Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience.

PubMed

Lalezari, Sepehr; Musielak, Matthew C; Broun, Lisa A; Curry, Trace W

2018-06-01

We present our experience with same-day discharge (without an overnight stay) after laparoscopic sleeve gastrectomy (SG) in 821 consecutive patients from 2011 to 2015. This is the largest series published to date of patients undergoing ambulatory surgery for such a procedure. To review our outcomes from ambulatory SG over 52 months to determine if SG can be safely performed in the ambulatory setting. Ambulatory surgery center. Retrospective review of all consecutive patients undergoing ambulatory SG from January 2011 to April 2015. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and admission to the hospital after discharge was reviewed up to 30 days from surgery. From January 2011 to April 2015, 821 consecutive patients underwent SG. Nineteen 30-day complications occurred in the series, 17 of them requiring admission to the hospital. Of the 19 cases, gastric leaks accounted for 7, intr-aabdominal abscess for 4, and dehydration/nausea/vomiting for 4; 4 were due to other causes. Complication and readmission rates at 30 days were 2.3% and 2.1%, respectively. Follow-up at 30 days was 98.4%. With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that SG may be suitable for the outpatient setting. Experience and comfort with bariatric surgery is essential on the part of the operating surgeon to ensure good outcomes. Our low overall readmission and complication rate portends to the feasibility of laparoscopic SG as a safe outpatient procedure. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Nationwide use and outcomes of ambulatory surgery in morbidly obese patients in the United States.

PubMed

Rosero, Eric B; Joshi, Girish P

2014-05-01

To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. Retrospective, propensity-matched cohort study. Academic medical center. The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65] min; P < 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed discharge were similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95% confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese. Copyright © 2014 Elsevier Inc. All rights reserved.

77 FR 37680 - Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-22

...] Medicare and Medicaid Programs; Application From the Accreditation Association for Ambulatory Health Care... of an application from the Accreditation Association for Ambulatory Health Care for continued... by CMS. The Accreditation Association for Ambulatory Health Care (AAAHC) current term of approval for...

75 FR 51464 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-20

... Surgery Facilities for Continued Deeming Authority for Ambulatory Surgical Centers AGENCY: Centers for... to approve without condition the American Association for Accreditation of Ambulatory Surgery... of Ambulatory Surgery Facilities on November 27, 2009. II. Deeming Applications Approval Process...

77 FR 70446 - Medicare and Medicaid Programs; Approval of the American Association for Accreditation of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-26

... Surgery Facilities (AAAASF) for Continuing CMS Approval of Its Ambulatory Surgical Center Accreditation... announces our decision to approve the American Association for Accreditation of Ambulatory Surgery... years or sooner as determined by CMS. American Association for Accreditation of Ambulatory Surgery...

The Efficacy of Lavender Aromatherapy in Reducing Preoperative Anxiety in Ambulatory Surgery Patients Undergoing Procedures in General Otolaryngology

PubMed Central

Wotman, Michael; Levinger, Joshua; Leung, Lillian; Kallush, Aron; Mauer, Elizabeth

2017-01-01

Background Preoperative anxiety is a common problem in hospitals and other health care centers. This emotional state has been shown to negatively impact patient satisfaction and outcomes. Aromatherapy, the therapeutic use of essential oils extracted from aromatic plants, may offer a simple, low‐risk and cost‐effective method of managing preoperative anxiety. The purpose of this study was to evaluate the efficacy of lavender aromatherapy in reducing preoperative anxiety in ambulatory surgery patients undergoing procedures in general otolaryngology. Methods A prospective and controlled pilot study was conducted with 100 patients who were admitted to New York‐Presbyterian/Weill Cornell Medical Center for ambulatory surgery from January of 2015 to August of 2015. The subjects were allocated to two groups; the experimental group received inhalation lavender aromatherapy in the preoperative waiting area while the control group received standard nursing care. Both groups reported their anxiety with a visual analog scale (VAS) upon arriving to the preoperative waiting area and upon departure to the operating room. Results According to a Welch's two sample t‐test, the mean reduction in anxiety was statistically greater in the experimental group than the control group (p = 0.001). Conclusion Lavender aromatherapy reduced preoperative anxiety in ambulatory surgery patients. This effect was modest and possibly statistically significant. Future research is needed to confirm the clinical efficacy of lavender aromatherapy. Level of Evidence 2b PMID:29299520

Clinical effects of a hypercaloric and hyperproteic oral suplemment enhanced with W3 fatty acids and dietary fiber in postsurgical ambulatory head and neck cancer patients.

PubMed

de Luis, D A; de la Fuente, B; Izaola, O; Martin, T; Cuellar, L; Terroba, M C

2014-11-30

Patients with head and neck cancer undergoing surgery have a high risk of nutritional complications. The aim of our study was to investigate the influence of a hypercaloric and hyperproteic oral supplement enriched with w3 FATTY ACIDS and fiber in clinical parameters in head and neck tumor postsurgical ambulatory patients with or without radiotherapy. A population of 37 ambulatory postsurgical patients with oral and laryngeal cancer was enrolled. At Hospital discharge postsurgical head and neck cancer patients were asked to consume two units per day of a hypercaloric and hyperproteic oral supplement for a twelve week period. The mean age was 63.8+/-7.1 years (16 female/ 21 males). Duration of supplementation was 98.1±19.1 days. A significant increase of albumin and transferrin levels was observed, in total group and in patients undergoing radiotherapy and without it. No differences were detected in weight and other anthropometric parameters in total group and in patients with radiotherapy during the protocol. Nevertheless, patients without radiotherapy showed a significant improvement of BMI; weight, fat free mass and fat mass. An omega 3 and fiber enriched formula improved seric protein levels in ambulatory postoperative head and neck cancer patients. Improvement of weight, fat mass and fat free mass was observed in patients whom not received radiotherapy during the follow up. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Case report. Candida lusitaniae peritonitis in a patient on continuous ambulatory peritoneal dialysis.

PubMed

Cinar, S; Nedret Koç, A; Taşkapan, H; Dogukan, A; Tokgöz, B; Utaş, C

2002-04-01

We report a case of Candida lusitania peritonitis in continuous ambulatory peritoneal dialysis. Since fluconazole therapy was not successful in this patient, the peritoneal catheter was removed and antifungal therapy continued, and the patient was then converted to haemodialysis. This treatment protocol was successful. We suggest that early peritoneal catheter removal should be considered in such cases.

German Ambulatory Care Physicians' Perspectives on Continuing Medical Education--A National Survey

ERIC Educational Resources Information Center

Kempkens, Daniela; Dieterle, Wilfried E.; Butzlaff, Martin; Wilson, Andrew; Bocken, Jan; Rieger, Monika A.; Wilm, Stefan; Vollmar, Horst C.

2009-01-01

Introduction: This survey aimed to investigate German ambulatory physicians' opinions about mandatory continuing medical education (CME) and CME resources shortly before the introduction of mandatory CME in 2004. Methods: A structured national telephone survey of general practitioners and specialists was conducted. Main outcome measures were…

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada

PubMed Central

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I fan

2017-01-01

Objectives: Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Methods: Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Results: Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Conclusion: Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice. PMID:28894501

Incorporating assessment and prescribing for ambulatory ailments skills into practice: An environmental scan of continuing education for pharmacist prescribing in Canada.

PubMed

Habicht, Dana; Ng, Sheila; Dunford, Drena; Shearer, Brenna; Kuo, I Fan

2017-01-01

Pharmacists in Canadian provinces are at different stages of applying prescribing legislation into practice. The purpose of this environmental scan was to examine differences in legislation, remuneration, professional uptake, continuing education requirements and continuing education resources relating to pharmacist prescribing for ambulatory ailments, with a focus on continuing education. Data were collected between May and December 2016 using websites and communication with provincial professional regulatory bodies, advocacy bodies, drug coverage programs and other organizations that offer continuing education for pharmacists. Training requirements to prescribe for ambulatory ailments vary provincially, including no training requirements, online tutorials and a comprehensive application process. Government-funded remuneration for prescribing services is absent in most provinces. Pharmacist uptake of the training required to obtain prescribing authority ranges from 30% to 100% of pharmacists. Continuing education programs on the topic of prescribing across the country include online courses, in-person courses, webinars, panel discussions and preparation courses. Many aspects of pharmacist prescribing for ambulatory ailments, including the style and content of continuing education resources, vary from province to province. Further research on this topic would help to determine the effect of these differences on the success of incorporating pharmacist prescribing into practice.

Changing Habits of Practice

PubMed Central

Bowen, Judith L; Salerno, Stephen M; Chamberlain, John K; Eckstrom, Elizabeth; Chen, Helen L; Brandenburg, Suzanne

2005-01-01

Purpose The majority of health care, both for acute and chronic conditions, is delivered in the ambulatory setting. Despite repeated proposals for change, the majority of internal medicine residency training still occurs in the inpatient setting. Substantial changes in ambulatory education are needed to correct the current imbalance. To assist educators and policy makers in this process, this paper reviews the literature on ambulatory education and makes recommendations for change. Methods The authors searched the Medline, Psychlit, and ERIC databases from 2000 to 2004 for studies that focused specifically on curriculum, teaching, and evaluation of internal medicine residents in the ambulatory setting to update previous reviews. Studies had to contain primary data and were reviewed for methodological rigor and relevance. Results Fifty-five studies met criteria for review. Thirty-five of the studies focused on specific curricular areas and 11 on ambulatory teaching methods. Five involved evaluating performance and 4 focused on structural issues. No study evaluated the overall effectiveness of ambulatory training or investigated the effects of current resident continuity clinic microsystems on education. Conclusion This updated review continues to identify key deficiencies in ambulatory training curriculum and faculty skills. The authors make several recommendations: (1) Make training in the ambulatory setting a priority. (2) Address systems problems in practice environments. (3) Create learning experiences appropriate to the resident's level of development. (4) Teach and evaluate in the examination room. (5) Expand subspecialty-based training to the ambulatory setting. (6) Make faculty development a priority. (7) Create and fund multiinstitutional educational research consortia. PMID:16423112

Factors Affecting Resident Satisfaction in Continuity Clinic-a Systematic Review.

PubMed

Stepczynski, J; Holt, S R; Ellman, M S; Tobin, D; Doolittle, Benjamin R

2018-05-07

In recent years, with an increasing emphasis on time spent in ambulatory training, educators have focused attention on improving the residents' experience in continuity clinic. The authors sought to review the factors associated with physician trainee satisfaction with outpatient ambulatory training. A systematic literature review was conducted for all English language articles published between January 1980 and December 2016 in relevant databases, including Medline (medicine), CINAHL (nursing), PSYCHinfo (psychology), and the Cochrane Central Register of Controlled Clinical Trials. Search terms included internship and residency, satisfaction, quality of life, continuity of care, ambulatory care, and medical education. We included studies that directly addressed resident satisfaction in the ambulatory setting through interventions that we considered reproducible. Three hundred fifty-seven studies were reviewed; 346 studies were removed based on exclusion criteria with 11 papers included in the final review. Seven studies emphasized aspects of organizational structure such as block schedules, working in teams, and impact on resident-patient continuity (continuity between resident provider and patient as viewed from the provider's perspective). Four studies emphasized the importance of a dedicated faculty for satisfaction. The heterogeneity of the studies precluded aggregate analysis. Clinic structures that limit inpatient and outpatient conflict and enhance continuity, along with a dedicated outpatient faculty, are associated with greater resident satisfaction. Implications for further research are discussed.

Effects of a minor surgery on health related quality of life in children from different perspectives

PubMed

Brazo-Sayavera, Javier; Parejo-Cabezas, Inés M; Gusi, Narcís; Olivares, Pedro R

2018-01-01

To compare the health related quality of life (HRQoL) perceptions in parents and physician regarding the patient undergoing ambulatory surgery, and to analyse the evolution of HRQoL before and after the ambulatory surgery. 36 patients underwent ambulatory surgical interventions taken part in this study. The questionnaires EQ-5D-Y were administered to the patients and questionnaires EQ-5D-Y proxy to parents and physicians. Variable TTO was used. Statistical differences were found at baseline between answers of patients and physicians (p < 0.05). However, after surgery, answers of patients and proxies were similar. Paediatric patients undergone to a minor surgery improve HRQoL after the operation and this improvement goes on a month after the surgery. Copyright: © 2018 SecretarÍa de Salud

The Ambulatory Long-Block: An Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP)

PubMed Central

Schauer, Daniel P.; Diers, Tiffiny; Mathis, Bradley R.; Neirouz, Yvette; Boex, James R.; Rouan, Gregory W.

2008-01-01

Introduction Historical bias toward service-oriented inpatient graduate medical education experiences has hindered both resident education and care of patients in the ambulatory setting. Aim Describe and evaluate a residency redesign intended to improve the ambulatory experience for residents and patients. Setting Categorical Internal Medicine resident ambulatory practice at the University of Cincinnati Academic Health Center. Program Description We created a year-long continuous ambulatory group-practice experience separated from traditional inpatient responsibilities called the long block as an Accreditation Council for Graduate Medical Education Educational Innovations Project. The practice adopted the Chronic Care Model and residents received extensive instruction in quality improvement and interprofessional teams. Program Evaluation The long block was associated with significant increases in resident and patient satisfaction as well as improvement in multiple quality process and outcome measures. Continuity and no-show rates also improved. Discussion An ambulatory long block can be associated with improvements in resident and patient satisfaction, quality measures, and no-show rates. Future research should be done to determine effects of the long block on education and patient care in the long term, and elucidate which aspects of the long block most contribute to improvement. PMID:18612718

Using patient classification systems to identify ambulatory care costs.

PubMed

Karpiel, M S

1994-11-01

Ambulatory care continues to increase as a percentage of total hospital revenue. Until recently, reimbursement for ambulatory care was provided on a cost basis. However, payers are attempting to exert more control over reimbursement for ambulatory care. The Health Care Financing Administration, for example, is expanding the use of prospective payment to cover more forms of outpatient care. Thus, in order to ensure the financial viability of their organizations, healthcare financial managers will need cost-accounting tools, such as patient classification systems, to ascertain the direct and indirect costs of emergency or outpatient visits and thereby to refine pricing, contracting, staffing, productivity, and profitability analyses for ambulatory care.

Pediatric ambulatory anesthesia.

PubMed

August, David A; Everett, Lucinda L

2014-06-01

Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. The relative merits of caudal and dorsal penile nerve block for pain after circumcision are also discussed. Copyright © 2014 Elsevier Inc. All rights reserved.

Associations Between the Continuity of Ambulatory Care of Adult Diabetes Patients in Korea and the Incidence of Macrovascular Complications.

PubMed

Gong, Young-Hoon; Yoon, Seok-Jun; Seo, Hyeyoung; Kim, Dongwoo

2015-07-01

The goal of this study was to identify association between the continuity of ambulatory care of diabetes patients in South Korea (hereafter Korea) and the incidence of macrovascular complications of diabetes, using claims data compiled by the National Health Insurance Services of Korea. This study was conducted retrospectively. The subjects of the study were 43 002 patients diagnosed with diabetes in 2007, who were over 30 years of age, and had insurance claim data from 2008. The macrovascular complications of diabetes mellitus were limited to ischemic heart disease and ischemic stroke. We compared the characteristics of the patients in whom macrovascular complications occurred from 2009 to 2012 to the characteristics of the patients who had no such complications. Multiple logistic regression was used to assess the effects of continuity of ambulatory care on diabetic macrovascular complications. The continuity of ambulatory diabetes care was estimated by metrics such as the medication possession ratio, the quarterly continuity of care and the number of clinics that were visited. Patients with macrovascular complications showed statistically significant differences regarding sex, age, comorbidities, hypertension, dyslipidemia and continuity of ambulatory diabetes care. Visiting a lower number of clinics reduced the odds ratio for macrovascular complications of diabetes. A medication possession ratio below 80% was associated with an increased odds ratio for macrovascular complications, but this result was of borderline statistical significance. Diabetes care by regular health care providers was found to be associated with a lower occurrence of diabetic macrovascular complications. This result has policy implications for the Korean health care system, in which the delivery system does not work properly.

Pharmacokinetics of single-dose oral ciprofloxacin in patients undergoing chronic ambulatory peritoneal dialysis.

PubMed Central

Shalit, I; Greenwood, R B; Marks, M I; Pederson, J A; Frederick, D L

1986-01-01

The prevention and treatment of peritonitis in patients undergoing peritoneal dialysis is often complicated by several factors, including nephrotoxicity, requirement for hospitalization, parenteral antibiotic therapy, and infection caused by resistant microorganisms. Ciprofloxacin, a new carboxyquinolone derivative, may offer the advantages of oral administration, a broad spectrum of antibacterial activity, and safety for the management of these patients. The pharmacokinetics of ciprofloxacin in serum and peritoneal fluid of eight adult patients undergoing chronic ambulatory peritoneal dialysis (CAPD) were investigated. Each patient ingested a single 750-mg dose of ciprofloxacin, and drug concentrations were measured by high-pressure liquid chromatography in serum and peritoneal fluid for 48 h after the dose. Serum concentrations reached a mean peak of 3.6 micrograms/ml 1 to 2 h after the oral dose. The mean terminal serum half-life was 16.8 h, and the mean peritoneal fluid/serum concentration ratio was 0.64. The mean peak ciprofloxacin concentration in peritoneal fluid was 1.3 micrograms/ml, and the bioactivity of the drug in peritoneal fluid was confirmed. These data indicated that therapeutic concentrations of ciprofloxacin against bacterial pathogens commonly associated with peritonitis in CAPD patients may be achievable in the peritoneal fluid after oral administration to patients undergoing CAPD. In addition, the pharmacokinetic data provide guidelines for further clinical studies of oral ciprofloxacin in CAPD patients. PMID:2944477

Curvularia lunata, a rare fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD); a rare case report.

PubMed

Subramanyam, Haritha; Elumalai, Ramprasad; Kindo, Anupma Jyoti; Periasamy, Soundararajan

2016-01-01

Peritonitis is an inflammation of the peritoneum that occurs in patients with end-stage renal disease (ESRD) treated by peritoneal dialysis. Fungal peritonitis is a dreaded complication of peritoneal dialysis. Curvularia lunata is known to cause extra renal disease like endocarditis, secondary allergic bronchopulmonary aspergillosis and endophthalmitis. This case report presents a case of continuous ambulatory peritoneal dialysis peritonitis with this disease and its management. This case is of a 45-year-old man, presented with ESRD, secondary to diabetic nephropathy. After 3 months of hemodialysis the patient was put on continuous ambulatory peritoneal dialysis (CAPD). Local Examination at catheter site showed skin excoriation and purulent discharge. Further peritoneal dialysis (PD) fluid analysis showed neutrophilic leukocytosis and diagnosis of Curvularia lunata PD peritonitis.

Redesigning the regulatory framework for ambulatory care services in New York.

PubMed

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

2014-12-01

Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients. While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers' understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path. Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery. © 2014 Milbank Memorial Fund.

Use of an Automated Mobile Phone Messaging Robot in Postoperative Patient Monitoring.

PubMed

Anthony, Chris A; Lawler, Ericka A; Ward, Christina M; Lin, Ines C; Shah, Apurva S

2018-01-01

Mobile phone messaging software robots allow clinicians and healthcare systems to communicate with patients without the need for human intervention. The purpose of this study was to (1) describe a method for communicating with patients postoperatively outside of the traditional healthcare setting by utilizing an automated software and mobile phone messaging platform and to (2) evaluate the first week of postoperative pain and opioid use after common ambulatory hand surgery procedures. The investigation was a prospective, multicenter investigation of patient-reported pain and opioid usage after ambulatory hand surgery. Inclusion criteria included any adult with a mobile phone capable of text messaging, who was undergoing a common ambulatory hand surgical procedure at one of three tertiary care institutions. Participants received daily, automated text messages inquiring about their pain level and how many tablets of prescription pain medication they had taken in the past 24 h. Initial 1-week response rate was assessed and compared between different patient demographics. Patient-reported pain and opioid use were also quantified for the first postoperative week. Statistical significance was set as p < 0.05. Forty-seven (n = 47) patients were enrolled in this investigation. Total response rate of both pain and opioid medication questions through 7 days was 88.3%. Pain trended down on a daily basis for the first postoperative week, with the highest levels of pain being reported in the first 48 h after surgery. Patients reported an average use of 15.9 ± 14.8 tablets of prescription opioid pain medication. We find that a mobile phone messaging software robot allows for effective data collection of postoperative pain and pain medication use. Patients undergoing common ambulatory hand procedures utilized an average of 16 tablets of opioid medication in the first postoperative week.

Variability in opioid prescribing for children undergoing ambulatory surgery in the United States.

PubMed

Van Cleve, William C; Grigg, Eliot B

2017-09-01

We attempted to describe the opioid prescribing patterns for ambulatory pediatric surgery in the United States from 2007 to 2014. Retrospective database review. Operating room ambulatory encounters as determined by the Truven Health Marketscan Commercial Claims and Encounters database. A total of 929,874 ambulatory surgical encounters were identified in patients <18years of age and, of these, 439,286 encounters generated an analgesic prescription. N/A MEASUREMENTS: The analgesic prescription was described in terms of the type of opioid along with the inclusion of acetaminophen and/or NSAIDs. The probability of receiving a post-operative analgesic prescription increased with age, ranging from 18.2% of infants to 71.7% of teens. Acetaminophen with codeine (APAP/C) was the most common drug for infants (63.8%), while acetaminophen with hydrocodone (APAP/H) was the most common analgesic prescription for teens (53.6%). APAP/C and APAP/H were the predominant drugs used for all procedure types. Substantial variability in analgesic prescribing at the level of the procedure performed, both in terms of the probability of receiving a prescription and in which drugs were prescribed. We observed significant age and procedure-based variability in opioid prescribing following pediatric ambulatory surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

[Ambulatory laparoscopic cholecystectomy by minilaparoscopy versus traditional multiport ambulatory laparoscopic cholecystectomy. Prospective randomized trial].

PubMed

Planells Roig, Manuel; Arnal Bertomeu, Consuelo; Garcia Espinosa, Rafael; Cervera Delgado, Maria; Carrau Giner, Miguel

2016-02-01

Difference analysis of ambulatorization rate, pain, analgesic requirements and daily activities recovery in patients undergoing laparoscopic cholecystectomy with standard multiport access (CLMP) versus a minilaparoscopic, 3mm size, technique. Prospective randomized trial of 40 consecutive patients undergoing laparoscopic cholecystectomy. Comparison criteria included predictive ultrasound factors of difficult cholecystectomy, previous history of complicated biliary disease and demographics. Results are analyzed in terms of ambulatorization rate, pain, analgesic requirements, postoperative recovery, technical difficulty, hemorrhage intensity, overnight stay, readmission rate and total or partial conversion. Both procedures were similar in surgery time, technical score and hemorrhage score. MLC was associated with similar ambulatorization rate, 85%, and over-night stay 15%, with only 15% partial conversion rate. MLC showed less postoperative pain (P=.026), less analgesic consumption (P=.006) and similar DAR (P=.879). MLC is similar to CLMP in terms of ambulatorization with less postoperative pain and analgesic requirements without differences in postoperative recovery. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

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

PubMed

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

2014-05-01

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

[Cataract surgery under topical anesthesia with oral anticoagulants].

PubMed

Wirbelauer, C; Weller, A; Häberle, H; Pham, D T

2004-09-01

Approximately 14 % of cataract surgery patients receive blood-thinning agents. In a prospective study, the influence of oral anticoagulants on intraoperative and postoperative hemorrhages in patients undergoing cataract surgery in topical anesthesia was investigated. 128 patients presenting for cataract surgery under oral anticoagulation were included. The mean preoperative prothrombin time was 39 +/- 18 %. Most patients (81 %) continued their oral anticoagulation (prothrombin time 34 +/- 13 %). All surgeries were performed in topical anesthesia. In 9 patients (7 %) an ocular hemorrhagic event was observed. These were not sight-threatening and resorbed spontaneously within a few days. Only one patient (0.8 %) had a slight hemorrhage in the anterior chamber. There were no differences (P > 0.05) between patients with or without hemorrhagic complications in the postoperative visual acuity, the intraocular pressure, the prothrombin time or the discontinuation of oral anticoagulants. Cataract surgery in topical anesthesia under oral anticoagulation did not increase the risk of sight-threatening hemorrhages. The continuation of oral anticoagulation seems particularly indicated for ambulatory cataract surgery.

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

PubMed

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

2018-01-01

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

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

PubMed

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

2016-09-01

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

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

PubMed

Mawar, Shashi; Gupta, Sanjay; Mahajan, Sandeep

2012-08-01

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

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

PubMed Central

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

2017-01-01

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

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting.

PubMed

Vadivelu, Nalini; Kai, Alice M; Kodumudi, Vijay; Berger, Jack M

2016-01-01

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

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

PubMed

Epplen, Kelly T

2014-08-15

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

Functional Decline in Children Undergoing Selective Dorsal Rhizotomy after Age 10

ERIC Educational Resources Information Center

MacWilliams, Bruce A.; Johnson, Barbara A.; Shuckra, Amy L.; D'Astous, Jacques L.

2011-01-01

Aim: To compare function and gait in a group of children older than most children who received selective dorsal rhizotomy (SDR) with age- and function-matched peers who received either orthopedic surgery or no surgical intervention. Method: A retrospective study examined ambulatory children with diplegic cerebral palsy, aged between 10 years and…

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

PubMed Central

Kabali, Conrad; Xie, Xuanqian; Higgins, Caroline

2017-01-01

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

Determinants of Slow Walking Speed in Ambulatory Patients Undergoing Maintenance Hemodialysis

PubMed Central

Matsuzawa, Ryota; Kutsuna, Toshiki; Yamamoto, Shuhei; Yoneki, Kei; Harada, Manae; Ishikawa, Ryoma; Watanabe, Takaaki; Yoshida, Atsushi

2016-01-01

Walking ability is significantly lower in hemodialysis patients compared to healthy people. Decreased walking ability characterized by slow walking speed is associated with adverse clinical events, but determinants of decreased walking speed in hemodialysis patients are unknown. The purpose of this study was to identify factors associated with slow walking speed in ambulatory hemodialysis patients. Subjects were 122 outpatients (64 men, 58 women; mean age, 68 years) undergoing hemodialysis. Clinical characteristics including comorbidities, motor function (strength, flexibility, and balance), and maximum walking speed (MWS) were measured and compared across sex-specific tertiles of MWS. Univariate and multivariate logistic regression analyses were performed to examine whether clinical characteristics and motor function could discriminate between the lowest, middle, and highest tertiles of MWS. Significant and common factors that discriminated the lowest and highest tertiles of MWS from other categories were presence of cardiac disease (lowest: odds ratio [OR] = 3.33, 95% confidence interval [CI] = 1.26–8.83, P<0.05; highest: OR = 2.84, 95% CI = 1.18–6.84, P<0.05), leg strength (OR = 0.62, 95% CI = 0.40–0.95, P<0.05; OR = 0.57, 95% CI = 0.39–0.82, P<0.01), and standing balance (OR = 0.76, 95% CI = 0.63–0.92, P<0.01; OR = 0.81, 95% CI = 0.68–0.97, P<0.05). History of fracture (OR = 3.35, 95% CI = 1.08–10.38; P<0.05) was a significant factor only in the lowest tertile. Cardiac disease, history of fracture, decreased leg strength, and poor standing balance were independently associated with slow walking speed in ambulatory hemodialysis patients. These findings provide useful data for planning effective therapeutic regimens to prevent decreases in walking ability in ambulatory hemodialysis patients. PMID:27018891

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

PubMed

Hirsch, Irl B; Verderese, Carol A

2017-11-01

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

Effect of pyrazinamide and probenecid on peritoneal urate transport kinetics during continuous ambulatory peritoneal dialysis.

PubMed

Spaia, S; Magoula, I; Tsapas, G; Vayonas, G

2000-01-01

We administered pyrazinamide (PZA) and probenecid (PB) --two well-known modulators of urate transport via the proximal tubules - to evaluate their impact on urate transport through the peritoneal membrane and to clarify mechanisms affecting peritoneal transport. A continuous ambulatory peritoneal dialysis (CAPD) unit in 2nd Hospital of IKA (Social Services Institute), Greece. In 20 stable CAPD patients, on the study day, a 4-hour, 2-L, 1.36% glucose exchange was performed (control exchange). Pyrazinamide 3 g was given orally and another identical exchange was performed (study exchange). The same protocol was repeated with 2 g PB. KtN, peritoneal clearances of urea, creatinine, and urate for each exchange, and mass transfer area coefficients (MTAC) for the three solutes and their dialysate-to-plasma concentration (D/P) ratios were used to estimate peritoneal transport. Administration of PZA resulted in decreased clearances and MTAC values for the three solutes. The D/P ratio decreased significantly only for urate, indicating a more intense influence of PZA on urate. After PB administration, clearances of urea, creatinine, and urate were increased. MTAC and DIP ratio increased significantly only for urate (p < 0.05), demonstrating an action similar to that exerted on renal tubules. These findings provide evidence that unrestricted diffusion is not the only transport mechanism in the case of urate, and demonstrate the existence of an active mechanism in peritoneal urate transport with a reabsorptive and, probably, a secretive component that resembles that of renal tubule urate transport. Attention should be given in the case of CAPD patients undergoing antituberculous (PZA) treatment: it might have a negative impact on urea, creatinine, and urate peritoneal transport rates.

Effects of a magnesium-free dialysate on magnesium metabolism during continuous ambulatory peritoneal dialysis.

PubMed

Shah, G M; Winer, R L; Cutler, R E; Arieff, A I; Goodman, W G; Lacher, J W; Schoenfeld, P Y; Coburn, J W; Horowitz, A M

1987-10-01

While the use of magnesium-containing compounds is usually contraindicated in dialysis patients, the risk of toxicity from hypermagnesemia can be reduced by lowering the magnesium concentration in dialysate. We examined the effects of a magnesium-free dialysate on both serum magnesium level and the peritoneal removal rate of magnesium over 12 weeks in 25 stable patients undergoing continuous ambulatory peritoneal dialysis (CAPD). After 2 weeks, the serum magnesium level decreased from 2.2 to 1.9 mg/dL (0.9 to 0.8 mmol/L) (P less than .02) and the peritoneal removal rate increased from 66 to 83 mg/d (2.8 to 3.5 mmol/d) (P less than .05), with both values remaining stable thereafter. There was a strong association between these parameters (r = -0.62, P less than .05), suggesting that the serum magnesium level decreased as a result of the initial increased peritoneal removal rate. For an additional 4-week period, a subgroup of nine patients received magnesium-containing, phosphate binding agents instead of those containing only aluminum. During this phase, serum inorganic phosphorus was well controlled. The serum magnesium level increased only from 1.8 to 2.5 mg/dL (0.7 to 1.0 mmol/L) (P less than .05), due in great part to the concomitant 41% rise in peritoneal magnesium removal from 91 to 128 mg/d (3.8 to 5.3 mmol/d) (P less than .05). No toxicity was noted during the entire 16-week study period, nor did serum calcium change. Thus, serum magnesium levels remained within an acceptable range as magnesium-containing phosphate binders were given through the use of magnesium-free peritoneal dialysate.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of Residual Renal Function Decline in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

PubMed Central

Szeto, Cheuk-Chun; Kwan, Bonnie Ching-Ha; Chow, Kai-Ming; Chung, Sebastian; Yu, Vincent; Cheng, Phyllis Mei-Shan; Leung, Chi-Bon; Law, Man-Ching; Li, Philip Kam-Tao

2015-01-01

♦ Background: Residual renal function (RRF) is an important prognostic indicator in continuous ambulatory peritoneal dialysis (CAPD) patients. We determined the predictors of RRF loss in a cohort of incident CAPD patients. ♦ Methods: We reviewed the record of 645 incident CAPD patients. RRF loss is represented by the slope of decline of residual glomerular filtration rate (GFR) as well as the time to anuria. ♦ Results: The average rate of residual GFR decline was -0.083 ± 0.094 mL/min/month. The rate of residual GFR decline was faster with a higher proteinuria (r = -0.506, p < 0.0001) and baseline residual GFR (r = -0.560, p < 0.0001). Multivariate analysis showed that proteinuria, baseline residual GFR, and the use of diuretics were independent predictors of residual GFR decline. Cox proportional hazard model showed that proteinuria, glucose exposure, and the number of peritonitis episodes were independent predictors of progression to anuria, while a higher baseline GFR was protective. Each 1 g/day of proteinuria is associated with a 13.2% increase in the risk of progressing to anuria, each 10 g/day higher glucose exposure is associated with a 2.5% increase in risk, while each peritonitis episode confers a 3.8% increase in risk. ♦ Conclusions: Our study shows that factors predicting the loss of residual solute clearance and urine output are different. Proteinuria, baseline residual GFR, and the use of diuretics are independently related to the rate of RRF decline in CAPD patients, while proteinuria, glucose exposure, and the number of peritonitis episodes are independent predictors for the development of anuria. The role of anti-proteinuric therapy and measures to prevent peritonitis episodes in the preservation of RRF should be tested in future studies. PMID:24497594

[Results of Longo's stapled hemorrhoidectomy in ambulatory surgery for grade III-IV hemorrhoids].

PubMed

Zaragozá, Cristóbal; García Fadrique, Alfonso; Castaño, Sergio; Villalba, Raúl; Bruna Esteban, Marcos; Redondo Cano, Carlos

2007-03-01

We prospectively evaluated the results of stapled hemorrhoidectomy for grade III-IV hemorrhoids in the ambulatory setting. Eighty-five consecutive patients with grade III-IV hemorrhoids, treated with the stapled technique with PPH01 in the Ambulatory Surgery Service of the General Hospital of Valencia were studied. Symptomatic, ASA I-II patients who agreed to undergo ambulatory surgery (vehicle, an accompanying adult, address with telephone, elevator, and basic hygiene conditions) were included. Thirty-nine percent were women and 61% were men, with a mean age of 47.6 years. A total of 85.9% had grade IV hemorrhoids and 14.1% had grade III. The average surgical time was 29.81+/- 12 minutes with a mean length of hospital stay of 168.88 +/- 88 minutes. Surgical complications consisted of 16 hemorrhages of the staple line (18.8%) and five hemorrhages due to mucous tear (5.9%). During the first 8 days the most frequent complication was pain (45.9%); only 7.1% of the patients required analgesia with opiates, and one patient required admission for 24 hours for analgesic purposes. Bleeding occurred in 10 patients, five of whom reported slight bleeding on defecation that stopped spontaneously; the remaining five required admission for 24 hours after surgical revision. Nine patients (10.6%) were admitted to the hospital for 24 hours, three due to intraoperative hemorrhage, five due to postoperative hemorrhage and one due to pain. A second intervention was required in 8.2%. Stapled hemorrhoidectomy can be applied in an ambulatory regime. Although technically simple with a short learning curve, this technique is not free of complications. Suitable patient selection and adequate perioperative information are indispensable for the ambulatory management of this disorder.

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

PubMed

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

2015-03-01

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

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

PubMed Central

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

2015-01-01

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

Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

PubMed

Kabré, Yvette B; Traoré, Idriss S S; Kaboré, Flavien A R; Ki, Bertille; Traoré, Alain I; Ouédraogo, Isso; Bandré, Emile; Wandaogo, Albert; Ouédraogo, Nazinigouba

2017-02-01

Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain. The family had to live within 1 hour of the hospital and be available by telephone. During the study period, a total of 1250 patients underwent surgery, of whom 515 were elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average age of 59.74 ± 41.57 months, actually underwent surgery. The principal indications for surgery were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

Prospective study of the factors associated with poor tolerance to ambulatory colonoscopy under conscious sedation.

PubMed

Grilo-Bensusan, Israel; Herrera Martín, Pablo; Jiménez-Mesa, Remedios; Aguado Álvarez, Valle

2018-04-01

conscious sedation with benzodiazepines and opiates for colonoscopy is a widespread clinical practice. to determine the patient's tolerance to colonoscopy and identify the factors associated with lower tolerance. a prospective, single-center, descriptive study of patients undergoing ambulatory colonoscopy under conscious sedation. The pain was assessed using a visual analogue scale with a score of 0 to 100 and also qualitatively. three hundred patients with a median age of 54 years completed the study (p25-75: 45-64); 138 were men (46%). Tolerance was good in 273 cases (91%). The median value of tolerance was 13 (p25-p75: 4-33). Pain was considered as mild in 215 (71.7%), moderate in 57 (19%) and intense in 28 (9.3%). In the univariate study, greater pain was associated with females, anxiety, the indication for the procedure, the length of time and difficulty of the examination, and the doses of sedatives. In the multivariate study, both the indication (OR 2.92, 95% CI = 1.03-8.2, p < 0.05) and the difficulty of the examination (OR 4.68, 95% CI = 1.6-13.6, p < 0.01) were significant. Complications were found in 16 patients (5.3%), although all of them were insignificant. tolerance of patients undergoing ambulatory colonoscopy under conscious sedation is good in most cases and complications are infrequent and minor. A worse tolerance to the test is associated with women patients, individuals with anxiety prior to colonoscopy, indication, difficult and longer exploration and lower doses of sedatives.

Anatomical and procedural determinants of ambulatory blood pressure lowering following catheter-based renal denervation using radiofrequency.

PubMed

Lauder, Lucas; Ewen, Sebastian; Tzafriri, Abraham R; Edelman, Elazer R; Cremers, Bodo; Kulenthiran, Saarraaken; Ukena, Christian; Linz, Dominik; Kindermann, Ingrid; Tsioufis, Costas; Scheller, Bruno; Böhm, Michael; Mahfoud, Felix

2018-03-02

Catheter-based renal sympathetic denervation (RDN) has been introduced to lower blood pressure (BP) and sympathetic activity in patients with uncontrolled hypertension with at best equivocal results. It has been postulated that anatomic and procedural elements introduce unaccounted variability and yet little is known of the impact of renal anatomy and procedural parameters on BP response to RDN. Anatomical parameters such as length and diameter were analyzed by quantitative vascular analysis and the prevalence of accessory renal arteries and renal artery disease were documented in 150 patients with resistant hypertension undergoing bilateral RDN using a mono-electrode radiofrequency catheter (Symplicity Flex, Medtronic). Accessory renal arteries and renal artery disease were present in 56 (37%) and 14 patients (9%), respectively. At 6-months, 24 h-ambulatory BP was reduced by 11/6 mm Hg (p < 0.001 for both). Change of systolic blood pressure (SBP) was not related to the presence of accessory renal arteries (p = 0.543) or renal artery disease (p = 0.598). Patients with at least one main renal artery diameter ≤ 4 mm had a more pronounced reduction of 24 h-ambulatory SBP compared to patients where both arteries were >4 mm (-19 vs. -10 mmHg; p = 0.038). Neither the length of the renal artery nor the number of RF ablations influenced 24 h-ambulatory BP reduction at 6 months. 24 h-ambulatory BP lowering was most pronounced in patients with smaller renal artery diameter but not related to renal artery length, accessory arteries or renal artery disease. Further, there was no dose-response relationship observed with increasing number of ablations. Because little is known of the impact of renal anatomy and procedural parameters on blood pressure (BP) response to renal denervation (RDN), anatomical and procedural data were analyzed in 150 patients undergoing bilateral RDN. BP lowering was most pronounced in patients with smaller renal artery diameter but not related to renal artery length, the presence of renal artery disease or accessory renal arteries. Further, there was no dose-response relationship observed with increasing number of ablations. Copyright © 2018. Published by Elsevier Inc.

Accreditation of ambulatory facilities.

PubMed

Urman, Richard D; Philip, Beverly K

2014-06-01

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

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

PubMed

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

2008-02-01

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

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

PubMed

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

2014-08-01

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

Virtual reality on mobile phones to reduce anxiety in outpatient surgery.

PubMed

Mosso, José L; Gorini, Alessandra; De La Cerda, Gustavo; Obrador, Tomas; Almazan, Andrew; Mosso, Dejanira; Nieto, Jesus J; Riva, Giuseppe

2009-01-01

When undergo ambulatory surgical operations, the majority of patients experience high level of anxiety. Different experimental studies have shown that distraction techniques are effective in reducing pain and related anxiety. Since Virtual reality (VR) has been demonstrated a good distraction technique, it has been repeatedly used in hospital contexts for reducing pain in burned patients, but it has never been used during surgical operations. With the present randomized controlled study we intended to verify the effectiveness of VR in reducing anxiety in patients undergoing ambulatory operations under local or regional anaesthesia. In particular, we measured the degree to which anxiety associated with surgical intervention was reduced by distracting patients with immersive VR provided through a cell phone connected to an HMD compared to a no-distraction control condition. A significant reduction of anxiety was obtained after 45 minutes of operation in the VR group, but not in the control group and, after 90 minutes, the reduction was larger in the experimental group than in other one. In conclusion, this study presents an innovative promising technique to reduce anxiety during surgical interventions, even if more studies are necessary to investigate its effectiveness in other kinds of operations and in larger numbers of patients.

Influence of Patient Characteristics on Success of Ambulatory Blood Pressure Monitoring

PubMed Central

Fravel, Michelle A.; Ernst, Michael E.; Weber, Cynthia A.; Dawson, Jeffrey D.; Carter, Barry L.; Bergus, George R.

