in our patients because the chronological coincidence of muscular symptoms was contra-directional to serum ferritin levels and significant clinical improvement was observed promptly after cessation of deferasirox even before transplantation. These observations suggest that the development of muscular weakness in patients on deferasirox should be recognised as a possible adverse effect of the drug. Copyright © 2016 Elsevier B.V. All rights reserved.

Type I Chiari malformation presenting central sleep apnea.

PubMed

Kitamura, Takuro; Miyazaki, Soichiro; Kadotani, Hiroshi; Kanemura, Takashi; Okawa, Masako; Tanaka, Toshihiko; Komada, Ichiro; Hatano, Taketo; Suzuki, Hideaki

2014-04-01

Sleep apnea is a rare but a well-known clinical feature of type I Chiari malformation. It may be obstructive or central in nature. Sleep apnea in patients with type I Chiari malformation rarely presents without accompanying neurological signs or symptoms. We here report a case of a 10-year-old girl who presented with central sleep apnea without any other neurological signs but was ultimately diagnosed with type I Chiari malformation. The patient initially showed mild improvement in symptoms after administration of an acetazolamide. Finally, posterior fossa decompression dramatically improved her respiratory status during sleep, both clinically and on polysomnography. This case suggests that type I Chiari malformation should be considered in the differential diagnoses of central apneas in children, even if there are no other neurological signs and symptoms. Furthermore, sagittal craniocervical magnetic resonance imaging may be necessary for a definitive diagnosis. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Improving Service Coordination and Reducing Mental Health Disparities Through Adoption of Electronic Health Records.

PubMed

McGregor, Brian; Mack, Dominic; Wrenn, Glenda; Shim, Ruth S; Holden, Kisha; Satcher, David

2015-09-01

Despite widespread support for removing barriers to the use of electronic health records (EHRs) in behavioral health care, adoption of EHRs in behavioral health settings lags behind adoption in other areas of health care. The authors discuss barriers to use of EHRs among behavioral health care practitioners, suggest solutions to overcome these barriers, and describe the potential benefits of EHRs to reduce behavioral health care disparities. Thoughtful and comprehensive strategies will be needed to design EHR systems that address concerns about policy, practice, costs, and stigma and that protect patients' privacy and confidentiality. However, these goals must not detract from continuing to challenge the notion that behavioral health and general medical health should be treated as separate and distinct. Ultimately, utilization of EHRs among behavioral health care providers will improve the coordination of services and overall patient care, which is essential to reducing mental health disparities.

Using emotional intelligence to facilitate strengthened appraiser development.

PubMed

Tavabie, Abdol; Koczwara, Anna; Patterson, Fiona

2010-01-01

This paper describes a new approach to developing strengthened medical appraiser skills prior to the introduction of medical revalidation. We describe how we extended previous skills-based models and competency checklists to produce a behavioural model of effective appraiser performance. Development centre (DC) methods were used to produce a one-day workshop to encourage appraisers to reflect on their current level of ability and to identify and address additional required skills through observation, practice and feedback. In describing the DC, we discuss the impact of using the concept of emotional intelligence (EI) to develop appraiser skills and improve self-awareness. This aimed to support appraisers to effectively influence appraisees' continual professional development (CPD) and review appraisee practice through audit, significant events and patient and colleague feedback, with the ultimate aim of improving patient care. Finally, we provide initial evaluation data for our DC approach.

Patterns of knowing: proposing a theory for nursing leadership.

PubMed

Jackson, Janet R; Clements, Paul T; Averill, Jennifer B; Zimbro, Kathie

2009-01-01

In a time of chaotic and unpredictable health care, it is vital for nursing to employ a nursing leadership theory that is specifically applicable to nurses and will holistically, and comprehensively address and support both the science and art of this honored profession. The authors propose that Nursing Leadership Knowing can address and impact the myriad issues confronting managers and administrators within the turbulent health care industry, with the ultimate goals of quality comprehensive patient care and improved employee satisfaction. They believe that Nursing Leadership Knowing, grounded in the realties of nursing experience, is a logical theoretical extension that can be translated into nursing leadership practice particular and specific focus on empirics and evidence-based practice will not attend to the robust and multidimensional underpinnings of the lived experience that is so vital to nursing as a caring profession. The ideal of nursing leadership theory is not a single-focused shadow of its history, but a rich, inclusive, multi-faceted network of knowing. As such, Nursing Leadership Knowing provides a forum for leaders to enhance their practice, as well as their relationship with their employees, which ultimately translates into optimal care for the patients we serve.

Harmonization in laboratory medicine: Requests, samples, measurements and reports.

PubMed

Plebani, Mario

2016-01-01

In laboratory medicine, the terms "standardization" and "harmonization" are frequently used interchangeably as the final goal is the same: the equivalence of measurement results among different routine measurement procedures over time and space according to defined analytical and clinical quality specifications. However, the terms define two distinct, albeit closely linked, concepts based on traceability principles. The word "standardization" is used when results for a measurement are equivalent and traceable to the International System of Units (SI) through a high-order primary reference material and/or a reference measurement procedure (RMP). "Harmonization" is generally used when results are equivalent, but neither a high-order primary reference material nor a reference measurement procedure is available. Harmonization is a fundamental aspect of quality in laboratory medicine as its ultimate goal is to improve patient outcomes through the provision of accurate and actionable laboratory information. Patients, clinicians and other healthcare professionals assume that clinical laboratory tests performed by different laboratories at different times on the same sample and specimen can be compared, and that results can be reliably and consistently interpreted. Unfortunately, this is not necessarily the case, because many laboratory test results are still highly variable and poorly standardized and harmonized. Although the initial focus was mainly on harmonizing and standardizing analytical processes and methods, the scope of harmonization now also includes all other aspects of the total testing process (TTP), such as terminology and units, report formats, reference intervals and decision limits as well as tests and test profiles, requests and criteria for interpretation. Several projects and initiatives aiming to improve standardization and harmonization in the testing process are now underway. Laboratory professionals should therefore step up their efforts to provide interchangeable and comparable laboratory information in order to ultimately assure better diagnosis and treatment in patient care.

Computed tomographic imaging in the pediatric patient with a seatbelt sign: still not good enough.

PubMed

Kopelman, Tammy R; Jamshidi, Ramin; Pieri, Paola G; Davis, Karole; Bogert, James; Vail, Sydney J; Gridley, Daniel; Singer Pressman, Melissa A

2018-02-01

Considering the improvements in CT over the past decade, this study aimed to determine whether CT can diagnose HVI in pediatric trauma patients with seatbelt signs (SBS). We retrospectively identified pediatric patients with SBS who had abdominopelvic CT performed on initial evaluation over 5 1/2years. Abnormal CT was defined by identification of any intra-abdominal abnormality possibly related to trauma. One hundred twenty patients met inclusion criteria. CT was abnormal in 38/120 (32%) patients: 34 scans had evidence of HVI and 6 showed solid organ injury (SOI). Of the 34 with suspicion for HVI, 15 (44%) had small amounts of isolated pelvic free fluid as the only abnormal CT finding; none required intervention. Ultimately, 16/120 (13%) patients suffered HVI and underwent celiotomy. Three patients initially had a normal CT but required celiotomy for clinical deterioration within 20h of presentation. False negative CT rate was 3.6%. The sensitivity, specificity and accuracy of CT to diagnose significant HVI in the presence of SBS were 81%, 80%, and 80%, respectively. Despite improvements in CT, pediatric patients with SBS may have HVI not evident on initial CT confirming the need to observation for delayed manifestation of HVI. Level II Study of a Diagnostic Test. Copyright © 2017 Elsevier Inc. All rights reserved.

Sex- and gender-specific research priorities in cardiovascular resuscitation: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Resuscitation Research Workgroup.

PubMed

Wigginton, Jane G; Perman, Sarah M; Barr, Gavin C; McGregor, Alyson J; Miller, Andrew C; Napoli, Anthony M; Napoli, Anthony F; Safdar, Basmah; Weaver, Kevin R; Deutsch, Steven; Kayea, Tami; Becker, Lance

2014-12-01

Significant sex and gender differences in both physiology and psychology are readily acknowledged between men and women; however, data are lacking regarding differences in their responses to injury and treatment and in their ultimate recovery and survival. These variations remain particularly poorly defined within the field of cardiovascular resuscitation. A better understanding of the interaction between these important factors may soon allow us to dramatically improve outcomes in disease processes that currently carry a dismal prognosis, such as sudden cardiac arrest. As part of the 2014 Academic Emergency Medicine consensus conference "Gender-Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," our group sought to identify key research questions and knowledge gaps pertaining to both sex and gender in cardiac resuscitation that could be answered in the near future to inform our understanding of these important issues. We combined a monthly teleconference meeting of interdisciplinary stakeholders from largely academic institutions with a focused interest in cardiovascular outcomes research, an extensive review of the existing literature, and an open breakout session discussion on the recommendations at the consensus conference to establish a prioritization of the knowledge gaps and relevant research questions in this area. We identified six priority research areas: 1) out-of-hospital cardiac arrest epidemiology and outcome, 2) customized resuscitation drugs, 3) treatment role for sex steroids, 4) targeted temperature management and hypothermia, 5) withdrawal of care after cardiac arrest, and 6) cardiopulmonary resuscitation training and implementation. We believe that exploring these key topics and identifying relevant questions may directly lead to improved understanding of sex- and gender-specific issues seen in cardiac resuscitation and ultimately improved patient outcomes. © 2014 by the Society for Academic Emergency Medicine.

Postoperative pain management techniques in hip and knee arthroplasty.

PubMed

Parvizi, Javad; Porat, Manny; Gandhi, Kishor; Viscusi, Eugene R; Rothman, Richard H

2009-01-01

Adequate control of postoperative pain following hip and knee arthroplasty can be a challenging task fraught with potential complications. Postoperative pain is perceived by the patient via a complex network and a multitude of molecular messengers in both the peripheral and central nervous systems. This allows the physician to modulate pain via an array of medications that act on different sites within the body. Using both contemporary and traditional pain modulators, the delivery and timing of these medications can affect postoperative pain and, ultimately, rehabilitation of the arthroplasty patient. Current techniques for controlling pain use both multimodal and preemptive analgesia to improve the outcome of the surgery while minimizing the potential adverse effects of the medications given.

Pathogens and glioma: a history of unexpected discoveries ushering in novel therapy.

PubMed

Shah, Ashish H; Jusué-Torres, Ignacio; Ivan, Michael E; Komotar, Ricardo J; Kasahara, Noriyuki

2018-04-01

In the late 19th century, Dr. William B. Coley introduced the theory that infections may aid in the treatment of malignancy. With the creation of Coley's toxin, reports of remission during viral illnesses for systemic malignancies soon emerged. A few decades after this initial discovery, Austrian physicians performed intravascular injections of Clostridium to induce oncolysis in patients with glioblastoma. Since then, suggestions between improved survival and infectious processes have been reported in several patients with glioma, which ultimately marshaled the infamous use of intracerebral Enterobacter. These early observations of tumor regression and concomitant infection piloted a burgeoning field focusing on the use of pathogens in molecular oncology.

Herpes Zoster Meningitis Presenting With a Cerebrospinal Fluid Leukemoid Reaction in an Adolescent With preB-ALL in Remission.

PubMed

Adachi, Kristina; Song, Sophie X; Kao, Roy L; Van Dyne, Elizabeth; Kempert, Pamela; Deville, Jaime G

2016-08-01

A 19-year-old girl with a history of precursor B acute lymphoblastic leukemia in remission presented with fever, headache, and a skin rash. Cerebrospinal fluid (CSF) examination reported pleocytosis with blast-like cells concerning for a central nervous system leukemic relapse. After the patient showed significant improvement on intravenous acyclovir, a repeat lumbar puncture revealed normalization of CSF. The abnormal CSF cells were reviewed and ultimately determined to be activated and atypical lymphocytes. The patient recovered uneventfully. Atypical lymphocytes resembling leukemic blasts are an unusual finding in viral meningitis. Varicella zoster virus reactivation should be considered during initial evaluation for central nervous system relapse of leukemia.

European Society of Cardiology smartphone and tablet applications for patients with atrial fibrillation and their health care providers.

PubMed

Kotecha, Dipak; Chua, Winnie W L; Fabritz, Larissa; Hendriks, Jeroen; Casadei, Barbara; Schotten, Ulrich; Vardas, Panos; Heidbuchel, Hein; Dean, Veronica; Kirchhof, Paulus

2018-02-01

We are in the midst of a digital revolution in health care, although the application of new and useful technology in routine clinical practice is variable. The Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly (CATCH ME) Consortium, in collaboration with the European Society of Cardiology (ESC), has funded the creation of two applications (apps) in atrial fibrillation (AF) for use in smartphones and tablets. The patient app aims to enhance patient education, improve communication between patients and health care professionals, and encourage active patient involvement in the management of their condition. The health care professional app is designed as an interactive management tool incorporating the new ESC Practice Guidelines on AF and supported by the European Heart Rhythm Association (EHRA), with the aim of improving best practice approaches for the care of patients with AF. Both stand-alone apps are now freely available for Android and iOS devices though the Google Play, Amazon, and Apple stores. In this article, we outline the rationale for the design and implementation of these apps. Our objective is to demonstrate the value of integrating novel digital technology into clinical practice, with the potential for patient engagement, optimization of pharmacological and interventional therapy in AF, and ultimately to improve patient outcomes. © The Author 2017. Published by Oxford University Press on behalf of the European Society of Cardiology.

The internet and the physician-patient relationship.

PubMed

Sechrest, Randale C

2010-10-01

Since the emergence of the public Internet in the early 1990s, the healthcare industry has been struggling to understand how best to utilize this resource. During the last decade there has been an increase in both the interest and participation by healthcare providers in the Internet space, but many observers continue to push for more development of healthcare resources to better support the provider-patient relationship. This paper will review the historical development of the Internet, the core concepts that have driven the emergence and evolution of the Internet as a mass medium of information exchange, and how the healthcare industry can harness the Internet to improve the provider patient relationship. WHERE ARE WE NOW?: The healthcare industry continues to lag behind other industries that have been transformed by the Internet. Numerous industries including travel, real estate, retail sales, and banking have migrated both comprehensive information resources and transactions to the Internet in order to improve efficiency and customer satisfaction. That same process is occurring now in the healthcare industry. Credible and comprehensive Information resources are beginning to mature. Transactions are still in their infancy, reflecting a continued concern about privacy and security. WHERE DO WE NEED TO GO?: We need to improve information resources to educate and inform patients. Improving the availability and credibility of information resources will empower patients to make better healthcare decisions and I contend will ultimately reduce the cost of delivering care. HOW DO WE GET THERE?: Orthopaedists must first recognize the value of information resources to the patient. Effective communication with patients is a critical component of providing healthcare services. All healthcare providers should reflect on the importance of developing an effective communications strategy for their own practice and consider the benefits of participating in efforts by professional organizations to improve existing information resources.

The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text].

PubMed

Stiles, Brandie M; Fish, Anne F; Vandermause, Roxanne; Malik, Azfar M

2018-06-01

Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder. The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening. An integrative review was conducted using standard criteria for evaluating research articles. Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed. Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.

[Plastic surgery treatment techniques for interdisciplinary therapy of pressure sores].

PubMed

Müller, Karin; Becker, Frederic; Pfau, Matthias; Werdin, Frank

2017-06-01

Pressure sores in geriatric patients represent a challenge for all disciplines involved in the treatment process; however, the prerequisite for successful treatment is the elaboration of an interdisciplinary treatment concept. The treatment goals should be adapted to the individual needs of the patients including the life situation, general condition and local findings. In addition to general basic operative techniques, such as wound cleansing and conditioning, plastic and reconstructive surgery provides a wide range of highly specialized operative techniques for the treatment of these patients by which a definitive defect coverage can be achieved. The aim of this article is to raise awareness for these complex and highly specialized procedures for all disciplines participating in the treatment in order to improve the interdisciplinary cooperation and ultimately the quality of treatment.

Tumescent liposuction report performance measurement initiative: national survey results.

PubMed

Hanke, William; Cox, Sue Ellen; Kuznets, Naomi; Coleman, William P

2004-07-01

This study was created by the Accreditation Association for Ambulatory Health Care Institute for Quality Improvement to measure clinical performance and improvement opportunities for physicians and ambulatory health-care organizations. Data were collected prospectively between February 2001 and August 2002. Thirty-nine study centers participated, and 688 patients who had tumescent liposuction were surveyed and followed for 6 months. The objective was to determine patient satisfaction with tumescent liposuction and examine current liposuction practice and the safety of tumescent liposuction in a representative cohort of patients. The Accreditation Association for Ambulatory Health Care Institute for Quality Improvement collected prospective data from February 2001 to August 2002 from 68 organizations registered for this study. Ultimately 39 organizations submitted 688 useable cases performed totally with local anesthesia, "tumescent technique." The overall clinical complication rate found in the Accreditation Association for Ambulatory Health Care Institute for Quality Improvement study was 0.7% (5 of 702). There was a minor complication rate of 0.57%. The major complication rate was 0.14% with one patient requiring hospitalization. Seventy-five percent of the patients reported no discomfort during their procedures. Of the 59% of patients who responded to a 6-month postoperative survey, 91% were positive about their decision to have liposuction (rating of 4 or 5 on a scale of 1-5) and 84% had high levels (4 or 5 on a scale of 1-5) of overall satisfaction with the procedure. Our findings are consistent with others in that tumescent liposuction is a safe procedure with a low complication rate and high patient satisfaction.

The Use of Team-Building Activities to Build a Better Resident.

PubMed

Ireland, James D; Deloney, Linda A; Renfroe, Shyann; Jambhekar, Kedar

We implemented team building activities to build a better resident during our orientation process and we have refined the choice of activities each year since. Resident satisfaction with their team building actives provided feedback to improve the following years' experience. While there is no definite way to demonstrate the effectiveness of our team building initiative, our expectation is it will improve the residency experience and work environment, and ultimately, result in better patient care. We focus on five aspects of team building - personal history sharing, creativity and imagination, common bonds, cooperation, and shared experience. The purpose of this paper is to recommend activities in each of these areas based on our experience. Published by Elsevier Inc.

When overcrowding paralyzes an emergency department.

PubMed

Twanmoh, Joseph R; Cunningham, Gail P

2006-06-01

Emergency department overcrowding is a critical problem nation-wide. A survey by the Lewin Group in 2002 found that 90 percent of Level 1 trauma centers and hospitals with more than 300 beds reported being over capacity. Although ED overcrowding has many causes, external factors are most commonly blamed--too many patients, lack of inpatient capacity, inappropriate use of the ED, the Emergency Medical Treatment and Active Labor Act (EMTALA), lack of primary care availability, and lack of access to health care for the uninsured. In this article, we describe a series of changes that were implemented in the ED of a regional medical center. Those changes improved operational efficiency, expedited patient care, and reduced ED overcrowding. The changes focused on patient input, throughput, and output. In terms of input, we revamped the triage and admission processes. To improve throughput, we modified the physical layout of the urgent care area to maximize efficiency in staff movement and communications, changed staffing patterns to match anticipated patient volume, and revised our policies regarding exchanges with the radiology staff. To facilitate patient flow out of the ED, we identified the causes of delays in discharges and admissions, instituted the practice of flagging the charts of patients ready for discharge, and implemented admission orders to decrease patient waiting times. Improving patient throughput increases ED efficiency, and thus capacity, in terms of the number of patients that can be treated over a given time period, and it promotes the cost-effective use of institutional resources. Decreased waiting times should ultimately lead to increased patient satisfaction and better patient care.

Mindfulness-based stress reduction: an intervention to enhance the effectiveness of nurses' coping with work-related stress.

PubMed

Smith, Sarah A

2014-06-01

This critical literature review explored the current state of the science regarding mindfulness-based stress reduction (MBSR) as a potential intervention to improve the ability of nurses to effectively cope with stress. Literature sources include searches from EBSCOhost, Gale PowerSearch, ProQuest, PubMed Medline, Google Scholar, Online Journal of Issues in Nursing, and reference lists from relevant articles. Empirical evidence regarding utilizing MBSR with nurses and other healthcare professionals suggests several positive benefits including decreased stress, burnout, and anxiety; and increased empathy, focus, and mood. Nurse use of MBSR may be a key intervention to help improve nurses' ability to cope with stress and ultimately improve the quality of patient care provided. © 2014 NANDA International, Inc.

Insurgents to Presidents: Contemporary Civil-Military Relations In Brazil, El Salvador, and Uruguay

DTIC Science & Technology

2016-03-01

executives. In fact, civil–military relations under ex -insurgent presidents have been improved over the last decade in each country. Ultimately, this thesis...fact, civil–military relations under ex -insurgent presidents have been improved over the last decade in each country. Ultimately, this thesis... ex -insurgent presidents and the expansion of military roles and missions. This comparative analysis of Brazil, El

Syncope management unit: evolution of the concept and practice implementation.

PubMed

Shen, Win K; Traub, Stephen J; Decker, Wyatt W

2013-01-01

Syncope, a clinical syndrome, has many potential causes. The prognosis of a patient experiencing syncope varies from benign outcome to increased risk of mortality or sudden death, determined by the etiology of syncope and the presence of underlying disease. Because a definitive diagnosis often cannot be established immediately, hospital admission is frequently recommended as the "default" approach to ensure patient's safety and an expedited evaluation. Hospital care is costly while no studies have shown that clinical outcomes are improved by the in-patient practice approach. The syncope unit is an evolving practice model based on the hypothesis that a multidisciplinary team of physicians and allied staff with expertise in syncope management, working together and equipped with standard clinical tools could improve clinical outcomes. Preliminary data have demonstrated that a specialized syncope unit can improve diagnosis in a timely manner, reduce hospital admission and decrease the use of unnecessary diagnostic tests. In this review, models of syncope units in the emergency department, hospital and outpatient clinics from different practices in different countries are discussed. Similarities and differences of these syncope units are compared. Outcomes and endpoints from these studies are summarized. Developing a syncope unit with a standardized protocol applicable to most practice settings would be an ultimate goal for clinicians and investigators who have interest, expertise, and commitment to improve care for this large patient population. Copyright © 2013 Elsevier Inc. All rights reserved.

Family satisfaction with critical care: measurements and messages.

PubMed

Rothen, Hans U; Stricker, Kay H; Heyland, Daren K

2010-12-01

Family satisfaction in the ICU reflects the extent to which perceived needs and expectations of family members of critically ill patients are met by healthcare professionals. Here, we present recently developed tools to assess family satisfaction, with a special focus on their psychometric properties. Assessing family satisfaction, however, is not of much use if it is not followed by interpretation of the results and, if needed, consecutive measures to improve care of the patients and their families, or improvement in communication and decision-making. Accordingly, this review will outline recent findings in this field. Finally, possible areas of future research are addressed. To assess family satisfaction in the ICU, several domains deserve attention. They include, among others, care of the patient, counseling and emotional support of family members, information and decision-making. Overall, communication between physicians or nurses and members of the family remains a key topic, and there are many opportunities to improve. They include not only communication style, timing and appropriate wording but also, for example, assessments to see if information was adequately received and also understood. Whether unfulfilled needs of individual members of the family or of the family as a social system result in negative long-term sequels remains an open question. Assessing and analyzing family satisfaction in the ICU ultimately will support healthcare professionals in their continuing effort to improve care of critically ill patients and their families.

Rapidly progressive Scheuermann's disease in an adolescent after pectus bar placement treated with posterior vertebral-column resection: case report and review of the literature.

PubMed

Sugrue, Patrick A; OʼShaughnessy, Brian A; Blanke, Kathy M; Lenke, Lawrence G

2013-02-15

Case report and review of the literature. This case illustrates the importance of the costosternal complex in maintaining the stability and alignment of the thoracic spine. The patient was iatrogenically destabilized by placement of a pectus bar leading to rapid symptomatic progression of his Scheuermann's kyphosis, ultimately requiring surgical correction. Scheuermann's kyphosis is a disease process defined by strict radiographical and clinical criteria. Surgical treatment is generally recommended for curves greater than 75°. This case demonstrates the critical role of the costosternal complex in maintaining the stability of the thoracic spine. The patient described in this report underwent placement of a pectus bar for correction of symptomatic pectus excavatum. He subsequently developed a progressive symptomatic Scheuermann's kyphosis as a result of the destabilization of his costosternal complex. This patient ultimately required removal of the pectus bar and posterior instrumented kyphosis correction. Progressive symptomatic Scheuermann's kyphosis (105°) corrected by removal of the pectus bar, T11 posterior vertebral-column resection and T4-L3 instrumented posterior spinal fusion. The patient had an uneventful immediate postoperative course. He was discharged neurologically intact with dramatic kyphosis correction and significant symptomatic improvement. Radiographs obtained 3 years postoperatively reveal stable thoracolumbar correction. The costosternal complex plays a critically important role in the intrinsic stability of the thoracic spine. Iatrogenic disruption of the costosternal complex can result in rapid progression of thoracic/thoracolumbar kyphosis in the setting of Scheuermann's disease.

Molecular Markers and Targeted Therapeutics in Metastatic Tumors of the Spine: Changing the Treatment Paradigms.

PubMed

Goodwin, C Rory; Abu-Bonsrah, Nancy; Rhines, Laurence D; Verlaan, Jorrit-Jan; Bilsky, Mark H; Laufer, Ilya; Boriani, Stefano; Sciubba, Daniel M; Bettegowda, Chetan

2016-10-15

A review of the literature. The aim of this study was to discuss the evolution of molecular signatures and the history and development of targeted therapeutics in metastatic tumor types affecting the spinal column. Molecular characterization of metastatic spine tumors is expected to usher in a revolution in diagnostic and treatment paradigms. Molecular characterization will provide critical information that can be used for initial diagnosis, prognosticating the ideal treatment strategy, assessment of treatment efficacy, surveillance and monitoring recurrence, and predicting complications, clinical outcome, and overall survival in patients diagnosed with metastatic cancers to the spinal column. A review of the literature was performed focusing on illustrative examples of the role that molecular-based therapeutics have played in clinical outcomes for patients diagnosed with metastatic tumor types affecting the spinal column. The impact of molecular therapeutics including receptor tyrosine kinases and immune checkpoint inhibitors and the ability of molecular signatures to provide prognostic information are discussed in metastatic breast cancer, lung cancer, prostate cancer, melanoma, and renal cell cancer affecting the spinal column. For the providers who will ultimately counsel patients diagnosed with metastases to the spinal column, molecular advancements will radically alter the management/surgical paradigms utilized. Ultimately, the translation of these molecular advancements into routine clinical care will greatly improve the quality and quantity of life for patients diagnosed with spinal malignancies and provide better overall outcomes and counseling for treating physicians. N/A.

Improving clinical outcomes for naltrexone as a management of problem alcohol use

PubMed Central

Hulse, Gary K

2013-01-01

Despite being a relatively effective and safe treatment, the clinical management of alcohol abuse/dependence by oral naltrexone can be compromised due to the patient's non-compliance with daily use of this medication. Over the past decade an increasing body of research has suggested that the use of sustained release depot naltrexone preparations can overcome this issue and deliver improved clinical outcomes. However, at the same time, research findings from diverse areas of pharmacogenetics, neurobiology and behavioural psychology have also been converging to identify variables including genetic markers, patient psychosocial characteristics and drug use history differences, or clusters of these variables that play a major role in mediating the response of alcohol abuse/dependent persons to treatment by naltrexone. While this article does not attempt to review all available data pertaining to an individual alcohol dependent patient's response to treatment by naltrexone, it does identify relevant research areas and highlights the importance of data arising from them. The characterization of clinical markers, to identify those patients who are most likely to benefit from naltrexone and to tailor a more individual naltrexone treatment, will ultimately provide significant benefit to both patients and clinicians by optimizing treatment outcome. PMID:22946873

The Limited English Proficiency Patient Family Advocate Role: Fostering Respectful and Effective Care Across Language and Culture in a Pediatric Oncology Setting.

PubMed

Gil, Stephanie; Hooke, Mary C; Niess, Dawn

2016-01-01

Patients and families with limited English proficiency (LEP) face a multitude of barriers both inside and outside the hospital walls. These barriers can contribute to difficulty accessing care and understanding/adhering to treatment recommendations, ultimately placing them at higher risk for poorer outcomes than their English-speaking counterparts. The LEP Patient Family Advocate role was created with the aim of improving access, promoting effective communication, and equalizing care for children with cancer from families with LEP. The goal of this mixed methods study was to describe the level of satisfaction and experiences of parents and health care providers who used the LEP Patient Family Advocate while receiving or providing care. Twelve parents and 15 health care providers completed quantitative surveys and an open-ended question about their experiences. High levels of satisfaction were reported. Themes about the role from qualitative responses included its positive effect on communication, trust, and connectedness between parents and staff. Continuity of care and safety were improved, and parents thought the role helped decrease their stress. The LEP Patient Family Advocate has a positive influence on family-centered cultural care. © 2015 by Association of Pediatric Hematology/Oncology Nurses.

Why Is Your Patient Still Short of Breath? Understanding the Complex Pathophysiology of Dyspnea in Chronic Kidney Disease.

PubMed

Salerno, Fabio Rosario; Parraga, Grace; McIntyre, Christopher William

2017-01-01

Dyspnea is one of the most common symptoms associated with CKD. It has a profound influence on the quality of life of CKD patients, and its underlying causes are often associated with a negative prognosis. However, its pathophysiology is poorly understood. While hemodialysis may address fluid overload, it often does not significantly improve breathlessness, suggesting multiple and co-existing alternative issues exist. The aim of this article is to discuss the main pathophysiologic mechanisms and the most important putative etiologies underlying dyspnea in CKD patients. Congestive heart failure, unrecognized chronic lung disease, pulmonary hypertension, lung fibrosis, air microembolism, dialyzer bio-incompatibility, anemia, sodium, and fluid overload are potential frequent causes of breathing disorders in this population. However, the relative contributions in any one given patient are poorly understood. Systemic inflammation is a common theme and contributes to the development of endothelial dysfunction, lung fibrosis, anemia, malnutrition, and muscle wasting. The introduction of novel multimodal imaging techniques, including pulmonary functional magnetic resonance imaging with inhaled contrast agents, could provide new insights into the pathophysiology of dyspnea in CKD patients and ultimately contribute to improving our clinical management of this symptom. © 2016 Wiley Periodicals, Inc.

Integrating palliative care into the trajectory of cancer care

PubMed Central

Hui, David; Bruera, Eduardo

2016-01-01

Over the past five decades, palliative care has evolved from serving patients at the end of life into a highly specialized discipline focused on delivering supportive care to patients with life-limiting illnesses throughout the disease trajectory. A growing body of evidence is now available to inform the key domains in the practice of palliative care, including symptom management, psychosocial care, communication, decision-making, and end-of-life care. Findings from multiple studies indicate that integrating palliative care early in the disease trajectory can result in improvements in quality of life, symptom control, patient and caregiver satisfaction, quality of end-of-life care, survival, and costs of care. In this narrative Review, we discuss various strategies to integrate oncology and palliative care by optimizing clinical infrastructures, processes, education, and research. The goal of integration is to maximize patient access to palliative care and, ultimately, to improve patient outcomes. We provide a conceptual model for the integration of supportive and/or palliative care with primary and oncological care. We end by discussing how health-care systems and institutions need to tailor integration based on their resources, size, and the level of primary palliative care available. PMID:26598947

Compliance in peritoneal dialysis: a qualitative study of renal nurses.

PubMed

McCarthy, Alexandra; Cook, Peta S; Fairweather, Carrie; Shaban, Ramon; Martin-McDonald, Kristine

2009-06-01

End-stage renal failure is a life-threatening condition, often treated with home-based peritoneal dialysis (PD). PD is a demanding regimen, and the patients who practise it must make numerous lifestyle changes and learn complicated biomedical techniques. In our experience, the renal nurses who provide most PD education frequently express concerns that patient compliance with their teaching is poor. These concerns are mirrored in the renal literature. It has been argued that the perceived failure of health professionals to improve compliance rates with PD regimens is because 'compliance' itself has never been adequately conceptualized or defined; thus, it is difficult to operationalize and quantify. This paper examines how a group of Australian renal nurses construct patient compliance with PD therapy. These empirical data illuminate how PD compliance operates in one practice setting; how it is characterized by multiple and often competing energies; and how ultimately it might be pointless to try to tame 'compliance' through rigid definitions and measurement, or to rigidly enforce it in PD patients. The energies involved are too fractious and might be better spent, as many of the more experienced nurses in this study argue, in augmenting the energies that do work well together to improve patient outcomes.

Exploring the predictive ability of two new complementary instruments for assessing effective therapeutic communication skills of dental and dental hygiene students.

PubMed

Schönwetter, Dieter J; Emmons Wener, Mickey; Mazurat, Nita; Yakiwchuk, Ben

2012-10-01

Research on the development of effective therapeutic communication skills for oral health providers is slowly evolving. One of the initial steps in this research is to identify and address gaps in the work of previous researchers. Ultimately, the educational goal of competence in communications skills development is to provide improved patient care including improved patient satisfaction. This article is the third in a series describing the development of and findings from the new complementary Patient Communication Assessment Instrument (PCAI) and Student Communication Assessment Instrument (SCAI). The aim of the study reported here was to look at the relationship between communication skills and patient and student clinician gender interactions, sociodemographic factors (e.g., age, income), and changes in these interactions with length of treatment. A total of 410 patient assessments (PCAI) and 410 matching student self-assessments (SCAI) were used for further data analysis. Patients of female student clinicians, female patients, patients of a higher and the lowest income range, and older patients reported statistically significant higher student communication scores. The PCAI identified that certain groups of patients consistently report higher scores than other groups, whereas the SCAI identified differences between male and female student clinicians. The results have implications for educational protocols, communication strategies, and the need for continued research regarding sociodemographic factors and their relationship to patient satisfaction.

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management

PubMed Central

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-01-01

Abstract Background and Aims The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012–2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. Methods During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. Results The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Conclusions Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. PMID:28981622

Social Functioning Trajectories of Young First-Episode Psychosis Patients with and without Cannabis Misuse: A 30-Month Follow-Up Study

PubMed Central

González-Blanch, César; Gleeson, John F.; Koval, Peter; Cotton, Sue M.; McGorry, Patrick D.; Alvarez-Jimenez, Mario

2015-01-01

The aim of the study was to investigate trajectories of social functioning in young people with first-episode psychosis (FEP) with and without cannabis misuse using a secondary analysis of data from the Episode-II trial. Forty-two young people with FEP and comorbid cannabis use disorder were compared with 39 young people with FEP but without a cannabis use disorder. Social functioning was assessed every 6 months during a 30-month follow-up. Multilevel linear growth curve modeling was used to compare the social functioning trajectories over time for those with and without cannabis misuse. Cannabis misuse was not associated with social functioning at baseline assessment. Over a 30-month follow-up, FEP patients without cannabis disorder showed significant improvements in their social functioning, whereas patients with cannabis misuse at baseline displayed no such improvement. Patients with and without cannabis misuse differed significantly in their levels of social functioning after 24 months. Similar results were obtained after adjusting for potential confounders (i.e., age, gender, negative symptoms, premorbid functioning, DSM-IV diagnoses, baseline social functioning and other substance use). In the context of a specialized early intervention service, patients with cannabis misuse at baseline did not attain the improvements in social outcomes observed in their counterparts without cannabis misuse. There is a need to develop effective interventions to reduce cannabis misuse to ultimately improve social outcomes in young people with psychosis. PMID:25849623

Improving the value of costly genetic reference laboratory testing with active utilization management.

PubMed

Dickerson, Jane A; Cole, Bonnie; Conta, Jessie H; Wellner, Monica; Wallace, Stephanie E; Jack, Rhona M; Rutledge, Joe; Astion, Michael L

2014-01-01

Tests that are performed outside of the ordering institution, send-out tests, represent an area of risk to patients because of complexity associated with sending tests out. Risks related to send-out tests include increased number of handoffs, ordering the wrong or unnecessary test, specimen delays, data entry errors, preventable delays in reporting and acknowledging results, and excess financial liability. Many of the most expensive and most misunderstood tests are send-out genetic tests. To design and develop an active utilization management program to reduce the risk to patients and improve value of genetic send-out tests. Send-out test requests that met defined criteria were reviewed by a rotating team of doctoral-level consultants and a genetic counselor in a pediatric tertiary care center. Two hundred fifty-one cases were reviewed during an 8-month period. After review, nearly one-quarter of genetic test requests were modified in the downward direction, saving a total of 2% of the entire send-out bill and 19% of the test requests under management. Ultimately, these savings were passed on to patients. Implementing an active utilization strategy for expensive send-out tests can be achieved with minimal technical resources and results in improved value of testing to patients.

Interpreter services in emergency medicine.

PubMed

Chan, Yu-Feng; Alagappan, Kumar; Rella, Joseph; Bentley, Suzanne; Soto-Greene, Marie; Martin, Marcus

2010-02-01

Emergency physicians are routinely confronted with problems associated with language barriers. It is important for emergency health care providers and the health system to strive for cultural competency when communicating with members of an increasingly diverse society. Possible solutions that can be implemented include appropriate staffing, use of new technology, and efforts to develop new kinds of ties to the community served. Linguistically specific solutions include professional interpretation, telephone interpretation, the use of multilingual staff members, the use of ad hoc interpreters, and, more recently, the use of mobile computer technology at the bedside. Each of these methods carries a specific set of advantages and disadvantages. Although professionally trained medical interpreters offer improved communication, improved patient satisfaction, and overall cost savings, they are often underutilized due to their perceived inefficiency and the inconclusive results of their effect on patient care outcomes. Ultimately, the best solution for each emergency department will vary depending on the population served and available resources. Access to the multiple interpretation options outlined above and solid support and commitment from hospital institutions are necessary to provide proper and culturally competent care for patients. Appropriate communications inclusive of interpreter services are essential for culturally and linguistically competent provider/health systems and overall improved patient care and satisfaction. Copyright (c) 2010 Elsevier Inc. All rights reserved.

Refractory Pain Management in Amyloid-Associated Peripheral Neuropathy.

PubMed

Warner, Nafisseh S; Watson, James C; Bendel, Markus A; Moeschler, Susan M

2018-05-01

Systemic amyloidosis is a disease that often involves multiple organ systems, including the peripheral nervous system. Patients may present with severe, refractory neuropathic pain; however, the optimal treatment approach for pain for these patients remains unclear. A man with severe, refractory neuropathic pain in his bilateral upper and lower extremities and the trunk secondary to amyloid neuropathy is presented. Multiple medication trials, including neuropathic and opioid agents, produced considerable adverse effects and minimal relief. Scrambler therapy, a novel electrical stimulation modality, was used and was associated with substantial short-term but nonsustained benefit. Spinal cord stimulation was considered, but given his diffuse symptoms, it was deemed a less-than-optimal approach. Ultimately, an intrathecal drug delivery system was placed with infusion of hydromorphone, resulting in substantial pain reduction in all involved areas and with an improved adverse effect profile. This intervention resulted in immense improvement in the patient's quality of life, despite progression of his systemic amyloidosis. Severe pain in the setting of amyloid neuropathy is often difficult to treat. To our knowledge, this represents the first report of Scrambler therapy or an implanted intrathecal drug delivery system used for a patient with refractory amyloidosis-related neuropathic pain, resulting in substantial analgesic benefit and improved quality of life.

Strategies to reduce disparities in maternal morbidity and mortality: Patient and provider education.

PubMed

Jain, Joses; Moroz, Leslie

2017-08-01

A reduction in racial disparities in maternal morbidity and mortality requires effective education of both patients and providers. Although providers seem to recognize that disparities exist, there is a widespread need for improving our understanding differences in health care and outcomes and the factors that contribute to them. There are increasingly more educational materials available for the purpose of augmenting disparities education among patients and providers. However, it is important to incorporate contemporary learning methodologies and technologies to address our current knowledge deficit. Collaborative educational models with a multi-disciplinary approach to patient education will be essential. Ultimately, the comprehensive education of providers and patients will require efforts on the part of numerous stakeholders within patient care delivery models. Further investigation will be necessary to determine how best to disseminate this information to maximize the impact of patient and provider educations with the goal of eliminating disparities in maternal morbidity and mortality. Copyright © 2017 Elsevier Inc. All rights reserved.

Tracking and sustaining improvement initiatives: leveraging quality dashboards to lead change in a neurosurgical department.

PubMed

McLaughlin, Nancy; Afsar-Manesh, Nasim; Ragland, Victoria; Buxey, Farzad; Martin, Neil A

2014-03-01

Increasingly, hospitals and physicians are becoming acquainted with business intelligence strategies and tools to improve quality of care. In 2007, the University of California Los Angeles (UCLA) Department of Neurosurgery created a quality dashboard to help manage process measures and outcomes and ultimately to enhance clinical performance and patient care. At that time, the dashboard was in a platform that required data to be entered manually. It was then reviewed monthly to allow the department to make informed decisions. In 2009, the department leadership worked with the UCLA Medical Center to align mutual quality-improvement priorities. The content of the dashboard was redesigned to include 3 areas of priorities: quality and safety, patient satisfaction, and efficiency and use. Throughout time, the neurosurgery quality dashboard has been recognized for its clarity and its success in helping management direct improvement strategies and monitor impact. We describe the creation and design of the neurosurgery quality dashboard at UCLA, summarize the evolution of its assembly process, and illustrate how it can be used as a powerful tool of improvement and change. The potential challenges and future directions of this business intelligence tool are also discussed.

Enhanced recovery after surgery: Current research insights and future direction

PubMed Central

Abeles, Aliza; Kwasnicki, Richard Mark; Darzi, Ara

2017-01-01

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes. PMID:28289508

Teleophthalmology: improving patient outcomes?

PubMed Central

Sreelatha, Omana Kesary; Ramesh, Sathyamangalam VenkataSubbu

2016-01-01

Teleophthalmology is gaining importance as an effective eye care delivery modality worldwide. In many developing countries, teleophthalmology is being utilized to provide quality eye care to the underserved urban population and the unserved remote rural population. Over the years, technological innovations have led to improvement in evidence and teleophthalmology has evolved from a research tool to a clinical tool. The majority of the current teleophthalmology services concentrate on patient screening and appropriate referral to experts. Specialty care using teleophthalmology services for the pediatric group includes screening as well as providing timely care for retinopathy of prematurity (ROP). Among geriatric eye diseases, specialty teleophthalmology care is focused toward screening and referral for diabetic retinopathy (DR), glaucoma, age-related macular degeneration (ARMD), and other sight-threatening conditions. Comprehensive vision screening and refractive error services are generally covered as part of most of the teleophthalmology methods. Over the past decades, outcome assessment of health care system includes patients’ assessments on their health, care, and services they receive. Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care. Teleophthalmology produces the same desired clinical outcome as the traditional system. Remote portals allow specialists to provide care over a larger region, thereby improving health outcomes and increasing accessibility of specialty care to a larger population. A high satisfaction level and acceptance is reported in the majority of the studies because of increased accessibility and reduced traveling cost and time. Considering the improved quality of patient care and patient satisfaction reported for these telemedicine services, this review explores how teleophthalmology helps to improve patient outcomes. PMID:26929592

RECURRENT MACULAR HOLES IN THE ERA OF SMALL-GAUGE VITRECTOMY: A Review of Incidence, Risk Factors, and Outcomes.

PubMed

Abbey, Ashkan M; Van Laere, Lily; Shah, Ankoor R; Hassan, Tarek S

2017-05-01

To evaluate the preoperative features, intraoperative management, and postoperative outcomes of recurrent macular holes that developed after initial successful repair with small-gauge vitrectomy techniques. We retrospectively reviewed 392 eyes with idiopathic macular holes successfully treated with small-gauge vitrectomy. Thirteen of these eyes underwent reoperation after macular hole reopening. We assessed patient demographics, visual acuity, postoperative anatomical success, potential precipitating clinical factors of hole reopening, and details of the surgical repairs of these eyes. Macular hole reopening occurred in 13 (3.3%) of 392 eyes in a mean of 28 months (range, 1-120 months) after initial repair. All 13 recurrent holes closed after a second vitrectomy, but 4 (31%) holes reopened again and had vitrectomy. Of these, 2 reopened a third time. Ultimately, 11 (85%) holes were closed at the most recent follow-up. The mean best-corrected visual acuity was 20/81 before initial repair, 20/148 after the first reopening, 20/115 after repair of the first reopening, and 20/55 after repair of >1 reopening. Ten of 13 (77%) patients had, or later developed, macular holes in the other eye during follow-up. Reoperation successfully achieved hole closure and ultimate visual improvement in most eyes with recurrent macular holes. Most patients with recurrent holes previously had, or later developed, full-thickness macular holes in the other eye.

Atypical psychotic symptoms and Dandy-Walker variant.

PubMed

Williams, Aislinn J; Wang, Zhenni; Taylor, Stephan F

2016-10-01

New-onset psychotic symptoms often respond well to antipsychotic treatment; however, symptoms may be difficult to treat when an underlying brain malformation is present. Here, we present a case of atypical psychotic symptoms in the context of a congenital cerebellar malformation (Dandy-Walker variant). The patient ultimately improved with paliperidone palmitate after multiple antipsychotic medication trials (both oral and one long-acting injectable) were ineffective. Neuroimaging may provide valuable diagnostic and prognostic information in cases of new-onset psychosis with atypical features and treatment resistance, even in the absence of neurologic signs and symptoms.

Positive beliefs and privacy concerns shape the future for the Personally Controlled Electronic Health Record.

PubMed

Lehnbom, E C; Douglas, H E; Makeham, M A B

2016-01-01

The uptake of the Personally Controlled Electronic Health Record (PCEHR) has been slowly building momentum in Australia. The purpose of the PCEHR is to collect clinically important information from multiple healthcare providers to provide a secure electronic record to patients and their authorised healthcare providers that will ultimately enhance the efficiency and effectiveness of healthcare delivery. Reasons for the slow uptake of the PCEHR and future directions to improve its usefulness is discussed later. © 2016 Royal Australasian College of Physicians.

A Clinical Librarian-Nursing Partnership to Bridge Clinical Practice and Research in an Oncology Setting.

PubMed

Ginex, Pamela K; Hernandez, Marisol; Vrabel, Mark

2016-09-01

Nurses in clinical settings in which evidence-based, individualized care is expected are often the best resource to identify important clinical questions and gaps in practice. These nurses are frequently challenged by a lack of resources to fully develop their questions and identify the most appropriate methods to answer them. A strategic and ongoing partnership between medical library services and nursing can support nurses as they embark on the process of answering these questions and, ultimately, improving patient care and clinical outcomes

Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study.

PubMed

Khu, Kathleen Joy; Doglietto, Francesco; Radovanovic, Ivan; Taleb, Faisal; Mendelsohn, Daniel; Zadeh, Gelareh; Bernstein, Mark

2010-05-01

Routine and nonselective use of awake and outpatient craniotomy for supratentorial tumors has been shown to be safe and effective from a medical standpoint. In this study the authors aim was to explore patients' perceptions about awake and outpatient craniotomy. Qualitative research methodology was used. Two semistructured, open-ended interviews were conducted with 27 participants, who were ambulatory adult patients who underwent craniotomy for brain tumor excision between October 2008 and April 2009. The participants were each assigned to one of the following categories: 1) awake outpatient; 2) awake inpatient; 3) outpatient under general anesthesia; and 4) inpatient under general anesthesia. Interviews were audiotaped and transcribed, and the data were subjected to thematic analysis. The following 6 overarching themes emerged from the data: 1) patients had a positive experience with awake craniotomy; 2) patient satisfaction with outpatient surgery was high; 3) patients understood the rationale behind awake surgery; 4) patients were surprised that brain surgery can be done on an outpatient basis; 5) trust in one's surgeon was important; and 6) patients were more concerned about the disease than the procedure. The results reflected positively on the patients' awake and outpatient surgery experience, but there were some areas that require improvement, specifically perioperative pain control and postoperative care. These insights on patients' perspectives can lead to better delivery of care, and ultimately, improved health outcomes.

Design-of-Experiments Approach to Improving Inferior Vena Cava Filter Retrieval Rates.

PubMed

Makary, Mina S; Shah, Summit H; Warhadpande, Shantanu; Vargas, Ivan G; Sarbinoff, James; Dowell, Joshua D

2017-01-01

The association of retrievable inferior vena cava filters (IVCFs) with adverse events has led to increased interest in prompt retrieval, particularly in younger patients given the progressive nature of these complications over time. This study takes a design-of-experiments (DOE) approach to investigate methods to best improve filter retrieval rates, with a particular focus on younger (<60 years) patients. A DOE approach was executed in which combinations of variables were tested to best improve retrieval rates. The impact of a virtual IVCF clinic, primary care physician (PCP) letters, and discharge instructions was investigated. The decision for filter retrieval in group 1 was determined solely by the referring physician. Group 2 included those patients prospectively followed in an IVCF virtual clinic in which filter retrieval was coordinated by the interventional radiologist when clinically appropriate. In group 3, in addition to being followed through the IVCF clinic, each patient's PCP was faxed a follow-up letter, and information regarding IVCF retrieval was added to the patient's discharge instructions. A total of 10 IVCFs (8.4%) were retrieved among 119 retrievable IVCFs placed in group 1. Implementation of the IVCF clinic in group 2 significantly improved the retrieval rate to 25.3% (23 of 91 retrievable IVCFs placed, P < .05). The addition of discharge instructions and PCP letters to the virtual clinic (group 3) resulted in a retrieval rate of 33.3% (17 of 51). The retrieval rates demonstrated more pronounced improvement when examining only younger patients, with retrieval rates of 11.3% (7 of 62), 29.5% (13 of 44, P < .05), and 45.2% (14 of 31) for groups 1, 2, and 3, respectively. DOE methodology is not routinely executed in health care, but it is an effective approach to evaluating clinical practice behavior and patient quality measures. In this study, implementation of the combination of a virtual clinic, PCP letters, and discharge instructions improved retrieval rates compared with a virtual clinic alone. Quality improvement strategies such as these that augment patient and referring physician knowledge on interventional radiologic procedures may ultimately improve patient safety and personalized care. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes.

