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Optimal Care (optimal + care)
Selected AbstractsEmergent excision of a prenatally diagnosed sacrococcygeal teratomaPEDIATRIC ANESTHESIA, Issue 5 2008KHA M. TRAN MD Summary Prenatally diagnosed sacrococcygeal teratomas (SCT) have higher mortality rates than those diagnosed in the neonatal period. Natural history of SCT varies, and management depends on pathophysiology. Treatment may be minimally invasive or require open surgery. Intervention may take place in the prenatal period, or it may occur within minutes to days after birth. Optimal care requires close follow up and communication between members of a multidisciplinary team. We present a case of prenatally diagnosed SCT and address the evaluation, anesthetic considerations, and mechanisms needed to care for this high risk population. [source] Utilization of hospital and outpatient care for adverse cutaneous reactions to medicationsPHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 10 2005Robert S. Stern MD Abstract Purpose To quantify hospitalizations, visits to office based physicians, hospital clinics and emergency departments with primary diagnoses of skin conditions that are often due to drug reaction. Methods I analyzed data from the National Hospital Discharge Summary (1997,2001), National Ambulatory Care Survey (1995,2000) and National Hospital Ambulatory Care Survey (1995,2000) to determine the number of hospitalizations and visits with primary diagnoses of skin conditions that are often attributed to drugs. Using statistical methods for surveys, I determined the demographic characteristics of patients with these diagnoses and compared them with patients seeking care for other reasons. Results In the United States, there are about 5000 hospitalizations each year with a primary diagnosis of erythema multiform, Stevens,Johnson Syndrome or Toxic Epidermal Necrolysis, of which 35% are specifically ascribed to drugs. Annually, there are more than 100,000 outpatient visits for these diagnoses and about two million visits for immediate hypersensitivity reactions that may be due to drugs. Outpatient visits for drug eruptions and drug allergies that include a skin component exceed 500,000 annually. Conclusions Skin conditions often attributed to drugs are frequent reasons for hospitalization and physician visits. Optimal care of the individual patients with these conditions requires careful attention to drugs as a possible cause. Copyright © 2005 John Wiley & Sons, Ltd. [source] Pulmonary Regurgitation after Tetralogy of Fallot Repair: Clinical Features, Sequelae, and Timing of Pulmonary Valve ReplacementCONGENITAL HEART DISEASE, Issue 6 2007Naser M. Ammash MD ABSTRACT Pulmonary regurgitation following repair of tetralogy of Fallot is a common postoperative sequela associated with progressive right ventricular enlargement, dysfunction, and is an important determinant of late morbidity and mortality. Although pulmonary regurgitation may be well tolerated for many years following surgery, it can be associated with progressive exercise intolerance, heart failure, tachyarrhythmia, and late sudden death. It also often necessitates re-intervention. Identifying the appropriate timing of such intervention could be very challenging given the risk of prosthetic valve degeneration and the increased risk of reoperation. Comprehensive informed and regular assessment of the postoperative patient with tetralogy of Fallot, including evaluation of pulmonary regurgitation, right heart structure and function, is crucial to the optimal care of these patients. Pulmonary valve replacement performed in an experienced tertiary referral center is associated with low operative morbidity and mortality and very good long-term results. Early results of percutaneous pulmonary valve replacement are also promising. [source] Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort studyDIABETIC MEDICINE, Issue 6 2008L. Prompers Abstract Aims To determine current management and to identify patient-related factors and barriers that influence management strategies in diabetic foot disease. Methods The Eurodiale Study is a prospective cohort study of 1232 consecutive individuals presenting with a new diabetic foot ulcer in 14 centres across Europe. We determined the use of management strategies: referral, use of offloading, vascular imaging and revascularization. Results Twenty-seven percent of the patients had been treated for > 3 months before referral to a foot clinic. This varied considerably between countries (6,55%). At study entry, 77% of the patients had no or inadequate offloading. During follow-up, casting was used in 35% (0,68%) of the plantar fore- or midfoot ulcers. Predictors of use of casting were male gender, large ulcer size and being employed. Vascular imaging was performed in 56% (14,86%) of patients with severe limb ischaemia; revascularization was performed in 43%. Predictors of use of vascular imaging were the presence of infection and ischaemic rest pain. Conclusion Treatment of many patients is not in line with current guidelines and there are large differences between countries and centres. Our data suggest that current guidelines are too general and that healthcare organizational barriers and personal