2014-01-01

Study Objective To examine the influence of specific patient characteristics on the success of ambulatory blood pressure monitoring (ABPM). Design Retrospective analysis. Setting University-affiliated family care center. Patients Five hundred thirty patients (mean age 52.7 yrs, range 14–90 yrs) who were undergoing ABPM between January 1, 2001, and July 1, 2007. Measurement and Main Results Specific patient characteristics were identified through an electronic medical record review and then examined for association with ABPM session success rate. These patient characteristics included age, sex, weight, height, body mass index (BMI), occupation, clinic blood pressure, travel distance to clinic, and presence of diabetes mellitus or renal disease. The percentage of valid readings obtained during an ABPM session was analyzed continuously (0–100%), whereas overall session success was analyzed dichotomously (0–79% or 80–100%). Univariate and multivariate regression analyses were performed to examine the influence of patient characteristics on the percentage of valid readings and the overall likelihood of achieving a successful session. In the 530 patients, the average percentage of valid readings was 90%, and a successful ABPM session (≥ 80% valid readings) was obtained in 84.7% (449 patients). A diagnosis of diabetes was found to negatively predict ABPM session success (continuous variable analysis, p=0.019; dichotomous variable analysis, odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23–0.87, p=0.019), as did renal disease (continuous variable analysis, p=0.006; dichotomous variable analysis, OR 0.39, 95% CI 0.17–0.90, p=0.027) and increasing BMI (continuous variable analysis, p<0.001; dichotomous variable analysis, OR 0.78, 95% CI 0.65–0.93, p=0.005). Renal disease and BMI remained significant predictors in adjusted analyses. Conclusion For most patients, ABPM was successful; however, elevated BMI and renal disease were associated with less complete ABPM session results. Adaptation and individualization of the ABPM process may be necessary to improve results in these patients. PMID:18956994

The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status.

PubMed

Chevalier, S; Saoud, F; Gray-Donald, K; Morais, J A

2008-12-01

To estimate the prevalence of malnutrition in frail elders undergoing rehabilitation and the association between their nutritional status and physical function. Observational study of new participants undergoing ambulatory rehabilitation. Two Geriatric Day Hospitals (GDH) in Montreal, Quebec. 121 women and 61 men. Evaluation of nutritional status, body composition and physical function. The nutritional status was assessed with a composite index based on anthropometric measurements and serum albumin, as well as using the Mini Nutritional Assessment (MNA) questionnaire. Patients were classified as well-nourished, having mild/at risk of malnutrition or malnourished. Body composition was estimated by bioimpedance and handgrip strength and gait speed by standard methods. 13% of patients were found to be mildly malnourished, whereas 6% were malnourished. Malnourished patients were older and had worse cognition, lower BMI, and % body fat (all p<0.05). Malnourished patients and those with mild malnutrition had lower weight, triceps skinfold thickness, muscle and fat mass (all, p<0.003). Handgrip strength was different according to the nutritional status (p=0.034) and correlated with muscle mass (r=0.65, p<0.001). MNA classified 53% of patients as being at risk whereas 3% were malnourished and it correlated with gait speed (r=0.26, p=0.001). There is a high prevalence of patients in GDH at risk or with mild malnutrition. Being malnourished was associated with worse physical performance, which suggests that a nutritional intervention may be of benefit in improving their physical function.

Inhaled methoxyflurane for pain and anxiety relief during burn wound care procedures: an Australian case series.

PubMed

Wasiak, Jason; Mahar, Patrick D; Paul, Eldho; Menezes, Hana; Spinks, Anneliese B; Cleland, Heather

2014-02-01

Pain is a common and significant feature of burn injury. The use of intravenous opioids forms the mainstay of procedural burn pain management, but in an outpatient setting, the demand for novel agents that do not require parenteral access, are easy to administer and have a rapid onset are urgently needed. One such agent is the inhaled anaesthetic agent, methoxyflurane (MF). The aim of this study was to conduct a pilot investigation into the clinical effectiveness of MF inhaler on pain and anxiety scores in patients undergoing burn wound care procedures in an outpatient setting. A prospective case series involved recruiting patients undergoing a burn wound care procedure in an ambulatory burn care setting. Pain and anxiety were assessed using numerical rating scales. Overall, median numerical pain rating score was significantly higher post-dressing [pre-dressing: 2; interquartile range (IQR): 1-3 versus post-dressing: 3; IQR 1·5-4; P = 0·01], whereas median numerical anxiety score significantly reduced following the dressing (pre-dressing: 5; IQR 4-7 versus post-dressing: 2; IQR 1-2; P < 0·001). Our study suggests that there is a role for MF in the pain management armamentarium in those undergoing burn care procedures in the ambulatory care setting. However, there is an urgent need for larger case series and randomised controlled trials to determine its overall clinical effectiveness. © 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

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

PubMed

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

2000-01-01

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

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

PubMed

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

2012-02-01

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

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

PubMed

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

2008-01-01

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

Psychological reactions to continuous ambulatory peritoneal dialysis.

PubMed

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

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

Ambulatory consolidation chemotherapy for acute myeloid leukemia with antibacterial prophylaxis is associated with frequent bacteremia and the emergence of fluoroquinolone resistant E. Coli

PubMed Central

2013-01-01

Background Ambulatory consolidation chemotherapy for acute myeloid leukemia (AML) is frequently associated with bloodstream infections but the spectrum of bacterial pathogens in this setting has not been well-described. Methods We evaluated the emergence of bacteremias and their respective antibiotic susceptibility patterns in AML patients receiving ambulatory-based consolidation therapy. Following achievement of complete remission, 207 patients received the first cycle (C1), and 195 the second cycle (C2), of consolidation on an ambulatory basis. Antimicrobial prophylaxis consisted of ciprofloxacin, amoxicillin and fluconazole. Results There were significantly more positive blood cultures for E. coli in C2 as compared to C1 (10 vs. 1, p=0.0045); all E. coli strains for which susceptibility testing was performed demonstrated resistance to ciprofloxacin. In patients under age 60 there was a significantly higher rate of Streptococccus spp. bacteremia in C2 vs. C1; despite amoxicillin prophylaxis all Streptococcus isolates in C2 were sensitive to penicillin. Patients with Staphylococcus bacteremia in C1 had significantly higher rates of Staphylococcus bacteremia in C2 (p=0.009, OR=8.6). Conclusions For AML patients undergoing outpatient-based intensive consolidation chemotherapy with antibiotic prophylaxis, the second cycle is associated with higher rates of ciprofloxacin resistant E. coli, penicillin-sensitive Streptococcus bacteremias and recurrent Staphylococcus infections. PMID:23800256

Determinants of patient satisfaction in ambulatory oncology: a cross sectional study based on the OUT-PATSAT35 questionnaire

PubMed Central

2011-01-01

Background The aim of this study was to identify factors associated with satisfaction with care in cancer patients undergoing ambulatory treatment. We investigated associations between patients' baseline clinical and socio-demographic characteristics, as well as self-reported quality of life, and satisfaction with care. Methods Patients undergoing ambulatory chemotherapy or radiotherapy in 2 centres in France were invited, at the beginning of their treatment, to complete the OUT-PATSAT35, a 35 item and 13 scale questionnaire evaluating perception of doctors, nurses and aspects of care organisation. Additionally, for each patient, socio-demographic variables, clinical characteristics and self-reported quality of life using the EORTC QLQ-C30 questionnaire were recorded. Results Among 692 patients included between January 2005 and December 2006, only 6 were non-responders. By multivariate analysis, poor perceived global health strongly predicted dissatisfaction with care (p < 0.0001). Patients treated by radiotherapy (vs patients treated by chemotherapy) reported lower levels of satisfaction with doctors' technical and interpersonal skills, information provided by caregivers, and waiting times. Patients with primary head and neck cancer (vs other localisations), and those living alone were less satisfied with information provided by doctors, and younger patients (< 55 years) were less satisfied with doctors' availability. Conclusions A number of clinical of socio-demographic factors were significantly associated with different scales of the satisfaction questionnaire. However, the main determinant was the patient's global health status, underlining the importance of measuring and adjusting for self-perceived health status when evaluating satisfaction. Further analyses are currently ongoing to determine the responsiveness of the OUT-PATSAT35 questionnaire to changes over time. PMID:22204665

Assessment of pre and postoperative anxiety in patients undergoing ambulatory oral surgery in primary care

PubMed Central

Reyes-Gilabert, Eva; Luque-Romero, Luis-Gabriel; Bejarano-Avila, Gracia; Garcia-Palma, Alfonso; Rollon-Mayordomo, Angel

2017-01-01

Background To analyze the pre- and postoperative anxiety level in patients undergoing ambulatory oral surgery (AOS) in a primary healthcare center (PHC). Material and Methods Prospective and descriptive clinical study on 45 patients who underwent AOS procedures in the dental clinic of a public PHC of Spain between April and September 2015. Anxiety analysis was carried out with pre- and postoperative anxiety-state (STAI-S), anxiety-trait (STAI-T) and dental anxiety (MDAS) questionnaires. A descriptive, inferential and binary logistic regression analysis were performed for the variables age, sex, educational level, previous experience of oral treatment, type of oral surgery, degree of third molar impaction, surgical time, intraoperative complications, postoperative complications, and pain score with a visual analogue scale (VAS). Results The majority were female (57.8%) with a mean age of 33.5+9.6 years. The most frequent procedure was the lower third molar removal (82.2%). The mean pain score on the VAS was 1.6+1.8. The incidence of complications was low (7.8%). There was a statistically significant association between post- and preoperative anxiety (r=0.56, p<0.001) and a correlation between pain score and postoperative anxiety (Rho= -0.35, p=0.02). The likelihood of postoperative anxiety was related to preoperative anxiety (OR=1.3, p=0.03). Conclusions AOS in a HPC is safe and should be more encouraged in the public primary care. The emotional impact on users was relatively low, highlighting that the preoperative anxiety levels were higher than the postoperative ones. Psychological factors related to pre- and postoperative anxiety should be considered in the AOS carried out in PC. Key words:Anxiety, oral surgery, ambulatory surgery, primary care, STAI scale, postoperative pain. PMID:29053655

Zinc Supplementation Alters Plasma Aluminum and Selenium Status of Patients Undergoing Dialysis: A Pilot Study

PubMed Central

Guo, Chih-Hung; Chen, Pei-Chung; Hsu, Guoo-Shyng W.; Wang, Chia-Liang

2013-01-01

End stage renal disease patients undergoing long-term dialysis are at risk for abnormal concentrations of certain essential and non-essential trace metals and high oxidative stress. We evaluated the effects of zinc (Zn) supplementation on plasma aluminum (Al) and selenium (Se) concentrations and oxidative stress in chronic dialysis patients. Zn-deficient patients receiving continuous ambulatory peritoneal dialysis or hemodialysis were divided into two groups according to plasma Al concentrations (HA group, Al > 50 μg/L; and MA group, Al > 30 to ≤ 50 μg/L). All patients received daily oral Zn supplements for two months. Age- and gender-matched healthy individuals did not receive Zn supplement. Clinical variables were assessed before, at one month, and after the supplementation period. Compared with healthy subjects, patients had significantly lower baseline plasma Se concentrations and higher oxidative stress status. After two-month Zn treatment, these patients had higher plasma Zn and Se concentrations, reduced plasma Al concentrations and oxidative stress. Furthermore, increased plasma Zn concentrations were related to the concentrations of Al, Se, oxidative product malondialdehyde (MDA), and antioxidant enzyme superoxide dismutase activities. In conclusion, Zn supplementation ameliorates abnormally high plasma Al concentrations and oxidative stress and improves Se status in long-term dialysis patients. PMID:23609777

Risk stratification of ambulatory patients with advanced heart failure undergoing evaluation for heart transplantation.

PubMed

Kato, Tomoko S; Stevens, Gerin R; Jiang, Jeffrey; Schulze, P Christian; Gukasyan, Natalie; Lippel, Matthew; Levin, Alison; Homma, Shunichi; Mancini, Donna; Farr, Maryjane

2013-03-01

Risk stratification of ambulatory heart failure (HF) patients has relied on peak VO(2)<14 ml/kg/min. We investigated whether additional clinical variables might further specify risk of death, ventricular assist device (VAD) implantation (INTERMACS <4) or heart transplantation (HTx, Status 1A or 1B) within 1 year after HTx evaluation. We hypothesized that right ventricular stroke work index (RVSWI), pulmonary capillary wedge pressure (PCWP) and the model for end-stage liver disease-albumin score (MELD-A) would be additive prognostic predictors. We retrospectively collected data on 151 ambulatory patients undergoing HTx evaluation. Primary outcomes were defined as HTx, LVAD or death within 1 year after evaluation. Average age in our cohort was 55 ± 11.1 years, 79.1% were male and 39% had an ischemic etiology (LVEF 21 ± 10.5% and peak VO(2) 12.6 ± 3.5 ml/kg/min). Fifty outcomes (33.1%) were observed (27 HTxs, 15 VADs and 8 deaths). Univariate logistic regression showed a significant association of RVSWI (OR 0.47, p = 0.036), PCWP (OR 2.65, p = 0.007) and MELD-A (OR 2.73, p = 0.006) with 1-year events. Stepwise regression showed an independent correlation of RVSWI<5gm-m(2)/beat (OR 6.70, p < 0.01), PCWP>20 mm Hg (OR 5.48, p < 0.01), MELD-A>14 (OR 3.72, p< 0.01) and peak VO(2)<14 ml/kg/min (OR 3.36, p = 0.024) with 1-year events. A scoring system was developed: MELD-A>14 and peak VO(2)<14-1 point each; and PCWP>20 and RVSWI<5-2 points each. A cut-off at≥4 demonstrated a 54% sensitivity and 88% specificity for 1-year events. Ambulatory HF patients have significant 1-year event rates. Risk stratification based on exercise performance, left-sided congestion, right ventricular dysfunction and liver congestion allows prediction of 1-year prognosis. Our findings support early and timely referral for VAD and/or transplant. Copyright © 2013 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

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

PubMed Central

Sidhu, Ravindar S.; Walker, G. Ross

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

Ambulatory surgery centers best practices for the 90s.

PubMed

Hoover, J A

1994-05-01

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

Effect of provider volume on resource utilization for surgical procedures of the knee.

PubMed

Jain, Nitin; Pietrobon, Ricardo; Guller, Ulrich; Shankar, Anoop; Ahluwalia, Ajit S; Higgins, Laurence D

2005-05-01

Operating-room time and patient disposition on discharge are important determinants of healthcare resource utilization and cost. We examined the relation between these determinants and hospital/surgeon volume for anterior cruciate ligament (ACL) reconstruction and meniscectomy procedures. Patients undergoing ACL reconstruction (18,390 cases) and meniscectomy (123,012 cases) were extracted from the State Ambulatory Surgery Databases for the years 1997-2000. Surgeon and hospital volume were divided into low-, intermediate-, and high-volume categories. Multivariate logistic regression models were used to estimate the adjusted association between surgeon and hospital volume and patient discharge status and operating-room time. Patients undergoing ACL reconstruction or meniscectomy performed by low-volume surgeons were significantly more likely to be non-routinely discharged as compared to high-volume surgeons (adjusted odds ratio 3.5, 95% confidence interval 1.7-7.2 for ACL reconstruction; adjusted odds ratio 2.0, 95% confidence interval 1.6-2.3 for meniscectomy). The mean operating-room time for performing ACL reconstruction or meniscectomy was significantly higher in low- and intermediate-volume surgeons and hospitals as compared to high-volume surgeons and hospitals (p < or = 0.001). High-volume providers utilize healthcare resources more efficiently. Our findings may help surgeons and hospitals in optimizing resource utilization and cost for routinely-performed ambulatory surgery procedures.

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

PubMed Central

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

2015-01-01

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

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

PubMed

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

2016-06-01

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

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

PubMed

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

2015-07-01

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

Redesigning the Regulatory Framework for Ambulatory Care Services in New York

PubMed Central

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

2014-01-01

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

A case of bacterial peritonitis caused by Roseomonas mucosa in a patient undergoing continuous ambulatory peritoneal dialysis.

PubMed

Matsukuma, Yuta; Sugawara, Koji; Shimano, Shota; Yamada, Shunsuke; Tsuruya, Kazuhiko; Kitazono, Takanari; Higashi, Harumichi

2014-11-01

Bacterial peritonitis remains a life-threatening complication of peritoneal dialysis (PD). Roseomonas is a bacterial genus of pink-pigmented, oxidized, gram-negative coccobacilli that was first named in 1993. Importantly, Roseomonas mucosa exhibits antibiotic resistance, with significant resistance to cephalosporin, which is often selected as an empirical antibiotic regimen for peritonitis in PD patients. We herein report the case of a PD patient with bacterial peritonitis caused by Roseomonas mucosa that was fortunately identified using 16S rRNA gene sequencing and successfully treated with ciprofloxacin. Given that Roseomonas demonstrates resistance to a variety of antibiotics. The administration of empiric antibiotic therapy based on the recommendation of the International Society of Peritoneal Dialysis guidelines occasionally fails, leading to the aggravation of bacterial peritonitis. Hence, nephrologists should consider Roseomonas as one of the potential causative organisms of peritonitis, especially when gram-negative bacilli are resistant to cephalosporin and cannot be identified using standard laboratory methods.

Icodextrine and insulin resistance in continuous ambulatory peritoneal dialysis patients.

PubMed

Canbakan, Mustafa; Sahin, Gülizar Manga

2007-01-01

Insulin resistance is commonly observed in uremic patients. Glucose-based peritoneal dialysis solutions have long-term metabolic complications like hyperinsulinemia, hyperlipidemia, and obesity. The purpose of this study was to examine the insulin resistance in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with standard glucose and icodextrin containing solutions. The entire non diabetic CAPD patients of our center were studied: forty-four patients in all who were on CAPD treatment for 36.2 +/- 23.7 months. Twenty-seven of them (11 male and 16 female) with a mean age of 46 +/- 16 years were treated with standard glucose solutions (glucose group). The other 17 patients (10 male and 7 female) with a mean age of 49 +/- 16 years were treated with standard glucose solutions during the day and icodextrin dwell during the night, for a median of 12 +/- 6.3 months (icodextrin group). Morning fasting serum insulin levels were 20.59 +/- 17.86 in the glucose group and 10.15 +/- 6.87 in the icodextrin group (p = 0.0001). Homeostasis Model Assessment Method scores of the glucose group were significantly higher (4.8+/-4.1 vs 2.3+/- 1.7; p = 0.025) than the icodextrin group. A significant positive correlation of HOMA score with insulin, fasting plasma glucose, and triglyceride levels were found in HOMA (IR+) patients. Twenty patients of the icodextrin group (74%) and 15 patients of the glucose group (88%) were hypertensive, but there was no statistically significant difference between the two groups (p = 0.13). The groups showed no significant differences for body mass index and serum levels of glucose, total cholesterol, LDL cholesterol, VLDL cholesterol, HDL cholesterol, triglyceride, intact parathyroid hormone (iPTH), and fibrinogen. In conclusion, the use of icodextrin in the long nighttime dwell can reduce serum insulin levels and increase insulin sensitivity in CAPD patients.

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

PubMed

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

2011-01-01

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

The evolution of ambulatory ECG monitoring.

PubMed

Kennedy, Harold L

2013-01-01

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

A computerized resolution of scheduling conflicts.

PubMed

Bolinger, R E; McFarlane, M J

1989-01-01

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

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

PubMed

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

2004-08-01

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

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

PubMed

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

2016-12-20

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

Ambulatory surgery under local anesthesia for parathyroid adenoma: Feasibility and outcome.

PubMed

Benhami, A; Chuffart, E; Christou, N; Liva-Yonnet, S; Mathonnet, M

2017-12-21

The aim of this study was to evaluate the results of ambulatory parathyroid resection performed under local anesthesia (LA). Outpatients undergoing parathyroid adenoma resection by a focused approach under LA were included. Results were evaluated by intraoperative serum parathormone levels (ioPTH) and the balance of phosphate and calcium postoperatively, at 3 months, 1 year and at the point date. The quality of ambulatory care was evaluated by the number of cancelled interventions, the number of patients hospitalized after surgery or during the first postoperative month. The patient data manager of the institution carried out a medico-economic analysis. From 2005 to 2014, 129 patients met the inclusion criteria [women: 82% (sex ratio 1:5), median age: 72 years]. There was no morbidity for 98% of patients. Twelve patients had no statistically significant drop in ioPTH: two had persistent primary hyperparathyroidism (PHP). LA failed in four patients and PTH was late to normalize in six patients. Six patients had recurrent PHP (4.6%), of which two occurred four years after excision. Outpatient treatment was successful in 95%, without deprogramming or rehospitalization. The cost of the treatment under LA and on an outpatient basis was € 2014.90 (vs. € 2581.47 under general anesthesia and traditional hospitalization) CONCLUSION: Excision of single parathyroid adenomas can be performed under LA in an ambulatory setting without any major risk for the patient. The risk of recurrence after the focused approach requires regular laboratory monitoring for at least five years. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

The effect of race on postsurgical ambulatory medical follow-up among United States Veterans.

PubMed

Schonberger, Robert B; Dai, Feng; Brandt, Cynthia; Burg, Matthew M

2017-08-01

To investigate the association between self-identified black or African American race and the presence of ambulatory internal medicine follow-up in the year after surgery. Our hypothesis was that among US Veterans who presented for surgery, black or African American race would be associated with a decreased likelihood to receive ambulatory internal medicine follow-up in the year after surgery. Retrospective observational. All US Veterans Affairs hospitals. A total of 236,200 Veterans undergoing surgery between 2006 and 2011 who were discharged within 10 days of surgery and survived the full 1-year exposure period. None. Attendance at an internal medicine follow-up appointment within 1 year after surgery. After controlling for year of surgery, age, age ≥65 years, sex, Hispanic ethnicity, and number of inpatient days, black or African American patients were 11% more likely to lack internal medicine follow-up after surgery (adjusted odds ratio, 1.11; 95% confidence interval, 1.06-1.16). When accounting for geographic region, this difference remained significant at the Bonferoni-corrected P < .007 level only in the Midwest United States where black or African American patients were 28% more likely to lack medical follow-up in the year after surgery (odds ratio, 1.28; 95% confidence interval, 1.16-1.42; P < .0001). The disparity in ambulatory medical follow-up following surgery among black or African American vs nonblack or non-African American Veterans in the Midwest region deserves further study and may lead to important quality improvement initiatives aimed specifically at this population. Copyright © 2016 Elsevier Inc. All rights reserved.

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

PubMed Central

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

2017-01-01

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

Six-minute walk test predicts all-cause mortality and technique failure in ambulatory peritoneal dialysis patients.

PubMed

Shi, Yuanyuan; Zheng, Dongxia; Zhang, Lin; Yu, Zanzhe; Yan, Hao; Ni, Zhaohui; Qian, Jiaqi; Fang, Wei

2017-02-01

This study investigated the associated factors of 6-min walk test (6MWT) and its predictive value of outcome in patients undergoing peritoneal dialysis (PD). This is a single centre prospective observational cohort study. Stable ambulatory PD patients in our centre between 1 May 2010 and 30 April 2011 were enrolled in this study. All included subjects performed 6MWT, and 6-min walk distances (6MWDs) were recorded. Patients were divided into two groups according to 6MWD and prospectively followed up until death, cessation of PD or to the end of the study (30 September 2012). A total of 145 patients were enrolled, including 63 (43%) males. Multiple stepwise regression showed that age (β = -0.295, P = 0.001), diastolic blood pressure (DBP) (β = 0.292, P = 0.001), left ventricular ejection fraction (LVEF) (β = 0.198, P = 0.019) were independently associated with lower 6MWD. By the end of the study, six (8%) patients died in long 6MWD group while 15 (20%) died in the short 6MWD group, a significantly lower patient survival was observed in short 6MWD group (Log-rank = 4.983, P = 0.026). Patients with short 6MWD also showed inferior technique survival (Log-rank = 4.838, P = 0.028). There was no significant difference in peritonitis-free survival between the two groups (Log-rank = 0.801, P = 0.371). However, more patients in short 6MWD group had been transferred to hemodialysis due to peritonitis (25% vs 4.2%, P = 0.013). Age, diastolic blood pressure, LVEF are independent associated factors of 6MWD in patients undergoing PD. Having the advantages of easy applicability and safety, 6MWT may be proposed as an important predictor of outcome in ambulatory PD patients. © 2016 Asian Pacific Society of Nephrology.

Urologist ownership of ambulatory surgery centers and urinary stone surgery use.

PubMed

Hollingsworth, John M; Ye, Zaojun; Strope, Seth A; Krein, Sarah L; Hollenbeck, Ann T; Hollenbeck, Brent K

2009-08-01

To understand how physician ownership of ambulatory surgery centers (ASCs) relates to surgery use. Using the State Ambulatory Surgery Databases, we identified patients undergoing outpatient surgery for urinary stone disease in Florida (1998-2002). We empirically derived a measure of physician ownership and externally validated it through public data. We employed linear mixed models to examine the relationship between ownership status and surgery use. We measured how a urologist's surgery use varied by the penetration of owners within his local health care market. Owners performed a greater proportion of their surgeries in ASCs than nonowners (39.6 percent versus 8.0 percent, p<.001), and their utilization rates were over twofold higher ( p<.001). After controlling for patient differences, an owner averaged 16.32 (95 percent confidence interval [CI], 10.98-21.67; p<.001) more cases annually than did a nonowner. Further, for every 10 percent increase in the penetration of owners within a urologist's local health care market, his annual caseload increased by 3.32 (95 percent CI, 2.17-4.46; p<.001). These data demonstrate a significant association between physician ownership of ASCs and increased surgery use. While its interpretation is open to debate, one possibility relates to the financial incentives of ownership. Additional work is necessary to see if this is a specialty-specific phenomenon.

The incidence of un-indicated preoperative testing in a tertiary academic ambulatory center: a retrospective cohort study.

PubMed

Onuoha, Onyi C; Hatch, Michael B; Miano, Todd A; Fleisher, Lee A

2015-01-01

Despite existing evidence and guidelines advocating for appropriate risk stratification, ambulatory surgery in low-risk patients continues to be accompanied by a battery of routine tests prior to surgery. Using a single-center retrospective cohort study, we aimed to quantify the incidence of un-indicated preoperative testing in an academic ambulatory center by utilizing recommendations by the recently developed American Society of Anesthesiology (ASA) "Choosing Wisely" Top-5 list. We utilized data from the EPIC medical records of 3111 patients who had ambulatory surgery at the Hospital of the University of Pennsylvania during a 6-month period. Data were abstracted from laboratory studies- complete blood count, electrolyte panel, coagulation studies, and cardiac studies-stress test, and echocardiogram obtained within 30 days prior to surgery. Preoperative tests obtained from each patient were categorized into "indicated" (ASA ≥ 3) and "un-indicated" (ASA 1 and 2) tests, and percentages were reported. During the study period, 52.9 % (95 % confidence interval (CI) 37.6-66.4) of all patients had at least one un-indicated laboratory test performed preoperatively. Further analysis revealed variation in the incidence of preoperative ordering between tests; 73 % of all complete blood counts (CBCs), 70 % of all metabolic panels, and 49 % of all coagulation studies were considered un-indicated by "Top-5 List" criteria. Stated differently, of the patients included in the sample, 51 % of patients received an un-indicated CBC, 41 % an un-indicated metabolic panel, and 16 % un-indicated coagulation studies. Twelve percent of "any un-indicated preoperative test" were obtained from ASA 1 healthy patients. Of the 587 patients less than 36 years old, 331 (56 %) had at least one test that was deemed un-indicated. Forty-one patients had either an echocardiogram or stress test ordered and performed within 30 days of surgery. Of these, eight (19.5 %) studies were un-indicated as determined by chart review. The incidence of ordering "at least one un-indicated preoperative test" in low-risk patients undergoing low-risk surgery remains high even in academic tertiary institutions. In the emerging era of optimizing patient safety and financial accountability, further studies are needed to better understand the problem of overuse while identifying modifiable attitudes and institutional influences on perioperative practices among all stakeholders involved. Such information would drive the development of feasible interventions.

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

PubMed

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

2016-01-01

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

Single dose systemic acetaminophen to improve patient reported quality of recovery after ambulatory segmental mastectomy: A prospective, randomized, double-blinded, placebo controlled, clinical trial.

PubMed

De Oliveira, Gildasio S; Rodes, Meghan E; Bialek, Jane; Kendall, Mark C; McCarthy, Robert J

2017-11-15

Few systemic drug interventions are efficacious to improve patient reported quality of recovery after ambulatory surgery. We aimed to evaluate whether a single dose systemic acetaminophen improve quality of recovery in female patients undergoing ambulatory breast surgery. We hypothesized that patients receiving a single dose systemic acetaminophen at the end of the surgical procedure would have a better global quality of postsurgical recovery compared to the ones receiving saline. The study was a prospective randomized double blinded, placebo controlled, clinical trial. Healthy female subjects were randomized to receive 1 g single dose systemic acetaminophen at the end of the surgery or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test. The association between opioid consumption and quality of recovery was evaluated using Spearman rho. P < .05 was used to reject the null hypothesis for the primary outcome. Seventy subjects were randomized and sixty-five completed the study. Patients' baseline characteristics and surgical factors were similar between the study groups. There was a clinically significant difference in the global QoR-40 scores between the acetaminophen and the saline groups, median (IQR) of 189 (183 to 194) and 183 (175 to 190), respectively, P = .01. In addition, there was an inverse relationship (Spearman's rho= -0.33) between oral opioid consumption at home (oral morphine equivalents) and 24 hour postoperative quality of recovery, P = .007. A single dose of systemic acetaminophen improves patient reported quality of recovery after ambulatory breast surgery. The use of systemic acetaminophen is an efficacious strategy to improve patient perceived quality of postsurgical recovery and analgesic outcomes after hospital discharge for ambulatory breast surgery. © 2017 Wiley Periodicals, Inc.

Daily Energy Expenditure and Its Relation to Health Care Costs in Patients Undergoing Ambulatory Electrocardiographic Monitoring.

PubMed

George, Jason; Abdulla, Rami Khoury; Yeow, Raymond; Aggarwal, Anshul; Boura, Judith; Wegner, James; Franklin, Barry A

2017-02-15

Our increasingly sedentary lifestyle is associated with a heightened risk of obesity, diabetes, heart disease, and cardiovascular mortality. Using the recently developed heart rate index formula in 843 patients (mean ± SD age 62.3 ± 15.7 years) who underwent 24-hour ambulatory electrocardiographic (ECG) monitoring, we estimated average and peak daily energy expenditure, expressed as metabolic equivalents (METs), and related these data to subsequent hospital encounters and health care costs. In this cohort, estimated daily average and peak METs were 1.7 ± 0.7 and 5.5 ± 2.1, respectively. Patients who achieved daily bouts of peak energy expenditure ≥5 METs had fewer hospital encounters (p = 0.006) and median health care costs that were nearly 50% lower (p <0.001) than their counterparts who attained <5 METs. In patients whose body mass index was ≥30 kg/m 2 , there were significant differences in health care costs depending on whether they achieved <5 or ≥5 METs estimated by ambulatory ECG monitoring (p = 0.005). Interestingly, patients who achieved ≥5 METs had lower and no significant difference in their health care costs, regardless of their body mass index (p = 0.46). Patients with previous percutaneous coronary intervention who achieved ≥5 METs had lower health care costs (p = 0.044) and fewer hospital encounters (p = 0.004) than those who achieved <5 METs. In conclusion, average and peak daily energy expenditures estimated from ambulatory ECG monitoring may provide useful information regarding health care utilization in patients with and without previous percutaneous coronary intervention, irrespective of body habitus. Our findings are the first to link lower intensities of peak daily energy expenditure, estimated from ambulatory ECG monitoring, with increased health care utilization. Copyright © 2016 Elsevier Inc. All rights reserved.

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

PubMed

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

2017-07-01

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

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

NASA Technical Reports Server (NTRS)

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

2011-01-01

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

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

PubMed

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

2006-06-01

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

Unhealthy Competition: Consequences of Health Plan Choice in California Medicaid

PubMed Central

Chattopadhyay, Arpita; Bindman, Andrew B.

2010-01-01

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

New antithrombotic agents in the ambulatory setting.

PubMed

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

2014-12-01

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

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

PubMed Central

Moore, Jillian; Garcia, Pablo; Flood, David

2018-01-01

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

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

PubMed

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

2012-02-01

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

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

PubMed Central

Kuhn, Ingeborg M.; Wiederhold, Gio

1981-01-01

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

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

PubMed

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

2004-09-01

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

Improved pupil dilation with medication-soaked pledget sponges.

PubMed

Weddle, Celeste; Thomas, Nikki; Dienemann, Jacqueline

2013-08-01

Use of multiple preoperative drops for pupil dilation has been shown to be inexact, to delay surgery, and to cause dissatisfaction among perioperative personnel. This article reports on an evidence-based, quality improvement project to locate and appraise research on improved effectiveness and efficiency of mydriasis (ie, pupillary dilation), and the subsequent implementation of a pledget-sponge procedure for pupil dilation at one ambulatory surgery center. Project leaders used an evidence-based practice model to assess the problem, research options for improvement, define goals, and implement a pilot project to test the new dilation technique. Outcomes from the pilot project showed a reduced number of delays caused by poor pupil dilation and a decrease in procedure turnover time. The project team solicited informal feedback from preoperative nurses, which reflected increased satisfaction in preparing patients for cataract procedures. After facility administrators and surgeons accepted the procedure change, it was adopted for preoperative use for all patients undergoing cataract surgery at the ambulatory surgery center. Copyright © 2013 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Effectiveness of transmucosal sedation for special needs populations in the ambulatory care setting.

PubMed

Tetef, Sue

2014-12-01

Transmucosal is an alternative route for administering medications (ie, dexmedetomidine, midazolam, naloxone) that can be effective for procedural or moderate sedation in patients with special needs when other routes are not practical or are contraindicated. Special needs populations include children, older adults, pregnant and breast-feeding women, and people with disabilities or conditions that limit their ability to function and cope. Understanding the perioperative nurse's role in the care of patients receiving medications via the transmucosal route can lead to better clinical outcomes. Successful use of the transmucosal route requires knowledge of when to administer a medication, how often and how much of a medication should be administered, the onset and duration of action, the adverse effects or contraindications, and the key benefits. In addition, a case study approach suggests that transmucosal sedation can decrease patient stress and anxiety related to undergoing medical procedures or surgery in the ambulatory care setting. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Oral yeast colonization in peritoneal dialysis and hemodialysis patients and renal transplant recipients.

PubMed

Gulcan, Aynur; Gulcan, Erim; Keles, Mustafa; Aktas, Esin

2016-06-01

We aimed to investigate the frequency of oral yeast colonization (OYC) and the risk factors for patients who received continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis (HD) or were renal transplant recipients (RTRs). The patients admitted to the Nephrology Clinic at Ataturk University Medical School from January through April 2013 were included in the study. A questionnaire about risk factors was filled out, and swab cultures were taken from the tongue surface of each participant. OYC was detected in 32.1% of the RTRs, 40% of the HD patients, 20.9% of the CAPD patients, and 18% of the healthy control (HC) group. Of the 42 yeast strains isolated from the renal replacement therapy groups, 26 strains (61.9%) were Candida albicans, nine (21.4%) were Candida glabrata, two (4.7%) were Candida krusei, two (4.7%) were Candida kefyr, one (2.38%) was Candida parapsilosis, and two (4.7%) were Geotrichum candidum. Risk factors for OYC in the RTRs group included antibiotic use and the presence of dental prostheses; however, in patients with chronic renal failure undergoing CAPD, only the presence of dental prostheses was found to be a statistically significant risk factor. Although OYC was mostly detected in patients with chronic kidney disease (undergoing HD, a variety of isolated yeast strains in the RTRs was noted. The rates of OYC and isolated Candida species in CAPD were similar to those of the HC group. Copyright © 2016 Elsevier Ltd. All rights reserved.

PS1-10: How Can the Same Practice Be Classified as Having 2 and 900 MDs? NAMCS Data Collection in a Changing Ambulatory Care Environment

PubMed Central

Halley, Meghan; Gillespie, Katherine; Rendle, Katharine; Luft, Harold

2014-01-01

Background/Aims Since 1973, the National Ambulatory Medical Care Survey (NAMCS), administered by the National Center for Health Statistics (NCHS) has been widely used in studies of ambulatory care. With the growth in large multispecialty practices – including many members of the HMORN – there is a need to understand how NAMCS data are collected and whether current processes yield accurate and reliable data. NAMCS collects data from physicians about their practices and abstracts a sample of patient visit records. This study reports on the physician component. Methods In collaboration with NCHS, nine physicians were randomly sampled from a multispecialty clinic using standard NAMCS recruitment procedures; eight physicians were eligible and agreed to participate. Using their standard protocols, three Field Representatives (FRs) conducted NAMCS physician interviews while a trained ethnographer (MH, KR) observed and audio-recorded each interview. Transcripts and field notes were analyzed using a grounded theory approach to identify key themes. Results Data have been collected and analyzed. They are currently undergoing standard confidentiality review by NCHS. However, this process has been delayed due to the government shutdown. We fully anticipate that results will be released in time for presentation at the HMORN conference. Conclusions Though we are precluded from disseminating results at this time, we will provide a full report of our results in our HMORN conference presentation.

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

PubMed

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

2017-09-03

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

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

PubMed

Sadick, Neil S; Wasser, Samuel

2004-05-01

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

Assessment of the feasibility of an ultra-low power, wireless digital patch for the continuous ambulatory monitoring of vital signs.

PubMed

Hernandez-Silveira, Miguel; Ahmed, Kamran; Ang, Su-Shin; Zandari, Fahriya; Mehta, Tinaz; Weir, Rebecca; Burdett, Alison; Toumazou, Chris; Brett, Stephen J

2015-05-19

Vital signs are usually recorded at 4-8 h intervals in hospital patients, and deterioration between measurements can have serious consequences. The primary study objective was to assess agreement between a new ultra-low power, wireless and wearable surveillance system for continuous ambulatory monitoring of vital signs and a widely used clinical vital signs monitor. The secondary objective was to examine the system's ability to automatically identify and reject invalid physiological data. Single hospital centre. Heart and respiratory rate were recorded over 2 h in 20 patients undergoing elective surgery and a second group of 41 patients with comorbid conditions, in the general ward. Primary outcome measures were limits of agreement and bias. The secondary outcome measure was proportion of data rejected. The digital patch provided reliable heart rate values in the majority of patients (about 80%) with normal sinus rhythm, and in the presence of abnormal ECG recordings (excluding aperiodic arrhythmias such as atrial fibrillation). The mean difference between systems was less than ±1 bpm in all patient groups studied. Although respiratory data were more frequently rejected as invalid because of the high sensitivity of impedance pneumography to motion artefacts, valid rates were reported for 50% of recordings with a mean difference of less than ±1 brpm compared with the bedside monitor. Correlation between systems was statistically significant (p<0.0001) for heart and respiratory rate, apart from respiratory rate in patients with atrial fibrillation (p=0.02). Overall agreement between digital patch and clinical monitor was satisfactory, as was the efficacy of the system for automatic rejection of invalid data. Wireless monitoring technologies, such as the one tested, may offer clinical value when implemented as part of wider hospital systems that integrate and support existing clinical protocols and workflows. 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.

Case Report of a Patient With Idiopathic Hypersomnia and a Family History of Malignant Hyperthermia Undergoing General Anesthesia: An Overview of the Anesthetic Considerations.

PubMed

Aflaki, Sena; Hu, Sally; Kamel, Rami A; Chung, Frances; Singh, Mandeep

2017-05-01

The pathophysiologic underpinnings of idiopathic hypersomnia and its interactions with anesthetic medications remain poorly understood. There is a scarcity of literature describing this patient population in the surgical setting. This case report outlines the anesthetic considerations and management plan for a 55-year-old female patient with a known history of idiopathic hypersomnia undergoing an elective shoulder arthroscopy in the ambulatory setting. In addition, this case offers a unique set of considerations and conflicts related to the patient having a family history of malignant hyperthermia. A combined technique of general and regional anesthesia was used. Anesthesia was maintained with total intravenous anesthesia via the use of propofol and remifentanil. The depth of anesthesia was monitored with entropy. There were no perioperative complications.

Toward an integrated computerized patient record.

PubMed

Dole, T R; Luberti, A A

2000-04-01

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

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

PubMed

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

2016-04-01

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

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

PubMed

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

2007-01-01

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

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

PubMed

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

2018-01-01

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

[Management of iodine-131 ablation therapy for thyroid carcinoma in a patient on chronic hemodialysis].

