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PubMed2001

Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Chronic Disease↗

PubMed2001

Economic implications of neonatal intensive care unit collaborative quality improvement.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January 1, 1994 to December 31, 1997. Data on resources expended by hospitals to conduct this project were collected in a survey for the period January 1, 1995 to December 31, 1996. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Nine other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (N = 2993) and the 9 comparison NICUs (N = 2203); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (N = 663) and the 9 comparison NICUs (N = 1007). INTERVENTIONS: NICUs formed multidisciplinary teams which worked together to undertake a collaborative quality improvement effort between January 1995 and December 1996. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: Treatment cost per infant is the primary economic outcome measure. In addition, the resources spent by hospitals in undertaking the collaborative quality improvement effort were determined. RESULTS: Between 1994 and 1996, the median treatment cost per infant with birth weight 501 to 1500 g at the 6 project NICUs in the infection group decreased from $57 606 to $46 674 (a statistical decline); at the 4 chronic lung disease hospitals, for infants with birth weights 501 to 1000 g, it decreased from $85 959 to $77 250. Treatment costs at hospitals in the control group rose over the same period. There was heterogeneity in the effects among the NICUs in both project groups. Cost savings were maintained in the year following the intervention. On average, hospitals spent $68 206 in resources to undertake the collaborative quality improvement effort between 1995 and 1996. Two thirds of these costs were incurred in the first year, with the remaining third in the second year. The average savings per hospital in patient care costs for very low birth weight infants in the infection group was $2.3 million in the post-intervention year (1996). There was considerable heterogeneity in the cost savings across hospitals associated with participation in the collaborative quality improvement project. CONCLUSION: Cost savings may be achieved as a result of collaborative quality improvement efforts and when they occur, they appear to be sustainable, at least in the short run. In high-cost patient populations, such as infants with very low birth weights, cost savings can quickly offset institutional expenditures for quality improvement efforts.

Chronic Disease↗

PubMed2002

Mycological characterization and comparison of climax forest associations in the Mecsek Mountains.

Deciduous forests, developed in Submediterrean climate, differ essentially from those in Central and Western Europe. Present paper concerns fungistical characterization of four Submediterranean climax associations based on 8 years investigation, as well as on literary data. Near common and rare species differential and local character ones are considered, those with indicative value, too. In addition, functional distribution of these associations is discussed.

Climate↗

PubMedDate not supplied

[The quality of radiology services in five Latin American countries].

OBJECTIVE: To determine the correlation between certain quality indicators for imaging services and the accurate interpretation of radiological exams for four frequent complaints: breast lumps, gastrointestinal discomfort, back pain, and symptoms of tuberculosis. METHODS: Twenty-six radiology services in Argentina, Bolivia, Colombia, Cuba, and Mexico were assessed. The mammography and conventional radiographic/fluoroscopic equipment used in selected services were evaluated utilizing common protocols, data sheets, testing instruments, phantoms, and calibrated dosimetry systems. The studies were performed in medium-complexity facilities. Informed consent was obtained from all patients studied, and the confidentiality of results was guaranteed. The following parameters were documented: type of facility (public vs. private); population covered; patient workload; radiological and image-processing equipment and supplies; education and training of professional and technical staff; quality assurance and preventive maintenance programs, and adherence to radiation safety standards. The performance of x-ray units, image receptors and processors; darkroom and image viewing conditions; patient doses and image quality, were determined using standardized parameters in all cases. Independent panels of radiologists, recognized as experts by the local radiological society, assessed the quality of the clinical images obtained and performed a radiological interpretation for each patient using the same films and clinical history available to the institution's imaging physicians. The agreement between the panel of expert's reports and those of local radiologists was taken as an indicator of the radiological diagnostic accuracy. RESULTS: Analyses were carried out of 366 mammograms, 343 radiological procedures for gastrointestinal complaints, 319 X-rays of the spinal column, and 157 chest radiographs. The agreement between the radiological interpretation of the panel of experts and of the local physician ranged from 70% to 100%, except in the case of spinal column films in Cuba (57.8%) and of mammograms in Mexico (33.3%), which the panel of experts found to be among those having the poorest quality. There was a significant positive correlation between the accuracy of the radiological interpretation and the quality of the radiological images. Image quality showed a positive correlation with the technicians' level of education and training. Studies performed in services that had automatic film processors and that complied with the indicators established for screen-film contact yielded better images and a higher proportion of studies with concordant results. More than 50% of the viewboxes did not satisfy the quality criteria for luminance and homogeneity. CONCLUSIONS: A good quality image is critical to achieving an accurate diagnosis. Emphasis should be placed on the continuing education of radiology technicians and on the acquisition and maintenance of adequate equipment and accessories, especially viewboxes, intensifying screens, and automatic film processors, given the impact they have on image quality.