PubMed

Sorrentino, Patricia

2016-01-01

The purpose of this article is to describe a quality improvement process using failure mode and effects analysis (FMEA) to evaluate systems handoff communication processes, improve emergency department (ED) throughput and reduce crowding through development of a standardized handoff, and, ultimately, improve patient safety. Risk of patient harm through ineffective communication during handoff transitions is a major reason for breakdown of systems. Complexities of ED processes put patient safety at risk. An increased incidence of submitted patient safety event reports for handoff communication failures between the ED and inpatient units solidified a decision to implement the use of FMEA to identify handoff failures to mitigate patient harm through redesign. The clinical nurse specialist implemented an FMEA. Handoff failure themes were created from deidentified retrospective reviews. Weekly meetings were held over a 3-month period to identify failure modes and determine cause and effect on the process. A functional block diagram process map tool was used to illustrate handoff processes. An FMEA grid was used to list failure modes and assign a risk priority number to quantify results. Multiple areas with actionable failures were identified. A majority of causes for high-priority failure modes were specific to communications. Findings demonstrate the complexity of transition and handoff processes. The FMEA served to identify and evaluate risk of handoff failures and provide a framework for process improvement. A focus on mentoring nurses to quality handoff processes so that it becomes habitual practice is crucial to safe patient transitions. Standardizing content and hardwiring within the system are best practice. The clinical nurse specialist is prepared to provide strong leadership to drive and implement system-wide quality projects.

Listening to the patient as a possible route to cost-effective rehabilitation: a case report.

PubMed

Grandi, Attilia; Mazzola, Marcella; Angelini, Lucia; Chiappedi, Matteo

2012-01-17

Adolescents with cerebral palsy often do not need a specific rehabilitative treatment; however, when specific needs are expressed, clinicians should listen and try to answer them. We present the case of a 17-year-old Italian male patient with hemiplegia who had received standard physiotherapy and, ultimately, after a period of adapted physical activity performed in a group, was under consideration for discharge. However, due to unsatisfactory hand control, he asked for help to reach a personal goal, the ability to drive a motorbike, without surgery. Functional taping showed efficacy, but was neither cost-effective nor practical for the patient and his family; by contrast, a dynamic orthosis associated with training in a real-life environment was instead successful. The present case underlines the importance of considering solutions involving the motivation and compliance of the patient in order to improve his activity and participation.

Platforms.

PubMed

Josko, Deborah

2014-01-01

The advent of DNA sequencing technologies and the various applications that can be performed will have a dramatic effect on medicine and healthcare in the near future. There are several DNA sequencing platforms available on the market for research and clinical use. Based on the medical laboratory scientist or researcher's needs and taking into consideration laboratory space and budget, one can chose which platform will be beneficial to their institution and their patient population. Although some of the instrument costs seem high, diagnosing a patient quickly and accurately will save hospitals money with fewer hospital stays and targeted treatment based on an individual's genetic make-up. By determining the type of disease an individual has, based on the mutations present or having the ability to prescribe the appropriate antimicrobials based on the knowledge of the organism's resistance patterns, the clinician will be better able to treat and diagnose a patient which ultimately will improve patient outcomes and prognosis.

Treatment of psychological factors in a child with difficult asthma: a case report.

PubMed

Anbar, Ran D; Sachdeva, Shagun

2011-07-01

Difficult asthma is defined as the persistence of asthma symptoms, abnormal pulmonary function showing airway obstruction, and continued requirement for short-acting bronchodilator therapy, despite adequate treatment with inhaled corticosteroids. It calls for a thorough evaluation of the patient to look into alternate and complicating diagnoses. The authors report a case of a 9-year-old patient with difficult asthma who failed to respond to conventional therapy. Although it was recognized that he had a number of potential medical complicating factors including allergies, chronic sinusitis, and gastroesophageal reflux, a psychological intervention using hypnosis ultimately appeared to help alleviate his symptoms completely. Thus, psychological evaluation and intervention should be considered early in the course of management of a patient with difficult asthma, because it may help avoid time-consuming and expensive investigations of potential complicating factors, and it may yield rapid improvement in the patient's clinical condition.

Epidural Blood Patch Using Manometry for Sinking Skin Flap Syndrome.

PubMed

Turner, James D; Farmer, Justin L; Dobson, Sean W

2016-06-01

We describe here a 55-year-old male patient with a medical history significant for chronic back pain and substance abuse with cocaine who sustained a traumatic subarachnoid hemorrhage after a fall from a roof while acutely intoxicated on cocaine requiring decompressive hemicraniectomy and cranioplasty that was complicated by an epidural abscess requiring a repeat craniectomy. He was diagnosed with sinking skin flap syndrome consistent with altered mental status and a sunken skin flap with increased midline shift. Despite treatment with Trendelenburg positioning and appropriate fluid management, the patient continued to decline, and an epidural blood patch was requested for treatment. After placement of the epidural blood patch using manometry in the epidural space, the patient's neurologic status improved allowing him to ultimately receive a cranioplasty. The patient is now able to perform several of his activities of daily living and communicate effectively.

CAC-DRS: Coronary Artery Calcium Data and Reporting System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT).

PubMed

Hecht, Harvey S; Blaha, Michael J; Kazerooni, Ella A; Cury, Ricardo C; Budoff, Matt; Leipsic, Jonathon; Shaw, Leslee

2018-03-30

The goal of CAC-DRS: Coronary Artery Calcium Data and Reporting System is to create a standardized method to communicate findings of CAC scanning on all noncontrast CT scans, irrespective of the indication, in order to facilitate clinical decision-making, with recommendations for subsequent patient management. The CAC-DRS classification is applied on a per-patient basis and represents the total calcium score and the number of involved arteries. General recommendations are provided for further management of patients with different degrees of calcified plaque burden based on CAC-DRS classification. In addition, CAC-DRS will provide a framework of standardization that may benefit quality assurance and tracking patient outcomes with the potential to ultimately result in improved quality of care. Copyright © 2018 Society of Cardiovascular Computed Tomography. All rights reserved.

Could pharmacogenetic data explain part of the interindividual sensitivity to methadone-induced respiratory depression?

PubMed Central

Crettol, Séverine; Monnat, Martine; Eap, Chin B

2007-01-01

In this issue of Critical Care, Megarbane and colleagues present a case report of methadone-induced respiratory depression and conduct a toxicokinetic/toxicodynamic evaluation. An opioid-dependent patient receiving methadone maintenance treatment (daily dose 70 mg) was found unconscious after ingesting 240 mg methadone and 2 mg flunitrazepam. Significant improvement in consciousness was achieved after an intravenous bolus of 0.3 mg naloxone followed by a continuous infusion of naloxone at 0.3 mg/hour. In patients receiving methadone maintenance treatment, an occasional intake of two to four times the usual daily dose of methadone is not an exceptional occurrence. However, few such patients experience episodes of life-threatening respiratory depression. Here, we discuss whether recent pharmacogenetic data could help us to understand interindividual variability in sensitivity to respiratory depression and, ultimately, to predict which patients are most likely to be affected. PMID:17338832

Pregnancy and cystic fibrosis: Approach to contemporary management

PubMed Central

Tay, George; Callaway, Leonie; Bell, Scott C

2014-01-01

Over the previous 50 years survival of patients with cystic fibrosis has progressively increased. As a result of improvements in health care, increasing numbers of patients with cystic fibrosis are now considering starting families of their own. For the health care professionals who look after these patients, the assessment of the potential risks, and the process of guiding prospective parents through pregnancy and beyond can be both challenging and rewarding. To facilitate appropriate discussions about pregnancy, health care workers must have a detailed understanding of the various important issues that will ultimately need to be considered for any patient with cystic fibrosis considering parenthood. This review will address these issues. In particular, it will outline pregnancy outcomes for mothers with cystic fibrosis, issues that need to be taken into account when planning a pregnancy and the management of pregnancy for mothers with cystic fibrosis or mothers who have undergone organ transplantation as a result of cystic fibrosis. PMID:27512443

Improving the working relationship between doctors and pharmacists: is inter-professional education the answer?

PubMed

Gallagher, Ruth M; Gallagher, Helen C

2012-05-01

Despite their common history, there are many cultural, attitudinal and practical differences between the professions of medicine and pharmacy that ultimately influence patient care and health outcomes. While poor communication between doctors and pharmacists is a major cause of medical errors, it is clear that effective, deliberate doctor-pharmacist collaboration within certain clinical settings significantly improves patient care. This may be particularly true for those patients with chronic illnesses and/or requiring regular medication reviews. Moreover, in hospitals, clinical and antibiotic pharmacists are successfully influencing prescribing and infection control policy. Under the new Irish Pharmacy Act (2007), pharmacists are legally obliged to provide pharmaceutical care to their patients, thus fulfilling a more patient-centred role than their traditional 'dispensing' one. However, meeting this obligation relies on the existence of good doctor-pharmacist working relationships, such that inter-disciplinary teamwork in monitoring patients becomes the norm in all healthcare settings. As discussed here, efforts to improve these relationships must focus on the strategic introduction of agreed changes in working practices between the two professions and on educational aspects of pharmaceutical care. For example, standardized education of doctors/medical students such that they learn to prescribe in an optimal manner and ongoing inter-professional education of doctors and pharmacists in therapeutics, are likely to be of paramount importance. Here, insights into the types of factors that help or hinder the improvement of these working relationships and the importance of education and agreed working practices in defining the separate but inter-dependent professions of pharmacy and medicine are reviewed and discussed.

Physicians slow to e-mail routinely with patients.

PubMed

Boukus, Ellyn R; Grossman, Joy M; O'Malley, Ann S

2010-10-01

Some experts view e-mail between physicians and patients as a potential tool to improve physician-patient communication and, ultimately, patient care. Despite indications that many patients want to e-mail their physicians, physician adoption and use of e-mail with patients remains uncommon--only 6.7 percent of office-based physicians routinely e-mailed patients in 2008, according to a new national study from the Center for Studying Health System Change (HSC). Overall, about one-third of office-based physicians reported that information technology (IT) was available in their practice for e-mailing patients about clinical issues. Of those, fewer than one in five reported using e-mail with patients routinely; the remaining physicians were roughly evenly split between occasional users and non-users. Physicians in practices with access to electronic medical records and those working in health maintenance organizations (HMOs) or medical school settings were more likely to adopt and use e-mail to communicate with patients compared with other physicians. However, even among the highest users--physicians in group/staff-model HMOs--only 50.6 percent reported routinely e-mailing patients.

Patient experiences of in-hospital preparations for follow-up care at home.

PubMed

Keller, Gretchen; Merchant, Alefia; Common, Carol; Laizner, Andrea M

2017-06-01

To examine patient experiences of hospital-based discharge preparation for referral for follow-up home care services. To identify aspects of discharge preparation that will assist patients with their transition from hospital-based care to home-based follow-up care. To improve patients' transitions from hospital-based care to community-based home care, hospitals incorporate home care referral processes into discharge planning. This includes patient preparation for follow-up home care services. While there is evidence to support that such preparation needs to be more patient-centred to be effective, there is little knowledge of patient experiences of preparation that would guide improvements. Qualitative descriptive study. The study was carried out at a supra-regional hospital in Eastern Canada. Findings are based on thematic content analysis of 13 semi-structured interviews of patients requiring home care after hospitalisation on a medical or surgical unit. Most interviews were held within one week of discharge. Patient experiences were associated with patient attitudes and levels of engagement in preparation. Attitudes and levels of engagement were seen as related to one another. Those who 'didn't really think about it', had low engagement, while those with the attitude 'guide me', looked for partnership. Those who had an attitude of 'this is what I want', had a very high level of engagement. Previous experience with home care services influenced patients' level of trust in the health care system, and ultimately shaped their attitudes towards and levels of engagement in preparation. Patient preparation for follow-up home care can be improved by assessing their knowledge of and previous experiences with home care. Patients recognised as using a proactive approach may be highly vulnerable. © 2016 John Wiley & Sons Ltd.

Computed tomographic imaging interpretation improves fetal outcomes after maternal trauma.

PubMed

Kopelman, Tammy R; Bogert, James N; Walters, Jarvis W; Gridley, Daniel; Guzman, Oscar; Davis, Karole M; Pieri, Paola G; Vail, Sydney J; Pressman, Melissa

2016-12-01

Computed tomography (CT) has been validated to identify and classify placental abruption following blunt trauma. The purpose of this study was to demonstrate improvement in fetal survival when delivery occurs by protocol at the first sign of class III fetal heart rate tracing in pregnant trauma patients with a viable fetus on arrival and CT evidence of placental perfusion 50% or less secondary to placental abruption. This is a retrospective review of pregnant trauma patients at 26 weeks' gestation or greater who underwent abdominopelvic CT as part of their initial evaluation. Charts were reviewed for CT interpretation of placental pathology with classification of placental abruption based upon enhancement (Grade 1, >50% perfusion; Grade 2, 25%-50% perfusion; Grade 3, <25% perfusion), as well as need for delivery and fetal outcomes. Forty-one patients met inclusion criteria. Computed tomography revealed evidence of placental abruption in six patients (15%): Grade 1, one patient, Grade 2, one patient, and Grade 3, four patients. Gestational ages ranged from 26 to 39 weeks. All patients with placental abruption of Grade 2 or greater developed concerning fetal heart tracings and underwent delivery emergently at first sign. Abruption was confirmed intraoperatively in all cases. Each birth was viable, and Apgar scores at 10 minutes were greater than 7 in 80% of infants, all of whom were ultimately discharged home. The remaining infant was transferred to an outside facility. Delivery at first sign of nonreassuring fetal heart rate tracings in pregnant trauma patients (third trimester) with placental abruption of Grade 2 or greater can lead to improved fetal outcome. Therapeutic/care management study, level III.

The value of an educational video before consultation with a radiation oncologist.

PubMed

Matsuyama, Robin K; Lyckholm, Laurie J; Molisani, Anthony; Moghanaki, Drew

2013-06-01

This study aims to assess the efficacy of a radiation therapy (RT) education video for patients referred for treatment. The investigators produced a 23-min guide to radiation therapy DVD, combining didactic material and patient narratives. Patients (n=32) had not yet received their initial consultation. Baseline awareness about cancer and treatment was assessed by surveys including the rapid estimate of adult literacy in medicine. Knowledge about RT was assessed before and after viewing the video with a separate 21 question survey. Differences in benefit for sociodemographic subgroups including age, gender, ethnicity, income, education, and health literacy level were explored. Baseline assessments identified 78 % of patients regardless of sociodemographic status had "little" to "no" basic knowledge of RT. The mean number of correct responses in the 21 question survey assessing how RT works improved from 9.8 to 11.1 after watching the video (p<0.0001; 95 % CI: 1.3-3.0), a statistically significant benefit that was present among all sociodemographic subgroups, but more prominent among those with a greater than high school education (p=0.002). Patient satisfaction with the video was high. Knowledge among cancer patients regarding RT is poor, regardless of sociodemographic factors. This pilot study demonstrates the utility of a brief video to universally improve patient awareness about RT. While patients may ultimately learn about RT during their course of treatment, we advocate for any tools that can improve patient knowledge at the time of initial consultation as this is typically the time they are asked to acknowledge informed consent for treatment.

Support of the transplant team.

PubMed

Kiss, A

1994-01-01

Both patients and staff in a bone marrow transplantation (BMT) unit have to cope with the effects of an aggressive treatment that helps many patients but also kills some. This has led to the regular involvement of support services in most American BMT units. This article describes the experience in 4 years of continuous psychosomatic liaison activity at the BMT unit at the University Hospital in Basel. The specific stressors a transplant team is subject to are described, such as high morbidity and mortality of patients and the close relationship between patients and staff members. Support for the transplant team consists in the following activities: a psychosocial interview with each patient at the beginning of his or her hospital stay; weekly psychosocial round-ups with the whole team; regular participation in ward rounds; organization of workshops to prevent burnout. Although an empirical evaluation of this approach is lacking, the clinical evidence suggests that constant and reliable team support helps to stabilize the team, adding to its inner security. This ultimately improves patient care.

Humor in the "Twilight Zone": My Work as a Medical Clown With Patients With Dementia.

PubMed

Raviv, Amnon

2014-09-01

Medical clowning has been primarily identified with working with children in pediatrics wards in hospitals. Over the past decade, more and more medical clowns have been working with adults and with patients with dementia as part of holistic care. Along with traditional medical care by hospital staff, the medical clown treats the patient's emotional side. Furthermore, medical clowning has unique advantages in working with patients with dementia. Several studies have shown that humor assists in improving the quality of life of patients with dementia. The clown, as the ultimate comic figure, creates interactions with patients based on humor, which empowers, calms, and strengthens the patient while reinforcing the patient's connection with the surroundings. Medical clowning is an interdisciplinary therapeutic art, and the medical clown has a "kit" of multiple skills (including humor, drama, music, and dance), all of which have a beneficial, therapeutic impact on patients. The current article presents and analyzes case studies from my work as a medical clown with patients with dementia. © The Author(s) 2013.

Patient-centeredness and quality management in Dutch diabetes care organizations after a 1-year intervention

PubMed Central

Campmans-Kuijpers, Marjo JE; Lemmens, Lidwien C; Baan, Caroline A; Rutten, Guy EHM

2016-01-01

Background More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention. Methods This before–after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization’s quality management program. Patient-centeredness (0%–100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients’ access to medical files, patient education policy, safeguarding patients’ interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests. Results Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P=0.002), and on its subdomains “access to medical files” (from 42.0% to 49.4%), and “safeguarding patients’ interests” (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P=0.54) or its subdomains. “Formal patient involvement” remained low in both care groups (23.2%) and outpatient clinics (33.9%). Conclusion After a simple intervention, care groups significantly improved their quality management on patient-centeredness, but outpatient clinics did not. Interventions to improve quality management on patient-centeredness in diabetes care organizations should differ between primary and secondary care. PMID:27784994

A Rare Presentation of Isolated CNS Posttransplantation Lymphoproliferative Disorder

PubMed Central

Smith, Casey; Streicher, Andrew; Magnuson, Allison; Newman, Susan; Bertoli, Robert

2017-01-01

Posttransplantation lymphoproliferative disorder (PTLD) is a recognized and extremely morbid complication of solid organ transplantation, but central nervous system involvement, particularly in isolation, is rare. There are no standardized treatment strategies for PTLD, though commonly used strategies include reduction of immunosuppression, chemotherapy, rituximab, radiation, and surgery. We present a case of an unusual morphologic variant of primary central nervous system PTLD with successful response to rituximab and cranial radiation. A 69-year-old Asian male, who underwent postrenal transplant nine years earlier, presented with a one-month history of new onset seizure activity. His evaluation revealed multiple brain lesions on magnetic resonance imaging (MRI), as well as serologic and cerebrospinal fluid studies which were positive for Epstein-Barr Virus (EBV) infection. Ultimately, he underwent craniotomy with tissue biopsy with the final pathology report showing posttransplant lymphoproliferative disorder, polymorphic type. The patient was managed with reduction in immunosuppression, rituximab therapy, and cranial radiation treatments. He had demonstrated marked improvement in his neurologic function and was ultimately discharged to inpatient rehabilitation facility. PMID:28116196

A Rare Presentation of Isolated CNS Posttransplantation Lymphoproliferative Disorder.

PubMed

Morris, Jaime; Smith, Casey; Streicher, Andrew; Magnuson, Allison; Newman, Susan; Bertoli, Robert

2017-01-01

Posttransplantation lymphoproliferative disorder (PTLD) is a recognized and extremely morbid complication of solid organ transplantation, but central nervous system involvement, particularly in isolation, is rare. There are no standardized treatment strategies for PTLD, though commonly used strategies include reduction of immunosuppression, chemotherapy, rituximab, radiation, and surgery. We present a case of an unusual morphologic variant of primary central nervous system PTLD with successful response to rituximab and cranial radiation. A 69-year-old Asian male, who underwent postrenal transplant nine years earlier, presented with a one-month history of new onset seizure activity. His evaluation revealed multiple brain lesions on magnetic resonance imaging (MRI), as well as serologic and cerebrospinal fluid studies which were positive for Epstein-Barr Virus (EBV) infection. Ultimately, he underwent craniotomy with tissue biopsy with the final pathology report showing posttransplant lymphoproliferative disorder, polymorphic type. The patient was managed with reduction in immunosuppression, rituximab therapy, and cranial radiation treatments. He had demonstrated marked improvement in his neurologic function and was ultimately discharged to inpatient rehabilitation facility.

[Effect of Yishen capsule on serum vascular endothelial growth factor and cell immunity in patients with chronic glomerulonephritis].

PubMed

Wu, Xi-li; Sun, Wan-sen; Zhang, Wang-gang; Qiao, Cheng-lin; Wang, Zhu; Wang, Juan

2007-11-01

To explore the effect of Yishen capsule on the serum vascular endothelial growth factor (VEGF), the cell immunity and the theraphic. Serum VEGF and T cell subsets were studied in 30 normal subjects and 83 patients before and after treatment. Compare with normal subjects, CD3, CD4, CD4/CD8 were decreased, CD8 and serum VEGF were increased obviously (P <0. 05 or P <0. 01). After three months treatment with YiShen capsule, CD4/CD8 was increased, CD8 and serum VEGF were decreased significantly (P <0.05 or P <0.01). Yishen capsule can reduce the proteinuria, increase the function of immunity and improve the clinical symptom of patients with chronic glomerulonephritis, achieved the effects of allevating chronic glomerular sclerosis ultimately.

Comprehensive care of amyotrophic lateral sclerosis patients: a care model.

PubMed

Güell, Maria Rosa; Antón, Antonio; Rojas-García, Ricardo; Puy, Carmen; Pradas, Jesus

2013-12-01

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease that presents with muscle weakness, causing progressive difficulty in movement, communication, eating and ultimately, breathing, creating a growing dependence on family members and other carers. The ideal way to address the problems associated with the disease, and the decisions that must be taken, is through multidisciplinary teams. The key objectives of these teams are to optimise medical care, facilitate communication between team members, and thus to improve the quality of care. In our centre, we have extensive experience in the care of patients with ALS through an interdisciplinary team whose aim is to ensure proper patient care from the hospital to the home setting. In this article, we describe the components of the team, their roles and our way of working. Copyright © 2012 SEPAR. Published by Elsevier Espana. All rights reserved.

Challenges to neurology residency education in today's health care environment.

PubMed

Bega, Danny; Krainc, Dimitri

2016-09-01

Residency training has had to adapt to higher patient volumes, increased complexity of medical care, and the commercialized system of health care. These changes have led to a concerning culture shift in neurology. We review the relationship between the emerging health care delivery system and residency training, highlighting issues related to duty hours and work-life balance, the changing technological landscape, high patient volumes, and complex service obligations. We propose that the current challenges in health care delivery offer the opportunity to improve neurology residency through faculty development programs, bringing teaching back to the bedside, increasing resident autonomy, utilizing near-peer teaching, and rewarding educators who facilitate an environment of inquiry and scholarship, with the ultimate goal of better alignment between education and patient care. Ann Neurol 2016;80:315-320. © 2016 American Neurological Association.

Ultimate Gradient Limitation in Niobium Superconducting Accelerating Cavities

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

Checchin, Mattia; Grassellino, Anna; Martinello, Martina

2016-06-01

The present study is addressed to the theoretical description of the ultimate gradient limitation in SRF cavities. Our intent is to exploit experimental data to confirm models which provide feed-backs on how to improve the current state-of-art. New theoretical insight on the cavities limiting factor can be suitable to improve the quench field of N-doped cavities, and therefore to take advantage of high Q 0 at high gradients.

Expanding the role of pharmacists and pharmacy students in the promotion of organ donation awareness.

PubMed

Descourouez, Jillian L; Richards, Katelyn R; Sam, Teena; Crowther, Barrett

2014-06-01

The gap between supply and demand for available organs has resulted in numerous deaths of patients on the transplant waiting list each year. Given the substantial public health impact of the organ shortage crisis, efforts have been focused on the use of educational interventions aimed both at the public and health care professionals to spread awareness of the disparity in organ supply and demand and ultimately improve organ donation rates. Transplant pharmacists are fundamental members of transplant multidisciplinary teams and are expected to promote organ and tissue awareness in an effort to decrease the morbidity and mortality of patients on the transplant waiting list. The role of pharmacists and pharmacy students in the promotion of organ donation awareness is expanding.

An Experimental Study of Medical Error Explanations: Do Apology, Empathy, Corrective Action, and Compensation Alter Intentions and Attitudes?

PubMed

Nazione, Samantha; Pace, Kristin

2015-01-01

Medical malpractice lawsuits are a growing problem in the United States, and there is much controversy regarding how to best address this problem. The medical error disclosure framework suggests that apologizing, expressing empathy, engaging in corrective action, and offering compensation after a medical error may improve the provider-patient relationship and ultimately help reduce the number of medical malpractice lawsuits patients bring to medical providers. This study provides an experimental examination of the medical error disclosure framework and its effect on amount of money requested in a lawsuit, negative intentions, attitudes, and anger toward the provider after a medical error. Results suggest empathy may play a large role in providing positive outcomes after a medical error.

The future of pharmacogenetics in the treatment of heart failure.

PubMed

Anwar, Mohamed Subhan; Iskandar, Muhammad Zaid; Parry, Helen M; Doney, Alex S; Palmer, Colin N; Lang, Chim C

2015-11-01

Heart failure is a common disease with high levels of morbidity and mortality. Current treatment comprises β-blockers, ACE inhibitors, aldosterone antagonists and diuretics. Variation in clinical response seen in patients begs the question of whether there is a pharmacogenetic component yet to be identified. To date, the genes most studied involve the β-1, β-2, α-2 adrenergic receptors and the renin-angiotensin-aldosterone pathway, mainly focusing on SNPs. However results have been inconsistent. Genome-wide association studies and next-generation sequencing are seen as alternative approaches to discovering genetic variations influencing drug response. Hopefully future research will lay the foundations for genotype-led drug management in these patients with the ultimate aim of improving their clinical outcome.

Salvaging catastrophe in transcatheter aortic valve implantation: rehearsal, preassigned roles, and emergency preparedness.

PubMed

Tam, Derrick Y; Jones, Philip M; Kiaii, Bob; Diamantouros, Pantelis; Teefy, Patrick; Bainbridge, Daniel; Cleland, Andrew; Fernandes, Philip; Chu, Michael W A

2015-08-01

Emergency rescue plans for acute complications during transcatheter aortic valve implantation (TAVI) commonly include cardiopulmonary resuscitation, femoro-femoral cardiopulmonary bypass (CPB), and hemodynamic stabilization before definitive intervention is achieved. Nevertheless, most cases of emergency resuscitation remain chaotic and disorganized and often take longer than necessary, even in experienced centres. We sought to determine which factors and procedures may be associated with improved patient outcomes when emergencies arise during TAVI. MEDLINE(®) and EMBASE™ were searched with the following key words: "TAVI" or "TAVR" or "transcatheter valve implantation" or "transcatheter valve replacement" and "emergency cardiac surgery" or "conversion". Two hundred seventeen articles met the criteria and were reviewed. Utilization of a formal emergency checklist by a multidisciplinary TAVI team may reduce procedural errors, smooth the transition to CPB, and ultimately speed the delivery of corrective measures including emergency cardiac surgery. A well-organized regularly-rehearsed emergency rescue plan that preassigns resuscitative roles may shorten the duration of patient instability and resuscitation and improve patient outcomes when catastrophe occurs in TAVI. The anesthesia team plays a central role in preventing, detecting, and treating intraprocedural complications during TAVI.

Perioperative Blood Management in Pediatric Spine Surgery.

PubMed

Oetgen, Matthew E; Litrenta, Jody

2017-07-01

Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.

Attitudes of Physician Assistant Educators Toward Interprofessional Education and Collaborative Care.

PubMed

Levy, Laura A; Mathieson, Kathleen

2017-06-01

Interprofessional education (IPE) has been shown to improve collaboration in the workforce, ultimately improving patient care. The purpose of this study was to evaluate physician assistant (PA) educators' attitudes toward IPE and interprofessional (IP) health care teams. An online survey was sent to 1198 PA educators. The survey assessed 3 domains: attitudes toward IPE, attitudes toward IP health care teams, and attitudes toward IP learning in the academic setting. Most participants were involved in some form of IPE. Faculty attitudes were positive in all 3 domains but were more favorable toward IPE. The positive attitudes held by PA faculty members may change the way in which curricula are conceived and delivered, influencing IP collaboration of future health care providers.

Velocity Measurements in Nasal Cavities by Means of Stereoscopic Piv - Preliminary Tests

NASA Astrophysics Data System (ADS)

Cozzi, Fabio; Felisati, Giovanni; Quadrio, Maurizio

2017-08-01

The prediction of detailed flow patterns in human nasal cavities using computational fluid dynamics (CFD) can provide essential information on the potential relationship between patient-specific geometrical characteristics of the nasal anatomy and health problems, and ultimately led to improved surgery. The complex flow structure and the intricate geometry of the nasal cavities make achieving such goals a challenge for CFD specialists. The need for experimental data to validate and improve the numerical simulations is particularly crucial. To this aim an experimental set-up based on Stereo PIV and a silicon phantom of nasal cavities have been designed and realized at Politecnico di Milano. This work describes the main features and challenges of the set-up along with some preliminary results.

3D printing strategies for peripheral nerve regeneration.

PubMed

Petcu, Eugen B; Midha, Rajiv; McColl, Erin; Popa-Wagner, Aurel; Chirila, Traian V; Dalton, Paul D

2018-03-23

After many decades of biomaterials research for peripheral nerve regeneration, a clinical product (the nerve guide), is emerging as a proven alternative for relatively short injury gaps. This review identifies aspects where 3D printing can assist in improving long-distance nerve guide regeneration strategies. These include (1) 3D printing of the customizable nerve guides, (2) fabrication of scaffolds that fill nerve guides, (3) 3D bioprinting of cells within a matrix/bioink into the nerve guide lumen and the (4) establishment of growth factor gradients along the length a nerve guide. The improving resolution of 3D printing technologies will be an important factor for peripheral nerve regeneration, as fascicular-like guiding structures provide one path to improved nerve guidance. The capability of 3D printing to manufacture complex structures from patient data based on existing medical imaging technologies is an exciting aspect that could eventually be applied to treating peripheral nerve injury. Ultimately, the goal of 3D printing in peripheral nerve regeneration is the automated fabrication, potentially customized for the patient, of structures within the nerve guide that significantly outperform the nerve autograft over large gap injuries.

Improving strategies for syphilis control in China: selective testing of sexually transmitted disease patients--too little, too late?

PubMed

Yin, Y-P; Wong, S P Y; Liu, M-S; Wei, W-H; Yu, Y-H; Gao, X; Chen, Q; Fu, Z-Z; Cheng, F; Chen, X-S; Cohen, M S

2008-12-01

Syphilis testing guidelines in China are usually based on symptomatic criteria, overlooking risk assessment and ultimately opportunities for disease detection and control. We used data from 10,695 sexually transmitted disease (STD) clinic patients in Guangxi, China, to assess the efficacy of a potential screening tool inquiring about behavioural and health risk factors in identifying the STD patients who should not be triaged for syphilis testing under current guidelines, but on the contrary receive such testing. Validity testing of the screening tool was performed and receiver-operating characteristic curves were plotted to determine an optimal total risk score cut-off for testing. About 40.9% of patients with positive toluidine red unheated serum test and Treponema pallidum particle agglutination test did not show hallmark signs of syphilis. The screening tool was more sensitive in detecting infection in non-triaged male versus female patients (highest sensitivity = 90% vs. 55%) and the cut-off score to warrant testing was lower in non-triaged female patients than in non-triaged male patients (cut-off = 1 vs. 2). Most of the cases were missed among female STD patients. In spite of selective testing based on behavioural and health indicators that improve case detection, cases were still missed. Our study supports universal testing for syphilis in the STD population.

The Miracle Baby Grows Up: Hypoplastic Left Heart Syndrome in the Adult.

PubMed

Lewis, Matthew; Rosenbaum, Marlon

2017-08-01

Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the mitral valve, left ventricle, and aorta and is ultimately palliated with a single-ventricle repair. Universally fatal in infancy prior to the advent of modern surgical techniques, the majority of HLHS patients will now reach adulthood. However, despite improvements in early survival, the HLHS population continues to face significant morbidity and early mortality. This review delineates common sources of patient morbidity and highlights areas in need of additional research for this growing segment of the adult congenital heart disease population. It has become increasingly clear that palliated adult single ventricle patients, like those with HLHS, face significant life-long morbidity from elevated systemic venous pressures as a consequence of the Fontan procedure. Downstream organ dysfunction secondary to elevated Fontan pressures has the potential to significantly impact long-term management decisions, including strategies of organ allocation. Because of the presence of a morphologic systemic right ventricle, HLHS patients may be at even higher risk than other adult patients with a Fontan. Because the adult HLHS population continues to grow, recognition of common sources of patient morbidity and mortality is becoming increasingly important. A coordinated effort between patients and providers is necessary to address the many remaining areas of clinical uncertainty to help ensure continued improvement in patient prognosis and quality of life.

Professional environment and patient safety in emergency departments.

PubMed

Lambrou, Persefoni; Papastavrou, Evridiki; Merkouris, Anastasios; Middleton, Nicos

2015-04-01

The purpose of this study was to examine nurses' and physicians' perceptions of professional environment and its association with patient safety in public emergency departments in Cyprus. A total of 224 professionals (174 nurses and 50 physicians) participated (rr = 81%). Data were collected using the "Revised Professional Practice Environment" (RPPE) instrument and the Safety Climate Domain of the "Emergency Medical Services Safety Attitudes Questionnaire" (EMS-SAQ). The mean overall score of RPPE was 2.79 (SD = 0.30), among physicians 2.84 (SD = 0.25) and nurses 2.73 (SD = 0.33) (P-value = 0.07). Statistically significant differences were observed between the two study groups regarding "staff relationships", "motivation" and "cultural sensitivity" (P-values < 0.05). No significant differences were observed as regards EMS-SAQ (3.25 vs. 3.16 respectively; P-value = 0.28). All 8 components of the RPPE exhibited significant association with patient safety. Linear and stepwise regression analyses showed that "leadership" explains 28% of the variance of safety. This relationship suggests improvements in professional environment with the ultimate goal of improving patient safety. Copyright © 2014 Elsevier Ltd. All rights reserved.

The Impact of New Payment Models on Quality of Diabetes Care and Outcomes.

PubMed

McGinley, Erin L; Gabbay, Robert A

2016-06-01

Historic changes in healthcare reimbursement and payment models due to the Affordable Care Act in the United States have the potential to transform how providers care for chronic diseases such as diabetes. Payment experimentation has provided insights into how changing incentives for primary care providers can yield improvements in the triple aim: improving patient experience, improving the health of populations, and reducing costs of healthcare. Much of this has involved leveraging widespread adoption of the patient-centered medical home (PCMH) with diabetes often the focus. While evidence is mounting that the PCMH can improve diabetes outcomes, some PCMH demonstrations have displayed mixed results. One of the first large-scale PCMH demonstrations developed around diabetes was conducted by the Commonwealth of Pennsylvania. Different payment models were employed across a series of staggered regional rollouts that provided a case study for the influence of innovative payment models. These learning laboratories provide insights into the role of reimbursement models and changes in how practice transformation is implemented. Ultimately, evolving payment systems focused on the total cost of care, such as Accountable Care Organizations, hold promise to transform diabetes care and produce significant cost savings through the prevention of complications.

Effects of the Smartphone Application "Safe Patients" on Knowledge of Patient Safety Issues Among Surgical Patients.

PubMed

Cho, Sumi; Lee, Eunjoo

2017-12-01

Recently, the patient's role in preventing adverse events has been emphasized. Patients who are more knowledgeable about safety issues are more likely to engage in safety initiatives. Therefore, nurses need to develop techniques and tools that increase patients' knowledge in preventing adverse events. For this reason, an educational smartphone application for patient safety called "Safe Patients" was developed through an iterative process involving a literature review, expert consultations, and pilot testing of the application. To determine the effect of "Safe Patients," it was implemented for patients in surgical units in a tertiary hospital in South Korea. The change in patients' knowledge about patient safety was measured using seven true/false questions developed in this study. A one-group pretest and posttest design was used, and a total of 123 of 190 possible participants were tested. The percentage of correct answers significantly increased from 64.5% to 75.8% (P < .001) after implementation of the "Safe Patients" application. This study demonstrated that the application "Safe Patients" could effectively improve patients' knowledge of safety issues. This will ultimately empower patients to engage in safe practices and prevent adverse events related to surgery.

Simple interventions can greatly improve clinical documentation: a quality improvement project of record keeping on the surgical wards at a district general hospital.

PubMed

Glen, Peter; Earl, Naomi; Gooding, Felix; Lucas, Emily; Sangha, Nicole; Ramcharitar, Steve

2015-01-01

Clinical documentation is an integral part of the healthcare professional's job. Good record keeping is essential for patient care, accurate recording of consultations and for effective communication within the multidisciplinary team. Within the surgical department at the Great Western Hospital, Swindon, the case notes were deemed to be bulky and cumbersome, inhibiting effective record keeping, potentially putting patients' at risk. The aim of this quality improvement project was therefore to improve the standard of documentation, the labelling of notes and the overall filing. A baseline audit was firstly undertaken assessing the notes within the busiest surgical ward. A number of variables were assessed, but notably, only 12% (4/33) of the case notes were found to be without loose pages. Furthermore, less than half of the pages with entries written within the last 72 hours contained adequate patient identifiers on them. When assessing these entries further, the designation of the writer was only recorded in one third (11/33) of the cases, whilst the printed name of the writer was only recorded in 65% (21/33) of the entries. This project ran over a 10 month period, using a plan, do study, act methodology. Initial focus was on simple education. Afterwards, single admission folders were introduced, to contain only information required for that admission, in an attempt to streamline the notes and ease the filing. This saw a global improvement across all data subsets, with a sustained improvement of over 80% compliance seen. An educational poster was also created and displayed in clinical areas, to remind users to label their notes with patient identifying stickers. This saw a 4-fold increase (16%-68%) in the labelling of notes. In conclusion, simple, cost effective measures in streamlining medical notes, improves the quality of documentation, facilitates the filing and ultimately improves patient care.

Relative value unit-based compensation incentivization in an academic vascular practice improves productivity with no early adverse impact on quality.

PubMed

Awad, Nadia; Caputo, Francis J; Carpenter, Jeffrey P; Alexander, James B; Trani, José L; Lombardi, Joseph V

2017-02-01

Given the increased pressure from governmental programs to restructure reimbursements to reflect quality metrics achieved by physicians, review of current reimbursement schemes is necessary to ensure sustainability of the physician's performance while maintaining and ultimately improving patient outcomes. This study reviewed the impact of reimbursement incentives on evidence-based care outcomes within a vascular surgical program at an academic tertiary care center. Data for patients with a confirmed 30-day follow-up for the vascular surgery subset of our institution's National Surgical Quality Improvement Program submission for the years 2013 and 2014 were reviewed. The outcomes reviewed included 30-day mortality, readmission, unplanned returns to the operating room, and all major morbidities. A comparison of both total charges and work relative value units (RVUs) generated was performed before and after changes were made from a salary-based to a productivity-based compensation model. P value analysis was used to determine if there were any statistically significant differences in patient outcomes between the two study years. No statistically significant difference in outcomes of the core measures studied was identified between the two periods. There was a trend toward a lower incidence of respiratory complications, largely driven by a lower incidence in pneumonia between 2013 and 2014. The vascular division had a net increase of 8.2% in total charges and 5.7% in work RVUs after the RVU-based incentivization program was instituted. Revenue-improving measures can improve sustainability of a vascular program without negatively affecting patient care as evidenced by the lack of difference in evidence-based core outcome measures in our study period. Further studies are needed to elucidate the long-term effects of incentivization programs on both patient care and program viability. Copyright © 2016. Published by Elsevier Inc.

Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation.

PubMed

Tjoumakaris, Fotios Paul; Tucker, Bradfords Chofield; Post, Zachary; Pepe, Matthew David; Orozco, Fabio; Ong, Alvin C

2014-05-01

Arthrofibrosis after total knee arthroplasty (TKA) is a potentially devastating complication, resulting in loss of motion and function and residual pain. For patients in whom aggressive physical therapy and manipulation under anesthesia fail, lysis of adhesions may be the only option to rescue the stiff TKA. The purpose of this study is to report the results of arthroscopic lysis of adhesions after failed manipulation for a stiff, cruciate-substituting TKA. This retrospective study evaluated patients who had undergone arthroscopic lysis of adhesions for arthrofibrosis after TKA between 2007 and 2011. Minimum follow-up was 12 months (average, 31 months). Average total range of motion of patients in this series was 62.3°. Average preoperative flexion contracture was 16° and average flexion was 78.6°. Statistical analysis was performed using Student's t test. Pre- to postoperative increase in range of motion was significant (P<.001) (average, 62° preoperatively to 98° postoperatively). Average preoperative extension deficit was 16°, which was reduced to 4° at final follow-up. This value was also found to be statistically significant (P<.0001). With regard to ultimate flexion attained, average preoperative flexion was 79°, which was improved to 103° at final follow-up. This improvement in flexion was statistically significant (P<.0001). Patients can reliably expect an improvement after arthroscopic lysis of adhesions for a stiff TKA using a standardized arthroscopic approach; however, patients achieved approximately half of the improvement that was obtained at the time of surgery. Copyright 2014, SLACK Incorporated.

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management.

PubMed

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-10-27

The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012-2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com

Breaking the barrier: the Health Belief Model and patient perceptions regarding contraception.

PubMed

Brown, Wendy; Ottney, Anne; Nguyen, Sammie

2011-05-01

The study was conducted to determine the discrepancy between unintended pregnancies and use of contraception is attributed to imperfect use, misconceptions and an inability to adjust therapy to lifestyle. A survey administered at a Federal clinic incorporated the Health Belief Model to determine patient's emphasis in pregnancy prevention. Analysis focused on comparing participant demographics to reasons for contraceptive selection. Ease of use ranked the most important for contraception as patient's education levels increased (p=.001). As household income increased, emphasis on potential side effects became less (p=.02). Patients with private insurance ranked ease of use most frequently (p=.01). Males emphasized effectiveness and menstrual suppression more than females (p=.04 and .008). A positive correlation between perceived benefit regarding ease of use as educational level increased and perceived barriers due to side effects as income level decreased immerged. Special counseling by practitioners to improve patient's self-efficacy, ultimately enhancing contraceptive adherence, are warranted. Copyright © 2011 Elsevier Inc. All rights reserved.

Completing advance directives for health care decisions: getting to yes.

PubMed

Shewchuk, T R

1998-09-01

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician-hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved--providers, patients, families, and payors--in this most profound process.

Predicting Length of Stay for Obstetric Patients via Electronic Medical Records.

PubMed

Gao, Cheng; Kho, Abel N; Ivory, Catherine; Osmundson, Sarah; Malin, Bradley A; Chen, You

2017-01-01

Obstetric care refers to the care provided to patients during ante-, intra-, and postpartum periods. Predicting length of stay (LOS) for these patients during their hospitalizations can assist healthcare organizations in allocating hospital resources more effectively and efficiently, ultimately improving maternal care quality and reducing costs to patients. In this paper, we investigate the extent to which LOS can be forecast from a patient's medical history. We introduce a machine learning framework to incorporate a patient's prior conditions (e.g., diagnostic codes) as features in a predictive model for LOS. We evaluate the framework with three years of historical billing data from the electronic medical records of 9188 obstetric patients in a large academic medical center. The results indicate that our framework achieved an average accuracy of 49.3%, which is higher than the baseline accuracy 37.7% (that relies solely on a patient's age). The most predictive features were found to have statistically significant discriminative ability. These features included billing codes for normal delivery (indicative of shorter stay) and antepartum hypertension (indicative of longer stay).

Improving operating theatre efficiency: an intervention to significantly reduce changeover time.

PubMed

Soliman, Bishoy A B; Stanton, Raymond; Sowter, Steven; Rozen, Warren Matthew; Shahbaz, Shekib

2013-07-01

Operating theatre inefficiency and changeover delays are not only a significant source of wasted resources, but also a familiar source of frustration to patients and health-care providers. This study aimed to prove that the surgical registrar through active involvement in patient changeover can significantly improve operating room efficiency and minimize delays. A two-phase prospective cohort study was undertaken, conducted over the course of 4 weeks at a single institution. The only inclusion criteria comprised patients to undertake endoscopic urological day surgery cases and require general anaesthesia. There were no exclusions. In the first phase (observational, with no intervention), changeover times between cases were documented. The second phase followed a structured intervention, involving the surgical registrar being actively involved in the patient's operative journey. Outcome measures were qualitative measures of operative efficiency. Statistical analysis was undertaken. There were 42 patients included in this study, with 21 patients in each of its arms. A 48% (P-value < 0.01) reduction in overall case changeover times was demonstrated with the utilization of a structured intervention from 27.7 min (95% confidence interval (CI) 22.8-32.7%) to 15.7 min (95% CI 13.2-18.2%). The intervention results were statistically significant (P-value < 0.05) for all markers of efficiency except for the waiting time in the anaesthetic holding bay (P-value 0.13). The surgical registrar can improve operating room efficiency by using a structured intervention, ultimately reducing patient changeover times. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.

Towards patient safety in anaesthesia.

PubMed

Cooper, J B

1994-07-01

The anaesthesia specialty has focused on the safety of the patient and examination of untoward outcomes. Serious injuries are now rare in medically advanced countries. Still, anaesthesia deaths and complications are important because the anaesthetic itself has no intended therapeutic effect. Safety is a never-ending battle that requires continued effort because many forces have the potential to diminish whatever progress is made. This paper describes the modern movement in anaesthesia patient safety--the reasons it started, the major foci and explanations for why anaesthesia seems now to be safer than at any time in history. The American legal system, critical incident studies, studies of malpractice claims and large-scale studies of anaesthesia outcomes played a role in increasing the awareness of the need to enhance anaesthesia safety. Many efforts are believed to have contributed to improvements in the safety of anaesthesia: improved training of anaesthesia clinicians, new pharmaceuticals, new technologies for monitoring (especially pulse oximetry and capnography), standards for monitoring and other aspects of anaesthesia care, safety enhancements in anaesthesia equipment and the implementation of quality assurance and risk management programmes. The creation of the Anesthesia Patient Safety Foundation in the United States and a similar organization in Australia have helped to bring about awareness of safety issues and to support study of patient safety. Ultimately, the motto of the Anesthesia Patient Safety Foundation should be the goal of all anaesthesia professionals: "That no patient shall be harmed by anaesthesia".

Achieving Hand Hygiene Success With a Partnership Between Graduate Medical Education, Hospital Leadership, and Physicians.

PubMed

Rosenbluth, Glenn; Garritson, Susan; Green, Adrienne L; Milev, Dimiter; Vidyarthi, Arpana R; Auerbach, Andrew D; Baron, Robert B

2016-11-01

Engaging physicians in hand hygiene programs is a challenge faced by many academic medical centers. Partnerships between education and academic leaders present opportunities for effective collaboration and improvement. The authors developed a robust hand hygiene quality improvement program, with attention to rapid-cycle improvements, including all levels of staff and health care providers. The program included a defined governance structure, clear data collection process, educational interventions, rapid-cycle improvements, and financial incentive for staff and physicians (including residents and fellows). Outcomes were measured on patients in all clinical areas. Run charts were used to document compliance in aggregate and by subgroups throughout the project duration. Institutional targets were achieved and then exceeded, with sustained hand hygiene compliance >90%. Physician compliance lagged behind aggregate compliance but ultimately was sustained at a level exceeding the target. Successfully achieving the institutional goal required collaboration among all stakeholders. Physician-specific data and physician champions were essential to drive improvement. © The Author(s) 2015.

Case for tort reform in medical malpractice.

PubMed

DeLuke, Dean M

2006-05-01

Under tort law, injured parties have the basic right to seek indemnity for wrongful injury, including injury from medical malpractice. Unfortunately, the present system is associated with many undesirable secondary effects, including problems of patient access to care, excessive testing or overtreatment, and undertreatment due to doctors' fear of malpractice. Nationwide, there are innumerable cases of doctors abandoning obstetrical or other high risk practices, or migrating away from states with less friendly tort laws. The California MICRA legislation of 1976 is often cited as a model for tort reform, but even this model legislation may be insufficient to restore a beleaguered trust between medical providers and their patients. Several key research studies suggest that the jury system fails to fairly and reliably compensate injured patients, and fails to deter or discipline errant doctors. To adequately meet the common needs of patients and health care providers, there must be an appropriate emphasis on aggressive risk management, quality improvement, patient safety, professional oversight, and responsible insurance underwriting. Moreover, there must be a systemic improvement of the current tort system as it pertains to medical malpractice. Although incremental reforms at the state level are slowly occurring and should certainly be supported, a greater reward may ultimately stem from more radical restructuring to a system of medical tribunals.

