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PubMed2005

Improving access of associated states to advanced concepts in medical telematics--a day before the accession to EU.

Central and Eastern Europe countries (CEEC) undertook considerable efforts to include themselves in the main research and development activities in the area of health telematics in Europe. Countries of this region demonstrate diversified environments of economy transformation and health care systems status. The transition phase to market economy brings essential risks to the healthcare system performance. It seems that efforts of developing e-health environment in CEEC could be substantially accelerated by extended co-operation with partners from current member states of the European Union. The PRO-ACCESS project was initiated in the late phase of fifth Framework Programme as supporting action. It focused on the transfer of current concepts in medical telematics to countries remaining in the pre-accession phase. The process of dissemination of up-to-date approaches to e-health environment development is carried out by the Krakow Centre of Telemedicine and is supported by leading health telematics centres in Europe. To accelerate the dissemination activities the network of co-operating centres in CEEC was established. The strategy employed within the PRO-ACCESS project is supposed to yield "critical mass" necessary for facilitating the e-health development in this region of Europe. The activities employed to reach this objective included publishing activities, events and trainings as well as intake of solutions from supporting centres.

Database Management Systems↗

PubMed2000

Reaction centre accessibility. II. Role of reaction centre congestion in the calculation of reaction centre accessibility

Accessibility to reaction centres is as important as electronic reactivity in determining the success of a reaction. The possibility of its calculation becomes a necessary requisite in the prediction of reaction products. Using a recently proposed approach to the calculation of reaction centre congestion based on a two dimensional representation of molecules, a new system has been realised that can quickly evaluate the desired accessibility. The system is based on the simulation of the steric interaction between reactants in different orientations. The calculation of an interaction energy for each orientation and their combination permits the approximate estimation of the reaction probability for the steric factors concerned. Even though all the operations were performed using a two-dimensional representation the results are encouraging. It is obvious that at this level it is impossible to predict face accessibility preference.

Journal Article↗

PubMed2003

The LifeSite Hemodialysis Access System in patients with limited access.

OBJECTIVE: The LifeSite Hemodialysis Access System was recently introduced as a completely subcutaneous device with reported advantages of improved patient comfort and reduced catheter-related infection. The performance of the LifeSite catheter at a single, tertiary-care university medical center was reviewed. METHODS: We retrospectively reviewed all patients who underwent placement of the LifeSite catheter between February 2001 and March 2002. Kaplan-Meier analysis was used to determine the probability of patient survival, freedom from catheter-related infection, and freedom from device failure necessitating catheter removal. RESULTS: Thirty-six patients who had previously received dialysis for an average of 6.1 years underwent placement of 37 LifeSite catheters. Most patients (95%) were referred for LifeSite placement because they had exhausted all available arteriovenous fistula and graft sites. Mean follow-up was 6.8 months, with a patient survival rate of 81% at 8 months. Primary and secondary patency rates were 62% and 87% at 8 months, respectively. Two patients died from infectious device-related complications. Twelve of 17 patients (71%) with device-related infection did not manifest any signs or symptoms at the valve site. There were 2.4 catheter-related infections and 2.6 device failures requiring removal per 1000 patient-catheter days. Freedom from infection and device removal at 8 months was 46% and 49%, respectively. CONCLUSIONS: The LifeSite demonstrated acceptable patency, infection, and device failure rates; however, in patients with limited access, unrecognized infection and death may occur. The LifeSite should not be used as a substitute for a more permanent form of hemodialysis access.

Bacterial Infections↗

PubMed2005

[Alternate hemodialysis catheterization access in patients with occluded peripheral venous access sites].

