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PubMedDate not supplied

Organisational culture and consultant nurse outcomes: Part 2. Nurse outcomes.

AIM: The aim of this three-year study was to investigate the development of a consultant nurse post and consider whether it contributed to a new organisational culture. METHODOLOGY: Action research was used because it focuses on developing practitioners, developing practice and contributing to understanding both the phenomena being studied and the processes being used. RESULTS: The role of leadership is recognised as key to bringing about cultural change, as is the use of approaches that clarify values and highlight the contradiction between espoused culture and culture in practice. CONCLUSION: This new culture had a positive impact on the unit in which it was based, on practitioners and their practice, and also on the trust. A number of factors, including transformational leadership, other facilitative processes, expertise in the practice of nursing, and other subroles of the consultant nurse were shown to be influential. Part one, published last week, described the concept of organisational culture. This article discusses the consultant nurse outcomes.

Attitude of Health Personnel↗

PubMed1999

Outcomes for patients at risk for inheritable breast cancer: how the nurse practitioner can determine the proper course of action to ensure desired outcomes.

The topic of genetics and genetic testing pertaining to diseases such as hereditary breast cancer is an issue of which nurse practitioners need to be aware. In the general primary care practice where patients are seen daily with questions about genetic testing, the nurse practitioner is in an ideal setting to educate and counsel these men and women for an outcome that is acceptable to both practitioner and patient.

Adult↗

PubMedDate not supplied

Functional outcome after high tibial osteotomy: a study using individual goal achievement as the primary outcome variable.

Functional outcome after high tibial osteotomy (HTO) was evaluated with respect to both improvement and goal achievement. Fifty-seven subjects, 32 men and 25 women, with a mean age of 55 years were examined with the Functional Assessment System (FAS) 6 and 12 months after surgery. The FAS is an evaluation system, specifically designed to monitor lower extremity dysfunction. It shows a profile with preoperative status, individual goal, and postoperative status. Statistically significant improvement was seen in 6/20 variables after 6 months, and in 10/20 variables after 12 months. When goal achievement was examined, the results were not as impressive. The treatment goal was not reached on the group level for almost all variables. On the individual level, only 20\N40% of the patients achieved the goal as a result of surgery in most variables. Exceptions were pain and leisure time/hobbies, where there was a high degree of goal achievement. It is possible that postoperative training was inadequate. The authors recommend a new randomized study, where patients who receive specific individual training related to the individual goal and functional profile are compared with a control group.

Activities of Daily Living↗

PubMed2002

[Analysis of the outcome of the treatment of small bowel obstruction and factors which determine the outcome (10-year experience at the Kaunas Medical University Clinic)].

AIM: To evaluate the results of the treatment of small bowel obstruction in the Surgical clinic of Kaunas University of Medicine in 1990-1999, the changes of the results of the treatment, to evaluate the factors, which determine these changes. PATIENTS AND METHODS: 489 patients with small bowel obstruction (SBO) were treated during 10-year period. Acute SBO was found in 433 (88.5%) cases; 322 (65.8%) patients underwent surgery. The patients were divided into two groups: 1990-1995 year group (A) and 1996-1999 year group (B) according to the newly implemented methods of diagnostics and treatment (computer-aided diagnosis, laparoscopic cutting of adhesions, conservative small bowel decompression with long intestinal tube and etc.). Both groups were statistically similar. By means of statistical methods factors, which determine the results of the treatment of SBO, were found and the differences of distribution of these factors in both groups were evaluated. RESULTS: The mortality rate was 10.3% in group A and 1.8%--in group B. The most significant factors, which determine the outcome of the treatment of SBO, were: the time period of making diagnosis, adjacent illnesses, small bowel necrosis and its length, acute SBO, SBO due to multiple adhesions, surgical methods. In comparing both groups, they differed according to the time of making diagnosis (18.6 h and 9.6 h), the frequency of small bowel necrosis (14.2% and 5.7% cases); the methods of surgery also differed. CONCLUSION: The results of the treatment of SBO improved. The short-cut of the time period to make diagnosis, the more rare cases of bowel necrosis and new surgical methods influenced these changes.

Adolescent↗

PubMed2001

SMS Medical Outcomes Research Project Asthma Outcomes Study. Provider education the next step.