beliefs result in underuse of recommended therapies. Action should be undertaken to overcome these barriers and to guarantee the delivery of optimal care for the many individuals with diabetic foot disease. [source] Geriatric Oncology and Primary Care: Promoting Partnerships in Practice and ResearchJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2009Julia Hannum Rose PhD This supplement is a compilation of original work that was presented at an interdisciplinary conference on "Geriatric Oncology and Primary Care: Promoting Partnerships in Practice and Research" held in Cleveland, Ohio, April 3 to 4, 2008. An audience of 77 clinicians and researchers attended this conference, primarily coming from Ohio and adjacent states. Articles are organized around a conceptual framework to consider primary and shared care roles of primary care physicians (PCPs) and oncologists in the care of older patients with cancer and their families. Articles in Section One focus on evidence-based clinical practice and recommendations. Section Two includes articles on original psychosocial and health services research that inform this topic. Papers in this conference were developed in recognition of the greater prevalence and growing incidence of cancer in older adults; the unique geriatric expertise and practice considerations essential to the prevention and control of cancer in older adults; the important and effective roles that PCPs may play in such care; and the need to develop shared care models that foster collaboration between PCPs and oncologists, from cancer prevention through long-term survivorship and end-of-life care of older adults. Models of shared care between oncologists and PCPs should be tested and compared for optimal care of older patients with cancer and their families. Potential implications of ideally shared care include more-informed patient-centered decision-making, better adherence to treatment, improved match between older patient goals and treatments, and thus better outcomes. [source] Decision-making during hospitalization: parents' and children's involvementJOURNAL OF CLINICAL NURSING, Issue 3 2004Inger Hallström RN Background., Ethical duties of health professionals include the obligation to enhance their patients' competence and ability to participate. Aims and objectives., To explore what kind of decisions and how these decisions were made during a child's hospitalization. Design., During a 9-week period 24 children and their parents were followed during the course of events at the hospital. In total 135 hours of observations were made and analysed in two steps. Results., In most of the situations one or both parents were present with the child. Most decisions were of a medical nature, and commonly decisions were made in consultation with those affected by the decision. Although one or more persons protested in 83 of the 218 described situations, decisions were seldom reconsidered. Conclusions., The children and their parents were usually involved in the decision-making process. Children and parents made few decisions themselves and even if they disagreed with the decision made, few decisions were reconsidered. Relevance to clinical practice., Having a voice in decision-making helps the child to develop a sense of himself as a person and gives the parents a feeling that they are part of a team giving their child optimal care during hospitalization. Promoting children's rights is one of the most important roles for the children's nurse. [source] Nurses' Views of Factors That Help and Hinder Their Intrapartum CareJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 3 2007Martha Sleutel Objective:, To explore labor and delivery nurses' views of intrapartum care, particularly factors that help or hinder their efforts to provide professional labor support. Design:, Content analysis of narrative comments that nurses wrote on questionnaires during a two-part research study on professional labor support in 2001. Participants:, Intrapartum registered nurses. Results:, Six themes emerged under the category of factors that hinder nurses' intrapartum care: (a) hastening, controlling, and mechanizing birth; (b) facility culture and resources; (c) mothers' knowledge, language, and medical status; (d) outdated practices; (e) conflict; and (f) professional/ethical decline. Under the category of factors that help nurses' intrapartum care, four themes emerged: (a) teamwork and collaboration, (b) philosophy of birth as a natural process, (c) facility culture and resources, and (d) nursing impact, experience, and autonomy. Conclusions:, Nurses conveyed a spectrum of feelings from intense pride and pleasure to disillusionment, dissatisfaction, and distress based on barriers and facilitators to their ability to provide effective optimal care. They felt strongly that medical interventions often hindered their care and prevented them from providing labor support. Nurses offered blunt, often scathing criticism and also glowing praise for their colleagues in nursing, nurse-midwifery, and medicine regarding the quality of their care. JOGNN, 36, 203-211; 2007. DOI: 10.1111/J.1552-6909.2007.00146.x [source] Diagnosis and management of paediatric hepatitis C virus infectionJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 