PubMed

Zenasni, Nadia; Elkhayat, Salma; Taleb, Sara; Zamd, Mohammed; Medkouri, Ghizlaine; Benghanem Gharbi, Mohammed; Ramdani, Benyounes; Aschawa, Hind; Guensi, Amal

2015-04-01

Iodine-131 ablation therapy for thyroid cancer in the patient on chronic hemodialysis represents a real problem since the main route of elimination of radioiodine is urinary. There is no recommendation on the management of this treatment in the patient on hemodialysis. We report our experience of management of this treatment in a patient aged 38 years, undergoing hemodialysis for chronic renal failure, and who have been indicated the treatment with iodine-131 for papillary thyroid carcinoma high risk. After multidisciplinary discussions (nephrologists and specialists in nuclear medicine and radiation safety), it has been decided to treat the patient with continuous ambulatory peritoneal dialysis therapy (CAPD). Because of the low but continuous elimination of iodine in the case of CAPD, the patient received a reduced ablative (131)I dose of 1850 MBq, which is 30% of the usual dose delivered in subjects with normal renal function. The patient was hospitalized for four days in nuclear medicine unit and the (131)I radioactivity emitted from him was 2.5 μSv/h at one meter at his hospital discharge. In conclusion, CAPD in relay of hemodialysis is a technique of renal replacement therapy that can be suggested to minimize exposure to radioactivity to the patient, his family and the medical staff. Copyright © 2015 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.

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

PubMed

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

2016-11-02

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

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

PubMed

Asim, Muhammad

2016-11-01

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

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

PubMed

Kleinpeter, M A; Butt, A A

2001-01-01

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

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

PubMed

Uzunoglu, E; Sahin, A M

2017-06-01

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

Prophylaxis for mucositis induced by ambulatory chemotherapy: systematic review.

PubMed

Manzi, Natália de Melo; Silveira, Renata Cristina de Campos Pereira; dos Reis, Paula Elaine Diniz

2016-04-01

The aim of this study was to perform a systematic review of clinical trials covering interventions used as prophylaxis for oral mucositis induced by ambulatory antineoplastic chemotherapy. Oral mucositis in patients undergoing chemotherapy is a side effect that can impact the quality of treatment and can interfere with eating and therapeutic adherence. Quantitative systematic review. Relevant databases were searched, from January 2002-July 2013, by using the combination of the keywords mucositis, stomatitis, neoplasms, antineoplastic agents, drug therapy, prevention and control and chemotherapy. Two researchers independently read the titles and abstracts from every cross-reference. The quality of the included studies was analysed by the Jadad Scale and the Cochrane Collaboration Risk of Bias Tool. Data were extracted from the selected studies with a data collection form developed specifically for this purpose. Of the 23 controlled clinical trials that were identified in this study, five articles evaluated the use of oral cryotherapy to prevent oral mucositis and three studies analysed the prophylactic use of glutamine. Interventions of protocols for oral care, palifermin, allopurinol and chlorhexidine were evaluated by two articles each. Interventions of zinc sulphate, amifostine, chewing gum, sucralfate, recombination human intestinal trefoil factor, kefir and vitamin E were evaluated by one article each. There is strong evidence that cryotherapy can prevent oral mucositis arising from ambulatory treatment with 5-flurouracil chemotherapy. Other interventions, although showing positive results in preventing oral mucositis, require further study to confirm their conclusions. © 2015 John Wiley & Sons Ltd.

Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management

PubMed Central

White, Paul F.; Elvir Lazo, Ofelia Loani; Galeas, Lidia; Cao, Xuezhao

2017-01-01

The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer experiencing joint pain. The use of epidural local analgesia for perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients undergoing abdominal surgery. In a retrospective study involving over 390,000 outpatients more than 66 years of age who underwent minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. In a review of 11 million patients undergoing elective surgery from 2002 to 2011, both opioid overdoses and opioid dependence were found to be increasing over time. Opioid-dependent surgical patients were more likely to experience postoperative pulmonary complications, require longer hospital stays, and increase costs to the health-care system. The Centers for Disease Control and Prevention emphasized the importance of finding alternatives to opioid medication for treating pain. In the new clinical practice guidelines for back pain, the authors endorsed the use of non-pharmacologic therapies. However, one of the more widely used non-pharmacologic treatments for chronic pain (namely radiofrequency ablation therapy) was recently reported to have no clinical benefit. Therefore, this clinical commentary will review evidence in the peer-reviewed literature supporting the use of electroanalgesia and laser therapies for treating acute pain, cervical (neck) pain, low back pain, persistent post-surgical pain after spine surgery (“failed back syndrome”), major joint replacements, and abdominal surgery as well as other common chronic pain syndromes (for example, myofascial pain, peripheral neuropathic pain, fibromyalgia, degenerative joint disease/osteoarthritis, and migraine headaches). PMID:29333260

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

PubMed

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

2016-09-01

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

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

PubMed

Jovanović, Natasa; Lausević, Mirjana; Stojimirović, Biljana

2005-01-01

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

OUTPATIENT ANTERIOR CERVICAL DISCECTOMY: A FRENCH STUDY AND LITERATURE REVIEW.

PubMed

Gennari, Antoine; Mazas, Simon; Coudert, Pierre; Gille, Olivier; Vital, Jean-Marc

2018-06-11

In France, surgery for lumbar disc herniation is now being done in the outpatient ambulatory setting at select facilities. However, surgery for the cervical spine in this setting is controversial because of the dangers of neck hematoma. We wanted to share our experience with performing ambulatory anterior cervical discectomy in 30 patients at our facility. Since 2014, 30 patients (16 men, 14 women; mean age of 47.2 years) with cervical radiculopathy due to single-level cervical disc disease (19 at C5-C6 and 11 at C6-C7) were operated at our ambulatory surgery center. After anterior cervical discectomy, cervical disc replacement was performed in 13 patients and fusion in 17 patients. The mean operative time was 38minutes and the mean duration of postoperative monitoring was 7hours 30minutes. The patients stayed at the healthcare facility for an average of 10hours 10minutes. One female patient (3%) was transferred to a standard hospital unit due to a neurological deficit requiring surgical revision with no cause identified. Two patients (7%) were rehospitalized on Day 1 due to dysphagia that resolved spontaneously. Thus the "ambulatory success rate" was 90% (27/30). There were no other complications and the overall satisfaction rate was excellent (9.6/10). Outpatient anterior cervical discectomy is now widely performed in the United States. Ours is the first study of French patients undergoing this procedure. The complication rate was very low (< 2%) and even lower than patients treated in an inpatient hospital setting in comparative studies. Note that our patients were carefully selected for outpatient surgery as certain risk factors for complications have previously been identified (age, 3+levels, comorbidities / ASA> 2). No deaths in the first 30 days postoperative have been reported in the literature. Wound hematoma leading to airway compromise is rare in the ambulatory setting (0.2%). The few cases that occurred were detected early and the hematoma drained before the patient was discharged. Dysphagia is actually the most common complication (8% to 30%). Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. Our criteria are patients less than 65 years of age, single-level disease, ASA <2, and standard cervical morphology. The complication and readmission rates are low. Careful hemostasis combined with close postoperative monitoring for at least 6hours helps to reduce the risk of neck hematoma. Prevention of postoperative dysphagia must be a focus of the care provided. Copyright © 2018. Published by Elsevier Masson SAS.

A prospective observational study comparing a physiological scoring system with time-based discharge criteria in pediatric ambulatory surgical patients.

PubMed

Armstrong, James; Forrest, Helen; Crawford, Mark W

2015-10-01

Discharge criteria based on physiological scoring systems can be used in the postanesthesia care unit (PACU) to fast-track patients after ambulatory surgery; however, studies comparing physiological scoring systems with traditional time-based discharge criteria are lacking. The purpose of this study was to compare PACU discharge readiness times using physiological vs time-based discharge criteria in pediatric ambulatory surgical patients. We recorded physiological observations from consecutive American Society of Anesthesiologists physical status I-III patients aged 1-18 yr who were admitted to the PACU after undergoing ambulatory surgery in a tertiary academic pediatric hospital. The physiological score was a combination of the Aldrete and Chung systems. Scores were recorded every 15 min starting upon arrival in the PACU. Patients were considered fit for discharge once they attained a score ≥12 (maximum score, 14), provided no score was zero, with the time to achieve a score ≥12 defining the criteria-based discharge (CBD) time. Patients were discharged from the PACU when both the CBD and the existing time-based discharge (TBD) criteria were met. The CBD and TBD data were compared using Kaplan-Meier and log-rank analysis. Observations from 506 children are presented. Median (interquartile range [IQR]) age was 5.5 [2.8-9.9] yr. Median [IQR] CBD and TBD PACU discharge readiness times were 30 [15-45] min and 60 [45-60] min, respectively. Analysis of Kaplan-Meier curves indicated a significant difference in discharge times using the different criteria (hazard ratio, 5.43; 95% confidence interval, 4.51 to 6.53; P < 0.001). All patients were discharged home without incident. This prospective study suggests that discharge decisions based on physiological criteria have the potential for significantly speeding the transit of children through the PACU, thereby enhancing PACU efficiency and resource utilization.

Detection and quantification of intraperitoneal fluid using electrical impedance tomography.

PubMed

Sadleir, R J; Fox, R A

2001-04-01

A prototype electrical impedance tomography system was evaluated prior to its use for the detection of intraperitoneal bleeding, with the assistance of patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The system was sensitive enough to detect small amounts of dialysis fluid appearing in subtractive images over short time periods. Uniform sensitivity to blood appearing anywhere within the abdominal cavity was produced using a post-reconstructive filter that corrected for changes in apparent resistivity of anomalies with their radial position. The image parameter used as an indication of fluid quantity, the resistivity index, varied approximately linearly with the quantity of fluid added. A test of the system's response to the introduction of conductive fluid out of the electrode plane (when a blood-equivalent fluid was added to the stomach) found that the sensitivity of the system was about half that observed in the electrode plane. Breathing artifacts were found to upset quantitative monitoring of intraperitoneal bleeding, but only on time scales short compared with the fluid administration rate. Longer term breathing changes, such as those due to variations in the functional residual capacity of the lungs, should ultimately limit the sensitivity over long time periods.

Laparoscopy to evaluate scrotal edema during peritoneal dialysis.

PubMed

Haggerty, Stephen P; Jorge, Juaquito M

2013-01-01

Acute scrotal edema is an infrequent complication in patients who undergo continuous ambulatory peritoneal dialysis (CAPD), occurring in 2% to 4% of patients. Inguinal hernia is usually the cause, but the diagnosis is sometimes confusing. Imaging modalities such as computed tomographic peritoneography are helpful but can be equivocal. We have used diagnostic laparoscopy in conjunction with open unilateral or bilateral hernia repair for diagnosis and treatment of peritoneal dialysis (PD) patients with acute scrotal edema. TECHNIQUE AND CASES: Three patients with acute scrotal edema while receiving CAPD over the span of 7 years had inconclusive results at clinical examination and on diagnostic imaging. All patients underwent diagnostic laparoscopy that revealed indirect inguinal hernia, which was concomitantly repaired using an open-mesh technique. Diagnostic laparoscopy revealed the etiology of the scrotal edema 100% of the time, with no complications, and allowed concomitant repair of the hernia. One patient had postoperative catheter outflow obstruction, which was deemed to be unrelated to the hernia repair. Diagnostic laparoscopy is helpful in confirming the source of acute scrotal edema in CAPD patients and can be performed in conjunction with an open-mesh repair with minimal added time or risk.

Psychosocial adjustment and adherence to dialysis treatment regimes.

PubMed

Brownbridge, G; Fielding, D M

1994-12-01

Sixty children and adolescents in end-stage renal failure who were undergoing either haemodialysis or continuous ambulatory peritoneal dialysis at one of five United Kingdom dialysis centres were assessed on psychosocial adjustment and adherence to their fluid intake, diet and medication regimes. Parental adjustment was also measured and data on sociodemographic and treatment history variables collected. A structured family interview and standardised questionnaire measures of anxiety, depression and behavioural disturbance were used. Multiple measures of treatment adherence were obtained, utilising children's and parents' self-reports, weight gain between dialysis, blood pressure, serum potassium level, blood urea level, dietitians' surveys and consultants' ratings. Correlational analyses showed that low treatment adherence was associated with poor adjustment to diagnosis and dialysis by children and parents (P < 0.01), self-ratings of anxiety and depression in children and parents (P < 0.001), age (adolescents tended to show poorer adherence than younger children, P < 0.001), duration of dialysis (P < 0.05), low family socioeconomic status (P < 0.05) and family structure (P < 0.01). These findings demonstrate the importance of psychosocial care in the treatment of this group of children. Future research should develop and evaluate psychosocial interventions aimed at improving treatment adherence.

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

PubMed

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

2000-01-01

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

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

PubMed

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

2016-01-01

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

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

PubMed Central

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

2010-01-01

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

Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery.

PubMed

Martínez-Ramos, Carlos; Cerdán, María Teresa; López, Rodrigo S

2009-01-01

A pilot study was done to address the efficacy of a General Packet Radio Service mobile phone-based telemedicine system used to improve follow-up after ambulatory surgery. The method involves sending images of surgical wounds or other areas from the patient's home, to assess local complications and avoid unnecessary hospital visits. Ninety-six (N = 96) patients were enrolled in the study. The phone used was a Nokia 6600, which provides images in Joint Photographic Experts Group format. These images were sent via e-mail and visualized on a standard 17-inch screen of a personal computer. After the follow-up period, self-reported patient satisfaction was assessed by analyzing the replies to a 9-item questionnaire. Thirty of the 96 patients (31.3%) reported local problems including: hematoma in 20 (66.7%) patients, surgical bandage blood-stained in 7 (23.3%), exudates in 1 (3.3%), allergic skin reactions in 1 (3.3%), and bandage too tight in 1 (3.3%). In total, 225 photographs were evaluated by 3 physicians. In all cases, it was possible to identify and assess the postoperative problem with consensus among the 3 physicians. Images served to resolve patients' concerns in 20 individuals (66.7%). In 10 patients (33.3%), concerns were satisfied but it was suggested that follow-up images be sent in the following days. Only 1 patient (3.3%) was asked to visit the hospital. The telemedicine system proposed increases the efficiency of home follow-up to ambulatory surgery, avoids unnecessary hospital visits, and clearly improves patient satisfaction.

Incidence and risk factors for preoperative deep venous thrombosis in 314 consecutive patients undergoing surgery for spinal metastasis.

PubMed

Zacharia, Brad E; Kahn, Sweena; Bander, Evan D; Cederquist, Gustav Y; Cope, William P; McLaughlin, Lily; Hijazi, Alexa; Reiner, Anne S; Laufer, Ilya; Bilsky, Mark

2017-08-01

OBJECTIVE The authors of this study aimed to identify the incidence of and risk factors for preoperative deep venous thrombosis (DVT) in patients undergoing surgical treatment for spinal metastases. METHODS Univariate analysis of patient age, sex, ethnicity, laboratory values, comorbidities, preoperative ambulatory status, histopathological classification, spinal level, and surgical details was performed. Factors significantly associated with DVT univariately were entered into a multivariate logistic regression model. RESULTS The authors identified 314 patients, of whom 232 (73.9%) were screened preoperatively for a DVT. Of those screened, 22 (9.48%) were diagnosed with a DVT. The screened patients were older (median 62 vs 55 years, p = 0.0008), but otherwise similar in baseline characteristics. Nonambulatory status, previous history of DVT, lower partial thromboplastin time, and lower hemoglobin level were statistically significant and independent factors associated with positive results of screening for a DVT. Results of screening were positive in only 6.4% of ambulatory patients in contrast to 24.4% of nonambulatory patients, yielding an odds ratio of 4.73 (95% CI 1.88-11.90). All of the patients who had positive screening results underwent preoperative placement of an inferior vena cava filter. CONCLUSIONS Patients requiring surgery for spinal metastases represent a population with unique risks for venous thromboembolism. This study showed a 9.48% incidence of DVT in patients screened preoperatively. The highest rates of preoperative DVT were identified in nonambulatory patients, who were found to have a 4-fold increase in the likelihood of harboring a DVT. Understanding the preoperative thrombotic status may provide an opportunity for early intervention and risk stratification in this critically ill population.

Comparison of a new metamizole formulation and carprofen for extended post-operative analgesia in dogs undergoing ovariohysterectomy.

PubMed

Kalchofner Guerrero, K S; Schwarz, A; Wuhrmann, R; Feldmann, S; Hartnack, S; Bettschart-Wolfensberger, R

2015-04-01

A newly developed slow-release tablet formulation of metamizole was compared with carprofen for post-operative analgesia in dogs undergoing ovariohysterectomy. Twenty-three dogs were randomly assigned to one of two groups, and administered 50 mg/kg metamizole PO (Group M) or 4 mg/kg carprofen PO (Group C) 1 h before anaesthetic induction and 24 and 48 h later. Anaesthesia was induced with propofol and maintained with isoflurane and fentanyl, after premedication with 0.005 mg/kg medetomidine and 0.3 mg/kg methadone IM. A blinded observer assessed post-operative sedation, and analgesia using a visual analogue scale, a dynamic interactive visual analogue scale, the Glasgow composite pain scale (GCPS), and a mechanical nociceptive threshold device (T = 0.5, 1, 2, 4, 8, 12, 18, 21, 24, 36, 45, 60 and 70 h after surgery). Rescue methadone was administered if the GCPS was >6/24 in ambulatory dogs, or >5/20 in non-ambulatory dogs. Plasma concentrations of test drugs were quantified. The dose range for metamizole was 39-56 mg/kg. At T = 0.5 h sedation scores were significantly higher in Group C and GCPS scores were significantly higher in Group M. Three dogs required rescue methadone (Group M, n = 1; Group C, n = 2). Vomiting occurred post-operatively in 45% of dogs in Group M. Carprofen and metamizole were both well absorbed; peak concentrations occurred within 4-24 h, and 4-16 h for carprofen and metamizole, respectively. Both drugs provided adequate analgesia of similar duration. No side effects were observed with carprofen while vomiting was frequent following administration of metamizole. Copyright © 2015 Elsevier Ltd. All rights reserved.

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

PubMed

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

2018-05-01

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

Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases.

PubMed

Nielsen, Karen C; Greengrass, Roy A; Pietrobon, Ricardo; Klein, Stephen M; Steele, Susan M

2003-01-01

Continuous interscalene brachial plexus blockade (CIBPB) in a hospital setting can provide excellent surgical conditions and postoperative analgesia for major shoulder surgery. This is a case report of four patients on the efficacy and advantages of CIBPB for postoperative analgesia at home. Four patients scheduled for rotator cuff repair under CIBPB were discharged home the day of surgery with an interscalene catheter connected to an automated infusion pump administering 0.2% ropivacaine at 10 mL x hr(-1) for 72 hr. Prior to discharge, patients and their attendant were given verbal and written instructions concerning local anesthetic toxicity and explicit contact information for an anesthesiologist or nurse. Outcomes were measured pre- and postoperatively, including verbal analogue pain scores (pain VAS), verbal analogue nausea scores (nausea VAS), side effects, cognitive function (mini-mental state questionnaire), sleep (hours/night), and patient satisfaction (Likert scale). Postoperative VAS scores over three days were very low. Two patients reported only one episode of nausea. There were no complications associated with local anesthetic toxicity or catheter use. Cognitive function improved over three days. Sleep increased from a mean of five hours before surgery to seven hours over the next three nights. Patient satisfaction with care was high. Significant cost savings were documented. The use of CIBPB for 72 hr in patients undergoing major ambulatory shoulder surgery can result in good analgesia with minimal opioid requirement, cost savings and possibly improvement in outcome measures.

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

PubMed

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

2016-11-15

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

The Effect of Mobile App Home Monitoring on Number of In-Person Visits Following Ambulatory Surgery: Protocol for a Randomized Controlled Trial

PubMed Central

Coyte, Peter C; Bhatia, R Sacha; Semple, John L

2015-01-01

Background Women’s College Hospital, Toronto, Canada, offers specialized ambulatory surgical procedures. Patients often travel great distances to undergo surgery. Most patients receiving ambulatory surgery have a low rate of postoperative events necessitating clinic visits. However, regular follow-up is still considered important in the early postoperative phase. Increasingly, telemedicine is used to overcome the distance patients must travel to receive specialized care. Telemedicine data suggest that mobile monitoring and follow-up care is valued by patients and can reduce costs to society. Women’s College Hospital has used a mobile app (QoC Health Inc) to complement in-person postoperative follow-up care for breast reconstruction patients. Preliminary studies suggest that mobile app follow-up care is feasible, can avert in-person follow-up care, and is cost-effective from a societal and health care system perspective. Objective We hope to expand the use of mobile app follow-up care through its formal assessment in a randomized controlled trial. In postoperative ambulatory surgery patients at Women’s College Hospital (WCH), can we avert in-person follow-up care through the use of mobile app follow-up care compared to conventional, in-person follow-up care in the first 30 days after surgery. Methods This will be a pragmatic, single-center, open, controlled, 2-arm parallel-group superiority randomized trial comparing mobile app and in-person follow-up care over the first month following surgery. The patient population will comprise all postoperative ambulatory surgery patients at WCH undergoing breast reconstruction. The intervention consists of a postoperative mobile app follow-up care using the quality of recovery-9 (QoR9) and a pain visual analog scale (VAS), surgery-specific questions, and surgical site photos submitted daily for the first 2 weeks and weekly for the following 2 weeks. The primary outcome is the total number of physician visits related to the surgery over the first 30-days postoperative. The secondary outcomes include (1) the total number of phone calls and emails to a health care professional related to surgery, (2) complication rate, (3) societal and health care system costs, and (4) patient satisfaction over the first 30 days postoperative. Permutated-block randomization will be conducted by blocks of 4-6 using the program ralloc in Stata. This is an open study due to the nature of the intervention. Results A sample of 72 (36 patients per group) will provide an E-test for count data with a power of 95% (P=.05) to detect a difference of 1 visit between groups, assuming a 10% drop out rate. Count variables will be analyzed using Poisson regression. Categorical variables will be tested using a chi-square test. Cost-effectiveness will be analyzed using net benefit regression. Outcomes will be assessed over the first 30 days following surgery. Conclusions We hope to show that the use of a mobile app in follow-up care minimizes the need for in-person visits for postoperative patients. Trial Registration Clinicaltrials.gov NCT02318953; https://clinicaltrials.gov/ct2/show/NCT02318953 (Archived by WebCite at http://www.webcitation.org/6Yifzdjph). PMID:26040252

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

PubMed Central

Agarwal, Rajiv

2015-01-01

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

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

PubMed

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

2011-01-01

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

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

NASA Technical Reports Server (NTRS)

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

1977-01-01

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

Glucose absorption in acute peritoneal dialysis.

PubMed

Podel, J; Hodelin-Wetzel, R; Saha, D C; Burns, G

2000-04-01

During acute peritoneal dialysis (APD), it is known that glucose found in the dialysate solution contributes to the provision of significant calories. It has been well documented in continuous ambulatory peritoneal dialysis (CAPD) that glucose absorption occurs. In APD, however, it remains unclear how much glucose absorption actually does occur. Therefore, the purpose of this study was to determine whether it is appropriate to use the formula used to calculate glucose absorption in CAPD (Grodstein et al) among patients undergoing APD. Actual measurements of glucose absorption (Method I) were calculated in 9 patients undergoing APD treatment for >24 hours who were admitted to the intensive care unit. Glucose absorption using the Grodstein et al formula (Method II) was also determined and compared with the results of actual measurements. The data was then further analyzed based on the factors that influence glucose absorption, specifically dwell time and concentration. The mean total amount of glucose absorbed was 43% +/- 15%. However, when dwell time and concentration were further examined, significant differences were noted. Method I showed a cumulative increase over time. Method II showed that absorption was fixed. This suggests that with the variation in dwell time commonly seen in the acute care setting, the use of Method II may not be accurate. In each of the 2 methods, a significant difference in glucose absorption was noted when comparing the use of 1.5% and 4.25% dialysate concentrations. The established formula designed for CAPD should not be used for calculating glucose absorption in patients receiving APD because variation in dwell time and concentration should be taken into account. Because of the time constraints and staffing required to calculate each exchange individually, combined with the results of the study, we recommend the use of the percentage estimate of 40% to 50%.

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

PubMed

Hüppe, Tobias; Kneller, Nicole; Raddatz, Alexander

2018-05-01

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

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

PubMed

Phillips, J H

1989-01-01

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

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

Code of Federal Regulations, 2010 CFR

2010-10-01

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

[Sedation with midazolam for ambulatory pediatric dentistry].

PubMed

Shavlokhova, E A; Ostreĭkov, I F; Korolenkova, M V

2014-01-01

To improve the quality of dental treatment in children by using combined anaesthesia technique including local anaesthesia and conscious sedation, and to assess the effectiveness of conscious sedation for younger children undergoing dental treatment. The study included 208 children aged 14-88 months who received dental treatment for tooth decay and its complication under combined anaesthesia. Midazolam was used as sedative medication. Sedation level was assessed by visual scale and BIS-monitoring. ANI-monitoring was also used for pain sensitiveness evaluation. Results All 208 children were successfully treated under combined anaesthesia which showed satisfactory sedation rates both by visual scale and and BIS-monitoring values. While mean patient age was 39 months 20.6% were younger than 24 months. These data are extremely valuable as according to literature review conscious sedation in early infancy remains controversial. Our results proved conscious sedation to be effective in younger children undergoing dental treatment thus representing important alternative for general anaesthesia and providing a basis for later behavior management.

Under "real world" conditions, desflurane increases drug cost without speeding discharge after short ambulatory anesthesia compared to isoflurane.

PubMed

Schwarz, Stephan K W; Butterfield, Noam N; Macleod, Bernard A; Kim, Edward Y; Franciosi, Luigi G; Ries, Craig R

2004-11-01

To compare the measured "real world" perioperative drug cost and recovery associated with desflurane- and isoflurane-based anesthesia in short (less than one hour) ambulatory surgery. We conducted a prospective, randomized, blinded trial with patients undergoing arthroscopic meniscectomy under general anesthesia. Following iv induction, patients received either isoflurane (group I; n = 25) or desflurane (group D; n = 20) for maintenance. The primary outcome variable was total perioperative drug cost per patient in Canadian dollars. Secondary outcome variables included volatile agent consumption and cost, adjuvant anesthetic and postanesthesia care unit (PACU) drug cost, readiness for PACU discharge, and incidence of adverse events. Total perioperative drug cost per patient was 14.58 +/- 6.83 Canadian dollars (mean +/- standard deviation) for group I, and 21.47 +/- 5.18 Canadian dollars for group D (P < 0.001). Isoflurane consumption per patient was 6.0 +/- 3.0 mL compared to 18.6 +/- 7.7 mL for desflurane (P < 0.0001); corresponding costs were 0.83 +/- 0.42 Canadian dollars vs 7.61 +/- 3.15 Canadian dollars (P < 0.0001). There were no differences in adjuvant anesthetic or PACU drug cost. All but one patient from each group were deemed ready for PACU discharge at 15 min postoperatively (Aldrete score >or= 9). One patient in group D experienced postoperative nausea. No other adverse events were noted. Measured total perioperative drug cost for a short ambulatory procedure (less than one hour) under general anesthesia was higher when desflurane rather than isoflurane was used for maintenance, essentially due to volatile agent cost. Desflurane use did not translate into faster PACU discharge under "real world" conditions.

Balloon aortic valvuloplasty to improve candidacy of patients evaluated for transcatheter aortic valve replacement.

PubMed

Arsalan, Mani; Khan, Samir; Golman, Jake; Szerlip, Molly; Mahoney, Cecile; Herbert, Morley; Brown, David; Mack, Michael; Holper, Elizabeth M

2018-02-01

Evaluate the role of balloon aortic valvuloplasty (BAV) in improving candidacy of patients for transcatheter aortic valve replacement (TAVR). Patients who are not candidates for TAVR may undergo BAV to improve functional and clinical status. 117 inoperable or high-risk patients with critical aortic stenosis underwent BAV as a bridge-to-decision for TAVR. Frailty measures including gait speed, serum albumin, hand grip, activities of daily living (ADL); and NYHA functional class before and after BAV were compared. Mean age was 81.6 ± 8.5 years and the mean Society of Thoracic Surgeons predicted risk of mortality was 9.57 ± 5.51, with 19/117 (16.2%) patients non-ambulatory. There was no significant change in mean GS post-BAV, but all non-ambulatory patients completed GS testing at follow-up. Albumin and hand grip did not change after BAV, but there was a significant improvement in mean ADL score (4.85 ± 1.41 baseline to 5.20 ± 1.17, P = 0.021). The number of patients with Class IV congestive heart failure (CHF) was significantly lower post BAV (71/117 [60.7%] baseline versus 18/117 [15.4%], P = 0.008). 78/117 (66.7%) of patients were referred to definitive valve therapy after BAV. When evaluating frailty measures post BAV, we saw no significant improvement in mean GS, however, we observed a significant improvement in non-ambulatory patients and ADL scores. We also describe improved Class IV CHF symptoms. With this improved health status, the majority of patients underwent subsequent valve therapy, demonstrating that BAV may improve candidacy of patients for TAVR. © 2017, Wiley Periodicals, Inc.

The structure, organisation and perioperative management of ambulatory surgery and anaesthesia in France: Methodology of the SFAR-OPERA study.

PubMed

Albaladejo, Pierre; Aubrun, Frédéric; Samama, Charles-Marc; Jouffroy, Laurent; Beaussier, Marc; Benhamou, Dan; Romegoux, Pauline; Skaare, Kristina; Bosson, Jean-Luc; Ecoffey, Claude

2017-10-01

The organization of health care establishments and perioperative care are essential for ensuring the quality of care and safety of patients undergoing outpatient surgery. In order to correctly inventory these organizations and practices, in 2013-2014, the French society of anaesthesia and intensive care organized an extensive practical survey in French ambulatory surgery units entitled the "OPERA" study (Organisation periopératoire de l'anesthésie en chirurgie ambulatoire). From among all of the ambulatory surgery centres listed by the Agences régionales de santé (Regional health agencies, France), 206 public and private centres were randomly selected. A structural (typology, organization) survey and a medical-practice survey (focusing on the management of postoperative pain, nausea and vomiting as well as the prevention of venous thromboembolism) were collected and managed by a prospective audit of practices occurring on two randomly selected days. The latter was further accompanied by an additional audit specifically focussing on ten representative procedures: (1) stomatology surgery (third molar removal); (2) knee arthroscopy; (3) surgery of the abdominal wall (including inguinal hernia); (4) perianal surgery; (5) varicose vein surgery; (6) digestive laparoscopy-cholecystectomy; (7) breast surgery (tumourectomy); (8) uterine surgery; (9) hallux valgus and (10) hand surgery (excluding carpal tunnel). Over the 2 days of observation, 7382 patients were included comprising 2174 patients who underwent one of the procedures from the above list. The analysis of these data will provide an overview of the organization of health establishments, the modalities thus supported and compliance with standards. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Value of preoperative esophageal function studies before laparoscopic antireflux surgery.

PubMed

Chan, Walter W; Haroian, Laura R; Gyawali, C Prakash

2011-09-01

The value of esophageal manometry and ambulatory pH monitoring before laparoscopic antireflux surgery (LARS) has been questioned because tailoring the operation to the degree of hypomotility often is not required. This study evaluated a consecutive cohort of patients referred for esophageal function studies in preparation for LARS to determine the rates of findings that would alter surgical decisions. High-resolution manometry (HRM) was performed for each subject using a 21-lumen water-perfused system, and motor function was characterized. Gastroesophageal reflux disease (GERD) was evident from ambulatory pH monitoring if thresholds for acid exposure time and/or positive symptom association probability were passed. Of 1,081 subjects (age, 48.4 ± 0.4 years; 56.7% female) undergoing preoperative HRM, 723 (66.9%) also had ambulatory pH testing performed. Lower esophageal sphincter (LES) hypotension (38.9%) and nonspecific spastic disorder (NSSD) of the esophageal body (36.1%) were common. Obstructive LES pathophysiology was noted in 2.5% (achalasia in 1%; incomplete LES relaxation in 1.5%), and significant esophageal body hypomotility in 4.5% (aperistalsis in 3.2%; severe hypomotility in 1.3%) of the subjects. Evidence of GERD was absent in 23.9% of the subjects. Spastic disorders were more frequent in the absence of GERD (43.9% vs. 23.1% with GERD; p < 0.0001), whereas hypomotility and normal patterns were more common with GERD. Findings considered absolute or relative contraindications for standard 360º fundoplication are detected in 1 of 14 patients receiving preoperative HRM. Additionally, spastic findings associated with persistent postoperative symptoms are detected at esophageal function testing that could be used in preoperative counseling and candidate selection. Physiologic testing remains important in the preoperative evaluation of patients being considered for LARS.

Use of Quantile Regression to Determine the Impact on Total Health Care Costs of Surgical Site Infections Following Common Ambulatory Procedures.

PubMed

Olsen, Margaret A; Tian, Fang; Wallace, Anna E; Nickel, Katelin B; Warren, David K; Fraser, Victoria J; Selvam, Nandini; Hamilton, Barton H

2017-02-01

To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution. Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs. We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution. The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile). SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.

Use of Quantile Regression to Determine the Impact on Total Health Care Costs of Surgical Site Infections Following Common Ambulatory Procedures

PubMed Central

Olsen, Margaret A.; Tian, Fang; Wallace, Anna E.; Nickel, Katelin B.; Warren, David K.; Fraser, Victoria J.; Selvam, Nandini; Hamilton, Barton H.

2017-01-01

Objective To determine the impact of surgical site infections (SSIs) on healthcare costs following common ambulatory surgical procedures throughout the cost distribution. Background Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs. Methods We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery (BCS), anterior cruciate ligament reconstruction (ACL), and hernia repair from 12/31/2004–12/31/2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day healthcare costs throughout the cost distribution. Results The incidence of serious and non-serious SSIs were 0.8% and 0.2% after 21,062 ACL, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 BCS procedures. Serious SSIs were associated with significantly higher costs than non-serious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs. no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile). Conclusions SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased healthcare costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on healthcare costs at the upper end of the cost distribution. PMID:28059961

[Febrile neutropenia at the emergency department of a cancer hospital].

PubMed

Debey, C; Meert, A-P; Berghmans, T; Thomas, J M; Sculier, J P

2011-01-01

Febrile neutropenia is an important cause of fever in the cancer patient. When he/she is undergoing chemotherapy, the priority is to exclude that complication because it requires rapid administration of empiric broad-spectrum antibiotics. We have studied the rate and characteristics of febrile neutropenia in cancer patients consulting in a emergency department. We have conducted a retrospective study in the emergency department of a cancer hospital over the year 2008. Every patient with cancer and fever > or = 38 degrees C was included. Over 2.130 consultations, 408 were selected (313 patients) including 21.6% (88) for febrile neutropenia. A focal symptom or physical sign was present in the majority of the cases. 88% were assessed as low risk for severe complications and about half of them received oral antibiotics. There were only a few patients with a nude fever for which it was difficult to make a hypothetical diagnosis in order to administer a probabilistic treatment. The majority of the consultations lead to hospital admission. Over the 80 hospitalisations, 6 deaths occurred. There was no death among the patients who remained ambulatory. In conclusion, our study shows that febrile neutropenia is frequent in ambulatory cancer patients presenting with fever and that in the majority of the cases, it is associated with a low risk. In such a situation, ambulatory management is more and more often considered or, at least, a rapid discharge after a short admission in case of low risk febrile neutropenia. In that context, the role of the general practioner has to be emphasised and to facilitate the outpatient management, we propose an algorithm that requires validation.

Chronic rhinosinusitis, race, and ethnicity.

PubMed

Soler, Zachary M; Mace, Jess C; Litvack, Jamie R; Smith, Timothy L

2012-01-01

Little is known regarding the epidemiology of chronic rhinosinusitis (CRS) in racial and ethnic minorities in the United States. This study was designed to comprehensively evaluate the current prevalence of CRS across various treatment settings to identify possible disparities in health care access and use between racial and ethnic populations. The National Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS), and National Hospital Ambulatory Medical Care Survey (NHAMCS) database registries were extracted to identify the national prevalence of CRS in race/ethnic populations and resource use in ambulatory care settings. Systematic literature review identified studies reporting treatment outcomes in minority patients electing endoscopic sinus surgery (ESS). Data were supplemented using a multi-institutional cohort of patients undergoing surgical treatment. National survey data suggest CRS is a significant health condition for all major race/ethnic groups in the United States, accounting for a sizable portion of office, emergency, and outpatient visits. Differences in insurance status, work absenteeism, and resource use were found between race/ethnic groups. Despite its prevalence, few published studies include information regarding minority patients with CRS. Most (90%) cohort studies did not provide details of race/ethnicity for ESS outcomes. Prospective cohort analysis indicated that minority surgical patients accounted for only 18%, when compared with national census estimates (35%). CRS is an important health condition for all major race/ethnic groups in the United States. Significant differences may exist across racial and ethnic categories with regard to CRS health status and health care use. Given current demographic shifts in the United States, specific attention should be given to understanding CRS within the context of racial and ethnic populations. Public clinical trial registration (www.clinicaltrials.gov) I.D. No. NCT00799097.

Magnitude of Hypotension Based on Office and Ambulatory Blood Pressure Monitoring: Results From a Cohort of 5066 Treated Hypertensive Patients Aged 80 Years and Older.

PubMed

Divisón-Garrote, Juan A; Ruilope, Luis M; de la Sierra, Alejandro; de la Cruz, Juan J; Vinyoles, Ernest; Gorostidi, Manuel; Escobar-Cervantes, Carlos; Velilla-Zancada, Sonsoles M; Segura, Julián; Banegas, José R

2017-05-01

Elderly patients can be particularly susceptible to the adverse effects of excessive blood pressure (BP) lowering by antihypertensive treatment. The identification of hypotension is thus especially important. Ambulatory BP monitoring (ABPM) is a more accurate technique than office for classifying BP status. This study examined the prevalence of hypotension and associated demographic and clinical factors among very old treated hypertensive patients undergoing ABPM. Cross-sectional study in which 5066 patients aged 80 years and older with treated hypertension drawn from the Spanish ABPM Registry were included. Office BP and 24-hour ambulatory BP were determined using validated devices under standardized conditions. Based on previous studies, hypotension was defined as systolic/diastolic BP <110 and/or 70 mmHg with office measurement, <105 and/or 65 mmHg with daytime ABPM, <90 and/or 50 mmHg with nighttime ABPM, and <100 and/or 60 mmHg with 24-hour ABPM. Participants' mean age was 83.2 ± 3.1 years (64.4% women). Overall, 22.8% of patients had office hypotension, 33.7% daytime hypotension, 9.2% nighttime hypotension, and 20.5% 24-hour ABPM hypotension. Low diastolic BP values were responsible for 90% of cases of hypotension. In addition, 59.1% of the cases of hypotension detected by daytime ABPM did not correspond to hypotension according to office BP. The variables independently associated with office and ABPM hypotension were diabetes, coronary heart disease, and a higher number of antihypertensive medications. One in 3 very elderly treated hypertensive patients attended in usual clinical practice were potentially at risk of having hypotension according to daytime ABPM. More than half of them had masked hypotension; that is, they were not identified if relying on office BP alone. Thus, ABPM could be especially helpful for identifying ambulatory hypotension and avoiding overtreatment, in particular, in patients with diabetes, heart disease, or on antihypertensive polytherapy. Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.

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

PubMed

Eckmanns, Tim; Richter, Doreen; Feig, Marcel

2014-01-01

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

Relationship of IgG, C3 and transferrin with opsonising and bacteriostatic activity of peritoneal fluid from CAPD patients and the incidence of peritonitis.

PubMed

McGregor, S J; Brock, J H; Briggs, J D; Junor, B J

1987-01-01

IgG, C3 and transferrin in peritoneal dialysis effluent of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) were 1%-2% of those in serum. In contrast, the values in normal peritoneal fluid were not significantly different from those in serum. The three proteins correlated with each other in peritoneal dialysis effluent, but were independent of the amount in the corresponding patients' sera. There was also an overall inverse correlation between total protein in peritoneal dialysis effluent and time on CAPD during the first 6 months of treatment but not thereafter, which suggests that changes in membrane permeability occur during the early months. In peritoneal dialysis effluent, but not in normal peritoneal fluid, there was a correlation between opsonising capacity and IgG or C3 concentrations. An inverse correlation between opsonic activity of peritoneal dialysis effluent and frequency of peritonitis was also found. Peritoneal dialysis effluent permitted significantly faster multiplication of Staphylococcus epidermidis than sera or normal peritoneal fluid, and the growth rate correlated inversely with the transferrin levels in peritoneal dialysis effluent. Overall IgG, C3 and transferrin in peritoneal dialysis effluent are inadequate for optimal opsonising and bacteriostatic activity, and the peritoneal cavities of CAPD patients are therefore immunocompromised sites.

Adolescent medicine training in pediatric residency programs.

PubMed

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

2010-01-01

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

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

ERIC Educational Resources Information Center

Hulburd, Kimberly

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-28

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

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

PubMed

Ramanathan, Kumaresan; Padmanabhan, Giri; Vijayaraghavan, Bhooma

2016-05-01

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

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

PubMed Central

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

1998-01-01

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

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

PubMed

Solá, J; Proença, M; Chételat, O

2013-01-01

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

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

PubMed

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

1996-07-01

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

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

PubMed

Mercado, Arlene B

2008-08-01

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

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

PubMed

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

2005-08-01

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

Clinical Characteristics of Seven Patients with Lanthanum Phosphate Deposition in the Stomach.