Since the initial meeting of the Asthma Study Group in the summer of 1996, the group worked with MORP staff to develop an outcomes instrument, define a study population, survey more than 800 adults with the diagnosis of asthma, and report the survey results back to the providers involved with those patients. After reviewing the survey results, the group developed an Asthma Toolkit aimed at providing reference materials for physicians and their staff and also useable materials for their patients with asthma. The Asthma Toolkit was produced through the efforts of the study group, the SMS MORP staff and the SMS Marketing and Communications Department. We developed an education program to disseminate the toolkit and improve the care of the patient with asthma. Initial reaction to this educational program has been enthusiastic, and evaluation of the Asthma Toolkit's usefulness is underway.

Adolescent↗

PubMed2004

Long-term outcome and factors influencing the outcome of thymectomy for myasthenia gravis.

Thymectomy has gained widespread acceptance as a treatment for patients with myasthenia gravis (MG). Patients with myasthenia gravis who had undergone thymectomy by extended transsternal approach between 1981 and 1987 were retrospectively reviewed to evaluate the result of thymectomy, time to remission, time to maximum improvement and factors influencing remission after thymectomy. There were 128 patients, 45 men and 83 women and the mean ages at the time of thymectomy were 35.7 and 32.2 years respectively. After thymectomy, 41.2% of the patients were in remission, 53% improved and 5.8% had no response. The remission rates at 1, 2, 5 and 10 years after thymectomy were 9%, 17%, 37% and 53% respectively and the median time to remission was 9 years. The maximum improvement rates at 1, 2, 5 and 10 years after thymectomy were estimated to be 30%, 40%, 57% and 78% respectively and the median time to maximum improvement was 3.6 years. Patients with ocular MG, longer duration of symptoms before thymectomy and atrophic thymus gland appeared to take longer to achieve remission although none of the factors was significantly associated with the time to remission. Thymectomy is beneficialfor MG patients with satisfactory remission and improvement rates. It is recommended that thymectomy should be advocatedfor these patients early in the course of the disease because the duration of the symptoms appeared to be the main determinant of the outcome.

Adult↗

PubMed1989

The stroke rehabilitation outcome study: Part II. Relative merits of the total Barthel index score and a four-item subscore in predicting patient outcomes.

Part I of this series described the background of the study; the characteristics of the patient population; and their functional status before onset of stroke, at rehabilitation admission, at discharge, and at six months after discharge. Results at follow-up showed that patients with higher Barthel index scores living in the community were more likely to be satisfied with life in general, to have more person-to-person contacts, and to be more active in community affairs. Part II describes the utility of two sets of data derived from the admission Barthel index (combinations of independent performance of four basic items of the index vs the total score) in predicting the likely range of Barthel index scores at discharge and functional outcomes at six-month follow-up.

Activities of Daily Living↗

PubMed1995

Variation in patient utilities for outcomes of the management of chronic stable angina. Implications for clinical practice guidelines. Ischemic Heart Disease Patient Outcomes Research Team.

OBJECTIVE: Although practice guidelines sometimes make recommendations based on symptom severity, they rarely account for how patients feel about their symptoms. To investigate the possible importance of patient preferences in treatment of ischemic heart disease, we assessed attitudes toward symptoms in patients with angina pectoris. DESIGN: Case series. SETTING: Ambulatory cardiology clinics at two tertiary care medical centers. PATIENTS: A total of 220 subjects were selected from 589 patients with chronic stable angina referred from cardiologists to achieve patients samples balanced for sex, race, and angina severity. MAIN OUTCOME MEASURES: We measured patients' attitudes toward their angina using the rating scale, time trade-off, and standard gamble utility metrics. Reliability of measurements was evaluated by repeating the assessments 2 weeks later on 50 willing patients. RESULTS: While the mean responses followed the expected patterns (those with more severe Canadian Cardiovascular Society scores chose lower utilities), attitudes toward symptoms varied substantially among patients with similarly severe angina. For example, there was a 33% chance that a patient with class II angina had a time trade-off utility that was lower (ie, more bothered by symptoms) than a patient with more severe angina (class III/IV). This variation in utilities was not due to random error in the assessments. CONCLUSIONS: Angina patients with similar functional limitation vary considerably in their tolerance for their symptoms, as measured by utilities. Our findings suggest that guidelines for the management of ischemic heart disease should be based on the preferences of the individual patient rather than on symptom severity alone.

Adult↗

PubMed1994

Tricompartmental knee replacement. A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes. Knee Replacement Patient Outcomes Research Team.