The HOME network: an Australian national initiative for home therapies.

PubMed

Chow, Josephine; Fortnum, Debbie; Moodie, Jo-Anne; Simmonds, Rosemary; Tomlins, Melinda

2013-01-01

Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia. In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network. Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies. The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies. © 2013 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Anterior Cruciate Ligament Reconstruction Rehabilitation

PubMed Central

Wright, Rick W.; Haas, Amanda K.; Anderson, Joy; Calabrese, Gary; Cavanaugh, John; Hewett, Timothy E.; Lorring, Dawn; McKenzie, Christopher; Preston, Emily; Williams, Glenn; Amendola, Annunziato

2015-01-01

Context: Anterior cruciate ligament (ACL) reconstruction rehabilitation has evolved over the past 20 years. This evolution has been driven by a variety of level 1 and level 2 studies. Evidence Acquisition: The MOON Group is a collection of orthopaedic surgeons who have developed a prospective longitudinal cohort of the ACL reconstruction patients. To standardize the management of these patients, we developed, in conjunction with our physical therapy committee, an evidence-based rehabilitation guideline. Study Design: Clinical review. Level of Evidence: Level 2. Results: This review was based on 2 systematic reviews of level 1 and level 2 studies. Recently, the guideline was updated by a new review. Continuous passive motion did not improve ultimate motion. Early weightbearing decreases patellofemoral pain. Postoperative rehabilitative bracing did not improve swelling, pain range of motion, or safety. Open chain quadriceps activity can begin at 6 weeks. Conclusion: High-level evidence exists to determine appropriate ACL rehabilitation guidelines. Utilizing this protocol follows the best available evidence. PMID:26131301

Validation of a Portuguese version of the Information Needs in Cardiac Rehabilitation (INCR) scale in Brazil.

PubMed

Ghisi, Gabriela Lima de Melo; Dos Santos, Rafaella Zulianello; Bonin, Christiani Batista Decker; Roussenq, Suellen; Grace, Sherry L; Oh, Paul; Benetti, Magnus

2014-01-01

To translate, culturally adapt and psychometrically validate the Information Needs in Cardiac Rehabilitation (INCR) tool to Portuguese. The identification of information needs is considered the first step to improve knowledge that ultimately could improve health outcomes. The Portuguese version generated was tested in 300 cardiac rehabilitation patients (CR) (34% women; mean age = 61.3 ± 2.1 years old). Test-retest reliability was assessed using intraclass correlation coefficient (ICC), the internal consistency using Cronbach's alpha, and the criterion validity was assessed with regard to patients' education and duration in CR. All 9 subscales were considered internally consistent (á > 0.7). Significant differences between mean total needs and educational level (p < 0.05) and duration in CR (p = 0.03) supported criterion validity. The overall mean (4.6 ± 0.4), as well as the means of the 9 subscales were high (emergency/safety was the greatest need). The Portuguese INCR was demonstrated to have sufficient reliability, consistency and validity. Copyright © 2014 Elsevier Inc. All rights reserved.

Radiomics: there is more than meets the eye in medical imaging (Conference Presentation)

NASA Astrophysics Data System (ADS)

Aerts, Hugo

2016-03-01

Imaging-based techniques have traditionally been restricted to the diagnosis of cancer and staging of cancer. But technological advances are moving imaging modalities into the heart of patient care. Radiomics uses imaging assays to develop biomarkers which complement those derived from biopsies. The ultimate goal of radiomics is to improve personalized medicine strategies by allowing clinicians to monitor disease in real time as patients move through treatment. Several studies in different cancer types have demonstrated that radiomic biomarkers have strong prognostic performance, and are associated with underlying mutation and gene-expression patterns. In this talk, Dr. Aerts will discuss recent developments from his lab and collaborators performing research at the intersection of radiology and bioinformatics. Also, he will discuss recent work of building a computational image analysis system to extract a rich radiomics set and use these features to build prognostic radiomics signatures. The presentation will conclude with a discussion of future work on building integrative systems incorporating both molecular and phenotypic data to improve cancer therapies.

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication.

PubMed

Bereznicki, B; Peterson, G; Jackson, S; Walters, E H; Gee, P

2011-04-01

A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3-fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short-acting beta-2 agonists). This follow-up study aimed to determine the long-term effects of the intervention programme on the preventer-to-reliever (P:R) ratio. The same data mining software was modified so that it could re-identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de-identified, encrypted and transferred via the Internet to a secure server. The follow-up dispensing data for all patients were compared with their pre- and post-intervention data collected originally. Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow-up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001). The follow-up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long-lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system. © 2010 Blackwell Publishing Ltd.

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial

PubMed Central

Subramaniam, Hamsa L.; Prust, Margaret L.; Prescott, Marta R.; Mpasela, Felton; Mwango, Albert; Namonje, Leah; Moyo, Crispin; Chibuye, Benjamin; van den Broek, Jan Willem; Hehman, Lindsey; Moberley, Sarah

2017-01-01

Introduction In urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence. Methods Formative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention’s impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services. Results The mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2–48.5; P = 0.2). Conclusion A more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia’s urban clinics. PMID:28419106

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial.

PubMed

McCarthy, Elizabeth A; Subramaniam, Hamsa L; Prust, Margaret L; Prescott, Marta R; Mpasela, Felton; Mwango, Albert; Namonje, Leah; Moyo, Crispin; Chibuye, Benjamin; van den Broek, Jan Willem; Hehman, Lindsey; Moberley, Sarah

2017-01-01

In urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence. Formative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention's impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services. The mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2-48.5; P = 0.2). A more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia's urban clinics.

Emergency transport by aeromedical blimp.

PubMed Central

Cottrell, J. J.; Garrard, C.

1989-01-01

Recently there has been an explosive growth in the use of helicopters and fixed wing aircraft for the transportation of patients who are ill and injured. Although using such methods of transport may result in faster access to health care centres, their ultimate role for the civilian population is unclear. Unfortunately, there are many problems associated with aeromedical transport, particularly with rotary wing aircraft, which have shown an alarming tendency to crash. The use of lighter than air vehicles (blimps, hot air balloons) might offer most of the advantages of conventional aieromedical transport, with an appreciable improvement in safety. Images p869-a PMID:2497829

Emergency transport by aeromedical blimp.

PubMed

Cottrell, J J; Garrard, C

1989-04-01

Recently there has been an explosive growth in the use of helicopters and fixed wing aircraft for the transportation of patients who are ill and injured. Although using such methods of transport may result in faster access to health care centres, their ultimate role for the civilian population is unclear. Unfortunately, there are many problems associated with aeromedical transport, particularly with rotary wing aircraft, which have shown an alarming tendency to crash. The use of lighter than air vehicles (blimps, hot air balloons) might offer most of the advantages of conventional aieromedical transport, with an appreciable improvement in safety.

Computer-assisted diagnosis of melanoma.

PubMed

Fuller, Collin; Cellura, A Paul; Hibler, Brian P; Burris, Katy

2016-03-01

The computer-assisted diagnosis of melanoma is an exciting area of research where imaging techniques are combined with diagnostic algorithms in an attempt to improve detection and outcomes for patients with skin lesions suspicious for malignancy. Once an image has been acquired, it undergoes a processing pathway which includes preprocessing, enhancement, segmentation, feature extraction, feature selection, change detection, and ultimately classification. Practicality for everyday clinical use remains a vital question. A successful model must obtain results that are on par or outperform experienced dermatologists, keep costs at a minimum, be user-friendly, and be time efficient with high sensitivity and specificity. ©2015 Frontline Medical Communications.

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis

PubMed Central

Perl, Jeffrey; Davies, Simon J.; Lambie, Mark; Pisoni, Ronald L.; McCullough, Keith; Johnson, David W.; Sloand, James A.; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M.

2016-01-01

♦ Background: Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ Methods: The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ Results: A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ Conclusion: The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. PMID:26526049

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis.

PubMed

Perl, Jeffrey; Davies, Simon J; Lambie, Mark; Pisoni, Ronald L; McCullough, Keith; Johnson, David W; Sloand, James A; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M

2016-01-01

♦ Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. Copyright © 2016 International Society for Peritoneal Dialysis.

New therapeutic options for allergic rhinitis: back to the future with intranasal corticosteroid aerosols.

PubMed

Carr, Warner W

2013-01-01

Under current guidelines, intranasal corticosteroids (INSs) are considered the most effective first-line therapy to improve allergic rhinitis (AR) symptoms and burden of disease. In the late 1980s-1990s, chlorofluorocarbon (CFC)-propelled corticosteroid aerosol nasal sprays formed the standard of care for the treatment of AR. Because of environmental concerns, CFC aerosols were gradually phased out, and aqueous INS formulations of nasal sprays became the standard of care. Although many aqueous INS sprays are available, specific product-related factors can reduce patient adherence to an INS and subsequently reduce treatment efficacy. The purpose of this paper was to review the evolution of AR therapeutics and drug devices and how it may have an effect on patient adherence/compliance and patient satisfaction with current available therapies and show the unmet need to improve INS delivery systems. Although aqueous INSs are effective and well tolerated, use in some patients may be compromised because of patient sensory perception and device preference. A historical review of the evolution of intranasal delivery of INSs was undertaken to provide further insight into improving treatment options for patients with AR. Although the various approved INSs appear to be equivalent in terms of reducing AR disease burden, the method in which an INS is delivered to a patient has significant bearing on the overall success of each specific drug product. Hydrofluoroalkane-propelled INS drug products offer a back-to-the-future delivery approach that may be further tailored to the individual patient's needs. Past experiences and the development of new devices are paving the way toward further therapy choices, ultimately affording health care providers access to the most effective treatments for patients with AR.

Advances in aortic disease management: a year in review.

PubMed

Garg, Vinay; Ouzounian, Maral; Peterson, Mark D

2016-03-01

The medical and surgical management of aortic disease is continually changing in search for improved outcomes. Our objective is to highlight recent advances in a few select areas pertaining to aortic disease and aortic surgery: the genetics of aortopathy, medical therapy of aortic aneurysms, advances in cardiac imaging, and operative strategies for the aortic arch. As our understanding of the genetic basis for aortopathy continues to improve, routine genetic testing may be of value in assessing patients with genetically triggered forms of aortic disease. With regard to medical advances, treating patients with Marfan syndrome with either losartan or atenolol at an earlier stage in their disease course improves outcomes. In addition, novel imaging indices such as wall shear stress and aortic stiffness assessed by MRI may become useful markers of aortopathy and warrant further study. With regard to the optimal technique for cerebral perfusion in aortic arch surgery, high-quality data are still lacking. Finally, in patients with complex, multilevel aortic disease, the frozen elephant trunk is a viable single-stage option compared with the conventional elephant trunk, although with an increased risk for spinal cord injury. Based on recent advances, continued studies in genetics, cardiac imaging, and surgical trials will further elucidate the etiology of aortopathy and ultimately guide management, both medically and surgically.

[Transparency of medical quality data. Ethical obligation to deliver or instrument to create unfair competitive advantage?].

PubMed

Ennker, J; Albert, A; Thanner, M; Nagel, E; Rosendahl, U; Ennker, I

2009-10-01

Annually about 100,000 acute cardiac deaths occur in Germany. For this reason, there is the obvious need, from a public health perspective, to inform the population about possible measures of their prevention and treatment. Ultimately every patient or admission referring doctor can be thought of as a recipient of "marketing". Other than within the context of economics, in medicine the subject of marketing is likely to produce a negative response. Any doctor engaging in marketing is quickly considered to be engaging in unfair competition at the expense of colleagues ("economic competitors"). However, despite some reservations it would seem sensible to provide transparency concerning the results of treatment. If the manner of competition is the right one, i.e. one that has as its aim to improve patient care, it can at the same time improve such care, motivate doctors and frequently also reduce costs. Transparency of the various aspects of improved medical care in this way represent a "pay-back" to everyone working in the health services. It is desirable to establish an external process of assessing any published data and, as far as possible, exclude all incorrect data from relevant measures of comparison. Competition can then be to the patient's benefit.

Can Economic Model Transparency Improve Provider Interpretation of Cost-effectiveness Analysis? Evaluating Tradeoffs Presented by the Second Panel on Cost-effectiveness in Health and Medicine.

PubMed

Padula, William V; McQueen, Robert Brett; Pronovost, Peter J

2017-11-01

The Second Panel on Cost-Effectiveness in Health and Medicine convened on December 7, 2016 at the National Academy of Medicine to disseminate their recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses (CEAs). Following its summary, panel proceedings included lengthy discussions including the field's struggle to disseminate findings efficiently through peer-reviewed literature to target audiences. With editors of several medical and outcomes research journals in attendance, there was consensus that findings of cost-effectiveness analyses do not effectively reach other researchers or health care providers. The audience members suggested several solutions including providing additional training to clinicians in cost-effectiveness research and requiring that cost-effectiveness models are made publicly available. However, there remains the questions of whether making economic modelers' work open-access through journals is fair under the defense that these models remain one's own intellectual property, or whether journals can properly manage the peer-review process specifically for cost-effectiveness analyses. In this article, we elaborate on these issues and provide some suggested solutions that may increase the dissemination and application of cost-effectiveness literature to reach its intended audiences and ultimately benefit the patient. Ultimately, it is our combined view as economic modelers and clinicians that cost-effectiveness results need to reach the clinician to improve the efficiency of medical practice, but that open-access models do not improve clinician access or interpretation of the economics of medicine.

Study on a practical robotic follower to support home oxygen therapy patients--questionnaire-based concept evaluation by the patients-.

PubMed

Endo, Gen; Iemura, Yu; Fukushima, Edwardo F; Hirose, Shigeo; Iribe, Masatsugu; Ikeda, Ryota; Onishi, Kohei; Maeda, Naoto; Takubo, Toshio; Ohira, Mineko

2013-06-01

Home oxygen therapy (HOT) is a medical treatment for the patients suffering from severe lung diseases. Although walking outdoors is recommended for the patients to maintain physical strength, the patients always have to carry a portable oxygen supplier which is not sufficiently light weight for this purpose. Our ultimate goal is to develop a mobile robot to carry an oxygen tank and follow a patient in an urban outdoor environment. We have proposed a mobile robot with a tether interface to detect the relative position of the foregoing patient. In this paper, we report the questionnaire-based evaluation about the two developed prototypes by the HOT patients. We conduct maneuvering experiments, and then obtained questionnaire-based evaluations from the 20 patients. The results show that the basic following performance is sufficient and the pulling force of the tether is sufficiently small for the patients. Moreover, the patients prefer the small-sized prototype for compactness and light weight to the middle-sized prototype which can carry larger payload. We also obtained detailed requests to improve the robots. Finally the results show the general concept of the robot is favorably received by the patients.

Call for action: how to improve use of patient-reported outcomes to guide clinical decision making in rheumatoid arthritis.

PubMed

Fautrel, Bruno; Alten, Rieke; Kirkham, Bruce; de la Torre, Inmaculada; Durand, Frederick; Barry, Jane; Holzkaemper, Thorsten; Fakhouri, Walid; Taylor, Peter C

2018-06-01

Current guidelines for the management of rheumatoid arthritis (RA) recommend early treatment and a treat-to-target goal of remission or low disease activity. Over the past decade, this approach has been extremely successful in reducing disease activity and joint damage in patients with RA. At the same time, however, overall patient perception of well-being appears to have decreased with respect to outcome measures considered important by patients themselves, such as pain, fatigue, physical function and quality of life. The timely and effective use of patient-reported outcomes (PROs) could encourage physicians to focus more on the impact of RA on patients and how patients are feeling. This in turn would facilitate shared decision making between patients and physicians, ultimately leading to a more patient-centered approach and improved patient care. Indeed, PROs provide information about individual patients that complements information provided by physical assessment and composite scores, and can also be used to guide patient care, such as determining whether a clinic visit is needed or whether treatment modifications are necessary. This is particularly important for patients who do not achieve the aspirational target of remission or low disease activity with pharmacological treatment. A number of validated PRO questionnaires are available, but how and which PROs should be incorporated into rheumatology clinical practice as part of the decision-making process is still controversial. Combining PROs with technology, such as computer adaptive tests, electronic PRO systems, web-based platforms and patient dashboards, could further aid PRO integration into daily rheumatology clinical practice.

Strategies to support spirituality in health care communication: a home hospice cancer caregiver case study.

PubMed

Reblin, Maija; Otis-Green, Shirley; Ellington, Lee; Clayton, Margaret F

2014-12-01

Although there is growing recognition of the importance of integrating spirituality within health care, there is little evidence to guide clinicians in how to best communicate with patients and family about their spiritual or existential concerns. Using an audio-recorded home hospice nurse visit immediately following the death of a patient as a case-study, we identify spiritually-sensitive communication strategies. The nurse incorporates spirituality in her support of the family by 1) creating space to allow for the expression of emotions and spiritual beliefs and 2) encouraging meaning-based coping, including emphasizing the caregivers' strengths and reframing negative experiences. Hospice provides an excellent venue for modeling successful examples of spiritual communication. Health care professionals can learn these techniques to support patients and families in their own holistic practice. All health care professionals benefit from proficiency in spiritual communication skills. Attention to spiritual concerns ultimately improves care. © The Author(s) 2014.

[Nutritional treatment for bronchopleural fistula-promising effect of arginine as a pharmaconutrient].

PubMed

Inoue, Mari; Kinoshita, Kahori; Isogawa, Naoto; Hino, Nao; Sano, Fumiyasu; Kobayashi, Mizuho; Yasuda, Shigeo; Komatsu, Teruya; Takahashi, Koji; Fujinaga, Takuji

2013-12-01

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

Anticipating issues related to increasing preimplantation genetic diagnosis use: a research agenda.

PubMed

Klitzman, Robert; Appelbaum, Paul S; Chung, Wendy; Sauer, Mark

2008-01-01

Increasing use of preimplantation genetic diagnosis (PGD) poses numerous clinical, social, psychological, ethical, legal and policy dilemmas, many of which have received little attention. Patients and providers are now considering and using PGD for a widening array of genetic disorders, and patients may increasingly seek 'designer babies.' In the USA, although governmental oversight policies have been discussed, few specific guidelines exist. Hence, increasingly, patients and providers will face challenging ethical and policy questions of when and for whom to use PGD, and how it should be financed. These issues should be better clarified and addressed through collection of data concerning the current use of PGD in the USA, including factors involved in decision making about PGD use, as well as the education of the various communities that are, and should be, involved in its implementation. Improved understanding of these issues will ultimately enhance the development and implementation of future clinical guidelines and policies.

Surgical robotics for patient safety in the perioperative environment: realizing the promise.

PubMed

Fuji Lai; Louw, Deon

2007-06-01

Surgery is at a crossroads of complexity. However, there is a potential path toward patient safety. One such course is to leverage computer and robotic assist techniques in the reduction and interception of error in the perioperative environment. This white paper attempts to facilitate the road toward realizing that promise by outlining a research agenda. The paper will briefly review the current status of surgical robotics and summarize any conclusions that can be reached to date based on existing research. It will then lay out a roadmap for future research to determine how surgical robots should be optimally designed and integrated into the perioperative workflow and process. Successful movement down this path would involve focused efforts and multiagency collaboration to address the research priorities outlined, thereby realizing the full potential of surgical robotics to augment human capabilities, enhance task performance, extend the reach of surgical care, improve health care quality, and ultimately enhance patient safety.

Neurologist-patient communication about epilepsy in the United States, Spain, and Germany.

PubMed

Stern, John M; Cendes, Fernando; Gilliam, Frank; Kwan, Patrick; Ryvlin, Philippe; Sirven, Joseph; Smith, Brien; Adomas, Aleksandra; Walter, Lauren

2018-04-01

Effective communication between patients and their health care providers is recognized as critically important to improve the quality of health services for individuals with epilepsy. We aimed to describe in-office neurologist-patient conversations about epilepsy and focus on disease identification, shared decision-making, and care planning. Transcripts and audio recordings of conversations between patients and neurologists in the United States, Spain, and Germany were analyzed linguistically in the topic areas of epilepsy identification and diagnosis, disease education, treatments, and care planning. Analyses included word-level assessments, topic switching, strategies of information elicitation, identification of topics discussed, quantification of questions asked, and assessment of types of questions asked. Conversations of 17 neurologists in the United States, 12 in Spain, and 6 in Germany, with 50, 20, and 16 patients, respectively, were analyzed. Neurologists tended to utilize an event-based, patient-friendly vocabulary to refer to seizures, and in the United States, they avoided using the term "epilepsy." Regardless of who initiated the treatment discussion, the neurologists in all 3 countries were unilaterally responsible for the treatment decision and choice of medication. When describing a new medication, neurologists most often discussed potential side effects but did not review potential benefits. Neurologists rarely defined seizure control and did not ask patients what seizure control meant to them. We identified opportunities related to vocabulary, decision-making, and treatment goal setting that could be targeted to improve neurologist-patient communication about epilepsy, and ultimately, the overall treatment experience and outcomes for patients.

Strategic hospital partnerships: improved access to care and increased epilepsy surgical volume.

PubMed

Vadera, Sumeet; Chan, Alvin Y; Mnatsankanyan, Lilit; Sazgar, Mona; Sen-Gupta, Indranil; Lin, Jack; Hsu, Frank P K

2018-05-01

OBJECTIVE Surgical treatment of patients with medically refractory focal epilepsy is underutilized. Patients may lack access to surgically proficient centers. The University of California, Irvine (UCI) entered strategic partnerships with 2 epilepsy centers with limited surgical capabilities. A formal memorandum of understanding (MOU) was created to provide epilepsy surgery to patients from these centers. METHODS The authors analyzed UCI surgical and financial data associated with patients undergoing epilepsy surgery between September 2012 and June 2016, before and after institution of the MOU. Variables collected included the length of stay, patient age, seizure semiology, use of invasive monitoring, and site of surgery as well as the monthly number of single-surgery cases, complex cases (i.e., staged surgeries), and overall number of surgery cases. RESULTS Over the 46 months of the study, a total of 104 patients underwent a total of 200 operations; 71 operations were performed in 39 patients during the pre-MOU period (28 months) and 129 operations were performed in 200 patients during the post-MOU period (18 months). There was a significant difference in the use of invasive monitoring, the site of surgery, the final therapy, and the type of insurance. The number of single-surgery cases, complex-surgery cases, and the overall number of cases increased significantly. CONCLUSIONS Partnerships with outside epilepsy centers are a means to increase access to surgical care. These partnerships are likely reproducible, can be mutually beneficial to all centers involved, and ultimately improve patient access to care.

The utah beacon experience: integrating quality improvement, health information technology, and practice facilitation to improve diabetes outcomes in small health care facilities.

PubMed

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J; North, Christie

2014-01-01

The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010-2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC(3) was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients' diabetes outcomes at 21 participating smaller, independent clinics. Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC(3) helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients' diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC(3) Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC(3) Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC(3) Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape.

The Hidden Curriculum: What Are We Actually Teaching about the Fundamentals of Care?

PubMed

MacMillan, Kathleen

2016-01-01

The issues of missed or inadequately provided basic nursing care and related complications are being identified as worldwide phenomena of interest. Without being aware of it, educators and practicing nurses may be teaching nursing students that fundamental nursing care is unimportant, uncomplicated and not really nursing's responsibility. This paper explores the concept of the "hidden curriculum" in nursing education, as it relates to fundamental nursing care and calls for greater partnerships between education and service to uncover the hidden curriculum; to effectively shape it to achieve alignment between classroom and practice; and, ultimately, to improve care processes and patient outcomes through collaboration. A renewed focus on the vital importance of what is considered "basics" to patient outcomes is required in nursing education. Copyright © 2016 Longwoods Publishing.

European regulations and their impact on tissue banking.

PubMed

Tatarenko, Alina

2006-01-01

Extensive CoE-EU cooperation ensures coherence and complementarities between the principles of the CoE guides which can be regarded as recommendations on best practice, and the technical requirements of the EU directives which set out legally binding requirements. This means that the same standards now exist throughout European continent. Having a common set of standards facilitates cooperation between different healthcare systems, especially in cases of emergencies, and the export-import issues. Adoption of the same quality management and traceability systems helps to minimise the risks and prevent disease transmissions. It reassures patients who undergo treatments outside of their countries. The tissue establishments need to introduce technical and structural changes to adhere to the new regulations which ultimately results in saving and improving of lives of many patients.

Granulomatosis with polyangiitis presenting as facial nerve palsy in a teenager.

PubMed

Wang, James C; Leader, Brittany A; Crane, Ryan A; Koch, Bernadette L; Smith, Matthew M; Ishman, Stacey L

2018-04-01

Granulomatosis with polyangiitis (GPA, previously known as Wegener's granulomatosis) is an autoimmune systemic small-vessel vasculitis, associated with the presence of anti-neurophil cytoplasmic antibodies with a cytoplasmic staining pattern (c-ANCA). It is characterized by necrotizing granulomas, usually affecting the airways and kidneys. GPA should be considered when patients do not improve despite adequate treatment of otologic symptoms, when patients have unspecific symptoms suggesting systemic disease (e.g. fever, malaise), or when other organs are involved (kidney, lungs, etc.). We present an interesting case of a 14-year-old female with eight-weeks of bilateral otalgia, unilateral facial nerve palsy, decreased appetite, and fatigue refractory to steroid, anti-viral, and antibiotic treatment ultimately diagnosed with GPA. Copyright © 2018. Published by Elsevier B.V.

Gas gangrene in the diabetic foot: lessons learned from a salvaged limb.

PubMed

Aerden, D; Lipsky, B A; Denecker, N; Nieboer, K; Keymeulen, B

2014-01-01

A 55 year old man was seen in the emergency department with an infected right foot and sepsis. Examination of the right foot revealed subcutaneous crepitus from the metatarsal head up to the tarsus; interstitial and intramedullary gas was confirmed on x-rays and computed tomographic scans. During 44 days of hospitalization, the patient was treated with multiple courses of antibiotic therapy, various wound care modalities (including negative wound pressure therapy) and several surgical interventions (debridements, amputations, revascularizations and reconstructive plastic surgery). Although limb salvage was ultimately accomplished, in retrospect many management decisions were suboptimal. A critical reassessment of our approach to this patient allowed us to identify several areas for improvement and this audit provided us an opportunity to learn from managing this difficult case.

Precision medicine in chronic disease management: the MS BioScreen

PubMed Central

Gourraud, Pierre-Antoine; Henry, Roland; Cree, Bruce AC; Crane, Jason C; Lizee, Antoine; Olson, Marram P; Santaniello, Adam V.; Datta, Esha; Zhu, Alyssa H.; Bevan, Carolyn J.; Gelfand, Jeffrey M.; Graves, Jennifer A.; Goodin, Douglas E.; Green, Ari; von Büdingen, H.-Christian; Waubant, Emmanuelle; Zamvil, Scott S.; Crabtree-Hartman, Elizabeth; Nelson, Sarah; Baranzini, Sergio E.; Hauser, Stephen L.

2014-01-01

We present a precision medicine application developed for multiple sclerosis (MS): the MS BioScreen. This new tool addresses the challenges of dynamic management of a complex chronic disease; the interaction of clinicians and patients with such a tool illustrates the extent to which translational digital medicine – i.e. the application of information technology to medicine—has the potential to radically transform medical practice. We introduce three key evolutionary phases in displaying data to health care providers, patients, and researchers: visualization (accessing data), contextualization (understanding the data), and actionable interpretation (real-time use of the data to assist decision-making). Together these form the stepping-stones that are expected to accelerate standardization of data across platforms, promote evidence-based medicine, support shared decision-making, and ultimately lead to improved outcomes. PMID:25263997

Social Determinants of Racial Disparities in CKD

PubMed Central

Norton, Jenna M.; Moxey-Mims, Marva M.; Eggers, Paul W.; Narva, Andrew S.; Star, Robert A.; Rodgers, Griffin P.

2016-01-01

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups. PMID:27178804

Clinical decision support systems for addressing information needs of physicians.

PubMed

Denekamp, Yaron

2007-11-01

Clinicians routinely practice in a state of incomplete information--about the patient, and about medical knowledge pertaining to patients' care. Consequently, there is now growing interest in the use of CDSS to bring decision support to the point of care. CDSS can impact physician behavior in routine practice. Nonetheless, CDSSs are meant to support humans who are ultimately responsible for the clinical decisions, rather than replace them. Although the adoption of CDSS has proceeded at a slow pace, there is a widespread recognition that CDSSs are expected to play a crucial role in reducing medical errors and improving the quality and efficacy of health care. This will be facilitated by the gradual maturation of electronic health record systems and the emergence of standard terminologies and messaging standards for the exchange of clinical data.

Enrolling African-American and Latino patients with asthma in comparative effectiveness research: Lessons learned from 8 patient-centered studies.

PubMed

Kramer, C Bradley; LeRoy, Lisa; Donahue, Sara; Apter, Andrea J; Bryant-Stephens, Tyra; Elder, John P; Hamilton, Winifred J; Krishnan, Jerry A; Shelef, Deborah Q; Stout, James W; Sumino, Kaharu; Teach, Stephen J; Federman, Alex D

2016-12-01

African-American and Latino patients are often difficult to recruit for asthma studies. This challenge is a barrier to improving asthma care and outcomes for these populations. We sought to examine the recruitment experiences of 8 asthma comparative effectiveness studies that specifically targeted African-American and Latino patients, and identify the solutions they developed to improve recruitment. Case report methodology was used to gather and evaluate information on study design, recruitment procedures and outcomes from study protocols and annual reports, and in-depth interviews with each research team. Data were analyzed for themes, commonalities, and differences. There were 4 domains of recruitment challenges: individual participant, institutional, research team, and study intervention. Participants had competing demands for time and some did not believe they had asthma. Institutional challenges included organizational policies governing monetary incentives and staff hiring. Research team challenges included ongoing training needs of recruitment staff, and intervention designs often were unappealing to participants because of inconveniences. Teams identified a host of strategies to address these challenges, most importantly engagement of patients and other stakeholders in study design and troubleshooting, and flexibility in data collection and intervention application to meet the varied needs of patients. Asthma researchers may have greater success with recruitment by addressing uncertainty among patients about asthma diagnosis, engaging stakeholders in all aspects of study design and implementation, and maximizing flexibility of study and intervention protocols. However, even with such efforts, engagement of African-American and Latino patients in asthma research may remain low. Greater investment in research on engaging these populations in asthma research may ultimately be needed to improve their asthma care and outcomes. Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Bioregulatory systems medicine: an innovative approach to integrating the science of molecular networks, inflammation, and systems biology with the patient's autoregulatory capacity?

PubMed Central

Goldman, Alyssa W.; Burmeister, Yvonne; Cesnulevicius, Konstantin; Herbert, Martha; Kane, Mary; Lescheid, David; McCaffrey, Timothy; Schultz, Myron; Seilheimer, Bernd; Smit, Alta; St. Laurent, Georges; Berman, Brian

2015-01-01

Bioregulatory systems medicine (BrSM) is a paradigm that aims to advance current medical practices. The basic scientific and clinical tenets of this approach embrace an interconnected picture of human health, supported largely by recent advances in systems biology and genomics, and focus on the implications of multi-scale interconnectivity for improving therapeutic approaches to disease. This article introduces the formal incorporation of these scientific and clinical elements into a cohesive theoretical model of the BrSM approach. The authors review this integrated body of knowledge and discuss how the emergent conceptual model offers the medical field a new avenue for extending the armamentarium of current treatment and healthcare, with the ultimate goal of improving population health. PMID:26347656

Fontan Surgical Planning: Previous Accomplishments, Current Challenges, and Future Directions.

PubMed

Trusty, Phillip M; Slesnick, Timothy C; Wei, Zhenglun Alan; Rossignac, Jarek; Kanter, Kirk R; Fogel, Mark A; Yoganathan, Ajit P

2018-04-01

The ultimate goal of Fontan surgical planning is to provide additional insights into the clinical decision-making process. In its current state, surgical planning offers an accurate hemodynamic assessment of the pre-operative condition, provides anatomical constraints for potential surgical options, and produces decent post-operative predictions if boundary conditions are similar enough between the pre-operative and post-operative states. Moving forward, validation with post-operative data is a necessary step in order to assess the accuracy of surgical planning and determine which methodological improvements are needed. Future efforts to automate the surgical planning process will reduce the individual expertise needed and encourage use in the clinic by clinicians. As post-operative physiologic predictions improve, Fontan surgical planning will become an more effective tool to accurately model patient-specific hemodynamics.

The Medicine with Respect Project: a stakeholder focus group evaluation.

PubMed

Hemingway, Steve; White, Jacquie; Turner, James; Dewhirst, Kate; Smith, George

2012-11-01

The administration of medicines is a role that fundamentally impacts on the wellbeing of the patient and has been described as one of the highest risk activities that a nurse undertakes. This article reports on the Medicine with Respect Project where collaborating organisations sought to improve the education and training of Mental Health Nurses toward safe and competence practice. Focus groups were used to evaluate stakeholders experiences and what emerged was overall satisfaction but with specific suggestions in how to improve the effectiveness of the project. All groups emphasised that all nurses in administering medicines should undergo a rigorous assessment of their medicines administration performance. This would make the ultimate aim of competent and safe practice more achievable. Copyright © 2012 Elsevier Ltd. All rights reserved.

Improving left spatial neglect through music scale playing.

PubMed

Bernardi, Nicolò Francesco; Cioffi, Maria Cristina; Ronchi, Roberta; Maravita, Angelo; Bricolo, Emanuela; Zigiotto, Luca; Perucca, Laura; Vallar, Giuseppe

2017-03-01

The study assessed whether the auditory reference provided by a music scale could improve spatial exploration of a standard musical instrument keyboard in right-brain-damaged patients with left spatial neglect. As performing music scales involves the production of predictable successive pitches, the expectation of the subsequent note may facilitate patients to explore a larger extension of space in the left affected side, during the production of music scales from right to left. Eleven right-brain-damaged stroke patients with left spatial neglect, 12 patients without neglect, and 12 age-matched healthy participants played descending scales on a music keyboard. In a counterbalanced design, the participants' exploratory performance was assessed while producing scales in three feedback conditions: With congruent sound, no-sound, or random sound feedback provided by the keyboard. The number of keys played and the timing of key press were recorded. Spatial exploration by patients with left neglect was superior with congruent sound feedback, compared to both Silence and Random sound conditions. Both the congruent and incongruent sound conditions were associated with a greater deceleration in all groups. The frame provided by the music scale improves exploration of the left side of space, contralateral to the right hemisphere, damaged in patients with left neglect. Performing a scale with congruent sounds may trigger at some extent preserved auditory and spatial multisensory representations of successive sounds, thus influencing the time course of space scanning, and ultimately resulting in a more extensive spatial exploration. These findings offer new perspectives also for the rehabilitation of the disorder. © 2015 The British Psychological Society.

Patient Education for Endoscopic Sinus Surgery: Preliminary Experience Using 3D-Printed Clinical Imaging Data.

PubMed

Sander, Ian M; Liepert, Taimi T; Doney, Evan L; Leevy, W Matthew; Liepert, Douglas R

2017-04-07

Within the Ear, Nose, and Throat (ENT) medical space, a relatively small fraction of patients follow through with elective surgeries to fix ailments such as a deviated septum or occluded sinus passage. Patient understanding of their diagnosis and treatment plan is integral to compliance, which ultimately yields improved medical outcomes and better quality of life. Here we report the usage of advanced, polyjet 3D printing methods to develop a multimaterial replica of human nasal sinus anatomy, derived from clinical X-ray computed tomography (CT) data, to be used as an educational aid during physician consultation. The final patient education model was developed over several iterations to optimize material properties, anatomical accuracy and overall display. A two-arm, single-center, randomized, prospective study was then performed in which 50 ENT surgical candidates (and an associated control group, n = 50) were given an explanation of their anatomy, disease state, and treatment options using the education model as an aid. Statistically significant improvements in patient ratings of their physician's explanation of their treatment options ( p = 0.020), self-rated anatomical understanding ( p = 0.043), self-rated understanding of disease state ( p = 0.016), and effectiveness of the visualization ( p = 0.007) were noted from the population that viewed the 3D education model, indicating it is an effective tool which ENT surgeons may use to educate and interact with patients.

Integration of the CLS doctorate into the healthcare organization.

PubMed

Montoya, Isaac; Kimball, Olive

2009-01-01

A review of how the doctorally prepared CLS fits into the healthcare organization. Literature review. Numerous national studies have called for a reshaping of the health care delivery system and the need to improve patient outcomes. Because of unprecedented advances in laboratory related technology as well as the need for economic retrenchment strategies in health care, with its significant influence on patient care, the laboratory has become the subject of intensive study. It has been concluded that the traditional organizational structure of the laboratory information process and the required personnel skills both need rethinking. In order to foster change in the laboratory, an advanced degreed CLS laboratory professional is needed, one already equipped with a broad scientific base developed via a baccalaureate/masters level of education. With the addition of advanced technical expertise, basic medical skills, data interpretation skills and patient interaction abilities, and medical research experience, this laboratory professional can enhance the effective and efficient use of laboratory information and ultimately improve patient care. The clinical doctorates in CLS are educationally and experientially prepared to recommend support and enhance appropriate testing. They translate and transform complex laboratory data into an understandable product necessary for clinicians to be able to assess the validity of current and new assays to ensure better patient care. In addition, they assist in reducing questionable test usage, thereby reducing costs for both the patient and the laboratory.

Building a Biopsychosocial Conceptual Framework to Explore Pressure Ulcer Pain for Hospitalized Patients.

PubMed

Kim, Junglyun; Ahn, Hyochol; Lyon, Debra E; Stechmiller, Joyce

2016-01-08

Although pressure ulcers are a prevalent condition, pain associated with pressure ulcers is not fully understood. Indeed, previous studies do not shed light on the association between pressure ulcer stages and the experience of pain. Especially, pain characteristics of suspected deep tissue injury, which is a new category that was recently added by the National Pressure Ulcer Advisory Panel, are yet unknown. This is concerning because the incidence of pressure ulcers in hospitalized patients has increased exponentially over the last two decades, and health care providers are struggling to ensure providing adequate care. Thus, in order to facilitate the development of effective interventions, this paper presents a conceptual framework to explore pressure ulcer pain in hospitalized patients. The concepts were derived from a biopsychosocial model of pain, and the relationships among each concept were identified through a literature review. Major propositions are presented based on the proposed conceptual framework, which integrates previous research on pressure ulcer pain, to ultimately improve understanding of pain in hospitalized patients with pressure ulcers.

[Multidisciplinary team building in enhanced recovery after surgery].

PubMed

Jia, W D

2018-01-01

There has been 10 years to explore the road in line with China's actual enhanced recovery after surgery(ERAS) since Academician Li Jieshou introduced the view of ERAS into China. ERAS has been widely carried out in the field of surgery, and gradually formed with Chinese characteristics of ERAS clinical pathway.The clinical implementation of ERAS relies on the effective integration of a series of perioperative methods, and any single technique or method can't completely reduce the perioperative physiological and psychological traumatic stress of the patient, so as to achieve the patient's rapid rehabilitation patient-centered multidisciplinary team(MDT)collaboration is an inevitable trend in ERAS development. On the basis of drawing lessons from foreign experience, the establishment of ERAS-MDT model in line with China's national conditions is a new subject that needs to be studied at present. The construction of ERAS-MDT might promote the development of new ERAS services, new technologies, and ultimately promote the improvement of surgical treatment, and bring the greatest clinical benefit to the society and patients.

Quality of patient education materials for rehabilitation after neurological surgery.

PubMed

Agarwal, Nitin; Sarris, Christina; Hansberry, David R; Lin, Matthew J; Barrese, James C; Prestigiacomo, Charles J

2013-01-01

To evaluate the quality of online patient education materials for rehabilitation following neurological surgery. Materials were obtained from the National Institute of Neurological Disorders and Stroke (NINDS), U.S. National Library of Medicine (NLM), American Occupational Therapy Association (AOTA), and the American Academy of Orthopaedic Surgeons (AAOS). After removing unnecessary formatting, the readability of each site was assessed using the Flesch Reading Ease and Flesch-Kincaid Grade Level evaluations with Microsoft Office Word software. The average values of the Flesch Reading Ease and Flesch-Kincaid Grade Level were 41.5 and 11.8, respectively, which are well outside the recommended reading levels for the average American. Moreover, no online section was written below a ninth grade reading level. Evaluations of several websites from the NINDS, NLM, AOTA, and AAOS demonstrated that their reading levels were higher than that of the average American. Improved readability might be beneficial for patient education. Ultimately, increased patient comprehension may correlate to positive clinical outcomes.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study.

PubMed

Wilbanks, Bryan A; Geisz-Everson, Marjorie; Boust, Rebecca R

2016-09-01

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

Dynamic consent: a possible solution to improve patient confidence and trust in how electronic patient records are used in medical research.

PubMed

Williams, Hawys; Spencer, Karen; Sanders, Caroline; Lund, David; Whitley, Edgar A; Kaye, Jane; Dixon, William G

2015-01-13

With one million people treated every 36 hours, routinely collected UK National Health Service (NHS) health data has huge potential for medical research. Advances in data acquisition from electronic patient records (EPRs) means such data are increasingly digital and can be anonymised for research purposes. NHS England's care.data initiative recently sought to increase the amount and availability of such data. However, controversy and uncertainty following the care.data public awareness campaign led to a delay in rollout, indicating that the success of EPR data for medical research may be threatened by a loss of patient and public trust. The sharing of sensitive health care data can only be done through maintaining such trust in a constantly evolving ethicolegal and political landscape. We propose that a dynamic consent model, whereby patients can electronically control consent through time and receive information about the uses of their data, provides a transparent, flexible, and user-friendly means to maintain public trust. This could leverage the huge potential of the EPR for medical research and, ultimately, patient and societal benefit.

The use of simulation in teaching the basic sciences.

PubMed

Eason, Martin P

2013-12-01

To assess the current use of simulation in medical education, specifically, the teaching of the basic sciences to accomplish the goal of improved integration. Simulation is increasingly being used by the institutions to teach the basic sciences. Preliminary data suggest that it is an effective tool with increased retention and learner satisfaction. Medical education is undergoing tremendous change. One of the directions of that change is increasing integration of the basic and clinical sciences to improve the efficiency and quality of medical education, and ultimately to improve the patient care. Integration is thought to improve the understanding of basic science conceptual knowledge and to better prepare the learners for clinical practice. Simulation because of its unique effects on learning is currently being successfully used by many institutions as a means to produce that integration through its use in the teaching of the basic sciences. Preliminary data indicate that simulation is an effective tool for basic science education and garners high learner satisfaction.

Surgical Mortality Audit-lessons Learned in a Developing Nation.

PubMed

Bindroo, Sandiya; Saraf, Rakesh

2015-06-01

Surgical audit is a systematic, critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognized standards. It is used to improve surgical practice with the ultimate goal of improving patient care. As the pattern of surgical care is different in the developing world, we analyzed mortalities in a referral medical institute of India to suggest interventions for improvement. An analysis of total admissions, different surgeries, and mortalities over 1 year in an urban referral medical institute of northern India was performed, followed by "peer review" of the mortalities. Mortality rates as outcomes and classification was done to provide comparative results. Of 10,005 surgical patients, 337 (male = 221, female = 116) deaths were reported over 1 year. The overall mortality rate was 3.36%, while mortality in operative cases was 1.76%. Total deaths were classified into (1) Viable: 153 (45%), (2) Nonviable: 174 (52%), and (3) Indeterminate: 10 (3%). Exclusion of the nonviable group reduced the mortality rate from 3.36% to 1.62%. Trauma was the major cause of mortality (n = 235; 70%) as compared to other surgical patients (n = 102; 30%). Increased mortality was also associated with emergency procedures (3.66%) as compared to elective surgeries (0.34%). In conclusion, audit of mortality and morbidity helps in initiating and implementing preventive strategies to improve surgical practice and patient care, and to reduce mortality rates. The mortality and morbidity forum is an important educational activity. It should be considered a mandatory activity in all postgraduate training programs.

"Getting the Knowledge Right": Patient Communication, Agency, and Knowledge.

PubMed

Gouge, Catherine

2016-03-28

In 2013, in accordance with a provision in the Patient Protection and Affordable Care Act (2010), the U.S. government began fining hospitals with "excessive" patient readmission rates. Those working to respond to this issue have identified discharge communication with patients as a critical component. In response to this exigency and to contribute to the conversation in the medical humanities about the field's purview and orientation, this article analyzes studies of and texts about communication in health and medicine, ultimately arguing that the on-going circulation of compliance rhetoric and assumptions has limited efforts to improve patient communication. The article, furthermore, considers that humanist ideals of agentic action, the patient-centered care movement's emphasis on the patient, and biomedicine's tendency to treat evidence-based knowledge as fixed and given may have combined to support a rationale for using patient adherence to treatment guidelines as metrics in measurement studies designed to identify effective communication strategies. Finally, the article proposes that those working in the medical humanities consider the value of interdisciplinary posthumanist scholarship-specifically, its treatment of agency and knowledge as emergent, distributed, and contingent-and its potential to transform or extend in productive ways the conversation about what constitutes effective communication with patients.

Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT

PubMed Central

Radcliff, Kris; Kepler, Christopher; Hilibrand, Alan; Rihn, Jeffrey; Zhao, Wenyan; Lurie, Jon; Tosteson, Tor; Vaccaro, Alexander; Albert, Todd; Weinstein, James

2013-01-01

Summary of Background Data Lumbar spinal stenosis is a common incidental finding among adults over the age of 60, The use of ESI in these patients is common, although there is little evidence in the literature to demonstrate the long-term benefit of ESI in the treatment of lumbar stenosis. Objective The hypothesis of this study was that patients who received epidural steroid injections (ESI) during initial treatment as part of the Spine Patient Outcomes Research Trial (SPORT) would have improved clinical outcomes and a lower rate of crossover to surgery compared to patients who did not receive ESI. Methods Patients with lumbar spinal stenosis who received epidural steroid injections within the first three months of enrollment in SPORT (ESI) were compared to patients who did not receive epidural injections during the first three months of the study (No ESI). Results There were 69 ESI patients and 207 No-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (62% vs. 33%, p <0.001). There was an average 26 minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over four years, there was significantly less improvement in SF36 PF among surgically treated ESI patients (ESI 14.8 vs. No-ESI 22.5, p=0.025). In addition, there was also significantly less improvement among the nonsurgically treated patients in SF36 BP (ESI 7.3 vs. No-ESI 16.7, p=0.007) and SF36 PF (ESI 5.5 vs. No-ESI 15.2, p=0.009). Of the patients assigned to surgical treatment, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. No ESI 11%, p=0.012). Of the patients assigned to non-operative treatment, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. No ESI 32%, p=0.003). Conclusion Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT. Furthermore, ESI were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically. PMID:23238485

The early effects of Medicare's mandatory hospital pay-for-performance program.

PubMed

Ryan, Andrew M; Burgess, James F; Pesko, Michael F; Borden, William B; Dimick, Justin B

2015-02-01

To evaluate the impact of hospital value-based purchasing (HVBP) on clinical quality and patient experience during its initial implementation period (July 2011-March 2012). Hospital-level clinical quality and patient experience data from Hospital Compare from up to 5 years before and three quarters after HVBP was initiated. Acute care hospitals were exposed to HVBP by mandate while critical access hospitals and hospitals located in Maryland were not exposed. We performed a difference-in-differences analysis, comparing performance on 12 incentivized clinical process and 8 incentivized patient experience measures between hospitals exposed to the program and a matched comparison group of nonexposed hospitals. We also evaluated whether hospitals that were ultimately exposed to HVBP may have anticipated the program by improving quality in advance of its introduction. Difference-in-differences estimates indicated that hospitals that were exposed to HVBP did not show greater improvement for either the clinical process or patient experience measures during the program's first implementation period. Estimates from our preferred specification showed that HVBP was associated with a 0.51 percentage point reduction in composite quality for the clinical process measures (p > .10, 95 percent CI: -1.37, 0.34) and a 0.30 percentage point reduction in composite quality for the patient experience measures (p > .10, 95 percent CI: -0.79, 0.19). We found some evidence that hospitals improved performance on clinical process measures prior to the start of HVBP, but no evidence of this phenomenon for the patient experience measures. The timing of the financial incentives in HVBP was not associated with improved quality of care. It is unclear whether improvement for the clinical process measures prior to the start of HVBP was driven by the expectation of the program or was the result of other factors. © Health Research and Educational Trust.

Religious versus Conventional Psychotherapy for Major Depression in Patients with Chronic Medical Illness: Rationale, Methods, and Preliminary Results

PubMed Central

Koenig, Harold G.