PURPOSE: The goal of this study was to evaluate translumbar and transhepatic placement of hemodialysis (HD) catheters for patients with occlusion of the veins that are commonly used for hemodialysis access. METHOD: Over a 12-month period three translumbar and one transhepatic hemodialysis catheters were placed in 4 patients suffering from end-stage renal disease, who had thrombosis of the upper and lower extremity veins as well as the jugular veins. The percutaneous access was performed under fluoroscopic guidance. After successful passage of a guidewire into the right atrium and creation of a subcutaneous tunnel at the skin entry site, all patients received a 14 F double-lumen catheter that was placed with its tip in the right atrium. RESULTS: Percutaneous translumbar and transhepatic placement of the HD catheters was successful in all patients. No intervention-associated complications were observed. Hemodialysis could be started 1 to 20 hours after initial catheter placement in all patients. During an observation period of 3 to 7 months, 3 patients underwent hemodialysis without any complications. In one patient, an occlusion of an translumbar HD catheter was observed after 5 months. This catheter could be temporarily recanalized using rTPA injection and was then exchanged after 6 months. CONCLUSION: Transhepatic and translumbar placement of HD catheters is a safe and viable alternative for patients who have exhausted conventional venous access sites.

Adult↗

PubMed2004

Static intra-access pressure ratio does not correlate with access blood flow.

BACKGROUND: Access flow (Qa) measurement is recommended by Kidney Disease Outcomes Quality Initiative (K/DOQI) as the preferred method for access surveillance. Static intra-access pressure ratio (SIAPR) measurement is the second surveillance method of choice. The purpose of this prospective multicenter study was to investigate the relationship between SIAPR and Qa and to examine the premise upon which SIAPR surveillance is based-namely, that high SIAPR is a surrogate for low Qa associated with hemodynamically significant stenosis. METHODS: SIAPR and Qa (HD01; Transonic Systems, Inc., Ithaca, NY, USA) were simultaneously measured monthly in 242 patients [146 prosthetic arteriovenous bridge grafts (AVG), 96 autogenous arteriovenous fistulas (AVF)] from three centers. SIAPR was measured according to the K/DOQI protocol. RESULTS: There was no correlation between Qa and venous or arterial SIAPR in AVGs (R(2)= 0.0037 and R(2)= 0.006, respectively, N= 730), or in AVFs (R(2)= 0.0247 and R(2)= 0.0329, respectively, N= 431). Of the high SIAPR measurements in AVGs, 81% and 50% were associated with Qa > or =600 and Qa > or =1000 mL/min, respectively. Of the AVGs studied, 41% (60/146) had consistently high Qa > or =1000 mL/min. Seventy percent (42/60) of these high-Qa AVGs had at least two consecutive sessions with high SIAPR measurements, thereby meeting the K/DOQI SIAPR criteria for referral. In addition, 78% (14/18) of new AVGs with Qa > or =1000 mL/min, and 86% (6/7) of AVGs with the highest Qa (> or =2000 mL/min), had high SIAPR. As a result, these high-Qa AVGs, which represented the best functioning AVGs by K/DOQI Qa standards, were erroneously targeted for referral based on SIAPR measurements. CONCLUSION: SIAPR does not correlate with Qa or discriminate between high and low Qa. Therefore, because the utility of SIAPR surveillance for detection of clinically significant stenosis depends on a correlation with Qa, the current use of absolute K/DOQI SIAPR thresholds for intervention based on the presumption that such thresholds are indicative of low Qa is not justified, and should be discontinued. Studies need to be done to examine the utility of SIAPR for trend analysis.

Arteriovenous Shunt, Surgical↗

PubMed1997

Creating integrated service systems for homeless persons with mental illness: the ACCESS Program. Access to Community Care and Effective Services and Supports.

The Access to Community Care and Effective Services and Supports (ACCESS) demonstration program was initiated in 1993 by the U.S. Department of Health and Human Services as part of a national agenda to end homelessness among persons with serious mental illness. Demonstration projects have been established in nine states to develop integrated systems of care for this population. This paper provides an overview of the ACCESS program and presents definitions of services integration and systems integration. Evaluating the effectiveness of integration strategies is a critical aspect of the program. The authors describe the evaluation design and the integration strategies being evaluated and summarize findings from a formative evaluation of the project's first two years. The evaluation revealed several problems that were addressed by providing technical assistance to the states. States were helped to articulate a broader mission of addressing system-level barriers, develop an expanded plan, strengthen the authority of interagency councils, involve leaders at the state and agency levels, and develop joint funding strategies.

Adult↗

PubMed2002

Ins and outs of enteral access. Part 1: short-term enteral access.