3 2002AM Kesson Abstract: Hepatitis C virus (HCV) infection in children is uncommon and there are few guidelines indicating optimal management. It is estimated that 125,250 children are infected vertically with HCV in Australia each year and very few of these children are diagnosed and followed medically. Without accurate diagnosis and follow up, these children cannot be offered optimal care, and are at risk of presenting in adult life with significant liver pathology and long-term sequelae. [source] The Challenge of asthma in adolescencePEDIATRIC PULMONOLOGY, Issue 8 2007Diletta de Benedictis MD Abstract The adolescents with asthma are a distinct group of patients with different problems and needs compared to children and adults. Specific issues of asthma in adolescence are the variability of the clinical spectrum, the presence of particular risk factors for the persistence of symptoms, underdiagnosis and undertreatment of the disease. Refusal of the sick role, denial of symptoms, carelessness about dangerous inhalation exposure, erratic self-medication, overexertion without taking precautions against exercise-induced asthma, and a poor relationship between patients, their families, and often doctors are the main obstacles to successful management of asthma in this critical age. There are also major problems of compliance for these patients. The goal of optimal quality of life will be achieved only if the physician thoroughly understands the adolescent's needs and provides optimal care. Pediatr Pulmonol. 2007, 42:683,692. © 2007 Wiley-Liss, Inc. [source] Prospective study of the patient-level cost of asthma care in children,PEDIATRIC PULMONOLOGY, Issue 2 2001Wendy J. Ungar PhD Abstract Our objective was to assess the cost of asthma care at the patient level in children from the perspectives of society, the Ontario Ministry of Health, and the patient. In this longitudinal evaluation, health service use data and costs were collected during telephone interviews at 1, 3, and 6 months with parents of 339 Ontario children with asthma. Direct costs were respiratory-related visits to healthcare providers, emergency rooms, hospital admissions, pulmonary function tests, prescription medications, devices, and out-of-pocket expenses. Indirect costs were parents' absences from work/usual activities and travel and waiting time. Hospital admissions accounted for 43%, medications for 31%, and parent productivity losses for 12% of total costs from a societal perspective. Statistically significant predictors of higher total costs were worse symptoms, younger age group, and season of participation. Adjusted annual societal costs per patient in 1995 Canadian dollars varied from $1,122 in children aged 4,14 years to $1,386 in children under 4 years of age. From the Ministry of Health perspective, adjusted annual costs per patient were $663 in children over 4 years and $904 in younger children. Adjusted annual costs from the patient perspective were $132 in children over 4 years and $129 in children under 4 years. The rising incidence of pediatric asthma demands that greater attention be paid to the delivery of optimal care to this segment of the population. Appropriate methods must be used to analyze healthcare costs and the use of services in the midst of widespread healthcare reform. The quality of clinical and health policy decision-making may be enhanced by cost-of-illness estimates that are comprehensive, precise, and expressed from multiple perspectives. Pediatr Pulmonol. 2001; 32:101,108. © 2001 Wiley-Liss, Inc. [source] Asthma management: Reinventing the wheel in sickle cell disease,AMERICAN JOURNAL OF HEMATOLOGY, Issue 4 2009Claudia R. Morris Asthma is a common comorbidity in sickle cell disease (SCD) with a reported prevalence of 30,70%. The high frequency of asthma in this population cannot be attributed to genetic predisposition alone, and likely reflects in part, the contribution of overlapping mechanisms shared between these otherwise distinct disorders. There is accumulating evidence that dysregulated arginine metabolism and in particular, elevated arginase activity contributes to pulmonary complications in SCD. Derangements of arginine metabolism are also emerging as newly appreciated mechanism in both asthma and pulmonary hypertension independent of SCD. Patients with SCD may potentially be at risk for an asthma-like condition triggered or worsened by hemolysis-driven release of erythrocyte arginase and low nitric oxide bioavailability, in addition to classic familial asthma. Mechanisms that contributed to asthma are complex and multifactorial, influenced by genetic polymorphisms as well as environmental and infectious triggers. Given the association of asthma with inflammation, oxidative stress and hypoxemia, factors known to contribute to a vasculopathy in SCD, and the consequences of these factors on sickle erythrocytes, comorbid asthma would likely contribute to a vicious cycle of sickling and subsequent complications of SCD. Indeed a growing body of evidence documents what should come as no surprise: Asthma in SCD is associated with acute chest syndrome, stroke, pulmonary hypertension, and early mortality, and should therefore be aggressively managed based on established National