2012-01-01

This paper (1) reviews the physical and religious barriers to CBT that disabled medically ill-depressed patients face, (2) discusses research on the relationship between religion and depression-induced physiological changes, (3) describes an ongoing randomized clinical trial of religious versus secular CBT in chronically ill patients with mild-to-moderate major depression designed to (a) overcome physical and religious barriers to CBT and (b) compare the efficacy of religious versus secular CBT in relieving depression and improving immune and endocrine functions, and (4) presents preliminary results that illustrate the technical difficulties that have been encountered in implementing this trial. CBT is being delivered remotely via instant messaging, telephone, or Skype, and Christian, Jewish, Muslim, Buddhist, and Hindu versions of religious CBT are being developed. The preliminary results described here are particular to the technologies employed in this study and are not results from the CBT clinical trial whose findings will be published in the future after the study ends and data are analyzed. The ultimate goal is to determine if a psychotherapy delivered remotely that integrates patients' religious resources improves depression more quickly than a therapy that ignores them, and whether religious CBT is more effective than conventional CBT in reversing depression-induced physiological changes. PMID:22778932

[Recommendations for institutional response to an adverse event].

PubMed

2016-01-01

The organizational response after an Adverse Event (AE) is critical for the patient recovery and trust restoration in the health system. It is also crucial for the involved caregiver psychological recovery. To design a frame of recommendations to help the healthcare services, institutions and organizations to provide a systematic approach to an AE. A reduced group of authors performed a non-systematic review of the literature and developed an initial draft. The draft was sent to the rest of authors, who suggested modifications in structure, content, references and style throughout successive manuscript versions until a final one was accepted. AE response includes the patient's clinical stabilization and a therapeutic plan to mitigate harm, the safeguard of used materials or health products involved, the appropriate disclosure to patient and family, the support of affected staff and their replacement if needed, the report to appropriate clinical and management heads, the event circumstances documentation and the starting of the AE investigation and analysis. Besides the professional, family and patient's trust and health recovery, the ultimate target of a correct AE response is the improvement of healthcare processes to prevent its repetition considering the AE as a system failure and learning and improving through its analysis. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.

Clinical consequences of iron overload in patients with myelodysplastic syndromes: the case for iron chelation therapy.

PubMed

Shammo, Jamile M; Komrokji, Rami S

2018-06-14

Patients with myelodysplastic syndromes (MDS) are at increased risk of iron overload due to ineffective erythropoiesis and chronic transfusion therapy. The clinical consequences of iron overload include cardiac and/or hepatic failure, endocrinopathies, and infection risk. Areas covered: Iron chelation therapy (ICT) can help remove excess iron and ultimately reduce the clinical consequences of iron overload. The authors reviewed recent (last five years) English-language articles from PubMed on the topic of iron overload-related complications and the use of ICT (primarily deferasirox) to improve outcomes in patients with MDS. Expert Commentary: While a benefit of ICT has been more firmly established in other transfusion-dependent conditions such as thalassemia, its role in reducing iron overload in MDS remains controversial due to the lack of prospective controlled data demonstrating a survival benefit. Orally administered chelation agents (e.g., deferasirox), are now available, and observational and/or retrospective data support a survival benefit of using ICT in MDS. The placebo-controlled TELESTO trial (NCT00940602) is currently examining the use of deferasirox in MDS patients with iron overload, and is evaluating specifically whether use of ICT to alleviate iron overload can also reduce iron overload-related complications in MDS and improve survival.

Social Determinants of Health, the Chronic Care Model, and Systemic Lupus Erythematosus

PubMed Central

Williams, Edith M.; Ortiz, Kasim; Browne, Teri

2014-01-01

Systemic lupus erythematosus (SLE) is a chronic inflammatory rheumatic disease that disproportionately affects African Americans and other minorities in the USA. Public health attention to SLE has been predominantly epidemiological. To better understand the effects of this cumulative disadvantage and ultimately improve the delivery of care, specifically in the context of SLE, we propose that more research attention to the social determinants of SLE is warranted and more transdisciplinary approaches are necessary to appropriately address identified social determinants of SLE. Further, we suggest drawing from the chronic care model (CCM) for an understanding of how community-level factors may exacerbate disparities explored within social determinant frameworks or facilitate better delivery of care for SLE patients. Grounded in social determinants of health (SDH) frameworks and the CCM, this paper presents issues relative to accessibility to suggest that more transdisciplinary research focused on the role of place could improve care for SLE patients, particularly the most vulnerable patients. It is our hope that this paper will serve as a springboard for future studies to more effectively connect social determinants of health with the chronic care model and thus more comprehensively address adverse health trajectories in SLE and other chronic conditions. PMID:26464854

Characteristics, expectations and needs of the dutch endometriosis society members.

PubMed

Roos-Eysbouts, Yalck; De Bie-Rocks, Bianca; Van Dijk, Jolanda; Nap, Annemiek W

2015-01-01

BACKGROUND/AIM STUDY QUESTION: Endometriosis is associated with a significant reduction in the quality of life and higher depression and anxiety rates. The Dutch Endometriosis Society (ES) was founded to increase the recognition and knowledge in patients and health care professionals, stimulate research and improve care. This study was conducted to explore the characteristics of the members and evaluate their needs and expectations. A descriptive questionnaire-based survey was conducted among all members of the ES. The response rate was 51% (n = 571). ES members appear to be highly educated women with a wide variety of endometriosis-related symptoms resulting in considerable restrictions in daily life. Information transmission was considered the main aim of ES (97%), whereas 56% expected social support, and 38% expected advocacy. The majority (71%) reported an improvement in their quality of life after contact with the ES. The results of this study underline patients' primary quest for information about endometriosis. Patient support groups such as ES can fulfil a useful role in disseminating knowledge from medical professionals to those suffering a chronic illness, resulting in a greater understanding and ultimately increasing their quality of life. © 2015 S. Karger AG, Basel.

Using the Internet in the management of asthma.

PubMed

Patel, A M

2001-01-01

The ultimate goals of managing asthma are to eliminate death, prevent or promptly treat exacerbations, and maximize the quality of life and health status of patients. Current strategies include appropriate education, trigger control, and timely access to effective pharmacotherapy and follow-up. Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions. The main types of Internet-based applications for asthma management include remote monitoring and feedback between health professionals and their patients; online education and marketing for either patients or professionals; networking and collaborative research; and administrative oversight through policy making, planning, and decision support. With increased understanding of integrated disease management and the technostructural as well as psychodynamic issues related to Internet use, further refinement and evolution of the Internet and related technologies may drastically improve the way we monitor, educate, treat, and establish policies for this global problem while attending to individual or local community needs. This review presents a conceptual overview of the current challenges and use of the Internet for improving asthma management through timely and tailored education and appropriate access to health care expertise.

EHealth Acceptance and New Media Preferences for Therapy Assistance Among Breast Cancer Patients

PubMed Central

Drewes, Caroline; Kirkovits, Thomas; Schiltz, Daniel; Schinkoethe, Timo; Haidinger, Renate; Harbeck, Nadia

2016-01-01

Background Electronic health (eHealth) and mobile communication-based health care (mHealth) applications have been increasingly utilized in medicine over the last decade, and have facilitated improved adherence to therapy regimens in patients with chronic conditions. Due to the long duration of breast cancer therapy, and the long course of disease in metastatic breast cancer, a need for more intensified physician-patient communication has emerged. Various support mechanisms, including new media such as mHealth and eHealth, have been proposed for this purpose. Objective The aim of this study was to analyze the correlation between sociodemographic factors, as well as health status of breast cancer patients, and their current utilization of new media, or their willingness to use Internet and mobile phone apps for improvement of therapy management. Methods The survey for this study was conducted anonymously during the 2012 Mamazone Projekt Diplompatient meeting (Augsburg, Germany), which hosted approximately 375 participants per day. A total of 168 questionnaires were completed. The questionnaire aimed to assess sociodemographic status, disease patterns, and current use of new media (ie, Internet, mobile phone, and mobile phone apps) in breast cancer patients. Habits and frequency of use for these new technologies, as well as patients’ affinity towards eHealth and mHealth tools for therapy management improvement, were investigated. Results Almost all participants used the Internet (95.8%, 161/168), with 91.5% (151/165) also utilizing this technology for health-related issues. Approximately 23% (38/168) of respondents owned a mobile phone. When asked about their preferences for therapy assistance, 67.3% (113/168) of respondents were interested in assistance via the Internet, 25.0% (42/168) via mobile phone, and 73.2% (123/168) via call center. Patients diagnosed with breast cancer <5 years before the survey were significantly more interested in a call center than patients diagnosed >5 years before survey participation. Conclusions The vast majority of breast cancer patients accept the Internet for therapy assistance, which indicates that eHealth is a promising medium to improve patient-physician communication. Such technologies may improve individual disease management and ultimately lead to an enhanced adherence to therapy regimens. PMID:28410189

The relation between concepts of quality-of-life, health and happiness.

PubMed

Musschenga, A W

1997-02-01

In the last two decades, the term "quality-of-life" has become popular in medicine and health care. There are, however, important differences in the meaning and the use of the term. The message of all quality-of-life talk is that medicine and health care are not valuable in themselves. They are valuable to the extent that they contribute to the quality of life of patients. The ultimate aims of medicine and health care are not health or prolongation of life as such, but preservation or improvement of the quality of life. The primary aims of medicine and health care, such as the prolongation of life, can--but need not always--come into conflict with the ultimate ones: medical treatments do not always benefit a patient. In this article I will, first, summarize the results of my explorations of the use and the meaning of the term "quality-of-life." The use and the meaning of the term turn out to depend on the contexts of medical decision-making in which it is used. I will show that there are at least three different concepts of quality-of-life. Second, I will argue that the different concepts of quality-of-life are not unrelated. They point to different components of and/or conditions for happiness. Third, I will analyze the relation between the three concepts of quality-of-life, health and happiness.

Improving the accuracy of camber predictions for precast pretensioned concrete beams : [tech transfer summary].

DOT National Transportation Integrated Search

2015-07-01

Implementing the recommendations of this study is expected to significantly : improve the accuracy of camber measurements and predictions and to : ultimately help reduce construction delays, improve bridge serviceability, : and decrease costs.

Nutritional requirements of the critically ill patient.

PubMed

Chan, Daniel L

2004-02-01

The presence or development of malnutrition during critical illness has been unequivocally associated with increased morbidity and mortality in people. Recognition that malnutrition may similarly affect veterinary patients emphasizes the need to properly address the nutritional requirements of hospitalized dogs and cats. Because of a lack in veterinary studies evaluating the nutritional requirements of critically ill small animals, current recommendations for nutritional support of veterinary patients are based largely on sound clinical judgment and the best information available, including data from experimental animal models and human studies. This, however, should not discourage the veterinary practitioner from implementing nutritional support in critically ill patients. Similar to many supportive measures of critically ill patients, nutritional interventions can have a significant impact on patient morbidity and may even improve survival. The first step of nutritional support is to identify patients most likely to benefit from nutritional intervention. Careful assessment of the patient and appraisal of its nutritional needs provide the basis for a nutritional plan, which includes choosing the optimal route of nutritional support, determining the number of calories to provide, and determining the composition of the diet. Ultimately, the success of the nutritional management of critically ill dogs and cats will depend on close monitoring and frequent reassessment.

Black bile of melancholy or gallstones of biliary colics: historical perspectives on cholelithiasis.

PubMed

Bielefeldt, Klaus

2014-11-01

Barely 130 years after its first description, cholecystectomies are among the most commonly performed surgeries in the USA. The success of this operation with subsequent technical improvements, such as laparoscopic approaches, caused a paradigm shift in the management of gallstone disease. However, symptoms persist in 10-40 % of successfully operated patients. Reviewing monographs, textbooks, and articles published during the last 300 years, several important factors emerge as likely contributors to limited or poor treatment responses. Early on, clinicians recognized that cholelithiasis is quite common and thus often an incidental finding, especially if patients present with vague or atypical symptoms. Consistent with these observations, patients with such atypical symptoms are less likely to benefit from cholecystectomy. Similarly, lasting improvements are more reliably seen in patients with symptoms of presumed biliary origin and documented gallstones compared to individuals without stones, an important point in view of increasing rates of surgery for biliary dyskinesia. While cholelithiasis can cause serious complications, the overall incidence of clinically relevant problems is so low that prophylactic cholecystectomy cannot be justified. This conclusion corresponds to epidemiologic data showing that the rise in elective cholecystectomies decreased hospitalizations due to gallstone disease, but was associated with a higher volume of postoperative complications, ultimately resulting in stable combined mortality due to gallstone disease and its treatment. These trends highlight the tremendous gains in managing gallstone disease, while at the same time reminding us that the tightening rather than expanding indications for cholecystectomy may improve outcomes.

"Mobile technology to improve heart failure outcomes: A proof of concept paper".

PubMed

Athilingam, Ponrathi; Jenkins, Bradlee A; Zumpano, Heather; Labrador, Miguel A

2018-02-01

Heart failure (HF) causes significant symptom burden and human suffering with considerable economic burden due to hospital readmissions. Targeted interventions to encourage and support self-management behavior is warranted. To test the proof of concept of a mobile application (HeartMapp) in improving self-care management of patients with heart failure. An exploratory inquiry used a field study strategy with purposeful sampling and constant comparative analysis to test the proof of concept of HeartMapp using The Business Model Canvas framework. A total of 125 individuals, who were identified as potential candidates to use the HeartMapp completed the interview over a seven-week period in 2016. Constant comparative analysis indicated themes that Skilled Nursing Facilities had increased readmissions. Participants from Skilled Nursing Facilities reported concern on lack of staffing, star rating, and malpractice claims. Two types of patients were identified as early adapters of technology and those in denial. Health care facilities reported challenges on transitional care, nurses struggle with engagement of patients on self-care management. To avoid readmission penalty, hospitals task home care agencies to keep the patients home for 30-days. While home care agencies rely on remote telemonitoring reported that current telemonitoring devices are costly to maintain, thus exploring novel technology. The Business Model Canvas provided directions for future testing of HeartMapp for its usability as an adjunct device in home health setting to improve self-management and enhance communication with providers, and ultimately reduce readmissions. Copyright © 2017 Elsevier Inc. All rights reserved.

Treatment choices and outcomes of patients with manometrically diagnosed achalasia.

PubMed

Yeung, J C; Finley, C; Hanna, W C; Miller, L; Ferri, L; Urbach, D R; Darling, G E

2016-07-01

This prospective population-based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre-diagnosis and Medical Outcomes Study 36-item Short-Form (SF-36) survey. Treatment decisions were made by the referring physician and the patient. Follow-up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1-year follow-up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty-four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/- 12.2, 17 +/- 10.9, and 9 +/- 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of -3.5 +/- 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF-36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment. © 2015 International Society for Diseases of the Esophagus.

[Leukemia research in Germany: the Competence Network Acute and Chronic Leukemias].

PubMed

Kossak-Roth, Ute; Saußele, Susanne; Aul, Carlo; Büchner, Thomas; Döhner, Hartmut; Dugas, Martin; Ehninger, Gerhard; Ganser, Arnold; Giagounidis, Aristoteles; Gökbuget, Nicola; Griesshammer, Martin; Hasford, Jörg; Heuser, Michael; Hiddemann, Wolfgang; Hochhaus, Andreas; Hoelzer, Dieter; Niederwieser, Dietger; Reiter, Andreas; Röllig, Christoph; Hehlmann, Rüdiger

2016-04-01

The Competence Network "Acute and Chronic Leukemias" was founded in 1997 by the consolidation of the leading leukemia study groups in Germany. Key results are the development of new trials and cooperative studies, the setup of patient registries and biobanking facilities, as well as the improvement of study infrastructure. In 2003, the concept of the competence network contributed to the foundation of the European LeukemiaNet (ELN). Synergy with the ELN resulted in cooperation on a European and international level, standardization of diagnostics and treatment, and recommendations for each leukemia and interdisciplinary specialty. The ultimate goal of the network is the cure of leukemia through cooperative research.

Laser Capture Microdissection in the Genomic and Proteomic Era: Targeting the Genetic Basis of Cancer

PubMed Central

Domazet, Barbara; MacLennan, Gregory T.; Lopez-Beltran, Antonio; Montironi, Rodolfo; Cheng, Liang

2008-01-01

The advent of new technologies has enabled deeper insight into processes atsubcellular levels, which will ultimately improve diagnostic procedures and patient outcome. Thanks to cell enrichment methods, it is now possible to study cells in their native environment. This has greatly contributed to a rapid growth in several areas, such as gene expression analysis, proteomics, and metabolonomics. Laser capture microdissection (LCM) as a method of procuring subpopulations of cells under direct visual inspection is playing an important role in these areas. This review provides an overview of existing LCM technology and its downstream applications in genomics, proteomics, diagnostics and therapy. PMID:18787684

Laser capture microdissection in the genomic and proteomic era: targeting the genetic basis of cancer.

PubMed

Domazet, Barbara; Maclennan, Gregory T; Lopez-Beltran, Antonio; Montironi, Rodolfo; Cheng, Liang

2008-03-15

The advent of new technologies has enabled deeper insight into processes at subcellular levels, which will ultimately improve diagnostic procedures and patient outcome. Thanks to cell enrichment methods, it is now possible to study cells in their native environment. This has greatly contributed to a rapid growth in several areas, such as gene expression analysis, proteomics, and metabolonomics. Laser capture microdissection (LCM) as a method of procuring subpopulations of cells under direct visual inspection is playing an important role in these areas. This review provides an overview of existing LCM technology and its downstream applications in genomics, proteomics, diagnostics and therapy.

Design and Evaluation of Ergonomic Interventions for the Prevention of Musculoskeletal Disorders in India

PubMed Central

2014-01-01

Background Improper workstation, work procedures and tools are found to be the risk factors for the development of musculoskeletal disorders among the informal sector workers of the developing countries. Low cost ergonomic interventions can effectively improve such adverse conditions. Case presentation In the present article some studies related to design interventions in different informal and agricultural sectors were discussed and their efficacies were analyzed. It was observed that with the help of appropriate interventions musculoskeletal disorders were reduced, adverse physiological conditions were improved when awkward postures were corrected and ultimately the organisational productivity was increased. Conclusion Proper implementation of ergonomic interventions can ultimately improve the economy of the nation. PMID:25009740

Circuit training enhances function in patients undergoing total knee arthroplasty: a retrospective cohort study.

PubMed

Hsu, Wei-Hsiu; Hsu, Wei-Bin; Shen, Wun-Jer; Lin, Zin-Rong; Chang, Shr-Hsin; Hsu, Robert Wen-Wei

2017-10-19

The number of patients receiving total knee arthroplasty (TKA) has been rising every year due to the aging population and the obesity epidemic. Post-operative rehabilitation is important for the outcome of TKA. A series of 34 patients who underwent primary unilateral TKA was retrospectively collected and divided into either exercise group (n = 16) and control group (n = 18). The exercise group underwent a 24-week course of circuit training beginning 3 months after total knee arthroplasty (TKA). The effect of circuit training on TKA patients in terms of motion analysis, muscle strength testing, Knee injury and Osteoarthritis Outcomes Score (KOOS) questionnaire and patient-reported outcome measurement Short-Form Health Survey (SF-36) at the pre-operation, pre-exercise, mid-exercise, and post-exercise. Motion analysis revealed the stride length, step velocity, and excursion of active knee range of motion significantly improved in the exercise group when compared to those in the control group. KOOS questionnaire showed a greater improvement in pain, ADL, and total scores in the exercise group. The SF-36 questionnaire revealed a significant improvement in general health, bodily pain, social function, and physical components score in the exercise group. The post-operative circuit training intervention can facilitate recovery of knee function and decrease the degree of pain in the TKA and might be considered a useful adjunct rehabilitative modality. The ultimate influence of circuit training on TKA needs further a prospective randomized clinical trial study and long-term investigation. NCT02928562.

Dutch Lung Surgery Audit: A National Audit Comprising Lung and Thoracic Surgery Patients.

PubMed

Berge, Martijn Ten; Beck, Naomi; Heineman, David Jonathan; Damhuis, Ronald; Steup, Willem Hans; van Huijstee, Pieter Jan; Eerenberg, Jan Peter; Veen, Eelco; Maat, Alexander; Versteegh, Michel; van Brakel, Thomas; Schreurs, Wilhemina Hendrika; Wouters, Michel Wilhelmus

2018-04-21

The nationwide Dutch Lung Surgery Audit (DLSA) started in 2012 to monitor and evaluate the quality of lung surgery in the Netherlands as an improvement tool. This outline describes the establishment, structure and organization of the audit by the Dutch Society of Lung Surgeons (NVvL) and the Dutch Society of Cardiothoracic Surgeons (NVT), in collaboration with the Dutch Institute for Clinical Auditing (DICA). In addition, first four-year results are presented. The NVvL and NVT initiated a web-based registration including weekly updated online feedback for participating hospitals. Data verification by external data managers is performed on regular basis. The audit is incorporated in national quality improvement programs and participation in the DLSA is mandatory by health insurance organizations and the National Healthcare Inspectorate. Between 1 January 2012 and 31 December 2015, all hospitals performing lung surgery participated and a total of 19,557 patients were registered from which almost half comprised lung cancer patients. Nationwide the guideline adherence increased over the years and 96.5% of lung cancer patients were discussed in preoperative multidisciplinary teams. Overall postoperative complications and mortality after non-small cell lung cancer surgery were 15.5% and 2.0%, respectively. The audit provides reliable benchmarked information for caregivers and hospital management with potential to start local, regional or national improvement initiatives. Currently, the audit is further completed with data from non-surgical lung cancer patients including treatment data from pulmonary oncologists and radiation oncologists. This will ultimately provide a comprehensive overview of lung cancer treatment in The Netherlands. Copyright © 2018. Published by Elsevier Inc.

The Utility of a Wireless Implantable Hemodynamic Monitoring System in Patients Requiring Mechanical Circulatory Support.

PubMed

Feldman, David S; Moazami, Nader; Adamson, Philip B; Vierecke, Juliane; Raval, Nir; Shreenivas, Satya; Cabuay, Barry M; Jimenez, Javier; Abraham, William T; O'Connell, John B; Naka, Yoshifumi

Proper timing of left ventricular assist device (LVAD) implantation in advanced heart failure patients is not well established and is an area of intense interest. In addition, optimizing LVAD performance after implantation remains difficult and represents a significant clinical need. Implantable hemodynamic monitoring systems may provide physicians with the physiologic information necessary to improve the timing of LVAD implantation as well as LVAD performance when compared with current methods. The CardioMEMS Heart sensor Allows for Monitoirng of Pressures to Improve Outcomes in NYHA Class III heart failure patients (CHAMPION) Trial enrolled 550 previously hospitalized patients with New York Heart Association (NYHA) class III heart failure. All patients were implanted with a pulmonary artery (PA) pressure monitoring system and randomized to a treatment and control groups. In the treatment group, physicians used the hemodynamic information to make heart failure management decisions. This information was not available to physicians for the control group. During an average of 18 month randomized follow-up, 27 patients required LVAD implantation. At the time of PA pressure sensor implantation, patients ultimately requiring advanced therapy had higher PA pressures, lower systemic pressure, and similar cardiac output measurements. Treatment and control patients in the LVAD subgroup had similar clinical profiles at the time of enrollment. There was a trend toward a shorter length of time to LVAD implantation in the treatment group when hemodynamic information was available. After LVAD implantation, most treatment group patients continued to provide physicians with physiologic information from the hemodynamic monitoring system. As expected PA pressures declined significantly post LVAD implant in all patients, but the magnitude of decline was higher in patients with PA pressure monitoring. Implantable hemodynamic monitoring appeared to improve the timing of LVAD implantation as well as optimize LVAD performance when compared with current methods. Further studies are necessary to evaluate these findings in a prospective manner.

Asymmetric Meckel Cave Enlargement: A Potential Marker of PHACES Syndrome.

PubMed

Wright, J N; Wycoco, V

2017-06-01

PHACES syndrome is a complex of morphologic abnormalities of unknown cause and includes posterior fossa abnormalities; head and neck infantile hemangiomas; arterial, cardiac, and eye anomalies; and sternal or abdominal wall defects. Accurate identification of the syndrome is important for optimal treatment. The purpose of this study was to investigate the incidence of asymmetric Meckel cave enlargement, a potential novel imaging marker, in a population of patients referred for evaluation of possible PHACES syndrome. Eighty-five patients referred for neuroimaging evaluation of possible PHACES syndrome were identified and stratified on the basis of their ultimate clinical PHACES diagnosis categorization into PHACES, possible PHACES, or not PHACES. MR imaging studies were subsequently reviewed for the presence or absence of unilateral Meckel cave enlargement, with the reviewer blinded to the ultimate PHACES syndrome categorization. Twenty-five of 85 patients (29%) were ultimately categorized as having PHACES or possible PHACES according to consensus guidelines. Asymmetric Meckel cave enlargement was present in 76% (19/25) of these patients and in 82% (19/23) of only those patients with definite PHACES. This finding was present in none of the 60 patients determined not to have PHACES syndrome. In 7/19 patients (37%) with this finding, subtle MR imaging abnormalities consistent with PHACES were missed on the initial MR imaging interpretation. Asymmetric Meckel cave enlargement was a common feature of patients with PHACES in our cohort and may serve as a novel imaging marker. Increased awareness of this imaging feature has the potential to increase the diagnostic accuracy of PHACES. © 2017 by American Journal of Neuroradiology.

Pediatric Digital Necrosis Secondary to Dressing Application: A Case Series.

PubMed

Bjorklund, Kim A; Rice, Dahlia M; Amalfi, Ashley N

2018-04-01

Pediatric digital necrosis resulting in revision amputation is a devastating outcome following digital dressing application. We report a series of 4 pediatric patients (age: 21 months-11 years) who presented for surgical consultation related to digital ischemia and irreversible necrosis following the application of Coban digital dressings. A review of the literature demonstrated that such injuries had not previously been described. In our case series, Coban dressing was utilized as a deterrent for thumb sucking, fingertip tuft fractures with nail bed lacerations, and a phalanx fracture secondary to crush injury. All 4 children suffered digital necrosis secondary to Coban dressings and ultimately required revision amputation. We discuss risks factors, application practices, and strategies to minimize complications with digital dressings in the pediatric population with the intent of creating awareness among hand surgeons to help promote safe practices and improve patient outcomes.

Central Sensitization Syndrome and the Initial Evaluation of a Patient with Fibromyalgia: A Review

PubMed Central

Fleming, Kevin C.; Volcheck, Mary M.

2015-01-01

In both primary care and consultative practices, patients presenting with fibromyalgia (FM) often have other medically unexplained somatic symptoms and are ultimately diagnosed as having central sensitization (CS). Central sensitization encompasses many disorders where the central nervous system amplifies sensory input across many organ systems and results in myriad symptoms. A pragmatic approach to evaluate FM and related symptoms, including a focused review of medical records, interviewing techniques, and observations, is offered here, giving valuable tools for identifying and addressing the most relevant symptoms. At the time of the clinical evaluation, early consideration of CS may improve the efficiency of the visit, reduce excessive testing, and help in discerning between typical and atypical cases so as to avoid an inaccurate diagnosis. Discussion of pain and neurophysiology and sensitization often proves helpful. PMID:25973272

How Comparative Effectiveness Research Can Help To Advance ‘Personalized Medicine’ In Cancer Treatment

PubMed Central

Ramsey, Scott D.; Veenstra, David L.; Tunis, Sean R.; Garrison, Louis P.; Crowley, John J.; Baker, Laurence H.

2012-01-01

The use of biomarkers to “personalize” cancer treatment —identifying discrete genes, proteins, or other indicators that can differentiate one type of cancer from another and enable the use of highly tailored therapies -- offers tremendous potential for improved outcomes and lower treatment costs. However, the rapid development of cancer biomarker, or genomic, tests— combined with a paucity of evidence to support the effectiveness of the tests—presents a challenge for patients, clinicians and other stakeholders. In this article, we propose that comparative effectiveness research be used to strengthen what is now a haphazard process for developing and marketing cancer biomarker tests. We suggest novel funding approaches and a systematic process for moving from regulatory approval to the generation of evidence that meets the needs of stakeholders and, ultimately, patients. PMID:22147853

Using Big Data Analytics to Advance Precision Radiation Oncology.

PubMed

McNutt, Todd R; Benedict, Stanley H; Low, Daniel A; Moore, Kevin; Shpitser, Ilya; Jiang, Wei; Lakshminarayanan, Pranav; Cheng, Zhi; Han, Peijin; Hui, Xuan; Nakatsugawa, Minoru; Lee, Junghoon; Moore, Joseph A; Robertson, Scott P; Shah, Veeraj; Taylor, Russ; Quon, Harry; Wong, John; DeWeese, Theodore

2018-06-01

Big clinical data analytics as a primary component of precision medicine is discussed, identifying where these emerging tools fit in the spectrum of genomics and radiomics research. A learning health system (LHS) is conceptualized that uses clinically acquired data with machine learning to advance the initiatives of precision medicine. The LHS is comprehensive and can be used for clinical decision support, discovery, and hypothesis derivation. These developing uses can positively impact the ultimate management and therapeutic course for patients. The conceptual model for each use of clinical data, however, is different, and an overview of the implications is discussed. With advancements in technologies and culture to improve the efficiency, accuracy, and breadth of measurements of the patient condition, the concept of an LHS may be realized in precision radiation therapy. Copyright © 2018 Elsevier Inc. All rights reserved.

Precision medicine in chronic disease management: The multiple sclerosis BioScreen.

PubMed

Gourraud, Pierre-Antoine; Henry, Roland G; Cree, Bruce A C; Crane, Jason C; Lizee, Antoine; Olson, Marram P; Santaniello, Adam V; Datta, Esha; Zhu, Alyssa H; Bevan, Carolyn J; Gelfand, Jeffrey M; Graves, Jennifer S; Goodin, Douglas S; Green, Ari J; von Büdingen, H-Christian; Waubant, Emmanuelle; Zamvil, Scott S; Crabtree-Hartman, Elizabeth; Nelson, Sarah; Baranzini, Sergio E; Hauser, Stephen L

2014-11-01

We present a precision medicine application developed for multiple sclerosis (MS): the MS BioScreen. This new tool addresses the challenges of dynamic management of a complex chronic disease; the interaction of clinicians and patients with such a tool illustrates the extent to which translational digital medicine-that is, the application of information technology to medicine-has the potential to radically transform medical practice. We introduce 3 key evolutionary phases in displaying data to health care providers, patients, and researchers: visualization (accessing data), contextualization (understanding the data), and actionable interpretation (real-time use of the data to assist decision making). Together, these form the stepping stones that are expected to accelerate standardization of data across platforms, promote evidence-based medicine, support shared decision making, and ultimately lead to improved outcomes. © 2014 American Neurological Association.

[Lifestyle medicine: the importance of considering all the causes of disease].

PubMed

Mora Ripoll, Ramón

2012-01-01

The enormous potential effects of health behavior change on mortality, morbidity, and health care costs provide ample motivation for the concept of lifestyle medicine. Lifestyle medicine involves the therapeutic use of lifestyle interventions on health and quality of life, and considers not only risk factors and markers, but also a range of antecedent factors from all levels of causality. Treatment would ultimate employ a combination of clinical (patient-centered) and public-health interventions. Examples of target patient behaviors include, but are not limited to, eliminating tobacco use, moderating alcohol consumption, increasing physical activity, improving diet, sleep, and emotional and mental well-being. The effective implementation of lifestyle medicine should be a priority within the necessary changes in current healthcare systems and public health policies. Copyright © 2010 SEP y SEPB. Published by Elsevier Espana. All rights reserved.

Becoming a leader in patient satisfaction: changing the culture of care in an academic community hospital.

PubMed

Deitrick, Lynn M; Capuano, Terry A; Paxton, Stuart S; Stern, Glenn; Dunleavy, Jack; Miller, William L

2006-01-01

In the context of the current health care payer system, quality of care standards, financial incentives and consumer choice are not well aligned, yet competition for increased admissions has become a matter of survival. Satisfaction and loyalty are two constructs that are the most meaningful measures in the context of sustaining and increasing admissions. Lehigh Valley Hospital and Health Network (LVHHN) launched an ambitious patient satisfaction improvement initiative in 2001. LVHHN augmented existing patient service excellence programs with an ethnographic study of a representative unit. Interview and observational data were analyzed using NVivo software. These results (four distilled domains of patient experience) can then be used to identify key components of the care environment that made meaningful differences in the perceptions of patients and their satisfaction. A designated interdepartmental task force can then develop interventions from those learnings, track outcomes through the Press Ganey scores, and ultimately yield increased admissions through unit-specific process change across the hospital. Admissions for fiscal year 2001 to fiscal year 2003 increased from 5,817 to 7,795 patients. The clear value and return on this initiative for our organization included a 34% increase in patient admissions over a four-year period. Improvements in both patient satisfaction and loyalty were demonstrated by a 24% increase for the question, "Likelihood of your recommending this hospital to others" as measured by the Press Ganey Inpatient survey. This initiative demonstrates the successful application of qualitative methods in a clinical microsystem to better understand patient perceptions that determine their satisfaction with medical care.

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery.

PubMed

Herrinton, Lisa J; Altschuler, Andrea; McMullen, Carmit K; Bulkley, Joanna E; Hornbrook, Mark C; Sun, Virginia; Wendel, Christopher S; Grant, Marcia; Baldwin, Carol M; Demark-Wahnefried, Wendy; Temple, Larissa K F; Krouse, Robert S

2016-09-01

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society. © 2016 American Cancer Society.

Utility of silicone esophageal bypass stents in the management of delayed complex esophageal disruptions.

PubMed

Kim, Anthony W; Liptay, Michael J; Snow, Norman; Donahue, Philip; Warren, William H

2008-06-01

The objective of this study was to review the clinical experience of temporarily placing an endoesophageal silicone salivary bypass stent and its value in managing patients with life-threatening esophageal disruptions. Clinical records of patients undergoing placement of silicone Montgomery salivary bypass stents from June 1998 to September 2007 were reviewed. Seventeen patients had a proven esophageal disruption in the absence of malignancy and with life-threatening sepsis refractory to conventional management. Underlying conditions were iatrogenic trauma from prior pulmonary surgery (4 patients), significant anastomotic leaks after an esophagogastrectomy (4 patients), delayed presentation (> 24 hours) of a perforated esophagus (4 patients), leak after esophageal surgery (3 patients), and esophagobronchial fistula secondary to inflammation and infection (2 patients). Stents were placed without securing, were sutured in place to the esophageal wall at the time of thoracotomy, or were secured by bringing holding sutures through the nostrils and tied over the bridge of the nose. In all cases, placement of the esophageal stent led to prompt improvement of the leak and, within a week, improvement of the sepsis. Supportive measures were continued after placement of the stent. Sixteen patients overcame the sepsis with ultimate healing of the esophageal disruption (13 patients) or maturation of the perforation into a chronic fistula (3 patients). Endoscopic stent removal was performed 2 to 16 weeks after placement. No patient had a stricture develop at the disruption site. One patient died of ruptured thoracic aorta. Silicone salivary bypass stents serve as an effective way of diverting and excluding the oral-alimentary stream, thereby providing optimal conditions for sepsis control. They are a useful adjunct in the management of complex esophageal conditions.

Narrative review of provider behavior in primary care behavioral health: How process data can inform quality improvement.

PubMed

Beehler, Gregory P; Lilienthal, Kaitlin R; Possemato, Kyle; Johnson, Emily M; King, Paul R; Shepardson, Robyn L; Vair, Christina L; Reyner, Jacqueline; Funderburk, Jennifer S; Maisto, Stephen A; Wray, Laura O

2017-09-01

Primary care behavioral health (PCBH) is a population-based approach to delivering mental and behavioral health care in the primary care setting. Implementation of the PCBH model varies across practice settings, which can impact how PCBH providers deliver services to patients and in turn may predict a variety of important outcomes. This article aims to characterize PCBH provider engagement in key processes of integrated care as demonstrated in results from empirical studies of real-world clinical practice. For this narrative review of published studies on PCBH provider engagement in processes of care, PubMed and PsycINFO databases were searched from January 1990 through May 2016 to identify relevant articles. Provider adherence to the brief, time-limited treatment model appears suboptimal. Common mental health conditions, such as depression, were often the primary focus of provider attention, with less consistent emphasis on behavioral medicine concerns. Whereas providers regularly conducted qualitative functional assessments with patients, routine use of standardized measures was low. Engagement in interprofessional collaboration with the primary care team was also low, but engagement in behaviors that fostered therapeutic relationships was high. This review identified several strengths and weaknesses of typical PCBH provider practices. Results are discussed in relation to their value as areas for future quality improvement initiatives that can improve PCBH service delivery and, ultimately, patient outcomes. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

A mHealth Application for Chronic Wound Care: Findings of a User Trial

PubMed Central

Friesen, Marcia R.; Hamel, Carole; McLeod, Robert D.

2013-01-01

This paper reports on the findings of a user trial of a mHealth application for pressure ulcer (bedsore) documentation. Pressure ulcers are a leading iatrogenic cause of death in developed countries and significantly impact quality of life for those affected. Pressure ulcers will be an increasing public health concern as the population ages. Electronic information systems are being explored to improve consistency and accuracy of documentation, improve patient and caregiver experience and ultimately improve patient outcomes. A software application was developed for Android Smartphones and tablets and was trialed in a personal care home in Western Canada. The software application provides an electronic medical record for chronic wounds, replacing nurses’ paper-based charting and is positioned for integration with facility’s larger eHealth framework. The mHealth application offers three intended benefits over paper-based charting of chronic wounds, including: (1) the capacity for remote consultation (telehealth between facilities, practitioners, and/or remote communities), (2) data organization and analysis, including built-in alerts, automatically-generated text-based and graph-based wound histories including wound images, and (3) tutorial support for non-specialized caregivers. The user trial yielded insights regarding the software application’s design and functionality in the clinical setting, and highlighted the key role of wound photographs in enhancing patient and caregiver experiences, enhancing communication between multiple healthcare professionals, and leveraging the software’s telehealth capacities. PMID:24256739

Robotics and neurosurgery.

PubMed

Nathoo, Narendra; Pesek, Todd; Barnett, Gene H

2003-12-01

Ultimately, neurosurgery performed via a robotic interface will serve to improve the standard of a neurosurgeon's skills, thus making a good surgeon a better surgeon. In fact, computer and robotic instrumentation will become allies to the neurosurgeon through the use of these technologies in training, diagnostic, and surgical events. Nonetheless, these technologies are still in an early stage of development, and each device developed will entail its own set of challenges and limitations for use in clinical settings. The future operating room should be regarded as an integrated information system incorporating robotic surgical navigators and telecontrolled micromanipulators, with the capabilities of all principal neurosurgical concepts, sharing information, and under the control of a single person, the neurosurgeon. The eventual integration of robotic technology into mainstream clinical neurosurgery offers the promise of a future of safer, more accurate, and less invasive surgery that will result in improved patient outcome.

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: A case report

PubMed Central

Downs, Jairon; Wolfe, Tracy; Walker, Heather

2014-01-01

Context Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel. Findings Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved. Conclusion/Clinical relevance This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel. PMID:24617444

Clinical Trial Participation and Time to Treatment Among Adolescents and Young Adults With Cancer: Does Age at Diagnosis or Insurance Make a Difference?

PubMed Central

Parsons, Helen M.; Harlan, Linda C.; Seibel, Nita L.; Stevens, Jennifer L.; Keegan, Theresa H.M.

2011-01-01

Purpose Because adolescent and young adult (AYA) patients with cancer have experienced variable improvement in survival over the past two decades, enhancing the quality and timeliness of cancer care in this population has emerged as a priority area. To identify current trends in AYA care, we examined patterns of clinical trial participation, time to treatment, and provider characteristics in a population-based sample of AYA patients with cancer. Methods Using the National Cancer Institute Patterns of Care Study, we used multivariate logistic regression to evaluate demographic and provider characteristics associated with clinical trial enrollment and time to treatment among 1,358 AYA patients with cancer (age 15 to 39 years) identified through the Surveillance, Epidemiology, and End Results Program. Results In our study, 14% of patients age 15 to 39 years had enrolled onto a clinical trial; participation varied by type of cancer, with the highest participation in those diagnosed with acute lymphoblastic leukemia (37%) and sarcoma (32%). Multivariate analyses demonstrated that uninsured, older patients and those treated by nonpediatric oncologists were less likely to enroll onto clinical trials. Median time from pathologic confirmation to first treatment was 3 days, but this varied by race/ethnicity and cancer site. In multivariate analyses, advanced cancer stage and outpatient treatment alone were associated with longer time from pathologic confirmation to treatment. Conclusion Our study identified factors associated with low clinical trial participation in AYA patients with cancer. These findings support the continued need to improve access to clinical trials and innovative treatments for this population, which may ultimately translate into improved survival. PMID:21931022

Quality and Safety Implications of Emergency Department Information Systems

PubMed Central

Farley, Heather L.; Baumlin, Kevin M.; Hamedani, Azita G.; Cheung, Dickson S.; Edwards, Michael R.; Fuller, Drew C.; Genes, Nicholas; Griffey, Richard T.; Kelly, John J.; McClay, James C.; Nielson, Jeff; Phelan, Michael P.; Shapiro, Jason S.; Stone-Griffith, Suzanne; Pines, Jesse M.

2013-01-01

The Health Information Technology for Economic and Clinical Health Act of 2009 and the Centers for Medicare & Medicaid Services “meaningful use” incentive programs, in tandem with the boundless additional requirements for detailed reporting of quality metrics, have galvanized hospital efforts to implement hospital-based electronic health records. As such, emergency department information systems (EDISs) are an important and unique component of most hospitals’ electronic health records. System functionality varies greatly and affects physician decisionmaking, clinician workflow, communication, and, ultimately, the overall quality of care and patient safety. This article is a joint effort by members of the Quality Improvement and Patient Safety Section and the Informatics Section of the American College of Emergency Physicians. The aim of this effort is to examine the benefits and potential threats to quality and patient safety that could result from the choice of a particular EDIS, its implementation and optimization, and the hospital’s or physician group’s approach to continuous improvement of the EDIS. Specifically, we explored the following areas of potential EDIS safety concerns: communication failure, wrong order–wrong patient errors, poor data display, and alert fatigue. Case studies are presented that illustrate the potential harm that could befall patients from an inferior EDIS product or suboptimal execution of such a product in the clinical environment. The authors have developed 7 recommendations to improve patient safety with respect to the deployment of EDISs. These include ensuring that emergency providers actively participate in selection of the EDIS product, in the design of processes related to EDIS implementation and optimization, and in the monitoring of the system’s ongoing success or failure. Our recommendations apply to emergency departments using any type of EDIS: custom-developed systems, best-of-breed vendor systems, or enterprise systems. PMID:23796627

Predictive capabilities of preoperative and postoperative pulmonary function tests in delayed repair of congenital diaphragmatic hernia.

PubMed

Tracy, T F; Bailey, P V; Sadiq, F; Noguchi, A; Silen, M L; Weber, T R

1994-02-01

To improve the survival of newborns with congenital diaphragmatic hernia (CHD), preoperative stabilization with conventional ventilatory therapy and extracorporeal membrane oxygenation (ECMO) have been used. Measurements that quantify pulmonary function may allow an accurate assessment of lethal pulmonary hypoplasia and predict outcome. Pulmonary function tests (PFTs) were obtained in 20 infants preoperatively and postoperatively; these included measurements of compliance, dynamic compliance, and tidal volume. Overall survival was 75%. Six surviving infants were initially managed with ventilator therapy alone, followed by repair (group 1). The remaining 14 patients, who were moribund at presentation or whose initial ventilator therapy failed, were placed on ECMO and received repair during bypass; nine survived (group 2), and five died (group 3). Compliance, dynamic compliance, and tidal volume obtained at initial presentation and immediately preoperatively were significantly higher for group 1 as compared with groups 2 and 3. Infants whose initial compliance was greater than 0.25 mL/cm H2O/kg and initial tidal volume was greater than 3.5 mL/kg did not require ECMO. Ultimate improvement in compliance was noted in 5 of 6 patients in group 1, 8 of 8 patients in group 2, and 5 of 5 in group 3. This improvement followed an initial decline in compliance in 9 of 14 survivors, from 15% to 76%. All six patients in group 1 had tidal volumes of more than 4 mL/kg, as did 7 of 9 patients in group 2. Only one patient among the ECMO nonsurvivors (group 3) had a postoperative tidal volume of this magnitude. These data suggest that initial PFTs may predict which infants will require ECMO.(ABSTRACT TRUNCATED AT 250 WORDS)

A web-based, patient driven registry for Angelman syndrome: the global Angelman syndrome registry.

PubMed

Napier, Kathryn R; Tones, Megan; Simons, Chloe; Heussler, Helen; Hunter, Adam A; Cross, Meagan; Bellgard, Matthew I

2017-08-01

Angelman syndrome (AS) is a rare neurodevelopmental disorder that is characterised by severe global developmental delays, ataxia, loss of speech, epilepsy, sleep disorders, and a happy disposition. There is currently no cure for AS, though several pharmaceutical companies are anticipating drug trials for new therapies to treat AS. The Foundation for Angelman Therapeutics (FAST) Australia therefore identified a need for a global AS patient registry to identify patients for recruitment for clinical trials.The Global AS Registry was deployed in September 2016 utilising the Rare Disease Registry Framework, an open-source tool that enables the efficient creation and management of patient registries. The Global AS Registry is web-based and allows parents and guardians worldwide to register, provide informed consent, and enter data on individuals with AS. 286 patients have registered in the first 8 months since deployment.We demonstrate the successful deployment of the first patient-driven global registry for AS. The data generated from the Global AS Registry will be crucial in identifying patients suitable for clinical trials and in informing research that will identify treatments for AS, and ultimately improve the lives of individuals and their families living with AS.

21 CFR 821.1 - Scope.

Code of Federal Regulations, 2012 CFR

2012-04-01

... patient. Effective tracking of devices from the manufacturing facility, through the distributor network..., and licensed practitioners) and, ultimately, to the patient is necessary for the effectiveness of remedies prescribed by the act, such as patient notification (section 518(a) of the act) or device recall...

21 CFR 821.1 - Scope.

Code of Federal Regulations, 2014 CFR

2014-04-01

... patient. Effective tracking of devices from the manufacturing facility, through the distributor network..., and licensed practitioners) and, ultimately, to the patient is necessary for the effectiveness of remedies prescribed by the act, such as patient notification (section 518(a) of the act) or device recall...

21 CFR 821.1 - Scope.

Code of Federal Regulations, 2013 CFR

2013-04-01

... patient. Effective tracking of devices from the manufacturing facility, through the distributor network..., and licensed practitioners) and, ultimately, to the patient is necessary for the effectiveness of remedies prescribed by the act, such as patient notification (section 518(a) of the act) or device recall...

Value Based Care and Patient-Centered Care: Divergent or Complementary?

PubMed

Tseng, Eric K; Hicks, Lisa K

2016-08-01

Two distinct but overlapping care philosophies have emerged in cancer care: patient-centered care (PCC) and value-based care (VBC). Value in healthcare has been defined as the quality of care (measured typically by healthcare outcomes) modified by cost. In this conception of value, patient-centeredness is one important but not necessarily dominant quality measure. In contrast, PCC includes multiple domains of patient-centeredness and places the patient and family central to all decisions and evaluations of quality. The alignment of PCC and VBC is complicated by several tensions, including a relative lack of patient experience and preference measures, and conceptions of cost that are payer-focused instead of patient-focused. Several strategies may help to align these two philosophies, including the use of patient-reported outcomes in clinical trials and value determinations, and the purposeful integration of patient preference in clinical decisions and guidelines. Innovative models of care, including accountable care organizations and oncology patient-centered medical homes, may also facilitate alignment through improved care coordination and quality-based payment incentives. Ultimately, VBC and PCC will only be aligned if patient-centered outcomes, perspectives, and preferences are explicitly incorporated into the definitions and metrics of quality, cost, and value that will increasingly influence the delivery of cancer care.

The dilemma of an incidental preoperative electrocardiogram showing a Brugada phenotype.

PubMed

Welman, Kiera; Matloob, Samir; Dubrey, Simon William; Elliott, Perry

2011-08-31

A Brugada pattern on routine electrocardiography is one of several features that can indicate the potential for life threatening rhythm disturbances. The authors describe such a scenario in an asymptomatic 38-year-old woman who required significant surgery under anaesthesia. The diagnosis and possible management routes are outlined with an emphasis on the incumbent psychosocial and familial issues that are encountered. The patient underwent her surgery and was then further investigated to 'prove' the diagnosis. Ultimately, the patient declined further investigations and interventions. This case highlights the dilemma faced by anaesthetists and clinicians, not to mention the patients and their family when a Brugada phenotype is identified on a routine ECG. Clinicians should seek an expert opinion but ultimately, as in this case, the patient should be positioned to make an informed decision on what route to follow.

Health-related quality of life in cancer patients at the end of life, translation, validation, and longitudinal analysis of specific tools: study protocol for a randomized controlled trial.