Proper selection of the type of enteral access in a given clinical situation is important to maximize the benefit to the patient and minimize the discomfort to the patient, the morbidity and mortality, and the cost. This decision is based on whether or not the patient needs short-term (<4-6 weeks) or long-term enteral nutrition support. This article focuses on short-term access including nasogastric (NG) and nasoenteric (NE) tubes and reviews each of these enteral access tubes along with their indications, contraindications, advantages, and disadvantages.

Journal Article↗

PubMed2005

The Smartcanula: a new tool for remote access perfusion in limited access cardiac surgery.

Devices for venous cannulation have seen significant progress over time: the original, rigid steel cannulas have evolved toward flexible plastic cannulas with wire support that prevents kinking, very thin walled wire wound cannulas allowing for percutaneous application, and all sorts of combinations. In contrast to all these rectilinear venous cannula designs, which present the same cross-sectional area over their entire intravascular path, the smartcanula concept of "collapsed insertion and expansion in situ" is the logical next step for venous access. Automatically adjusting cross-sectional area up to a pre-determined diameter or the vessel lumen provides optimal flow and ease of use for both, insertion and removal. Smartcanula performance was assessed in a small series of patients (76 +/- 17 kg) undergoing redo procedures. The calculated target pump flow (2.4 L/min/m2) was 4.42 +/- 61 L/ min. Mean pump flow achieved during cardiopulmonary bypass was 4.84 +/- 87 L/min or 110% of the target. Reduced atrial chatter, kink resistance in situ, and improved blood drainage despite smaller access orifice size, are the most striking advantages of this new device. The benefits of smart cannulation are obvious in remote cannulation for limited access cardiac surgery, but there are many other cannula applications where space is an issue, and that is where smart cannulation is most effective.

Cardiac Surgical Procedures↗

PubMed1999

Defining organ involvement in sarcoidosis: the ACCESS proposed instrument. ACCESS Research Group. A Case Control Etiologic Study of Sarcoidosis.

BACKGROUND: Sarcoidosis is a multiorgan granulomatous disease of unknown cause. Lack of an objective system for assessment of sarcoidosis to evaluate disease course and effectiveness of therapy is a major problem. METHODS: The sarcoidosis assessment instrument was developed by the Steering Committee of A Case Control Etiologic Study of Sarcoidosis (ACCESS) which included investigators at the ten ACCESS Clinical Centers, the Clinical Coordinating Center, and representatives of the National Heart, Blood, and Lung Institute. This system was developed to assess sarcoidosis organ involvement in ACCESS patients who would be followed over a two-year period. The system represents a consensus of opinions of members of the Steering Committee based on review of their experience and the medical literature. RESULTS: Criteria for involvement in patients with biopsy-confirmed sarcoidosis are presented for organs and systems that are commonly involved (lung, skin, eyes, liver, calcium metabolism), unusual but clinically important (nervous system, kidney, heart) and other sites (non-thoracic lymph nodes, bone marrow, spleen, bone/joint, ear/nose/throat, parotid/salivary glands, muscles). CONCLUSION: The proposed instrument is partially subjective in that it depends upon the clinician's diligence in pursuing evidence for sarcoidosis involvement of various organs. It is hoped that this instrument will lead to increased standardization in the definition of sarcoidosis organ involvement to help clinicians and researchers better characterize patients with sarcoidosis.

Bone Diseases↗

PubMed2002

When debiasing backfires: accessible content and accessibility experiences in debiasing hindsight.

Two studies demonstrated that attempts to debias hindsight by thinking about alternative outcomes may backfire and traced this to the influence of subjective accessibility experiences. Participants listed either few (2) or many (10) thoughts about how an event might have turned out otherwise. Listing many counterfactual thoughts was experienced as difficult and consistently increased the hindsight bias, presumably because the experienced difficulty suggested that there were not many ways in which the event might have turned out otherwise. No significant hindsight effects were obtained when participants listed only a few counterfactual thoughts, a task subjectively experienced as easy. The interplay of accessible content and subjective accessibility experiences in the hindsight bias is discussed.

Analysis of Variance↗

PubMed2004

Intra-access blood flow in patients with newly created upper-arm arteriovenous native fistulae for hemodialysis access.