The chance of a person with osteoarthritis of the knee receiving a knee replacement is highly variable. To understand better the reasons for this variation, all practicing orthopaedists in Indiana were surveyed about their management of severe knee osteoarthritis and their perception of tricompartmental knee replacement as a therapeutic option. Their perceptions of indications and outcomes of knee replacement were compared with the self reported annual number of patients for whom they performed (or referred to other surgeons for) tricompartmental knee replacements. A completed survey was returned by 220 (79%) of the 280 orthopaedists surveyed; analyses were limited to the 188 respondents who had cared for at least one patient with osteoarthritis of the knee in the prior 2 weeks (mean = 13). These surgeons reported performing (or referring patients for) a mean of 31 knee replacements in the prior year (SD 45, median 21, range 0-480 knee replacements). There was strong agreement (> 95%) among respondents for seven (21%) of 33 surgical indications and contraindications, and more general agreement (> 60%) for 21 (64%). In the five factors (15%) for which there was disagreement, there was no consistent relationship between opinions and self reported knee replacement performance rate. Surgeons reporting more knee replacements had significantly higher estimates of pain relief and functional improvement following surgery, and lower estimates of prosthesis infection and failure rates. When all responses were considered together, four decision factors correlated independently with the performance of more knee replacements, but these four factors explained only 24% of the variation in self reported knee replacement performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1996

Indications and immediate patient outcomes of pathology intraoperative consultations. College of American Pathologists/Centers for Disease Control and Prevention Outcomes Working Group Study.

OBJECTIVE: To evaluate the reasons (indications) for and immediate intraoperative surgical results (outcomes) associated with pathology intraoperative consultation. DESIGN: In 1992 and 1993, surgeons collaborated with pathologists in 472 voluntarily participating institutions from the United States (462), Canada (7), Australia (2), and New Zealand (1) in a study jointly sponsored by the College of American Pathologists and the Centers for Disease Control and Prevention. Pathologists selected 20 consecutive intraoperative consultations and assembled a cover letter, a checklist questionnaire, and a copy of the corresponding surgical pathology report, all of which were sent to the surgeon(s) for retrospective evaluation. PARTICIPANTS: The study was distributed to participants in the College of American Pathologists voluntary Q-Probes quality improvement and Surgical Pathology Performance Improvement programs and to Canadian and Australian hospitals with more than 200 beds. RESULTS: Evaluation of 9164 cases established the five most common indications for intraoperative consultation: (1) establish or confirm diagnosis to determine type or extent of operation (51%), (2) confirm adequacy of margins (16%), (3) confirm nature of tissue to direct sampling for immediate culture or other laboratory study (10%), (4) expedite obtaining diagnosis to inform family or patient (8%), and (5) confirm sufficient tissue submitted to secure diagnosis in permanent section (8%). The information provided by the intraoperative consultation resulted in changed surgical procedures that were either modified, terminated, or newly initiated in 47%, 30%, 6%, 9%, and 28% of cases, corresponding respectively to each of the above five common indications. Rarely cited reasons for intraoperative consultation were to expedite obtaining diagnosis for surgeon's knowledge (3%), to facilitate patient management, other professional communication or discharge planning prior to permanent section availability (3%), academic protocol (< 1%), and consultation not needed or no reason for request (< 1%). CONCLUSIONS: This multi-institutional, interdisciplinary database confirms that pathology intraoperative consultations, regardless of the initial indications, influence immediate patient care decisions, resulting in changed surgical procedures in an average of 39% of all operative cases.

Australia↗

PubMed1995

[Outcome-oriented Barolin Neurorehabilitation Scale: 476 cases over 6 years--multi-nodal statistical correlation of neurorehabilitation groups in diagnosis, prognosis and outcome].

This evaluation documents practicability and scientific value of the scale, since many years developed in our institute and in use there. Patients with left hemispheric lesions suffer from stronger disturbances of eating than others. Systematic neurological rehabilitations leads to a marked increased unnecessity of catheterism and by that to a marked better social integration. Associate depression (after Barolin) is a main source of rehabilitation hospitalism (as called by Barolin). Multiple sclerosis and Morbus Parkinson give better outcomes than cerebro-vascular patients. A new finding that also proofs to be neurophysiologically interesting is that higher agedness is mostly a non-limiting factor for rehabilitation, as far as not lesser endavours produce a self fulfilling prophecy. However a slight limitation in higher age groups is to be found in the patients with lesions on the dominant hemisphere, whereas lesions on the subdominant hemisphere produce no limitation to rehabilitation at all by higher age.