PubMed

Poirier, Anne-Lise; Kwiatkowski, Fabrice; Commer, Jean-Marie; D'Aillières, Bénédicte; Berger, Virginie; Mercier, Mariette; Bonnetain, Franck

2012-04-20

The end of life for cancer patients is the ultimate stage of the disease, and care in this setting is important as it can improve the wellbeing not only of patients, but also the patients' family and close friends. As it is a matter of profoundly personal concerns, patients' perception of this phase of the disease is difficult to assess and has thus been insufficiently studied. Nonetheless, caregivers are required to provide specific care to help patients and to treat them in order to improve their wellbeing during this period.While tools to assess health-related quality of life (QoL) in cancer patients at the end of life exist in English, to our knowledge, no validated tools are available in French. This randomized multicenter cohort study will be carried out to cross-culturally adapt and validate a French version of the English QUAL-E and the Missoula Vitas Quality Of Life Index (MVQOLI) questionnaires for advanced cancer patients in a palliative setting. A randomized clinical trial component in addition to a cohort study is implemented in order to test psychometric hypotheses: order effect and improvement of sensibility to change.The validation procedure will ensure that the psychometric properties are maintained.The main criterion to assess the reliability of the questionnaires will be reproducibility (test-retest method) using intraclass correlation coefficients. It will be necessary to include 372 patients. The sensitivity to change, discriminant capability as well as convergent validity will be also investigated. If the cross-cultural validation of the MVQOLI and QUAL-E questionnaires for advanced cancer patients in a palliative setting have satisfactory psychometric properties, it will allow us to assess the specific dimensions of QoL at the end of life. Current Controlled Trials NCT01545921.

Impact of Pharmacists' audit on improving the quality of prescription of dabigatran etexilate methanesulfonate: a retrospective study.

PubMed

Shimizu, Teppei; Momose, Yoshio; Ogawa, Ryuichi; Takahashi, Masahiro; Echizen, Hirotoshi

2017-01-01

Appropriate prescription of dabigatran etexilate methanesulfonate (JAN) is more complicated than assumed, because there are totally 10 items of contraindications and instructions for dosage reduction depending on patients' characteristics. We aimed to study whether the routine audit of first-time prescriptions of dabigatran performed by pharmacists is effective in improving the quality of prescription. A retrospective re-audit was performed on all the prescriptions of dabigatran issued at Kitahara International Hospital, Tokyo between March 2011 and February 2014, by evaluating the prescriptions rigorously against the approved prescribing information of the drug. The original routine audit of the prescriptions for inpatients was performed by hospital pharmacists using electronic medical records (EMR), whereas the audit for ambulant patients receiving external prescriptions was performed by community pharmacists using information obtained mainly by questioning patients. The frequencies of inappropriate prescriptions detected by the re-audit in the two groups were compared. Two hundred and twenty-eight patients (131 ambulant patients and 97 inpatients) were prescribed dabigatran for the first time during the study period. All patients met the approved indications. While 33% of the prescriptions for ambulant patients showed at least one violation of the approved usage, only 11% of the prescriptions for inpatients showed violations ( p  < 0.001). Two ambulant patients with creatinine clearance < 30 mL/min were dispensed dabigatran, whereas no such case was found among inpatients. A significantly greater proportion of ambulant patients aged ≥70 years showed violation of the instruction for dosage reduction compared to inpatients of the same age group (18 and 4%, respectively). The present study suggests that pharmacists may achieve better performance in auditing prescriptions of dabigatran when medical records are fully available than when information is available mainly by questioning patients. Further large-scale studies are required to clarify whether the audit of dabigatran prescriptions improves ultimate therapeutic outcomes or complications.

Neural Network Optimization of Ligament Stiffnesses for the Enhanced Predictive Ability of a Patient-Specific, Computational Foot/Ankle Model.

PubMed

Chande, Ruchi D; Wayne, Jennifer S

2017-09-01

Computational models of diarthrodial joints serve to inform the biomechanical function of these structures, and as such, must be supplied appropriate inputs for performance that is representative of actual joint function. Inputs for these models are sourced from both imaging modalities as well as literature. The latter is often the source of mechanical properties for soft tissues, like ligament stiffnesses; however, such data are not always available for all the soft tissues nor is it known for patient-specific work. In the current research, a method to improve the ligament stiffness definition for a computational foot/ankle model was sought with the greater goal of improving the predictive ability of the computational model. Specifically, the stiffness values were optimized using artificial neural networks (ANNs); both feedforward and radial basis function networks (RBFNs) were considered. Optimal networks of each type were determined and subsequently used to predict stiffnesses for the foot/ankle model. Ultimately, the predicted stiffnesses were considered reasonable and resulted in enhanced performance of the computational model, suggesting that artificial neural networks can be used to optimize stiffness inputs.

Advanced Neuroimaging in Traumatic Brain Injury

PubMed Central

Edlow, Brian L.; Wu, Ona

2013-01-01

Advances in structural and functional neuroimaging have occurred at a rapid pace over the past two decades. Novel techniques for measuring cerebral blood flow, metabolism, white matter connectivity, and neural network activation have great potential to improve the accuracy of diagnosis and prognosis for patients with traumatic brain injury (TBI), while also providing biomarkers to guide the development of new therapies. Several of these advanced imaging modalities are currently being implemented into clinical practice, whereas others require further development and validation. Ultimately, for advanced neuroimaging techniques to reach their full potential and improve clinical care for the many civilians and military personnel affected by TBI, it is critical for clinicians to understand the applications and methodological limitations of each technique. In this review, we examine recent advances in structural and functional neuroimaging and the potential applications of these techniques to the clinical care of patients with TBI. We also discuss pitfalls and confounders that should be considered when interpreting data from each technique. Finally, given the vast amounts of advanced imaging data that will soon be available to clinicians, we discuss strategies for optimizing data integration, visualization and interpretation. PMID:23361483

Adult soft tissue sarcomas: conventional therapies and molecularly targeted approaches.

PubMed

Mocellin, Simone; Rossi, Carlo R; Brandes, Alba; Nitti, Donato

2006-02-01

The therapeutic approach to soft tissue sarcomas (STS) has evolved over the past two decades based on the results from randomized controlled trials, which are guiding physicians in the treatment decision-making process. Despite significant improvements in the control of local disease, a significant number of patients ultimately die of recurrent/metastatic disease following radical surgery due to a lack of effective adjuvant treatments. In addition, the characteristic chemoresistance of STS has compromised the therapeutic value of conventional antineoplastic agents in cases of unresectable advanced/metastatic disease. Therefore, novel therapeutic strategies are urgently needed to improve the prognosis of patients with STS. Recent advances in STS biology are paving the way to the development of molecularly targeted therapeutic strategies, the efficacy of which relies not only on the knowledge of the molecular mechanisms underlying cancer development/progression but also on the personalization of the therapeutic regimen according to the molecular features of individual tumours. In this work, we review the state-of-the-art of conventional treatments for STS and summarize the most promising findings in the development of molecularly targeted therapeutic approaches.

How good is "evidence" from clinical studies of drug effects and why might such evidence fail in the prediction of the clinical utility of drugs?

PubMed

Naci, Huseyin; Ioannidis, John P A

2015-01-01

Promising evidence from clinical studies of drug effects does not always translate to improvements in patient outcomes. In this review, we discuss why early evidence is often ill suited to the task of predicting the clinical utility of drugs. The current gap between initially described drug effects and their subsequent clinical utility results from deficits in the design, conduct, analysis, reporting, and synthesis of clinical studies-often creating conditions that generate favorable, but ultimately incorrect, conclusions regarding drug effects. There are potential solutions that could improve the relevance of clinical evidence in predicting the real-world effectiveness of drugs. What is needed is a new emphasis on clinical utility, with nonconflicted entities playing a greater role in the generation, synthesis, and interpretation of clinical evidence. Clinical studies should adopt strong design features, reflect clinical practice, and evaluate outcomes and comparisons that are meaningful to patients. Transformative changes to the research agenda may generate more meaningful and accurate evidence on drug effects to guide clinical decision making.

B-mode Ultrasound Versus Color Doppler Twinkling Artifact in Detecting Kidney Stones

PubMed Central

Harper, Jonathan D.; Hsi, Ryan S.; Shah, Anup R.; Dighe, Manjiri K.; Carter, Stephen J.; Moshiri, Mariam; Paun, Marla; Lu, Wei; Bailey, Michael R.

2013-01-01

Abstract Purpose To compare color Doppler twinkling artifact and B-mode ultrasonography in detecting kidney stones. Patients and Methods Nine patients with recent CT scans prospectively underwent B-mode and twinkling artifact color Doppler ultrasonography on a commercial ultrasound machine. Video segments of the upper pole, interpolar area, and lower pole were created, randomized, and independently reviewed by three radiologists. Receiver operator characteristics were determined. Results There were 32 stones in 18 kidneys with a mean stone size of 8.9±7.5 mm. B-mode ultrasonography had 71% sensitivity, 48% specificity, 52% positive predictive value, and 68% negative predictive value, while twinkling artifact Doppler ultrasonography had 56% sensitivity, 74% specificity, 62% positive predictive value, and 68% negative predictive value. Conclusions When used alone, B-mode is more sensitive, but twinkling artifact is more specific in detecting kidney stones. This information may help users employ twinkling and B-mode to identify stones and developers to improve signal processing to harness the fundamental acoustic differences to ultimately improve stone detection. PMID:23067207

Current and future molecular approaches in the diagnosis of cystic fibrosis.

PubMed

Bergougnoux, Anne; Taulan-Cadars, Magali; Claustres, Mireille; Raynal, Caroline

2018-05-01

Cystic Fibrosis is among the first diseases to have general population genetic screening tests and one of the most common indications of prenatal and preimplantation genetic diagnosis for single gene disorders. During the past twenty years, thanks to the evolution of diagnostic techniques, our knowledge of CFTR genetics and pathophysiological mechanisms involved in cystic fibrosis has significantly improved. Areas covered: Sanger sequencing and quantitative methods greatly contributed to the identification of more than 2,000 sequence variations reported worldwide in the CFTR gene. We are now entering a new technological age with the generalization of high throughput approaches such as Next Generation Sequencing and Droplet Digital PCR technologies in diagnostics laboratories. These powerful technologies open up new perspectives for scanning the entire CFTR locus, exploring modifier factors that possibly influence the clinical evolution of patients, and for preimplantation and prenatal diagnosis. Expert commentary: Such breakthroughs would, however, require powerful bioinformatics tools and relevant functional tests of variants for analysis and interpretation of the resulting data. Ultimately, an optimal use of all those resources may improve patient care and therapeutic decision-making.

Color-coded fluid-attenuated inversion recovery images improve inter-rater reliability of fluid-attenuated inversion recovery signal changes within acute diffusion-weighted image lesions.

PubMed

Kim, Bum Joon; Kim, Yong-Hwan; Kim, Yeon-Jung; Ahn, Sung Ho; Lee, Deok Hee; Kwon, Sun U; Kim, Sang Joon; Kim, Jong S; Kang, Dong-Wha

2014-09-01

Diffusion-weighted image fluid-attenuated inversion recovery (FLAIR) mismatch has been considered to represent ischemic lesion age. However, the inter-rater agreement of diffusion-weighted image FLAIR mismatch is low. We hypothesized that color-coded images would increase its inter-rater agreement. Patients with ischemic stroke <24 hours of a clear onset were retrospectively studied. FLAIR signal change was rated as negative, subtle, or obvious on conventional and color-coded FLAIR images based on visual inspection. Inter-rater agreement was evaluated using κ and percent agreement. The predictive value of diffusion-weighted image FLAIR mismatch for identification of patients <4.5 hours of symptom onset was evaluated. One hundred and thirteen patients were enrolled. The inter-rater agreement of FLAIR signal change improved from 69.9% (k=0.538) with conventional images to 85.8% (k=0.754) with color-coded images (P=0.004). Discrepantly rated patients on conventional, but not on color-coded images, had a higher prevalence of cardioembolic stroke (P=0.02) and cortical infarction (P=0.04). The positive predictive value for patients <4.5 hours of onset was 85.3% and 71.9% with conventional and 95.7% and 82.1% with color-coded images, by each rater. Color-coded FLAIR images increased the inter-rater agreement of diffusion-weighted image FLAIR recovery mismatch and may ultimately help identify unknown-onset stroke patients appropriate for thrombolysis. © 2014 American Heart Association, Inc.

Elevated compartment pressures from copperhead envenomation successfully treated with antivenin.

PubMed

Mazer-Amirshahi, Maryann; Boutsikaris, Amy; Clancy, Cathleen

2014-01-01

Copperhead envenomation causes local soft tissue effects; however, associated compartment syndrome is rare. We report a case of a 17-month-old with significantly elevated compartment pressures successfully treated with antivenin and supportive care. A 17-month-old girl sustained a copperhead bite to the foot and presented with circumferential edema, erythema, and ecchymosis of the foot and distal ankle. The patient had palpable pulses and was neurologically intact. Four vials of Crotalidae polyvalent immune Fab was initiated and additional doses were administered in an attempt to achieve local control. Within 10 h of presentation, the patient's edema extended to the groin, although sensation was maintained and pulses were documented by Doppler. Lower-extremity compartment pressures were measured and were most notable for an anterior pressure of 85 mm Hg, despite having received 12 vials of antivenin. Fasciotomy was deferred and the patient received two additional six-vial doses of antivenin to achieve local control. Compartment pressures improved with a 2.2-cm mean decrease in limb diameter within 48 h. Maintenance dosing was initiated and the patient ultimately received a total of 26 vials of antivenin. The patient did not develop significant coagulopathy or thrombocytopenia. Swelling continued to improve with return of limb function. In this case, early and aggressive treatment with antivenin may have avoided invasive fasciotomy, and its use should be considered in patients with copperhead envenomation and significantly elevated compartment pressures. Copyright © 2014 Elsevier Inc. All rights reserved.

Incretin Therapy – Present and Future

PubMed Central

Garber, Alan J.

2011-01-01

Although newer treatments for type 2 diabetes (T2D) patients have produced continual improvements in outcome, a large and growing population with prediabetes remains under-treated. In the last few years, incretin-based therapies have become an important treatment option for patients with T2D. There are two classes of incretin agents: the dipeptidyl peptidase-4 (DPP-4) inhibitors and the glucagon like peptide 1 (GLP-1) receptor agonists. The ultimate goal of agents within both of these classes is to increase GLP-1 signaling, which results in augmented glucose-induced insulin secretion, inhibition of glucagon secretion, and decreased appetite. This should result in improved regulation of glucose homeostasis. GLP-1 receptor agonists enable patients to achieve significant weight loss. In contrast, DPP-4 inhibitors result in a less dramatic increase in GLP-1 levels; therefore, they are weight neutral. Incretin therapies are currently recommended for use early in the treatment algorithm for T2D patients whose disease is not manageable by diet and exercise alone, but the potential for these agents may be farther reaching. Current studies are evaluating the potential benefits of combining incretin therapies with basal insulin to provide continuous glucose control before and after meals. In addition, these agents may be promising for patients with prediabetes since they effectively reduce glycosylated hemoglobin levels and fasting plasma glucose levels, enable weight control, and have the potential to preserve β-cell function. Clearly, all of these properties are desirable for patients with prediabetes. PMID:22262069

Conversational assessment in memory clinic encounters: interactional profiling for differentiating dementia from functional memory disorders.

PubMed

Jones, Danielle; Drew, Paul; Elsey, Christopher; Blackburn, Daniel; Wakefield, Sarah; Harkness, Kirsty; Reuber, Markus

2016-01-01

In the UK dementia is under-diagnosed, there is limited access to specialist memory clinics, and many of the patients referred to such clinics are ultimately found to have functional (non-progressive) memory disorders (FMD), rather than a neurodegenerative disorder. Government initiatives on 'timely diagnosis' aim to improve the rate and quality of diagnosis for those with dementia. This study seeks to improve the screening and diagnostic process by analysing communication between clinicians and patients during initial specialist clinic visits. Establishing differential conversational profiles could help the timely differential diagnosis of memory complaints. This study is based on video- and audio recordings of 25 initial consultations between neurologists and patients referred to a UK memory clinic. Conversation analysis was used to explore recurrent communicative practices associated with each diagnostic group. Two discrete conversational profiles began to emerge, to help differentiate between patients with dementia and functional memory complaints, based on (1) whether the patient is able to answer questions about personal information; (2) whether they can display working memory in interaction; (3) whether they are able to respond to compound questions; (4) the time taken to respond to questions; and (5) the level of detail they offer when providing an account of their memory failure experiences. The distinctive conversational profiles observed in patients with functional memory complaints on the one hand and neurodegenerative memory conditions on the other suggest that conversational profiling can support the differential diagnosis of functional and neurodegenerative memory disorders.

Disease management programs: barriers and benefits.

PubMed

Magnezi, Racheli; Kaufman, Galit; Ziv, Arnona; Kalter-Leibovici, Ofra; Reuveni, Haim

2013-04-01

The healthcare system in Israel faces difficulties similar to those of most industrialized countries, including limited resources, a growing chronically ill population, and demand for high quality care. Disease management programs (DMPs) for patients with a chronic illness aim to alleviate some of these problems, primarily by improving patient self-management skills and quality of care. This study surveyed the opinions of senior healthcare administrators regarding barriers, benefits, and support for implementing DMPs. Cross-sectional survey. A 21-item questionnaire was self-completed by 87 of 105 (83%) healthcare administrators included in the study. Participants were 65.5% male and 47% physicians, 25.3% nurses, 17.3% administrators, and 10.3% other healthcare professionals. The main perceived benefit of DMPs among all respondents was improving quality of care. Other benefits noted were better contact with patients (81.6%) and better compliance with treatment (75.9%). Efficient long-term utilization of system resources was perceived as a benefit by only 58.6%. The main perceived barriers to implementing DMPs were lack of budgetary resources (69%) and increased time required versus financial compensation received (63.2%). The benefits of DMPs were patient oriented; barriers were perceived as financial and limiting professional autonomy. Information regarding long-term benefits (better patient outcomes) that ultimately provide better value for the system versus short-term barriers (increased costs and expenditures of time without compensation) might encourage the implementation of DMPs in countries faced with a growing population of patients with at least 1 chronic illness.

The Patient Protection and Affordable Care Act: what every provider of gynecologic oncology care should know.

PubMed

Duska, Linda R; Engelhard, Carolyn L

2013-06-01

The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama in 2010. While initial implementation of the law began shortly thereafter, the full implementation will take place over the next few years. With respect to cancer care, the act was intended to make care more accessible, affordable, and comprehensive across different parts of the country. For our cancer patients and our practices, the ACA has implications that are both positive and negative. The Medicaid expansion and access to insurance exchanges are intended to increase the number of insured patients and thus improve access to care, but many states have decided to opt out of the Medicaid program and in these states access problems will persist. Screening programs will be put in place for insured patients but may supplant federally funded programs that are currently in place for uninsured patients and may not follow current screening guidelines. Both hospice and home health providers will be asked to provide more services with less funding, and quality measures, including readmission rates, will factor into reimbursement. Insured patients will have access to all phases of clinical trial research. There is a need for us as providers of Gynecologic Oncology care to be active in the implementation of the ACA in order to ensure that our patients and our practices can survive and benefit from the changes in health care reimbursement, with the ultimate goals of improving access to care and quality while reducing unsustainable costs. Copyright © 2013 Elsevier Inc. All rights reserved.

Conversations for Providers Caring for Rectal Cancer Patients: Comparison of Long-Term Patient-Centered Outcomes for Low Rectal Cancer Patients Facing Ostomy or Sphincter-Sparing Surgery

PubMed Central

Herrinton, Lisa J.; Altschuler, Andrea; McMullen, Carmit K.; Bulkley, Joanna E.; Hornbrook, Mark C.; Sun, Virginia; Wendel, Christopher S.; Grant, Marcia; Baldwin, Carol M.; Demark-Wahnefried, Wendy; Temple, Larissa K.F.; Krouse, Robert S.

2017-01-01

For some low rectal cancer patients, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients eligible for sphincter-sparing surgery may not be well served by the surgery and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries, or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects following the two surgeries has not been synthesized. We therefore conducted a systematic review to examine this ? This systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. Our goals are: 1) improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) increase the patient’s participation in the decision; (3) alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, improve patients’ long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery, as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. PMID:26999757

Statewide shoulders study.

DOT National Transportation Integrated Search

2015-08-01

With the ultimate purpose of enhancing safety and improving mobility, the Statewide Shoulders Study was initiated to : develop a prioritized list of candidate locations for shoulder improvements. The need for this study stems directly from : ADOTs...

The Role of Patient-Provider Communication in Engagement and Re-engagement in HIV Treatment in Bamako, Mali: A Qualitative Study.

PubMed

Hurley, Emily A; Harvey, Steven A; Winch, Peter J; Keita, Mariam; Roter, Debra L; Doumbia, Seydou; Diarra, Nièlè H; Kennedy, Caitlin E

2018-01-01

Mounting evidence in sub-Saharan Africa suggests poor patient-provider communication (PPC) negatively impacts patient engagement (retention in care and adherence to medication) in antiretroviral therapy (ART) programs. In Bamako, Mali, where 36% of ART patients are lost to follow-up within 12 months of initiating treatment, we aimed to define features of positive PPC according to patient values and explore the mechanisms by which these features may sustain engagement and re-engagement according to patient and provider experiences. We conducted 33 in-depth interviews and 7 focus groups with 69 patients and 17 providers in five ART clinics. Regarding sustaining engagement, participants highlighted "establishing rapport" as a foundational feature of effective PPC, but also described how "responding to emotional needs", "eliciting patient conflicts and perspective" and "partnering to mitigate conflicts" functioned to address barriers to engagement and increase connectedness to care. Patients who had disengaged felt that "communicating reacceptance" may have prompted them re-engage sooner and that tailored "partnering to mitigate conflicts" would be more effective in sustaining re-engagement than the standard adherence education providers typically offer. Optimizing provider skills related to these key PPC features may help maximize ART patient engagement, ultimately improving health outcomes and decreasing HIV transmission in sub-Saharan Africa.

[Efficacy of epidural steroid injections for chronic lumbar pain syndromes without neurological deficits. A randomized, double blind study as part of a multimodal treatment concept].

PubMed

Niemier, K; Schindler, M; Volk, T; Baum, K; Wolf, B; Eberitsch, J; Seidel, W

2015-07-01

Chronic lumbar pain syndromes without neurological deficits are generated by a multitude of causes. Functional, morphological and psychosocial factors are discussed. In many cases a diseased intervertebral disc is found on radiological examination but the clinical relevance of these findings is not clear. For this study it was postulated that a diseased disc results in a local inflammatory reaction therefore causing pain and impairing treatability of patients. An epidural injection of steroids can reduce inflammation and therefore improve treatability and ultimately treatment outcome. A double blind randomized prospective trial was carried out. Patients treated in hospital for a chronic lumbar pain syndrome without neurological deficits within a multimodal treatment program were screened for indications for an epidural steroid injection (e.g. diseased lumbar disc and intention to treat). Patients eligible for the study were randomized into two groups. The treatment group received an epidural injection of 80 mg triamcinolone and 8 ml bupivacaine 0.25 %. The control group received only an epidural injection of 8 ml bupivacaine 0.25 %. In both groups pain intensity and treatability showed a statistically significant improvement after the epidural injection. The differences between the control and treatment groups were small and not clinically relevant. A small subgroup might profit from the steroid injection. In addition the treatability was dependent on psychometric values and the long-term outcome from a reduction of muscular skeletal dysfunctions. After the epidural injection the decrease in pain and increase in treatability was statistically significant. The mechanism of the improvement is not clear and should be examined further. The epidural injection of a steroid in this subgroup of patients did not lead to a clinical improvement in the outcome.

Impact of developing a multidisciplinary coded dataset standard on administrative data accuracy for septoplasty, septorhinoplasty and nasal trauma surgery.

PubMed

Nouraei, S A R; Hudovsky, A; Virk, J S; Saleh, H A

2017-04-01

This study aimed to develop a multidisciplinary coded dataset standard for nasal surgery and to assess its impact on data accuracy. An audit of 528 patients undergoing septal and/or inferior turbinate surgery, rhinoplasty and/or septorhinoplasty, and nasal fracture surgery was undertaken. A total of 200 septoplasties, 109 septorhinoplasties, 57 complex septorhinoplasties and 116 nasal fractures were analysed. There were 76 (14.4 per cent) changes to the primary diagnosis. Septorhinoplasties were the most commonly amended procedures. The overall audit-related income change for nasal surgery was £8.78 per patient. Use of a multidisciplinary coded dataset standard revealed that nasal diagnoses were under-coded; a significant proportion of patients received more precise diagnoses following the audit. There was also significant under-coding of both morbidities and revision surgery. The multidisciplinary coded dataset standard approach can improve the accuracy of both data capture and information flow, and, thus, ultimately create a more reliable dataset for use outcomes and health planning.

Neuropsychological impairments predict the clinical course in schizophrenia.

PubMed

Wölwer, Wolfgang; Brinkmeyer, Jürgen; Riesbeck, Mathias; Freimüller, Lena; Klimke, Ansgar; Wagner, Michael; Möller, Hans-Jürgen; Klingberg, Stefan; Gaebel, Wolfgang

2008-11-01

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.

Sanjad-Sakati syndrome with macrocytic anemia and failure to thrive: a case from South Jordan.

PubMed

Ajarmeh, Salma A; Al Tamimi, Eyad M

2018-04-25

Backgorund: Sanjad-Sakati syndrome (SSS) is a rare autosomal recessive disease caused by a deletion mutation (155-166del) in exon 3 of the TBCE gene on chromosome 1q42-43. The syndrome is characterized by primary hypoparathyroidism, typical dysmorphic features and severe growth retardation. We encountered a 2-year-old boy with hypocalcemia, failure to thrive and macrocytic anemia. The patient had the characteristic features of SSS and genetic testing confirmed that he was homozygous for the TBCE mutation. Although malabsorption was initially considered the cause of his symptoms, the results did not confirm that diagnosis. Our patient had cow milk protein allergy and folic acid deficiency, which has not been described in previous SSS cases. It was difficult to treat the patient's hyperphosphatemia and we ultimately selected sevelamer treatment, which was tolerated well and improved his hypocalcemia. SSS should be considered in the differential diagnosis of any infant with hypocalcemia, dysmorphism and failure to thrive.

Cybersecurity in healthcare: A narrative review of trends, threats and ways forward.

PubMed

Coventry, Lynne; Branley, Dawn

2018-07-01

Electronic healthcare technology is prevalent around the world and creates huge potential to improve clinical outcomes and transform care delivery. However, there are increasing concerns relating to the security of healthcare data and devices. Increased connectivity to existing computer networks has exposed medical devices to new cybersecurity vulnerabilities. Healthcare is an attractive target for cybercrime for two fundamental reasons: it is a rich source of valuable data and its defences are weak. Cybersecurity breaches include stealing health information and ransomware attacks on hospitals, and could include attacks on implanted medical devices. Breaches can reduce patient trust, cripple health systems and threaten human life. Ultimately, cybersecurity is critical to patient safety, yet has historically been lax. New legislation and regulations are in place to facilitate change. This requires cybersecurity to become an integral part of patient safety. Changes are required to human behaviour, technology and processes as part of a holistic solution. Copyright © 2018 Elsevier B.V. All rights reserved.

Statewide shoulders study : executive summary.

DOT National Transportation Integrated Search

2015-08-01

With the ultimate purpose of enhancing safety and improving mobility, the Statewide Shoulders Study was initiated to : develop a prioritized list of candidate locations for shoulder improvements. The need for this study stems directly from : ADOTs...

Plant breeding and genetics

USDA-ARS?s Scientific Manuscript database

The ultimate goal of plant breeding is to develop improved crops. Improvements can be made in crop productivity, crop processing and marketing, and/or consumer quality. The process of developing an improved cultivar begins with intercrossing lines with high performance for the traits of interest, th...

Motivational Interviewing to Increase Postdischarge Antibiotic Adherence in Older Adults with Pneumonia.

PubMed

Eyler, Rachel; Shvets, Kristina; Blakely, Michelle L

2016-01-01

To evaluate the impact of a pharmacist-led, motivational interviewing on antibiotic adherence following discharge in older adults with pneumonia. Inpatient medical wards in a large tertiary academic medical center. Older adults diagnosed with pneumonia were enrolled from December 1, 2013, to August 1, 2014, at Yale-New Haven Hospital. Motivational interviewing-a patient-centered method of communication-has gained recognition as a tool that can aid pharmacists in addressing negative health behaviors (e.g., medication adherence, health screenings, substance abuse during counseling sessions). However, the potential role of motivational interviewing in older adults to improve medication adherence during transitions of care is not clear. In this study, in addition to standard discharge care, older adults hospitalized with pneumonia who were randomized to the intervention group received enhanced care: pharmacist-led motivational interviewing. Evaluation of adherence to prescribed antibiotic regimens and patient satisfaction with the motivational interviewing, enhanced-care session. Ultimately, 87% of patients in the intervention group (n = 16) compared with 64% of patients in the control group (n = 14) were adherent to their antibiotic regimens. Patient satisfaction with the motivational interviewing intervention was high. Pharmacist-led motivational interviewing sessions have the potential to positively influence antibiotic adherence rates and patient satisfaction.

Work engagement and attitudes toward caring for dying patients and families among home-visiting nurses in Japan.

PubMed

Mahiro, Sakai; Takashi, Naruse; Satoko, Nagata

2014-07-01

Nurses with higher levels of work engagement tend to be highly efficient in their work and more willing to keep working and to provide patient-centred care. However, whether more engaged nurses provide end-of-life care more proactively has not been examined in the home-care setting. This study aimed to examine work engagement among home-visiting nurses in Japan and its relationship with their attitudes toward caring for dying patients and their families. A total of 343 nurses working in 62 agencies across Chiba prefecture, eastern Japan, received an anonymous self-administered questionnaire from July to August 2012. The authors performed multiple regression analysis to explore the relationships between home-visiting nurses' work engagement and attitudes. Data from 184 nurses (53.6%) was analysed. Work engagement was significantly positively related to the nurses' attitudes toward caring for dying patients and their families. As more engaged nurses tend to have more positive attitudes toward caring for dying patients and their families, further research is needed to identify the factors that might help nursing managers to enhance their staff's engagement and perhaps thereby improve their attitudes, with the ultimate aim of achieving better outcomes for patients and families.

Vemurafenib: an evidence-based review of its clinical utility in the treatment of metastatic melanoma.

PubMed

Swaika, Abhisek; Crozier, Jennifer A; Joseph, Richard W

2014-01-01

The discovery of BRAF mutations in the majority of patients with metastatic melanoma combined with the identification of highly selective BRAF inhibitors have revolutionized the treatment of patients with metastatic melanoma. The first highly specific BRAF inhibitor, vemurafenib, began clinical testing in 2008 and moved towards a rapid approval in 2011. Vemurafenib induced responses in ~50% of patients with metastatic BRAF-mutant melanoma and demonstrated improved overall survival in a randomized Phase III trial. Furthermore, vemurafenib is well-tolerated with a low toxicity profile and rapid onset of action. Finally, vemurafenib is active even in patients with widely metastatic disease. Despite the success of vemurafenib in treating patients with BRAF-mutant metastatic melanoma, most, if not all, patients ultimately develop resistance resulting in disease progression at a median time of ~6 months. Multiple mechanisms of resistance have been described and rationale strategies are underway to combat resistance. This review highlights the development, clinical utility, resistance mechanisms, and future use of vemurafenib both in melanoma and other malignancies. We consulted PubMed, Scopus, MEDLINE, ASCO annual symposium abstracts, and http://clinicaltrials.gov/ for the purpose of this review.

Vemurafenib: an evidence-based review of its clinical utility in the treatment of metastatic melanoma

PubMed Central

Swaika, Abhisek; Crozier, Jennifer A; Joseph, Richard W

2014-01-01

The discovery of BRAF mutations in the majority of patients with metastatic melanoma combined with the identification of highly selective BRAF inhibitors have revolutionized the treatment of patients with metastatic melanoma. The first highly specific BRAF inhibitor, vemurafenib, began clinical testing in 2008 and moved towards a rapid approval in 2011. Vemurafenib induced responses in ~50% of patients with metastatic BRAF-mutant melanoma and demonstrated improved overall survival in a randomized Phase III trial. Furthermore, vemurafenib is well-tolerated with a low toxicity profile and rapid onset of action. Finally, vemurafenib is active even in patients with widely metastatic disease. Despite the success of vemurafenib in treating patients with BRAF-mutant metastatic melanoma, most, if not all, patients ultimately develop resistance resulting in disease progression at a median time of ~6 months. Multiple mechanisms of resistance have been described and rationale strategies are underway to combat resistance. This review highlights the development, clinical utility, resistance mechanisms, and future use of vemurafenib both in melanoma and other malignancies. We consulted PubMed, Scopus, MEDLINE, ASCO annual symposium abstracts, and http://clinicaltrials.gov/ for the purpose of this review. PMID:24966667

Rheumatoid arthritis patient perceptions on the value of predictive testing for treatments: a qualitative study.

PubMed

Kumar, Kanta; Peters, Sarah; Barton, Anne

2016-11-08

Rheumatoid arthritis (RA) is a long term condition that requires early treatment to control symptoms and improve long-term outcomes. Lack of response to RA treatments is not only a waste of healthcare resources, but also causes disability and distress to patients. Identifying biomarkers predictive of treatment response offers an opportunity to improve clinical decisions about which treatment to recommend in patients and could ultimately lead to better patient outcomes. The aim of this study was to explore the understanding of and factors affecting Rheumatoid Arthritis (RA) patients' decisions around predictive treatment testing. A qualitative study was conducted with a purposive sample of 16 patients with RA from three major UK cities. Four focus groups explored patient perceptions of the use of biomarker tests to predict response to treatments. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis by three researchers. Data were organised within three interlinking themes: [1] Perceptions of predictive tests and patient preference of tests; [2] Utility of the test to manage expectations; [3] The influence of the disease duration on take up of predictive testing. During consultations for predictive testing, patients felt they would need, first, careful explanations detailing the consequences of untreated RA and delayed treatment response and, second, support to balance the risks of tests, which might be invasive and/or only moderately accurate, with the potential benefits of better management of symptoms. This study provides important insights into predictive testing. Besides supporting clinical decision making, the development of predictive testing in RA is largely supported by patients. Developing strategies which communicate risk information about predictive testing effectively while reducing the psychological burden associated with this information will be essential to maximise uptake.

Postburn Head and Neck Reconstruction: An Algorithmic Approach.

PubMed

Heidekrueger, Paul Immanuel; Broer, Peter Niclas; Tanna, Neil; Ninkovic, Milomir

2016-01-01

Optimizing functional and aesthetic outcomes in postburn head and neck reconstruction remains a surgical challenge. Recurrent contractures, impaired range of motion, and disfigurement because of disruption of the aesthetic subunits of the face, can result in poor patient satisfaction and ultimately, contribute to social isolation of the patient. In an effort to improve the quality of life of these patients, this study evaluates different surgical approaches with an emphasis on tissue expansion of free and regional flaps. Regional and free-flap reconstruction was performed in 20 patients (26 flaps) with severe postburn head and neck contractures. To minimize donor site morbidity and obtain large amounts of thin and pliable tissue, pre-expansion was performed in all patients treated with locoregional flap reconstructions (12/12), and 62% (8/14) of patients with free-flap reconstructions. Algorithms regarding pre- and intraoperative decision-making are discussed, and complications between the techniques as well as long-term (mean follow-up 3 years) results are analyzed. Complications, including tissue expander infection with need for removal or exchange, partial or full flap loss, were evaluated and occurred in 25% (3/12) of patients with locoregional and 36% (5/14) of patients receiving free-flap reconstructions. Secondary revision surgery was performed in 33% (4/12) of locoregional flaps and 93% (13/14) of free flaps. Both locoregional as well as distant tissue transfers have their role in postburn head and neck reconstruction, whereas pre-expansion remains an invaluable tool. Paying attention to the presented principles and keeping the importance of aesthetic facial subunits in mind, range of motion, aesthetics, and patient satisfaction were improved long term in all our patients, while minimizing donor site morbidity.

A novel rapid access testicular cancer clinic: prospective evaluation after one year.

PubMed

Carey, K; Davis, N F; Elamin, S; Ahern, P; Brady, C M; Sweeney, P

2016-02-01

Our institution has recently developed a rapid access outpatient clinic to investigate men with testicular lumps and/or pain suspicious for testicular cancer (TCa). To present our experience after 12 months. All referrals to the rapid access testicular clinic (RATC) clinic were prospectively analysed from 01/01/2013 to 01/01/2014. The primary outcome variable was incidence of TCa in the referred patient cohort. Secondary outcome variables were waiting times prior to clinical review and waiting times prior to radical orchidectomy in patients diagnosed with TCa. Seventy-four new patients were referred to the RATC during the 1-year period and the mean age was 34 (range 15-81 years). TCa was the most common diagnosis and was found in 18 (25 %) patients. Patients diagnosed with TCa underwent radical orchidectomy, a median of 3 (range 1-5) days after their initial GP referral. Patients requiring surgical intervention for benign scrotal pathology underwent their procedure a median of 32 (range 3-61) days after their initial referral. Of the 18 patients diagnosed with TCa, 9 (50 %) were diagnosed with a seminomatous germ cell tumour on histopathology. The RATC is a new initiative in Ireland that provides expedient and definitive treatment of patients with newly diagnosed TCa. Early treatment will ultimately improve long-term prognosis in this patient cohort.

Cultural competence for the 21st century dermatologist practicing in the United States.

PubMed

McKesey, Jacqueline; Berger, Timothy G; Lim, Henry W; McMichael, Amy J; Torres, Abel; Pandya, Amit G

2017-12-01

Significant health disparities exist among under-represented minorities in the Unites States, which can partially be accounted for by the quality of patient-physician interaction. A distinguishing factor of this interaction is the ability of the provider to demonstrate cultural competence, or address the social, cultural, and community influences on healthcare behaviors and incorporate these elements into patient care. However, this practice has yet to be universally implemented in our healthcare system. These factors become even more important as the racial, ethnic and cultural distribution of the United States population changes. Multiple studies have suggested that cultural competence of the health care provider and staff leads to improved patient adherence, satisfaction, and ultimately, health outcome. Cultural competence in the workplace also leads to efficient and cost-effective healthcare and better community integration into healthcare systems. The purpose of this review is to help dermatologists understand the benefits of culturally competent care for their patients and themselves and identify methods and resources to achieve this goal. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Building a Biopsychosocial Conceptual Framework to Explore Pressure Ulcer Pain for Hospitalized Patients

PubMed Central

Kim, Junglyun; Ahn, Hyochol; Lyon, Debra E.; Stechmiller, Joyce

2016-01-01

Although pressure ulcers are a prevalent condition, pain associated with pressure ulcers is not fully understood. Indeed, previous studies do not shed light on the association between pressure ulcer stages and the experience of pain. Especially, pain characteristics of suspected deep tissue injury, which is a new category that was recently added by the National Pressure Ulcer Advisory Panel, are yet unknown. This is concerning because the incidence of pressure ulcers in hospitalized patients has increased exponentially over the last two decades, and health care providers are struggling to ensure providing adequate care. Thus, in order to facilitate the development of effective interventions, this paper presents a conceptual framework to explore pressure ulcer pain in hospitalized patients. The concepts were derived from a biopsychosocial model of pain, and the relationships among each concept were identified through a literature review. Major propositions are presented based on the proposed conceptual framework, which integrates previous research on pressure ulcer pain, to ultimately improve understanding of pain in hospitalized patients with pressure ulcers. PMID:27417595

Augmentation treatment in major depressive disorder: focus on aripiprazole

PubMed Central

Nelson, J Craig; Pikalov, Andrei; Berman, Robert M

2008-01-01

Major depressive disorder (MDD) is a disabling psychiatric condition for which effective treatment remains an outstanding need. Antidepressants are currently the mainstay of treatment for depression; however, almost two-thirds of patients will fail to achieve remission with initial treatment. As a result, a range of augmentation and combination strategies have been used in order to improve outcomes for patients. Despite the popularity of these approaches, limited data from double-blind, randomized, placebo-controlled studies are available to allow clinicians to determine which are the most effective augmentation options or which patients are most likely to respond to which options. Recently, evidence has shown that adjunctive therapy with atypical antipsychotics has the potential for beneficial antidepressant effects in the absence of psychotic symptoms. In particular, aripiprazole has shown efficacy as an augmentation option with standard antidepressant therapy in two, large, randomized, double-blind studies. Based on these efficacy and safety data, aripiprazole was recently approved by the FDA as adjunctive therapy for MDD. The availability of this new treatment option should allow more patients with MDD to achieve remission and, ultimately, long-term, successful outcomes. PMID:19183784

Intensive Home Hemodialysis: An Eye at the Past Looking for the Hemodialysis of the Future.

PubMed

Naso, Agostino; Scaparrotta, Giuseppe; Naso, Elena; Calò, Lorenzo A

2015-09-01

Multiple observational studies along with a limited number of randomized clinical trials suggest that intensive hemodialysis (IHD) not only improves outcomes for uremic patients undergoing chronic dialysis but does so with a more favorable cost/benefit ratio compared with conventional hemodialysis. As a result of this, there has been a rapid increase in the interest in home hemodialysis (HHD) as HHD represents the easiest means of implementing IHD. While HHD has generated increased interest given its association with better outcomes/reduced hospitalizations, there are very few randomized controlled trials comparing HHD with other hemodialysis methods. Reported HHD-associated increased survival benefits compared with in-center hemodialysis are from uncontrolled studies, which raise patient selection bias as underlying the differences found. Thus, while HHD draws increasing attention, studies that pay careful attention to the psychosocial, demographic, and clinical factors associated with patients selected to undergo HHD will be needed to ultimately demonstrate its benefits, clarify the clinical applications, and determine the limits of IHD use in dialysis patients. Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Integrating cultural humility into health care professional education and training.

PubMed

Chang, E-shien; Simon, Melissa; Dong, XinQi

2012-05-01

As US populations become increasing diverse, healthcare professionals are facing a heightened challenge to provide cross-cultural care. To date, medical education around the world has developed specific curricula on cultural competence training in acknowledgement of the importance of culturally sensitive and grounded services. This article proposes to move forward by integrating the concept of cultural humility into current trainings, in which we believe, is vital in complementing the current model, and better prepare future professionals to address health challenges with culturally appropriate care. Based on the works of Chinese philosophers, cultural values and the contemporary Chinese immigrants' experience, we hereby present the QIAN (Humbleness) curriculum: the importance of self-Questioning and critique, bi-directional cultural Immersion, mutually Active-listening, and the flexibility of Negotiation. The principles of the QIAN curriculum reside not only between the patient and the healthcare professional dyad, but also elicit the necessary support of family, health care system as well as the community at large. The QIAN curriculum could improve practice and enhance the exploration, comprehension and appreciation of the cultural orientations between healthcare professionals and patients which ultimately could improve patient satisfaction, patient-healthcare professional relationship, medical adherence and the reduction of health disparities. QIAN model is highly adaptable to other cultural and ethnic groups in multicultural societies around the globe. Incorporating its framework into the current medical education may enhance cross-cultural clinical encounters.

Evidence-based Guidelines for Precision Risk Stratification-Based Screening (PRSBS) for Colorectal Cancer: Lessons learned from the US Armed Forces: Consensus and Future Directions

PubMed Central

Avital, Itzhak; Langan, Russell C.; Summers, Thomas A.; Steele, Scott R.; Waldman, Scott A.; Backman, Vadim; Yee, Judy; Nissan, Aviram; Young, Patrick; Womeldorph, Craig; Mancusco, Paul; Mueller, Renee; Noto, Khristian; Grundfest, Warren; Bilchik, Anton J.; Protic, Mladjan; Daumer, Martin; Eberhardt, John; Man, Yan Gao; Brücher, Björn LDM; Stojadinovic, Alexander

2013-01-01

Colorectal cancer (CRC) is the third most common cause of cancer-related death in the United States (U.S.), with estimates of 143,460 new cases and 51,690 deaths for the year 2012. Numerous organizations have published guidelines for CRC screening; however, these numerical estimates of incidence and disease-specific mortality have remained stable from years prior. Technological, genetic profiling, molecular and surgical advances in our modern era should allow us to improve risk stratification of patients with CRC and identify those who may benefit from preventive measures, early aggressive treatment, alternative treatment strategies, and/or frequent surveillance for the early detection of disease recurrence. To better negotiate future economic constraints and enhance patient outcomes, ultimately, we propose to apply the principals of personalized and precise cancer care to risk-stratify patients for CRC screening (Precision Risk Stratification-Based Screening, PRSBS). We believe that genetic, molecular, ethnic and socioeconomic disparities impact oncological outcomes in general, those related to CRC, in particular. This document highlights evidence-based screening recommendations and risk stratification methods in response to our CRC working group private-public consensus meeting held in March 2012. Our aim was to address how we could improve CRC risk stratification-based screening, and to provide a vision for the future to achieving superior survival rates for patients diagnosed with CRC. PMID:23459409

Patients do not always complain when they are dissatisfied: implications for service quality and patient safety.

PubMed

Howard, Matylda; Fleming, Mary Louise; Parker, Elizabeth

2013-12-01

This study aimed to explore the actions taken by patients who had been admitted to an acute care Queensland hospital and experienced dissatisfaction with service delivery. It is proposed that before complaints can be used as part of a strategy to inform health service improvement and ultimately ensure patient safety, an understanding of the effectiveness of the complaints handling process from the patient's perspective must be gained. In-depth qualitative interviews using a phenomenological exploration were undertaken. The theoretical framework supporting the thematic analysis of the interview data was drawn from Lazarus's cognitive emotive model of coping. Analysis of the research data, aided by Leximancer software, revealed a series of relational themes that supported the interpretative data analysis process undertaken. In 16 interviews, the study outcomes identified that 15 of the participants did not voice their complaint at the time of the event, but after the event, they stated they wished that they had reacted differently and complained at the actual point in time that they were dissatisfied. The themes that emerged that reflected potential lost opportunities included issues with ineffective communication, being treated with disrespect, inconsistent standards of care, perceptions of negligence, and lack of information about how to make a complaint. Our findings suggest that health-care professionals should take a more active role in identifying and responding to patients who are experiencing dissatisfaction but are not actively complaining. This level of vigilance and responsiveness will ensure opportunities to improve health service delivery, and patient safety are not lost.

Obstructive sleep apnea: strategies for minimizing liability and enhancing patient safety.

PubMed

Svider, Peter F; Pashkova, Anna A; Folbe, Adam J; Eloy, Jean Daniel; Setzen, Michael; Baredes, Soly; Eloy, Jean Anderson

2013-12-01

To characterize malpractice litigation regarding obstructive sleep apnea (OSA) and educate physicians on frequently cited factors. Analysis of the Westlaw legal database. Jury verdict and settlement reports were examined for outcome, awards, patient demographic factors, defendant specialty, and alleged causes of malpractice. Out of 54 identified cases, 33 (61.1%) cases were resolved in favor of defendants, 12 (22.2%) via settlement, and 9 (16.7%) through jury award. Median settlement and jury awards did not significantly differ ($750,000 vs $550,000, P > .50). Age and gender did not affect outcome. Otolaryngologists and anesthesiologists were the most frequently named defendants. Forty-seven cases (87.1%) stemmed from OSA patients who underwent procedures with resultant perioperative adverse events. Common alleged factors included death (48.1%), permanent deficits (42.6%), intraoperative complications (35.2%), requiring additional surgery (25.9%), anoxic brain injury (24.1%), inadequate informed consent (24.1%), inappropriate medication administration (22.2%), and inadequate monitoring (20.4%). Litigation related to OSA is frequently associated with perioperative complications more than nonoperative issues such as a failure to diagnose this disorder. Nonetheless, OSA is considerably underdiagnosed, and special attention should be paid to at-risk patients, including close monitoring of their clinical status and the medications they receive. For patients with diagnosed or suspected OSA with planned operative intervention, whether for OSA or an unrelated issue, a comprehensive informed consent process detailing the factors outlined in this analysis is an effective strategy to increase communication and improve the physician-patient relationship, minimize liability, and ultimately improve patient safety.

Sentinel node status prediction by four statistical models: results from a large bi-institutional series (n = 1132).

PubMed

Mocellin, Simone; Thompson, John F; Pasquali, Sandro; Montesco, Maria C; Pilati, Pierluigi; Nitti, Donato; Saw, Robyn P; Scolyer, Richard A; Stretch, Jonathan R; Rossi, Carlo R

2009-12-01

To improve selection for sentinel node (SN) biopsy (SNB) in patients with cutaneous melanoma using statistical models predicting SN status. About 80% of patients currently undergoing SNB are node negative. In the absence of conclusive evidence of a SNBassociated survival benefit, these patients may be over-treated. Here, we tested the efficiency of 4 different models in predicting SN status. The clinicopathologic data (age, gender, tumor thickness, Clark level, regression, ulceration, histologic subtype, and mitotic index) of 1132 melanoma patients who had undergone SNB at institutions in Italy and Australia were analyzed. Logistic regression, classification tree, random forest, and support vector machine models were fitted to the data. The predictive models were built with the aim of maximizing the negative predictive value (NPV) and reducing the rate of SNB procedures though minimizing the error rate. After cross-validation logistic regression, classification tree, random forest, and support vector machine predictive models obtained clinically relevant NPV (93.6%, 94.0%, 97.1%, and 93.0%, respectively), SNB reduction (27.5%, 29.8%, 18.2%, and 30.1%, respectively), and error rates (1.8%, 1.8%, 0.5%, and 2.1%, respectively). Using commonly available clinicopathologic variables, predictive models can preoperatively identify a proportion of patients ( approximately 25%) who might be spared SNB, with an acceptable (1%-2%) error. If validated in large prospective series, these models might be implemented in the clinical setting for improved patient selection, which ultimately would lead to better quality of life for patients and optimization of resource allocation for the health care system.