BACKGROUND: The upper-arm native arteriovenous fistula for hemodialysis (HD) vascular access is an important option in the long-term HD population. This single-center cohort study evaluated intra-access blood flow (Q AC) in 3 variants of newly created upper-arm fistulae. METHODS: Fifty-three patients with mature, working, upper-arm fistulae composed of brachial artery to cephalic vein (n = 27), brachial artery to basilic vein (n = 13), and brachial artery to median antecubital vein (n = 13) fistulae were included. Nine of 13 brachio-median antecubital fistulae were of the Gracz type and used the deep perforating vein. Q AC was measured by means of ultrasound velocity dilution during HD. In brachio-median antecubital fistulae, additional flow in the alternate draining vein was measured by means of duplex ultrasound, with 9 of 11 studied patients showing a patent alternate outflow, of whom 7 patients showed substantial flow (median, 0.7 L/min). RESULTS: Q AC in the HD-used primary vein in brachio-median antecubital fistulae (0.85 L/min) was significantly less than those of brachiocephalic and brachiobasilic fistulae (1.4 and 1.7 L/min, respectively). However, when the additional flow provided by the patent alternate vein in brachio-median antecubital fistulae was considered, flow rates provided by all 3 variants of fistulae appeared similar. The inverse correlation between alternate-vein and primary-vein flows (r = -0.70; P = 0.017) suggested there was competitive flow between the 2 venous outlets. There was no instance of access recirculation. CONCLUSION: Upper-arm fistulae, regardless of type, provide excellent blood flows and should be considered routinely if a wrist fistula is not feasible. The patent alternate vein in the brachio-median antecubital or Gracz fistula may continue to drain a substantial amount of blood.

Adult↗

PubMed1988

An evaluation of expanded polytetrafluoroethylene (PTFE) loop grafts in the thigh as vascular access for haemodialysis in patients with access problems.

A total of 21 patients with vascular access problems received 22 PTFE loop grafts in the thigh as vascular access for haemodialysis. Eighteen of 22 grafts supported haemodialysis during the patients' lifetime. Actuarial patient survival was 50% at 2 years with a cumulative graft patency in the survivors of 80.5%. Although early thrombosis has been a problem, no graft has been lost from infection. We feel that these results are encouraging enough to recommend the use of PTFE grafts in the thigh of patients with vascular access problems.

Adolescent↗

PubMed1984

[Chronology of vascular access in hemodialysis. Apropos of 244 accesses in 150 hemodialysis patients].

Out of an experience of 244 vascular access in 150 patients the authors try do find the best chronology of the angioaccess procedures. 68% of the patients see their need in vascular access definitely resolved by the first classical forearm internal arterio-venous fistula and everything must be done in the dialysis population to avoid the failure of the fistula. This would lead to internal shunt procedures using graft materials of which we know the limited potency, leading to periodic operations. Emergency situations are approached by use of the femoral vein catheterization for hemodialysis. Only the impossibility of femoral or jugular catheterization would lead to the use of the external A.V. Shunt which would be placed on the leg to preserve the vessels of the arms. For some patients the repeated failure of the successive A.V. fistula and shunts have drived us towards either peritoneal dialysis or "hemasite" vascular access system.

Acute Kidney Injury↗

PubMedDate not supplied

Venous access device study: identification of number of patients with venous access device lines.

As part of the Quality Assurance and Improvement Process, the need to determine the number and location of patients having venous access devices in a 600-bed tertiary care facility was identified. In the overall study, 167 patients on 18 wards had venous access device lines in place for a total of 455 weeks. As a direct result of the study, policies/procedures and other practice changes regarding patients with venous access devices have been reviewed and revised. Furthermore, the data helped to provide an in-depth look at the central-line issues for patient care.

Catheterization, Central Venous↗

PubMed1994

Random and continuous-access immunoassays with chemiluminescent detection by Access automated analyzer.