Humans↗

PubMed1977

A probability-based formula for calculating interobserver agreement.

Estimates of observer agreement are necessary to assess the acceptability of interval data. A common method for assessing observer agreement, per cent agreement, includes several major weaknesses and varies as a function of the frequency of behavior recorded and the inclusion or exclusion of agreements on nonoccurrences. Also, agreements that might be expected to occur by chance are not taken into account. An alternative method for assessing observer agreement that determines the exact probability that the obtained number of agreements or better would have occurred by chance is presented and explained. Agreements on both occurrences and nonoccurrences of behavior are considered in the calculation of this probability.

Journal Article↗

PubMed2004

Neurotransmitters and substances of abuse: effects on adult neurogenesis.

Neurogenesis in the adult brain is now a well-recognized phenomenon. The compelling subject of interest now is that besides the intrinsic, what are the environmental factors which affect neural stem cells ability to maintain themselves and enter the pool of the adult brain. While the molecular and cellular mechanisms that regulate this process remain to be elucidated, substantial data implicate common pathways involving action of neurotransmitters through neurotrophic factors to regulate the neural stem cells. This transmitter-mediated neurotrophic factor pathway could be altered by extrinsic environmental factors including enriched environment, exercise, stress, and drug abuse (i.e. alcohol, opioid, methamphetamine). Our special attention focuses on the role of neurotransmitters; among them are serotonin (5-HT), glutamate and gamma-amino-butyric acid (GABA). Substances of abuse including alcohol, which may interact through these neurotransmitters and neurotrophic factors to affect neurogenesis, are also reviewed.

Animals↗

PubMed1987

Euthyroid hyperthyroxinaemia in acute psychiatric admissions.

Of 98 patients studied prospectively during admission to the psychiatric ward of a general hospital, 13% showed an initial transient elevation of the serum thyroxine (T4) level (range 142-174 nmol/l) with the incidence increasing to 15% on serial testing at days five and fourteen. There was no clinical evidence of a thyrometabolic disorder and, as the mild hyperthyroxinaemia normalised rapidly, recourse to other thyroid function tests was not required. The possible causes of the transient hyperthyroxinaemia are discussed, but examination of the hyperthyroxinaemic patients' diagnoses did not reveal anything in common. These data indicate that the results of routine thyroid function tests in acute psychiatric admissions should be interpreted with care, and that historical and physical examination remains the primary avenue of diagnosis of thyroid disorders.

Adult↗

PubMed1981

Whipple's disease: a review emphasizing immunology and microbiology.

Whipple's disease is an important and fascinating problem of local immunity in the gastrointestinal tract. Does the disease occur when an organism that is rare in nature infects an individual or do patients with Whipple's disease have a definable defect in their immune response that permits infection by a more common agent? Data in recent years indicate that there is only one type of microorganism that causes Whipple's disease. It is rod-shaped by electron microscopy and has a definable antigenic pattern by immunofluorescence. Paradoxically (considering its geometry), it reacts most strongly with antisera directed to streptococcal antigens. Patients with Whipple's disease do not have a disorder of immunoglobulin synthesis and do not have immune complexes present in their gut walls. Further, although earlier studies indicated that a defective response of T-lymphocytes to PHA is consistently present in these patients even years after therapy, more recent studies have found no consistent defect in mitogenic responses to PHA, CON A, or PWM. Also, recent studies indicate that mononuclear cells from patients with Whipple's disease usually mediate antibody-dependent cell-mediated cytotoxicity as well as controls, although spontaneous cell-mediated killing may be decreased. All these studies suggest that the defect is not primarily of lymphocytes, rather it is more likely that a defect exists in monocytes and macrophages. Future studies on Whipple's disease should add to existing knowledge of how the immune processes intracellular microorganisms.