Institutes of Health Guidelines for asthma management. Barriers to appropriate asthma management in SCD are discussed as well as strategies to overcome these obstacles in order to provide optimal care. Am. J. Hematol., 2009. © 2008 Wiley-Liss, Inc. [source] Performance and consistency of care in admitted trauma patients: our next great opportunity in trauma care?ANZ JOURNAL OF SURGERY, Issue 6 2009Wei Chong Chua Abstract Few studies have prospectively analysed the delivery of care in trauma patients. This study undertook a prospective analysis of performance and consistency of care at a Level 1 trauma centre. A 3-month prospective study was undertaken of all admitted trauma patients at Liverpool Hospital. Data were collected on patient demographics, mechanism of injury, injury severity score (ISS), length of hospital stay, patient outcome and cause of death. Delivery of care was evaluated using 30 performance indicators and assessment of errors. Two hundred and thirty-six consecutive major trauma patients were studied. 73.3% were male, mean age 39 years. The main mechanism of injury was road trauma in 46.2%. Mean ISS was 12 and 64 patients had an ISS ,16. Error-free care was delivered in 145/236 (61.4%). There were 145 errors in 91 patients (38.6%). Errors in judgement and delays in diagnosis accounted for 56/145 (38.6%) and 48/145 (33.1%), respectively. Errors occurred most commonly in the Emergency Department (ED) (48.3%), and trainees from all specialties were responsible for 67.5% of errors. There were 25 near misses detected. Three patients developed major sequelae or complications from errors. One of 13 deaths was deemed potentially preventable. This study has shown that while 61.4% of admitted trauma patients receive optimal care, errors are frequent, resulting in a spectrum of outcomes from near misses to death. The majority of errors result from the activity of unsupervised trainees and relate to errors in judgement and delays in diagnosis. Clearly, there is room for improvement of the delivery of trauma care. [source] Promoting mental health care in a rural paediatric unit through participatory action researchAUSTRALIAN JOURNAL OF RURAL HEALTH, Issue 3 2009Brenda Happell Abstract Objective:,To explore, advance and evaluate mental health practices in a rural general paediatric unit through participatory action research. Design:,A participatory action research approach guided this study, providing an opportunity for nursing staff to become actively involved in the design, direction and outcomes of the research. Setting:,A 16-bed paediatric unit of a rural general hospital. Participants:,A purposive convenience sample of all paediatric nursing staff (n = 20; of 24 nurses). Outcome measures:,In the first phase of this study, focus groups were conducted to explore the experiences of nurses. Results:,Participants considered mental health to be a specialist discipline area and the role of the mental health nurse to be complex. They felt that their lack of training and experience with mental health issues was detrimental to the delivery of optimal patient care. There was concern about differing approaches to treatment, relationships with other mental health services and the suitability of the ward environment for young people with a mental health problem. Participants called for training by qualified mental health staff and the development of policies and clinical guidelines to facilitate their delivery of care to patients with a mental health problem in an acute medical environment. Conclusions:,There is a clear need for nursing specialities to work together to ensure that optimal care is given to patients admitted to general hospital with a mental health issue. Given the absence of accessible specialist child mental health inpatient units in regional and remote areas, upskilling paediatric nurses must be a priority. [source] Patterns of care for early stage bladder cancer,,CANCER, Issue 11 2010Seth A. Strope MD Abstract BACKGROUND: Early stage bladder cancer is a heterogeneous disease with a variable risk of progression and mortality. Uncertainty surrounding the optimal care for these patients may result in a mismatch between disease risk and treatment intensity. METHODS: Using Surveillance, Epidemiology, End Results-Medicare data, we identified patients diagnosed with early stage bladder cancer (n = 24,980) between 1993 and 2002. We measured patients' treatment intensity by totaling all Medicare payments made for bladder cancer in the 2 years after diagnosis. Using multiple logistic regression, we assessed relationships between clinical characteristics and treatment intensity. Finally, we determined the extent to which a patient's disease risk matched with their treatment intensity. RESULTS: The average per capita expenditures increased from $6,936 to $7,642 over the study period (10.2% increase; P < .01). This increase was driven by greater use of intravesical therapy (2.6 vs 3.7 instillations per capita, P < .01) and physician office visits (3.0 vs 4.8 visits per capita, P < .01). Generally, treatment intensity was appropriately aligned with many clinical characteristics, including age, comorbidity, tumor stage, and grade. However, treatment intensity matched disease risk for only 55% and 