PubMed

Murakami, Naoko; Yoshioka, Masao; Iwamuro, Masaya; Nasu, Junichirou; Nose, Soichiro; Shiode, Junji; Okada, Hiroyuki; Yamamoto, Kazuhide

2017-08-15

Objective To analyze the clinical characteristics and endoscopic features of patients with lanthanum deposition in the stomach. Patients We retrospectively reviewed seven patients with lanthanum deposition in the stomach who were diagnosed at Okayama Saiseikai General Hospital. We investigated the patient sex, age at diagnosis, medical and medication histories, gastrointestinal symptoms, complications, presence or absence of gastric atrophy, and outcome. We also investigated any changes in the endoscopic features if previous endoscopic images were available. Results Seven patients (six males and one female) had lanthanum deposition. The median age was 65 years (range, 50-79 years). All patients had been undergoing dialysis (continuous ambulatory peritoneal dialysis in one patient, hemodialysis in six patients). The dialysis period ranged from 16 to 73 months (median, 52 months). The patients had all been taking lanthanum carbonate for a period ranging from 5 to 45 months (median, 27 months). Gastric atrophy was noted in 6 patients (85.7%). One patient had difficulty swallowing, and 1 other patient had appetite loss. The other 5 patients were asymptomatic. Endoscopic features included annular whitish mucosa (n = 4), diffuse whitish mucosa (n = 3), and whitish spots (n = 2). Five patients underwent multiple esophagogastroduodenoscopy. The endoscopic features were unchanged in 2 patients, whereas the whitish mucosa became apparent and spread during the course in 3 patients. Conclusion We identified 7 patients with lanthanum deposition in the stomach. All patients showed whitish lesions macroscopically. Although the pathogenicity of gastric lanthanum deposition is uncertain, lanthanum-related lesions in the stomach progressed during continuous lanthanum phosphate intake in several patients.

Effects of auditory and audiovisual presentations on anxiety and behavioral changes in children undergoing elective surgery.

PubMed

Hatipoglu, Z; Gulec, E; Lafli, D; Ozcengiz, D

2018-06-01

: Preoperative anxiety is a critical issue in children, and associated with postoperative behavioral changes. : The purpose of the current study is to evaluate how audiovisual and auditory presentations about the perioperative period impact preoperative anxiety and postoperative behavioral disturbances of children undergoing elective ambulatory surgery. : A total of 99 patients between the ages of 5-12, scheduled to undergo outpatient surgery, participated in this study. Participants were randomly assigned to one of three groups; audiovisual group (Group V, n = 33), auditory group (Group A, n = 33), and control group (Group C, n = 33). During the evaluation, the Modified Yale Preoperative Anxiety Scale (M-YPAS) and the posthospitalization behavioral questionnaire (PHBQ) were used. : There were no significant differences in demographic characteristics between the groups. M-YPAS scores were significantly lower in Group V than in Groups C and A (P < 0.001 and P < 0.001, respectively). PHBQ scores in Group C were statistically higher than in Groups A and V, but, no statistical difference was found between Groups A and V. Compared to auditory presentations, audiovisual presentations, in terms of being memorable and interesting, may be more effective in reducing children's anxiety. In addition, we can suggest that both methods can be equally effective for postoperative behavioral changes.

Safety and effectiveness evaluation of a domestic peritoneal dialysis fluid packed in non-PVC bags: study protocol for a randomized controlled trial.

PubMed

Zhou, Jianhui; Cao, Xueying; Lin, Hongli; Ni, Zhaohui; He, Yani; Chen, Menghua; Zheng, Hongguang; Chen, Xiangmei

2015-12-29

Peritoneal dialysis is an important type of renal replacement therapy for uremic patients. In peritoneal dialysis, fluids fill in and flow out of the abdominal cavity three to five times per day. Usually, the fluid is packed in a polyvinyl chloride (PVC) bag. Safety concerns have arisen over di-(2-ethylhexyl) phthalate, which is essential in the formation of PVC materials. In 2011, the National Development and Reform Commission of China released a catalog of industrial structural adjustments, mandating the elimination of PVC bags for intravenous infusion and food containers. Although bags for peritoneal dialysis fluid were not included in the elimination list, several manufacturers began to develop new materials for fluid bags. HUAREN peritoneal dialysis fluid consists of the same electrolytes and buffer agent as in Baxter fluid, but is packed in bags that do not contain PVC. This multicenter randomized controlled trial was designed to compare peritoneal dialysis fluid packed in non-PVC-containing and PVC-containing bags. Further, the study sought to determine the proper dose of peritoneal dialysis fluid and the actual survival rates of Chinese patients undergoing peritoneal dialysis. The study participants are adults undergoing continuous ambulatory peritoneal dialysis for 30 days to 6 months. All eligible patients are randomized (1:1) to peritoneal dialysis with Baxter and HUAREN dialysis fluids (initial dose, 6 l/day), with dosages adjusted according to a unified protocol. The primary outcomes are the 1-, 2-, 3-, 4-, and 5-year overall survival rates. Secondary outcome measures include technique survival rates, reductions in estimated glomerular filtration rate, nutritional status, quality of life, cardiovascular events, medical costs and drop-out rates. Safety outcome measures include adverse events, changes in vital signs and laboratory parameters, peritonitis, allergies, and quality of products. This study is the first to evaluate the long-term safety and effectiveness of a non-PVC packed peritoneal dialysis fluid. The effects of plasticizer on patient long-term survival will be determined. The characteristics of Chinese patients undergoing peritoneal dialysis will be determined, including proper dose, technique survival rates, patient survival rates, and medical costs. Clinicaltrials.gov NCT01779557 .

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

PubMed

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

2012-12-01

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

[Face-lift surgery in ambulatory].

PubMed

Soulhiard, F

2017-10-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-07

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

Outpatients' Knowledge About and Attitude Toward Randomised Clinical Trials

ClinicalTrials.gov

2017-03-23

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

Ambulatory Surgery Centers and Their Intended Effects on Outpatient Surgery.

PubMed

Hollenbeck, Brent K; Dunn, Rodney L; Suskind, Anne M; Strope, Seth A; Zhang, Yun; Hollingsworth, John M

2015-10-01

To assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events. Twenty percent national sample of Medicare beneficiaries. A retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups-those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission. Adjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p < .001 for test between slopes). Within these markets, procedure use at ASCs outpaced the decline observed in the hospital setting. Perioperative mortality and admission rates remained flat after ASC opening (both p > .4 for test between slopes). The opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals. © Health Research and Educational Trust.

Long-term outcomes following high intensity focused ultrasound ablation for atrial fibrillation.

PubMed

Davies, Edward J; Bazerbashi, Samer; Asopa, Sanjay; Haywood, Guy; Dalrymple-Hay, Malcolm

2014-01-01

The aim of this study is to assess the safety and efficacy of the Epicor high intensity focused ultrasound (St. Jude, Inc.®, Minneapolis, MN, USA) system using seven-day ambulatory electrocardiogram (ECG) monitoring over a two-year follow-up period. One hundred and ten patients undergoing ablation were included from a single center between January 2006 and December 2009. Rhythm was assessed using seven-day ambulatory ECG or permanent pacemaker interrogation. Seventeen patients were lost to follow-up, seven through death. Results were reported according to atrial fibrillation (AF) class preoperatively: paroxysmal, persistent, and long-standing persistent (LSP). Forty-nine percent of patients remained in sinus rhythm at greater than two years. The percentage of patients in sinus rhythm according to preoperative AF class were 81% (paroxysmal AF), 56% (persistent AF), and 18% (long-standing AF). The class of AF prior to surgery, left atrium size, and body mass index determined the long-term outcome. There were no procedure-related complications. We conclude that high intensity focused ultrasound ablation for atrial fibrillation using the Epicor system is safe and effective for surgical patients with paroxysmal AF. The persistent and LSP AF results suggest that alternative ablation strategies should be considered for these patients. © 2013 Wiley Periodicals, Inc.

Preemptive versus postoperative lumiracoxib for analgesia in ambulatory arthroscopic knee surgery

PubMed Central

Grifka, Joachim; Enz, Rudolf; Zink, Joachim; Hugot, Jean Louis; Kreiss, Andreas; Arulmani, Udayasankar; Yu, Vincent; Rebuli, Rosemary; Krammer, Gerhard

2008-01-01

We compared the efficacy and safety of preemptive vs postoperative dosing of lumiracoxib 400 mg in patients undergoing minor ambulatory arthroscopic knee surgery. Eligible patients were randomized to preemptive lumiracoxib, postoperative lumiracoxib, and placebo. The main efficacy parameter was pain intensity (PI) (0–100 mm visual analog scale) in the target knee upon movement, 2 hours after surgery. Other efficacy variables included PI in the target knee at rest and upon movement at 1, 3, 4, and 24 hours, time to first rescue medication intake. In the lumiracoxib preemptive and postoperative groups, the estimated treatment difference compared to placebo for primary endpoint was −4.0 (95% CI: −9, −1; p = 0.007) and −3.5 (95% CI: −8.5, 0; p = 0.052), respectively. There was no statistical significant difference between two active treatment groups (p = 0.602). Both preemptive and postoperative lumiracoxib resulted in significantly lower PI scores at rest and after movement at all time-points and no statistically significant difference was observed between the active treatments. Time to rescue medication intake was comparable for both active treatments. The proportion of adverse events was similar among all groups. We conclude that the efficacy of lumiracoxib 400 mg is not affected by the timing of administration (preemptive or postoperative). PMID:21197285

Quality organization and risk in anaesthesia: the French perspective.

PubMed

Marty, Jean; Samain, Emmanuel

2017-04-01

Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization. Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands. The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified.

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

PubMed

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

2012-01-01

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

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

PubMed

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

2010-01-01

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

42 CFR 23.21 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

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

Measuring hot flash phenomenonology using ambulatory prospective digital diaries

PubMed Central

Fisher, William I.; Thurston, Rebecca C.

2016-01-01

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

Measuring hot flash phenomenonology using ambulatory prospective digital diaries.

PubMed

Fisher, William I; Thurston, Rebecca C

2016-11-01

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

Disenrollment from Medicare HMOs.

PubMed

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

2001-01-01

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

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

PubMed

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

2016-01-01

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

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

PubMed Central

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

2016-01-01

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

Early Ambulation Decreases Length of Hospital Stay, Perioperative Complications and Improves Functional Outcomes in Elderly Patients Undergoing Surgery for Correction of Adult Degenerative Scoliosis.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Fialkoff, Jared; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos

2017-09-15

Ambispective cohort review. To examine the effects of early mobilization on patient outcomes, complications profile, and 30-day readmission rates. Prolonged immobilization after surgery can result in functional decline and an increased risk of hospital-associated complications. We conducted an ambispective study of 125 elderly patients (>65 years) undergoing elective spinal surgery for correction of adult degenerative scoliosis. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. "Days of immobility" was defined as the number of days until a patient moved out of bed beyond a chair. Patients in the top and bottom quartiles were dichotomized into "early ambulators" and "late ambulators", respectively. Early ambulators were ambulatory within 24 hours of surgery, whereas late ambulators were ambulatory at a minimum of 48 hours after surgery. Complication rates, duration of hospital stay, and 30-day readmission rates were compared between early ambulators and late ambulators. Baseline characteristics were similar between both cohorts. Compared with patients with a longer duration of immobility (i.e., late ambulators), the prevalence of at least one perioperative complication was significantly lower in the early ambulators cohort (30% vs. 54%, P = 0.06). The length of inhospital stay was 34% shorter in the early ambulators cohort (5.33 days vs. 8.11 days, P = 0.01). Functional independence was superior in the early ambulators cohort, with the majority of patients discharged directly home after surgery compared with late ambulators (71.2% vs. 22.0%, P = 0.01). Early ambulation after surgery significantly reduces the incidence of perioperative complications, shortens duration of inhospital stay, and contributes to improved perioperative functional status in elderly patients. Even a delay of 24 hours to ambulation is associated with higher complication rates and inferior functional outcomes. 3.

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

PubMed

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

2014-06-01

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

Retroperitoneal hemorrhage from an unrecognized puncture of the lumbar right segmental artery during lumbar chemical sympathectomy: diagnosis and management.

PubMed

Shin, Ho-Jin; Choi, Yun-Mi; Kim, Hye-Jin; Lee, Sun-Jae; Yoon, Seok-Hyun; Kim, Kyung-Hoon

2014-12-01

Lumbar chemical sympathectomy has been performed using fluoroscopic guidance for needle positioning. An 84 year old woman with atherosclerosis obliterans was referred to the pain clinic for intractable cold allodynia of her right foot. A thermogram showed decreased temperature of both feet compared with temperatures above both ankles. The patient agreed to undergo lumbar chemical sympathectomy using fluoroscopy after being informed of the associated risks of nerve injury, hemorrhage, infection, transient back pain, and transient hypotension. During the procedure and three hours afterward, no abnormal signs or symptoms were found except an increase in right leg temperature. The patient was ambulatory after the procedure. However, one day after undergoing lumbar chemical sympathectomy, she visited our emergency department for abdominal discomfort and postural dizziness. Her blood pressure was 80/50 mmHg, and flank tenderness was noted. Retroperitoneal hemorrhage from the second right lumbar segmental artery was shown on computed tomography and angiography. Vital signs were stabilized immediately after embolization into the right lumbar segmental artery. Copyright © 2014 Elsevier Inc. All rights reserved.

Wearable electroencephalography. What is it, why is it needed, and what does it entail?

PubMed

Casson, Alexander; Yates, David; Smith, Shelagh; Duncan, John; Rodriguez-Villegas, Esther

2010-01-01

The electroencephalogram (EEG) is a classic noninvasive method for measuring a person's brain waves and is used in a large number of fields: from epilepsy and sleep disorder diagnosis to brain-computer interfaces (BCIs). Electrodes are placed on the scalp to detect the microvolt-sized signals that result from synchronized neuronal activity within the brain. Current long-term EEG monitoring is generally either carried out as an inpatient in combination with video recording and long cables to an amplifier and recording unit or is ambulatory. In the latter, the EEG recorder is portable but bulky, and in principle, the subject can go about their normal daily life during the recording. In practice, however, this is rarely the case. It is quite common for people undergoing ambulatory EEG monitoring to take time off work and stay at home rather than be seen in public with such a device. Wearable EEG is envisioned as the evolution of ambulatory EEG units from the bulky, limited lifetime devices available today to small devices present only on the head that can record EEG for days, weeks, or months at a time. Such miniaturized units could enable prolonged monitoring of chronic conditions such as epilepsy and greatly improve the end-user acceptance of BCI systems. In this article, we aim to provide a review and overview of wearable EEG technology, answering the questions: What is it, why is it needed, and what does it entail? We first investigate the requirements of portable EEG systems and then link these to the core applications of wearable EEG technology: epilepsy diagnosis, sleep disorder diagnosis, and BCIs. As a part of our review, we asked 21 neurologists (as a key user group) for their views on wearable EEG. This group highlighted that wearable EEG will be an essential future tool. Our descriptions here will focus mainly on epilepsy and the medical applications of wearable EEG, as this is the historical background of the EEG, our area of expertise, and a core motivating area in itself, but we will also discuss the other application areas. We continue by considering the forthcoming research challenges, principally new electrode technology and lower power electronics, and we outline our approach for dealing with the electronic power issues. We believe that the optimal approach to realizing wearable EEG technology is not to optimize any one part but to find the best set of tradeoffs at both the system and implementation level. In this article, we discuss two of these tradeoffs in detail: investigating the online compression of EEG data to reduce the system power consumption and the optimal method for providing this data compression.

NATIONAL SURVEY FOR AMBULATORY SURGERY (NSAS)

EPA Science Inventory

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

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

PubMed

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

2017-12-01

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

Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors.

PubMed

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

2013-11-01

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

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

PubMed

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

2010-01-01

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

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

PubMed Central

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

2004-01-01

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

Ambulatory surgery: is the liability risk lower?

PubMed

Metzner, Julia; Kent, Christopher D

2012-12-01

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

[Ambulatory anesthesia in pediatric surgery].

PubMed

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

2000-04-01

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

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

PubMed

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

2018-05-29

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

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

PubMed

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

2016-11-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-27

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

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

PubMed

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

2008-01-01

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

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

PubMed Central

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

2012-01-01

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

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

PubMed

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

1981-03-15

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

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

PubMed

Sterba, John A

2006-01-01

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

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

PubMed

Cody, M

1996-01-01

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

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

PubMed

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

2014-04-01

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

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

PubMed

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

1991-03-30

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

Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

ERIC Educational Resources Information Center

Singh, Hardeep; Weingart, Saul N.

2009-01-01

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

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

PubMed

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

2002-10-01

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

Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Outpatient Continuous Telemetry After Embolic Stroke of Undetermined Source.

PubMed

Sebasigari, Denise; Merkler, Alexander; Guo, Yang; Gialdini, Gino; Kummer, Benjamin; Hemendinger, Morgan; Song, Christopher; Chu, Antony; Cutting, Shawna; Silver, Brian; Elkind, Mitchell S V; Kamel, Hooman; Furie, Karen L; Yaghi, Shadi

2017-06-01

Biomarkers of atrial dysfunction or "cardiopathy" are associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict AF on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS). This was a single-center retrospective study including all patients with ESUS undergoing 30 days of ambulatory heart-rhythm monitoring to look for AF between January 1, 2013 and December 31, 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was a new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in electrocardiogram (ECG) lead V1, and P wave - R wave (PR) interval on ECG. A multiple logistic regression model was used to assess the relationship between atrial biomarkers and AF detection. Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 years versus 61.4 years, P < .001) and had larger left atrial diameter (39.2 mm versus 35.7 mm, P = .03). In a multivariable model, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; P = .04). Atrial biomarkers were weakly associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

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

PubMed

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

2013-05-01

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

Comparison of ambulatory and inpatient cleft lip surgery for adults.

PubMed

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

2010-01-01

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

Concept of the Ambulatory Pain Physician.

PubMed

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

2017-01-01

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

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

PubMed

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

2013-01-01

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

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

PubMed

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

2016-11-01

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

A comparison of total intravenous anaesthesia using propofol with sevoflurane or desflurane in ambulatory surgery: systematic review and meta-analysis.

PubMed

Kumar, G; Stendall, C; Mistry, R; Gurusamy, K; Walker, D

2014-10-01

With the popularity of ambulatory surgery ever increasing, we carried out a systematic review and meta-analysis to determine whether the type of anaesthesia used had any bearing on patient outcomes. Total intravenous propofol anaesthesia was compared with two of the newer inhalational agents, sevoflurane and desflurane. In total, 18 trials were identified; only trials where nitrous oxide was administered to, or omitted from, both groups were included. A total of 1621 patients were randomly assigned to either propofol (685 patients) or inhalational anaesthesia (936 patients). If surgical causes of unplanned admissions were excluded, there was no difference in unplanned admission to hospital between propofol and inhalational anaesthesia (1.0% vs 2.9%, respectively; p = 0.13). The incidence of postoperative nausea and vomiting was lower with propofol than with inhalational agents (13.8% vs 29.2%, respectively; p < 0.001). However, no difference was noted in post-discharge nausea and vomiting (23.9% vs 20.8%, respectively; p = 0.26). Length of hospital stay was shorter with propofol, but the difference was only 14 min on average. The use of propofol was also more expensive, with a mean (95% CI) difference of £6.72 (£5.13-£8.31 (€8.16 (€6.23-€10.09); $11.29 ($8.62-$13.96))) per patient-anaesthetic episode (p < 0.001). Therefore, based on the published evidence to date, maintenance of anaesthesia using propofol appeared to have no bearing on the incidence of unplanned admission to hospital and was more expensive, but was associated with a decreased incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients undergoing ambulatory surgery. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities.

PubMed

Gupta, Varun; Parikh, Rikesh; Nguyen, Lyly; Afshari, Ashkan; Shack, R Bruce; Grotting, James C; Higdon, K Kye

2017-02-01

There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned. This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals. A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed. Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01). Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3. © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.

Retinoic Acid Improves Morphology of Cultured Peritoneal Mesothelial Cells from Patients Undergoing Dialysis

PubMed Central

Retana, Carmen; Sanchez, Elsa I.; Gonzalez, Sirenia; Perez-Lopez, Alejandro; Cruz, Armando; Lagunas-Munoz, Jesus; Alfaro-Cruz, Carmen; Vital-Flores, Socorro; Reyes, José L.

2013-01-01

Patients undergoing continuous ambulatory peritoneal dialysis are classified according to their peritoneal permeability as low transporter (low solute permeability) or High transporter (high solute permeability). Factors that determine the differences in permeability between them have not been fully disclosed. We investigated morphological features of cultured human peritoneal mesothelial cells from low or high transporter patients and its response to All trans retinoic Acid (ATRA, vitamin A active metabolite), as compared to non-uremic human peritoneal mesothelial cells. Control cells were isolated from human omentum. High or low transporter cells were obtained from dialysis effluents. Cells were cultured in media containing ATRA (0, 50, 100 or 200 nM). We studied length and distribution of microvilli and cilia (scanning electron microscopy), epithelial (cytokeratin, claudin-1, ZO-1 and occludin) and mesenchymal (vimentin and α-smooth muscle actin) transition markers by immunofluorescence and Western blot, and transforming growth factor β1 expression by Western blot. Low and high transporter exhibited hypertrophic cells, reduction in claudin-1, occludin and ZO-1 expression, cytokeratin and vimentin disorganization and positive α-smooth muscle actin label. Vimentin, α-smooth muscle actin and transforming growth factor- β1 were overexpressed in low transporter. Ciliated cells were diminished in low and high transporters. Microvilli number and length were severely reduced in high transporter. ATRA reduced hypertrophic cells number in low transporter. It also improved cytokeratin and vimentin organization, decreased vimentin and α-smooth muscle actin expression, and increased claudin 1, occludin and ZO-1 expression, in low and high transporter. In low transporter, ATRA reduced transforming growth factor-β1 expression. ATRA augmented percentage of ciliated cells in low and high transporter. It also augmented cilia length in high transporter. Alterations in structure, epithelial mesenchymal markers and transforming growth factor-β1expression were differential between low and high transporter. Beneficial effects of ATRA were improved human peritoneal mesothelial cells morphology tending to normalize structures. PMID:24223992

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

USDA-ARS?s Scientific Manuscript database

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

Sedation with intranasal midazolam of Angolan children undergoing invasive procedures.

PubMed

Kawanda, Lumana; Capobianco, Ivan; Starc, Meta; Felipe, Daniel; Zanon, Davide; Barbi, Egidio; Munkela, Nadine; Rodrigues, Verónica; Malundo, Lúis; Not, Tarcisio

2012-07-01

Ambulatory surgery is a daily requirement in poor countries, and limited means and insufficient trained staff lead to the lack of attention to the patient's pain. Midazolam is a rapid-onset, short-acting benzodiazepine which is used safely to reduce pain in children. We evaluated the practicability of intranasal midazolam sedation in a suburban hospital in Luanda (Angola), during the surgical procedures. Intranasal midazolam solution was administered at a dose of 0.5 mg/kg. Using the Ramsay's reactivity score, we gave a score to four different types of children's behaviour: moaning, shouting, crying and struggling, and the surgeon evaluated the ease of completing the surgical procedure using scores from 0 (very easy) to 3 (managing with difficulty). Eighty children (median age, 3 years) were recruited, and 140 surgical procedures were performed. Fifty-two children were treated with midazolam during 85 procedures, and 28 children were not treated during 55 procedures. We found a significant difference between the two groups on the shouting, crying and struggling parameters (p < 0.001). The mean score of the ease of completing the procedures was significantly different among the two groups (p < 0.0001). These results provide a model of procedural sedation in ambulatory surgical procedures in poor countries, thus abolishing pain and making the surgeon's job easier. © 2012 The Author(s)/Acta Paediatrica © 2012 Foundation Acta Paediatrica.

The content of hope in ambulatory patients with colon cancer.

PubMed

Beckman, Emily S; Helft, Paul R; Torke, Alexia M

2013-01-01

Although hope is a pervasive concept in cancer treatment, we know little about how ambulatory patients with cancer define or experience hope. We explored hope through semistructured interviews with ten patients with advanced (some curable, some incurable) colon cancer at one Midwestern, university-based cancer center. We conducted a thematic analysis to identify key concepts related to patient perceptions of hope. Although we did ask specifically about hope, patients also often revealed their hopes in response to indirect questions or by telling stories about their cancer experience. We identified four major themes related to hope: 1) hope is essential, 2) a change in perspective, 3) the content of hope, and 4) communicating about hope. The third theme, the content of hope, included three subthemes: a) the desire for normalcy, b) future plans, and c) hope for a cure. We conclude that hope is an essential concept for patients undergoing treatment for cancer as it pertains to their psychological well-being and quality of life, and hope for a cure is not and should not be the only consideration. In a clinical context, the exploration of patients' hopes and aspirations in light of their cancer diagnosis is important because it provides a frame for understanding their goals for treatment. Exploration of the content of patients' hope can not only help to illuminate misunderstandings but also clarify how potential treatments may or may not contribute to achieving patients' goals.

Attribute correlates of hospital outpatient satisfaction.

PubMed

Krueckeberg, H F; Hubbert, A

1995-01-01

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

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

PubMed

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

2012-01-01

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

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

PubMed

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

2015-10-01

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

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

PubMed

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

2009-08-01

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

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

PubMed

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

2015-05-01

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

Metadata - National Hospital Ambulatory Medical Care Survey (NHAMCS)

EPA Pesticide Factsheets

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

Developments in ambulatory surgery in orthopedics in France in 2016.

PubMed

Hulet, C; Rochcongar, G; Court, C

2017-02-01

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

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

PubMed

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

2018-04-01

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

Cost sharing and hospitalizations for ambulatory care sensitive conditions.

PubMed

Arrieta, Alejandro; García-Prado, Ariadna

2015-01-01

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

Ambulatory blood pressure and cardiovascular events in chronic kidney disease

PubMed Central

Agarwal, Rajiv

2007-01-01

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

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

PubMed

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

2002-06-01

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

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

DTIC Science & Technology

2003-10-01

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

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

PubMed

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

2008-01-01

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

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

PubMed

2012-11-15

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2007-06-01

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

Recovery of dynamic balance after general anesthesia with sevoflurane in short-duration oral surgery.

PubMed

Fujisawa, Toshiaki; Miyamoto, Eriko; Takuma, Shigeru; Shibuya, Makiko; Kurozumi, Akihiro; Kimura, Yukifumi; Kamekura, Nobuhito; Fukushima, Kazuaki

2009-01-01

Recovery of dynamic balance, involving adjustment of the center of gravity, is essential for safe discharge on foot after ambulatory anesthesia. The purpose of this study was to assess the recovery of dynamic balance after general anesthesia with sevoflurane, using two computerized dynamic posturographies. Nine hospitalized patients undergoing oral surgery of less than 2 h duration under general anesthesia (air-oxygensevoflurane) were studied. A dynamic balance test, assessing the ability of postural control against unpredictable perturbation stimuli (Stability System; Biodex Medical), a walking analysis test using sheets with foot pressure sensors (Walk Way-MG1000; Anima), and two simple psychomotor function tests were performed before anesthesia (baseline), and 150 and 210 min after the emergence from anesthesia. Only the double-stance phase in the walking analysis test showed a significant difference between baseline and results at 150 min. None of the other variables showed any differences among results at baseline and at 150 and 210 min. The recovery times for dynamic balance and psychomotor function seem to be within 150 min after emergence from general anesthesia with sevoflurane in patients undergoing oral surgery of less than 2-h duration.

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

PubMed

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

2017-12-01

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

Association Between Hospital Case Volume and the Use of Bronchoscopy and Esophagoscopy During Head and Neck Cancer Diagnostic Evaluation

PubMed Central

Sun, Gordon H.; Aliu, Oluseyi; Moloci, Nicholas M.; Mondschein, Joshua K.; Burke, James F.; Hayward, Rodney A.

2013-01-01

Background There are no clinical guidelines on best practices for the use of bronchoscopy and esophagoscopy in diagnosing head and neck cancer. This retrospective cohort study examined variation in the use of bronchoscopy and esophagoscopy across hospitals in Michigan. Patients and Methods We identified 17,828 head and neck cancer patients in the 2006–2010 Michigan State Ambulatory Surgery Databases. We used hierarchical, mixed-effect logistic regression to examine whether a hospital’s risk-adjusted rate of concurrent bronchoscopy or esophagoscopy was associated with its case volume (<100, 100–999, or ≥1000 cases/hospital) for those undergoing diagnostic laryngoscopy. Results Of 9,218 patients undergoing diagnostic laryngoscopy, 1,191 (12.9%) received concurrent bronchoscopy and 1,675 (18.2%) underwent concurrent esophagoscopy. The median hospital rate of bronchoscopy was 2.7% (range 0–61.1%), and low-volume (OR 27.1 [95% CI 1.9, 390.7]) and medium-volume (OR 28.1 [95% CI 2.0, 399.0]) hospitals were more likely to perform concurrent bronchoscopy compared to high-volume hospitals. The median hospital rate of esophagoscopy was 5.1% (range 0–47.1%), and low-volume (OR 9.8 [95% CI 1.5, 63.7]) and medium-volume (OR 8.5 [95% CI 1.3, 55.0]) hospitals were significantly more likely to perform concurrent esophagoscopy relative to high-volume hospitals. Conclusions Head and neck cancer patients undergoing diagnostic laryngoscopy are much more likely to undergo concurrent bronchoscopy and esophagoscopy at low- and medium-volume hospitals than at high-volume hospitals. Whether this represents over-use of concurrent procedures or appropriate care that leads to earlier diagnosis and better outcomes merits further investigation. PMID:24114146

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

PubMed

Becker, Scott; Harned, Nicholas

2002-04-01

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

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

PubMed

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

2011-10-01

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

Acceptance of Ambulatory Laparoscopic Cholecystectomy in Central Switzerland.

PubMed

Widjaja, Sandra P; Fischer, Henning; Brunner, Alexander R; Honigmann, Philipp; Metzger, Jürg

2017-11-01

Currently, most patients undergoing laparoscopic cholecystectomy (LC) in Switzerland are inpatients for 2-3 days. Due to a lack of available hospital beds, we asked whether day-case surgery would be an option for patients in central Switzerland. The questions of acceptability of outpatient LC and factors contributing to the acceptability thus arose. Hundred patients suffering from symptomatic cholecystolithiasis, capable of communicating in German, and between 18 and 65 years old, were included. Patients received a pre-operative questionnaire on medical history and social situation when informed consent on surgery and participation in the study was obtained. Exclusion criteria were patients suffering from acute cholecystitis or any type of cancer; having a BMI >40 kg/m 2 ; needing conversion to open cholecystectomy or an intraoperative drainage; and non-German speakers. Surgery was performed laparoscopically. Both surgeon and patient filled in a postoperative questionnaire. The surgeon's questionnaire listed medical and technical information, and the patients' questionnaire listed medical information, satisfaction with the treatment and willingness to be released on the same day. These data from both questionnaires were grouped into social and medical factors and analysed on their influence upon willingness to accept an ambulatory procedure. No outpatient follow-up apart from checking for readmission to our hospital within 1 month after discharge was performed. Of the 100 participants, one-third was male. More than two-thirds were Swiss citizens. Only one participant was ineligible for rapid release evaluation due to need of a drainage. Among the social factors contributing to the acceptability of ambulatory care, we found nationality to be relevant; Swiss citizens preferred an inpatient procedure, whereas non-Swiss citizens were significantly more willing to return home on the same day. Household size, sex and age did not correlate with a preference for inpatient care in our study population. Furthermore, medical input factors such as the surgeon's level of experience, operation time or use of local anaesthesia at the end of surgery had also no significant influence on whether patients preferred inpatient care or not. Medical output factors not found to contribute to the patients' decisions included co-morbidities or postoperative nausea and vomiting (PONV). Patients of experienced surgeons reported significantly less pain at the operation site. This was correlated with a somewhat increased willingness to accept ambulatory treatment. Given the choice, about half of the LC patients in central Switzerland prefer to stay in hospital overnight. PONV, age, sex or social surroundings were not predictive of the preferred treatment modality. Only being a non-Swiss citizen and experiencing little pain at the operation site due to the surgeon's skills seem to be factors that lead to a preference for ambulatory LC (ALC). Therefore, ALC in central Switzerland is most acceptable to non-Swiss citizens, operated upon by experienced surgeons.

The Dose-response of Intrathecal Ropivacaine Co-administered with Sufentanil for Cesarean Delivery under Combined Spinal-epidural Anesthesia in Patients with Scarred Uterus

PubMed Central

Xiao, Fei; Xu, Wen-Ping; Zhang, Yin-Fa; Liu, Lin; Liu, Xia; Wang, Li-Zhong

2015-01-01

Background: Spinal anesthesia is considered as a reasonable anesthetic option in lower abdominal and lower limb surgery. This study was to determine the dose-response of intrathecal ropivacaine in patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia. Methods: Seventy-five patients with scarred uterus undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blinded, dose-ranging study. Patients received 6, 8, 10, 12, or 14 mg intrathecal hyperbaric ropivacaine with 5 μg sufentanil. Successful spinal anesthesia was defined as a T4 sensory level achieved with no need for epidural supplementation. The 50% effective dose (ED50) and 95% effective dose (ED95) were calculated with a logistic regression model. Results: ED50 and ED95 of intrathecal hyperbaric ropivacaine for patients with scarred uterus undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA) were 8.28 mg (95% confidence interval [CI]: 2.28–9.83 mg) and 12.24 mg (95% CI: 10.53–21.88 mg), respectively. Conclusion: When a CSEA technique is to use in patients with scarred uterus for an elective cesarean delivery, the ED50 and ED95 of intrathecal hyperbaric ropivacaine along with 5 μg sufentanil were 8.28 mg and 12.24 mg, respectively. In addition, this local anesthetic is unsuitable for emergent cesarean delivery, but it has advantages for ambulatory patients. PMID:26415793

Helping You Choose Quality Ambulatory Care

MedlinePlus

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

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

PubMed Central

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

1987-01-01

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

Continuous Blood Pressure Monitoring in Daily Life

NASA Astrophysics Data System (ADS)

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

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

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

PubMed

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

2007-01-01

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

Usability Testing of Two Ambulatory EHR Navigators.

PubMed

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

2016-01-01

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

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

PubMed

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

2014-01-01

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

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

DTIC Science & Technology

2016-01-01

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

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

PubMed Central

Berman, P.

2000-01-01

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

Views of Japanese patients on the advantages and disadvantages of hemodialysis and peritoneal dialysis.

PubMed

Nakamura-Taira, Nanako; Muranaka, Yoshimi; Miwa, Masako; Kin, Seikon; Hirai, Kei

2013-08-01

The preference for dialysis modalities is not well understood in Japan. This study explored the subjective views of Japanese patients undergoing dialysis regarding their treatments. The participants were receiving in-center hemodialysis (CHD) or continuous ambulatory peritoneal dialysis (CAPD). In Study 1, 34 participants (17 CHD and 17 CAPD) were interviewed about the advantages and disadvantages of dialysis modalities. In Study 2, 454 dialysis patients (437 CHD and 17 CAPD) rated the advantages and disadvantages of CHD and CAPD in a cross-sectional survey. Interviews showed that professional care and dialysis-free days were considered as advantages of CHD, while independence, less hospital visits, and flexibility were considered as advantages of CAPD. Disadvantages of CHD included restriction of food and fluids and unpleasant symptoms after each dialysis session. Catheter care was an additional disadvantage of CAPD. Survey showed that the highly ranked advantages were professional care in CHD and less frequent hospital visits in CAPD, while the highly ranked disadvantages were concerns about emergency and time restrictions in CHD, and catheter care and difficulty in soaking in a bath in CAPD. The total scores of advantages and disadvantages showed that CHD patients subjectively rated their own modality better CHD over CAPD, while CAPD patients had the opposite opinion. The results of this study indicate that the factors affecting the decision-making process of Japanese patients are unique to Japanese culture, namely considering the trouble caused to the people around patients (e.g., families, spouses, and/or caregivers).

Evaluation of the impact of preoperative education in ambulatory laparoscopic cholecystectomy. A prospective, double-blind randomized trial.

PubMed

Subirana Magdaleno, Helena; Caro Tarragó, Aleidis; Olona Casas, Carles; Díaz Padillo, Alba; Franco Chacón, Mario; Vadillo Bargalló, Jordi; Saludes Serra, Judit; Jorba Martín, Rosa

2018-02-01

Outpatient laparoscopic cholecystectomy is a safe procedure and provides a better use of health resources and perceived satisfaction without affecting quality of care. Preoperative education has shown less postoperative stress, pain and nausea in some interventions. The principal objective of this study is to assess the impact of preoperative education on postoperative pain in patients undergoing ambulatory laparoscopic cholecystectomy. Secondary objectives were: to evaluate presence of nausea, morbidity, hospital admissions, readmissions rate, quality of life and satisfaction. Prospective, randomized, and double blind study. Between April 2014 and May 2016, 62 patients underwent outpatient laparoscopic cholecystectomy. ASA I-II, age 18-75, outpatient surgery criteria, abdominal ultrasonography with cholelithiasis. Patient randomization in two groups, group A: intensified preoperative education and group B: control. Sixty-two patients included, 44 women (71%), 18 men (29%), mean age 46,8 years (20-69). Mean BMI 27,5. Outpatient rate 92%. Five cases required admission, two due to nausea. Pain scores obtained using a VAS was at 24-hour, 2,9 in group A and 2,7 in group B. There were no severe complications or readmissions. Results of satisfaction and quality of life scores were similar for both groups. We did not find differences due to intensive preoperative education. However, we think that a correct information protocol should be integrated into the patient's preoperative preparation. Registered in ISRCTN number ISRCTN83787412. Copyright © 2017 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

[§ 116b SGB V (social insurance code, book five) for rheumatology patients. An empirical assessment on the basis of administrative data].

PubMed

Rath, T; Bokern, E; Sefo-Bukow, E; Büscher, G; Lüngen, M; Rubbert-Roth, A

2011-01-01

The choice between outpatient and inpatient care is currently undergoing major changes within the German health care system with the amendment of § 116b SGB V. This study investigates what proportion of hitherto inpatient rheumatologic care could potentially be given on an outpatient basis. The analysis is based on administrative inpatient data from 2004 to 2008 covering approximately 23.6 million private health insurance insurants. The selection of patients with rheumatological diseases was based on diagnosis according to ICD-10 of § 116b SGB V. From 2004 to 2008 the number of all rheumatologic cases increased by 13.9%, while the average length of hospital stay decreased from 9.46 days to 8.08 days and the number of attending hospitals declined by 3.1%. The number of rheumatologic cases with a short inpatient stay (≤2 days) increased by 32.3%. We define the ambulatory potential as the proportion of patients with a short length of stay to the total of inpatient rheumatologic cases; this increased from 25.7% to 29.9%. Not all patients with a short inpatient stay can be transferred problem-free to ambulatory care. No channeling of patients to specialized centres has taken place thus far in Germany. Quality of care at the hospitals studied has not been considered. Further data are needed to link administrative data with quality care data.

Continuous recording of pulmonary artery pressure in unrestricted subjects.

PubMed Central

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

1984-01-01

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

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

PubMed Central

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

2016-01-01

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

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

PubMed

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

2017-01-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2016-05-01

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

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

PubMed Central

2010-01-01

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

Defining and evaluating quality for ambulatory care educational programs.

PubMed

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

1997-06-01

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

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

PubMed

Krüll, A; Debatin, J F

2013-02-01

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

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

PubMed

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

2014-03-01

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

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

PubMed Central

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

2010-01-01

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

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

PubMed

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

2017-12-01

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

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

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-17

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

Development of a practice-based research program.

PubMed

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

1998-01-01

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

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

DTIC Science & Technology

1982-08-01

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

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

DTIC Science & Technology

2018-01-01

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

Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery.

PubMed

Williams, B A; DeRiso, B M; Engel, L B; Figallo, C M; Anders, J W; Sproul, K A; Ilkin, H; Harner, C D; Fu, F H; Nagarajan, N J; Evans, J H; Watkins, W D

1998-11-01

(1) To introduce anesthesia clinical pathways as a management tool to improve the quality of care; (2) to use the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as a template for data collection and analysis; and (3) to determine the effects of anesthesia clinical pathways on surgical processes, outcomes, and costs in common ambulatory orthopedic surgery. Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathways existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. Regional anesthesia options were routinely offered to patients in the clinical pathway. Ambulatory surgery center in a teaching hospital. The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients underwent clinical pathway anesthesia care in which the intraoperative and postoperative anesthesia process was standardized with respect to symptom management, drugs, and equipment used. 1995-1996 patients did not have a standardized intraoperative and postoperative anesthetic course with respect to the management of common symptoms or to specific drugs and supplies used. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by the use of the anesthesia clinical pathway, were measured. Clinical pathway anesthesia care of ACLR in 1996-1997, which actively incorporated regional anesthesia options, reduced pharmacy and materials cost variability; slightly increased turnover time; improved intraoperative anesthesia and surgical efficiency, recovery times, and unexpected admission rates; and decreased the number of required nursing interventions for common postoperative symptoms. Clinical pathway patient management systems in anesthesia care are likely to produce useful outcome data of current practice patterns when compared with historical controls. This management tool may be useful in simultaneously containing costs and improving process efficiency and patient outcomes.