Patient Self-reported quality of life assessment in Type 2 diabetes mellitus: A pilot study.

PubMed

PrasannaKumar, H R; Mahesh, M G; Menon, V B; Srinath, K M; Shashidhara, K C; Ashok, P

2018-03-01

Quality of life (QoL) is an important outcome measure to assess the diabetic care and is increasingly replacing the traditional indicators of health. The aim is to evaluate the QoL in patients with type 2 diabetes mellitus (DM) using a third generation individualized QoL instrument like an audit of diabetes-dependent QoL (ADDQoL) questionnaire and to determine the predictors. Patients who met the inclusion and exclusion criteria were recruited from a tertiary care hospital by convenience sampling. Sociodemographic and other relevant details were collected from the study patients, and ADDQoL questionnaire were administered to them. A total of 200 patients were included in the study among which 66% of patients had uncontrolled type 2 DM as suggested by their glycated hemoglobin (HbA1c) values. The mean QoL score was 0.07 (0.91) and diabetes-dependent QoL was -1.33 (0.58). Approximately 38% were associated with poor health-related QoL with a mean average weighted impact score of -0.51 (0.51). Most frequently affected life domain was the freedom to eat. A positive correlation was observed between QoL and gender, age, domicile, education status, occupation, family structure, duration of type 2 DM, HbA1c, insulin treatment, and the presence of comorbidities. The study highlights the impact of type 2 DM on QoL. Improving QoL of type 2 diabetic patients is important and knowledge of these preventable risk factors help to implement strategies to better management of type 2 DM and ultimately improve therapeutic outcome.

Developing a Comprehensive Model of Intensive Care Unit Processes: Concept of Operations.

PubMed

Romig, Mark; Tropello, Steven P; Dwyer, Cindy; Wyskiel, Rhonda M; Ravitz, Alan; Benson, John; Gropper, Michael A; Pronovost, Peter J; Sapirstein, Adam

2015-04-23

This study aimed to use a systems engineering approach to improve performance and stakeholder engagement in the intensive care unit to reduce several different patient harms. We developed a conceptual framework or concept of operations (ConOps) to analyze different types of harm that included 4 steps as follows: risk assessment, appropriate therapies, monitoring and feedback, as well as patient and family communications. This framework used a transdisciplinary approach to inventory the tasks and work flows required to eliminate 7 common types of harm experienced by patients in the intensive care unit. The inventory gathered both implicit and explicit information about how the system works or should work and converted the information into a detailed specification that clinicians could understand and use. Using the ConOps document, we created highly detailed work flow models to reduce harm and offer an example of its application to deep venous thrombosis. In the deep venous thrombosis model, we identified tasks that were synergistic across different types of harm. We will use a system of systems approach to integrate the variety of subsystems and coordinate processes across multiple types of harm to reduce the duplication of tasks. Through this process, we expect to improve efficiency and demonstrate synergistic interactions that ultimately can be applied across the spectrum of potential patient harms and patient locations. Engineering health care to be highly reliable will first require an understanding of the processes and work flows that comprise patient care. The ConOps strategy provided a framework for building complex systems to reduce patient harm.

The use of discrete-event simulation modelling to improve radiation therapy planning processes.

PubMed

Werker, Greg; Sauré, Antoine; French, John; Shechter, Steven

2009-07-01

The planning portion of the radiation therapy treatment process at the British Columbia Cancer Agency is efficient but nevertheless contains room for improvement. The purpose of this study is to show how a discrete-event simulation (DES) model can be used to represent this complex process and to suggest improvements that may reduce the planning time and ultimately reduce overall waiting times. A simulation model of the radiation therapy (RT) planning process was constructed using the Arena simulation software, representing the complexities of the system. Several types of inputs feed into the model; these inputs come from historical data, a staff survey, and interviews with planners. The simulation model was validated against historical data and then used to test various scenarios to identify and quantify potential improvements to the RT planning process. Simulation modelling is an attractive tool for describing complex systems, and can be used to identify improvements to the processes involved. It is possible to use this technique in the area of radiation therapy planning with the intent of reducing process times and subsequent delays for patient treatment. In this particular system, reducing the variability and length of oncologist-related delays contributes most to improving the planning time.

Effectiveness of oncogenetics training on general practitioners' consultation skills: a randomized controlled trial

PubMed Central

Houwink, Elisa J.F.; Muijtjens, Arno M.M.; van Teeffelen, Sarah R.; Henneman, Lidewij; Rethans, Jan Joost; van der Jagt, Liesbeth E.J.; van Luijk, Scheltus J.; Dinant, Geert Jan; van der Vleuten, Cees; Cornel, Martina C.

2014-01-01

Purpose: General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills. Methods: In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires. Results: Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored. Conclusion: The general practitioner–specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care. PMID:23722870

Integral pharmacological management of bone mineral disorders in chronic kidney disease (part II): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification.

PubMed

Bover, J; Ureña-Torres, P; Lloret, M J; Ruiz, C; DaSilva, I; Diaz-Encarnacion, M M; Mercado, C; Mateu, S; Fernández, E; Ballarin, J

2016-07-01

Chronic kidney disease-mineral and bone disorders (CKD-MBD) are associated with costly complications and dismal hard-outcomes. In two comprehensive articles we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (part 1) and hyperparathyroidism (this part 2), taking into account CKD-accelerated cardiovascular calcification (CVC) processes. Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Here, initial guidance to control hyperparathyroidism is provided, taking into account the presence/absence of CVC. We include also measures for patients at risk of adynamic bone disease or suffering from calciphylaxis. Many epidemiological studies (relating to vitamin D) and thorough analyses of recent randomized clinical trials (of cinacalcet) point towards benefits of attempting to improve biochemical parameters while trying to, at least, avoid progression of CVC by more rational use of intestinal P-binders and low-dose vitamin D derivatives and/or calcimimetics. This approach does not seem to be far away from significantly improving hard-outcomes, at least in the dialysis population. The availability of new drugs and the performance of randomized clinical trials should ultimately lead to define earlier, clearer, and more cost-effective patient stratification and biochemical targets with consequent significant clinical improvements.

Conscious Leadership.

PubMed

Ward, Suzanne F; Haase, Beth

2016-11-01

Health care leaders need to use leadership methodologies that support safe patient care, satisfy employees, and improve the bottom line. Conscious leaders help create desirable personal and professional life experiences for themselves using specific tools that include mindfulness, context, and the observer-self, and they strive to help their employees learn to use these tools as well. In perioperative nursing, conscious leaders create an environment in which nurses are supported in their aim to provide the highest level of patient care and in which transformations are encouraged to take place; this environment ultimately promotes safety, contributes to fulfilling and meaningful work, and enhances a facility's financial viability. This article discusses some of the key concepts behind conscious leadership, how perioperative leaders can reach and maintain expanded consciousness, and how they can best assist their staff members in their own evolution to a more mindful state. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Transcatheter Aortic Valve Replacement: a Kidney’s Perspective

PubMed Central

Cheungpasitporn, Wisit; Thongprayoon, Charat; Kashani, Kianoush

2016-01-01

Transcatheter aortic valve replacement (TAVR) has now emerged as a viable treatment option for high-risk patients with severe aortic stenosis (AS) who are not suitable candidates for surgical aortic valve replacement (SAVR). Despite encouraging published outcomes, acute kidney injury (AKI) is common and lowers the survival of patients after TAVR. The pathogenesis of AKI after TAVR is multifactorial including TAVR specific factors such as the use of contrast agents, hypotension during rapid pacing, and embolization; preventive measures may include pre-procedural hydration, limitation of contrast dye exposure, and avoidance of intraprocedural hypotension. In recent years, the number of TAVR performed worldwide has been increasing, as well as published data on renal perspectives of TAVR including AKI, chronic kidney disease, end-stage kidney disease, and kidney transplantation. This review aims to present the current literature on the nephrology aspects of TAVR, ultimately to improve the patients’ quality of care and outcomes. PMID:27069960

Molecular diagnostics in the management of rhabdomyosarcoma.

PubMed

Arnold, Michael A; Barr, Fredric G

2017-02-01

A classification of rhabdomyosarcoma (RMS) with prognostic relevance has primarily relied on clinical features and histologic classification as either embryonal or alveolar RMS. The PAX3-FOXO1 and PAX7-FOXO1 gene fusions occur in 80% of cases with the alveolar subtype and are more predictive of outcome than histologic classification. Identifying additional molecular hallmarks that further subclassify RMS is an active area of research. Areas Covered: The authors review the current state of the PAX3-FOXO1 and PAX7-FOXO1 fusions as prognostic biomarkers. Emerging biomarkers, including mRNA expression profiling, MYOD1 mutations, RAS pathway mutations and gene fusions involving NCOA2 or VGLL2 are also reviewed. Expert commentary: Strategies for modifying RMS risk stratification based on molecular biomarkers are emerging with the potential to transform the clinical management of RMS, ultimately improving patient outcomes by tailoring therapy to predicted patient risk and identifying targets for novel therapies.

Sarcoid polyneuropathy masquerading as chronic inflammatory demyelinating polyneuropathy.

PubMed

Singhal, Neel S; Irodenko, Viktoriya S; Margeta, Marta; Layzer, Robert B

2015-10-01

Sarcoid polyneuropathy is a rare and clinically heterogeneous disorder that may be the initial presentation of sarcoidosis. We report the clinical, electrophysiological, and pathological findings of a patient who carried a diagnosis of sensory-predominant chronic inflammatory demyelinating polyneuropathy (CIDP) for over a decade but was ultimately found to have sarcoid polyneuropathy. A 36-year-old man presented with a several-week history of gait difficulty and muscle cramps. He had a diagnosis of CIDP but had not received lasting benefit from steroid-sparing immunosuppressive drugs. Electrodiagnostic studies were consistent with a chronic demyelinating polyradiculoneuropathy with conduction blocks. After he developed systemic symptoms, tissue biopsies revealed granulomatous disease. Symptoms improved with steroid therapy. Sarcoid polyneuropathy presents a diagnostic challenge, but, in patients with atypical neuropathy, characteristic systemic symptoms, or a poor response to standard treatment, nerve and muscle biopsies can help diagnose this treatable disorder. © 2015 Wiley Periodicals, Inc.

Cognitive Impairment in Bipolar Disorder: Treatment and Prevention Strategies.

PubMed

Solé, Brisa; Jiménez, Esther; Torrent, Carla; Reinares, Maria; Bonnin, Caterina Del Mar; Torres, Imma; Varo, Cristina; Grande, Iria; Valls, Elia; Salagre, Estela; Sanchez-Moreno, Jose; Martinez-Aran, Anabel; Carvalho, André F; Vieta, Eduard

2017-08-01

Over the last decade, there has been a growing appreciation of the importance of identifying and treating cognitive impairment associated with bipolar disorder, since it persists in remission periods. Evidence indicates that neurocognitive dysfunction may significantly influence patients' psychosocial outcomes. An ever-increasing body of research seeks to achieve a better understanding of potential moderators contributing to cognitive impairment in bipolar disorder in order to develop prevention strategies and effective treatments. This review provides an overview of the available data from studies examining treatments for cognitive dysfunction in bipolar disorder as well as potential novel treatments, from both pharmacological and psychological perspectives. All these data encourage the development of further studies to find effective strategies to prevent and treat cognitive impairment associated with bipolar disorder. These efforts may ultimately lead to an improvement of psychosocial functioning in these patients. © The Author 2017. Published by Oxford University Press on behalf of CINP.

Cancer care decision making in multidisciplinary meetings.

PubMed

Dew, Kevin; Stubbe, Maria; Signal, Louise; Stairmand, Jeannine; Dennett, Elizabeth; Koea, Jonathan; Simpson, Andrew; Sarfati, Diana; Cunningham, Chris; Batten, Lesley; Ellison-Loschmann, Lis; Barton, Josh; Holdaway, Maureen

2015-03-01

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes. © The Author(s) 2014.

Endoscopic laser treatment of subglottic and tracheal stenosis

NASA Astrophysics Data System (ADS)

Correa, Alex J.; Garrett, C. Gaelyn; Reinisch, Lou

1999-06-01

The ideal laser produces discrete wounds in a reproducible manner. The CO2 laser with its 10.6 micron wavelength is highly absorbed by water, its energy concentrated at the point of impact and the longer wavelength creates less scatter in tissue. The development of binocular endoscopic delivery system for use with binocular microlaryngoscopes have aided in using CO2 laser to treat patients with subglottic and tracheal stenosis. Often, patients with these disease processes require multiple endoscopic or open reconstructive procedures and my ultimately become tracheotomy dependent. The canine model of subglottic stenosis that has been develop allows testing of new agents as adjuncts to laser treatment. Mitomycin-C is an antibiotic with antitumor activity used in chemotherapy and also in ophthalmologic surgery due to its known inhibition of fibroblast proliferation. Current studies indicate this drug to have significant potential for improving our current management of this disease process.

Development and Implementation of a Training-of-Trainers Program for Continuous Positive Airway Pressure in Neonatal and Pediatric Patients in Five Low- and Middle-Income Countries.

PubMed

Wilson, Patrick T; Benckert, Megan M; Moresky, Rachel T; Morris, Marilyn C

2017-10-01

We describe a pragmatic training-of-trainers program for the use of continuous positive airway pressure (CPAP) for neonatal and pediatric patients. The program is designed for medical professionals working in low- and middle-income countries and involves 2 days of in-class training followed by 1 day of in-service training. The program was created after training in Cambodia, Ghana, Honduras, Kenya and Rwanda and addresses the issues of resource availability, cultural context and local buy-in and partnership in low- and middle-income countries. We hope others will use the training program to increase knowledge and use of CPAP with the ultimate goal of improving neonatal and pediatric survival globally. © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Multidisciplinary management of heart failure just beginning in Japan.

PubMed

Sato, Yukihito

2015-09-01

The mortality associated with end-stage heart failure (HF) is high despite the development of new and increasingly effective drugs and non-pharmacological therapies. Repetitive hospitalizations predict fatal outcomes and each hospitalization should prompt individual conversations with the patient, the family, and the caregivers. A multidisciplinary disease management program promotes the education of patients and their families and modifies their behavior, with a view to ultimately improve the prognosis and quality of life. From the early to the late stages of HF, a multidisciplinary disease management program should be implemented. In Western societies this multidisciplinary management has long been debated and endorsed, in contrast to Japan, where it has just begun. In 2012, the Japanese Nursing Association launched a certification in chronic HF nursing. A Japanese version of HF disease management should soon be developed in its own social environment. Copyright © 2015. Published by Elsevier Ltd.

Towards diagnostic markers for the psychoses.

PubMed

Lawrie, Stephen M; O'Donovan, Michael C; Saks, Elyn; Burns, Tom; Lieberman, Jeffrey A

2016-04-01

Psychotic disorders are currently grouped under broad phenomenological diagnostic rubrics. Researchers hope that progress in identifying aetiological mechanisms will ultimately enable more precise division of heterogeneous diagnoses into specific and valid subgroups. This goal has been an aim of psychiatry since the 19th century, when patients with general paresis were thought to have "insanity" similar to dementia praecox and manic depressive illness. Nowadays, the constructs of organic-induced and substance-induced psychotic disorder show that our diagnostic classification system already reflects, in part, aetiological factors. Most recently, gene copy number variation and autoimmunity have been associated with schizophrenia. We suggest how, on the basis of recent scientific advances, we can progress the identification of further putative subgroups and make the most of currently available interventions. Prompt diagnosis and treatment, and a more routine search for causes, could preserve function and improve outcome, and therefore be more acceptable to patients and carers. Copyright © 2016 Elsevier Ltd. All rights reserved.

A multi-marker molecular signature approach for treatment-specific subgroup identification with survival outcomes.

PubMed

Li, L; Guennel, T; Marshall, S; Cheung, L W-K

2014-10-01

Delivering on the promise of personalized medicine has become a focus of the pharmaceutical industry as the era of the blockbuster drug is fading. Central to realizing this promise is the need for improved analytical strategies for effectively integrating information across various biological assays (for example, copy number variation and targeted protein expression) toward identification of a treatment-specific subgroup-identifying the right patients. We propose a novel combination of elastic net followed by a maximal χ(2) and semiparametric bootstrap. The combined approaches are presented in a two-stage strategy that estimates patient-specific multi-marker molecular signatures (MMMS) to identify and directly test for a biomarker-driven subgroup with enhanced treatment effect. This flexible strategy provides for incorporation of business-specific needs, such as confining the search space to a subgroup size that is commercially viable, ultimately resulting in actionable information for use in empirically based decision making.

Localizing epileptic seizure onsets with Granger causality

NASA Astrophysics Data System (ADS)

Adhikari, Bhim M.; Epstein, Charles M.; Dhamala, Mukesh

2013-09-01

Accurate localization of the epileptic seizure onset zones (SOZs) is crucial for successful surgery, which usually depends on the information obtained from intracranial electroencephalography (IEEG) recordings. The visual criteria and univariate methods of analyzing IEEG recordings have not always produced clarity on the SOZs for resection and ultimate seizure freedom for patients. Here, to contribute to improving the localization of the SOZs and to understanding the mechanism of seizure propagation over the brain, we applied spectral interdependency methods to IEEG time series recorded from patients during seizures. We found that the high-frequency (>80 Hz) Granger causality (GC) occurs before the onset of any visible ictal activity and causal relationships involve the recording electrodes where clinically identifiable seizures later develop. These results suggest that high-frequency oscillatory network activities precede and underlie epileptic seizures, and that GC spectral measures derived from IEEG can assist in precise delineation of seizure onset times and SOZs.

Incorporating Measures of Sleep Quality into Cancer Studies

PubMed Central

Redeker, Nancy S.; Pigeon, Wilfred R.; Boudreau, Eilis A.

2014-01-01

Introduction/background Sleep disturbance may influence the development of cancer and responses to treatment. It is also closely tied to recovery and quality of life in cancer patients, survivors, and caregivers, and recent studies have begun to show beneficial effects of sleep promoting interventions. Despite the importance of sleep to cancer and its treatment and the availability of numerous tools for measuring sleep quality and quantity, sleep measurements are underutilized in cancer studies. Methods This review, written for cancer researchers interested in incorporating sleep measures into their studies, is designed to raise awareness about the importance of sleep and suggest strategies for including sleep evaluation in cancer studies. Conclusions Inclusion of readily available sleep measures may ultimately improve cancer care by facilitating studies that lead to a greater understanding of how sleep and sleep disturbance influence all aspects of cancer care and the patient experience. PMID:25510361

Seizure detection, seizure prediction, and closed-loop warning systems in epilepsy.

PubMed

Ramgopal, Sriram; Thome-Souza, Sigride; Jackson, Michele; Kadish, Navah Ester; Sánchez Fernández, Iván; Klehm, Jacquelyn; Bosl, William; Reinsberger, Claus; Schachter, Steven; Loddenkemper, Tobias

2014-08-01

Nearly one-third of patients with epilepsy continue to have seizures despite optimal medication management. Systems employed to detect seizures may have the potential to improve outcomes in these patients by allowing more tailored therapies and might, additionally, have a role in accident and SUDEP prevention. Automated seizure detection and prediction require algorithms which employ feature computation and subsequent classification. Over the last few decades, methods have been developed to detect seizures utilizing scalp and intracranial EEG, electrocardiography, accelerometry and motion sensors, electrodermal activity, and audio/video captures. To date, it is unclear which combination of detection technologies yields the best results, and approaches may ultimately need to be individualized. This review presents an overview of seizure detection and related prediction methods and discusses their potential uses in closed-loop warning systems in epilepsy. Copyright © 2014. Published by Elsevier Inc.

Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study.

PubMed

Rajfur, Joanna; Pasternok, Małgorzata; Rajfur, Katarzyna; Walewicz, Karolina; Fras, Beata; Bolach, Bartosz; Dymarek, Robert; Rosinczuk, Joanna; Halski, Tomasz; Taradaj, Jakub

2017-01-07

BACKGROUND In the currently available research publications on electrical therapy of low back pain, generally no control groups or detailed randomization were used, and such studies were often conducted with relatively small groups of patients, based solely on subjective questionnaires and pain assessment scales (lacking measurement methods to objectify the therapeutic progress). The available literature also lacks a comprehensive and large-scale clinical study. The purpose of this study was to assess the effects of treating low back pain using selected electrotherapy methods. The study assesses the influence of individual electrotherapeutic treatments on reduction of pain, improvement of the range of movement in lower section of the spine, and improvement of motor functions and mobility. MATERIAL AND METHODS The 127 patients qualified for the therapy (ultimately, 123 patients completed the study) and assigned to 6 comparison groups: A - conventional TENS, B - acupuncture-like TENS, C - high-voltage electrical stimulation, D - interferential current stimulation, E - diadynamic current, and F - control group. RESULTS The research showed that using electrical stimulation with interferential current penetrating deeper into the tissues results in a significant and more efficient elimination of pain, and an improvement of functional ability of patients suffering from low back pain on the basis of an analysis of both subjective and objective parameters. The TENS currents and high voltage were helpful, but not as effective. The use of diadynamic currents appears to be useless. CONCLUSIONS Selected electrical therapies (interferential current, TENS, and high voltage) appear to be effective in treating chronic low back pain.

Can we improve patient safety?

PubMed

Corbally, Martin Thomas

2014-01-01

Despite greater awareness of patient safety issues especially in the operating room and the widespread implementation of surgical time out World Health Organization (WHO), errors, especially wrong site surgery, continue. Most such errors are due to lapses in communication where decision makers fail to consult or confirm operative findings but worryingly where parental concerns over the planned procedure are ignored or not followed through. The WHO Surgical Pause/Time Out aims to capture these errors and prevent them, but the combination of human error and complex hospital environments can overwhelm even robust safety structures and simple common sense. Parents are the ultimate repository of information on their child's condition and planned surgery but are traditionally excluded from the process of Surgical Pause and Time Out, perhaps to avoid additional stress. In addition, surgeons, like pilots, are subject to the phenomenon of "plan-continue-fail" with potentially disastrous outcomes. If we wish to improve patient safety during surgery and avoid wrong site errors then we must include parents in the Surgical Pause/Time Out. A recent pilot study has shown that neither staff nor parents found it added to their stress, but, moreover, 100% of parents considered that it should be a mandatory component of the Surgical Pause nor does it add to the stress of surgery. Surgeons should be required to confirm that the planned procedure is in keeping with the operative findings especially in extirpative surgery and this "step back" should be incorporated into the standard Surgical Pause. It is clear that we must improve patient safety further and these simple measures should add to that potential.

Efficacy of Selected Electrical Therapies on Chronic Low Back Pain: A Comparative Clinical Pilot Study

PubMed Central

Rajfur, Joanna; Pasternok, Małgorzata; Rajfur, Katarzyna; Walewicz, Karolina; Fras, Beata; Bolach, Bartosz; Dymarek, Robert; Rosinczuk, Joanna; Halski, Tomasz; Taradaj, Jakub

2017-01-01

Background In the currently available research publications on electrical therapy of low back pain, generally no control groups or detailed randomization were used, and such studies were often conducted with relatively small groups of patients, based solely on subjective questionnaires and pain assessment scales (lacking measurement methods to objectify the therapeutic progress). The available literature also lacks a comprehensive and large-scale clinical study. The purpose of this study was to assess the effects of treating low back pain using selected electrotherapy methods. The study assesses the influence of individual electrotherapeutic treatments on reduction of pain, improvement of the range of movement in lower section of the spine, and improvement of motor functions and mobility. Material/Methods The 127 patients qualified for the therapy (ultimately, 123 patients completed the study) and assigned to 6 comparison groups: A – conventional TENS, B – acupuncture-like TENS, C – high-voltage electrical stimulation, D – interferential current stimulation, E – diadynamic current, and F – control group. Results The research showed that using electrical stimulation with interferential current penetrating deeper into the tissues results in a significant and more efficient elimination of pain, and an improvement of functional ability of patients suffering from low back pain on the basis of an analysis of both subjective and objective parameters. The TENS currents and high voltage were helpful, but not as effective. The use of diadynamic currents appears to be useless. Conclusions Selected electrical therapies (interferential current, TENS, and high voltage) appear to be effective in treating chronic low back pain. PMID:28062862

Improved survival time: what can survival cure models tell us about population-based survival improvements in late-stage colorectal, ovarian, and testicular cancer?

PubMed

Huang, Lan; Cronin, Kathleen A; Johnson, Karen A; Mariotto, Angela B; Feuer, Eric J

2008-05-15

The objective of the current study was to investigate the long-term impact of treatment advances on the survival of patients with late-stage ovarian, colorectal (American Joint Committee on Cancer stage III, men), and testicular cancers by estimating the increase in the percentage cured from their disease and the change in survival time of uncured patients. Cause-specific survival data from 1973 to 2000 were obtained from the Surveillance, Epidemiology, and End Results Program. Survival cure models were fit and were used to estimate the gain in life expectancy (GLE) attributed to an increase in the fraction of cured patients and to prolonged survival among noncured patients. Treatment improvement for ovarian cancer resulted in a total GLE of 2 years, and 80% of that GLE was because of an extension of survival time in uncured patients (from 0.9 years to 2.1 years) rather than an increased cure fraction (from 12% to 14%). In contrast, the cure rate rose from 29% to 47% for colorectal cancer, representing 82% of a 2.8-year GLE, and from 23% to 81% for testicular cancer, representing 100% of a 24-year GLE. The current results suggested that treatment benefits for testicular and colorectal cancer in men with late-stage disease primarily are the result of increases in cure fraction, whereas survival gains for ovarian cancer occur despite persisting disease. Cure models, in combination with population-level data, provide insight into how treatment advances are changing survival and ultimately impacting mortality. Survival patterns reflect the underlying biology of response to cancer treatment and suggest promising directions for future research.

Understanding patient participation behaviour in studies of COPD support programmes such as pulmonary rehabilitation and self-management: a qualitative synthesis with application of theory.

PubMed

Sohanpal, Ratna; Steed, Liz; Mars, Thomas; Taylor, Stephanie J C

2015-09-17

In chronic obstructive pulmonary disease (COPD), the problem of poor patient participation in studies of self-management (SM) and pulmonary rehabilitation (PR) programmes (together referred to as COPD support programmes) is established. Understanding this problem beyond the previously reported socio-demographics and clinical factors is critical. The aim of this study was to explore factors that explain patient participation in studies of COPD support programmes. Thematic 'framework' synthesis was conducted on literature published from 1984 to 1 February 2015. Emergent themes and subthemes were mapped onto the adapted 'attitude-social influence-external barriers' and the 'self-regulation' models to produce analytical themes. Ten out of 12 studies were included: PR (n=9) and SM (n=1). Three descriptive themes with 38 subthemes were mapped onto the models' constructs, and it generated four analytical themes: 'attitude', 'social influences' and 'illness' and 'intervention representations'. The following factors influenced (1) attendance-helping oneself through health improvements, perceived control of worsening condition, perceived benefits and positive past experience of the programme, as well as perceived positive influence of professionals; (2) non-attendance-perceived negative effects and negative past experience of the programme, perceived physical/practical concerns related to attendance, perceived severity of condition/symptoms and perceived negative influence of professionals/friends; (3) dropout-no health improvements perceived after attending a few sessions of the programme, perceived severity of the condition and perceived physical/practical concerns related to attendance. Psychosocial factors including perceived practical/physical concerns related to attendance influenced patients' participation in COPD support programmes. Addressing the negative beliefs/perceptions via behaviour change interventions may help improve participation in COPD support programmes and, ultimately, patient outcomes.

Biomedical Simulation: Evolution, Concepts, Challenges and Future Trends.

PubMed

Sá-Couto, Carla; Patrão, Luís; Maio-Matos, Francisco; Pêgo, José Miguel

2016-12-30

Biomedical simulation is an effective educational complement for healthcare training, both at undergraduate and postgraduate level. It enables knowledge, skills and attitudes to be acquired in a safe, educationally orientated and efficient manner. In this context, simulation provides skills and experience that facilitate the transfer of cognitive, psychomotor and proper communication competences, thus changing behavior and attitudes, and ultimately improving patient safety. Beyond the impact on individual and team performance, simulation provides an opportunity to study organizational failures and improve system performance. Over the last decades, simulation in healthcare had a slow but steady growth, with a visible maturation in the last ten years. The simulation community must continue to provide the core leadership in developing standards. There is a need for strategies and policy development to ensure its coordinated and cost-effective implementation, applied to patient safety. This paper reviews the evolutionary movements of biomedical simulation, including a review of the Portuguese initiatives and nationwide programs. For leveling knowledge and standardize terminology, basic but essential concepts in clinical simulation, together with some considerations on assessment, validation and reliability are presented. The final sections discuss the current challenges and future initiatives and strategies, crucial for the integration of simulation programs in the greater movement toward patient safety.

Development of a standardized Intranet database of formulation records for nonsterile compounding, Part 2.

PubMed

Haile, Michael; Anderson, Kim; Evans, Alex; Crawford, Angela

2012-01-01

In part 1 of this series, we outlined the rationale behind the development of a centralized electronic database used to maintain nonsterile compounding formulation records in the Mission Health System, which is a union of several independent hospitals and satellite and regional pharmacies that form the cornerstone of advanced medical care in several areas of western North Carolina. Hospital providers in many healthcare systems require compounded formulations to meet the needs of their patients (in particular, pediatric patients). Before a centralized electronic compounding database was implemented in the Mission Health System, each satellite or regional pharmacy affiliated with that system had a specific set of formulation records, but no standardized format for those records existed. In this article, we describe the quality control, database platform selection, description, implementation, and execution of our intranet database system, which is designed to maintain, manage, and disseminate nonsterile compounding formulation records in the hospitals and affiliated pharmacies of the Mission Health System. The objectives of that project were to standardize nonsterile compounding formulation records, create a centralized computerized database that would increase healthcare staff members' access to formulation records, establish beyond-use dates based on published stability studies, improve quality control, reduce the potential for medication errors related to compounding medications, and (ultimately) improve patient safety.

Acute oxygen therapy: a review of prescribing and delivery practices

PubMed Central

Cousins, Joyce L; Wark, Peter AB; McDonald, Vanessa M

2016-01-01

Oxygen is a commonly used drug in the clinical setting and like other drugs its use must be considered carefully. This is particularly true for those patients who are at risk of type II respiratory failure in whom the risk of hypercapnia is well established. In recent times, several international bodies have advocated for the prescription of oxygen therapy in an attempt to reduce this risk in vulnerable patient groups. Despite this guidance, published data have demonstrated that there has been poor uptake of these recommendations. Multiple interventions have been tested to improve concordance, and while some of these interventions show promise, the sustainability of these interventions are less convincing. In this review, we summarize data that have been published on the prevalence of oxygen prescription and the accurate and appropriate administration of this drug therapy. We also identify strategies that have shown promise in facilitating changes to oxygen prescription and delivery practice. There is a clear need to investigate the barriers, facilitators, and attitudes of clinicians in relation to the prescription of oxygen therapy in acute care. Interventions based on these findings then need to be designed and tested to facilitate the application of evidence-based guidelines to support sustained changes in practice, and ultimately improve patient care. PMID:27307722

Cellular Response to Ionizing Radiation: A MicroRNA Story

PubMed Central

Halimi, Mohammad; Asghari, S. Mohsen; Sariri, Reyhaneh; Moslemi, Dariush; Parsian, Hadi

2012-01-01

MicroRNAs (miRNAs) represent a class of small non-coding RNA molecules that regulate gene expression at the post-transcriptional level. They play a crucial role in diverse cellular pathways. Ionizing radiation (IR) is one of the most important treatment protocols for patients that suffer from cancer and affects directly or indirectly cellular integration. Recently it has been discovered that microRNA-mediated gene regulation interferes with radio-related pathways in ionizing radiation. Here, we review the recent discoveries about miRNAs in cellular response to IR. Thoroughly understanding the mechanism of miRNAs in radiation response, it will be possible to design new strategies for improving radiotherapy efficiency and ultimately cancer treatment. PMID:24551775

A Unique Application of Negative Pressure Wound Therapy Used to Facilitate Patient Engagement in the Amputation Recovery Process.

PubMed

Wise, Jessica; White, Alicia; Stinner, Daniel J; Fergason, John R

2017-08-01

Amputation rates during recent military conflicts were at an all-time high, but medical treatment of those amputations and attitudes of service members to get back to duty are also surging ahead. We present the cases of an active duty rescue C130 pilot with an above-the-knee amputation and a retired army sergeant with a below-the-knee amputation. Successful rehabilitation was augmented in both cases by using negative pressure incorporated in a custom prosthetic socket to accelerate incision closure, improve self-efficacy in wound care, and self-management, ultimately leading to faster recovery times, full engagement of the rehabilitation process, and return to active duty.

From teaching to learning in a mobile, wireless world.

PubMed

Billings, Diane M

2005-08-01

What research evidence justifies this shift from teaching to learning in the mobile, wireless world? We do not need evidence to answer questions such as, "Will the mobile, wireless device technology support teaching and learning?" (we already know it will), or "Will distance learning with mobile, wireless devices be as effective as that in the classroom?" (abundant evidence indicates there will be no significant differences). However, we do need to know, "How can we use these learning technologies to improve student learning and the outcomes of our academic programs?" Answers to this question will ultimately help educators prepare students to deliver safe and competent patient care in the mobile, wireless world.

Tyrosine kinase inhibition: A therapeutic target for the management of chronic-phase chronic myeloid leukemia

PubMed Central

Jabbour, Elias J; Cortes, Jorge E; Kantarjian, Hagop M

2014-01-01

Chronic myeloid leukemia (CML) is a hematologic neoplasm with a progressive, ultimately terminal, disease course. In most cases, CML arises owing to the aberrant formation of a chimeric gene for a constitutively active tyrosine kinase. Inhibition of the signaling activity of this kinase has proved to be a highly successful treatment target transforming the prognosis of patients with CML. New tyrosine kinase inhibitors (TKIs) continue to improve the management of CML, offering alternative options for those resistant to or intolerant of standard TKIs. Here we review the pathobiology of CML and explore emerging strategies to optimize the management of chronic-phase CML, particularly first-line treatment. PMID:24236822

Update on therapeutic interventions for the management of achalasia.

PubMed

Gunasingam, Nishmi; Perczuk, Adam; Talbot, Michael; Kaffes, Arthur; Saxena, Payal

2016-08-01

Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Sickle cell disease in children.

PubMed

Meier, Emily Riehm; Miller, Jeffery L

2012-05-07

Early identification of infants with sickle cell disease (SCD) by newborn screening, now universal in all 50 states in the US, has improved survival, mainly by preventing overwhelming sepsis with the early use of prophylactic penicillin. Routine transcranial Doppler screening with the institution of chronic transfusion decreases the risk of stroke from 10% to 1% in paediatric SCD patients. Hydroxyurea decreases the number and frequency of painful crises, acute chest syndromes and number of blood transfusions in children with SCD. Genetic research continues to be driven toward the prevention and ultimate cure of SCD before adulthood. This review focuses on clinical manifestations and therapeutic strategies for paediatric SCD as well as the evolving topic of gene-focused prevention and therapy.

"On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists.

PubMed

Feldman, Mitchell D; Petersen, Amy Jean; Tice, Jeffrey A

2010-03-01

In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.

Application of single-cell technology in cancer research.

PubMed

Liang, Shao-Bo; Fu, Li-Wu

2017-07-01

In this review, we have outlined the application of single-cell technology in cancer research. Single-cell technology has made encouraging progress in recent years and now provides the means to detect rare cancer cells such as circulating tumor cells and cancer stem cells. We reveal how this technology has advanced the analysis of intratumor heterogeneity and tumor epigenetics, and guided individualized treatment strategies. The future prospects now are to bring single-cell technology into the clinical arena. We believe that the clinical application of single-cell technology will be beneficial in cancer diagnostics and treatment, and ultimately improve survival in cancer patients. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Future Directions for Monitoring Treatment Response in Colorectal Cancer

PubMed Central

Walker, Avery S.; Zwintscher, Nathan P.; Johnson, Eric K.; Maykel, Justin A.; Stojadinovic, Alexander; Nissan, Aviram; Avital, Itzhak; Brücher, Björn LDM; Steele, Scott R.

2014-01-01

Treatment of advanced colon and rectal cancer has significantly evolved with the introduction of neoadjuvant chemoradiation therapy so much that, along with more effective chemotherapy regimens, surgery has been considered unnecessary among some institutions for select patients. The tumor response to these treatments has also improved and ultimately has been shown to have a direct effect on prognosis. Yet, the best way to monitor that response, whether clinically, radiologically, or with laboratory findings, remains controversial. The authors' aim is to briefly review the options available and, more importantly, examine emerging and future options to assist in monitoring treatment response in cases of locally advanced rectal cancer and metastatic colon cancer. PMID:24396497

Point-of-care technology: integration for improved delivery of care.

PubMed

Gregory, Debbie; Buckner, Martha

2014-01-01

The growing complexity of technology, equipment, and devices involved in patient care delivery can be staggering and overwhelming. Technology is intended to be a tool to help clinicians, but it can also be a frustrating hindrance if not thoughtfully planned and strategically aligned. Critical care nurses are key partners in the collaborations needed to improve safety and quality through health information technology (IT). Nurses must advocate for systems that are interoperable and adapted to the context of care experiences. The involvement and collaboration between clinicians, information technology specialists, biomedical engineers, and vendors has never been more relevant and applicable. Working together strategically with a shared vision can effectively provide a seamless clinical workflow, maximize technology investments, and ultimately improve patient care delivery and outcomes. Developing a strategic integrated clinical and IT roadmap is a critical component of today's health care environment. How can technology strategy be aligned from the executive suite to the bedside caregiver? What is the model for using clinical workflows to drive technology adoption? How can the voice of the critical care nurse strengthen this process? How can success be assured from the initial assessment and selection of technology to a sustainable support model? What is the vendor's role as a strategic partner and "co-caregiver"?

[Physical rehabilitation in multiple sclerosis: general principles and high-tech approaches].

PubMed

Peresedova, A V; Chernikova, L A; Zavalishin, I A

2013-01-01

In a chronic and disabling disease like multiple sclerosis, rehabilitation programs are of major importance for the preservation of physical, physiological, social and professional functioning and improvement of quality of life. Currently, it is generally assumed that physical activity is an important component of non-pharmacological rehabilitation in multiple sclerosis. Properly organized exercise is a safe and efficient way to induce improvements in a number of physiological functions. A multidisciplinary rehabilitative approach should be recommended. The main recommendations for the use of exercise for patients with multiple sclerosis have been listed. An important aspect of the modern physical rehabilitation in multiple sclerosis is the usage of high-tech methods. The published results of robot-assisted training to improve the hand function and walking impairment have been represented. An important trend in the rehabilitation of patients with multiple sclerosis is the reduction of postural disorders through training balance coordination. The role of transcranial magnetic stimulation in spasticity reducing is being investigated. The use of telemedicine capabilities is quite promising. Due to the fact that the decline in physical activity can lead to the deterioration of many aspects of physiological functions and, ultimately, to mobility decrease, further research of the role of physical rehabilitation as an important therapeutic approach in preventing the progression of disability in multiple sclerosis is required.

Cardiovascular risk reduction by reversing endothelial dysfunction:ARBs, ACE inhibitors, or both? Expectations from The ONTARGET Trial Programme

PubMed Central

Ruilope, Luis Miguel; Redón, Josep; Schmieder, Roland

2007-01-01

Endothelial dysfunction is the initial pathophysiological step in a progression of vascular damage that leads to overt cardiovascular and chronic kidney disease. Angiotensin II, the primary agent of the renin–angiotensin system (RAS), has a central role in endothelial dysfunction. Therefore, RAS blockade with an angiotensin receptor blocker (ARB) and/or angiotensin-converting enzyme (ACE) inhibitor provides a rational approach to reverse endothelial dysfunction, reduce microalbuminuria, and, thus, improves cardiovascular and renal prognosis. ARBs and ACE inhibitors act at different points in the RAS pathway and recent evidence suggests that there are differences regarding their effects on endothelial dysfunction. In addition to blood pressure lowering, studies have shown that ARBs reduce target-organ damage, including improvements in endothelial dysfunction, arterial stiffness, the progression of renal dysfunction in patients with type 2 diabetes, proteinuria, and left ventricular hypertrophy. The ONgoing Telmisartan Alone in combination with Ramipril Global Endpoint Trial (ONTARGET) Programme is expected to provide the ultimate evidence of whether improved endothelial function translates into reduced cardiovascular and renal events in high-risk patients, and to assess possible differential outcomes with telmisartan, the ACE inhibitor ramipril, or a combination of both (dual RAS blockade). Completion of ONTARGET is expected in 2008. PMID:17583170

Management of hypothermia: impact of lecture-based interactive workshops on training of pediatric nurses.

PubMed

Altun, Insaf; Karakoç, Ali

2012-05-01

This study aimed to determine the efficacy of interactive workshop on the management of hypothermia and its impact on pediatric nurses' training. This is a pretest-to-posttest quasi-experimental descriptive study. Thirty pediatric nurses attended an interactive lecture-based interactive workshop on the management of hypothermia. Participants had to accept an invitation to the presentation before the training event. They completed the lecture, and a multiple-choice question test before and after the lecture was given. There was a significant improvement in mean test scores after the lecture when compared with those before the lecture (mean [SD], 15.5 [1.3] vs 5.0 [1.7], P < 0.001). The information gained in this study will be valuable as a baseline for further research and help guide improvements in the management of hypothermia with the ultimate goal of enhancing safe and quality patient care.

W. Edwards Deming and total quality management: an interpretation for nursing practice.

PubMed

Williams, T; Howe, R

1992-01-01

The purpose of this article is to introduce nurses to W. Edwards Deming and the 14 points of his management philosophy, the basis of total quality management (TQM) (Deming, 1986). Each of Deming's points has been subject to in-depth analysis from business executives for the past 40 years. Quality improvement is at the very center of TQM. To adopt TQM will require a major thought transformation for many nursing leaders, but the benefits that nurses and the profession as a whole can reap from this revolutionary style of management make the effort to change worthwhile. If you are not satisfied with the status quo and are looking for a better way to conduct business, the information in this article will begin to define quality improvement and will help you strive for the highest possible level of service to your ultimate customer--the patient.

Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years.

PubMed

Loubert, C; Hinova, A; Fernando, R

2011-03-01

Several strategies and alternative therapies have been used to provide analgesia for labour pain. Over the last few years, a number of improvements have enhanced the efficacy and safety of neuraxial analgesia and ultimately have improved mothers' satisfaction with their birth experience. As labour analgesia is a field of obstetric anaesthesia that is rapidly evolving, this review is an update, from a clinical point of view, of developments over the last 5-7 years. We discuss advantages and controversies related to combined spinal-epidural analgesia, patient controlled epidural analgesia and the integration of computer systems into analgesic modalities. We also review the recent literature on future clinical and research perspectives including ultrasound guided neuraxial block placement, epidural adjuvants and pharmacogenetics. We finally look at the latest work with regards to epidural analgesia and breastfeeding. © 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.

Antimicrobial stewardship

PubMed Central

Chung, Gladys W.; Wu, Jia En; Yeo, Chay Leng; Chan, Douglas; Hsu, Li Yang

2013-01-01

Antimicrobial stewardship is an emerging field currently defined by a series of strategies and interventions aimed toward improving appropriate prescription of antibiotics in humans in all healthcare settings. The ultimate goal is the preservation of current and future antibiotics against the threat of antimicrobial resistance, although improving patient safety and reducing healthcare costs are important concurrent aims. Prospective audit and feedback interventions are probably the most widely practiced of all antimicrobial stewardship strategies. Although labor-intensive, they are more easily accepted by physicians compared with formulary restriction and preauthorization strategies and have a higher potential for educational opportunities. Objective evaluation of antimicrobial stewardship is critical for determining the success of such programs. Nonetheless, there is controversy over which outcomes to measure and there is a pressing need for novel study designs that can objectively assess antimicrobial stewardship interventions despite the limitations inherent in the structure of most such programs. PMID:23302793

Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes.

PubMed

Chung, Gladys W; Wu, Jia En; Yeo, Chay Leng; Chan, Douglas; Hsu, Li Yang

2013-02-15

Antimicrobial stewardship is an emerging field currently defined by a series of strategies and interventions aimed toward improving appropriate prescription of antibiotics in humans in all healthcare settings. The ultimate goal is the preservation of current and future antibiotics against the threat of antimicrobial resistance, although improving patient safety and reducing healthcare costs are important concurrent aims. Prospective audit and feedback interventions are probably the most widely practiced of all antimicrobial stewardship strategies. Although labor-intensive, they are more easily accepted by physicians compared with formulary restriction and preauthorization strategies and have a higher potential for educational opportunities. Objective evaluation of antimicrobial stewardship is critical for determining the success of such programs. Nonetheless, there is controversy over which outcomes to measure and there is a pressing need for novel study designs that can objectively assess antimicrobial stewardship interventions despite the limitations inherent in the structure of most such programs.

THE FUTURE OF MOBILE HEALTH APPLICATIONS AND DEVICES IN CARDIOVASCULAR HEALTH.

PubMed

Kelli, Heval Mohamed; Witbrodt, Bradley; Shah, Amit

2017-01-01

Mobile health (mHealth) is the utilisation of mobile technologies in healthcare and has particular relevance in improving lifestyle behaviours which may ultimately reduce cardiovascular disease risk. Various intervention studies for example integrate self-monitoring of diet and physical activity with text messaging systems to improve intermediate outcomes. Currently the future progress of mHealth technologies in formal diagnostic and therapeutic roles is pending and includes the need to validate and standardise accelerometer and heart rate data from various devices. Data also needs to be integrated from such devices into the medical record system to facilitate communication between providers and patients. Although short-term behaviour changes have been found with technologies such as Fitbit® (Fitbit, Inc., San Francisco, California, USA), whether such technologies/interventions lead to sustained behaviour change and reduced risk of myocardial infarction and death remains to be seen.

Obesity: which drug and when?

PubMed

Lean, M; Mullan, A

2007-09-01

Obesity, with all its consequences, is audaciously confronting medical professionals and health service providers worldwide. Diet and exercise intervention is an essential part of any weight management strategy, but may not succeed in isolation. Effective approaches for routine practice are more likely to involve affordable, efficacious and well-tolerated drug therapy than the more expensive, case selective approach of bariatric surgery. Advancement of pharmacotherapy is expanding the battery of available drugs; the clinician is faced with an increasingly complex therapeutic decision. Which drug to use, and when, is influenced by a range of factors, discussed here. There is a large body of high quality evidence in the literature to support the presently available drugs; however, many questions remain unanswered including duration of therapy and whether longer-term goals of improved morbidity and mortality are achievable. Clinician and patient awareness of these issues will provide a more informed therapeutic decision and ultimately improve the potential for reaching the weight management targets.

Keep it clean: a visual approach to reinforce hand hygiene compliance in the emergency department.

PubMed

Wiles, Lynn L; Roberts, Chris; Schmidt, Kim

2015-03-01

Although hand hygiene strategies significantly reduce health care-associated infections, multiple studies have documented that hand hygiene is the most overlooked and poorly performed infection control intervention. Emergency nurses and technicians (n = 95) in a 41-bed emergency department in eastern Virginia completed pretests and posttests, an education module, and two experiential learning activities reinforcing hand hygiene and infection control protocols. Posttest scores were significantly higher than pretest scores (t (108) = -6.928, P = .048). Hand hygiene compliance rates improved at the conclusion of the project and 3 months after the study (F (2, 15) = 9.89, P = .002). Interfaces with staff as they completed the interactive exercise, as well as anecdotal notes collected during the study, identified key times when compliance suffered and offered opportunities to further improve hand hygiene and, ultimately, patient safety. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Diabetes and oral disease: implications for health professionals

PubMed Central

Albert, David A.; Ward, Angela; Allweiss, Pamela; Graves, Dana T.; Knowler, William C.; Kunzel, Carol; Leibel, Rudolph L.; Novak, Karen F.; Oates, Thomas W.; Papapanou, Panos N.; Schmidt, Ann Marie; Taylor, George W.; Lamster, Ira B.; Lalla, Evanthia

2012-01-01

“Diabetes and Oral Disease: Implications for Health Professionals” was a one-day conference convened by the Columbia University College of Dental Medicine, the Columbia University College of Physicians and Surgeons, and the New York Academy of Sciences on May 4, 2011in New York City. The program included an examination of the bidirectional relationship between oral disease and diabetes and the inter-professional working relationships for the care of people who have diabetes. The overall goal of the conference was to promote discussion among the healthcare professions who treat people with diabetes, encourage improved communication and collaboration among them and ultimately, improve patient management of the oral and overall effects of diabetes. Attracting over 150 members of the medical and dental professions from eight different countries, the conference included speakers from academia and government and was divided into four sessions. This report summarizes the scientific presentations of the event. PMID:22409777

Use of methylphenidate in the treatment of patients suffering from refractory postural tachycardia syndrome.