49% of the lowest and highest risk patients, respectively. CONCLUSIONS: The initial treatment intensity of early stage bladder cancer is increasing, primarily through greater use of intravesical therapy and office visits. Treatment intensity matches disease risk for many, but up to 1 in 5 patients may receive too much or too little care, suggesting opportunities for improvement. Cancer 2010. © 2010 American Cancer Society. [source] Unmet needs in the treatment of glaucoma related to compliance, tolerability and concomitant dry eyeACTA OPHTHALMOLOGICA, Issue 2008G HOLLO Purpose Compliance to long-term topical treatment of glaucoma can be less than optimal. This may decrease the efficacy of the treatment. This presentation summarises the unmet needs in the current topical treatment of glaucoma related to compliance, tolerability and concomitant dry eye and discusses the expectations for future therapies. Results Glaucoma is a life long conditions and its management is multifactorial. However, compliance to topical glaucoma treatment can be less than optimal. Forgetfulness and topical side effects have been identified as important reasons for non-compliance. Topical side effects decrease the quality of life of the patient, which impacts on compliance. Dry eye and glaucoma are often concomitant diseases. Therefore, it is advisable to consider the management of both diseases together for the optimal care for these patients. Preservative free preparations may have benefits for the long term treatment of glaucoma patients, especially those with dry/sensitive eyes. Conclusion Compliance remains a key issue in the management of glaucoma. Glaucoma and dry eye as concomitant diseases present specific challenges for the optimal care of the patient. [source] Congenital diaphragmatic hernia: review of the literature in reflection of unresolved dilemmasACTA PAEDIATRICA, Issue 12 2009S Grisaru-Granovsky Abstract Background:, Congenital diaphragmatic hernia (CDH) is a rare but clinically and scientifically challenging condition. The introduction of ultrasound has enabled early prenatal detection and consequently, hope of early therapeutic intervention. Aim:, We undertook the task to review the recent developments in understanding the pathology of CDH as well as the history and current management strategies to aid perinatologists in consultations with parents of CDH-affected foetuses. Study design:, A Medline search was undertaken of all reports and reviews published between 1980 and 2008 using MeSH search terms ,diaphragmatic hernia', ,congenital' and ,newborn'. Results:, The true incidence of CDH is still difficult to estimate because of the high incidence of hidden mortality of CDH. Complete case ascertainment also poses difficulties in assessment of the impact of new therapeutic modalities on overall survival. Recent improvements in prenatal detection are a milestone in affording time for re-assessments and parental counselling. The true benefit of antenatal therapy is circumscribed and should be offered only in selected cases of isolated severe CDH as defined by existing guidelines. Postnatal intensive respiratory supportive therapy and innovative surgical techniques within specialized tertiary centres has had a major impact on survival of babies with CDH. Conclusion:, The high survival of ,selected cases' that are live births and benefit from optimal care will be difficult to improve by antenatal interventions. The multidisciplinary approach to basic research and randomized clinical trials will further define the best approach to the foetus and neonate with CDH. [source] Inhaled nitric oxide improves oxygenation in very premature infants with low pulmonary blood flowACTA PAEDIATRICA, Issue 1 2004R Desandes Aim: Inhaled nitric oxide (iNO) is used to reduce right-to-left extrapulmonary shunting by decreasing pulmonary vascular resistance in term or near-term infants. The objectives of this study were to determine, first, the pulmonary blood flow status of very preterm infants with hypoxaemic respiratory failure, then the response of oxygenation to iNO therapy according to pulmonary blood flow (PBF) and, finally, to verify the lack of adverse side effects of iNO on the ductus arteriosus. Methods: Infants below 32 wk gestational age (GA) with hypoxic respiratory failure and aAO2 < 0.22 were randomized as the control or iNO group. PBF was evaluated by pulsed Doppler measurement of mean pulmonary blood flow velocity (MPBFV) in the left pulmonary artery. Low PBF (LPBF) was defined as MPBFV >0.2m/s. Results: Seventy infants of 23 to 31 wk GA with hypoxic respiratory failure were randomized either to receive or not to receive 5 ppm iNO in addition to optimal care. Twenty-eight infants were diagnosed with LPBF (11/35 in iNO vs 17/35 in the control groups). Thirty minutes after receiving iNO the number of LPBF infants dropped to 8/35. In the iNO group, aAO2 increased significantly from 0.14 ± 0.05 to 0.24 ± 0.08 after iNO, but only in the LPBF infants (mean ± SD; p= 0.027). Conclusion: In infants below 32 wk GA with hypoxic respiratory failure, Doppler echocardiographic assessment of LPBF seems to be able to determine which patients are likely to benefit from iNO therapy on systemic oxygenation. [source] | ||||||||||