A multinational clinical approach to assessing the effectiveness of catheter-based ultrasound renal denervation: The RADIANCE-HTN and REQUIRE clinical study designs.

PubMed

Mauri, Laura; Kario, Kazuomi; Basile, Jan; Daemen, Joost; Davies, Justin; Kirtane, Ajay J; Mahfoud, Felix; Schmieder, Roland E; Weber, Michael; Nanto, Shinsuke; Azizi, Michel

2018-01-01

Catheter-based renal denervation is a new approach to treat hypertension via modulation of the renal sympathetic nerves. Although nonrandomized and small, open-label randomized studies resulted in significant reductions in office blood pressure 6months after renal denervation with monopolar radiofrequency catheters, the first prospective, randomized, sham-controlled study (Symplicity HTN-3) failed to meet its blood pressure efficacy end point. New clinical trials with new catheters have since been designed to address the limitations of earlier studies. Accordingly, the RADIANCE-HTN and REQUIRE studies are multicenter, blinded, randomized, sham-controlled trials designed to assess the blood pressure-lowering efficacy of the ultrasound-based renal denervation system (Paradise) in patients with established hypertension either on or off antihypertensive medications, is designed to evaluate patients in 2 cohorts-SOLO and TRIO, in the United States and Europe. The SOLO cohort includes patients with essential hypertension, at low cardiovascular risk, and either controlled on 1 to 2 antihypertensive medications or uncontrolled on 0 to 2 antihypertensive medications. Patients undergo a 4-week medication washout period before randomization to renal denervation (treatment) or renal angiogram (sham). The TRIO cohort includes patients with hypertension resistant to at least 3 antihypertensive drugs including a diuretic. Patients will be stabilized on a single-pill, triple-antihypertensive-drug combination for 4weeks before randomization to treatment or sham. Reduction in daytime ambulatory systolic blood pressure (primary end point) will be assessed at 2months in both cohorts. A predefined medication escalation protocol, as needed for blood pressure control, is implemented between 2 and 6months in both cohorts by a study staff member blinded to the randomization process. At 6months, daytime ambulatory blood pressure and antihypertensive treatment score will be assessed. REQUIRE is designed to evaluate patients with resistant hypertension on standard of care medication in Japan and Korea. Reduction in 24-hour ambulatory systolic blood pressure will be assessed at 3months (primary end point). Both studies are enrolling patients, and their results are expected in 2018. Copyright © 2017 Elsevier Inc. All rights reserved.

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

PubMed

Cibulka, Nancy J

2011-11-01

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

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

PubMed

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

2016-08-01

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

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

PubMed

Roski, J; Gregory, R

2001-12-01

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

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

PubMed

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

2010-01-01

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

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

PubMed

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

2002-04-01

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

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

PubMed

Sorgatz, H

1994-01-01

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

Ambulatory cleft lip surgery: A value analysis.

PubMed

Arneja, Jugpal S; Mitton, Craig

2013-01-01

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

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

PubMed

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

2015-05-01

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

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

PubMed

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

2018-04-01

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

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

PubMed

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

2018-04-19

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

[The feasibility of CDDP administration for gastric cancer outpatients undergoing S-1/cisplatin combination therapy].

PubMed

Kishimoto, Tomono; Imamura, Hiroshi; Kawabata, Ryohei; Kimura, Yutaka; Fujii, Chika; Fukunaga, Mutsumi; Ohzato, Hiroki

2012-11-01

S-1/cisplatin(CDDP) combination therapy(SP therapy)(S-1: 80 mg/m2/day, day 1-21, CDDP: 60 mg/m2, day 8, q35 days) is a standard regimen for advanced gastric cancer in Japan. Hydration under hospitalization is necessary for CDDP administration to prevent renal toxicity; nevertheless, ambulatory chemotherapy has recently become commonly used. Therefore CDDP administration using a short hydration regimen for gastric cancer outpatients undergoing SP therapy has been performed in our institute. Between August 2009 and November 2011, 23 patients who were treated with SP therapy as a first line therapy and began CDDP treatment in the outpatient setting were examined, and monitored for adverse events, response rate[best objective response rate(ORR)], time to treatment failure(TTF) and overall survival. A short hydration regimen means 2,550 mL of fluid in 4 h and 55 min, and the necessity of an oral intake of more than 1,000 mL liquid per day on day 7 to 9 was explained to the patients. Grade 1/2 serum creatinine elevation occurred in 5 patients (22%), but there were no incidences of grade 3/4 serum creatinine elevation or heart failure. The best ORR was 69%, median time to treatment failure(mTTF) was 11.5 months, the 1-year survival rate was 77.8%, and the 2-year survival rate was 44.7%. CDDP administration using a short hydration regimen for gastric cancer outpatients undergoing SP therapy was considered to be feasible.

Military Health Service System Ambulatory Work Unit (AWU).

DTIC Science & Technology

1988-04-01

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

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

PubMed

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

2018-05-10

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

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

PubMed

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

2016-08-01

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

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

PubMed

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

2010-01-01

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

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

PubMed

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

2015-10-01

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

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

PubMed

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

2016-08-01

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

Coleman during ICV Assessment in the Kibo JPM during Expedition 26

NASA Image and Video Library

2011-01-07

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

Caseload management skills for improved efficiency.

PubMed

Ervin, Naomi E

2008-03-01

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

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

PubMed

Mastal, Margaret; Levine, June

2012-01-01

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

Development of Quality Metrics in Ambulatory Pediatric Cardiology.

PubMed

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

2017-02-07

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

Double-blind comparison of granisetron, promethazine, or a combination of both for the prevention of postoperative nausea and vomiting in females undergoing outpatient laparoscopies.

PubMed

Gan, Tong J; Candiotti, Keith A; Klein, Stephen M; Rodriguez, Yiliam; Nielsen, Karen C; White, William D; Habib, Ashraf S

2009-11-01

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) are common problems after surgery. Prophylactic combination antiemetic therapy is recommended for patients at high risk for developing PONV and PDNV. Granisetron, a serotonin antagonist, is an effective antiemetic that is devoid of sedative side effect. Although promethazine is effective, commonly used doses are associated with sedation. This study investigates the combination of low doses of granisetron and promethazine for the prevention of PONV. Women undergoing ambulatory gynecological laparoscopy were enrolled. A standard general anesthetic regimen was prescribed. Fifteen minutes before the expected end of surgery, the patients were randomly assigned to receive granisetron 0.1 mg iv, promethazine 6.25 mg iv, or a combination of the two drugs. Prophylaxis with oral promethazine 12.5 mg, granisetron 1 mg, or both was started in the respective groups 12 hr after the end of surgery and continued every 12 hr until postoperative day 3 (a total of five oral doses). The following outcomes were recorded: total response rate (defined as no vomiting, no more than mild nausea, and no use of rescue antiemetic); incidence of nausea, vomiting, and use of rescue antiemetics; severity of nausea; patient activity level; and patient satisfaction with PONV management. Patients in the combination group had a higher total response rate at 6, 24, 48, and 72 hr after surgery compared with those who received promethazine alone (at 24 hr, Combination 69.6%, Promethazine 36.2%, Granisetron 53.3%; P = 0.0079). The maximum nausea scores were also lower in the combination group at 6, 24, 48, and 72 hr (Combination 1.7 +/- 2.2, Promethazine 4.0 +/- 3.6, Granisetron 3.1 +/- 3.2 at 24 hr; P < 0.05). There was no difference in the sedation scores, incidence of drowsiness, patient activity level, and satisfaction with PONV management. Low-dose granisetron and promethazine combination was more effective in reducing PONV and PDNV than promethazine monotherapy. The combination also reduced the severity of nausea.

Triple Therapy with Scopolamine, Ondansetron, and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Moderate to High-Risk Patients Undergoing Craniotomy Under General Anesthesia: A Pilot Study.

PubMed

Bergese, Sergio D; Antor, Maria A; Uribe, Alberto A; Yildiz, Vedat; Werner, Joseph

2015-01-01

Postoperative nausea and vomiting (PONV) is one of the most common complaints from patients and clinicians after a surgical procedure. According to the current Society of Ambulatory Anesthesia Consensus Guidelines, the general incidence of vomiting and nausea is around 30 and 50%, respectively; and up to 80% in high-risk patients. In previous studies, the reported incidence of PONV at 24 h after craniotomy was 43-70%. The transdermal scopolamine (TDS) delivery system contains a 1.5-mg drug reservoir, which is designed to deliver a continuous slow release of scopolamine through intact skin during the first 72 h of patch application. Therefore, we designed this single arm, non-randomized, pilot study to assess the efficacy and safety of triple therapy with scopolamine, ondansetron, and dexamethasone to prevent PONV. In the preoperative area, subjects received an active TDS 1.5 mg that was applied to a hairless patch of skin in the mastoid area approximately 2 h prior to the operation. Immediately after anesthesia induction, all patients received a single 4 mg dose of ondansetron IV and a single 10 mg dose of dexamethasone IV. Patients who experienced nausea and/or vomiting received ondansetron 4 mg IV as the initial rescue medication. Postoperative nausea and vomiting assessments were performed for up to 120 h after surgery. A total of 36 subjects were analyzed. The overall incidence of PONV during the first 24 h after neurological surgery was 33% (n = 12). The incidence of nausea and emesis during the first 24 h after surgery was recorded as 33% (n = 12) and 16% (n = 6), respectively. Our data showed that this triple therapy regimen may be an efficient alternative regimen for PONV prophylaxis in patients undergoing neurological surgery with general anesthesia. Further studies using regimens affecting different receptor pathways should be performed to better prove the efficacy and safety in the prevention or delay of PONV.

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

PubMed Central

2014-01-01

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

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2018-03-01

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

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

ERIC Educational Resources Information Center

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

2017-01-01

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

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

PubMed

Debernardi, G; Borgogna, E

1975-01-01

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

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

PubMed

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

2016-01-01

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

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

PubMed

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

2001-03-01

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

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

PubMed

Carter, Brittany U; Kaylor, Mary Beth

2016-04-01

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

Report of the annual statistical survey of the Japanese Society for Dialysis Therapy in 1996.

PubMed

Shinzato, T; Nakai, S; Akiba, T; Yamagami, S; Yamazaki, C; Kitaoka, T; Kubo, K; Maeda, K; Morii, H

1999-02-01

Nearly 170,000 patients were treated by maintenance renal replacement therapy (RRT) in Japan in 1996. The current status of Japanese patients on RRT might, in some way, be suggestive for patients on RRT in other countries. The Japanese Society for Dialysis Therapy conducts a questionnaire survey of virtually every dialysis facility in Japan at the end of each year. Here we present the results of our survey of patients undergoing RRT as of the end of 1996, as well as five-year trends (1992-1996) in some of the data. The response rate was 99.8%. At the end of 1996, there were 167,192 patients on maintenance RRT in Japan (1,328 persons per million population). The numbers of patients on maintenance RRT continued to increase during the five-year period. The gross mortality rate for that period ranged from 9.4% to 9.7%. Cuprammonium rayon was the most commonly used material (24.0%) for dialyzer membranes, followed by cellulose triacetate (18.7%). Approximately 5.0% of hemodialysis (HD) patients had a prior history of surgical release of carpal tunnel. The longer the years on HD therapy, the greater the proportion of patients with a history of such an operation. The predialysis plasma beta 2-microglobulin concentration was highest in patients aged 30 to 45 years and declined slightly after the age of 45. There was no significant difference in the HbA1c level between continuous ambulatory peritoneal dialysis and HD patients, both in whom diabetes was the disease causing renal failure. Moreover, among HD patients with diabetes, there was a clear tendency for the HbA1c level to be higher when the normalized protein catabolic rate was higher. This report summarizes the latest results of the survey on Japanese patients on RRT.

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

PubMed Central

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

2017-01-01

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

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

PubMed

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

2004-01-01

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

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

PubMed

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

2011-12-01

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

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

PubMed

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

2017-01-01

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

Understanding the C-pulse device and its potential to treat heart failure.

PubMed

Sales, Virna L; McCarthy, Patrick M

2010-03-01

The Sunshine Heart C-Pulse (C-Pulse; Sunshine Heart Inc., Tustin, CA) device is an extra-aortic implantable counterpulsation pump designed as a non-blood contacting ambulatory heart assist device, which may provide relief from symptoms for class II-III congestive heart failure patients. It has a comparable hemodynamic augmentation to intra-aortic balloon counterpulsation devices. The C-Pulse cuff is implanted through a median sternotomy, secured around the ascending aorta, and pneumatically driven by an external system controller. Pre-clinical studies in the acute pig model, and initial temporary clinical studies in patients undergoing off-pump coronary bypass surgery have shown substantial increase in diastolic perfusion of the coronary vessels, which translated to a favorable improvement in ventricular function. A U.S. prospective multi-center trial to evaluate the safety and efficacy of the C-Pulse in class III patients with moderate heart failure is now in progress.

Comorbidity - a troublesome factor in PTSD treatment.

PubMed

Dadić-Hero, Elizabeta; Torić, Ines; Ruzić, Klementina; Medved, Paola; Graovac, Mirjana

2009-09-01

Posttraumatic stress syndrome (PTSD) is a disorder which emerges after the patient has experienced one or more psychotraumatic events, which equally include neurobiological deregulation and psychological dysfunction. Comorbidity is present in more than 80% of the diagnosed cases of PTSD, which makes treatment of the primary disorder very difficult. It has been identified that PTSD can be found in comorbidity with other psychiatric disorders as well as with physical illnesses. This study presents aged 42, who has been psychiatrically treated for the past 12 years, with a diagnose of chronic PTSD and who subsequently developed depression. The patient has been treated for psoriasis for the past seven years, and two years ago, had to undergo surgery due to bladder carcinoma, followed by a radiotherapy course. Multiple comorbidity significantly makes the treatment of the primary illness very difficult and it limits the choice of pharmacotherapy in ambulatory conditions.

Trend Extraction in Functional Data of Amplitudes of R and T Waves in Exercise Electrocardiogram

NASA Astrophysics Data System (ADS)

Cammarota, Camillo; Curione, Mario

The amplitudes of R and T waves of the electrocardiogram (ECG) recorded during the exercise test show both large inter- and intra-individual variability in response to stress. We analyze a dataset of 65 normal subjects undergoing ambulatory test. We model the dataset of R and T series in the framework of functional data, assuming that the individual series are realizations of a non-stationary process, centered at the population trend. We test the time variability of this trend computing a simultaneous confidence band and the zero crossing of its derivative. The analysis shows that the amplitudes of the R and T waves have opposite responses to stress, consisting respectively in a bump and a dip at the early recovery stage. Our findings support the existence of a relationship between R and T wave amplitudes and respectively diastolic and systolic ventricular volumes.

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

PubMed

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

2017-11-01

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

Preliminary evaluation of the effects of photobiomodulation therapy and physical rehabilitation on early postoperative recovery of dogs undergoing hemilaminectomy for treatment of thoracolumbar intervertebral disk disease.

PubMed

Bennaim, Michael; Porato, Mathilde; Jarleton, Astrid; Hamon, Martin; Carroll, James D; Gommeren, Kris; Balligand, Marc

2017-02-01

OBJECTIVE To evaluate the effects of postoperative photobiomodulation therapy and physical rehabilitation on early recovery variables for dogs after hemilaminectomy for treatment of intervertebral disk disease. ANIMALS 32 nonambulatory client-owned dogs. PROCEDURES Dogs received standard postoperative care with photobiomodulation therapy (n = 11), physical rehabilitation with sham photobiomodulation treatment (11), or sham photobiomodulation treatment only (10) after surgery. Neurologic status at admission, diagnostic and surgical variables, duration of postoperative IV analgesic administration, and recovery grades (over 10 days after surgery) were assessed. Time to reach recovery grades B (able to support weight with some help), C (initial limb movements present), and D (ambulatory [≥ 3 steps unassisted]) was compared among groups. Factors associated with ability to ambulate on day 10 or at last follow-up were assessed. RESULTS Time to reach recovery grades B, C, and D and duration of postoperative IV opioid administration did not differ among groups. Neurologic score at admission and surgeon experience were negatively associated with the dogs' ability to ambulate on day 10. The number of disk herniations identified by diagnostic imaging before surgery was negatively associated with ambulatory status at last follow-up. No other significant associations and no adverse treatment-related events were identified. CONCLUSIONS AND CLINICAL RELEVANCE This study found no difference in recovery-related variables among dogs that received photobiomodulation therapy, physical rehabilitation with sham photobiomodulation treatment, or sham photobiomodulation treatment only. Larger studies are needed to better evaluate effects of these postoperative treatments on dogs treated surgically for intervertebral disk disease.

Information perception, wishes, and satisfaction in ambulatory cancer patients under active treatment: patient-reported outcomes with QLQ-INFO25

PubMed Central

Pinto, Ana Catarina; Ferreira-Santos, Fernando; Lago, Lissandra Dal; de Azambuja, Evandro; Pimentel, Francisco Luís; Piccart-Gebhart, Martine; Razavi, Darius

2014-01-01

Background Information is vital to cancer patients. Physician–patient communication in oncology presents specific challenges. The aim of this study was to evaluate self-reported information of cancer patients in ambulatory care at a comprehensive cancer centre and examine its possible association with patients’ demographic and clinical characteristics. Patients and methods This study included adult patients with solid tumours undergoing chemotherapy at the Institute Jules Bordet’s Day Hospital over a ten-day period. EORTC QLQ-C30 and QLQ-INFO25 questionnaires were administered. Demographic and clinical data were collected. Descriptive and inferential statistics were used. Results 101 (99%) fully completed the questionnaires. They were mostly Belgian (74.3%), female (78.2%), with a mean age of 56.9 ± 12.8 years. The most frequent tumour was breast cancer (58.4%). Patients were well-informed about the disease and treatments, but presented unmet information domains. The Jules Bordet patients desired more information on treatment side effects, long-term outcome, nutrition, and recurrence symptoms. Patients on clinical trials reported having received less information about their disease and less written information than patients outside clinical trials. Higher information levels were associated with higher quality of life (QoL) scores and higher patient satisfaction. Conclusion Patients were satisfied with the information they received and this correlated with higher QoL, but they still expressed unmet information wishes. Additional studies are required to investigate the quality of the information received by patients enrolled in clinical trials. PMID:24834120

Gastrocnemius mitochondrial respiration: are there any differences between men and women?

PubMed

Thompson, Jonathan R; Swanson, Stanley A; Casale, George P; Johanning, Jason M; Papoutsi, Evlampia; Koutakis, Panagiotis; Miserlis, Dimitrios; Zhu, Zhen; Pipinos, Iraklis I

2013-11-01

Work on human and mouse skeletal muscle by our group and others has demonstrated that aging and age-related degenerative diseases are associated with mitochondrial dysfunction, which may be more prevalent in males. There have been, however, no studies that specifically examine the influence of male or female sex on human skeletal muscle mitochondrial respiration. The purpose of this study was to compare mitochondrial respiration in the gastrocnemius of adult men and women. Gastrocnemius muscle was obtained from male (n = 19) and female (n = 11) human subjects with healthy lower-extremity musculoskeletal and arterial systems and normal ambulatory function. All patients were undergoing operations for the treatment of varicose veins in their legs. Mitochondrial respiration was determined with a Clark electrode in an oxygraph cell containing saponin-skinned muscle bundles. Complex I-, II-, III-, and IV-dependent respiration was measured individually and normalized to muscle weight, total protein content, and citrate synthase (CS, index of mitochondrial content). Male and female patients had no evidence of musculoskeletal or arterial disease and did not differ with regard to age, race, body mass index, or other clinical characteristics. Complex I-, II-, III-, and IV-dependent respiration normalized to muscle weight, total protein content, and CS did not statistically differ for males compared with females. Our study evaluates, for the first time, gastrocnemius mitochondrial respiration of adult men and women who have healthy musculoskeletal and arterial systems and normal ambulatory function. Our data demonstrate there are no differences in the respiration of gastrocnemius mitochondria between men and women. Copyright © 2013 Elsevier Inc. All rights reserved.

[Simplified topical anesthesia protocol for ambulatory cataract surgery: safety and patient and surgeon satisfaction].

PubMed

Batta, B; Fuchs-Buder, T; Tréchot, F; Angioi, K

2014-09-01

The purpose of our study was to assess safety and efficacy of cataract surgery (CS) under topical anesthesia alone, i.e. without pre-anesthetic evaluation and without direct presence of an anesthesiologist. To this end we assessed the incidence of patients' preoperative anxiety, perioperative adverse events and patients' and surgeons' satisfaction. Patients undergoing CS under topical anesthesia over a one-month period were included. An anesthesiologist and nurse anesthetist were present in the area and could intervene in case of an adverse event. Patients' anxiety was scored using the Amsterdam Preoperative Anxiety & Information Scale (APAIS), and their satisfaction with the Iowa Satisfaction with Anesthesia Scale (ISAS). Surgeons' satisfaction was scored with a VAS from 0 to 10 (0: surgery not possible & 10: excellent surgical conditions). One hundred and twenty-four consecutive patients were included; mean age was 71 (±9.4) years. Mean APAIS I was 6.4/20 (±3.7). Mean APAIS II was 3.1 (±1.8). Mean ISAS score was 5.5/6 (±0.6), indicating high patient satisfaction. Surgeon satisfaction score was 8.9/10 (±1.7). Twenty-three adverse events occurred of which 16 required interventions by the anaesthesiologist or surgeon: 5 supplemental local or regional anaesthesia, 6 iv-analgesia, 5 management of hypertension. These preliminary data suggest that a simplified topical anesthesia protocol for ambulatory CS appears to be feasible and safe, as long as an anesthesia team is present in the area to intervene if needed. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

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

PubMed

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

2018-01-01

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

Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study.

PubMed

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

2015-11-01

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

Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

PubMed

Komen, Helga; Brunt, L Michael; Deych, Elena; Blood, Jane; Kharasch, Evan D

2018-05-25

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better analgesia and reduces opioid use compared with conventional repeated dosing of short-duration opioids. This investigation tested the hypothesis that in same-day ambulatory surgery, intraoperative methadone, compared with short-duration opioids, reduces opioid consumption and pain, and determined an effective intraoperative induction dose of methadone for same-day ambulatory surgery. A double-blind, dose-escalation protocol randomized 60 patients (2:1) to intraoperative single-dose intravenous methadone (initially 0.1 then 0.15 mg/kg ideal body weight) or conventional as-needed dosing of short-duration opioids (eg, fentanyl, hydromorphone; controls). Intraoperative and postoperative opioid consumption, pain, and opioid side effects were assessed before discharge. Patient home diaries recorded pain, opioid use, and opioid side effects daily for 30 days postoperatively. Primary outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30 days opioid consumption, pain intensity, and opioid side effects. Median (interquartile range) methadone doses were 6 (5-6) and 9 (8-9) mg in the 0.1 and 0.15 mg/kg methadone groups, respectively. Total opioid consumption (morphine equivalents) in the postanesthesia care unit was significantly less compared with controls (9.3 mg, 1.3-11.0) in subjects receiving 0.15 mg/kg methadone (0.1 mg, 0.1-3.3; P < .001) but not 0.1 mg/kg methadone (5.0 mg, 3.3-8.1; P = .60). Dose-escalation ended at 0.15 mg/kg methadone. Total in-hospital nonmethadone opioid use after short-duration opioid, 0.1 mg/kg methadone, and 0.15 mg/kg methadone was 35.3 (25.0-44.0), 7.1 (3.7-10.0), and 3.3 (0.1-5.8) mg morphine equivalents, respectively (P < .001 for both versus control). In-hospital pain scores and side effects were not different between groups. In the 30 days after discharge, patients who received methadone 0.15 mg/kg had less pain at rest (P = .02) and used fewer opioid pills than controls (P < .0001), whereas patients who received 0.1 mg/kg had no difference in pain at rest (P = .69) and opioid use compared to controls (P = .08). In same-day discharge surgery, this pilot study identified a single intraoperative dose of methadone (0.15 mg/kg ideal body weight), which decreased intraoperative and postoperative opioid requirements and postoperative pain, compared with conventional intermittent short-duration opioids, with similar side effects.

Current state of continuous ambulatory peritoneal dialysis in Egypt.

PubMed

Elzorkany, Khaled Mohamed Amin

2017-01-01

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

Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures.

PubMed

Fredman, Brian; Sheffer, Offer; Zohar, Edna; Paruta, Irena; Richter, Santiago; Jedeikin, Robert; White, Paul F

2002-03-01

Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I--III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75-150 microg center dot kg(-1) center dot min(-1) IV), isoflurane (0.7%-1.2% end tidal), or desflurane (3%-6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60-65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 +/- 23 vs 33 +/- 25 and 44 +/- 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass ("fast-tracking") of geriatric patients undergoing short urologic procedures. Geriatric outpatients undergoing brief urologic procedures more rapidly achieve fast-tracking discharge criteria after desflurane (versus isoflurane and propofol) anesthesia. Use of isoflurane was also associated with an increased need for nursing interventions in the early recovery period compared with desflurane and propofol.

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

PubMed

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

2013-07-01

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

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

PubMed

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

2014-02-01

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

First Case of Trichoderma longibrachiatum CIED (Cardiac Implantable Electronic Device)-Associated Endocarditis in a Non-immunocompromised Host: Biofilm Removal and Diagnostic Problems in the Light of the Current Literature.

PubMed

Tascini, Carlo; Cardinali, Gianluigi; Barletta, Valentina; Di Paolo, Antonello; Leonildi, Alessandro; Zucchelli, Giulio; Corte, Laura; Colabella, Claudia; Roscini, Luca; Consorte, Augusta; Pasticci, Maria Bruna; Menichetti, Francesco; Bongiorni, Maria Grazia

2016-04-01

Trichoderma species are saprophytic filamentous fungi producing localized and invasive infections that are cause of morbidity and mortality, especially in immunocompromised patients, causing up to 53% mortality. Non-immunocompromised patients, undergoing continuous ambulatory peritoneal dialysis, are other targets of this fungus. Current molecular diagnostic tools, based on the barcode marker ITS, fail to discriminate these fungi at the species level, further increasing the difficulty associated with these infections and their generally poor prognosis. We report on the first case of endocarditis infection caused by Trichoderma longibrachiatum in a 30-year-old man. This patient underwent the implantation of an implantable cardioverter defibrillator in 2006, replaced in 2012. Two years later, the patient developed fever, treated successfully with amoxicillin followed by ciprofloxacin, but an echocardiogram showed large vegetation onto the ventricular lead. After CIED extraction, the patient had high-grade fever. The culturing of the catheter tip was positive only in samples deriving from sonication according to the 2014 ESCMID guidelines, whereas the simple washing failed to remove the biofilm cells from the plastic surface. Subsequent molecular (ITS sequencing) and microbiological (macromorphology) analyses showed that the vegetation was due to T. longibrachiatum. This report showed that T. longibrachiatum is an effective threat and that sonication is necessary for the culturing of vegetations from plastic surfaces. Limitations of the current barcode marker ITS, and the long procedures required by a multistep approach, call for the development of rapid monophasic tests.

[Neumonía acquired in the community. Practical guide elaborated by a committee intersocieties].

PubMed

Luna, Carlos M; Calmaggi, Aníbal; Caberloto, Oscar; Gentile, Jorge; Valentini, Ricardo; Ciruzzi, Julian; Clara, Liliana; Rizzo, Oscar; Lasdica, Sergio; Blumenfeld, Marcelo; Benchetrit, Guillermo; Famiglietti, Angela; Apezteguia, Carlos; Monteverde, Alfredo

2003-01-01

Clinical practice guidelines for community-acquired pneumonia (CAP) contribute to improve patient's management. CAP undergoes continuous changes in etiology, epidemiology and antimicrobial sensitivity, requiring periodic guidelines revisions. An inter-society committee designed this guidelines dividing it into several topics based on prior guidelines and recent clinical studies. CAP compromises annually more than 1% of the population; most of the cases only require outpatient care but others are severe cases, reaching the 6th cause of death in Argentina. The cases are distributed unevenly into ambulatory, admitted in the general ward or in the intensive care unit. There is no way to predict the etiology. Unfavorable outcome predictors include age, antecedents and physical, laboratory and radiography findings. Ten to 25% of inpatients need to be admitted to the intensive care unit at the onset or during the follow-up, for mechanical ventilation or hemodynamic support (severe CAP). Severe CAP is associated with high mortality and requires adequate and urgent therapy. Pregnant, COPD and nursing home patients require special recommendations. Diagnosis is clinical, while complementary methods are useful to define etiology and severity; chest X-ray is the only one universally recommended. Other studies, including microbiologic evaluation are particularly appropriate in the hospitalized patients. The initial therapy is empiric, it must begin early, using antimicrobials active against the target microorganisms, avoiding their inappropriate use which can lead to the development of resistance. Length of therapy must not be unnecessarily prolonged. Hydratation, nutrition, oxygen and therapy of complications must complement antibiotic treatment. Prevention is based on influenza prophylaxis, anti-pneumococcal vaccine, aspiration prevention and other general measures.

The new look in rehabilitation.

PubMed

Eazell, D E

1987-01-01

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

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

PubMed

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

2017-11-01

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

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

PubMed

Brasil, Vinicius Paim; Costa, Juvenal Soares Dias da

2016-01-01

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

Pros and cons of the ambulatory surgery center joint venture.

PubMed

Giannini, Deborah

2008-01-01

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

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

ERIC Educational Resources Information Center

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

2012-01-01

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

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

PubMed Central

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

2013-01-01

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

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

PubMed

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

2013-02-01

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

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

PubMed

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

2015-12-01

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

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

PubMed

Sachdev, Gloria

2014-08-15

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

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

PubMed

Fletcher, K; Painter, V

2002-01-01

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

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

PubMed

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

2009-12-06

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

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

PubMed

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

2018-03-01

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

Ambulatory measurement of ankle kinetics for clinical applications.

PubMed

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

2011-10-13

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

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

PubMed

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

2017-02-01

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

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

PubMed

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

2008-09-01

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

The 8-item Short-Form Health Survey and the physical comfort composite score of the quality of recovery 40-item scale provide the most responsive assessments of pain, physical function, and mental function during the first 4 days after ambulatory knee surgery with regional anesthesia.

PubMed

Bost, James E; Williams, Brian A; Bottegal, Matthew T; Dang, Qianyu; Rubio, Doris M

2007-12-01

We evaluated the validity and responsiveness of three instruments: the numeric rating scale (NRS) pain score, the 8-item Short-Form Health Survey (SF-8), and the 40-item Quality of Recovery from Anesthesia (QoR) Survey in 154 outpatients undergoing anterior cruciate ligament reconstruction (ACLR). The objective was to provide a robust psychometric basis for outcome survey selection for surgical outpatients undergoing regional anesthesia without general anesthesia. Patients undergoing ACLR with a standardized spinal anesthesia plan were randomized to receive a perineural catheter with either placebo injection-infusion, or injection-infusion with levobupivacaine. Patients completed the NRS, SF-8, and QoR instruments for four postoperative days to evaluate pain, physical function, and mental function. Regarding pain, neither the NRS nor the QoR offered advantages over the SF-8. Regarding physical function, the QoR physical independence composite offered no advantage over the SF-8 physical component summary. The QoR physical comfort composite assessed short-term changes in treatment-related side effects, and thus provided information not covered by the SF-8. Regarding mental function, the SF-8 mental component summary and QoR emotional state composite showed little change over the four days, although the latter measure showed higher responsiveness to change. For ACLR outpatients receiving regional anesthesia, the SF-8 is sufficient to assess postoperative pain and physical function. Adding the QoR physical comfort composite will help assess short-term side effects.

A pretest prognostic score to assess patients undergoing exercise or pharmacological stress testing

PubMed Central

Morise, Anthony; Evans, Matthew; Jalisi, Farrukh; Shetty, Rajendra; Stauffer, Marc

2007-01-01

Objective A previously developed pretest score was validated to stratify patients presenting for exercise testing with suspected coronary disease according to the presence of angiographic coronary disease. Our goal was to determine how well this pretest score risk stratified patients undergoing pharmacological and exercise stress tests concerning prognostic endpoints. Design Retrospective cohort analysis. Setting University hospital stress laboratory. Patients 7452 unselected ambulatory patients with symptoms of suspected coronary disease undergoing stress testing between 1995 and 2004. Main outcomes measures All‐cause death, cardiac death and non‐fatal myocardial infarction. Results The rate of all‐cause death was 5.5% (CI 5.0 to 6.1) with 4.3 (SD 2.4) years of follow‐up (Exercise 2.8% (CI 2.3 to 3.2) v Pharmacological group 11.9% (CI 10.5 to 13.3); p<0.001). The rate of cardiac death/myocardial infarction was 2.6% (CI 2.2 to 3.0) (Exercise 1.4% (CI 1.1 to 1.8) v Pharmacological group 5.3% (CI 4.3 to 6.2); p<0.001). In both groups, stratification by pretest score was significant for all‐cause death and the combined endpoint. However, stratification was more effective in the pharmacological group using the combined endpoint rather than all‐cause death. Pharmacological stress patients in intermediate and high risk groups were at higher risk than their respective exercise test cohorts. Referral for pharmacological stress testing was found to be an independent predictor of time to death (2.7 (CI 2.0 to 3.6); p<0.001). Conclusion A pretest score previously validated to stratify according to angiographic outcomes, effectively risk stratified pharmacological and exercise stress patients according to the combined endpoint of cardiac death/myocardial infarction. PMID:17228070

A pretest prognostic score to assess patients undergoing exercise or pharmacological stress testing.

PubMed

Morise, Anthony; Evans, Matthew; Jalisi, Farrukh; Shetty, Rajendra; Stauffer, Marc

2007-02-01

A previously developed pretest score was validated to stratify patients presenting for exercise testing with suspected coronary disease according to the presence of angiographic coronary disease. Our goal was to determine how well this pretest score risk stratified patients undergoing pharmacological and exercise stress tests concerning prognostic endpoints. Retrospective cohort analysis. University hospital stress laboratory. 7452 unselected ambulatory patients with symptoms of suspected coronary disease undergoing stress testing between 1995 and 2004. All-cause death, cardiac death and non-fatal myocardial infarction. The rate of all-cause death was 5.5% (CI 5.0 to 6.1) with 4.3 (SD 2.4) years of follow-up (Exercise 2.8% (CI 2.3 to 3.2) v Pharmacological group 11.9% (CI 10.5 to 13.3); p<0.001). The rate of cardiac death/myocardial infarction was 2.6% (CI 2.2 to 3.0) (Exercise 1.4% (CI 1.1 to 1.8) v Pharmacological group 5.3% (CI 4.3 to 6.2); p<0.001). In both groups, stratification by pretest score was significant for all-cause death and the combined endpoint. However, stratification was more effective in the pharmacological group using the combined endpoint rather than all-cause death. Pharmacological stress patients in intermediate and high risk groups were at higher risk than their respective exercise test cohorts. Referral for pharmacological stress testing was found to be an independent predictor of time to death (2.7 (CI 2.0 to 3.6); p<0.001). A pretest score previously validated to stratify according to angiographic outcomes, effectively risk stratified pharmacological and exercise stress patients according to the combined endpoint of cardiac death/myocardial infarction.

Independent Association Between Preoperative Cognitive Status and Discharge Location After Surgery: A Strategy to Reduce Resource Use After Surgery for Deformity.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Sergesketter, Amanda; Vuong, Victoria D; Moreno, Jessica; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2018-02-01

The aim of this study is to determine whether preoperative scores on a screening measure for cognitive status (the Saint Louis University mental status examination), were associated with discharge to a location other than home in older patients undergoing surgery for deformity. Older patients (≥65 years) undergoing a planned elective spinal surgery for correction of adult degenerative scoliosis were enrolled in this study. Preoperative baseline cognition was assessed using the validated Saint Louis University mental status (SLUMS) test. SLUMS is 11 questions with a maximum of 30 points. Mild cognitive impairment was defined as a SLUMS score of 21-26 points, and severe cognitive impairment as a SLUMS score of 20 points or greater. Normal cognition was defined as a SLUMS score of 27 points or more. Postoperative length of stay and discharge location were recorded on all patients. Eighty-two subjects were included, with mean ± standard deviation age of 73.26 ± 6.08 years; 51% of patients were discharged to a facility (skilled nursing or acute rehabilitation). After adjustment for demographic variables, comorbidities, and baseline cognitive impairment, patients with preoperative cognitive impairment were 4-fold more likely to be discharged to a facility (skilled nursing or acute rehabilitation) compared with patients with normal cognitive status (odds ratio [OR], 3.93). In addition, patients who were not ambulatory before surgery were also more likely to be discharged to a facility (OR, 7.14). In geriatric patients undergoing surgery for deformity correction, cognitive screening before surgery can identify patients with impaired cognitive status who are less likely than those with normal cognitive status to return home after surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

Considerations for Providing Ambulatory Pharmacy Services for Pediatric Patients.

PubMed

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

2018-01-01

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

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

NASA Astrophysics Data System (ADS)

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

2014-10-01

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

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

DTIC Science & Technology

1987-05-01

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

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

PubMed

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

2004-02-01

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

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

PubMed

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

2014-01-01

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

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

PubMed

Renda, Rahime

2018-04-01

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

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

PubMed

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

2000-07-01

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

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

PubMed

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

2014-01-01

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

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

PubMed

Hyun Lee, Seung; Ahn, Jae Kyoun

2010-07-01

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

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

PubMed

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

2015-01-01

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

Anesthesia for hip arthroscopy: a narrative review.

PubMed

Yu, Hai Chuan; Al-Shehri, Mohammed; Johnston, Kelly D; Endersby, Ryan; Baghirzada, Leyla

2016-11-01

Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure. MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy. The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment. Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

Ambulatory treatment of snoring with CO2 laser: laser-assisted UPPP (LAUP), results on 856 patients

NASA Astrophysics Data System (ADS)

Kamami, Yves-Victor

1995-05-01

The usual treatment of snoring in the absence of sleep apneas has been UPPP. Patients are often reluctant to undergo this painful procedure under general anesthesia. The Laser Assisted Uvulopalatoplasty (LAUP) is a new procedure, introduced six years ago by the author, using local anesthesia for the treatment of snoring in an office setting. This technique is designed to correct breathing abnormalities during sleep, caused by pharyngeal airway obstruction in patients suffering of Snoring or Obstructive Sleep Apnea Syndrome. This is done by reducing the amount of tissue in the uvula, the velum, and the upper part of the posterior pillars. LAUP allows surgery for the relief of snoring to be performed in the office, under local anesthesia. LAUP has many advantages over the traditional UPPP. It is simple, reliable, hemostatic, and less painful. It is also less expensive as it can be performed as an outpatient. This makes the LAUP more accessible to patients. Our experience with LAUP in 856 patients from December 1988 to July 1994 (141 women and 715 men) is described. Good results were obtained in 94.8% of patients and there were no complications. This new technique can be easily performed by other otolaryngologists after serious suitable training. LAUP provides a simple alternative for many patients who do not wish to undergo a traditional UPPP.

Role of home blood pressure monitoring in hemodialysis patients.

PubMed

Agarwal, R

1999-04-01

To investigate the use of manual home blood pressure (BP) monitoring in chronic hemodialysis patients, daily home BPs in 20 patients undergoing chronic hemodialysis were compared with the 44-hour interdialytic ambulatory BPs (ABPs). Each patient recorded home BPs for 2 consecutive weeks with a digital BP monitor three times daily. Prehemodialysis and posthemodialysis BPs were recorded by an oscillometric device in the hemodialysis unit during the same 2 weeks. ABPs were recorded either after the first or second hemodialysis session of the second week during a 44-hour interdialytic period using a Spacelab 90207 ABP monitor. ABP monitoring showed that BP decreased progressively after dialysis, decreased during the first night, and rapidly reached predialysis levels by the next morning. There was no decrease in BP during the second night. There was an excellent correlation between average systolic and diastolic ABP and respective home BPs. Prehemodialysis diastolic BPs were a good reflection of diastolic ABP, but there was more variability in predialysis systolic BP. Posthemodialysis BPs did not correlate with ABP. In patients undergoing chronic hemodialysis, home BPs more reliably reflected the overall BP than incenter BP readings. Predialysis, but not postdialysis, BP should be used as a screening tool to detect hypertension in the hemodialysis unit. Home BP monitoring should be used as a cost-effective means to diagnose occult hypertension in chronic hemodialysis patients.

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

PubMed

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

2010-10-01

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

Evaluating the implementation of RxNorm in ambulatory electronic prescriptions

PubMed Central

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

2016-01-01

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

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

PubMed

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

2017-12-01

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

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

NASA Astrophysics Data System (ADS)

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

2005-05-01

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

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

PubMed

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

2018-01-17

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

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

PubMed

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

2010-04-01

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

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

PubMed

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

2018-03-01

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

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

DTIC Science & Technology

1989-05-11

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

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

PubMed

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

2009-06-01

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

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

PubMed

Saukaitis, C A

1994-09-01

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

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

PubMed

Heine, R P

1990-01-01

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

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

PubMed

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

2015-08-01

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

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

PubMed

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

2012-05-01

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

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

PubMed

Steptoe, A; Cropley, M; Joekes, K

2000-01-01

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

Ambulatory Blood Pressure Monitoring in Clinical Practice: A Review

PubMed Central

Viera, Anthony J.; Shimbo, Daichi

2016-01-01

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

Anesthesia for ambulatory anorectal surgery.