PubMed

Kanjwal, Khalil; Saeed, Bilal; Karabin, Beverly; Kanjwal, Yousuf; Grubb, Blair P

2012-01-01

Methylphenidate has been shown to be an effective therapy in patients with refractory neurocardiogenic syncope. However, the role of methylphenidate in patients suffering from postural orthostatic tachycardia (POTS) has not been reported. The study was approved by the institutional review board. A retrospective nonrandomized analysis was preformed on 24 patients evaluated at our autonomic center for POTS from 2003 to 2010. The diagnosis of POTS was based on patient history, physical examination, and response to head up tilt table testing. The mean follow-up period was 9 ± 3 months. The patients were included in the current study if they had a diagnosis of POTS with severe symptoms of orthostatic intolerance and were refractory to the commonly used medications. All of these patients were started on methylphenidate and the response to therapy was considered successful if it provided symptomatic relief. Twenty-four patients (age 28 ± 12, 20 women) met inclusion criterion for this study. The response to treatment was assed subjectively in each patient and was collected in a retrospective fashion from patient charts and physician communications. Four patients reported side effects in the form of nausea and 2 ultimately had to discontinue the treatment. Another 4 patients had a follow-up of less than 6 months. Thus, only 18 patients who received methylphenidate completed the follow-up of 6 months. Out of these 18 patients, 14 (77%) patients reported marked improvement in their symptoms. Nine out of 12 patients who had recurrent episodes of syncope reported no syncope at 6 months of follow-up. Fourteen (77%) patients reported marked improvement in their symptoms of fatigue and presyncope. Four patients continue to have symptoms of orthostatic intolerance and 3 continued to have recurrent episodes of syncope. Methylphenidate may be beneficial in patients with otherwise refractory postural tachycardia syndrome.

Acute meningitis prognosis using cerebrospinal fluid interleukin-6 levels.

PubMed

Vázquez, Jorge Alejandro; Adducci, Maria del Carmen; Coll, Carlos; Godoy Monzón, Daniel; Iserson, Kenneth V

2012-08-01

Improved diagnostic tests would aid in diagnosing and treating community-acquired meningitis. To analyze the diagnostic value of interleukin-6 (IL-6) in the cerebrospinal fluid (CSF) of patients presenting with symptoms of acute meningitis. In a 6-month prospective, observational, cross-sectional emergency department (ED) study, serum and CSF samples were obtained from all patients with a headache and fever in whom the physician suspected meningitis. Patients were excluded if computed tomography findings contraindicated a lumbar puncture, if they had bleeding disorders, or if their serum indicated bleeding. IL-6 levels were measured and compared in patients with (Group A) and without (Group B) bacterial meningitis. Samples were obtained from 53 patients, of whom 40 were ultimately found to have meningitis. These 40 patients averaged 49.6 ± 21.9 years, with number of men 18 (45%), hospitalizations 21 (52%), mortality 3 (.07%), and IL-6 average rating 491 (median: 14.5; range 0000-6000). Findings in the two groups were: Group A (with meningitis): n = 13, average IL-6 level: 1495 (median: 604; 25/75 percentiles: 232.5-2030; 95% confidence interval [CI] 371.7-2618.6; range 64-6000). Group B (with aseptic meningitis): n = 27, average IL-6 level: 7.34 (median: 5; 25/75 percentiles: 0.0/15.1; 95% CI 3.94-10.73; range 0-23.6). Mann-Whitney rank sum test: p < 0.0001. In patients with acute bacterial meningitis, CSF cytokine concentrations are elevated. Measuring CSF inflammatory cytokine levels in patients with acute meningitis could be a valuable ED diagnostic tool. Using this tool could improve the prognosis of patients with bacterial meningitis by allowing more rapid initiation of antibiotic treatment. Copyright © 2012 Elsevier Inc. All rights reserved.

Tuning the mechanical properties of glass fiber-reinforced bismaleimide–triazine resin composites by constructing a flexible bridge at the interface

PubMed Central

Zeng, Xiaoliang; Yu, Shuhui; Lai, Maobai; Sun, Rong; Wong, Ching-Ping

2013-01-01

We demonstrate a new method that can simultaneously improve the strength and toughness of the glass fiber-reinforced bismaleimide–triazine (BT) resin composites by using polyethylene glycol (PEG) to construct a flexible bridge at the interface. The mechanical properties, including the elongation, ultimate tensile stress, Young’s modulus, toughness and dynamical mechanical properties were studied as a function of the length of PEG molecular chain. It was found that the PEG molecule acts as a bridge to link BT resin and glass fiber through covalent and non-covalent bondings, respectively, resulting in improved interfacial bonding. The incorporation of PEG produces an increase in elongation, ultimate tensile stress and toughness. The Young’s modulus and Tg were slightly reduced when the length of the PEG molecular chain was high. The elongation of the PEG-modified glass fiber-reinforced composites containing 5 wt% PEG-8000 increased by 67.1%, the ultimate tensile stress by 17.9% and the toughness by 78.2% compared to the unmodified one. This approach provides an efficient way to develop substrate material with improved strength and toughness for integrated circuit packaging applications. PMID:27877621

Early markers of reperfusion injury after liver transplantation: association with primary dysfunction.

PubMed

Bruns, Helge; Heil, Jan; Schultze, Daniel; Al Saeedi, Mohammed; Schemmer, Peter

2015-06-01

In patients with end-stage liver disease, liver transplantation is the only available curative treatment. Although the outcome and quality of life in the patients have improved over the past decades, primary dys- or nonfunction (PDF/PNF) can occur. Early detection of PDF and PNF is crucial and could lead to individual therapies. This study was designed to identify early markers of reperfusion injury and PDF in liver biopsies taken during the first hour after reperfusion. Biopsies from donor livers were prospectively taken as a routine during the first hour after reperfusion. Recipient data, transaminases and outcome were routinely monitored. In total, 10 biopsy specimens taken from patients with 90-day mortality and PDF, and patients with long-term survival but without PDF were used for DNA microarrays. Markers that were significantly up- or down-regulated in the microarray were verified using quantitative real-time PCR. Age, indications and labMELD score were similar in both groups. Peak-transaminases during the first week after transplantation were significantly different in the two groups. In total, 20 differentially regulated markers that correlated to PDF were identified using microarray analysis and verified with quantitative real-time PCR. The markers identified in this study could predict PDF at a very early time point and might point to interventions that ameliorate reperfusion injury and thus prevent PDF. Identification of patients and organs at risk might lead to individualized therapies and could ultimately improve outcome.

An information management system for patients with tuberculosis: usability assessment with end-users.

PubMed

Darby, Jonathan; Black, Jim; Morrison, David; Buising, Kirsty

2012-01-01

Information systems with clinical decision support (CDS) offer great potential to assist the co-ordination of patients with chronic diseases and to improve patient care. Despite this, few have entered routine clinical use. Tuberculosis (TB) is an infection of public health importance. It has complex interactions with many comorbid conditions, requires close supervised care and prolonged treatment for effective cure. These features make it suitable for use with an information management system with CDS features. In close consultation with key stakeholders, a clinical application was developed for the management of TB patients in Victoria. A formal usability assessment using semi-structured case-scenario based exercises was performed. Subjects were 12 individuals closely involved in the care of TB patients, including Infectious Diseases and Respiratory Physicians, and Public Health Nurses. Two researchers conducted the sessions, independently analysed responses and discrepancies compared to the voice record for validity. Despite varied computer experience, responses were positive regarding user interface and content. Data location was not always intuitive, however this improved with familiarity of the program. Decision support was considered valuable, with useful suggestions for expansion of these features. Automated reporting for correspondence and notification to the Health Department were felt worth the initial investment in data entry. An important workflow-based issue regarding dismissal of alerts and several errors were detected. Usability assessment validated many design elements of the system, provided a unique insight into workflow issues faced by users and hopefully will impact on its ultimate clinical utility.

The Effect of Furlow Palatoplasty Timing on Speech Outcomes in Submucous Cleft Palate.

PubMed

Swanson, Jordan W; Mitchell, Brianne T; Cohen, Marilyn; Solot, Cynthia; Jackson, Oksana; Low, David; Bartlett, Scott P; Taylor, Jesse A

2017-08-01

Because some patients with submucous cleft palate (SMCP) are asymptomatic, surgical treatment is conventionally delayed until hypernasal resonance is identified during speech production. We aim to identify whether speech outcomes after repair of a SMCP is influenced by age of repair. We retrospectively studied nonsyndromic children with SMCP. Speech results, before and after any surgical treatment or physical management of the palate were compared using the Pittsburgh Weighted Speech Scoring system. Furlow palatoplasty was performed on 40 nonsyndromic patients with SMCP, and 26 patients were not surgically treated. Total composite speech scores improved significantly among children repaired between 3 and 4 years of age (P = 0.02), but not older than 4 years (P = 0.63). Twelve (86%) of 14 patients repaired who are older than 4 years had borderline or incompetent speech (composite Pittsburgh Weighted Speech Scoring ≥3) compared with 2 (29%) of 7 repaired between 3 and 4 years of age (P = 0.0068), despite worse prerepair scores in the latter group. Resonance improved in children repaired who are older than 4 years, but articulation errors persisted to a greater degree than those treated before 4 years of age (P = 0.01.) CONCLUSIONS: Submucous cleft palate repair before 4 years of age appears associated with lower ultimate rates of borderline or incompetent speech. Speech of patients repaired at or after 4 years of age seems to be characterized by persistent misarticulation. These findings highlight the importance of timely diagnosis and management.

Longitudinal associations of nursing staff turnover with patient outcomes in long-term care hospitals in Korea.

PubMed

Kim, Yoonseo; Han, Kihye

2018-01-10

To describe the characteristics of long-term care hospitals in 2010-2013 and to examine the longitudinal associations of nursing staff turnover with patient outcomes. The number of long-term care hospitals has exploded in Korea since the national long-term care insurance was launched in 2008. The care quality deviation across long-term care hospitals is large. This was a longitudinal secondary data analysis using the Health Insurance Review and Assessment Service's data. From 2010 to 2013, the nursing staff turnover rate decreased. The number of patients per registered nurse increased while that per total nursing staff and skill mix decreased. All adverse patient outcomes decreased. Higher nursing staff turnover and lower RN proportions were associated with adverse patient outcomes. Since the launch of the long-term care insurance, total nursing staffing, turnover rate and patient outcomes have improved, while the skill mix has decreased. Systematic efforts to decrease nursing staff turnover should be implemented for better long-term care patient outcomes. In addition to maintaining high levels of nurse staffing and skill mix, supportive work environments and competitive wages and benefits could reduce turnover, and ultimately adverse patient outcomes. Health care policy should separate nursing staffing levels for registered nurses and certified nursing assistants. © 2018 John Wiley & Sons Ltd.

Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: a single-center experience.

PubMed

Biscotti, Mauer; Lee, Alison; Basner, Robert C; Agerstrand, Cara; Abrams, Darryl; Brodie, Daniel; Bacchetta, Matthew

2014-01-01

Use of extracorporeal membrane oxygenation (ECMO) in adults has surged in recent years. Typical configurations are venovenous (VV), which provides respiratory support, or venoarterial (VA), which provides both respiratory and circulatory support. In patients supported with VV ECMO who develop hemodynamic compromise, an arterial limb can be added (venovenous-arterial ECMO) to provide additional circulatory support. For patients on VA ECMO who develop concomitant respiratory failure in the setting of some residual cardiac function, an oxygenated reinfusion limb can be added to the internal jugular vein (venoarterial-venous ECMO) to improve oxygen delivery to the cerebral and coronary circulation. Such hybrid configurations can provide differential support for various forms of cardiopulmonary failure. We describe 21 patients who ultimately received a hybrid configuration at our institution between 2012 and 2013. Eight patients (38.1%) died during ECMO support, four patients (19.0%) died after decannulation but before hospital discharge, and nine patients (42.9%) survived to hospital discharge. Our modest survival rate is likely related to the complexity and severity of illness of these patients, and this relative success suggests that hybrid configurations can be effective. It serves patients well to maintain a flexible and adaptable approach to ECMO configurations for their variable cardiopulmonary needs.

Telemedicine in a pediatric headache clinic: A prospective survey.

PubMed

Qubty, William; Patniyot, Irene; Gelfand, Amy

2018-05-08

The aim of this prospective study was to survey our patients about their experience with our clinic's telemedicine program to better understand telemedicine's utility for families, and to improve patient satisfaction and ultimately patient care. This was a prospective survey study of patients and their families who had a routine telemedicine follow-up visit with the University of California San Francisco Pediatric Headache Program. The survey was administered to patients and a parent(s) following their telemedicine visit. Fifty-one of 69 surveys (74%) were completed. All (51/51) patients and families thought that (1) telemedicine was more convenient compared to a clinic visit, (2) telemedicine caused less disruption of their daily routine, and (3) they would choose to do telemedicine again. The mean round-trip travel time from home to clinic was 6.8 hours (SD ± 8.6 hours). All participants thought telemedicine was more cost-effective than a clinic visit. Parents estimated that participating in a telemedicine visit instead of a clinic appointment saved them on average $486. This prospective, pediatric headache telemedicine study shows that telemedicine is convenient, perceived to be cost-effective, and patient-centered. Providing the option of telemedicine for routine pediatric headache follow-up visits results in high patient and family satisfaction. © 2018 American Academy of Neurology.

Do participation and personalization matter? A model-driven evaluation of an Internet-based patient education intervention for fibromyalgia patients.

PubMed

Camerini, Luca; Camerini, Anne-Linda; Schulz, Peter J

2013-08-01

To evaluate the effectiveness of an Internet-based patient education intervention, which was designed upon principles of personalization and participatory design. Fifteen months after the first release of the website, 209 fibromyalgia patients recruited through health professionals completed an online questionnaire to assess patients' use of the website, health knowledge, self-management behavior, and health outcomes. These constructs were combined into an a-priory model that was tested using a structural equation modeling approach. Results show that the usage of certain tools of the website - designed and personalized involving the end users - impacts patients' health knowledge, which in turn impacts self-management. Improvements in self-management ultimately lower the impact of Fibromyalgia Syndrome leading to better health outcomes. This study empirically confirmed that the adoption of a participatory approach to the design of eHealth interventions and the use of personalized contents enhance the overall effectiveness of systems. More time and effort should be invested in involving patients in the preliminary phases of the development of Internet-based patient education interventions and in the definition of models that can guide the systems' evaluation beyond technology-related variables such as usability, accessibility or adoption. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy: Introduction, Rationale, and Scope.

PubMed

Fehlings, Michael G; Tetreault, Lindsay A; Riew, K Daniel; Middleton, James W; Wang, Jeffrey C

2017-09-01

Degenerative cervical myelopathy (DCM) is a progressive spine disease and the most common cause of spinal cord dysfunction in adults worldwide. Patients with DCM may present with common signs and symptoms of neurological dysfunction, such as paresthesia, abnormal gait, decreased hand dexterity, hyperreflexia, increased tone, and sensory dysfunction. Clinicians across several specialties encounter patients with DCM, including primary care physicians, rehabilitation specialists, therapists, rheumatologists, neurologists, and spinal surgeons. Currently, there are no guidelines that outline how to best manage patients with mild (defined as a modified Japanese Orthopedic Association (mJOA) score of 15-17), moderate (mJOA = 12-14), or severe (mJOA ≤ 11) myelopathy, or nonmyelopathic patients with evidence of cord compression. This guideline provides evidence-based recommendations to specify appropriate treatment strategies for these populations. The intent of our recommendations is to (1) help identify patients at high risk of neurological deterioration, (2) define the role of nonoperative and operative management in each patient population, and (3) determine which patients are most likely to benefit from surgical intervention. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

How Is Adrenal Surgery Performed?

MedlinePlus

... ultimately be determined by: 1) tumor size, 2) patient characteristics (i.e. body size and shape, medical conditions, previous operations, etc), 3) the experience and expertise of the surgeon. The two ... in most patients. 20-23 However, for very large tumors and ...

High resistivity CMOS pixel sensors and their application to the STAR PXL detector

NASA Astrophysics Data System (ADS)

Dorokhov, A.; Bertolone, G.; Baudot, J.; Colledani, C.; Claus, G.; Degerli, Y.; de Masi, R.; Deveaux, M.; Dozière, G.; Dulinski, W.; Gélin, M.; Goffe, M.; Himmi, A.; Hu-Guo, Ch.; Jaaskelainen, K.; Koziel, M.; Morel, F.; Santos, C.; Specht, M.; Valin, I.; Voutsinas, G.; Winter, M.

2011-09-01

CMOS pixel sensors are foreseen to equip the vertex detector (called PXL) of the upgraded inner tracking system of the STAR experiment at RHIC. The sensors (called ULTIMATE) are being designed and their architecture is being optimized for the PXL specifications, extrapolating from the MIMOSA-26 sensor realized for the EUDET beam telescope.The paper gives an overview of the ULTIMATE sensor specifications and of the adaptation of its forerunner, MIMOSA-26, to the PXL specifications.One of the main changes between MIMOSA-26 and ULTIMATE is the use of a high resistivity epitaxial layer. Recent performance assessments obtained with MIMOSA-26 sensors manufactured on such an epitaxial layer are presented, as well as results of beam tests obtained with a prototype probing improved versions of the MIMOSA-26 pixel design. They show drastic improvements of the pixel signal-to-noise ratio and of the sensor radiation tolerance with respect to the performances achieved with a standard, i.e. low resistivity, layer.

A Novel Repair Method for Radial Tears of the Medial Meniscus: Biomechanical Comparison of Transtibial 2-Tunnel and Double Horizontal Mattress Suture Techniques Under Cyclic Loading.

PubMed

Bhatia, Sanjeev; Civitarese, David M; Turnbull, Travis Lee; LaPrade, Christopher M; Nitri, Marco; Wijdicks, Coen A; LaPrade, Robert F

2016-03-01

Complete radial tears of the medial meniscus have been reported to be functionally similar to a total meniscectomy. At present, there is no consensus on an ideal technique for repair of radial midbody tears of the medial meniscus. Prior attempts at repair with double horizontal mattress suture techniques have led to a reportedly high rate of incomplete healing or healing in a nonanatomic (gapped) position, which compromises the ability of the meniscus to withstand hoop stresses. A newly proposed 2-tunnel radial meniscal repair method will result in decreased gapping and increased ultimate failure loads compared with the double horizontal mattress suture repair technique under cyclic loading. Controlled laboratory study. Ten matched pairs of male human cadaveric knees (average age, 58.6 years; range, 48-66 years) were used. A complete radial medial meniscal tear was made at the junction of the posterior one-third and middle third of the meniscus. One knee underwent a horizontal mattress inside-out repair, while the contralateral knee underwent a radial meniscal repair entailing the same technique with a concurrent novel 2-tunnel repair. Specimens were potted and mounted on a universal testing machine. Each specimen was cyclically loaded 1000 times with loads between 5 and 20 N before experiencing a load to failure. Gap distances at the tear site and failure load were measured. The 2-tunnel repairs exhibited a significantly stronger ultimate failure load (median, 196 N; range, 163-212 N) than did the double horizontal mattress suture repairs (median, 106 N; range, 63-229 N) (P = .004). In addition, the 2-tunnel repairs demonstrated decreased gapping at all testing states (P < .05) with a final measured gapping of 1.7 mm and 4.1 mm after 1000 cycles for the 2-tunnel and double horizontal mattress suture repairs, respectively. The 2-tunnel repairs displayed significantly less gapping distance after cyclic loading and had significantly stronger ultimate failure loads compared with the double horizontal mattress suture repairs. Complete radial tears of the medial meniscus significantly decrease the ability of the meniscus to dissipate tibiofemoral loads, predisposing patients to early osteoarthritis. Improving the ability to repair medial meniscal radial tears in a way that withstands cyclic loads and heals in an anatomic position could significantly improve patient healing rates and result in improved preservation of the articular cartilage of the medial compartment of the knee. The 2-tunnel repair may be a more reliable and stronger repair option for midbody radial tears of the medial meniscus. Clinical studies are warranted to further evaluate these repairs. © 2015 The Author(s).

Interventions Using Social Media for Cancer Prevention and Management: A Systematic Review.

PubMed

Han, Claire Jungyoun; Lee, Young Ji; Demiris, George

2017-07-27

Regarding cancer awareness, social media effectively promotes health and supports self-management. Given the diverse study designs, methodologies, and approaches of social media interventions in oncology, it is difficult to determine the effects of social media on cancer prevention and management. We aim to systematically review intervention studies using social media for cancer care. A systematic search, using 7 electronic databases (PubMed, Web of Science, CINAHL, Cochrane Library, Scopus, EMBASE, and PsycINFO), was conducted to identify surveys and interventions using contemporary social media tools with a focus on cancer. Of the 18 selected studies, 7 were randomized controlled trials. Most studies were conducted for all types of cancer, and some were conducted for breast cancer in the United States, with mostly white female participants. Facebook was the most frequently used platform. Most studies targeted healthy participants providing cancer prevention education. With social media platforms as part of a larger intervention, or the main component of interventions, interventions were overall feasible and showed a significant improvement in cancer prevention and management. Social media tools have the potential to be effective in delivering interventions for cancer prevention and management. However, there was a dearth of studies with rigorous study methodologies to test social media effects on various cancer-related clinical outcomes. Social media use in cancer care will facilitate improved communication and support among patients, caregivers, and clinicians and, ultimately, improved patient care. Clinicians need to carefully harness social media to enhance patient care and clinical outcomes.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

PubMed Central

2013-01-01

Background Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient’s risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence. Methods/Design This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician’s degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms. Discussion The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient’s and clinician’s preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making ‘black box’ that currently exists between the delivery of decision aids to patients and subsequent patient behavior. Trial Registration ClinicalTrials.gov ID NCT01514786 PMID:24216139

Rational and combinatorial approaches to engineering styrene production by Saccharomyces cerevisiae.

PubMed

McKenna, Rebekah; Thompson, Brian; Pugh, Shawn; Nielsen, David R

2014-08-21

Styrene is an important building-block petrochemical and monomer used to produce numerous plastics. Whereas styrene bioproduction by Escherichia coli was previously reported, the long-term potential of this approach will ultimately rely on the use of hosts with improved industrial phenotypes, such as the yeast Saccharomyces cerevisiae. Classical metabolic evolution was first applied to isolate a mutant capable of phenylalanine over-production to 357 mg/L. Transcription analysis revealed up-regulation of several phenylalanine biosynthesis pathway genes including ARO3, encoding the bottleneck enzyme DAHP synthase. To catalyze the first pathway step, phenylalanine ammonia lyase encoded by PAL2 from A. thaliana was constitutively expressed from a high copy plasmid. The final pathway step, phenylacrylate decarboxylase, was catalyzed by the native FDC1. Expression of FDC1 was naturally induced by trans-cinnamate, the pathway intermediate and its substrate, at levels sufficient for ensuring flux through the pathway. Deletion of ARO10 to eliminate the competing Ehrlich pathway and expression of a feedback-resistant DAHP synthase encoded by ARO4K229L preserved and promoted the endogenous availability precursor phenylalanine, leading to improved pathway flux and styrene production. These systematic improvements allowed styrene titers to ultimately reach 29 mg/L at a glucose yield of 1.44 mg/g, a 60% improvement over the initial strain. The potential of S. cerevisiae as a host for renewable styrene production has been demonstrated. Significant strain improvements, however, will ultimately be needed to achieve economical production levels.

What patients with addiction disorders need from their primary care physicians: A qualitative study.

PubMed

Press, Katharine R; Zornberg, Giselle Z; Geller, Gail; Carrese, Joseph; Fingerhood, Michael I

2016-01-01

Although strong relationships between primary care providers (PCPs) and patients with addictive disease are essential for care, these relationships are often strained. Providers frequently have negative attitudes about treating these patients, in part due to the practical and psychosocial challenges that come with addictive disease. Resulting hostility frequently causes avoidance of primary care by patients with potentially increased morbidity. However, gaining knowledge of patient perspectives on these relationships could improve physician attitudes toward patients with addictive disease and relatedly improve care. The authors conducted 18 semistructured interviews of patients with current or prior debilitating addictive disease recruited from a primary care practice in East Baltimore. Interview transcripts were analyzed using editing analysis to reveal major themes. Participants elucidated several provider characteristics that were essential for successful relationships. Providers needed to be knowledgeable about addiction, feel responsible for treating these patients, emphasize overall health, and engage patients in their own care. Additionally, participants strongly desired providers who treated them as "people" that they cared about. Interestingly, interviewees also frequently cited patient characteristics that could affect the strength of patient-provider relationships. These included being concerned about their health, feeling deserving of care, and having appropriate psychiatric care for concomitant mental health conditions. Practical obstacles and a disorganized mindset impeded patient-provider relationships. The interpersonal dynamics of the patient-provider relationship are particularly important for patients with addictive disease, as this relationship may be one of the most stable and rewarding in their lives. Patients felt that greater understanding of the practical and psychosocial challenges of addiction enabled providers to more effectively address their health concerns and to be more caring and less judgmental. It is hoped that this work will contribute to providers' understanding of patients with addictions, thus allowing them to form stronger relationships and ultimately provide better care.

Improving Assessment Tasks through Addressing Our Unconscious Limits to Change

ERIC Educational Resources Information Center

Joughin, Gordon; Dawson, Phillip; Boud, David

2017-01-01

Despite widespread recognition of the need to improve assessment in higher education, assessment tasks in individual courses are too often dominated by conventional methods. While changing assessment depends on many factors, improvements to assessment ultimately depend on the decisions and actions of individual educators. This paper considers…

Using NSSE to Assess and Improve Undergraduate Education: Lessons from the Field

ERIC Educational Resources Information Center

National Survey of Student Engagement, 2009

2009-01-01

Assessment is a worthwhile undertaking when meaningful data are generated, evidence-based improvement initiatives are thoroughly considered and discussed, and results are ultimately used to improve educational effectiveness. National Survey of Student Engagement (NSSE) results are oriented toward such practical use. Each year, more campuses use…

Management of complex pediatric laryngotracheal stenosis with skin graft reconstruction.

PubMed

Bowe, Sarah N; Wentland, Carissa J; Sandhu, G S; Hartnick, Christopher J

2018-05-01

For pediatric patients with laryngotracheal stenosis, the ultimate goal is creation of a safe, functional airway. Unfortunately, wound healing in a hollow structure can complicate repair attempts, leading to restenosis. Herein, we present our experience using skin-grafting techniques in two complex pediatric laryngotracheal stenosis cases, leading to successful decannulation or speech production. A chart review was performed examining the evaluation and management of two pediatric patients with laryngotracheal stenosis despite prior reconstructive attempts. Patient history, bronchoscopic evaluation, intra-operative technique, post-operative management, treatment outcomes, and complications were noted. Harvesting and preparation of the split-thickness skin grafts (STSG) proceeded in a similar manner for each case. Stenting material varied based on the clinical scenario. Using this technique, our patient with a Type 3 glottic web achieved substantial improvement in exercise tolerance, as well as vocal strength and quality. In addition, our aphonic patient could vocalize for the first time since her laryngotracheal injury. Temporary endoluminal stenting with skin graft lining can reproduce epithelial continuity and provide "biological inhibition" to enhance the wound healing process. When previous reconstructive efforts have failed, use of STSG can be considered in the management of complex pediatric laryngotracheal stenosis. Copyright © 2018. Published by Elsevier B.V.

Allogeneic mesenchymal precursor cells (MPCs): an innovative approach to treating advanced heart failure.

PubMed

Westerdahl, Daniel E; Chang, David H; Hamilton, Michele A; Nakamura, Mamoo; Henry, Timothy D

2016-09-01

Over 37 million people worldwide are living with Heart Failure (HF). Advancements in medical therapy have improved mortality primarily by slowing the progression of left ventricular dysfunction and debilitating symptoms. Ultimately, heart transplantation, durable mechanical circulatory support (MCS), or palliative care are the only options for patients with end-stage HF. Regenerative therapies offer an innovative approach, focused on reversing myocardial dysfunction and restoring healthy myocardial tissue. Initial clinical trials using autologous (self-donated) bone marrow mononuclear cells (BMMCs) demonstrated excellent safety, but only modest efficacy. Challenges with autologous stem cells include reduced quality and efficacy with increased patient age. The use of allogeneic mesenchymal precursor cells (MPCs) offers an "off the shelf" therapy, with consistent potency and less variability than autologous cells. Preclinical and initial clinical trials with allogeneic MPCs have been encouraging, providing the support for a large ongoing Phase III trial-DREAM-HF. We provide a comprehensive review of preclinical and clinical data supporting MPCs as a therapeutic option for HF patients. The current data suggest allogeneic MPCs are a promising therapy for HF patients. The results of DREAM-HF will determine whether allogeneic MPCs can decrease major adverse clinical events (MACE) in advanced HF patients.

Predicting Postsurgical Satisfaction in Adolescents With Idiopathic Scoliosis: The Role of Presurgical Functioning and Expectations.

PubMed

Sieberg, Christine B; Manganella, Juliana; Manalo, Gem; Simons, Laura E; Hresko, M Timothy

2017-12-01

There is a need to better assess patient satisfaction and surgical outcomes. The purpose of the current study is to identify how preoperative expectations can impact postsurgical satisfaction among youth with adolescent idiopathic scoliosis undergoing spinal fusion surgery. The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire-Version 30, which assesses pain, self-image, mental health, and satisfaction with management, along with the Spinal Appearance Questionnaire, which measures surgical expectations was administered to 190 patients before surgery and 1 and 2 years postoperatively. Regression analyses with bootstrapping (with n=5000 bootstrap samples) were conducted with 99% bias-corrected confidence intervals to examine the extent to which preoperative expectations for spinal appearance mediated the relationship between presurgical mental health and pain and 2-year postsurgical satisfaction. Results indicate that preoperative mental health, pain, and expectations are predictive of postsurgical satisfaction. With the shifting health care system, physicians may want to consider patient mental health, pain, and expectations before surgery to optimize satisfaction and ultimately improve clinical care and patient outcomes. Level I-prognostic study.

Cardiovascular Hypertensive Crisis: Recent Evidence and Review of the Literature

PubMed Central

Varounis, Christos; Katsi, Vasiliki; Nihoyannopoulos, Petros; Lekakis, John; Tousoulis, Dimitris

2017-01-01

Despite the high prevalence of hypertension (HTN), only a small proportion of the hypertensive patients will ultimately develop hypertensive crisis. In fact, some patients with hypertensive crisis do not report a history of HTN or previous use of antihypertensive medication. The majority of the patients with hypertensive crisis often report non-specific symptoms, whereas heart-related symptoms (dyspnea, chest pain, arrhythmias, and syncope) are less common. Hypertensive crises can be divided into hypertensive emergencies or hypertensive urgencies according to the presence or absence of acute target organ damage, respectively. This differentiation is an extremely useful classification in clinical practice since a different management is needed, which in turn has a significant effect on the morbidity and mortality of these patients. Therefore, it is very crucial for the physician in the emergency department to identify the hypertensive emergencies and to manage them through blood pressure lowering medications in order to avoid further target organ damage or deterioration. The aim of this narrative review is to summarize the recent evidence in an effort to improve the awareness, recognition, risk stratification, and treatment of hypertensive crisis in patients referred to the emergency department. PMID:28119918

Cardiovascular Hypertensive Crisis: Recent Evidence and Review of the Literature.

PubMed

Varounis, Christos; Katsi, Vasiliki; Nihoyannopoulos, Petros; Lekakis, John; Tousoulis, Dimitris

2016-01-01

Despite the high prevalence of hypertension (HTN), only a small proportion of the hypertensive patients will ultimately develop hypertensive crisis. In fact, some patients with hypertensive crisis do not report a history of HTN or previous use of antihypertensive medication. The majority of the patients with hypertensive crisis often report non-specific symptoms, whereas heart-related symptoms (dyspnea, chest pain, arrhythmias, and syncope) are less common. Hypertensive crises can be divided into hypertensive emergencies or hypertensive urgencies according to the presence or absence of acute target organ damage, respectively. This differentiation is an extremely useful classification in clinical practice since a different management is needed, which in turn has a significant effect on the morbidity and mortality of these patients. Therefore, it is very crucial for the physician in the emergency department to identify the hypertensive emergencies and to manage them through blood pressure lowering medications in order to avoid further target organ damage or deterioration. The aim of this narrative review is to summarize the recent evidence in an effort to improve the awareness, recognition, risk stratification, and treatment of hypertensive crisis in patients referred to the emergency department.

The business of emergency medicine: a model for success.

PubMed

Proctor, John; Hall, Peter; Carr, Janet

2004-02-01

Today's EPOs and their physicians face an array of daunting challenges. Falling reimbursement, rising malpractice costs. ED and hospital crowding,and demands for improving ED efficiency and patient satisfaction all contribute to the challenging and sometimes threatening environment of EM practice. The EP involved in a busy and often hectic ED shift may feel unduly and unnecessarily distracted when required to continuously acknowledge and address the business aspect of the practice. Nevertheless,regardless of the size and structure, fiscal viability ultimately determines the EPO's ability to continue to offer access to care. This article contends that a comprehensive business strategy drives superior financial performance and supports the organization's mission. The business strategy must identify financial and non-financial determinants of the EPO's success and provide a mechanism for understanding how the organization's resources are converted to value for customers. The section offers a framework for developing this strategy, for identifying possible gaps or deficiencies, and for measuring and monitoring progress in achieving strategic objectives and ultimately, the EPO's mission. The importance of the mission and the dynamic EM environment require that the strategy development process be more than an annual exercise for the leadership of the organization. Though key leaders in any size EPO--set the course for the organization, the entire organization must be aware and understand the strategy before they commit themselves and adopt actions and behaviors that promote it. The model presented here provides a graphic display that lends itself well to consistent communication of a comprehensive strategy in a concise way throughout the organization.Furthermore, the balance of the model, across four perspectives, recognizes the value of balanced organizational objectives and lends itself well to the creation of a measurement system that supports cause and effect relation-ships through leading and lagging indicators. This can prevent the imposition of unproven, arbitrary metrics and expectations.EPOs that expend the time and resources required to develop and implement a comprehensive, well balanced strategy make a long-term investment in their patients and themselves. EPOs that go on to develop credible, efficient measurement systems are not only able to drive more commitment and accountability in the organization, they also have a competitive advantage. They can demonstrate performance history and targeted future performance to differentiate themselves from competitors and to stem efforts to impose unbalanced metrics that do not serve well the hospital, the EPO, and ultimately, patients. The power of such measurement systems, internal and external to the organization, strongly point to the need for consistently defined measures across the industry. Ultimately when faced with changes in the environment,the entire industry will be better equipped to respond in specific ways and to communicate its progress to communities or government authorities.

Exercise stress testing

NASA Technical Reports Server (NTRS)

Schuster, B.

1975-01-01

Positive maximum stress tests in the management of coronary patients are discussed. It is believed that coronary angiography would be the ultimate test to predict the future of patients with coronary heart disease. Progression of angina, myocardial infarction, and death due to heart disease were analyzed.

Prevalence of patent foramen ovale and usefulness of percutaneous closure device in carcinoid heart disease.

PubMed

Mansencal, Nicolas; Mitry, Emmanuel; Pillière, Rémy; Lepère, Céline; Gérardin, Benoît; Petit, Jérôme; Gandjbakhch, Iradj; Rougier, Philippe; Dubourg, Olivier

2008-04-01

The aim of this study was to assess (1) the incidence of patent foramen ovale (PFO) in carcinoid syndrome (CS) and (2) the feasibility of percutaneous closure procedure in selected patients with CS. One hundred eight patients were prospectively studied: 54 with CS and an age- and gender-matched control group. All patients underwent conventional and contrast echocardiography. Patients with clinical signs of dyspnea (New York Heart Association class > or =III), cyanosis, carcinoid heart disease (CHD), and severe PFO were referred for the percutaneous closure of PFO. The prevalence of PFO was 41% in patients with CS and 22% in the control group (p = 0.03) and was significantly higher in patients with CHD (59%, p = 0.009). Four patients (14% of those with CHD) were referred for the percutaneous closure of PFO, and 3 patients ultimately underwent PFO closure (using Amplatzer septal occluders). At 6-month follow-up, New York Heart Association class was improved in all patients, as well as arterial blood gas results (p = 0.04) and 6-minute walking distance (p = 0.03), but all patients presented residual right-to-left shunts. In conclusion, this prospective study demonstrates that in patients with CHD, the prevalence of PFO is high and that percutaneous closure of PFO is feasible, with a reduction in symptoms but with residual shunting.

Social Support Is a Predictor of Lower Stress and Higher Quality of Life and Resilience in Brazilian Patients With Colorectal Cancer.

PubMed

Costa, Ana Lucia Siqueira; Heitkemper, Margaret M; Alencar, Gizelton Pereira; Damiani, Lucas Petri; Silva, Rodrigo Marques da; Jarrett, Monica E

The well-being of patients undergoing chemotherapy treatment for colorectal cancer (CRC) is affected by psychological effects associated with cancer treatment. However, little is known about the impact of these psychological factors in Brazilian patients with CRC. The aim of this study was to determine whether perceived stress, social support, and resilience are associated with quality of life in urban Brazilian patients receiving chemotherapy treatment for CRC. This was a cross-sectional study conducted with 144 Brazilian CRC patients in an ambulatory oncology clinic. The participants completed 5 questionnaires: Demographics, Perceived Stress Scale 14, Social Support Satisfaction Scale, Resilience Scale, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (C30 and CR29). Confirmatory factor analysis modeling and Cronbach's α were used to examine construct validity and internal consistency. We used the MPlus 3.0 to construct and validate the structural model. There was a moderate and positive effect of resilience on the physical, social, and emotional aspects of quality of life. Social support had a strong and positive direct effect on quality of life (ie, social, physical, social, and emotional). Social support had a negative effect on stress perception. Resilience was also negatively related to stress perception. Family support and professional social support are important factors for Brazilian CRC patients. Resilience is an important ally for patients. It is important for nurses to consider this when developing educational and psychological interventional strategies to reduce stress and ultimately improve quality of life in this population. Psychological factors that improve quality of life should be evaluated in patients undergoing treatment for cancer.

The theoretical basis for practice-relevant medication use research: patient-centered/behavioral theories.

PubMed

Blalock, Susan J

2011-12-01

There is an urgent need for research to improve the quality of medication use among those who require pharmacotherapy. To describe how behavioral science theories can help to achieve this goal. We begin by describing what a theory is and the functions that theories serve. We then provide 8 guiding principles that are crucial for investigators to understand if they are to use theory appropriately. We conclude by discussing the need for a new model of patient medication self-management that incorporates information concerning factors operating at all levels of the ecological framework, ranging from patient-level to societal-level factors. The 8 guiding principles discussed are the following: (1) There is no single theory that is appropriate for guiding all medication use research; (2) Behavioral science theories are probabilistic, not deterministic; (3) When trying to influence a health behavior, the health behavior of interest must be defined precisely; (4) Many factors outside of patient control influence patient medication use; (5) Every patient is unique; (6) Patient motivation is a fundamental ingredient required to optimize medication use, especially when maintenance of long term behavior is the goal; (7) Health care providers can have a profound effect on patient medication use, and this effect can operate through several possible causal pathways; and (8) When planning an intervention to optimize medication use, it is important to develop a conceptual model that links intervention inputs to the ultimate outcomes that are desired. Medication use can be influenced by a wide variety of factors acting at different levels of the ecological model. The quality of research on medication use could be improved by development of an ecological model specific to medication self-management. Copyright © 2011 Elsevier Inc. All rights reserved.

The immunopathogenesis of celiac disease reveals possible therapies beyond the gluten-free diet.

PubMed

McAllister, Christopher S; Kagnoff, Martin F

2012-07-01

Celiac disease is a T cell-mediated autoimmune inflammatory disease of the small intestine that is activated by gluten. The diagnosis of celiac disease is challenging as patients display a wide range of symptoms and some are asymptomatic. A lifelong gluten-free diet is the only currently approved treatment of celiac disease. Although the diet is safe and effective, the compliance rates and patient acceptance vary. Furthermore, many patients treated with a gluten-free diet continue to be mildly to severely symptomatic with persistent histological abnormalities, and a small number of patients develop refractory celiac disease. New therapeutic adjuncts and potential alternatives to the gluten-free diet could improve the treatment options for these patients. Advances in understanding the immunopathogenesis of celiac disease have suggested several types of therapeutic strategies that may augment or supplant the gluten-free diet. Some of these strategies attempt to decrease the immunogenicity of gluten-containing grains by manipulating the grain itself or by using oral enzymes to break down immunogenic peptides that normally remain intact during digestion. Other strategies focus on preventing the absorption of these peptides, preventing tissue transglutaminase from rendering gluten peptides more immunogenic, or inhibiting their binding to celiac disease-specific antigen-presenting molecules. Strategies that limit T cell migration to the small intestine or that reestablish mucosal homeostasis and tolerance to gluten antigens are also being explored. Additionally, it is vital to develop new therapeutic options for refractory celiac disease patients. This review highlights therapeutic strategies that may ultimately improve the health and well-being of individuals with celiac disease.

The price of weight loss by jejunoileal shunt.

PubMed Central

Ravitch, M M; Brolin, R E

1979-01-01

In the performance of end-to-end jejunoileal shunt, operative mortality can be nearly eliminated and late deaths largely prevented by assiduous care and follow-up. We attempted to prevent serious complications by regular outpatient visits. However, 703 outpatient visits costing $49.00 per visit failed to improve results. There were 170 readmissions among 64 patients lasting 4--57 days (average hospital stay--16 days per admission at $3,000.00). Twenty-four of those patients alive and followed 18 months or more (53%) sustained adequate weight loss and were free of major problems. Patient satisfaction nevertheless appears high, and when there has been a good weight loss, even severe problems tend to be glossed over by the patient. The ultimate outcome is still unknown, but it seems clear that many of the patients are in a state of controlled malnutrition, which may lead to progressive penalties. We have documented gross pathologic lesions in the bypass enteritis syndrome and draw attention to neurologic sequelae of the bypass, which probably represents deficiency manifestations. Despite brilliant results in some patients and satisfactory results in perhaps half, the cost in life, suffering, dollars, patient and physician time, the uncertain long-term effects, and the unpredictability of the weight loss, all place in question the appropriateness of jejunoileal shunt as the remedy for morbid obesity. PMID:485613

Atherosclerotic renovascular disease – epidemiology, treatment and current challenges

PubMed Central

Vassallo, Diana

2017-01-01

The neutral results of recent large randomized controlled trials comparing renal revascularization with optimal medical therapy in patients with atherosclerotic renovascular disease (ARVD) have cast doubt on the role of revascularization in the management of unselected patients with this condition. However, these studies have strengthened the evidence base for the role of contemporary intensive medical vascular protection therapy and aggressive risk factor control in improving clinical outcomes in ARVD. Patients presenting with ‘high-risk’ clinical features such as uncontrolled hypertension, rapidly declining renal function or flash pulmonary oedema are underrepresented in these studies; hence these results may not be applicable to all patients with ARVD. In this ‘high-risk’ subgroup, conservative management may not be sufficient in preventing adverse events, and indeed, observational evidence suggests that this specific patient subgroup may gain benefit from timely renal revascularization. Current challenges include the development of novel diagnostic techniques to establish haemodynamic significance of a stenosis, patient risk stratification and prediction of post-revascularization outcomes to ultimately facilitate patient selection for revascularization. In this paper we describe the epidemiology of this condition and discuss treatment recommendations for this condition in light of the results of recent randomized controlled trials while highlighting important clinical unmet needs and challenges faced by clinicians managing this condition. PMID:29056991

IMAGE-GUIDED EVALUATION AND MONITORING OF TREATMENT RESPONSE IN PATIENTS WITH DRY EYE DISEASE

PubMed Central

Hamrah, Pedram

2014-01-01

Dry eye disease (DED) is one of the most common ocular disorders worldwide. The pathophysiological mechanisms involved in the development of DED are not well understood and thus treating DED has been a significant challenge for ophthalmologists. Most of the currently available diagnostic tests demonstrate low correlation to patient symptoms and have low reproducibility. Recently, sophisticated in vivo imaging modalities have become available for patient care, namely, in vivo confocal microscopy (IVCM) and optical coherence tomography (OCT). These emerging modalities are powerful and non-invasive, allowing real-time visualization of cellular and anatomical structures of the cornea and ocular surface. Here we discuss how, by providing both qualitative and quantitative assessment, these techniques can be used to demonstrate early subclinical disease, grade layer-by-layer severity, and allow monitoring of disease severity by cellular alterations. Imaging-guided stratification of patients may also be possible in conjunction with clinical examination methods. Visualization of subclinical changes and stratification of patients in vivo, allows objective image-guided evaluation of tailored treatment response based on cellular morphological alterations specific to each patient. This image-guided approach to DED may ultimately improve patient outcomes and allow studying the efficacy of novel therapies in clinical trials. PMID:24696045

Improving the Academic Achievement of Third and Fourth Grade Underachievers as a Result of Improved Self-Esteem.

ERIC Educational Resources Information Center

Coakley, Barbara Fairfax

This study was designed to improve the academic achievement of 35 third- and fourth-grade underachievers through improved self-esteem. Specific goals included focusing on self-concept and learning skills reinforcement, with the ultimate goal of increasing academic performance and motivation. Large group sessions with students focused on…

Practical strategies of black walnut genetic improvement—an update

Treesearch

George Rink; J.W. Van Sambeek; Phil O' Connor; Mark Coggeshall

2017-01-01

The ultimate goal of any tree improvement program is the large-scale production and distribution of genetically improved seedlings. In black walnut, projections based on earlier research indicate that genetically improved seedlings could provide growth improvement of between 15 to 25 percent by using seed or seedlings of the proper geographic origin (Bey 1980; Clausen...

Experience, Knowledge and Attitudes: Are Paramedic Students Prepared to Care for Older Patients?

ERIC Educational Resources Information Center

Ross, Linda; Jennings, Paul; Williams, Brett

2016-01-01

As the population ages, so does the number of older patients encountered by paramedics. It is vital that paramedics are adequately prepared to meet the unique and growing needs of these patients. Experience and education play key roles in the formation of attitudes that impact behavior, and ultimately patient care. The aim of this study was to…

Stem Cell Genetic Therapy for Fanconi Anemia - A New Hope.

PubMed

Hanenberg, Helmut; Roellecke, Katharina; Wiek, Constanze

2017-01-01

Fanconi anemia (FA) is a rare inherited DNA disorder clinically characterized by congenital malformations, progressive bone marrow failure, and cancer susceptibility. Due to a strong survival advantage of spontaneously corrected 'normal' hematopoietic stem cells (HSCs) in a few patients, FA is considered a model disorder for genetic correction of autologous stem cells, where genetically corrected stem cells and their progeny have a strong in vivo selective advantage, ultimately leading to normal hematopoiesis. Despite these apparently ideal circumstances, three HSC gene therapy trials with gammaretroviral vectors (stage I) designed to cure the hematological manifestation of FA completely failed to provide long-term clinical benefits for patients, predominantly due to the combination of insufficient gene transfer technologies and incompletely understood FA HSC pathobiology. Currently, FA gene therapy is in stage II where, based on an improved understanding of the cellular defects in FA HSCs, consequently adapted transduction protocols are being used in two phase I/II trials for in vitro genetic correction of FANCA-deficient hematopoietic stem cells. These results are eagerly awaited. Independent from the outcome of these studies, technologies are already available that seem highly attractive for testing in FA. In stage III, this would ultimately include targeted in vivo correction of autologous HSCs by overexpression of nonintegrating lentiviral vectors with scaffold/matrix attachment region elements using specific envelopes as pseudotypes. Although currently still challenging, in a few years in vivo genome editing approaches will be readily available in stage IV, in which the delivery of the editing machinery/ complex is targeted to the autologous FA HSCs by the nonintegrating lentiviral vectors established in stage III. Even low levels of corrected stem cells will then quickly repopulate the entire hematopoiesis of the patient. We therefore are sanguine that in the future, genetic therapy can be used clinically for the correction of FA HSCs in the standard care of FA patients. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

The role of dental therapists in pharmacological and non-pharmacological treatment of anxious and phobic patients.

PubMed

MacLeavey, Christine

2013-01-01

Dental Therapists are in a prime position to be involved with the management of anxious and phobic patients. They earn less than dentists and are therefore a more cost-effective way of providing specialised care for anxious patients. Dental Therapists can spend more time educating and acclimatising these patients, do most if not all of the patient's treatment, only referring back to the dentist for RCT, crown/bridgework/dentures and permanent extractions. Ultimately this means that the patient receives high quality continuity of care. Treating anxious and phobic patients is time-consuming but ultimately very rewarding. If handled correctly and sensitively the anxious and phobic patient will not always be anxious or phobic, in the same way that children won't always be children. Dental Therapists can now extend their duties to include Relative Analgesia. This should enhance their employability and role within the dental team especially in the management of anxious and phobic patients. Employing a therapist with a toolbox of techniques at their disposal can be seen as part of a long-term practice plan to ensure that anxious and phobic patients become rehabilitated, happy, compliant and loyal to the practice! In fact .... the sort of patients every dentist really wants to see.

Emergency Department Waiting Times (EDWaT): A Patient Flow Management and Quality of Care Rating mHealth Application.