Bacteria↗

PubMed1993

Naturalistic observation of adolescent tobacco use.

A naturalistic observation study of adolescent tobacco use was conducted to corroborate previous studies which used self-report questionnaire or structured interview methods to study this problem behavior. Several findings converged with previous accounts of adolescent tobacco use. For example, most use occurred in small groups. However, other findings diverged somewhat from previous research in that an unexpectedly low number of offers of tobacco was observed, nonusers were present in smoking groups, and solitary smoking was common. These data suggest that direct, normative social pressure to use tobacco may not be as frequent as more subtle informational social influence, at least in high school adolescent tobacco use groups.

Adolescent↗

PubMed2006

Aspergillus ustus infections among transplant recipients.

Aspergillus ustus is a mold that rarely infects humans; only 15 systemic cases have been reported. We report the first outbreak of invasive infection caused by A. ustus among hematopoietic stem cell transplant (HSCT) recipients. Six patients with infections were identified; 3 infections each occurred in both 2001 and 2003. Molecular typing by using randomly amplified polymorphic DNA (RAPD) and antifungal drug susceptibility testing were performed on clinical and environmental isolates recovered from our hospital from 1999 to 2003. The highest overall attack rate in HSCT patients was 1.6%. The overall death rate was 50%, and death occurred within 8 days after diagnostic culture collection. Clinical isolates exhibited decreased susceptibility to antifungal drugs, especially azoles. RAPD and phylogenetic analysis showed genetic similarity between isolates from different patients. Based on the clustering of cases in space and time and molecular data, common-source acquisition of this unusual drug-resistant species is possible.

Adult↗

PubMed2006

Dementia with lewy bodies: therapeutic opportunities and pitfalls.

OBJECTIVE: To review diagnoses and challenges of treating patients with dementia with Lewy bodies (DLB), commonly considered the second most common form of dementia. DATA SOURCES: MEDLINE, Web of Science, and International Pharmaceutical Abstracts databases were searched in January 2006 for clinical studies, case series, case studies, letters, and review articles on the treatment of DLB. Search terms included: aripiprazole, cholinesterase inhibitors, clozapine, dementia with Lewy bodies, donepezil, galantamine, Lewy body dementia, neuroleptics, olanzapine, quetiapine, risperidone, rivastigmine, tacrine, ziprasidone. Applicable articles in the English language were reviewed. The bibliographies of these articles provided additional references. STUDY SELECTION: Articles describing studies, case series, and case studies are included in this review. DATA SYNTHESIS: DLB is commonly considered the second most common form of dementia, although some experts believe vascular dementia to be the second most common form. DLB is often under-diagnosed and misdiagnosed as Alzheimer's disease or Parkinson's related dementia. The core features of dementia with Lewy bodies are cognitive decline plus at least one of the following: fluctuations in cognition, visual hallucinations, and parkinsonism. Other supportive features include: neuroleptic sensitivity, repeated falls, syncope, transient loss of consciousness, REM sleep disturbances, depression, delusions, and nonvisual hallucinations. CONCLUSION: Increased prudence with the use of neuroleptic agents is essential in DLBs because the use of these agents is associated with physical and cognitive decline and increased mortality. While neuroleptic sensitivity has been reported with the use of both typical and atypical antipsychotic medications, these medications are often necessary for the treatment of psychotic symptoms. Decreases in neuroleptic sensitivity can often be achieved by dose reductions, although neuroleptic discontinuation is sometimes necessary. Cholinesterase inhibitors may be especially useful in the treatment of DLB. Cholinergic deficits are associated with visual hallucinations, and cholinesterase inhibitors often result in resolution of hallucinations, improved cognition, and decreased behavioral disturbances.

Antiparkinson Agents↗

PubMed2005

Oral combination chemotherapy in the treatment of AIDS-associated Hodgkin's disease.