The Access Immunoassay System is an automated random and continuous-access analyzer for use with heterogeneous enzyme immunoassays. The instrument stores refrigerated reagent packs for as many as 24 different immunoassays. Throughput is 50-100 tests per hour. One- and two-step, and sandwich and competitive formats, each with various incubation times, can be accommodated, and sample sizes can vary from 10 to 200 microL. A paramagnetic microparticle solid phase combines with a chemiluminescent substrate for signal generation. Within-run CVs for noninfectious disease assays were 2.0% to 9.2%; total CVs were 3.4% to 11.1%. Regression analysis of method comparison studies with established procedures yielded slopes of 0.84 to 1.12 and correlation coefficients > or = 0.94 for 12 of 14 assays (range 0.83-0.99). Compared with culture methods, the Access assay for Chlamydia in urogenital specimens demonstrated sensitivity, specificity, and positive and negative predictive values of 90%, 99.7%, 95%, and 99%, respectively.

Autoanalysis↗

PubMed1998

Adolescents' access to care: teenagers' self-reported use of services and perceived access to confidential care.

BACKGROUND: Most surveys on adolescents' use of health services rely on parental report, and this may underestimate adolescents' use of confidential services. OBJECTIVE: To investigate adolescents' report of their own use of health services, access to care, and knowledge and use of confidential services. METHOD: A random digit-dialed survey of 14- to 19-year-old adolescents was conducted in Monroe County, New York. We screened 11 800 numbers and identified 4449 households (40%) of which 393 families (8.8%) had eligible adolescents. Of these, 259 (66%) consented and completed an interviewer-administered survey. RESULTS: Almost all adolescents (92%) rated their health as excellent or good and 90% had visited a health care provider within the year. Most (88%) identified a source of primary care. As many as 27% of adolescents had used more than one source of care. Many youth identify school personnel as important resources for health and counseling needs. Only 8.4% of respondents have used services confidentially, but nearly half of all youth did not know where they could obtain confidential care if they needed to. Adolescents were least likely to know where to obtain mental health or substance abuse and reproductive services. CONCLUSIONS: While most youth have used primary care, a substantial minority have not. Many teenagers depend on multiple sources of care, and they rely on school personnel as important sources of health information. Many do not know where they could go to review confidential services or for other services that they may need. Managed care insurance and public health policies should recognize adolescents' access needs to meet them appropriately.

Adolescent↗

PubMed1999

Case management models for persons who are homeless and mentally ill: the ACCESS demonstration project. Access to Community Care and Effective Services and Supports.

Persons who are homeless and mentally ill present unique challenges to service providers and human service systems. In vivo case management approaches such as assertive community treatment (ACT) have shown promise in engaging this population. This paper explores case management models employed within the ACCESS program, a five year, 18-site demonstration program enriching services for homeless persons with serious mental illness. We describe the implementation of case management with ACCESS programs and determine the extent of variation across sites using a measure of fidelity to ACT. While programs reported using four models, much similarity was found among programs on multiple dimensions.

Case Management↗

PubMedDate not supplied

Increasing access to dental care for medicaid preschool children: the Access to Baby and Child Dentistry (ABCD) program.

OBJECTIVE: Washington State's Access to Baby and Child Dent stry (ABCD) Program, first implemented in Spokane County in 1995, offers extended dental benefits to participating Medicaid-enrolled children and higher fees for certified providers. This study aimed to determine the program's effect on children's dental utilization and dental fear, and on parent satisfaction and knowledge. METHODS: The study used a posttest-only comparison group design. Trained interviewers conducted telephone interviews with 465 parents of chi dren ages 13 to 36 months (49% ABCD, 51% Medicaid-enrolled children not in ABCD). One year later, 282 of 465 parents completed a follow-up survey. Utilization and expenditures were calculated from Medicaid claims. RESULTS: Forty-three percent of children in the ABCD Program visited a dentist in the follow-up year, compared with 12% of Medicaid-enrolled children not in the ABCD Program. An ABCD child was 5.3 times as likely to have had at least one dental visit as a child not in the program. ABCD children were 4 to 13 times as likely to have used specific dental services. Parents of ABCD children were more likely to report having ever tried to make a dental appointment, less likely to report that their children were fearful of the dentist, and were more satisfied, compared to parents of non-ABCD children. CONCLUSION: The authors conclude that the ABCD Program was effective in increasing access for preschool children enrolled in Medicaid, reducing dental fear, and increasing parent satisfaction.

Child, Preschool↗