PubMed

Househ, Mowafa; Yunus, Faisel

2014-01-01

Saudi hospital emergency departments (ED) have suffered from long waiting times, which have led to a delay in emergency patient care. The increase in the population of Saudi Arabia is likely to further stretch the healthcare services due to overcrowding leading to decreased healthcare quality, long patient waits, patient dissatisfaction, ambulance diversions, decreased physician productivity, and increased frustration among medical staff. This will ultimately put patients at risk for poor health outcomes. Time is of the essence in emergencies and to get to an ED that has the shortest waiting time can mean life or death for a patient, especially in cases of stroke and myocardial infarction. In this paper, we present our work on the development of a mHealth Application - EDWaT - that will: provide patient flow information to the emergency medical services staff, help in quick routing of patients to the nearest hospital, and provide an opportunity for patients to review and rate the quality of care received at an ED, which will then be forwarded to ED services administrators. The quality ratings will help patients to choose between two EDs with the same waiting time and distance from their location. We anticipate that the use of EDWaT will help improve ED wait times and the quality of care provision in Saudi hospitals EDs.

Implications of Pathologic Complete Response Beyond Mediastinal Nodal Clearance With High-Dose Neoadjuvant Chemoradiation Therapy in Locally Advanced, Non-Small Cell Lung Cancer.

PubMed

Vyfhuis, Melissa A L; Burrows, Whitney M; Bhooshan, Neha; Suntharalingam, Mohan; Donahue, James M; Feliciano, Josephine; Badiyan, Shahed; Nichols, Elizabeth M; Edelman, Martin J; Carr, Shamus R; Friedberg, Joseph; Henry, Gavin; Stewart, Shelby; Sachdeva, Ashutosh; Pickering, Edward M; Simone, Charles B; Feigenberg, Steven J; Mohindra, Pranshu

2018-06-01

To determine, in a retrospective analysis of a large cohort of stage III non-small cell lung cancer patients treated with curative intent at our institution, whether having a pathologic complete response (pCR) influenced overall survival (OS) or freedom from recurrence (FFR) in patients who underwent definitive (≥60 Gy) neoadjuvant doses of chemoradiation (CRT). At our institution, 355 patients with locally advanced non-small cell lung cancer were treated with curative intent with definitive CRT (January 2000-December 2013), of whom 111 underwent mediastinal reassessment for possible surgical resection. Ultimately 88 patients received trimodality therapy. Chi-squared analysis was used to compare categorical variables. The Kaplan-Meier analysis was performed to estimate OS and FFR, with Cox regression used to determine the absolute hazards. Using high-dose neoadjuvant CRT, we observed a mediastinal nodal clearance (MNC) rate of 74% (82 of 111 patients) and pCR rate of 48% (37 of 77 patients). With a median follow-up of 34.2 months (range, 3-177 months), MNC resulted in improved OS and FFR on both univariate (OS: hazard ratio [HR] 0.455, 95% confidence interval [CI] 0.272-0.763, P = .004; FFR: HR 0.426, 95% CI 0.250-0.726, P = .002) and multivariate analysis (OS: HR 0.460, 95% CI 0.239-0.699, P = .001; FFR: HR 0.455, 95% CI 0.266-0.778, P = .004). However, pCR did not independently impact OS (P = .918) or FFR (P = .474). Mediastinal nodal clearance after CRT continues to be predictive of improved survival for patients undergoing trimodality therapy. However, a pCR at both the primary and mediastinum did not further improve survival outcomes. Future therapies should focus on improving MNC to encourage more frequent use of surgery and might justify use of preoperative CRT over chemotherapy alone. Copyright © 2018 Elsevier Inc. All rights reserved.

Brief review: pain management for cancer survivors: challenges and opportunities.

PubMed

Yazdani, Shiraz; Abdi, Salahadin

2014-08-01

As the number of cancer survivors continues to increase due to advances in medicine, many cancer survivors remain on their same pain management regimen long after their cancer treatment has been completed. Thus, the purpose of this review is to encourage awareness of the challenges and opportunities of pain management in cancer survivorship. It is our expectation that these patients will be referred to pain medicine specialists so their pain management can be optimized during the period of survivorship and ultimately improve their quality of life. Cancer and its treatment can cause significant pain which requires multidrug therapy, including strong analgesics such as opioids. Optimal pain management has been shown to improve the quality of life of cancer patients, and that is also true for cancer survivors. Nevertheless, the appropriate use of pain medications, especially opioids, must be re-evaluated and adjusted during treatment as the patient transitions into survivorship care and thereafter. This may otherwise result in unnecessary opioid use or may even lead to abuse. Fortunately, as cancer treatment is completed and the survivorship period begins, pain improves gradually and the need for pain medication should decrease. Unfortunately, some patients continue to take their potent analgesics during the period of survivorship although it may not be necessary. It is a challenge for pain practitioners who do not see these patients early in their disease or in the recovery period. Nevertheless, this challenge presents an opportunity for pain management providers to educate oncologists to refer cancer survivors to pain centres early during the period of their survivorship. Cancer survivors could then receive optimal care and maintain a better quality of life without having to take unnecessary pain medications. It is clear that there is a need to improve pain management in cancer patients, particularly in cancer survivors. Pain physicians should play a critical role as part of a multidisciplinary team that cares not only for cancer patients but also for cancer survivors. Optimizing pain management during the cancer survivorship period results in a better quality of life.

The Utah Beacon Experience: Integrating Quality Improvement, Health Information Technology, and Practice Facilitation to Improve Diabetes Outcomes in Small Health Care Facilities

PubMed Central

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J.; North, Christie

2014-01-01

Purpose: The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010–2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC3 was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients’ diabetes outcomes at 21 participating smaller, independent clinics. Innovation: Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC3 helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients’ diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Findings: Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC3 Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Conclusion and Discussion: Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC3 Beacon practices are currently smoothly transitioning to new models of care such as Patient-Centered Medical Homes. Thus, IC3 Beacon has been instrumental in creating a strong community partnership among various organizations to meet the shared vision of better health and lower costs, and the experience over the last few years has helped the community prepare for the changing health care landscape. PMID:25848624

Better O and M Programs is Ultimate Answer to O and M Problems

ERIC Educational Resources Information Center

Davanzo, A. C.; Thompson, William B.

1978-01-01

Describes is an improvement program for the operation and maintenance of municipal wastewater treatment plants in Detroit, Michigan. Improvements included expansion and upgrading of the existing city plant and a training program for plant personnel. (MA)

Scorecard cardiovascular medicine. Its impact and future directions.

PubMed

Topol, E J; Califf, R M

1994-01-01

Public release of operator-specific data for cardiovascular procedures has set a new precedent, introducing the "scorecard" era. Justification exists for public disclosure, but the mechanics of appropriate data release are complex from a clinical, statistical, and logistic standpoint. Scorecard medicine may appropriately promote regionalization of medical centers and consolidation of services, but unless the process is directed effectively, it may impair the development of new treatments because of a more restrictive clinical practice environment. We propose revamping our current system to facilitate rapid and accurate access to outcome data in the local practice environment so that improvement in practice occurs on a voluntary basis rather than in response to punitive restrictions. A rational plan needs to be developed for dealing with high-risk patients, perhaps through compensation in regression models used to calculate expected outcomes, and for the start-up of novice physicians. Special provisions are needed to promote clinical research. Before procedures are done, it would be ideal to provide a full disclosure informed consent, whereby the physician reports operator-specific data and the patient's decision-making process is facilitated. Overall, appropriate implementation of scorecards could ultimately lead to a substantial improvement in the quality of U.S. cardiovascular medicine.

Resting state activity in patients with disorders of consciousness

PubMed Central

Soddu, Andrea; Vanhaudenhuyse, Audrey; Demertzi, Athena; Bruno, Marie-Aurélie; Tshibanda, Luaba; Di, Haibo; Boly, Mélanie; Papa, Michele; Laureys, Steven; Noirhomme, Quentin

Summary Recent advances in the study of spontaneous brain activity have demonstrated activity patterns that emerge with no task performance or sensory stimulation; these discoveries hold promise for the study of higher-order associative network functionality. Additionally, such advances are argued to be relevant in pathological states, such as disorders of consciousness (DOC), i.e., coma, vegetative and minimally conscious states. Recent studies on resting state activity in DOC, measured with functional magnetic resonance imaging (fMRI) techniques, show that functional connectivity is disrupted in the task-negative or the default mode network. However, the two main approaches employed in the analysis of resting state functional connectivity data (i.e., hypothesis-driven seed-voxel and data-driven independent component analysis) present multiple methodological difficulties, especially in non-collaborative DOC patients. Improvements in motion artifact removal and spatial normalization are needed before fMRI resting state data can be used as proper biomarkers in severe brain injury. However, we anticipate that such developments will boost clinical resting state fMRI studies, allowing for easy and fast acquisitions and ultimately improve the diagnosis and prognosis in the absence of DOC patients’ active collaboration in data acquisition. PMID:21693087

To Cough or Not to Cough? Examining the Potential Utility of Cough Testing in the Clinical Evaluation of Swallowing

PubMed Central

Watts, Stephanie A.; Tabor, Lauren

2016-01-01

Purpose The clinical swallowing evaluation (CSE) represents a critical component of a comprehensive assessment of deglutition. Although universally utilized across clinical settings, the CSE demonstrates limitations in its ability to accurately identify all individuals with dysphagia. There exists a need to improve assessment and screening techniques to improve health outcomes, treatment recommendations and ultimately mortality in individuals at risk for dysphagia. The following narrative review provides a summary of currently used validated CSE’s and examines the potential role of cough testing and screening in the CSE. Recent findings Recent evidence highlights a relationship between objective physiologic measurements of both voluntarily and reflexively induced cough and swallowing safety status across several patient populations. Although more research is needed across a wider range of patient populations to validate these findings; emerging data supports the consideration of inclusion of cough testing during the CSE as an index of airway defense mechanisms and capabilities in individuals at risk for aspiration. Summary The sensorimotor processes of cough and swallowing share common neuroanatomical and functional substrates. Inclusion of voluntarily or reflexively induced cough testing in the CSE may aide in the identification of dysphagia and reduced airway protection capabilities. PMID:28529824

Transient Cardiomyopathy and Quadriplegia Induced by Ephedrine Decongestant.

PubMed

Snipelisky, David F; Kurklinsky, Andrew K; Chirila, Razvan

2015-12-01

Ephedrine decongestant products are widely used. Common side effects include palpitations, nervousness, and headache. More severe adverse reactions include cardiomyopathy and vasospasm. We report the case of an otherwise healthy 37-year-old woman who presented with acute-onset quadriplegia and heart failure. She had a normal chest radiograph on admission, but developed marked pulmonary edema and bilateral effusions the next day. Echocardiography revealed a left ventricular ejection fraction of 0.18 and no obvious intrinsic pathologic condition such as foramen narrowing on spinal imaging. Laboratory screening was positive for methamphetamines in the urine, and the patient admitted to having used, over the past several weeks, multiple ephedrine-containing products for allergy-symptom relief. She was ultimately diagnosed with an acute catecholamine-induced cardiomyopathy and spinal artery vasospasm consequential to excessive use of decongestants. Her symptoms resolved completely with supportive care and appropriate heart-failure management. An echocardiogram 2 weeks after admission showed improvement of the left ventricular ejection fraction to 0.33. Ten months after the event, the patient was entirely asymptomatic and showed further improvement of her ejection fraction to 0.45. To our knowledge, ours is the first report of spinal artery vasospasm resulting in quadriplegia in a human being after ephedrine ingestion.

Precision medicine in cardiology.

PubMed

Antman, Elliott M; Loscalzo, Joseph

2016-10-01

The cardiovascular research and clinical communities are ideally positioned to address the epidemic of noncommunicable causes of death, as well as advance our understanding of human health and disease, through the development and implementation of precision medicine. New tools will be needed for describing the cardiovascular health status of individuals and populations, including 'omic' data, exposome and social determinants of health, the microbiome, behaviours and motivations, patient-generated data, and the array of data in electronic medical records. Cardiovascular specialists can build on their experience and use precision medicine to facilitate discovery science and improve the efficiency of clinical research, with the goal of providing more precise information to improve the health of individuals and populations. Overcoming the barriers to implementing precision medicine will require addressing a range of technical and sociopolitical issues. Health care under precision medicine will become a more integrated, dynamic system, in which patients are no longer a passive entity on whom measurements are made, but instead are central stakeholders who contribute data and participate actively in shared decision-making. Many traditionally defined diseases have common mechanisms; therefore, elimination of a siloed approach to medicine will ultimately pave the path to the creation of a universal precision medicine environment.

Determining the status quo of infection prevention and control standards in the hospitals of iran: a case study in 23 hospitals.

PubMed

Shojaee, Jalil; Moosazadeh, Mahmood

2014-02-01

Applying Prevention and Control of Infection (PCI) standards in hospitals reduces probable risks to patients, staff and visitors; it also increases efficiency, and ultimately improves productivity of hospitals. The current study aimed to determine the status quo of international standards of PCI in hospitals located in the north of Iran. This cross-sectional study was conducted in 23 hospitals. Data collection tool was a questionnaire with confirmed validity and reliability. . In this regard, 260 managers, section supervisors and infection control nurses participated in the study according to census basis. SPSS software version 16 was employed to analyze the data through descriptive and analytical statistics. Among the studied hospitals, 18 hospitals were public. Hospitals enjoyed 77.2% of leadership and programming, 80.8% of focus of programs, 67.4% of isolating methods, 88.2% of hand health and protection techniques, 78.8% of improving patient's safety and quality, 90.3% of training personnel, and 78.7% of the average status quo of PCI standards. This study revealed that PCI standards were significantly observed in the studied hospitals and that there were necessary conditions for full deployment of nosocomial infection surveillance.

The future vision of simulation in health care

PubMed Central

Gaba, D

2004-01-01

Simulation is a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in health care can be categorised by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; health care domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviours addressed; the simulated patient's age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, health care payers, and ultimately the public. The future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality. PMID:15465951

Project ECHO: A Telementoring Program for Cervical Cancer Prevention and Treatment in Low-Resource Settings.

PubMed

Lopez, Melissa S; Baker, Ellen S; Milbourne, Andrea M; Gowen, Rose M; Rodriguez, Ana M; Lorenzoni, Cesaltina; Mwaba, Catherine; Msadabwe, Susan Citonje; Tavares, José Humberto; Fontes-Cintra, Georgia; Zucca-Matthes, Gustavo; Callegaro-Filho, Donato; Ramos-Martin, Danielle; Thiago de Carvalho, Icaro; Coelho, Robson; Marques, Renato Moretti; Chulam, Thiago; Pontremoli-Salcedo, Mila; Nozar, Fernanda; Fiol, Veronica; Maza, Mauricio; Arora, Sanjeev; Hawk, Ernest T; Schmeler, Kathleen M

2017-10-01

Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.

Patient Reasons for Non-Urgent Utilization of the Dwight David Eisenhower Army Medical Center Emergency Department

DTIC Science & Technology

2004-01-01

patient education opportunities, which may ultimately change both patient perception and ED utilization behavior. Statement of the... Patient education about the Emergency Department policies, triage process, and associated wait times should serve to narrow the gap between the patient’s...perceptions and the provider’s perceptions. The DDEAMC ED has made advancements in the patient education arena, as well as streamlining ED process

Leading with Intent: Cultivating Community Conversation to Create Shared Understanding

ERIC Educational Resources Information Center

Marsh, Scott; Waniganayake, Manjula; De Nobile, John J.

2016-01-01

School improvement is a central focus for school leaders. Whilst measures such as high-stakes testing and other government accountability agendas have at times marred the discourse of school improvement, how schools develop their capacity to ultimately improve the core business of student learning remains important. As an extensive area of…

Addressing parenting concerns of bone marrow transplant patients: opening (and closing) Pandora's box.

PubMed

Moore, C W; Rauch, P K

2006-12-01

Although a significant number of adults undergoing stem cell transplant (SCT) or bone marrow transplantation (BMT) care for dependent children, and these treatments pose significant challenges for families, research has virtually ignored the impact of parenting on patients' quality of life during BMT/SCT and children's responses to having a parent undergo these treatments. Physicians rarely inquire about parenting concerns related to the extended hospitalizations necessitated by these treatments, yet clinical experience suggests that addressing patient concerns about children's reactions to cancer and BMT/SCT can improve the experience of the patient and the patient's family, and help the medical team respond effectively to sources of patients' distress. Parents frequently want to know what reactions to expect from children, thus general developmental information is reviewed, and recommendations given for when professional help for children is warranted. A key way for parents to support their children is with open, honest communication; however, parents often find it extremely difficult to talk about cancer and BMT/SCT with their children. The medical team can assist patients' efforts to communicate with and support their children by asking about a patient's children, providing some targeted information, and discussing the potential impact of treatments on parenting capacity. Inquiring about and addressing parenting concerns may initially seem difficult, but can ultimately facilitate stronger doctor-patient alliances, and more compassionate care.

Reducing chronic obstructive pulmonary disease readmissions: the role of the durable medical equipment provider.

PubMed

Messenger, Robert W

2012-01-01

Exacerbation and frequent rehospitalization in chronic obstructive pulmonary disease exacts a heavy toll on the US health care system. To address these issues, new initiatives have been proposed that are largely based on financial penalties to promote patient education and postdischarge care. However, as laudable as these goals are, improving outcomes in the chronic obstructive pulmonary disease population is more confounding than it may first appear. Chronic hypoxia, cognitive dysfunction, poor nutrition, and economic disadvantage are just a few of the challenges that require creative solutions and ongoing support. Case managers need to utilize all the potential products and services that can assist in improving outcomes for these patients. Durable medical equipment providers are often viewed as purveyors of medical equipment that offer little in the form of clinical support. However, in many cases these providers represent an overlooked resource that provides individualized, highly structured patient education and ongoing support programs. The challenge is in identifying those durable medical equipment providers that offer patients contemporary technology, and have both the resources and the commitment to provide patient support that is amenable to the goals of the hospital. This article reviews many of the confounding issues that contribute to the frequent rehospitalization of chronic obstructive pulmonary disease patients. Recommendations to improve patient education and oxygen therapy outcomes are provided along with suggestions to aid in the vetting of durable medical equipment providers. Acute care hospitals, long-term acute care hospitals, extended care facilities, integrated delivery systems. 1. An understanding of the complex variables that play in the management of chronic obstructive pulmonary disease will help the case manager to plan an effective course of care. 2. Case managers need to ensure that patients receive long-term oxygen technology that supports their lifestyle, promotes compliance, and ultimately achieves the desired outcomes. 3. Case managers must advocate for coordinated, ongoing patient education and stress the need for continuing reinforcement. 4. Case managers must ensure that patients under their care be matched with durable medical equipment providers that provide the technology and support that favors positive clinical outcomes.

Associations between the prevalence of influenza vaccination and patient's knowledge about antibiotics: a cross-sectional study in the framework of the APRES-project in Austria.

PubMed

Hoffmann, Kathryn; van Bijnen, Evelien Me; George, Aaron; Kutalek, Ruth; Jirovsky, Elena; Wojczewski, Silvia; Maier, Manfred

2015-09-29

This study aimed to identify associations between GP patient's knowledge about the spectrum of effectiveness of antibiotics and the probability of vaccination against influenza. The underlying hypothesis was that individuals with an understanding that antibiotics are ineffective against viruses, common colds, and flu were more likely to be vaccinated than persons lacking this knowledge. This cross-sectional study was conducted within the context of the European APRES project in Austria. Between November 2010 and July 2011, patients were recruited from GP practices to complete questionnaires about their knowledge about antibiotics and their influenza vaccination status. Statistical analyses included subgroup analyses and logistic regression models. Data of 3224 patients was analyzed, demonstrating that patients with better knowledge concerning antibiotics had a significantly higher likelihood of being vaccinated (OR 1.35, CI 95 % 1.18-1.54). While the overall vaccination rate was low (18.6 % in 2009/2010 and 14.0 % in 2010/2011), elderly compared to younger adults (OR 0.06 CI 95 % 0.03-0.13) and healthcare workers (OR 2.24, CI 95 % 1.42-3.54) demonstrated higher likelihood of vaccination. Additionally, female GPs had significantly more vaccinated patients than male GPs (OR 2.90, CI 95 % 1.32-6.40). There has been little prior study on the association between a patient's knowledge of the effectiveness spectrum of antibiotics and influenza vaccination status. Given the public health imperative to increase annual prevalence of influenza vaccination, understanding this educational gap can improve specificity in counseling as well as vaccination rates. Ultimately, we found that those with a better knowledge on about antibiotics had a significantly higher likelihood of being vaccinated. The results of this study demonstrate that vaccination prevalence is associated with patient's knowledge about antibiotics. It can be concluded that one strategy to improve the overall low vaccination rates for seasonal influenza in Austria would be, particularly for male GPs, to have a specific discussion with patients about these circumstances by focusing on younger patients. Further, public health efforts could supplement in-office strategies to improve this area of health literacy.

Why primary care practices should become digital health information hubs for their patients.

PubMed

Baird, Aaron; Nowak, Samantha

2014-11-25

Two interesting health care trends are currently occurring: 1) patient-facing technologies, such as personal health records, patient portals, and mobile health apps, are being adopted at rapid rates, and 2) primary care, which includes family practice, is being promoted as essential to reducing health care costs and improving health care outcomes. While these trends are notable and commendable, both remain subject to significant fragmentation and incentive misalignments, which has resulted in significant data coordination and value generation challenges. In particular, patient-facing technologies designed to increase care coordination, often fall prey to the very digital fragmentation issues they are supposed to overcome. Additionally, primary care providers are treating patients that may have considerable health information histories, but generating a single view of such multi-source data is nearly impossible. We contribute to this debate by proposing that primary care practices become digital health information hubs for their patients. Such hubs would offer health data coordination in a medically professional setting with the benefits of expert, trustworthy advice coupled with active patient engagement. We acknowledge challenges including: costs, information quality and provenance, willingness-to-share information and records, willingness-to-use (by both providers and patients), primary care scope creep, and determinations of technical and process effectiveness. Even with such potential challenges, we strongly believe that more debate is needed on this topic prior to full implementation of various health information technology incentives and reform programs currently being designed and enacted throughout the world. Ultimately, if we do not provide a meaningful way for the full spectrum of health information to be used by both providers and patients, especially early in the health care continuum, effectively improving health outcomes may remain elusive. We view the primary care practice as a central component of digital information coordination, especially when considering the current challenges of digital health information fragmentation. Given these fragmentation issues and the emphasis on primary care as central to improving health and lower overall health care costs, we suggest that primary care practices should embrace their evolving role and should seek to become digital health information hubs for their patients.

Focal retinal phlebitis.

PubMed

Hoang, Quan V; Freund, K Bailey; Klancnik, James M; Sorenson, John A; Cunningham, Emmett T; Yannuzzi, Lawrence A

2012-01-01

To report three cases of solitary, focal retinal phlebitis. An observational case series. Three eyes in three patients were noted to have unilateral decreased vision, macular edema, and a focal retinal phlebitis, which was not at an arteriovenous crossing. All three patients developed a branch retinal vein occlusion at the site of inflammation. These patients had no other evidence of intraocular inflammation, including vitritis, retinitis, retinal vasculitis, or choroiditis, nor was there any systemic disorder associated with inflammation, infection, or coagulation identified. Focal retinal phlebitis appears to be an uncommon and unique entity that produces macular edema and ultimately branch retinal vein occlusion. In our patients, the focal phlebitis and venous occlusion did not occur at an arteriovenous crossing, which is the typical site for branch retinal venous occlusive disease. This suggests that our cases represent a distinct clinical entity, which starts with a focal abnormality in the wall of a retinal venule, resulting in surrounding exudation and, ultimately, ends with branch retinal vein occlusion.

Commentary: Online Reviews and Other Digital Marketing Strategies.

PubMed

Levin, Roger P

2017-02-01

As getting patient reviews posted on online sites appears problematic for periodontal practices, the author urges periodontists to encourage patients to review their practices online on Yelp and other sites. The more positive online reviews practices receive, the higher the rankings on review sites, which will translate into more website visits and, ultimately, more new patient appointments.

Consumer Health Informatics: Promoting Patient Self-care Management of Illnesses and Health.

PubMed

Jung, Minsoo

Consumer health informatics (CHI) is propelling important changes for medical providers and the lives of patients through information and communications technology. Independently, medical consumers seek, collect, and use health information for decision making. However, when constructing a CHI-based medical platform, high technology must be applied in a fully understandable and usable format for both health care providers and consumers. This study examines the present status of CHI and its effect on medical consumers. For the development of CHI, we discuss the need for tailored health communications and capacity building with chronic patients at the medical center. First, empowerment is a key characteristic needed for medical consumer health care management. However, promoting patient self-care management of illnesses and health is necessary to create conjugation where cooperation with medical service providers is possible. Also, establishing a health care delivery system that will support cooperation is necessary. Second, tailored health communications can uniquely construct the health information of patients, which prevents unnecessary or excessive information from leading patients to confused and inappropriate decisions. Ultimately, through the present environment of health communication, the innovation of a consumer health care information system has become the tide of the times and the positive effect of improved health can be expected.

Improving low health literacy and patient engagement: A social ecological approach.

PubMed

McCormack, Lauren; Thomas, Veronica; Lewis, Megan A; Rudd, Rima

2017-01-01

This article posits four principal objectives related to the overarching goal of broadening the conceptualization of health literacy. We propose a social ecological approach to health literacy and patient engagement by illustrating how this multilevel approach offers an array of strategic options for interventions. A social ecological approach supports a broader understanding of health literacy that aligns with increased patient engagement. The ecological model highlights the importance of context, demonstrates how health literacy and patient engagement are inextricably connected, and gives rise to strategies to enhance them both. We illustrate the five multilevel intervention strategies for addressing low health literacy and promoting patient engagement: accumulation, amplification, facilitation, cascade, and convergence strategies. In addition, we provide a theoretical foundation to facilitate the development of interventions to enhance health literacy and ultimately increase patient engagement. The practice implications of adopting a broader social ecological perspective to address low health literacy shifts the field from thinking about individual educational interventions to how individual interventions may be augmented or supported by interventions at additional levels of influence. The potential benefit of adopting a multilevel intervention approach is that combining interventions could produce synergies that are greater than interventions that only utilize one level of influence. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Recent Progress in the Diagnosis and Treatment of Ovarian Cancer

PubMed Central

Jelovac, Danijela; Armstrong, Deborah K.

2013-01-01

Epithelial ovarian cancer is the most lethal of the gynecologic malignancies, largely due to the advanced stage at diagnosis in most patients. Screening strategies using ultrasound and the cancer antigen (CA) 125 tumor marker are currently under study and may lower stage at diagnosis but have not yet been shown to improve survival. Women who have inherited a deleterious mutation in the BRCA1 or BRCA2 gene and those with the Lynch syndrome (hereditary nonpolyposis colorectal cancer) have the highest risk of developing ovarian cancer but account for only approximately 10% of those with the disease. Other less common and less well-defined genetic syndromes may increase the risk of ovarian cancer, but their contribution to genetic risk is small. A clear etiology for sporadic ovarian cancer has not been identified, but risk is affected by reproductive and hormonal factors. Surgery has a unique role in ovarian cancer, as it is used not only for diagnosis and staging but also therapeutically, even in patients with widely disseminated, advanced disease. Ovarian cancer is highly sensitive to chemotherapy drugs, particularly the platinum agents, and most patients will attain a remission with initial treatment. Recent advances in the delivery of chemotherapy using the intraperitoneal route have further improved survival after initial therapy. Although the majority of ovarian cancer patients will respond to initial chemotherapy, most will ultimately develop disease recurrence. Chemotherapy for recurrent disease includes platinum-based, multiagent regimens for women whose disease recurs more than 6 to 12 months after the completion of initial therapy and sequential single agents for those whose disease recurs earlier. New targeted biologic agents, particularly those involved with the vascular endothelial growth factor pathway and those targeting the poly (ADP-ribose) polymerase (PARP) enzyme, hold great promise for improving the outcome of ovarian cancer. PMID:21521830

Phenylketonuria: dietary and therapeutic challenges.

PubMed

Giovannini, M; Verduci, E; Salvatici, E; Fiori, L; Riva, E

2007-04-01

PKU subjects need special attention in the definition of optimal supplementation of nutrients, which may be insufficient in relation to the type of diet and may otherwise manifest symptoms of deficit. In particular, it is necessary to pay great attention to the long-chain polyunsaturated fatty acid (LC-PUFA) levels in relation to correct development of the central nervous system. On the basis of numerous beneficial effects currently known, a permanent supplementation with LC-PUFAs, in particular with docosahexaenoic acid, should be considered. Moreover, new formulas, Phe-free peptides, and 'modulated' amino acid preparations might help in preventing nutritional deficiencies and imbalances, with the ultimate aim of improving growth. New strategies--such as supply of tetrahydrobiopterin--need to be optimized in terms of targets, patients and expected outcomes.

The ENCCA-WP7/EuroSarc/EEC/PROVABES/EURAMOS 3rd European Bone Sarcoma Networking Meeting/Joint Workshop of EU Bone Sarcoma Translational Research Networks; Vienna, Austria, September 24-25, 2015. Workshop Report.

PubMed

Kager, Leo; Whelan, Jeremy; Dirksen, Uta; Hassan, Bass; Anninga, Jakob; Bennister, Lindsey; Bovée, Judith V M G; Brennan, Bernadette; Broto, Javier M; Brugières, Laurence; Cleton-Jansen, Anne-Marie; Copland, Christopher; Dutour, Aurélie; Fagioli, Franca; Ferrari, Stefano; Fiocco, Marta; Fleuren, Emmy; Gaspar, Nathalie; Gelderblom, Hans; Gerrand, Craig; Gerß, Joachim; Gonzato, Ornella; van der Graaf, Winette; Hecker-Nolting, Stefanie; Herrero-Martín, David; Klco-Brosius, Stephanie; Kovar, Heinrich; Ladenstein, Ruth; Lancia, Carlo; LeDeley, Marie-Cecile; McCabe, Martin G; Metzler, Markus; Myklebost, Ola; Nathrath, Michaela; Picci, Piero; Potratz, Jenny; Redini, Françoise; Richter, Günther H S; Reinke, Denise; Rutkowski, Piotr; Scotlandi, Katia; Strauss, Sandra; Thomas, David; Tirado, Oscar M; Tirode, Franck; Vassal, Gilles; Bielack, Stefan S

2016-01-01

This report summarizes the results of the 3rd Joint ENCCA-WP7, EuroSarc, EEC, PROVABES, and EURAMOS European Bone Sarcoma Network Meeting, which was held at the Children's Cancer Research Institute in Vienna, Austria on September 24-25, 2015. The joint bone sarcoma network meetings bring together European bone sarcoma researchers to present and discuss current knowledge on bone sarcoma biology, genetics, immunology, as well as results from preclinical investigations and clinical trials, to generate novel hypotheses for collaborative biological and clinical investigations. The ultimate goal is to further improve therapy and outcome in patients with bone sarcomas.

Challenges and perspective of drug repurposing strategies in early phase clinical trials.

PubMed

Kato, Shumei; Moulder, Stacy L; Ueno, Naoto T; Wheler, Jennifer J; Meric-Bernstam, Funda; Kurzrock, Razelle; Janku, Filip

2015-01-01

Despite significant investments in the development of new agents only 5% of cancer drugs entering Phase I clinical trials are ultimately approved for routine clinical cancer care. Drug repurposing strategies using novel combinations of previously tested anticancer agents could reduce the cost and improve treatment outcomes. At MD Anderson Cancer Center, early phase clinical trials with drug repurposing strategies demonstrated promising outcomes in patients with both rare and common treatment refractory advanced cancers. Despite clinical efficacy advancing drug repurposing strategies in the clinical trial trajectory beyond early phase studies has been challenging mainly due to lack of funding and interest from the pharmaceutical industry. In this review, we delineate our experience and challenges with drug repurposing strategies.

Medulloblastoma initiation and spread: Where neurodevelopment, microenvironment and cancer cross pathways.

PubMed

Martirosian, Vahan; Chen, Thomas C; Lin, Michelle; Neman, Josh

2016-12-01

Medulloblastomas are the most common malignant pediatric brain tumors. Over the past several decades, a wide range of tumor-centric studies have identified genes and their regulators within signaling pathways that promote medulloblastoma growth. This review aims to raise awareness that transdisciplinary research between developmental neurobiology and cancer foundations can advance our current understanding of how the nervous system contributes to medulloblastomas. By leveraging current advances in neurodevelopment, microenvironment (including secreted neuropeptides), neurotransmitters, and axon guidance cues, we can uncover novel mechanisms used by the nervous system to promote medulloblastoma growth and spread. This will ultimately result in development of improved strategies for cancer prevention and treatment of pediatric patients with this devastating disease. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Tube thoracostomy: the struggle to the "standard of care".

PubMed

Monaghan, Sean F; Swan, Kenneth G

2008-12-01

Tube thoracostomy for thoracic injuries has been standard for only the last 40 years. Its theoretic roots trace back to World War II, where the goal of treatment was restoration of intrathoracic organ function. Thoracentesis was used to evacuate the hemopneumothorax resulting from chest trauma and that compromised pulmonary function. Experience gained in military and civilian hospitals contributed to the development of tube thoracostomy as an alternative treatment for patients with chest trauma. Progress stalled due to technologic problems and unacceptable complications associated with tube thoracostomy use during the Korean War. Technology improved, however, as did the success of thoracostomy, and it eventually become the standard of care, first in the civilian community and, ultimately, in the Vietnam War.

All the World's a Stage: Facilitating Discovery Science and Improved Cancer Care through the Global Alliance for Genomics and Health.

PubMed

Lawler, Mark; Siu, Lillian L; Rehm, Heidi L; Chanock, Stephen J; Alterovitz, Gil; Burn, John; Calvo, Fabien; Lacombe, Denis; Teh, Bin Tean; North, Kathryn N; Sawyers, Charles L

2015-11-01

The recent explosion of genetic and clinical data generated from tumor genome analysis presents an unparalleled opportunity to enhance our understanding of cancer, but this opportunity is compromised by the reluctance of many in the scientific community to share datasets and the lack of interoperability between different data platforms. The Global Alliance for Genomics and Health is addressing these barriers and challenges through a cooperative framework that encourages "team science" and responsible data sharing, complemented by the development of a series of application program interfaces that link different data platforms, thus breaking down traditional silos and liberating the data to enable new discoveries and ultimately benefit patients. ©2015 American Association for Cancer Research.

[Treatment of idiopathic facial pain following implant placement].

PubMed

Gorisse, E; de Jongh, A; Hassan, B

2010-02-01

A 39-year-old woman suffered from chronic a-typicalfacial pain and complaints associated with Post Traumatic Stress Disorder. The pain originated from the surgical removal of a residual tooth root under an oral implant and the stress symptoms were the consequences of the pain. Eventually, these problems had led to dismissalfrom work and family problems. She was unable to attend her dentist for a periodic oral survey due to extreme fear. Pharmacologic treatment, acupuncture, homeopathy and hypnotherapy had not improved her condition. Treatment aimed at coping with the memories of the oral treatment using 'eye movement desensitization and reprocessing' ultimately led to decline of complaints. This case report demonstrates that an oral problem may disrupt a patient's life and how psychotherapy can complete medical treatment.

Combination treatment of pediatric coats' disease: a bicenter study in Taiwan.

PubMed

Lin, Chun-Ju; Chen, San-Ni; Hwang, Jiunn-Feng; Yang, Chung-May

2013-01-01

To present the clinical outcome of different combination treatment modalities in pediatric Coats' disease in two Taiwan medical centers. A retrospective review of clinical records was done of pediatric patients with Coats' disease treated at National Taiwan University Hospital and Changhua Christian Hospital. Data regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications were recorded. Changes in vision and retinal status with the different methods of treatment were specifically evaluated. From 2005 through 2011, 10 eyes of 9 patients were treated under the diagnosis of Coats' disease. The clinical manifestations varied from localized vascular abnormalities with subretinal fluid and hard exudates to extensive detachment with massive exudates and retinal hemorrhage. The main treatment modalities include argon laser photocoagulation, micropulse laser, and cryotherapy. The adjunctive therapies included intravitreal triamcinolone, bevacizumab, and ranibizumab. The mean follow-up was 40.50 ± 20.52 months (range: 14 to 72 months). Best corrected visual acuity at last follow-up was light perception to 1.0 (20/20 Snellen). Anatomic improvement was achieved in 9 eyes (90%). Visual improvement was noted in 7 eyes (70%), visual stabilization in 2 eyes (20%), and visual deterioration in 1 eye (10%). Vitreous fibrosis evolving into tractional retinal detachment occurred in 1 patient receiving cryotherapy combined with intravitreal bevacizumab injections. No enucleation was ultimately necessary. Pediatric Coats' disease varies greatly in severity. Carefully selected treatment modalities can improve most eyes with different conditions. Intravitreal anti-vascular endothelial growth factor agents may act as useful adjuncts to improve anatomic and functional outcome. Cryotherapy combined with the intravitreal bevacizumab injection in severe cases of exudative retinal detachment may carry the risk of vitreoretinal traction and tractional retinal detachment.

Physiological and brain activity after a combined cognitive behavioral treatment plus video game therapy for emotional regulation in bulimia nervosa: a case report.

PubMed

Fagundo, Ana Beatriz; Via, Esther; Sánchez, Isabel; Jiménez-Murcia, Susana; Forcano, Laura; Soriano-Mas, Carles; Giner-Bartolomé, Cristina; Santamaría, Juan J; Ben-Moussa, Maher; Konstantas, Dimitri; Lam, Tony; Lucas, Mikkel; Nielsen, Jeppe; Lems, Peter; Cardoner, Narcís; Menchón, Jose M; de la Torre, Rafael; Fernandez-Aranda, Fernando

2014-08-12

PlayMancer is a video game designed to increase emotional regulation and reduce general impulsive behaviors, by training to decrease arousal and improve decision-making and planning. We have previously demonstrated the usefulness of PlayMancer in reducing impulsivity and improving emotional regulation in bulimia nervosa (BN) patients. However, whether these improvements are actually translated into brain changes remains unclear. The aim of this case study was to report on a 28-year-old Spanish woman with BN, and to examine changes in physiological variables and brain activity after a combined treatment of video game therapy (VGT) and cognitive behavioral therapy (CBT). Ten VGT sessions were carried out on a weekly basis. Anxiety, physiological, and impulsivity measurements were recorded. The patient was scanned in a 1.5-T magnetic resonance scanner, prior to and after the 10-week VGT/CBT combined treatment, using two paradigms: (1) an emotional face-matching task, and (2) a multi-source interference task (MSIT). Upon completing the treatment, a decrease in average heart rate was observed. The functional magnetic resonance imaging (fMRI) results indicated a post-treatment reduction in reaction time along with high accuracy. The patient engaged areas typically active in healthy controls, although the cluster extension of the active areas decreased after the combined treatment. These results suggest a global improvement in emotional regulation and impulsivity control after the VGT therapy in BN, demonstrated by both physiological and neural changes. These promising results suggest that a combined treatment of CBT and VGT might lead to functional cerebral changes that ultimately translate into better cognitive and emotional performances.

Current state of biomarker development for clinical application in epithelial ovarian cancer

PubMed Central

Moore, Richard G.; MacLaughlan, Shannon; Bast, Robert C.

2011-01-01

Each year in the United States over 15,000 women die of epithelial ovarian cancer (EOC)and 22,000 are diagnosed with the disease. The incidence of ovarian cancer has remained stable over the past decade however, survival rates have improved steadily. Increases in survival rates can be attributed to the advances in surgical management, development of effective cytotoxic drugs and the route of administration of chemotherapy. Ovarian cancer survival rates could also be improved through screening and early detection. Disappointingly, effective screening methods have not been established and continue to be elusive. Historically the goal of a screening test was to achieve a positive predictive value (PPV) greater than 10% in order be considered cost effective and have an acceptable risk for the population being screened. Despite the inability of currently available screening algorithms to achieve the desired PPV there may be an advantage in producing a stage migration to lower stages at the time of diagnoses, thereby resulting in improved survival. Equally important recent studies have demonstrated that women who have their initial surgery performed by gynecologic oncologists, and women who have their surgeries at centers experienced in the treatment of ovarian cancer have higher survival rates. For these reasons it is essential that all women at high risk for ovarian cancer receive their initial care by gynecologic oncologists and at centers with multidisciplinary teams experienced in the optimal care of ovarian cancer patients. With this in mind, methods that facilitate the accurate triage of women who will ultimately be diagnosed with ovarian cancer could play a significant role in improving survival rates for these patients. This review article will examine the current state of biomarker use in ovarian cancer screening, risk assessment and for monitoring ovarian cancer patients. PMID:19879639

Physiological and Brain Activity After a Combined Cognitive Behavioral Treatment Plus Video Game Therapy for Emotional Regulation in Bulimia Nervosa: A Case Report

PubMed Central

Fagundo, Ana Beatriz; Via, Esther; Sánchez, Isabel; Jiménez-Murcia, Susana; Forcano, Laura; Soriano-Mas, Carles; Giner-Bartolomé, Cristina; Santamaría, Juan J; Ben-Moussa, Maher; Konstantas, Dimitri; Lam, Tony; Lucas, Mikkel; Nielsen, Jeppe; Lems, Peter; Cardoner, Narcís; Menchón, Jose M; de la Torre, Rafael

2014-01-01

Background PlayMancer is a video game designed to increase emotional regulation and reduce general impulsive behaviors, by training to decrease arousal and improve decision-making and planning. We have previously demonstrated the usefulness of PlayMancer in reducing impulsivity and improving emotional regulation in bulimia nervosa (BN) patients. However, whether these improvements are actually translated into brain changes remains unclear. Objective The aim of this case study was to report on a 28-year-old Spanish woman with BN, and to examine changes in physiological variables and brain activity after a combined treatment of video game therapy (VGT) and cognitive behavioral therapy (CBT). Methods Ten VGT sessions were carried out on a weekly basis. Anxiety, physiological, and impulsivity measurements were recorded. The patient was scanned in a 1.5-T magnetic resonance scanner, prior to and after the 10-week VGT/CBT combined treatment, using two paradigms: (1) an emotional face-matching task, and (2) a multi-source interference task (MSIT). Results Upon completing the treatment, a decrease in average heart rate was observed. The functional magnetic resonance imaging (fMRI) results indicated a post-treatment reduction in reaction time along with high accuracy. The patient engaged areas typically active in healthy controls, although the cluster extension of the active areas decreased after the combined treatment. Conclusions These results suggest a global improvement in emotional regulation and impulsivity control after the VGT therapy in BN, demonstrated by both physiological and neural changes. These promising results suggest that a combined treatment of CBT and VGT might lead to functional cerebral changes that ultimately translate into better cognitive and emotional performances. PMID:25116416

Precision Oncology and Genetic Risk Information: Exploring Patients' Preferences and Responses

Cancer.gov

Dr. Jada Hamilton is an Assistant Member at Memorial Sloan Kettering Cancer Center, as well as an Assistant Attending Psychologist in the Behavioral Sciences Service, Department of Psychiatry and Behavioral Sciences and in the Clinical Genetics Service, Department of Medicine at Memorial Hospital in New York, New York.  She leads a program of research at the intersection of behavioral science, cancer prevention, and genomics, with the goal of translating advances in genetic and genomic medicine into improved cancer care that is of high quality, aligned with patient preferences, and ultimately improves public health.  Dr. Hamilton is also currently leading a study to assess how patients and their families respond to inherited risk information that is revealed as part of tumor sequencing (funded through a Mentored Research Scholar Grant from the American Cancer Society), as well as studies to evaluate alternative models for offering genetic counseling and testing to patients with cancer, and to examine the effects of novel breast cancer genetic risk feedback on patients’ decision-making, psychological, and behavioral outcomes. Prior to joining the faculty of Memorial Sloan Kettering, Dr. Hamilton received a BA in Genetics and Psychology from Ohio Wesleyan University (2004), an MA and PhD in Social and Health Psychology from Stony Brook University (2006, 2009), and an MPH from the Mailman School of Public Health at Columbia University (2010).  She also completed a postdoctoral fellowship as part of the National Cancer Institute’s Cancer Prevention Fellowship Program.

True survival benefit of lung transplantation for cystic fibrosis patients: the Zurich experience.

PubMed

Hofer, Markus; Benden, Christian; Inci, Ilhan; Schmid, Christoph; Irani, Sarosh; Speich, Rudolf; Weder, Walter; Boehler, Annette

2009-04-01

Lung transplantation is the ultimate therapy for end-stage cystic fibrosis (CF) lung disease; however, the debate continues as to whether lung transplantation improves survival. We report post-transplant outcome in CF at our institution by comparing 5-year post-transplant survival with a calculated 5-year survival without lung transplantation, using a predictive 5-year survivorship model, and describe pre-transplant parameters influencing transplant outcome. CF patients undergoing lung transplantation at our center were included (1992 to 2007). Survival rates were calculated and compared, and univariate and multivariate Cox regression analyses were used for statistical assessment. Eighty transplants were performed in CF patients, 11 (13.8%) of whom were children. Mean age at transplant was 26.2 years (95% confidence interval: 24.4 to 28.0). The Liou raw score at transplant was -20 (95% confidence interval: -16 to -24), resulting in an estimated 5-year survival without transplantation of 33 +/- 14%, compared with a 5-year post-transplant survival of 68.2 +/- 5.6%. Further improvement was noted in the recent transplant era (since 2000), with a 5-year survival of 72.7 +/- 7.3%. Univariate analysis revealed that later year of transplant and diagnosis of diabetes influenced survival positively. Pediatric age had no negative impact. In the multivariate analysis, only diabetes influenced survival, in a positive manner. Lung transplantation performed at centers having experience with the procedure can offer a true survival benefit to patients with end-stage CF lung disease.

Leveraging the trusted clinician: increasing retention in disease management through integrated program delivery.

PubMed

Frazee, Sharon Glave; Sherman, Bruce; Fabius, Raymond; Ryan, Pamela; Kirkpatrick, Patricia; Davis, Jeffery

2008-10-01

Disease management's (DM's) value largely depends on achieving and maintaining participation. Simply being enrolled in a program does not guarantee engaged participation by enrollees, a necessary factor to achieve the improved health outcomes and subsequent reduced health care costs that are the ultimate objective of DM. The objective of this study is to test the hypothesis that an integrated disease management (IDM) protocol (patent-pending), which combines telephonic-delivered disease management (TDM) with a worksite-based primary care center and pharmacy delivery, yields higher patient retention rates than traditional remote DM alone. An earlier study of the IDM protocol found that integrating a worksite-based primary care and pharmacy delivery system with traditional telephonic-based DM substantially increased contact, enrollment, and engagement rates compared to traditional stand-alone telephonic DM. This prospective cohort study tracks contact and enrollment rates for persons assigned to either IDM or traditional TDM protocols and compares participation rates at 6- and 12-month intervals as well as measures of continued retention in the DM program. The IDM protocol showed a significant improvement in participation persistence over traditional TDM. Integrating a worksite-based primary care and pharmacy delivery system led by "trusted clinicians at the workplace"trade mark with traditional telephonic-based DM not only increases contact and enrollment rates, but also results in higher patient engagement and retention. These improvements in participation are expected to result in improved outcomes for a larger proportion of the target population than traditional telephonic DM.

Urologic sequelae of childhood genitourinary trauma and abuse in men: principles of recognition with fifteen case illustrations.

PubMed

McCarty, T; Roberts, L W; Hendrickson, K

1996-05-01

Providing urologic care to men who have been traumatized during childhood may be especially challenging because of the extent, severity, and unusual character of their urogenital problems. Recognition of past trauma entails attentiveness to patients' background and behaviors. As illustrated through these 15 cases, patients who present with too many past surgeries, too many unremitting urologic complaints, too little sexual function and too few genital parts, sexual impulses that are too strong, sexualized conduct in clinical settings, and self-destructive behaviors surrounding sexuality may have experienced trauma in the past. While empirical studies are necessary to demonstrate the ultimate utility of these categories, appreciation of these clinical indications improves the urologic care provided to traumatized men in four ways: by elucidating unusual and unusually recalcitrant urologic complaints, thereby clarifying clinical decisions; by allowing for appropriate use of psychiatric consultation; by promoting a better understanding of the sequelae of trauma in men; and by alleviating the discomfort naturally felt by urologists and their staff when caring for these difficult, multiproblem patients.

Emerging indications for extracorporeal membrane oxygenation in adults with respiratory failure.

PubMed

Abrams, Darryl; Brodie, Daniel

2013-08-01

Recent advances in technology have spurred the increasing use of extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure. However, this accounts for only a small percentage of patients with respiratory failure. We envision the application of ECMO in many other forms of respiratory failure in the coming years. Patients with less severe forms of acute respiratory distress syndrome, for instance, may benefit from enhanced lung-protective ventilation with the very low tidal volumes made possible by direct carbon dioxide removal from the blood. For those in whom hypercapnia predominates, extracorporeal support will allow for the elimination of invasive mechanical ventilation in some cases. The potential benefits of ECMO may be further enhanced by improved techniques, which facilitate active mobilization. Although ECMO for these and other expanded applications is under active investigation, it has yet to be proven beneficial in these settings in rigorous controlled trials. Ultimately, with upcoming and future technological advances, there is the promise of true destination therapy, which could lead to a major paradigm shift in the management of respiratory failure.