OBJECTIVES: To determine the effectiveness of an oral combination chemotherapy regimen administered to patients with AIDS-associated Hodgkin's disease. DESIGN: Prospective, pilot phase II clinical trial. SETTING: Consecutive patient recruitment occurred at two medical centers in the United States: Albany Medical Center, Albany, New York, where patients were recruited prior to December 31, 1996 (pre-HAART era); and University Hospitals of Cleveland, Cleveland, Ohio, where patients were recruited after January 1, 1997 (HAART era). INTERVENTION: Oral chemotherapy consisted of lomustine (100 mg/m2 day I for cycle one and odd cycles thereafter); etoposide (200 mg/m2 days 1 through 3); and cyclophosphamide and procarbazine (each 100 mg/m2 days 22 through 31). Cycles were repeated every six weeks. Colony-stimulating factor support (G-CSF in all instances) was allowed. MAIN OUTCOME MEASURES: Clinical demographic variables, peripheral blood counts, serum chemistries, CD4 lymphocyte count, histopathological subtype of Hodgkin's disease were identified for all patients, who were staged according to Ann Arbor criteria. DATA ANALYSIS: Common Toxicity Criteria were utilized to assess safety; response was assessed using ECOG criteria; and survival was analyzed by Kaplan-Meier methods and difference of survival between pre-HAART and HARART era was compared using log-rank test. RESULTS: Eleven patients (six in pre-HAART era), all but one male, with a median age of 36 years, excellent performance status and advanced International Prognostic Score were treated. Myelosuppression was the major side effect and there were minimal other grade 3 or greater toxicity all of which were promptly reversible. An overall objective response rate of 82% (with 18% complete responses) and median survival duration of 24 months (range 2.5 +/- 68) were observed. Survival was markedly improved in patients treated in the HAART era (median not reached versus 7.25 months, p = 0.034). CONCLUSIONS: This feasibility study demonstrates acceptable tolerance and excellent clinical activity of oral combination chemotherapy in patients with AIDS-associated Hodgkin's disease. Improved survival is observed in combination with HAART therapy. Dose-modification of this regimen would be suitable to evaluate in the resource constrained setting and larger confirmatory studies are encouraged.

Adult↗

PubMedDate not supplied

[Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management of three cases].

BACKGROUND: Pylephlebitis is thrombophlebitis of the portal vein and/or of its branches; it is acute and generally arises as a complication of inflammatory intra-abdominal processes or of surgical interventions in patients with blood discrasies. As its clinical picture is fairly non-specific, radiological findings, while not pathognomonic, are of great use in early diagnosis and improved vital prognosis of these patients. The aims of this study are to review the pathophysiology of this entity and its clinical and radiological presentation, which allow for early clinical suspicion. CLINICAL CASES: Three cases of pylephlebitis are presented, two of them post-surgical, in which the only common clinical data for suspicion were the febricula and leucocytosis. Diagnosis was obtained from the finding of helicoidal computer tomography with IV contrast - Somaton Siemens - and abdominal echography - Ellegra Siemens - carried out on the three. The result of these tests was decisive for an early diagnosis, efficient treatment and satisfactory evolution in the three cases. DISCUSSION: We wish to emphasize the importance of clinical suspicion and early radiology for an early diagnosis of this entity, which make it possible to establish an efficient treatment.

Adult↗

PubMed1990

Clear cell hidradenoma. A case report.

A case of clear cell hidradenoma occurring on the medial aspect of the first metatarsophalangeal joint of the right foot was presented. Common clinical data and histologic presentation were discussed. Although an infrequent tumor of the foot, this tumor should be included in a differential diagnosis of soft tissue tumors.

Adenoma, Sweat Gland↗

PubMed1999

Human leukocyte antigen polymorphisms in the Taiwanese population.