PubMed

Gudaityte, Jūrate; Marchertiene, Irena; Pavalkis, Dainius

2004-01-01

The prevalence of minor anorectal diseases is 4-5% of adult Western population. Operations are performed on ambulatory or 24-hour stay basis. Requirements for ambulatory anesthesia are: rapid onset and recovery, ability to provide quick adjustments during maintenance, lack of intraoperative and postoperative side effects, and cost-effectiveness. Anorectal surgery requires deep levels of anesthesia. The aim is achieved with 1) regional blocks alone or in combination with monitored anesthesia care or 2) deep general anesthesia, usually with muscle relaxants and tracheal intubation. Modern general anesthetics provide smooth, quickly adjustable anesthesia and are a good choice for ambulatory surgery. Popular regional methods are: spinal anesthesia, caudal blockade, posterior perineal blockade and local anesthesia. The trend in regional anesthesia is lowering the dose of local anesthetic, providing selective segmental block. Adjuvants potentiating analgesia are recommended. Postoperative period may be complicated by: 1) severe pain, 2) urinary retention due to common nerve supply, and 3) surgical bleeding. Complications may lead to hospital admission. In conclusion, novel general anesthetics are recommended for ambulatory anorectal surgery. Further studies to determine an optimal dose and method are needed in the group of regional anesthesia.

[Ambulatory pediatric surgery: 25 years of experience].

PubMed

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

2000-10-01

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

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

PubMed

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

2012-07-01

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

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

PubMed

Lichte, Thomas; Klement, Andreas; Herrmann, Markus

2009-01-01

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

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

PubMed

Wang, Da-xiong; Wang, Guo-jun

2005-06-01

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

Is increased joint loading detrimental to obese patients with knee osteoarthritis? A secondary data analysis from a randomized trial.

PubMed

Henriksen, M; Hunter, D J; Dam, E B; Messier, S P; Andriacchi, T P; Lohmander, L S; Aaboe, J; Boesen, M; Gudbergsen, H; Bliddal, H; Christensen, R

2013-12-01

To investigate whether increased knee joint loading due to improved ambulatory function and walking speed following weight loss achieved over 16 weeks accelerates symptomatic and structural disease progression over a subsequent 1 year weight maintenance period in an obese population with knee osteoarthritis (OA). Data from a prospective study of weight loss in obese patients with knee OA (the CARtilage in obese knee OsteoarThritis (CAROT) study) were used to determine changes in knee joint compressive loadings (model estimated) during walking after a successful 16 week weight loss intervention. The participants were divided into 'Unloaders' (participants that reduced joint loads) and 'Loaders' (participants that increased joint loads). The primary symptomatic outcome was changes in knee symptoms, measured with the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire, during a subsequent 52 weeks weight maintenance period. The primary structural outcome was changes in tibiofemoral cartilage loss assessed semi-quantitatively (Boston Leeds Knee Osteoarthritis Score (BLOKS) from MRI after the 52 weight maintenance period. 157 participants (82% of the CAROT cohort) with medial and/or lateral knee OA were classified as Unloaders (n = 100) or Loaders (n = 57). The groups showed similar significant changes in symptoms (group difference: -2.4 KOOS points [95% CI -6.8:1.9]) and cartilage loss (group difference: -0.06 BLOKS points [95% CI -0.22:0.11) after 1 year, with no statistically significant differences between Loaders and Unloaders. For obese patients undergoing a significant weight loss, increased knee joint loading for 1 year was not associated with accelerated symptomatic and structural disease progression compared to a similar weight loss group that had reduced ambulatory compressive knee joint loads. NCT00655941. Copyright © 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Forty-four-hour interdialytic ambulatory blood pressure monitoring and cardiovascular risk in pediatric hemodialysis patients.

PubMed

Katsoufis, Chryso P; Seeherunvong, Wacharee; Sasaki, Nao; Abitbol, Carolyn L; Chandar, Jayanthi; Freundlich, Michael; Zilleruelo, Gaston E

2014-02-01

Children undergoing chronic hemodialysis are at risk of cardiovascular disease and often develop left ventricular hypertrophy (LVH). Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is known to better predict cardiovascular morbidity than casual blood pressure (BP) measurement. Given the BP variability attributed to interdialytic fluid overload, 44-h ABPM should better delineate cardiovascular morbidity in pediatric hemodialysis patients. In this cross-sectional study, 17 children (16.7 ± 2.9 years) on chronic hemodialysis underwent 44-h interdialytic ABPM and routine echocardiogram. Left ventricular mass index (LVMI) was calculated by height-based equation; LVH was defined as an LVMI in the ≥95th percentile for height-age and gender. Hypertension was defined by the recommendations of the Fourth Report of the National High Blood Pressure Education Program for casual measurements, and by those of the American Heart Association for ABPM. Twenty-four percentage of patients were hypertensive by casual post-dialytic systolic BP, whereas 59% were hypertensive by ABPM. Eighty-eight percentage of patients had abnormal cardiac geometry: 53% had LVH. Thirty-five percentage (6 of 17) had masked hypertension, including four with abnormal cardiac geometry, of which, three had LVH. LVMI correlated with ABPM, but not with casual measurements. Strongest correlations with an increased LVMI were with 44-h diastolic BP: at night (r = 0.53, P = 0.03) and total load (r = 0.57, P = 0.02). LVH was similarly associated with 44-h nighttime BP: systolic (P = 0.02), diastolic (P = 0.01) and mean arterial (P = 0.01). Casual BP measurement underestimates hypertension in pediatric hemodialysis patients and does not correlate well with indicators of cardiovascular morbidity. In contrast, 44-h interdialytic ABPM better characterizes hypertension, with nighttime parameters most strongly predicting increased LVMI and LVH.

Comparison of a novel non-contact biomotion sensor with wrist actigraphy in estimating sleep quality in patients with obstructive sleep apnoea.

PubMed

Pallin, Michael; O'Hare, Emer; Zaffaroni, Alberto; Boyle, Patricia; Fagan, Ciara; Kent, Brian; Heneghan, Conor; de Chazal, Philip; McNicholas, Walter T

2014-08-01

Ambulatory monitoring is of major clinical interest in the diagnosis of obstructive sleep apnoea syndrome. We compared a novel non-contact biomotion sensor, which provides an estimate of both sleep time and sleep-disordered breathing, with wrist actigraphy in the assessment of total sleep time in adult humans suspected of obstructive sleep apnoea syndrome. Both systems were simultaneously evaluated against polysomnography in 103 patients undergoing assessment for obstructive sleep apnoea syndrome in a hospital-based sleep laboratory (84 male, aged 55 ± 14 years and apnoea-hypopnoea index 21 ± 23). The biomotion sensor demonstrated similar accuracy to wrist actigraphy for sleep/wake determination (77.3%: biomotion; 76.5%: actigraphy), and the biomotion sensor demonstrated higher specificity (52%: biomotion; 34%: actigraphy) and lower sensitivity (86%: biomotion; 94%: actigraphy). Notably, total sleep time estimation by the biomotion sensor was superior to actigraphy (average overestimate of 10 versus 57 min), especially at a higher apnoea-hypopnoea index. In post hoc analyses, we assessed the improved apnoea-hypopnoea index accuracy gained by combining respiratory measurements from polysomnography for total recording time (equivalent to respiratory polygraphy) with total sleep time derived from actigraphy or the biomotion sensor. Here, the number of misclassifications of obstructive sleep apnoea severity compared with full polysomnography was reduced from 10/103 (for total respiratory recording time alone) to 7/103 and 4/103 (for actigraphy and biomotion sensor total sleep time estimate, respectively). We conclude that the biomotion sensor provides a viable alternative to actigraphy for sleep estimation in the assessment of obstructive sleep apnoea syndrome. As a non-contact device, it is suited to longitudinal assessment of sleep, which could also be combined with polygraphy in ambulatory studies. © 2014 European Sleep Research Society.

Hypertension: New perspective on its definition and clinical management by bedtime therapy substantially reduces cardiovascular disease risk.

PubMed

Hermida, Ramón C; Ayala, Diana E; Fernández, José R; Mojón, Artemio; Smolensky, Michael H

2018-05-01

Diagnosis of hypertension-elevated blood pressure (BP) associated with increased cardiovascular disease (CVD) risk-and its management for decades have been based primarily on single time-of-day office BP measurements (OBPM) assumed representative of systolic (SBP) and diastolic BP (DBP) during the entire 24-hours span. Around-the-clock ambulatory blood pressure monitoring (ABPM), however, reveals BP undergoes 24-hours patterning characterized in normotensives and uncomplicated hypertensives by striking morning-time rise, 2 daytime peaks-one ~2-3 hours after awakening and the other early evening, small midafternoon nadir and 10-20% decline (BP dipping) in the asleep BP mean relative to the wake-time BP mean. A growing number of outcome trials substantiate correlation between BP and target organ damage, vascular and other risks is greater for the ABPM-derived asleep BP mean, independent and stronger predictor of CVD risk, than daytime OBPM or ABPM-derived awake BP. Additionally, bedtime hypertension chronotherapy, that is, ingestion of ≥1 conventional hypertension medications at bedtime to achieve efficient attenuation of asleep BP, better reduces total CVD events by 61% and major events (CVD death, myocardial infarction, ischaemic and haemorrhagic stroke) by 67%-even in more vulnerable chronic kidney disease, diabetes and resistant hypertension patients-than customary on-awaking therapy that targets wake-time BP. Such findings of around-the-clock ABPM and bedtime hypertension outcome trials, consistently indicating greater importance of asleep BP than daytime OBPM or ambulatory awake BP, call for a new definition of true arterial hypertension plus modern approaches for its diagnosis and management. © 2018 Stichting European Society for Clinical Investigation Journal Foundation.

Endocrine surgery as a model for value-based health care delivery.

PubMed

Abdulla, Amer G; Ituarte, Philip H G; Wiggins, Randi; Teisberg, Elizabeth O; Harari, Avital; Yeh, Michael W

2012-01-01

Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume. Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time. The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010. A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.

Paravertebral blocks reduce the risk of postoperative urinary retention in inguinal hernia repair.

PubMed

Bojaxhi, E; Lee, J; Bowers, S; Frank, R D; Pak, S H; Rosales, A; Padron, S; Greengrass, R A

2018-06-16

Inguinal hernia repair and general anesthesia (GA) are known risk factors for urinary retention. Paravertebral blocks (PVBs) have been utilized to facilitate enhanced recovery after surgery. We evaluate the benefit of incorporating PVBs into our anesthetic technique in a large cohort of ambulatory patients undergoing inguinal hernia repair. Records of 619 adults scheduled for ambulatory inguinal hernia repair between 2010 and 2015 were reviewed and categorized based on anesthetic and surgical approach [GA and open (GAO), GA and laparoscopic (GAL), PVB and open (PVBO), and GA/PVB and open (GA/PVBO)]. Patients were excluded for missing data, self-catheterization, chronic opioid tolerance, and additional surgical procedures coinciding with hernia repair. Risk factors associated with the primary outcome of urinary retention were examined using logistic regression. PVBO (n = 136) had significantly lower odds than GAO of experiencing urinary retention (odds ratio 0.16; 95% CI 0.05-0.51); overall (P < .01), with 4.4% (n = 6) of the patients in the PVBO group having urinary retention versus 22.6% (n = 7) with GAO. Expressed as intravenous morphine equivalences, the PVBO group had the lowest median opioid use (5 mg), followed by GA, PVB, and open (7.5 mg); GAO 25 mg; and GAL 25 mg. Also, 30% (n = 41) of the PVBO group required no opioid analgesia in the postanesthesia care unit. PVBs as the primary anesthetic or an adjunct to GA is the preferred anesthetic technique for open inguinal hernia repair as it facilitates enhanced recovery after surgery by decreasing risk of urinary retention, opioid requirements, and length of stay.

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

ClinicalTrials.gov

2018-06-16

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

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

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

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

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

DTIC Science & Technology

2014-01-14

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

Utilization of lean management principles in the ambulatory clinic setting.

PubMed

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

2009-03-01

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

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

PubMed

Wagner, Dale R

2011-03-01

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

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

PubMed

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

2016-01-01

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

Development of motion resistant instrumentation for ambulatory near-infrared spectroscopy

PubMed Central

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

2011-01-01

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

The Changing Impact of Gastroesophageal Reflux Disease in Clinical Practice.

PubMed

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

2017-03-01

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

Recent advances in diagnostic testing for gastroesophageal reflux disease.

PubMed

Naik, Rishi D; Vaezi, Michael F

2017-06-01

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

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

PubMed

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

2011-04-01

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

Overview of a pharmacist anticoagulation certificate program.

PubMed

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

2017-07-01

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

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

PubMed

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

2008-08-01

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

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

PubMed

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

2012-03-01

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

Office-based surgery: embracing patient safety strategies.

PubMed

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

2013-01-01

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

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

PubMed

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

2014-12-01

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

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

PubMed Central

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

2009-01-01

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

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

PubMed

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

2013-04-01

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

Ambulatory estimation of foot placement during walking using inertial sensors.

PubMed

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

2010-12-01

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

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

PubMed

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

2009-11-01

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

Prescription Drug Shortages: Implications for Ambulatory Pediatrics.

PubMed

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

2018-05-08

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

Evolving vendor market for HITECH-certified ambulatory EHR products.

PubMed

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

2013-11-01

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

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

PubMed

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

2004-05-01

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

Preliminary study of percutaneous nephrolithotomy on an ambulatory basis.

PubMed

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

2013-02-01

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

Perioperative Respiratory Adverse Events in Pediatric Ambulatory Anesthesia: Development and Validation of a Risk Prediction Tool.

PubMed

Subramanyam, Rajeev; Yeramaneni, Samrat; Hossain, Mohamed Monir; Anneken, Amy M; Varughese, Anna M

2016-05-01

Perioperative respiratory adverse events (PRAEs) are the most common cause of serious adverse events in children receiving anesthesia. Our primary aim of this study was to develop and validate a risk prediction tool for the occurrence of PRAE from the onset of anesthesia induction until discharge from the postanesthesia care unit in children younger than 18 years undergoing elective ambulatory anesthesia for surgery and radiology. The incidence of PRAE was studied. We analyzed data from 19,059 patients from our department's quality improvement database. The predictor variables were age, sex, ASA physical status, morbid obesity, preexisting pulmonary disorder, preexisting neurologic disorder, and location of ambulatory anesthesia (surgery or radiology). Composite PRAE was defined as the presence of any 1 of the following events: intraoperative bronchospasm, intraoperative laryngospasm, postoperative apnea, postoperative laryngospasm, postoperative bronchospasm, or postoperative prolonged oxygen requirement. Development and validation of the risk prediction tool for PRAE were performed using a split sampling technique to split the database into 2 independent cohorts based on the year when the patient received ambulatory anesthesia for surgery and radiology using logistic regression. A risk score was developed based on the regression coefficients from the validation tool. The performance of the risk prediction tool was assessed by using tests of discrimination and calibration. The overall incidence of composite PRAE was 2.8%. The derivation cohort included 8904 patients, and the validation cohort included 10,155 patients. The risk of PRAE was 3.9% in the development cohort and 1.8% in the validation cohort. Age ≤ 3 years (versus >3 years), ASA physical status II or III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) significantly predicted the occurrence of PRAE in a multivariable logistic regression model. A risk score in the range of 0 to 3 was assigned to each significant variable in the logistic regression model, and final score for all risk factors ranged from 0 to 11. A cutoff score of 4 was derived from a receiver operating characteristic curve to determine the high-risk category. The model C-statistic and the corresponding SE for the derivation and validation cohort was 0.64 ± 0.01 and 0.63 ± 0.02, respectively. Sensitivity and SE of the risk prediction tool to identify children at risk for PRAE was 77.6 ± 0.02 in the derivation cohort and 76.2 ± 0.03 in the validation cohort. The risk tool developed and validated from our study cohort identified 5 risk factors: age ≤ 3 years (versus >3 years), ASA physical status II and III (versus ASA physical status I), morbid obesity, preexisting pulmonary disorder, and surgery (versus radiology) for PRAE. This tool can be used to provide an individual risk score for each patient to predict the risk of PRAE in the preoperative period.

Meta-synthesis on nurse practitioner autonomy and roles in ambulatory care.

PubMed

Wang-Romjue, Pauline

2018-04-01

Many healthcare stakeholders view nurse practitioners (NPs) as an important workforce resource to help fill the anticipated shortage of 20,400 ambulatory care physicians that is expected by 2020. Multiple quantitative studies revealed the attributes of NPs' practice autonomy and roles. However, there is no qualitative meta-synthesis that describes the experiences of NPs' practice autonomy and roles. To describe and understand the experiences of NPs regarding their practice autonomy and roles in various ambulatory settings through the exploration of existing qualitative studies: meta-synthesis. A qualitative meta-synthesis was conducted to gain insight into ambulatory NPs' practice autonomy and roles through content analysis and reciprocal translation. Articles published between 2000 and 2017 were retrieved by searching 7 databases using the following key words: U.S. qualitative studies, advance practice nurses, NP role in ambulatory care, NP autonomy, and outpatient care. Autonomy, NPs' roles and responsibilities, practice relationships, and organizational work environment pressures are the four main themes that emerged from the content analysis of the nine selected qualitative studies. Within and between states, NPs' experiences with autonomy and NPs' roles are multifaceted depending on state regulations, practice relationships, and organizational work environments. © 2017 Wiley Periodicals, Inc.

Ambulatory diffuse optical tomography and multimodality physiological monitoring system for muscle and exercise applications

NASA Astrophysics Data System (ADS)

Hu, Gang; Zhang, Quan; Ivkovic, Vladimir; Strangman, Gary E.

2016-09-01

Ambulatory diffuse optical tomography (aDOT) is based on near-infrared spectroscopy (NIRS) and enables three-dimensional imaging of regional hemodynamics and oxygen consumption during a person's normal activities. Although NIRS has been previously used for muscle assessment, it has been notably limited in terms of the number of channels measured, the extent to which subjects can be ambulatory, and/or the ability to simultaneously acquire synchronized auxiliary data such as electromyography (EMG) or electrocardiography (ECG). We describe the development of a prototype aDOT system, called NINscan-M, capable of ambulatory tomographic imaging as well as simultaneous auxiliary multimodal physiological monitoring. Powered by four AA size batteries and weighing 577 g, the NINscan-M prototype can synchronously record 64-channel NIRS imaging data, eight channels of EMG, ECG, or other analog signals, plus force, acceleration, rotation, and temperature for 24+ h at up to 250 Hz. We describe the system's design, characterization, and performance characteristics. We also describe examples of isometric, cycle ergometer, and free-running ambulatory exercise to demonstrate tomographic imaging at 25 Hz. NINscan-M represents a multiuse tool for muscle physiology studies as well as clinical muscle assessment.

Ambulatory cardiovascular activity and hostility ratings in women with chronic posttraumatic stress disorder.

PubMed

Beckham, Jean C; Flood, Amanda M; Dennis, Michelle F; Calhoun, Patrick S

2009-02-01

The objective of the current study is to evaluate the relationship between hostility and ambulatory cardiovascular activity in women with and without posttraumatic stress disorder (PTSD). One hundred and one women completed 24 hours of ambulatory monitoring and standardized diagnostic and hostility measures. Generalized estimating equations analysis was used to examine the effects of group and hostility factor scores (hostile beliefs, overt hostility, and covert hostility) on ambulatory heart rate (AHR) and ambulatory systolic (ASBP) and diastolic (ADBP) blood pressure. After controlling for covariates, there was an interaction between PTSD and both hostile beliefs and overt hostility for AHR. Increases in hostility were associated with greater increases in heart rate among women with PTSD relative to those without PTSD. There was a similar interaction between hostile beliefs and group for ADBP. Increased AHR and blood pressure have been linked to poor cardiovascular outcomes in nonpsychiatric populations. Individuals with PTSD display increased hostility, a construct that has also been linked to poorer cardiovascular outcomes. Increases in hostile beliefs were associated with a greater increase in ADBP among women with PTSD as compared with control subjects. These data suggest that PTSD might in part moderate the relationship between hostility and cardiovascular outcomes.

Factors Associated with Mobility Outcomes in a National Spina Bifida Patient Registry

PubMed Central

Dicianno, Brad E.; Karmarkar, Amol; Houtrow, Amy; Crytzer, Theresa M.; Cushanick, Katelyn M.; McCoy, Andrew; Wilson, Pamela; Chinarian, James; Neufeld, Jacob; Smith, Kathryn; Collins, Diane M.

2017-01-01

Objective To provide descriptive data on ambulatory ability and muscle strength in a large cohort of individuals with spina bifida enrolled in a National Spina Bifida Patient Registry (NSBPR) and to investigate factors associated with ambulatory status. Design Cross-sectional analysis of data from a multi-site patient registry Results Descriptive analysis of mobility variables for 2604 individuals with spina bifida age 5 and above are presented from 19 sites in the United States. Analysis of a subset of NSBPR data from 380 individuals from three sites accompanied by data from a specialized spina bifida electronic medical record revealed that those with no history of a shunt, lower motor level, and no history of hip or knee contracture release surgery were more likely to be ambulatory at the community level than at the household or wheelchair level. Conclusion This study is the first to examine factors associated with ambulatory status in a large sample of individuals with myelomeningocele and non-myelomeningocele subtypes of SB. Results of this study delineate the breadth of strength and functional abilities within the different age groups and subtypes of SB. The results may inform clinicians of the characteristics of those with varying ambulatory abilities. PMID:26488146

Control of an Ambulatory Exoskeleton with a Brain-Machine Interface for Spinal Cord Injury Gait Rehabilitation.

PubMed

López-Larraz, Eduardo; Trincado-Alonso, Fernando; Rajasekaran, Vijaykumar; Pérez-Nombela, Soraya; Del-Ama, Antonio J; Aranda, Joan; Minguez, Javier; Gil-Agudo, Angel; Montesano, Luis

2016-01-01

The closed-loop control of rehabilitative technologies by neural commands has shown a great potential to improve motor recovery in patients suffering from paralysis. Brain-machine interfaces (BMI) can be used as a natural control method for such technologies. BMI provides a continuous association between the brain activity and peripheral stimulation, with the potential to induce plastic changes in the nervous system. Paraplegic patients, and especially the ones with incomplete injuries, constitute a potential target population to be rehabilitated with brain-controlled robotic systems, as they may improve their gait function after the reinforcement of their spared intact neural pathways. This paper proposes a closed-loop BMI system to control an ambulatory exoskeleton-without any weight or balance support-for gait rehabilitation of incomplete spinal cord injury (SCI) patients. The integrated system was validated with three healthy subjects, and its viability in a clinical scenario was tested with four SCI patients. Using a cue-guided paradigm, the electroencephalographic signals of the subjects were used to decode their gait intention and to trigger the movements of the exoskeleton. We designed a protocol with a special emphasis on safety, as patients with poor balance were required to stand and walk. We continuously monitored their fatigue and exertion level, and conducted usability and user-satisfaction tests after the experiments. The results show that, for the three healthy subjects, 84.44 ± 14.56% of the trials were correctly decoded. Three out of four patients performed at least one successful BMI session, with an average performance of 77.6 1 ± 14.72%. The shared control strategy implemented (i.e., the exoskeleton could only move during specific periods of time) was effective in preventing unexpected movements during periods in which patients were asked to relax. On average, 55.22 ± 16.69% and 40.45 ± 16.98% of the trials (for healthy subjects and patients, respectively) would have suffered from unexpected activations (i.e., false positives) without the proposed control strategy. All the patients showed low exertion and fatigue levels during the performance of the experiments. This paper constitutes a proof-of-concept study to validate the feasibility of a BMI to control an ambulatory exoskeleton by patients with incomplete paraplegia (i.e., patients with good prognosis for gait rehabilitation).

Control of an Ambulatory Exoskeleton with a Brain–Machine Interface for Spinal Cord Injury Gait Rehabilitation

PubMed Central

López-Larraz, Eduardo; Trincado-Alonso, Fernando; Rajasekaran, Vijaykumar; Pérez-Nombela, Soraya; del-Ama, Antonio J.; Aranda, Joan; Minguez, Javier; Gil-Agudo, Angel; Montesano, Luis

2016-01-01

The closed-loop control of rehabilitative technologies by neural commands has shown a great potential to improve motor recovery in patients suffering from paralysis. Brain–machine interfaces (BMI) can be used as a natural control method for such technologies. BMI provides a continuous association between the brain activity and peripheral stimulation, with the potential to induce plastic changes in the nervous system. Paraplegic patients, and especially the ones with incomplete injuries, constitute a potential target population to be rehabilitated with brain-controlled robotic systems, as they may improve their gait function after the reinforcement of their spared intact neural pathways. This paper proposes a closed-loop BMI system to control an ambulatory exoskeleton—without any weight or balance support—for gait rehabilitation of incomplete spinal cord injury (SCI) patients. The integrated system was validated with three healthy subjects, and its viability in a clinical scenario was tested with four SCI patients. Using a cue-guided paradigm, the electroencephalographic signals of the subjects were used to decode their gait intention and to trigger the movements of the exoskeleton. We designed a protocol with a special emphasis on safety, as patients with poor balance were required to stand and walk. We continuously monitored their fatigue and exertion level, and conducted usability and user-satisfaction tests after the experiments. The results show that, for the three healthy subjects, 84.44 ± 14.56% of the trials were correctly decoded. Three out of four patients performed at least one successful BMI session, with an average performance of 77.6 1 ± 14.72%. The shared control strategy implemented (i.e., the exoskeleton could only move during specific periods of time) was effective in preventing unexpected movements during periods in which patients were asked to relax. On average, 55.22 ± 16.69% and 40.45 ± 16.98% of the trials (for healthy subjects and patients, respectively) would have suffered from unexpected activations (i.e., false positives) without the proposed control strategy. All the patients showed low exertion and fatigue levels during the performance of the experiments. This paper constitutes a proof-of-concept study to validate the feasibility of a BMI to control an ambulatory exoskeleton by patients with incomplete paraplegia (i.e., patients with good prognosis for gait rehabilitation). PMID:27536214

77 FR 17068 - Medicare and Medicaid Programs; Approval of the Application by the American Association for...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-23

... of Ambulatory Surgery Facilities for Deeming Authority for Rural Health Clinics AGENCY: Centers for... decision to approve the American Association for Accreditation of Ambulatory Surgery Facilities [[Page...

Audiometric Testing Guideline Adherence in Children Undergoing Tympanostomy Tubes: A Population-Based Study.

PubMed

Beyea, Jason A; Rosen, Emily; Stephens, Trina; Nguyen, Paul; Hall, Stephen F

2018-02-01

Objective Tympanostomy tube (TT) insertion is the most common ambulatory surgery performed on children. American Academy of Otolaryngology-Head and Neck Surgery Founda-tion (AAO-HNSF) Clinical Practice Guidelines (CPGs) recommend hearing testing for all pediatric TT candidates. The aim of this study was to assess audiometric testing in this population. Study Design Retrospective population-based cohort study. Setting All hospitals in the Canadian province of Ontario. Subjects and Methods All patients 12 years of age and younger who underwent at least 1 TT procedure between January 1993 and June 2016. The primary outcomes were the percentage of patients who underwent a hearing test within 1 year before and/or 1 year after surgery. Results A total of 316,599 bilateral TT procedures were performed during the study period (1993 to 2016). Presurgical hearing tests increased from 55.7% to 74.9%, and postsurgical hearing tests increased from 42.2% to 68.9%. Younger surgeons demonstrated a greater adherence to the CPGs (relative risk [RR], 1.22; 95% CI, 1.08-1.38; P = .001). Remarkably, there was not a spike in preoperative hearing tests following the introduction of the CPGs in 2013 (RR, 1.12; 95% CI, 0.85-1.47; P = .432). Presurgical hearing testing ranged from 26.1% to 83.5% across health regions. Conclusion In this cohort of children who underwent TT placement, the trends of preoperative and postoperative audiometric testing are increasing but are still lower than recommended by the CPGs, despite a tripling of practicing audiologists. This study describes the current state of testing in Ontario and highlights issues of access to audiology services, possible parent preferences, and the importance of ongoing continuing medical education for all health care practitioners.

Value of routine investigations to predict loop diuretic down-titration success in stable heart failure.

PubMed

Martens, Pieter; Verbrugge, Frederik H; Boonen, Levinia; Nijst, Petra; Dupont, Matthias; Mullens, Wilfried

2018-01-01

Guidelines advocate down-titration of loop diuretics in chronic heart failure (CHF) when patients have no signs of volume overload. Limited data are available on the expected success rate of this practice or how routine diagnostic tests might help steering this process. Fifty ambulatory CHF-patients on stable neurohumoral blocker/diuretic therapy for at least 3months without any clinical sign of volume overload were prospectively included to undergo loop diuretic down-titration. All patients underwent a similar pre-down-titration evaluation consisting of a dyspnea scoring, physical examination, transthoracic echocardiography (diastolic function, right ventricular function, cardiac filling pressures and valvular disease), blood sample (serum creatinine, plasma NT-pro-BNP and neurohormones). Loop diuretic maintenance dose was subsequently reduced by 50% or stopped if dose was ≤40mg furosemide equivalents. Successful down-titration was defined as a persistent dose reduction after 30days without weight increase >1.5kg or new-onset symptoms of worsening heart failure. At 30-day follow-up, down-titration was successful in 62% (n=31). In 12/19 patients exhibiting down-titration failure, this occurred within the first week. Physical examination, transthoracic echocardiography and laboratory analysis had limited predictive capability to detect patients with down-titration success/failure (positive likelihood-ratios below 1.5, or area under the curve [AUC] non-statically different from AUC=0.5). Loop diuretic down-titration is feasible in a majority of stable CHF patients in which the treating clinician felt continuation of loops was unnecessary to sustain euvolemia. Importantly, routine diagnostics which suggest euvolemia, have limited diagnostic impact on the post-test probability. Copyright © 2017 Elsevier B.V. All rights reserved.

Nutrient intake during peritoneal dialysis at the Prince of Wales Hospital in Hong Kong.

PubMed

Wang, Angela Yee-Moon; Sea, Mandy Man-Mei; Ng, Kenway; Kwan, Mandy; Lui, Siu-Fai; Woo, Jean

2007-05-01

Individuals undergoing peritoneal dialysis are at increased risk of developing cardiac disease and malnutrition. A cross-sectional survey. 249 Chinese continuous ambulatory peritoneal dialysis (CAPD) patients were recruited from the Prince of Wales Hospital in Hong Kong. Another 249 age- and sex-matched controls were recruited from an archive of 1,010 individuals with known food frequency questionnaire (FFQ) data. To compare the dietary intake pattern of CAPD patients with controls and evaluate its association with background cardiac disease. Intake of different nutrients was estimated by using a 7-day FFQ. Intake of all nutrients was lower in CAPD patients than controls, with resulting lower overall energy intake. Nutrient intake was decreased further in CAPD patients with background cardiac disease, which corresponded to worse nutritional status. Controlling for age, male sex, body weight, diabetes mellitus, dialysis therapy duration, residual renal function, peritoneal dialysis urea clearance, and Charlson Comorbidity Index score, background cardiac disease was associated independently with less intake of energy and most macronutrients and micronutrients. However, the association between background cardiac disease and energy and most nutrient intake was decreased or even lost when additional adjustment was made for C-reactive protein and serum albumin levels. An FFQ is limited in that nutrient quantitation is not exact and may be underestimated as a result of underreporting by patients. CAPD patients were compared with a control group without cardiovascular disease ascertainment that did not include subjects with diabetes. Chinese CAPD patients had significantly lower nutrient intake than age- and sex-matched controls. The association between cardiac disease and lower dietary macronutrient and micronutrient intake in CAPD patients was mediated in part through systemic inflammation, which also was associated with more malnutrition. More attention should be focused on improving the intake pattern of Chinese CAPD patients.

Outcome of renal replacement treatment in patients with diabetes mellitus.

PubMed Central

McMillan, M A; Briggs, J D; Junor, B J

1990-01-01

OBJECTIVE--To compare the outcome of renal replacement treatment in patients with diabetes mellitus and in non-diabetic patients with end stage renal failure. DESIGN--Retrospective comparison of cases and matched controls. SETTING--Renal unit, Western Infirmary, Glasgow, providing both dialysis and renal transplantation. PATIENTS--82 Diabetic patients starting renal replacement treatment between 1979 and 1988, compared with 82 matched non-diabetic controls with renal failure and 39 different matched controls undergoing renal transplantation. MAIN OUTCOME MEASURES--Patient characteristics, history of smoking, prevalence of left ventricular hypertrophy and myocardial ischaemia at start of renal replacement treatment; survival of patients with renal replacement treatment and of patients and allografts with renal transplantation. RESULTS--The overall survival of the diabetic patients during the treatment was 83%, 59%, and 50% at one, three, and five years. Survival was significantly poorer in the diabetic patients than the controls (p less than 0.001). Particularly adverse features for outcome at the start of treatment were increasing age (p less than 0.01) and current cigarette smoking (relative risk (95% confidence interval) 2.28 (0.93 to 4.84), p less than 0.05). Deaths were mainly from cardiac and vascular causes. The incidence of peritonitis in patients on continuous ambulatory peritoneal dialysis was the same in diabetic patients and controls (49% in each group remained free of peritonitis after one year), and the survival of renal allografts was not significantly worse in diabetic patients (p less than 0.5). CONCLUSIONS--Renal replacement treatment may give good results in diabetic patients, although the outlook remains less favourable than for non-diabetic patients because of coexistent, progressive vascular disease, which is more severe in older patients. PMID:2207427

Peritoneal clearances in hypertensive CAPD patients after oral administration of clonidine, enalapril, and nifedipine.

PubMed

Favazza, A; Motanaro, D; Messa, P; Antonucci, F; Gropuzzo, M; Mioni, G

1992-01-01

The authors investigated whether the reduction of arterial pressure, induced by the oral administration of clonidine (CLO), enalapril (EN), and nifedipine (NIF), has any effect on peritoneal transport rates. The study was performed in nine hypertensive patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The patients were submitted to administration of CLO, EN, and NIF, each in randomized succession for two weeks, after withdrawal of any hypotensive therapy for eight days (washout period). The nine patients underwent a four-hour dwell exchange using a 2.27 g/dL glucose two-liter bag after washout and after each hypotensive period. The following parameters were analyzed: mean arterial pressure (MAP), performed in the sitting position; net ultrafiltration; effluent/initial dialysate glucose ratio (GL D/Do); peritoneal clearance of K, BUN, creatinine (Cr), phosphate, beta-2 microglobulin (beta 2), total proteins, and the ratio between beta 2 and Cr clearance. Moreover, residual renal Cr and beta 2 clearances were analyzed. The three drugs significantly reduced MAP at a similar rate. The peritoneal transport parameters after CLO were similar to the results in the washout period. On the contrary, after EN and NIF therapy, Cr and beta 2 clearances were significantly increased, and GL D/Do decreased in comparison to the washout period. The other peritoneal transport parameters after EN and NIF were similar to the washout period. Residual renal Cr and beta 2 clearances after the three drugs were similar to those in the washout. these data suggest that after two weeks of therapy with EN and NIF, glucose, Cr, and beta 2 peritoneal transports are influenced by these hypotensive drugs irrespective of the effect on the arterial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Computerized symptom and quality-of-life assessment for patients with cancer part II: acceptability and usability.

PubMed

Mullen, Kristin H; Berry, Donna L; Zierler, Brenda K

2004-09-01

To determine the acceptability and usability of a computerized quality-of-life (QOL) and symptom assessment tool and the graphically displayed QOL and symptom output in an ambulatory radiation oncology clinic. Descriptive, cross-sectional. Radiation oncology clinic located in an urban university medical center. 45 patients with cancer being evaluated for radiation therapy and 10 clinicians, who submitted 12 surveys. Acceptability of the computerized assessment was measured with an online, 16-item, Likert-style survey delivered as 45 patients undergoing radiation therapy completed a 25-item QOL and symptom assessment. Usability of the graphic output was assessed with clinician completion of a four-item paper survey. Acceptability and usability of computerized patient assessment. The patient acceptability survey indicated that 70% (n = 28) liked computers and 10% (n = 4) did not. The program was easy to use for 79% (n = 26), easy to understand for 91% (n = 30), and enjoyable for 71% (n = 24). Seventy-six percent (n = 25) believed that the amount of time needed to complete the computerized survey was acceptable. Sixty-six percent (n = 21) responded that they were satisfied with the program, and none of the participants chose the very dissatisfied response. Eighty-three percent (n = 10) of the clinicians found the graphic output helpful in promoting communication with patients, 75% (n = 9) found the output report helpful in identifying appropriate areas of QOL deficits or concerns, and 83% (n = 10) indicated that the output helped guide clinical interactions with patients. The computer-based QOL and symptom assessment tool is acceptable to patients, and the graphically displayed QOL and symptom output is useful to radiation oncology nurses and physicians. Wider application of computerized patient-generated data can continue in various cancer settings and be tested for clinical and organizational outcomes.

WHOQOL-100 Before and After Sex Reassignment Surgery in Brazilian Male-to-Female Transsexual Individuals.

PubMed

Cardoso da Silva, Dhiordan; Schwarz, Karine; Fontanari, Anna Martha Vaitses; Costa, Angelo Brandelli; Massuda, Raffael; Henriques, Alexandre Annes; Salvador, Jaqueline; Silveira, Esalba; Elias Rosito, Tiago; Lobato, Maria Inês Rodrigues

2016-06-01

The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence. Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Joint-venture proposals strengthen hospital-physician relationship.

PubMed

Rovinsky, M

2000-12-01

By proposing the joint-venture development of an ambulatory surgery center and medical office space with a group practice, one hospital succeeded in enhancing its relationship with the practice and paved the way for future collaboration. Although the hospital's proposal to jointly develop an ambulatory surgery center was not accepted, the hospital was able to dissuade the group practice from developing a competing ambulatory surgery facility while increasing the group's trust in and loyalty to the hospital. As a result, the hospital potentially will benefit from increased inpatient admissions.

Relationships of muscle strength and bone mineral density in ambulatory children with cerebral palsy.

PubMed

Chen, C-L; Lin, K-C; Wu, C-Y; Ke, J-Y; Wang, C-J; Chen, C-Y

2012-02-01

This work explores the relationships of muscle strength and areal bone mineral density (aBMD) in ambulatory children with cerebral palsy (CP). The knee extensor strength, but not motor function, was related to aBMD. Thus, muscle strength, especially antigravity muscle strength, was more associated with aBMD in these children than motor function. Muscle strength is related to bone density in normal children. However, no studies have examined these relationships in ambulatory children with CP. This work explores the relationships of muscle strength and aBMD in ambulatory children with CP. Forty-eight ambulatory children with spastic CP, aged 5-15 years, were classified into two groups based on Gross Motor Function Classification System levels: I (n = 28) and II (n = 20). Another 31 normal development (ND) children were recruited as the comparison group for the aBMD. Children with CP underwent assessments of growth, lumbar and distal femur aBMD, Gross Motor Function Measure-66 (GMFM-66), and muscle strength of knee extensor and flexor by isokinetic dynamometer. The distal femur aBMD, but not lumbar aBMD, was lower in children with CP than in ND children (p < 0.05). Children with level I had greater knee flexor strength and GMFM-66 scores than those with level II (p < 0.001). However, the knee extensor strength and distal femur and lumbar aBMD did not differ between two groups. Regression analysis revealed the weight and knee extensor strength, but not GMFM-66 scores, were related positively to the distal femur and lumbar aBMD (adjusted r (2) = 0.56-0.65, p < 0.001). These results suggest the muscle strength, especially antigravity muscle strength, were more associated with the bone density of ambulatory children with CP than motor function. The data may allow clinicians for early identifying the ambulatory CP children of potential low bone density.

Office blood pressure or ambulatory blood pressure for the prediction of cardiovascular events.

PubMed

Mortensen, Rikke Nørmark; Gerds, Thomas Alexander; Jeppesen, Jørgen Lykke; Torp-Pedersen, Christian

2017-11-21

To determine the added value of (i) 24-h ambulatory blood pressure relative to office blood pressure and (ii) night-time ambulatory blood pressure relative to daytime ambulatory blood pressure for 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. A total of 7927 participants were included from the International Database on Ambulatory blood pressure monitoring in relation to Cardiovascular Outcomes. We used cause-specific Cox regression to predict 10-year person-specific absolute risks of fatal and non-fatal cardiovascular events. Discrimination of 10-year outcomes was assessed by time-dependent area under the receiver operating characteristic curve (AUC). No differences in predicted risks were observed when comparing office blood pressure and ambulatory blood pressure. The median difference in 10-year risks (1st; 3rd quartile) was -0.01% (-0.3%; 0.1%) for cardiovascular mortality and -0.1% (-1.1%; 0.5%) for cardiovascular events. The difference in AUC (95% confidence interval) was 0.65% (0.22-1.08%) for cardiovascular mortality and 1.33% (0.83-1.84%) for cardiovascular events. Comparing daytime and night-time blood pressure, the median difference in 10-year risks was 0.002% (-0.1%; 0.1%) for cardiovascular mortality and -0.01% (-0.5%; 0.2%) for cardiovascular events. The difference in AUC was 0.10% (-0.08 to 0.29%) for cardiovascular mortality and 0.15% (-0.06 to 0.35%) for cardiovascular events. Ten-year predictions obtained from ambulatory blood pressure are similar to predictions from office blood pressure. Night-time blood pressure does not improve 10-year predictions obtained from daytime measurements. For an otherwise healthy population sufficient prognostic accuracy of cardiovascular risks can be achieved with office blood pressure. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review.