Activities of Daily Living↗

PubMed1997

Outcome of delirium: Part 1. Outcome of delirium diagnosed by DSM-III-R, ICD-10 and CAMDEX and derivation of the Reversible Cognitive Dysfunction Scale among acute geriatric inpatients.

OBJECTIVE: To study performance of DSM-III-R, ICD-10 and CAMDEX diagnoses of delirium as predictors of improvement in mental state in survivors, and to develop a brief rating scale which will predict reversibility of cognitive dysfunction. DESIGN: Prospective cohort study. SETTING: Acute geriatric inpatient units. PATIENTS: A random sample of consecutive acute admissions of patients over the age of 65 (N = 80). MAIN MEASUREMENTS: Serial assessments of mental state and cognitive function and observational data. Establishment of DSM-III-R, ICD-10, CAMDEX diagnoses. OUTCOME MEASURE: Patients with more than five points of 20% improvement in Mini Mental State Examination following the most severely impaired assessment operationally designated 'reversible cognitive dysfunction'. MAIN RESULTS: Diagnoses of delirium by DSM-III-R and ICD-10 do not predict improvement in cognitive function well; CAMDEX does rather better. Discriminant function analysis yielded the Reversible Cognitive Dysfunction Scale (RCDS), a simple clinical scale which accurately predicted improvement. This comprised reduced conscious level, poor attention, poor contact with the patient, incoherent speech, reduced psychomotor activity, lack of awareness of surroundings and poor orientation and memory. CONCLUSIONS: The concept of and diagnostic criteria for delirium should be reconsidered. The RCDS merits further evaluation.

Acute Disease↗

PubMed2006

Transgenic mice that overexpress the anti-apoptotic Bcl-2 protein have improved histological outcome but unchanged behavioral outcome after traumatic brain injury.

Increasing evidence suggests that apoptosis is a contributing factor to neuronal cell death in traumatic brain injury (TBI). There is increased expression, cleavage and activation of caspases as well as other proteins known to regulate apoptosis in neurons after TBI. These proteins include the proto-oncogene Bcl-2 which belongs to a family of proteins with both pro- and anti-apoptotic properties. To investigate the role of apoptosis in TBI and the importance of Bcl-2 protein on the severity and outcome of injury, Bcl-2 overexpressing transgenic and wild-type control mice were subjected to the controlled cortical impact model of TBI. There was no significant difference in the cleavage of caspase-3 or caspase-9 detected by Western blotting of hippocampal samples from transgenic or wild-type mice after TBI. Bcl-2 transgenic mice had smaller contusion volumes and increased numbers of surviving neurons in CA2 but not other regions of hippocampus compared to wild-type controls. By contrast, there was no difference in motor function determined by the round beam balance and wire grip tests between transgenic and wild-type mice after TBI. Cognitive function assessed by the Morris water maze was also not different between groups. These results suggest that overexpression of Bcl-2 is only partially neuroprotective and other members of this protein family may prove to be more important in protecting neurons from cell death.

Animals↗

PubMed2004

Attempted suicide among heroin users: 12-month outcomes from the Australian Treatment Outcome Study (ATOS).

A cohort of 495 heroin users, recruited for the Australian Treatment Outcome Study (ATOS), were re-interviewed at 12 months regarding suicide attempts over the follow-up period. The proportion who had attempted suicide in the 12 months since baseline was not significantly different from that reported in the 12 months preceding ATOS enrolment (12.2% versus 9.1%), and attempted suicide did not decline significantly in any of the index treatment groups. Among males, there was no significant reduction in attempted suicide (8.7% versus 8.1%). Among females, however, the proportion reporting an attempt declined significantly from 19.7 to 9.8%. Of those who reported suicidal ideation at baseline, 22.8% made an attempt over the follow-up period, as did 19.0% of those who had major depression. Large, and significant, declines in suicidal ideation (23.1% versus 6.9%) and major depression (25.5% versus 10.9%) occurred over the study period. Independent predictors of a suicide attempt over the follow-up period were: social isolation, having made an attempt in the preceding 12 months, suicidal ideation at baseline, a greater number of treatment episodes and higher levels of baseline polydrug use.

Adolescent↗

PubMed2000

Genetic polymorphism and clinical outcome: identification of individuals at risk of a poor clinical outcome.