Polymorphisms of human leukocyte antigens (HLA) are important in transplantation medicine, anthropologic studies, and paternity testing. We investigated the polymorphisms of HLA classes I and II in the Taiwanese population by means of serologic typing and polymerase chain reaction (PCR) analysis with sequence-specific primers. We calculated the HLA-A, -B, and -C gene frequencies in 673 Taiwanese subjects and the HLA-DRB1, and HLA-DQB1 gene frequencies in 204 subjects with available DNA samples. Haplotype frequencies and linkage-disequilibrium were analyzed on the basis of these data. The common HLA class I antigens were A11 (gene frequency, 34.9%), A2 (29.3%), A24 (15.8%), and A33 (9.8%); B60 (21.9%), B46 (13.1%), B58 (9.7%), and B13 (8.5%); and Cw1 (18.8%), Cw7 (15.3%), and Cw10 (10.7%). The common HLA-DRB1 and HLA-DQB1 alleles were DRB1*12 (15.2%), DRB1*09 (15.2%), DRB1*08 (12.0%), and DRB1*04 (12.0%); and DQB1*0301 (23.5%), DQB1*0303 (15.2%), DQB1*0601 (14.5%), and DQB1*02 (10.8%). The common two-locus haplotypes were A2-B46 (frequency, 9. 7%), A11-B60 (9.6%), and A33-B58 (6.8%); DRB1*09-DQB1*0303 (14.9%), DRB1*12-DQB1*0301 (14.2%), and DRB1*08-DQB1*0601 (10.7%). This study is the first to report the gene frequencies of HLA-DQB1 alleles and the common HLA-DR-DQ haplotypes among Taiwanese. Comparison of our results with those from two other Chinese populations in mainland China reveals that Taiwanese are more closely related to southern Han than to northern Han Chinese.

China↗

PubMed1999

Ostomy care: foundation for teaching and practice.

Current approaches to ostomy management evolved from the extensive experience of surgeons, enterostomal therapy nurses, staff nurses, patients, and manufacturers. Advances in surgical techniques in the 1950's led to decreased morbidity and mortality previously associated with ostomy surgery. With these advances, a corresponding demand emerged to meet the rehabilitative needs of these patients by providing significant physical and psychological support. The birth of enterostomal therapy in 1958 focused interest, energy, and resources on this important area of patient care. Today's tradition-based practice continues to go a long way in meeting the physical and psychological needs of individuals undergoing ostomy surgery. However, in this era of managed care, shrinking healthcare dollars, and standardized guidelines, care practices not derived from evidence or consensus may jeopardize a patient's access to appropriate interventions and supplies. An exhaustive review of the literature revealed a paucity of ostomy-related research. The effectiveness of preoperative stoma site selection, prevention, care, and treatment of peristomal skin problems; and pouch selection and wearing times revealed a wealth of empirical evidence, but little or no objective data supporting commonly accepted interventions. The care of individuals with urinary and fecal diversions is both an art and a science. Evidence-based practice is needed to provide a firm foundation from which the art of individualized patient care can flourish. Research related to pre- and postoperative care and rehabilitation of individuals with ostomies can only serve to improve education, continuity of care, reimbursement, and most importantly, optimize patient care.

Education, Nursing, Continuing↗

PubMed1995

Quality assurance in clinical neurophysiology: the ESTEEM project example.

This paper describes the current status of the utilisation of clinical practice guidelines (protocols) in the ESTEEM project as one form of the clinical quality assurance procedures considered in the project. The performance of electrodiagnostic studies, in terms of which types of conclusions need to be inferred during the examination plan, is briefly described. The main focus of the paper is a description of an European multicentre clinical audit in the field of Clinical Neurophysiology, using a common data-entry protocol for prospective EMG case collection and assessment with the ultimate objective of building up a multicentre reference database of EMG cases.

Computer Communication Networks↗

PubMed1999

[Effect of anesthetics on the function of the gastrointestinal tract].

In spite of numerous interactions between the gut and the entire organism, today's knowledge in this field is still limited. In intensive care patients, reduced gastrointestinal perfusion and motility result in sequestration of fluids and translocation of bacteria and endotoxins, and the immunological function of the gut is depressed. To prevent gastrointestinal organ failure, early restitution of enteral nutrition is a main goal in intensive care medicine. Thus, the influence of anaesthetics on gut function is of special importance in analgosedation of intensive care patients. Pharmacological data of common anaesthetics allow judgement of their global effects on the gut. Interactions with opioid receptors of the enteral nerve system and systemic effects on the vegetative nerve system are of special interest. The results of in vitro and clinical studies show profound negative effects of opiods on gastrointestinal motility. Piritramide seems to be excluded from this judgement, but further studies with equipotent analgetic doses, when compared with fentanyl, are necessary. Ketamine is an analgetic alternative without relevant negative effects on gastrointestinal motility. Among the sedative components of analgosedation, midazolam, gamma-hydroxy butyric acid and probably propofol are useful, whereas barbiturates seem to have negative effects. Epidural anaesthesia with local anaesthetics is of additional benefit.

Anesthetics↗