PubMed

Mus-Peters, Cindy T R; Huisstede, Bionka M A; Noten, Suzie; Hitters, Minou W M G C; van der Slot, Wilma M A; van den Berg-Emons, Rita J G

2018-05-22

Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.

Solute clearance measurement in the assessment of dialysis adequacy among African continuous ambulatory peritoneal dialysis patients.

PubMed

Abdu, Aliyu; Naidoo, Sagren; Malgas, Shirin; Naicker, Jocelyn T; Paget, Graham; Naicker, Saraladevi

2015-01-01

Solute clearance measurement is an objective means of quantifying the dose of peritoneal dialysis (PD). Despite continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients, guidelines based on solute clearance values are common in clinical practice. There is limited information on the solute clearance indices and PD adequacy parameters among this predominantly low socioeconomic status PD population. We investigated the solute clearance among continuous ambulatory peritoneal dialysis (CAPD) patients at the Charlotte Maxeke Johannesburg Academic Hospital and its relationship with other parameters of PD adequacy. Seventy patients on CAPD were studied in this cross-sectional study. Solute clearance was assessed using urea clearance (Kt/V). Linear regression analysis was used to determine factors associated with solute clearance, while analysis of variance was used to test the influence of weekly Kt/V on blood pressure (BP), hemoglobin (Hb) and other biochemical parameters. The mean age of the study population was 37.9 ± 12.4 years, 43% were females and 86% were black Africans. The mean duration on CAPD was 19.7 ± 20.8 months. Mean systolic and diastolic BP were 144 ± 28 and 92 ± 17 mm Hg, respectively. The mean Hb was 11.1 ± 2.2 g/dL and the mean weekly Kt/V was 1.7 ± 0.3. Factors like systolic BP, Hb level, serum levels of cholesterol, calcium, phosphate, parathyroid hormone and albumin were not significantly associated with the weekly Kt/V. We conclude that the dose of PD received by the majority of our patients in terms of the weekly Kt/V is within the recommended values and that this finding is significant considering the low socioeconomic background of our patients. There is no significant association between Kt/V and other indices of dialysis adequacy.

Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients: A retrospective study.

PubMed

Tian, Yuanshi; Xie, Xishao; Xiang, Shilong; Yang, Xin; Zhang, Xiaohui; Shou, Zhangfei; Chen, Jianghua

2016-12-01

Peritonitis remains a major complication of peritoneal dialysis (PD). A high peritonitis rate (HPR) affects continuous ambulatory peritoneal dialysis (CAPD) patients' technique survival and mortality. Predictors and outcomes of HPR, rather than the first peritonitis episode, were rarely studied in the Chinese population. In this study, we examined the risk factors associated with HPR and its effects on clinical outcomes in CAPD patients.This is a single center, retrospective, observational cohort study. A total of 294 patients who developing at least 1 episode of peritonitis were followed up from March 1st, 2002, to July 31, 2014, in our PD center. Multivariate logistic regression was used to determine the factors associated with HPR, and the Cox proportional hazard model was conducted to assess the effects of HPR on clinical outcomes.During the study period of 2917.5 patient-years, 489 episodes of peritonitis were recorded, and the total peritonitis rate was 0.168 episodes per patient-year. The multivariate analysis showed that factors associated with HPR include a quick occurrence of peritonitis after CAPD initiation (shorter than 12 months), and a low serum albumin level at the start of CAPD. In the Cox proportional hazard model, HPR was a significant predictor of technique failure. There were no differences between HPR and low peritonitis rate (LPR) group for all-cause mortality. However, when the peritonitis rate was considered as a continuous variable, a positive correlation was observed between the peritonitis rate and mortality.We found the quick peritonitis occurrence after CAPD and the low serum albumin level before CAPD were strongly associated with an HPR. Also, our results verified that HPR was positively correlated with technique failure. More importantly, the increase in the peritonitis rate suggested a higher risk of all-cause mortality.These results may help to identify and target patients who are at higher risk of HPR at the start of CAPD and to take interventions to reduce peritonitis incidence and improve clinical outcomes.

Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients

PubMed Central

Tian, Yuanshi; Xie, Xishao; Xiang, Shilong; Yang, Xin; Zhang, Xiaohui; Shou, Zhangfei; Chen, Jianghua

2016-01-01

Abstract Peritonitis remains a major complication of peritoneal dialysis (PD). A high peritonitis rate (HPR) affects continuous ambulatory peritoneal dialysis (CAPD) patients’ technique survival and mortality. Predictors and outcomes of HPR, rather than the first peritonitis episode, were rarely studied in the Chinese population. In this study, we examined the risk factors associated with HPR and its effects on clinical outcomes in CAPD patients. This is a single center, retrospective, observational cohort study. A total of 294 patients who developing at least 1 episode of peritonitis were followed up from March 1st, 2002, to July 31, 2014, in our PD center. Multivariate logistic regression was used to determine the factors associated with HPR, and the Cox proportional hazard model was conducted to assess the effects of HPR on clinical outcomes. During the study period of 2917.5 patient-years, 489 episodes of peritonitis were recorded, and the total peritonitis rate was 0.168 episodes per patient-year. The multivariate analysis showed that factors associated with HPR include a quick occurrence of peritonitis after CAPD initiation (shorter than 12 months), and a low serum albumin level at the start of CAPD. In the Cox proportional hazard model, HPR was a significant predictor of technique failure. There were no differences between HPR and low peritonitis rate (LPR) group for all-cause mortality. However, when the peritonitis rate was considered as a continuous variable, a positive correlation was observed between the peritonitis rate and mortality. We found the quick peritonitis occurrence after CAPD and the low serum albumin level before CAPD were strongly associated with an HPR. Also, our results verified that HPR was positively correlated with technique failure. More importantly, the increase in the peritonitis rate suggested a higher risk of all-cause mortality. These results may help to identify and target patients who are at higher risk of HPR at the start of CAPD and to take interventions to reduce peritonitis incidence and improve clinical outcomes. PMID:27930566

Ambulatory blood pressure response to a bout of HIIT in metabolic syndrome patients.

PubMed

Ramirez-Jimenez, M; Morales-Palomo, F; Pallares, J G; Mora-Rodriguez, Ricardo; Ortega, J F

2017-07-01

The effectiveness of exercise to lower blood pressure may depend on the type and intensity of exercise. We study the short-term (i.e., 14-h) effects of a bout of high-intensity aerobic interval training (HIIT) on blood pressure in metabolic syndrome (MetS) patients. Nineteen MetS patients (55.2 ± 7.3 years, 6 women) entered the study. Eight of them were normotensive and eleven hypertensive according to MetS threshold (≥130 mmHg for SBP and/or ≥85 mmHg for DBP). In the morning of 3 separated days, they underwent a cycling exercise bout of HIIT (>90% of maximal heart rate, ~85% VO 2max ), or a bout of isocaloric moderate-intensity continuous training (MICT; ~70% of maximal heart rate, ~60% VO 2max ), or a control no-exercise trial (REST). After exercise, ambulatory blood pressure (ABP; 14 h) was monitored, while subjects continued their habitual daily activities wearing a wrist-band activity monitor. No ABP differences were found for normotensive subjects. In hypertensive subjects, systolic ABP was reduced by 6.1 ± 2.2 mmHg after HIIT compared to MICT and REST (130.8 ± 3.9 vs. 137.4 ± 5.1 and 136.4 ± 3.8 mmHg, respectively; p < 0.05). However, diastolic ABP was similar in all three trials (77.2 ± 2.6 vs. 78.0 ± 2.6 and 78.9 ± 2.8 mmHg, respectively). Motion analysis revealed no differences among trials during the 14-h. This study suggests that the blood pressure reducing effect of a bout of exercise is influence by the intensity of exercise. A HIIT exercise bout is superior to an equivalent bout of continuous exercise when used as a non-pharmacological aid in the treatment of hypertension in MetS.

Optimising postoperative pain management in the ambulatory patient.

PubMed

Shang, Allan B; Gan, Tong J

2003-01-01

Over 60% of surgery is now performed in an ambulatory setting. Despite improved analgesics and sophisticated drug delivery systems, surveys indicate that over 80% of patients experience moderate to severe pain postoperatively. Inadequate postoperative pain relief can prolong recovery, precipitate or increase the duration of hospital stay, increase healthcare costs, and reduce patient satisfaction. Effective postoperative pain management involves a multimodal approach and the use of various drugs with different mechanisms of action. Local anaesthetics are widely administered in the ambulatory setting using techniques such as local injection, field block, regional nerve block or neuraxial block. Continuous wound infusion pumps may have great potential in an ambulatory setting. Regional anaesthesia (involving anaesthetising regional areas of the body, including single extremities, multiple extremities, the torso, and the face or jaw) allows surgery to be performed in a specific location, usually an extremity, without the use of general anaesthesia, and potentially with little or no sedation. Opioids remain an important component of any analgesic regimen in treating moderate to severe acute postoperative pain. However, the incorporation of non-opioids, local anaesthetics and regional techniques will enhance current postoperative analgesic regimens. The development of new modalities of treatment, such as patient controlled analgesia, and newer drugs, such as cyclo-oxygenase-2 inhibitors, provide additional choices for the practitioner. While there are different routes of administration for analgesics (e.g. oral, parenteral, intramuscular, transmucosal, transdermal and sublingual), oral delivery of medications has remained the mainstay for postoperative pain control. The oral route is effective, the simplest to use and typically the least expensive. The intravenous route has the advantages of a rapid onset of action and easier titratibility, and so is recommended for the treatment of acute pain.Non-pharmacological methods for the management of postoperative pain include acupuncture, electromagnetic millimetre waves, hypnosis and the use of music during surgery. However, further research of these techniques is warranted to elucidate their effectiveness in this indication. Pain is a multifactorial experience, not just a sensation. Emotion, perception and past experience all affect an individual's response to noxious stimuli. Improved postoperative pain control through innovation and creativity may improve compliance, ease of delivery, reduce length of hospital stay and improve patient satisfaction. Patient education, early diagnosis of symptoms and aggressive treatment of pain using an integrative approach, combining pharmacotherapy as well as complementary technique, should serve us well in dealing with this complex problem.

An Ambulatory Medical Education Program for Internal Medicine Residents.

ERIC Educational Resources Information Center

Wones, Robert G.; And Others

1987-01-01

An ambulatory medicine program for university hospital clinic residents was found to be effective in improving students' knowledge, enhancing attitudes toward the clinic, and improving performance of influenza vaccinations. No adverse program effects were found. (MSE)

Patient Safety Threat - Syringe Reuse

MedlinePlus

... Fingerstick Devices Clinical Reminder: Insulin Pens Publications Infection Control Assessment of Ambulatory Surgical Centers Meetings Insurance Stakeholders Meeting – December 2011 Ambulatory Surgical Centers – October 2010 Safety by Design – May 2010 Sticking with Safety – May 2010 Injection ...

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences

PubMed Central

Pereira, Chrystian R.; Harris, Ila M.; Moon, Jean Y.; Westberg, Sarah M.; Kolar, Claire

2016-01-01

Objective. To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). Design. Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students’ competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. Assessment. Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. Conclusions. Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs. PMID:26941440

Reliability and Validity of Ambulatory Cognitive Assessments

PubMed Central

Sliwinski, Martin J.; Mogle, Jacqueline A.; Hyun, Jinshil; Munoz, Elizabeth; Smyth, Joshua M.; Lipton, Richard B.

2017-01-01

Mobile technologies are increasingly used to measure cognitive function outside of traditional clinic and laboratory settings. Although ambulatory assessments of cognitive function conducted in people’s natural environments offer potential advantages over traditional assessment approaches, the psychometrics of cognitive assessment procedures have been understudied. We evaluated the reliability and construct validity of ambulatory assessments of working memory and perceptual speed administered via smartphones as part of an ecological momentary assessment (EMA) protocol in a diverse adult sample (N=219). Results indicated excellent between-person reliability (≥.97) for average scores, and evidence of reliable within-person variability across measurement occasions (.41–.53). The ambulatory tasks also exhibited construct validity, as evidence by their loadings on working memory and perceptual speed factors defined by the in-lab assessments. Our findings demonstrate that averaging across brief cognitive assessments made in uncontrolled naturalistic settings provide measurements that are comparable in reliability to assessments made in controlled laboratory environments. PMID:27084835

Hypertension and arterial stiffness in heart transplantation patients

PubMed Central

de Souza-Neto, João David; de Oliveira, Ítalo Martins; Lima-Rocha, Hermano Alexandre; Oliveira-Lima, José Wellington; Bacal, Fernando

2016-01-01

OBJECTIVES: Post-transplantation hypertension is prevalent and is associated with increased cardiovascular morbidity and subsequent graft dysfunction. The present study aimed to identify the factors associated with arterial stiffness as measured by the ambulatory arterial stiffness index. METHODS: The current study used a prospective, observational, analytical design to evaluate a group of adult heart transplantation patients. Arterial stiffness was obtained by monitoring ambulatory blood pressure and using the ambulatory arterial stiffness index as the surrogate outcome. Multivariate logistic regression analyses were performed to control confounding. RESULTS: In a group of 85 adult heart transplantation patients, hypertension was independently associated with arterial stiffness (OR 4.98, CI 95% 1.06-23.4) as well as systolic and diastolic blood pressure averages and nighttime descent. CONCLUSIONS: Measurement of ambulatory arterial stiffness index is a new, non-invasive method that is easy to perform, may contribute to better defining arterial stiffness prognosis and is associated with hypertension. PMID:27652829

Participation restrictions in ambulatory amyotrophic lateral sclerosis patients: Physical and psychological factors.

PubMed

Van Groenestijn, Annerieke C; Schröder, Carin D; Kruitwagen-Van Reenen, Esther T; Van Den Berg, Leonard H; Visser-Meily, Johanna M A

2017-11-01

The aim of this study was to assess the prevalence of participation restrictions in ambulatory patients with amyotrophic lateral sclerosis (ALS) and to identify physical and psychological contributory factors. In this cross-sectional study, self-reported participation restrictions of 72 ambulatory ALS patients were assessed using the social health status dimension (SIPSOC) of the Sickness Impact Profile (SIP-68). Associations between SIPSOC and physical functioning, psychological factors, and demographic factors were analyzed using hierarchical regression analyses. Ninety-two percent of the patients reported participation restrictions; 54.9% could be explained by physical functioning; psychological factors accounted for 8.1% of the variance. Lung capacity, functional mobility, fatigue, and helplessness were independently associated with participation restrictions. Ambulatory ALS patients have participation restrictions, which may be influenced if early ALS care is directed toward lung capacity, functional mobility, fatigue, and feelings of helplessness. Muscle Nerve 56: 912-918, 2017. © 2017 Wiley Periodicals, Inc.

[The scope and structure of ambulatory polyclinic visits of physicians in the Russian Federation in 2009-2011].

PubMed

Schepin, V O; Mirgorodskaya, O V

2013-01-01

The article presents the results of structural functional analysis of public statistic data concerning the appealability of population the Russian Federation for ambulatory polyclinic care in health institutions of Minzdrav of Russia in 2009-2011. The study was targeted to identify the institutions, the volume, the specialists, the groups of population and purpose of provided medical care. It is demonstrated that during three years the significant differences in volume and structure of ambulatory polyclinic care used per capita between adults and children, urban and rural residents still are present. This is an indication of different degree of need and availability of this kind of medical care. It is noted that in ambulatory polyclinic institutions the specialized medical care is provided mainly on the occasion of diseases. This situation is not fully in line with present conceptions of targets of this stage of medical care provision.

Support Vector Machines to improve physiologic hot flash measures: application to the ambulatory setting.

PubMed

Thurston, Rebecca C; Hernandez, Javier; Del Rio, Jose M; De La Torre, Fernando

2011-07-01

Most midlife women have hot flashes. The conventional criterion (≥2 μmho rise/30 s) for classifying hot flashes physiologically has shown poor performance. We improved this performance in the laboratory with Support Vector Machines (SVMs), a pattern classification method. We aimed to compare conventional to SVM methods to classify hot flashes in the ambulatory setting. Thirty-one women with hot flashes underwent 24 h of ambulatory sternal skin conductance monitoring. Hot flashes were quantified with conventional (≥2 μmho/30 s) and SVM methods. Conventional methods had low sensitivity (sensitivity=.57, specificity=.98, positive predictive value (PPV)=.91, negative predictive value (NPV)=.90, F1=.60), with performance lower with higher body mass index (BMI). SVMs improved this performance (sensitivity=.87, specificity=.97, PPV=.90, NPV=.96, F1=.88) and reduced BMI variation. SVMs can improve ambulatory physiologic hot flash measures. Copyright © 2010 Society for Psychophysiological Research.

Exploring the link between ambulatory care and avoidable hospitalizations at the Veteran Health Administration.

PubMed

Pracht, Etienne E; Bass, Elizabeth

2011-01-01

This paper explores the link between utilization of ambulatory care and the likelihood of rehospitalization for an avoidable reason in veterans served by the Veteran Health Administration (VA). The analysis used administrative data containing healthcare utilization and patient characteristics stored at the national VA data warehouse, the Corporate Franchise Data Center. The study sample consisted of 284 veterans residing in Florida who had been hospitalized at least once for an avoidable reason. A bivariate probit model with instrumental variables was used to estimate the probability of rehospitalization. Veterans who had at least 1 ambulatory care visit per month experienced a significant reduction in the probability of rehospitalization for the same avoidable hospitalization condition. The findings suggest that ambulatory care can serve as an important substitute for more expensive hospitalization for the conditions characterized as avoidable. © 2011 National Association for Healthcare Quality.

Biomedical Wireless Ambulatory Crew Monitor

NASA Technical Reports Server (NTRS)

Chmiel, Alan; Humphreys, Brad

2009-01-01

A compact, ambulatory biometric data acquisition system has been developed for space and commercial terrestrial use. BioWATCH (Bio medical Wireless and Ambulatory Telemetry for Crew Health) acquires signals from biomedical sensors using acquisition modules attached to a common data and power bus. Several slots allow the user to configure the unit by inserting sensor-specific modules. The data are then sent real-time from the unit over any commercially implemented wireless network including 802.11b/g, WCDMA, 3G. This system has a distributed computing hierarchy and has a common data controller on each sensor module. This allows for the modularity of the device along with the tailored ability to control the cards using a relatively small master processor. The distributed nature of this system affords the modularity, size, and power consumption that betters the current state of the art in medical ambulatory data acquisition. A new company was created to market this technology.

Continuing Versus New Prescriptions for Sedative-Hypnotic Medications: United States, 2005–2012

PubMed Central

Spira, Adam P.; Depp, Colin A.; Mojtabai, Ramin

2016-01-01

Objectives. To assess trends in continuing and new prescriptions for sedative-hypnotic medications, including benzodiazepines (BZDs) and non-BZD receptor agonists (nBZRAs). Methods. Data came from the National Ambulatory Medical Care Survey and comprised 287 288 randomly sampled patient visits. Physicians reported medications prescribed and whether they were “continuing” or “new” prescriptions. We assessed trends in continuing BZD, new BZD, continuing nBZRA, and new nBZRA prescriptions from 2005 to 2012. Results. Proportions of visits with continuing prescriptions increased from 3.4% in 2005 to 4.7% in 2012 (P < .01) for BZDs, and from 1.0% to 1.7% (P < .01) for nBZRAs. We noted no changes in new prescriptions. We observed the same patterns across patient age and physician specialties, except psychiatry. Despite no growth over time, the prevalence of visits involving continuing and new BZD and nBZRA prescriptions was much higher in psychiatry than in primary care and other specialties. Conclusions. Increased sedative-hypnotic prescribing in recent years may be attributable to long-term growth in continuing prescriptions, rather than new prescriptions. Public Health Implications. Findings call for renewed efforts to limit continuing prescribing of sedative-hypnotics to reduce their use in the population. PMID:27631754

Real-Time Management of Multimodal Streaming Data for Monitoring of Epileptic Patients.

PubMed

Triantafyllopoulos, Dimitrios; Korvesis, Panagiotis; Mporas, Iosif; Megalooikonomou, Vasileios

2016-03-01

New generation of healthcare is represented by wearable health monitoring systems, which provide real-time monitoring of patient's physiological parameters. It is expected that continuous ambulatory monitoring of vital signals will improve treatment of patients and enable proactive personal health management. In this paper, we present the implementation of a multimodal real-time system for epilepsy management. The proposed methodology is based on a data streaming architecture and efficient management of a big flow of physiological parameters. The performance of this architecture is examined for varying spatial resolution of the recorded data.

Physician-executives past, present, and future.

PubMed

Smallwood, K G; Wilson, C N

1992-08-01

The dramatic changes in the United States' health care system during the last decade have sparked increasing interest in physician-executives. These executives, skilled in both clinical medicine and health care management, can be found in hospitals, managed care organizations, group practices, and government institutions. This paper outlines the physician-executive's roles and the development process. The remarkable growth in the number of physician-executives is expected to continue as they demonstrate their abilities to help health care providers expand ambulatory services, facilitate provider-physician relationships and physician recruitment, and lend expertise in quality improvement and risk management issues.

Manpower Substitution and Productivity in Medical Practice

PubMed Central

Reinhardt, Uwe E.

1973-01-01

Probably in response to the often alleged physician shortage in this country, concerted research efforts are under way to identify technically feasible opportunities for manpower substitution in the production of ambulatory health care. The approaches range from descriptive studies of the effect of task delegation on output of medical services to rigorous mathematical modeling of health care production by means of linear or continuous production functions. In this article the distinct methodological approaches underlying mathematical models are presented in synopsis, and their inherent strengths and weaknesses are contrasted. The discussion includes suggestions for future research directions. Images Fig. 2 PMID:4586735

41 CFR 102-118.290 - Must every electronic and paper transportation bill undergo a prepayment audit?

Code of Federal Regulations, 2010 CFR

2010-07-01

... and paper transportation bill undergo a prepayment audit? 102-118.290 Section 102-118.290 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION TRANSPORTATION 118-TRANSPORTATION PAYMENT AND AUDIT Prepayment Audits of Transportation...

Ambulatory Antibiotic Stewardship through a Human Factors Engineering Approach: A Systematic Review.

PubMed

Keller, Sara C; Tamma, Pranita D; Cosgrove, Sara E; Miller, Melissa A; Sateia, Heather; Szymczak, Julie; Gurses, Ayse P; Linder, Jeffrey A

2018-01-01

In the United States, most antibiotics are prescribed in ambulatory settings. Human factors engineering, which explores interactions between people and the place where they work, has successfully improved quality of care. However, human factors engineering models have not been explored to frame what is known about ambulatory antibiotic stewardship (AS) interventions and barriers and facilitators to their implementation. We conducted a systematic review and searched OVID MEDLINE, Embase, Scopus, Web of Science, and CINAHL to identify controlled interventions and qualitative studies of ambulatory AS and determine whether and how they incorporated principles from a human factors engineering model, the Systems Engineering Initiative for Patient Safety 2.0 model. This model describes how a work system (ambulatory clinic) contributes to a process (antibiotic prescribing) that leads to outcomes. The work system consists of 5 components, tools and technology, organization, person, tasks, and environment, within an external environment. Of 1,288 abstracts initially identified, 42 quantitative studies and 17 qualitative studies met inclusion criteria. Effective interventions focused on tools and technology (eg, clinical decision support and point-of-care testing), the person (eg, clinician education), organization (eg, audit and feedback and academic detailing), tasks (eg, delayed antibiotic prescribing), the environment (eg, commitment posters), and the external environment (media campaigns). Studies have not focused on clinic-wide approaches to AS. A human factors engineering approach suggests that investigating the role of the clinic's processes or physical layout or external pressures' role in antibiotic prescribing may be a promising way to improve ambulatory AS. © Copyright 2018 by the American Board of Family Medicine.

Assessing patient safety in Canadian ambulatory surgery facilities: A national survey

PubMed Central

Ahmad, Jamil; Ho, Olivia A; Carman, Wayne W; Thoma, Achilles; Lalonde, Donald H; Lista, Frank

2014-01-01

BACKGROUND: There has been increased interest regarding patient safety and standards of care in Canadian ambulatory surgery facilities where surgical procedures are performed. The Canadian Association for Accreditation of Ambulatory Surgical Facilities (CAAASF) is a national organization formed to establish and maintain standards to ensure that surgical procedures conducted outside of public hospitals are performed safely. OBJECTIVE: To determine how many procedures are performed annually at CAAASF member sites, and to examine complication rates and several key patient safety practices. METHODS: All 69 facilities accredited by the CAAASF were surveyed. The survey focused on procedural data, complication rates and patient safety interventions. RESULTS: In 2010, 40,240 estimated procedures were performed. A total of 263 (0.007%) complications were reported. Sixteen (0.0004%) patients required reoperations in hospital and 19 (0.0004%) patients required transfer to hospital on the day of surgery. There were only two mortalities within 30 days of surgery reported in the past five years. With regard to patient safety practices, 93% used antimicrobial prophylaxis, 100% used strategies to maintain normothermia and 82% used measures for venous thromboembolism prevention. CONCLUSION: The present study is the first to report on the Canadian experience in ambulatory surgery facilities and provides insight into current practices at these facilities. Appropriate accreditation of ambulatory surgery facilities, well-established patient safety-related standards of care, careful patient selection and procedures performed by qualified health care professionals with appropriate certification practicing within the scope of their practice form the basis for safe and effective ambulatory surgery. PMID:25152645

Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors.

PubMed

Rosero, Eric B; Joshi, Girish P

2017-11-01

The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers. Copyright © 2017 Elsevier Inc. All rights reserved.

Clinical Assessment Applications of Ambulatory Biosensors

ERIC Educational Resources Information Center

Haynes, Stephen N.; Yoshioka, Dawn T.

2007-01-01

Ambulatory biosensor assessment includes a diverse set of rapidly developing and increasingly technologically sophisticated strategies to acquire minimally disruptive measures of physiological and motor variables of persons in their natural environments. Numerous studies have measured cardiovascular variables, physical activity, and biochemicals…

Predictors of exercise participation in ambulatory and non-ambulatory older people with multiple sclerosis

PubMed Central

Harris, Chelsea; Wallack, Elizabeth M.; Drodge, Olivia; Beaulieu, Serge; Mayo, Nancy

2015-01-01

Background. Exercise at moderate intensity may confer neuroprotective benefits in multiple sclerosis (MS), however it has been reported that people with MS (PwMS) exercise less than national guideline recommendations. We aimed to determine predictors of moderate to vigorous exercise among a sample of older Canadians with MS who were divided into ambulatory (less disabled) and non-ambulatory (more disabled) groups. Methods. We analysed data collected as part of a national survey of health, lifestyle and aging with MS. Participants (n = 743) were Canadians over 55 years of age with MS for 20 or more years. We identified ‘a priori’ variables (demographic, personal, socioeconomic, physical health, exercise history and health care support) that may predict exercise at moderate to vigorous intensity (>6.75 metabolic equivalent hours/week). Predictive variables were entered into stepwise logistic regression until best fit was achieved. Results. There was no difference in explanatory models between ambulatory and non-ambulatory groups. The model predicting exercise included the ability to walk independently (OR 1.90, 95% CI [1.24–2.91]); low disability (OR 1.50, 95% CI [1.34–1.68] for each 10 point difference in Barthel Index score), perseverance (OR 1.17, 95% CI [1.08–1.26] for each additional point on the scale of 0–14), less fatigue (OR 2.01, 95% CI [1.32–3.07] for those in the lowest quartile), fewer years since MS diagnosis (OR 1.58, 95% CI [1.11–2.23] below the median of 23 years) and fewer cardiovascular comorbidities (OR 1.55 95% CI [1.02–2.35] one or no comorbidities). It was also notable that the factors, age, gender, social support, health care support and financial status were not predictive of exercise. Conclusions. This is the first examination of exercise and exercise predictors among older, more disabled PwMS. Disability is a major predictor of exercise participation (at moderate to vigorous levels) in both ambulatory and non-ambulatory groups suggesting that more exercise options must be developed for people with greater disability. Perseverance, fatigue, and cardiovascular comorbidities are predictors that are modifiable and potential targets for exercise adherence interventions. PMID:26339540

Agreement between ambulatory, home, and office blood pressure variability.

PubMed

Juhanoja, Eeva P; Niiranen, Teemu J; Johansson, Jouni K; Puukka, Pauli J; Jula, Antti M

2016-01-01

Ambulatory, home, and office blood pressure (BP) variability are often treated as a single entity. Our aim was to assess the agreement between these three methods for measuring BP variability. Twenty-four-hour ambulatory BP monitoring, 28 home BP measurements, and eight office BP measurements were performed on 461 population-based or hypertensive participants. Five variability indices were calculated for all measurement methods: SD, coefficient of variation, maximum-minimum difference, variability independent of the mean, and average real variability. Pearson's correlation coefficients were calculated for indices measured with different methods. The agreement between different measurement methods on the diagnoses of extreme BP variability (participants in the highest decile of variability) was assessed with kappa (κ) coefficients. SBP/DBP variability was greater in daytime (coefficient of variation: 9.8 ± 2.9/11.9 ± 3.6) and night-time ambulatory measurements (coefficient of variation: 8.6 ± 3.4/12.1 ± 4.5) than in home (coefficient of variation: 4.4 ± 1.8/4.7 ± 1.9) and office (coefficient of variation: 4.6 ± 2.4/5.2 ± 2.6) measurements (P < 0.001/0.001 for all). Pearson's correlation coefficients for systolic/diastolic daytime or night-time ambulatory-home, ambulatory-office, and home-office variability indices ranged between 0.07-0.25/0.12-0.23, 0.13-0.26/0.03-0.22 and 0.13-0.24/0.10-0.19, respectively, indicating, at most, a weak positive (r < 0.3) relationship. The agreement between measurement methods on diagnoses of extreme SBP/DBP variability was only slight (κ < 0.2), with the κ coefficients for daytime and night-time ambulatory-home, ambulatory-office, and home-office agreement varying between-0.014-0.20/0.061-0.15, 0.037-0.18/0.082-0.15, and 0.082-0.13/0.045-0.15, respectively. Shorter-term and longer-term BP variability assessed by different methods of BP measurement seem to correlate only weakly with each other. Our study suggests that BP variability measured by different methods and timeframes may reflect different phenomena, not a single entity.

Interspecialty communication supported by health information technology associated with lower hospitalization rates for ambulatory care-sensitive conditions.

PubMed

O'Malley, Ann S; Reschovsky, James D; Saiontz-Martinez, Cynthia

2015-01-01

Practice tools such as health information technology (HIT) have the potential to support care processes, such as communication between health care providers, and influence care for "ambulatory care-sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization. To date, associations between such primary care practice capabilities and hospitalizations for ambulatory care-sensitive conditions have been primarily limited to smaller, local studies or unique delivery systems rather than nationally representative studies of primary care physicians in the United States. We analyzed a nationally representative sample of 1,819 primary care physicians who responded to the Center for Studying Health System Change's Physician Survey. We linked 3 years of Medicare claims (2007 to 2009) with these primary care physician survey respondents. This linkage resulted in the identification of 123,760 beneficiaries with one or more of 4 ambulatory care-sensitive chronic conditions (diabetes, chronic obstructive pulmonary disease, asthma, and congestive heart failure) for whom these physicians served as the usual provider. Key independent variables of interest were physicians' practice capabilities, including communication with specialists, use of care managers, participation in quality and performance measurement, use of patient registries, and HIT use. The dependent variable was a summary measure of ambulatory care-sensitive hospitalizations for one or more of these 4 conditions. Higher provider-reported levels of communication between primary care and specialist physicians were associated with lower rates of potentially avoidable hospitalizations. While there was no significant main effect between HIT use and ACSC hospitalizations, the associations between interspecialty communication and ACSC hospitalizations were magnified in the presence of higher HIT use. For example, patients in practices with both the highest level of interspecialty communication and the highest level of HIT use had lower odds of ambulatory care-sensitive hospitalizations than did those in practices with lower interspecialty communication and high HIT use (adjusted odds ratio, 0.70; 95% confidence limits, 0.59, 0.82). Greater primary care and specialist communication is associated with reduced hospitalizations for ambulatory care-sensitive conditions. This effect was magnified in the presence of higher provider-reported HIT use, suggesting that coordination of care with support from HIT is important in the treatment of ambulatory care-sensitive conditions. © Copyright 2015 by the American Board of Family Medicine.

41 CFR 102-118.295 - What are the limited exceptions to every bill undergoing a prepayment audit?

Code of Federal Regulations, 2010 CFR

2010-07-01

... exceptions to every bill undergoing a prepayment audit? 102-118.295 Section 102-118.295 Public Contracts and Property Management Federal Property Management Regulations System (Continued) FEDERAL MANAGEMENT REGULATION TRANSPORTATION 118-TRANSPORTATION PAYMENT AND AUDIT Prepayment Audits of Transportation Services...

[GPs' self-perception of their own role compared with hospital, ambulatory, academic, and health organisation physicians].

PubMed

Daghio, Maria Monica; Gaglianò, Giuseppe; Bevini, Massimo; Cadioli, Tiziano; Delvecchio, Carlo; Guidetti, Patrizia; Lorenzetti, Manuela; Fattori, Giuseppe; Ciardullo, Anna Vittoria

2005-05-01

Aim of the present study was to explore how the 76 general practitioners (GPs) - serving Carpi district (90,000 residents) - value their own role compared with the hospital, ambulatory, academic, and health organisation physicians'. GPs had a positive self-image only in comparison with health organisation doctors (7 vs 7 grades). GPs disappointed with themselves when comparing their role with ambulatory (-1.6 grades), academic (-1.9 grades) and hospital doctors (-2.2 grades). Secondarily, GPs perceived patients' valuing their professional role mostly 'subordinate' to the other physicians', except health organisation colleagues'.

Accounting for the move to ambulatory patient groups.

PubMed

Boyagian, H R; Dessingue, R F

1998-07-01

This article focuses on the cost accounting challenge an ambulatory patient group (APG)-like-based prospective payment system presents to providers and the issues associated with that challenge. In particular, how can costs be identified, how can the differences in costs be associated with alternative settings, and how do costs identified through a detailed resource costing methodology compare to estimates using alternative measures? The results presented suggest that decisions made based on current measures of ambulatory cost (i.e., charge-based measures) need to be reexamined. These decisions could include which services to provide, what setting is appropriate, and where marketshare opportunities exist.

New approaches to ambulatory care facilities in the United Kingdom--an investor developer's perspective.

PubMed

Eminson, C; Dawson, D

1999-01-01

The purpose of this article is to describe the strategic context within which ambulatory care facilities are being developed, to consider a range of models of care facilities available, and, by drawing on the experience of the authors, to comment on some of the investment and development issues arising from two projects in progress--the community hospitals in Richmond, Yorkshire, in rural north England, and Thames Ditton on the borders of outer south London. In the final section, we consider the possible future of ambulatory care development in the light of government policy.

Challenges of ambulatory physiological sensing.

PubMed

Healey, Jennifer

2004-01-01

Applications for ambulatory monitoring span the spectrum from fitness optimization to cardiac defibrillation. This range of applications is associated with a corresponding range of required detection accuracies and a range of inconvenience and discomfort that wearers are willing to tolerate. This paper describes a selection of physiological sensors and how they might best be worn in the unconstrained ambulatory environment to provide the most robust measurements and the greatest comfort to the wearer. Using wireless mobile computing devices, it will be possible to record, analyze and respond to changes in the wearers' physiological signals in real time using these sensors.

A validation of the Mobil O Graph (version 12) ambulatory blood pressure monitor.

PubMed

Jones, C R; Taylor, K; Chowienczyk, P; Poston, L; Shennan, A H

2000-08-01

To assess the clinical accuracy of the Mobil O Graph (version 12) ambulatory blood pressure monitor in an adult population. The accuracy of the device was assessed by predefined criteria (British Hypertension Society, BHS) in 85 subjects recruited from the patients and staff in a teaching hospital. A series of same-arm sequential blood pressure measurements were taken: first two observers taking simultaneous mercury readings, followed by a reading with the Mobil O Graph ambulatory monitor. A total of seven readings were taken from each subject in the sitting position. The data were then analysed according to the BHS protocol and the criteria of the Association for the Advancement of Medical Instrumentation (AAMI). The Mobil O Graph ambulatory monitor fulfilled the criteria of the BHS protocol, achieving a grade B for systolic blood pressure (SBP) and a grade A for diastolic blood pressure (DBP). The mean differences were -2+/-8 mmHg for SBP and -2+/-7 mmHg for DBP. The device therefore also passed the AAMI standard (the mean to be within 5+/-8 mmHg). The Mobil O Graph ambulatory monitor performed in a satisfactory manner according to the BHS and the AAMI criteria and can therefore be recommended for clinical use in the general population.

Burden of norovirus gastroenteritis in the ambulatory setting--United States, 2001-2009.

PubMed

Gastañaduy, Paul A; Hall, Aron J; Curns, Aaron T; Parashar, Umesh D; Lopman, Benjamin A

2013-04-01

Gastroenteritis remains an important cause of morbidity in the United States. The burden of norovirus gastroenteritis in ambulatory US patients is not well understood. Cause-specified and cause-unspecified gastroenteritis emergency department (ED) and outpatient visits during July 2001-June 2009 were extracted from MarketScan insurance claim databases. By using cause-specified encounters, time-series regression models were fitted to predict the number of unspecified gastroenteritis visits due to specific pathogens other than norovirus. Model residuals were used to estimate norovirus visits. MarketScan rates were extrapolated to the US population to estimate national ambulatory visits. During 2001-2009, the estimated annual mean rates of norovirus-associated ED and outpatient visits were 14 and 57 cases per 10 000 persons, respectively, across all ages. Rates for ages 0-4, 5-17, 18-64, and ≥65 years were 38, 10, 12, and 15 ED visits per 10 000 persons, respectively, and 233, 85, 35, and 54 outpatient visits per 10 000 persons, respectively. Norovirus was estimated to cause 13% of all gastroenteritis-associated ambulatory visits, with ~50% of such visits occurring during November-February. Nationally, norovirus contributed to approximately 400 000 ED visits and 1.7 million office visits annually, resulting in $284 million in healthcare charges. Norovirus is a substantial cause of gastroenteritis in the ambulatory setting.

A pilot audit of a protocol for ambulatory investigation of predicted low-risk patients with possible pulmonary embolism.

PubMed

McDonald, A H; Murphy, R

2011-09-01

Patients with possible pulmonary embolism (PE) commonly present to acute medical services. Research has led to the identification of low-risk patients suitable for ambulatory management. We report on a protocol designed to select low-risk patients for ambulatory investigation if confirmatory imaging is not available that day. The protocol was piloted in the Emergency Department and Medical Assessment Area at the Royal Infirmary of Edinburgh. We retrospectively analysed electronic patient records in an open observational audit of all patients managed in the ambulatory arm over five months of use. We analysed 45 patients' records. Of these, 91.1% required imaging to confirm or refute PE, 62.2% received a computed tomography pulmonary angiogram (CTPA). In 25% of patients, PE was confirmed with musculoskeletal pain (22.7%), and respiratory tract infection (15.9%) the next most prevalent diagnoses. Alternative diagnoses was provided by CTPA in 32% of cases. We identified no adverse events or readmissions but individualised follow-up was not attempted. The data from this audit suggests this protocol can be applied to select and manage low-risk patients suitable for ambulatory investigation of possible PE. A larger prospective comparative study would be required to accurately define the safety and effectiveness of this protocol.

Vascular Glucose Sensor Symposium: Continuous Glucose Monitoring Systems (CGMS) for Hospitalized and Ambulatory Patients at Risk for Hyperglycemia, Hypoglycemia, and Glycemic Variability.

PubMed

Joseph, Jeffrey I; Torjman, Marc C; Strasma, Paul J

2015-07-01

Hyperglycemia, hypoglycemia, and glycemic variability have been associated with increased morbidity, mortality, length of stay, and cost in a variety of critical care and non-critical care patient populations in the hospital. The results from prospective randomized clinical trials designed to determine the risks and benefits of intensive insulin therapy and tight glycemic control have been confusing; and at times conflicting. The limitations of point-of-care blood glucose (BG) monitoring in the hospital highlight the great clinical need for an automated real-time continuous glucose monitoring system (CGMS) that can accurately measure the concentration of glucose every few minutes. Automation and standardization of the glucose measurement process have the potential to significantly improve BG control, clinical outcome, safety and cost. © 2015 Diabetes Technology Society.

An Ambulatory System for Gait Monitoring Based on Wireless Sensorized Insoles.