Susceptibility and outcome in complex disorders such as asthma and cancer appear to be determined, at least in part, by genetic polymorphism. However, while our ability to identify new allelic variants and study them in case and control populations has greatly improved, considerable difficulties remain in elucidating how many genes determine particular clinical phenotypes. This is because most studies have concentrated on study of single genes in relatively small study groups. The important issues of gene-gene interactions (epistasis) and high-risk subgroups have not yet been adequately addressed. We now describe a general approach, using patients with head and neck cancers as an example. Our purpose is to demonstrate candidate gene selection, statistical approaches, and identification of patient subgroups.

Genetic Predisposition to Disease↗

PubMed2002

Factor XIII A-subunit concentration predicts outcome in stroke subjects and vascular outcome in healthy, middle-aged men.

There is growing evidence for a role of factor XIII (FXIII) in vascular disease. FXIII measures were determined in (i) a nested case-control study from the Second Northwick Park Heart Study of 63 men with myocardial infarction (MI) and 124 age-matched controls and (ii) in a case-control study of 475 subjects with acute stroke and 461 controls followed up for 54 months for mortality. In both studies, measures of FXIII A- and B-subunit antigen, FXIII activity and prothrombin fragments (F1 + 2) were made. An in vitro model was used to investigate the effects of thrombin activity on FXIII A- and B-subunit antigen levels. In study 1, patients clinically free of coronary artery disease who later developed MI had lower adjusted FXIII A-subunit levels at recruitment (129.2%vs 113.3%, P = 0.007). In study 2, stroke patients with large vessel disease had lower A-subunit antigen levels (102.1%vs 127.2%, P < 0.001), but higher F1 + 2 levels (0.941%vs 0.753%, P < 0.05), than subjects with small vessel disease. Levels of FXIII A-subunit (100%vs 117%, P < 0.0001) were lower and F1 + 2 higher (1.020%vs 0.702%, P < 0.0001) in stroke patients who had died compared with those still alive at the end of the follow-up period. Low concentrations of FXIII A-subunit antigen predicted vascular outcome in otherwise healthy subjects and relate to both size of infarct and poor post-stroke survival in patients with acute ischaemic stroke. Low in vitro concentrations of FXIII A-subunit antigen wererelated to increased thrombin generation and, thus, increased risk of thrombotic events.

Aged↗

PubMed2000

Medium-term outcomes are comparable with short-term outcomes in children with attention deficit hyperactivity disorder treated with stimulant medication.

OBJECTIVE: To compare the short- and medium-term effects of psychostimulant medication in children with attention deficit hyperactivity disorder (ADHD). METHODS: Seventy-three children with ADHD participated in a double-blind crossover study of dextroamphetamine (DEX) and methylphenidate (MPH; results previously reported). At the completion of this study, subjects continued to take the preferred stimulant. Subjects were restudied 6-9 months later. The principal outcome measures were the Revised Conners' Parent and Teacher Rating Scales. RESULTS: Fifty-three families (73%) returned the follow-up surveys. At 6-9 months, mean T scores were still significantly lower than the mean at baseline for all factors of both the CPRS-R and CTRS-R (P < 0.01). There were no statistically significant differences between scores at 6-9 months and scores at the completion of the corresponding medication period in the crossover trial. CONCLUSIONS: After 6-9 months treatment with stimulant medication, ratings remained significantly better than at baseline. This suggests that the early benefits of stimulants are sustained for at least 6 months.

Adolescent↗

PubMed1984

Neurologic outcome in children with inborn errors of urea synthesis. Outcome of urea-cycle enzymopathies.

We studied 26 children with inborn errors of urea synthesis who survived neonatal hyperammonemic coma. There was a 92 per cent one-year survival rate associated with nitrogen-restriction therapy and stimulation of alternative pathways of waste nitrogen excretion. Seventy-nine per cent of the children had one or more developmental disabilities at 12 to 74 months of age; the mean IQ was 43 +/- 6. There was a significant negative linear correlation between duration of Stage III or IV neonatal hyperammonemic coma and IQ at 12 months (r = -0.72, P less than 0.001) but not between the peak ammonium level (351 to 1800 microM) and IQ. There was also a significant correlation between CT abnormalities and duration of hyperammonemic coma (r = 0.85, P less than 0.01) and between CT abnormalities and concurrent IQ (r = -0.75, P less than 0.02). These results suggest that prolonged neonatal hyperammonemic coma is associated with brain damage and impairment of intellectual function. This outcome may be prevented by early diagnosis and therapy.

Amino Acid Metabolism, Inborn Errors↗