PubMed

González, Iván; Fontecha, Jesús; Hervás, Ramón; Bravo, José

2015-07-09

A new gait phase detection system for continuous monitoring based on wireless sensorized insoles is presented. The system can be used in gait analysis mobile applications, and it is designed for real-time demarcation of gait phases. The system employs pressure sensors to assess the force exerted by each foot during walking. A fuzzy rule-based inference algorithm is implemented on a smartphone and used to detect each of the gait phases based on the sensor signals. Additionally, to provide a solution that is insensitive to perturbations caused by non-walking activities, a probabilistic classifier is employed to discriminate walking forward from other low-level activities, such as turning, walking backwards, lateral walking, etc. The combination of these two algorithms constitutes the first approach towards a continuous gait assessment system, by means of the avoidance of non-walking influences.

Continuity of care after percutaneous coronary intervention: The patient's perspective across secondary and primary care settings.

PubMed

Valaker, Irene; Norekvål, Tone M; Råholm, Maj-Britt; Nordrehaug, Jan Erik; Rotevatn, Svein; Fridlund, Bengt

2017-06-01

Although patients may experience a quick recovery followed by rapid discharge after percutaneous coronary interventions (PCIs), continuity of care from hospital to home can be particularly challenging. Despite this fact, little is known about the experiences of care across the interface between secondary and primary healthcare systems in patients undergoing PCI. To explore how patients undergoing PCI experience continuity of care between secondary and primary care settings after early discharge. The study used an inductive exploratory design by performing in-depth interviews of 22 patients at 6-8 weeks after PCI. Nine were women and 13 were men; 13 were older than 67 years of age. Eight lived remotely from the PCI centre. Patients were purposively recruited from the Norwegian Registry for Invasive Cardiology. Interviews were analysed by qualitative content analysis. Patients undergoing PCI were satisfied with the technical treatment. However, patients experienced an unplanned patient journey across care boundaries. They were not receiving adequate instruction and information on how to integrate health information. Patients also needed help to facilitate connections to community-based resources and to schedule clear follow-up appointments. As high-technology treatment dramatically expands, healthcare organisations need to be concerned about all dimensions of continuity. Patients are witnessing their own processes of healthcare delivery and therefore their voices should be taken into greater account when discussing continuity of care. Nurse-led initiatives to improve continuity of care involve a range of interventions at different levels of the healthcare system.

42 CFR 416.180 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) MEDICARE PROGRAM AMBULATORY SURGICAL SERVICES Adjustment in Payment Amounts for New Technology Intraocular... technology intraocular lenses (IOLs) furnished at ambulatory surgical centers (ASCs). (b) Scope. This subpart sets forth— (1) The process for interested parties to request that CMS review the appropriateness of...

Ambulatory glucose profile analysis of the juvenile diabetes research foundation continuous glucose monitoring dataset-Applications to the pediatric diabetes population.

PubMed

Forlenza, Gregory P; Pyle, Laura L; Maahs, David M; Dunn, Timothy C

2017-11-01

Increased continuous glucose monitor (CGM) use presents both the benefit and burden of increased data for clinicians to rapidly analyze. The ambulatory glucose profile (AGP) is an evolving a universal software report for CGM data analysis. We utilized the Juvenile Diabetes Research Foundation-CGM dataset to evaluate the AGP across a broad spectrum of patients to show how AGP can be used clinically to assist with CGM-related decision making. We hypothesized that AGP metrics would be different across age and HbA1c strata. AGPs were generated from the JDRF-CGM trial dataset for all periods during which there were ≥10 days of CGM coverage in the 2 weeks adjacent to an HbA1c measurement yielding 1101 AGPs for 393 unique subjects. AGPs were stratified by age group (8-14, 15-24, and ≥25 years) and HbA1c (within or above target for age) and compared for between group differences in AGP metrics via two-factor ANOVA. Glycemic differences between time periods were analyzed via segmented regression analysis. Glucose exposure (average and estimated A1c) and variability (standard deviation and interquartile range) were different between the low and high HbA1c levels. Within a given HbA1c level all age groups were significantly different from each other with older patients having lower averages with less variability than younger patients. AGP analysis of the JDRF-CGM data highlights significant differences in glycemic profiles between pediatric and adult age groups and between well and less well-controlled patient populations. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

MISSED WELL-CHILD CARE VISITS, LOW CONTINUITY OF CARE, AND RISK FOR AMBULATORY CARE SENSITIVE HOSPITALIZATIONS IN YOUNG CHILDREN

PubMed Central

Tom, Jeffrey; Tseng, Chien-Wen; Davis, James; Solomon, Cam; Zhou, Chuan; Mangione-Smith, Rita

2013-01-01

Objectives To determine if adherence to the recommended well-child care (WCC) visit schedule, independent of continuity of care (COC), is associated with lower risk for Ambulatory Care Sensitive Hospitalizations (ACSH) and whether this association varies by chronic disease status. Design Population-based, retrospective cohort study Setting Hawaii’s largest health plan from 1999 to 2006 Patients/Participants 36,944 children ≤ 3.5 years-old who were eligible if they were enrolled prior to 2 months-old, had ≥ 4 outpatient visits during the study period, and had an enrollment period that overlapped with ≥ 1 WCC visit interval. Main Exposure(s) WCC visit adherence and COC Index Main Outcome Measure(s) Risk for ACSH (Hazard Ratio [HR]) Results Overall, 8,921 (24%) children had ≥ 1 chronic disease. The proportions of ACSH among healthy children versus those with ≥ 1 chronic disease were 3% (n= 751) and 7% (n= 645), respectively. For children with chronic disease, those with the lowest WCC visit adherence (0–25%) had 1.9 times (HR: 1.9, 95% Confidence Interval [CI]: 1.5–2.5) the risk of ACSH compared to those in the highest category (75–100%). The risk of ACSH for children with chronic disease who fell into the lowest COC category (0–0.25) was 2.4 times (HR 2.4, 95% CI: 1.7–3.5) higher than for those who fell into the highest category (0.75–1.0). Conclusions For children with chronic disease, both low WCC visit adherence and COC are independently associated with an increased risk of ACSH. Providing access to a consistent source of primary care appears important for this vulnerable population. PMID:21041598

Topical oxygen therapy promotes the healing of chronic diabetic foot ulcers: a pilot study.

PubMed

Hayes, P D; Alzuhir, N; Curran, G; Loftus, I M

2017-11-02

Interventions that can heal or reduce diabetic foot ulcer (DFU) size may reduce the incidence of infection and amputation, and reduce associated social and economic costs. Many chronic wounds exhibit a degree of hypoxia and this leads to a reduction in healing processes including cell division and differentiation, angiogenesis, infection prevention, and collagen production. The aim of this pilot study was to assess the effects of a device supplying continuous oxygen ambulatory therapy on healing in chronic DFUs. Patients with chronic DFUs from two tertiary referral hospitals in the UK received treatment with the device. Data were prospectively obtained on wound size using standardised digital images measured by a clinician blinded to the study. Data on device satisfaction and pain were also obtained. We recruited 10 patients, with a mean ulcer duration of 43 weeks (median: 43 weeks) before treatment. By week eight, mean ulcer size had decreased by 51% (median: 53%). Seven of the 10 ulcers were in a healing trajectory, one ulcer present for 56 weeks healed completely, a two-year old ulcer was reduced by more than 50%, and a third, present for 88 weeks, was down to 10% of its original size by the end of the eight-week study. There was also a non-significant trend towards reduction in pain and the device was extremely well tolerated. The ambulatory topical oxygen delivery device showed a significant beneficial effect on wound size. This poses practical advantages over currently existing oxygen-based wound therapies such as hyperbaric oxygen therapy due to its continuous oxygen delivery, ease of use, safety and lower cost. The results of this study warrant further review of the device in comparison to standard wound therapies.

Patient-Doctor Contact Interval and Clinical Outcomes in Continuous Ambulatory Peritoneal Dialysis Patients.

PubMed

Yi, Chunyan; Guo, Qunying; Lin, Jianxiong; Li, Jianying; Yu, Xueqing; Yang, Xiao

2017-01-01

The optimal patient-doctor contact (PDC) interval remains unknown in peritoneal dialysis (PD) patients. The aim was to investigate the association between PDC interval and clinical outcomes in continuous ambulatory PD (CAPD) patients. In this retrospective cohort study, CAPD patients who resided in Guangzhou city between January 2006 and December 2012 were included. According to receiver operating characteristic curve analysis, all patients were classified as high (PDC interval ≤2 months) and low (PDC interval >2 months) PDC frequency groups. Biochemical data, clinical events, and clinical outcomes during the follow-up period were compared. Of 433 CAPD patients, the mean age was 51.3 ± 15.7 years, 54.3% of patients were male, and 29.1% with diabetes. The median vintage of PD was 45.8 (26.3-69.1) months. Patients with high PDC frequency (n = 233) had better patient-survival rates (99.6, 87.7, and 76.5% vs. 92.7, 76.5, and 58.7% at 1, 3, and 5 years; p < 0.001), lower peritonitis rate (0.17 vs. 0.23 episodes per patient-year; p < 0.001), and hospitalization rate (0.49 vs. 0.67 episodes per patient-year; p < 0.001) than those in the low PDC frequency group (n = 200). After adjustment for confounders, PDC interval of no more than 2 months was independently associated with better patient survival (hazard ratio 0.60, 95% CI 0.42-0.86, p = 0.006). A PDC interval of 2 months or less was associated with better clinical outcomes in CAPD patients. This indicates that a shorter PDC interval should be encouraged for them to achieve better clinical outcomes. © 2017 S. Karger AG, Basel.

76 FR 42169 - Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-18

...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. These proposed changes would be applicable to services furnished on or after January 1, 2012. In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we set forth the proposed relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other proposed ratesetting information for the CY 2012 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2012. We are proposing to revise the requirements for the Hospital Outpatient Quality Reporting (IQR) Program, add new requirements for ASC Quality Reporting System, and make additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are proposing to allow eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. In addition, we are proposing to make changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

Prevalence of peritonitis and mortality in patients treated with continuous ambulatory peritoneal dialysis (CAPD) in Africa: a protocol for a systematic review and meta-analysis.

PubMed

Moloi, Mothusi Walter; Kajawo, Shepherd; Noubiap, Jean Jacques; Mbah, Ikechukwu O; Ekrikpo, Udeme; Kengne, Andre Pascal; Bello, Aminu K; Okpechi, Ikechi G

2018-05-24

Continuous ambulatory peritoneal dialysis (CAPD) is the ideal modality for renal replacement therapy in most African settings given that it is relatively cheaper than haemodialysis (HD) and does not require in-centre care. CAPD is, however, not readily utilised as it is often complicated by peritonitis leading to high rates of technique failure. The objective of this study is to assess the prevalence of CAPD-related peritonitis and all-cause mortality in patients treated with CAPD in Africa. We will search PubMed, EMBASE, SCOPUS, Africa Journal Online and Google Scholar for studies conducted in Africa from 1 January 1980 to 30 June 2017 with no language restrictions. Eligible studies will include cross-sectional, prospective observational and cohort studies of patients treated with CAPD. Two authors will independently screen, select studies, extract data and conduct risk of bias assessment. Data consistently reported across studies will be pooled using random-effects meta-analysis. Heterogeneity will be evaluated using Cochrane's Q statistic and quantified using I 2 statistics. Graphical and formal statistical tests will be used to assess for publication bias. Ethical approval will not be needed for this study as data used will be extracted from already published studies. Results of this review will be published in a peer-reviewed journal and presented at conferences. The Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015) framework guided the development of this protocol. CRD42017072966. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring.

PubMed

Ibe, O E; Austin, T; Sullivan, K; Fabanwo, O; Disu, E; Costello, A M de L

2004-09-01

Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.03-0.25). More cases of hyperthermia (> 37.5 degrees C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9 degrees C (RR 1.3, 0.9-1.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants, although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants. Copyright 2004 Liverpool School of Tropical Medicine

Effect of incident nocturnal home hemodialysis versus incident continuous ambulatory peritoneal dialysis on employment rate, clinical, and laboratory outcomes: A 1-year retrospective observation study.

PubMed

Li, John Wing; Wong, Joseph Ho Sing; Chak, Wai Leung; Chau, Ka Foon

2017-10-18

While studies demonstrated favorable outcomes of nocturnal home hemodialysis (NHHD), direct comparison on employment rate, clinical and laboratory outcomes between the NHHD and continuous ambulatory peritoneal dialysis (CAPD) had not been previously performed. A 1-year retrospective observation study was performed in 20 incidents alternate night NHHD and 81 incident CAPD patients of Chinese ethnicity, who were sex, diabetic status, and Charlson comorbidity index matched, but not age due to our center's age limit for NHHD enrollment. The primary outcome was the difference in employment rate at 1 year. Secondary outcomes included differences in clinical parameters (weight, blood pressure, number of antihypertensive medication, dosage of phosphate binders, and erythropoietin stimulating agent) and laboratory parameters (residual renal function, mineral metabolic markers, hemoglobin). NHHD subjects were 5 years younger than CAPD patients, and they had higher employment rate (80% vs. 33.3%, P < 0.01) at 1 year, with age-adjusted odds ratio for employment was 6.10 (95% confidence interval 1.77-20.99, P = 0.04). They consumed less aluminum-based phosphate binder (0 vs. 1800 mg, P < 0.01), but showed no significant disparities in other clinical parameters. Residual renal function in both groups declined comparably, nonetheless NHHD group had lower serum phosphate (1.37 vs. 1.71 mmol/L, P = 0.01) and calcium phosphate product (3.13 vs. 4.12 mmol 2 /L 2 , P < 0.01), with similar hemoglobin levels. NHHD appeared to offer higher employment rate, lower dosage of aluminum-based phosphate binder and mineral metabolic markers at 1 year compared with CAPD in Hong Kong. © 2017 International Society for Hemodialysis.

Predictors of Peritonitis and the Impact of Peritonitis on Clinical Outcomes of Continuous Ambulatory Peritoneal Dialysis Patients in Taiwan—10 Years’ Experience in a Single Center

PubMed Central

Hsieh, Yao-Peng; Chang, Chia-Chu; Wen, Yao-Ko; Chiu, Ping-Fang; Yang, Yu

2014-01-01

♦ Objective: Peritoneal dialysis (PD) has become more prevalent as a treatment modality for end-stage renal disease, and peritonitis remains one of its most devastating complications. The aim of the present investigation was to examine the frequency and predictors of peritonitis and the impact of peritonitis on clinical outcomes. ♦ Methods: Our retrospective observational cohort study enrolled 391 patients who had been treated with continuous ambulatory PD (CAPD) for at least 90 days. Relevant demographic, biochemical, and clinical data were collected for an analysis of CAPD-associated peritonitis, technique failure, drop-out from PD, and patient mortality. ♦ Results: The peritonitis rate was 0.196 episodes per patient-year. Older age (>65 years) was the only identified risk factor associated with peritonitis. A multivariate Cox regression model demonstrated that technique failure occurred more often in patients experiencing peritonitis than in those free of peritonitis (p < 0.001). Kaplan-Meier analysis revealed that the group experiencing peritonitis tended to survive longer than the group that was peritonitis-free (p = 0.11). After multivariate adjustment, the survival advantage reached significance (hazard ratio: 0.64; 95% confidence interval: 0.46 to 0.89; p = 0.006). Compared with the peritonitis-free group, the group experiencing peritonitis also had more drop-out from PD (p = 0.03). ♦ Conclusions: The peritonitis rate was relatively low in the present investigation. Elderly patients were at higher risk of peritonitis episodes. Peritonitis independently predicted technique failure, in agreement with other reports. However, contrary to previous studies, all-cause mortality was better in patients experiencing peritonitis than in those free of peritonitis. The underlying mechanisms of this presumptive “peritonitis paradox” remain to be clarified. PMID:24084840

Risk Factors for the First Episode of Peritonitis in Southern Chinese Continuous Ambulatory Peritoneal Dialysis Patients

PubMed Central

Fan, Xiaoguang; Huang, Rong; Wang, Juan; Ye, Hongjian; Guo, Qunying; Yi, Chunyan; Lin, Jianxiong; Zhou, Qian; Shao, Fengmin; Yu, Xueqing; Yang, Xiao

2014-01-01

Background The first episode of peritonitis affects survival of the peritoneal membrane as a medium for dialysis as well as survival of patients. The aim of this study is to investigate risk factors associated with the first episode of peritonitis in Southern Chinese continuous ambulatory peritoneal dialysis (CAPD) patients. Methods This is a single-center, retrospective, cohort study. All incident CAPD patients from 1 January 2006 to 31 December 2010 were recruited, and followed up until their first episode of peritonitis or 31 December, 2012. Baseline demographic, socioeconomic, clinical and laboratory data were collected. Cox proportional model was used to determine the factors associated with the first episode of peritonitis. Results In a cumulative 30756.5 patient-months follow-up (the median vintage 26.1 months) of 1117 CAPD patients, 309(27.7%) patients presented the first episodes of peritonitis. The cumulative peritonitis-free survival was 86.2%, 78.1%, 71.4% and 57.8% at 1, 2, 3 and 5 year, respectively. The multivariate analysis showed that factors associated with risk for the first episode of peritonitis were elderly patients (>65 years) [hazard ratio (HR) = 1.427, 95% confidence interval (CI) = 1.051 to 1.938, P = 0.023], male(HR = 1.315, 95% CI = 1.028 to 1.684, P = 0.030), lower education level (HR = 1.446, 95% CI: 1.127 to 1.855, P = 0.004) and albumin <38g/L (HR = 1.425, 95% CI: 1.112 to 1.825, P = 0.005). Conclusions Older age, male, lower educational level and hypoalbuminemia at the commencement of PD were the risk factors associated with the first episode of peritonitis in Southern Chinese CAPD patients. PMID:25222609

The effect of low-GDP solution on ultrafiltration and solute transport in continuous ambulatory peritoneal dialysis patients.

PubMed

Cho, Kyu-Hyang; Do, Jun-Young; Park, Jong-Won; Yoon, Kyung-Woo; Kim, Yong-Lim

2013-01-01

Several studies have reported benefits for human peritoneal mesothelial cell function of a neutral-pH dialysate low in glucose degradation products (GDPs). However, the effects of low-GDP solution on ultrafiltration (UF), transport of solutes, and control of body water remain elusive. We therefore investigated the effect of low-GDP solution on UF, solute transport, and control of body water. Among 79 new continuous ambulatory peritoneal dialysis (CAPD) patients, 60 completed a 12-month protocol (28 in a lactate-based high-GDP solution group, 32 in a lactate-based low-GDP solution group). Clinical indices--including 24-hour UF volume (UFV), 24-hour urine volume (UV), residual renal function, and dialysis adequacy--were measured at months 1, 6, and 12. At months 1, 6, and 12, UFV, glucose absorption, 4-hour dialysate-to-plasma (D/P) creatinine, and 1-hour D/P Na(+) were assessed during a modified 4.25% peritoneal equilibration test (PET). Body composition by bioelectric impedance analysis was measured at months 1 and 12 in 26 CAPD patients. Daily UFV was lower in the low-GDP group. Despite similar solute transport and aquaporin function, the low-GDP group also showed lower UFV and higher glucose absorption during the PET. Factors associated with UFV during the PET were lactate-based high-GDP solution and 1-hour D/P Na(+). No differences in volume status and obesity at month 12 were observed, and improvements in hypervolemia were equal in both groups. Compared with the high-GDP group, the low-GDP group had a lower UFV during a PET and a lower daily UFV during the first year after peritoneal dialysis initiation. Although the low-GDP group had a lower daily UFV, no difficulties in controlling edema were encountered.

Comparison of cost-utility between automated peritoneal dialysis and continuous ambulatory peritoneal dialysis.

PubMed

Cortés-Sanabria, Laura; Paredes-Ceseña, Carlos A; Herrera-Llamas, Rebeca M; Cruz-Bueno, Yolanda; Soto-Molina, Herman; Pazarín, Leonardo; Cortés, Margarita; Martínez-Ramírez, Héctor R

2013-11-01

The use of automated peritoneal dialysis (APD) is increasing compared to continuous ambulatory peritoneal dialysis (CAPD). Surprisingly, little data about health benefits and cost of APD exist, and virtually no information comparing the cost-utility between CAPD and APD is available. We undertook this study to evaluate and compare the health-related quality of life (HRQOL) and cost-utility indexes in patients on CAPD vs. This was a prospective cohort of patients initiating dialysis (2008-2009). Two questionnaires were self-administered: European Research Questionnaire Quality of Life (EQ-5D) and Kidney Disease Quality of Life (short form, KDQOL-SF, Rand, Santa Monica, CA). Direct medical costs (DMC) were determined from the health provider perspective including the following medical resource utilization: outpatient clinic/emergency care, dialysis procedures, medications, laboratory tests, hospitalization, and surgery. Cost-utility indexes were calculated dividing total mean cost by indicators of the HRQOL. One hundred twenty-three patients were evaluated: 77 on CAPD and 46 on APD. Results of the EQ-5D and KDQOL-SF questionnaires were significantly better in APD compared to the CAPD group. Main costs in both APD and CAPD were attributed to hospitalization and dialysis procedures followed by medication and surgery. Outpatient clinic visits and laboratory tests were significantly more costly in CAPD than in APD, whereas dialysis procedures were more expensive in the latter. Cost-utility indexes were significantly better in APD compared to CAPD. A significant cost-utility advantage of APD vs. CAPD was observed. The annual DMC per-patient were not different between groups but the HRQOL was better in the APD compared to the CAPD group. Copyright © 2013 IMSS. Published by Elsevier Inc. All rights reserved.

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period.

PubMed

2011-11-30

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

The contribution of viral hepatitis to the burden of chronic liver disease in the United States.

PubMed

Roberts, Henry W; Utuama, Ovie A; Klevens, Monina; Teshale, Eyasu; Hughes, Elizabeth; Jiles, Ruth

2014-03-01

Chronic liver disease (CLD) is increasingly recognized as a major public health problem. However, in the United States, there are few nationally representative data on the contribution of viral hepatitis as an etiology of CLD. We applied a previously used International Classification of Diseases, Ninth Revision, Clinical Modification-based definition of CLD cases to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases for 2006-2010. We estimated the mean number of CLD visits per year, prevalence ratio of visits by patient characteristics, and the percentage of CLD visits attributed to viral hepatitis and other selected etiologies. An estimated 6.0 billion ambulatory care visits occurred in the United States from 2006 to 2010, of which an estimated 25.8 million (0.43%) were CLD-related. Among adults aged 45-64 years, Medicaid and Medicare recipients were 3.9 (prevalence ratio (PR)=3.9, 95% confidence limit (CL; 2.8, 5.4)) and 2.3 (PR=2.3, 95% CL (1.6, 3.4)) times more likely to have a CLD-related ambulatory visit than those with private insurance, respectively. In the United States, from 2006 to 2010, an estimated 49.6% of all CLD-related ambulatory visits were attributed solely to viral hepatitis B and C diagnoses. In this unique application of health-care utilization data, we confirm that viral hepatitis is an important etiology of CLD in the United States, with hepatitis B and C contributing approximately one-half of the CLD burden. CLD ambulatory visits in the United States disproportionately occur among adults, aged 45-64 years, who are primarily minorities, men, and Medicare or Medicaid recipients.

Where the United States Spends its Spine Dollars: Expenditures on different ambulatory services for the management of back and neck conditions

PubMed Central

Davis, Matthew A.

2012-01-01

Study Design Serial, cross-sectional, nationally representative surveys of non-institutionalized adults. Objective To examine expenditures on common ambulatory health services for the management of back and neck conditions. Summary of Background Data Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. Methods We used the Medical Expenditure Panel Survey (MEPS) to examine adult (age ≥ 18 years) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Results Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. Over the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; while physical therapy was the most costly service overall, in recent years those costs have contracted. Conclusion Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions. PMID:22433497

Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions.

PubMed

Davis, Matthew A; Onega, Tracy; Weeks, William B; Lurie, Jon D

2012-09-01

Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults. To examine expenditures on common ambulatory health services for the management of back and neck conditions. Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population. We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted. Although this study did not explore the relative effectiveness of different ambulatory services, recent increasing costs associated with providing medical care for back and neck conditions (particularly subspecialty care) are contributing to the growing economic burden of managing these conditions.

A strategy utilizing ambulatory monitoring and home and clinic blood pressure measurements to optimize the safety evaluation of noncardiovascular drugs with potential for hemodynamic effects: a report from the SYNERGY trial.

PubMed

Weber, Michael A; Chapple, Christopher R; Gratzke, Christian; Herschorn, Sender; Robinson, Dudley; Frankel, Jeffrey M; Ridder, Arwin M; Stoelzel, Matthias; Paireddy, Asha; van Maanen, Robert; White, William B

2018-06-01

The aim of this study was to perform a blood pressure (BP) safety evaluation in patients with an overactive bladder receiving solifenacin (an antimuscarinic agent), mirabegron (a β3-adrenoceptor agonist), or both compared with placebo in the SYNERGY trial. Patients were randomized to receive solifenacin 5 mg+mirabegron 50 mg (combination 5+50 mg); solifenacin 5 mg+mirabegron 25 mg (combination 5+25 mg); solifenacin 5 mg; mirabegron 50 mg; mirabegron 25 mg; or placebo for a double-blind 12-week treatment period. Systolic BP, diastolic BP, and heart rate were measured by ambulatory BP monitoring, and in the clinic or home. A total of 715 patients were analyzed in an ambulatory BP monitoring substudy. At the end of treatment, ambulatory BP monitoring measurements showed no consistent increases from baseline in the mean 24-h systolic BP or diastolic BP for combination versus monotherapy groups or for monotherapy groups versus placebo. Analysis of 1-h BP averages during the 6 h range that included the Tmax values of both study drugs showed no significant BP effects. Shift analysis (switch between different normotension/hypertension stages) did not show differences among the active and placebo groups, nor did outlier analysis of major BP changes differ between placebo and active treatment. Similarly, there were no significant signals in the 24-h heart rate. Office and home measurements were consistent with ambulatory BP monitoring findings. A paradigm of ambulatory BP monitoring analysis designed to test BP safety of noncardiovascular drugs showed that solifenacin plus mirabegron combination therapy during 12 weeks produced no meaningful changes in BP or heart rate.

Separate aftereffects of morning and evening exercise on ambulatory blood pressure in prehypertensive men.

PubMed

Brito, Leandro C; Rezende, Rafael A; Mendes, Caroline; Silva-Junior, Natan D; Tinucci, Taís; Cipolla-Neto, José; de Moraes Forjaz, Cláudia L

2018-01-01

Clinic postexercise hypotension (PEH) is different after aerobic exercise performed in the morning and in the evening. Thus, ambulatory PEH should also differ after exercises conducted at different times of day. However, because of the circadian pattern of blood pressure (BP), ambulatory PEH should be assessed considering a control condition. Thus, this study was designed to verify the effects of morning and evening exercises on postexercise ambulatory BP averages and circadian parameters by comparing responses obtained at each time of day after an exercise and a control session. Thirteen prehypertensive men underwent four sessions (randomized order): two in the morning (9 am) and two in the evening (6:30 pm). At each time of day, a control (C) and an exercise (E: cycle ergometer 45 min, 50% VO2peak) sessions were performed. After the sessions, an ambulatory BP and heart rate (HR) monitoring was started for 24 h. Paired t-test or Wilcoxon Signed Rank Test were used to compare the E and the C sessions at each time of day. In the morning, 24 h, daytime and nighttime HR were higher after the E than the C session. In the evening, nighttime systolic BP (116±11 vs. 120±10 mmHg, P=0.04) and rate pressure product (7981±1294 vs. 8583±1523 mmHg.bpm, P=0.04), as well as MESOR (128±11 vs. 130±10 mmHg, P=0.03) were lower in the E than the C session. In prehypertensive men, morning exercise increased ambulatory HR, while evening exercise decreased nighttime BP and cardiac work, reducing the MESOR of systolic BP.

Ambulatory Aortic Stiffness Is Associated With Narrow Retinal Arteriolar Caliber in Hypertensives: The SAFAR Study.

PubMed

Aissopou, Evaggelia K; Argyris, Antoniοs A; Nasothimiou, Efthimia G; Konstantonis, George D; Tampakis, Kostas; Tentolouris, Nikolaos; Papathanassiou, Miltiadis; Theodossiadis, Panagiotis G; Papaioannou, Theodoros G; Stehouwer, Coen D A; Sfikakis, Petros P; Protogerou, Athanassios D

2016-05-01

Arterial stiffness measured under static conditions reclassifies significantly cardiovascular (CV) risk and associates with narrower retinal arterioles. However, arterial stiffness exhibits circadian variation, thus single static stiffness recordings do not correspond to the "usual" 24 hr, awake, and asleep average arterial stiffness. We aimed to test the hypothesis that ambulatory 24 hr, awake, and asleep aortic (a) pulse wave velocity (PWV) associate with retinal vessel calibers, independently of confounders and of static arterial stiffness, in hypertensive individuals free from diabetes and CV disease. Digital retinal images were obtained (181 individuals, age: 53.9±10.7 years, 55.2% men) and retinal vessel calibers were measured with validated software to determine central retinal arteriolar and venular equivalents (CRAE and CRVE, respectively); ambulatory (24 hr, awake, asleep) and static office aPWV were estimated by Mobil-O-Graph; and static office carotid to femoral (cf) PWV by SphygmoCor. Regression analysis performed in 320 gradable retinal images showed that, after adjustment for confounders: (i) ambulatory aPWV was significantly associated with narrower retinal arterioles but not with venules; (ii) asleep aPWV had stronger associations with CRAE than awake aPWV; (iii) both ambulatory aPWV and cfPWV were associated mutually independently with narrower retinal arterioles; aPWV introduction in the model of cfPWV, improved model's R2 (P = 0.012). Similar discriminatory ability of 24 hr aPWV and of cfPWV to detect the presence of retinal arteriolar narrowing was found. Ambulatory aPWV, estimated by an operator-independent method, provides additional information to cfPWV regarding the associations of arterial stiffness with the retinal vessel calibers. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Out-of-office blood pressure and target organ damage in children and adolescents: a systematic review and meta-analysis.

PubMed

Kollias, Anastasios; Dafni, Maria; Poulidakis, Emmanouil; Ntineri, Angeliki; Stergiou, George S

2014-12-01

In children, out-of-office blood pressure (BP) assessment (especially ambulatory monitoring) is regarded as indispensable for accurate hypertension diagnosis. This article reviewed the evidence on the association between out-of-office BP measurements and preclinical organ damage indices in children. A systematic review and meta-analysis of 93 relevant articles (1974-2012) was performed. Analysis of 10 studies (n = 480, pooled age 14.4 years, with hypertension 33%, renal disease 27%, type 1 diabetes 10%) revealed a significant association between systolic ambulatory BP and left ventricular mass index (LVMI), with pooled correlation coefficient r = 0.40 [95% confidence interval (CI) 0.30-0.50]. Eleven studies reported data on LVMI differences between normotensive (n = 428) and hypertensive children (n = 432), with higher values in the latter group by 6.53 g/m(2.7) (95% CI 4.73-8.33). A moderate association was found between systolic ambulatory BP and carotid intima-media thickness (three studies, n = 231, age 13.3 years, pooled r = 0.32, 95% CI 0.21-0.44), as well as between diastolic ambulatory BP and urine albumin excretion (five studies, n = 355, age 13.1 years, type 1 diabetes 42%, reflux nephropathy 28%, pooled r = 0.32, 95% CI 0.05-0.58). Two studies reported on the association between home BP and LVMI, with one of them showing comparable coefficients as for ambulatory monitoring. The available evidence suggests a moderate but significant association between ambulatory BP and preclinical organ damage, mainly based on studies in nephropathy and/or diabetes. More data are needed in essential hypertension without nephropathy or diabetes, as well as with home measurements.

[The determination of arterial pressure by the physician or the nurse: its relation to ambulatory pressure and left ventricular mass. The MAPA-Madrid Group. Monitorización Ambulatoria de la Presión Arterial (Ambulatory Monitoring of Arterial Pressure)].

PubMed

Martínez, M A; Aguirre, A; Sánchez, M; Nevado, A; Laguna, I; Torre, A; Manuel, E; Villar, C; García-Puig, J

1999-12-11

In the present study we evaluated the influence of the observer's status--physician or nurse--on blood pressure levels and the relationship among clinic blood pressure measurement with ambulatory blood pressure and left ventricle mass. Cross sectional study performed in seven primary care centers. Participating physicians and nurses were trained for blood pressure measurement prior to the study and subsequently retrained at 3 month intervals during the study. Patients included in the study were 122 subjects with mild to moderate hypertension who underwent the following study protocol: a) measurement of clinic blood pressure by physician and nurse, in an independent fashion, on 3 visits; b) clinic-epidemiologic questionnaire; c) conventional hematological and biochemical study; d) electrocardiogram; e) 24-hour ambulatory blood pressure monitoring, f) M-mode and Doppler echocardiography (only in 58 subjects). Nurse-measured blood pressure levels were higher than those determined by physicians (mean differences: 3.9 [6.7] mmHg in systolic blood pressure and 2.6 [5.4] mmHg in diastolic blood pressure). The blood pressure level differences between the two observers were higher in female patients and subjects with low educational level, independently of the observer's gender. Nurse-measured blood pressure was more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. Nurse-measured blood pressure levels are lower than those determined by physicians and more closely related to ambulatory blood pressure and left ventricle mass than physician-measured blood pressure. These data support that nurses, instead of doctors, should routinely measure blood pressure in primary care centers.

Opening ambulatory surgery centers and stone surgery rates in health care markets.

PubMed

Hollingsworth, John M; Krein, Sarah L; Birkmeyer, John D; Ye, Zaojun; Kim, Hyungjin Myra; Zhang, Yun; Hollenbeck, Brent K

2010-09-01

Ambulatory surgery centers deliver surgical care more efficiently than hospitals but may increase overall procedure use and adversely affect competing hospitals. Motivated by these concerns we evaluated how opening of an ambulatory surgery center impacts stone surgery use in a health care market and assessed the effect of its opening on the patient mix at nearby hospitals. In a 100% sample of outpatient surgery from Florida we measured annual stone surgery use between 1998 and 2006. We used multiple regression to determine if the rate of change in use differed between markets, defined by the hospital service area, without and with a recently opened ambulatory surgery center. Stone surgery use increased an average of 11 procedures per 100,000 individuals per year (95% CI 1-20, p <0.001) after an ambulatory surgery center opened in a hospital service area. Four years after opening the relative increase in the stone surgery rate was approximately 64% higher (95% CI 27 to 102) in hospital service areas where a center opened vs hospital service areas without a center. These market level increases in surgery were not associated with decreased surgical volume at competing hospitals and the absolute change in patient disease severity treated at nearby hospitals was small. While opening of an ambulatory surgery center did not appear to have an overly detrimental effect on competing hospitals, it led to a significant increase in the population based rate of stone surgery in the hospital service area. Possible explanations are the role of physician financial incentives and unmet surgical demand. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

A retrospective cross-sectional study of patients treated in US EDs and ambulatory care clinics with sexually transmitted infections from 2001 to 2010.

PubMed

Ware, Chelsea E; Ajabnoor, Yasser; Mullins, Peter M; Mazer-Amirshahi, Maryann; Pines, Jesse M; May, Larissa

2016-09-01

Sexually transmitted infections (STIs) are commonly seen in the ambulatory health care settings such as emergency departments (EDs) and outpatient clinics. Our objective was to assess trends over time in the incidence and demographics of STIs seen in the ED and outpatient clinics compared with office-based clinics using the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey. This study was conducted using 10 years of National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey data (2001-2010). We compared data from 2001-2005 to data from 2006-2010. Patients were included in analyses if they were 15 years and older and had an International Classification of Diseases, Ninth Revision code consistent with cervicitis, urethritis, chlamydia, gonorrhea, or trichomonas. We analyzed 82.4 million visits for STIs, with 16.5% seen in hospital-based EDs and 83.5% seen in office-based clinics between 2001 and 2010. Compared with patients seen in office-based clinics, ED patients were younger (P< .05), more likely to be male (P< .001) and nonwhite (P< .001), and less likely to have private insurance (P< .05). We found a significant increase in adolescent (15-18 years) ED visits (P< .05) from 2001-2015 to 2006-2010 and a decrease in adolescent and male STI visits in office-based settings (P< .05). Although patients with STI are most commonly seen in office-based clinics, EDs represent an important site of care. In particular, ED patients are relatively younger, male, and nonwhite, and less likely to be private insured. Copyright © 2016 Elsevier Inc. All rights reserved.

Trends in physician referrals in the United States, 1999-2009.

PubMed

Barnett, Michael L; Song, Zirui; Landon, Bruce E

2012-01-23

Physician referrals play a central role in ambulatory care in the United States; however, little is known about national trends in physician referrals over time. The objective of this study was to assess changes in the annual rate of referrals to other physicians from physician office visits in the United States from 1999 to 2009. We analyzed nationally representative cross-sections of ambulatory patient visits in the United States, using a sample of 845 243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2009, focusing on the decade from 1999 to 2009. The main outcome measures were survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.8% to 9.3% (P < .001), a 94% increase. The absolute number of visits resulting in a physician referral increased 159% nationally during this time, from 41 million to 105 million. This trend was consistent across all subgroups examined, except for slower growth among physicians with ownership stakes in their practice (P = .02) or those with the majority of income from managed care contracts (P = .007). Changes in referral rates varied according to the principal symptoms accounting for patients' visits, with significant increases noted for visits to primary care physicians from patients with cardiovascular, gastrointestinal, orthopedic, dermatologic, and ear/nose/throat symptoms. The percentage and absolute number of ambulatory visits resulting in a referral in the United States grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.

Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients.

PubMed

Sisante, Jason-Flor V; Abraham, Michael G; Phadnis, Milind A; Billinger, Sandra A; Mittal, Manoj K

2016-10-01

Ischemic stroke patients are at high risk (up to 18%) for venous thromboembolism. We conducted a retrospective cross-sectional study to understand the predictors of acute postmild ischemic stroke patient's ambulatory status and its relationship with venous thromboembolism, hospital length of stay, and in-hospital mortality. We identified 522 patients between February 2006 and May 2014 and collected data about patient demographics, admission NIHSS (National Institutes of Health Stroke Scale), venous thromboembolism prophylaxis, ambulatory status, diagnosis of venous thromboembolism, and hospital outcomes (length of stay, mortality). Chi-square test, t-test and Wilcoxon rank-sum test, and binary logistic regression were used for statistical analysis as appropriate. A total of 61 (11.7%), 48 (9.2%), and 23 (4.4%) mild ischemic stroke patients developed venous thromboembolism, deep venous thrombosis, and pulmonary embolism, respectively. During hospitalization, 281 (53.8%) patients were ambulatory. Independent predictors of in-hospital ambulation were being married (OR 1.64, 95% CI 1.10-2.49), being nonreligious (OR 2.19, 95% CI 1.34-3.62), admission NIHSS (per unit decrease in NIHSS; OR 1.62, 95% CI 1.39-1.91), and nonuse of mechanical venous thromboembolism prophylaxis (OR 1.62, 95% CI 1.02-2.61). After adjusting for confounders, ambulatory patients had lower rates of venous thromboembolism (OR .47, 95% CI .25-.89), deep venous thrombosis (OR .36, 95% CI .17-.73), prolonged length of hospital stay (OR .24, 95% CI .16-.37), and mortality (OR .43, 95% CI .21-.84). Our findings suggest that for hospitalized acute mild ischemic stroke patients, ambulatory status is an independent predictor of venous thromboembolism (specifically deep venous thrombosis), hospital length of stay, and in-hospital mortality. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Evaluating ambulatory care training in Firoozgar hospital based on Iranian national standards of undergraduate medical education

PubMed Central

Sabzghabaei, Foroogh; Salajeghe, Mahla; Soltani Arabshahi, Seyed Kamran

2017-01-01

Background: In this study, ambulatory care training in Firoozgar hospital was evaluated based on Iranian national standards of undergraduate medical education related to ambulatory education using Baldrige Excellence Model. Moreover, some suggestions were offered to promote education quality in the current condition of ambulatory education in Firoozgar hospital and national standards using the gap analysis method. Methods: This descriptive analytic study was a kind of evaluation research performed using the standard check lists published by the office of undergraduate medical education council. Data were collected through surveying documents, interviewing, and observing the processes based on the Baldrige Excellence Model. After confirming the validity and reliability of the check lists, we evaluated the establishment level of the national standards of undergraduate medical education in the clinics of this hospital in the 4 following domains: educational program, evaluation, training and research resources, and faculty members. Data were analyzed according to the national standards of undergraduate medical education related to ambulatory education and the Baldrige table for scoring. Finally, the quality level of the current condition was determined as very appropriate, appropriate, medium, weak, and very weak. Results: In domains of educational program 62%, in evaluation 48%, in training and research resources 46%, in faculty members 68%, and in overall ratio, 56% of the standards were appropriate. Conclusion: The most successful domains were educational program and faculty members, but evaluation and training and research resources domains had a medium performance. Some domains and indicators were determined as weak and their quality needed to be improved, so it is suggested to provide the necessary facilities and improvements by attending to the quality level of the national standards of ambulatory education PMID:29951400