Factors Associated with Hemodialysis Vascular Access Failure: A retrospective study in Colombia

Introduction: Vascular access (VA) remains a major source of morbidity for hemodialysis patients (HD). Few data sources adequately capture longitudinal patency of the VA. This study aimed to evaluate VA failure and its related factors in HD patients. Methods: A retrospective cohort study of 985 incident hemodialysis patients treated in clinics of BRCS in Colombia, from January 1rst ,2016, until December 3 of the same year, was done. The cohort's enrollment was on day 1 of HD, and with follow-up for up to 15 months. Association among a group of independent variables and time to failure of the VA was performed, and adjusted by baseline variables using a Cox regression model. Results: A total of 985 patients were included in the study, requiring 1774 procedures of vascular access during follow-up. The mean age was 61 ± 15.6 years. At day 1, 15 % were dialyzing with an arteriovenous fistula (AVF) or AVG; and at day 90, this proportion had increased to 70 %. The rate of vascular access procedure was 1.95 per patients-year, 95 % CI 1.86-2.04. The rate of vascular access failure was 0.66 per patients-year, 95 % CI 0.61-0.72. Risk factors for failure in AVF/AVG were age > 65 (p= 0.008), diabetes (p=0.019), female sex (p=0.002) rural housing (p<0.0001) and higher hemoglobin (p=0.021). Conclusions: Vascular access failure and the requirement for procedures associated with it are frequent in the dialysis population. Several risk factors, some of them modifiable, are related to vascular access failure.

Introducción: El acceso vascular (AV) sigue siendo una fuente importante de morbilidad para los pacientes en hemodiálisis (HD). Pocas fuentes de datos capturan adecuadamente la permeabilidad longitudinal del AV. Este estudio tiene como objetivo evaluar la falla del AV y los factores relacionados en pacientes en HD. Métodos: Se realizó un estudio de cohorte retrospectivo de 985 pacientes incidentes a hemodiálisis tratados en clínicas de BRCS en Colombia, entre el 1ro de enero de 2016, al 31 de diciembre de 2016. La incepción de la cohorte fue el día 1 de HD y con un seguimiento de hasta 15 meses. Se realizó la asociación entre un grupo de variables independientes y el tiempo hasta la falla del AV, asimismo se ajustó por variables basales mediante un modelo de regresión de Cox. Resultados: Se incluyeron en el estudio un total de 985 pacientes que requirieron 1774 procedimientos de AV durante el seguimiento. La edad media fue de 61 ± 15,6 años. En el día 1, el 15 % se dializaba con una fístula arteriovenosa (FAV) o injerto arteriovenoso (IAV); y al día 90, esta proporción había aumentado al 70 %. La tasa de procedimiento de acceso vascular fue de 1,95 por paciente-año, IC 95 % 1,86-2,04. La tasa de falla del AV fue de 0,66 por paciente-año, IC del 95 %: 0,61-0,72. Los factores de riesgo para falla del AV en FAV/IAV fueron edad > 65 años (p= 0,008), diabetes (p= 0,019), sexo femenino (p= 0,002), vivienda rural (p<0,0001) y hemoglobina elevada (p=0,021). Conclusión: La falla del acceso vascular y el requerimiento de procedimientos asociados a ella, son frecuentes en la población en diálisis. Varios factores de riesgo, algunos de ellos modificables, están relacionados con la falla del acceso vascular.

Analysis of price variation of some commonly used antibacterial agents

Background: Antimicrobial resistance is a serious problem. Resistance may develop due to irrational use including poor patient compliance due to prescription of expensive drugs. In present study, the variation in the price of commonly used antibacterial was analysed.Methods: The price of commonly used antibacterial agents listed in recent issues of CIMS and MIMS was analysed in respect of number of brands available, price range (10 tablets or capsules) and 1 ampoule or vial (parenteral preparation) i.e. minimum, maximum and average price and price ratio (maximum/minimum). FDCs and formulation with only 1-2 brands were excluded.Results: The number of brands of oral antibacterial agents varied from 3 (faropenem 200 mg) to 90 (azithromycin 500 mg). The maximum price variation amongst different brands was 21.64 for levofloxacin 500 mg followed by 14.28 and 11.26 for linezolid 600 mg and moxifloxacin 400 mg respectively. For parenteral preparations, the number of brands varied from 2 (gentamicin 80 mg) to 57 (ceftriaxone 1 g). The maximum price variation was 5.05 for meropenem 1 g followed by 3.69 and 2.63 for meropenem 500 mg and ceftriaxone 1 g respectively.Conclusions: A very wide price variation was observed amongst different brands of both oral and parenteral formulations of antibacterial agents. Prescribing expensive brands may lead to resistance due to poor patient compliance.

Health care quality improvement for cardiovascular surgery in China: the perspectives and initiatives / 中国胸心血管外科临床杂志

@#The cardiovascular surgery in China has reached a stable platform, with notable progress been achieved in the past several decades. However, significant divergency regarding the healthcare quality was also observed, which requiring effective intervention to start the transition from the focus on "quantity" to the pursuit of "quality". Quality improvement program, including the establishment of a national cardiovascular surgery database, the conformation of a standard key quality evaluation indicator system, and the conduction of quality intervention and improvement initiatives, are promising to consolidate and expand the advantages of cardiac surgery and lead to better patient outcomes.

Patient Concerns Inventory for head and neck cancer: Brazilian cultural adaptation / Inventário de Preocupações dos Pacientes com câncer de cabeça e pescoço: adaptação cultural brasileira

Summary Objective: The purpose of this study was to translate, culturally validate and evaluate the Patients Concerns Inventory - Head and Neck (PCI-H&N) in a consecutive series of Brazilian patients. Method: This study included adult patients treated for upper aerodigestive tract (UADT) cancer. The translation and cultural adaptation of the PCI-H&N followed internationally accepted guidelines and included a pretest sample of patients that completed the first Brazilian Portuguese version of the PCI. Use, feasibility and acceptability of the PCI were tested subsequently in a consecutive series of UADT cancer patients that completed the final Brazilian Portuguese version of the PCI and a Brazilian Portuguese version of the University of Washington Quality of Life Questionnaire (UW-QOL). Associations between physical and socio-emotional composite scores from the UW-QOL and the PCI were analyzed. Results: Twenty (20) patients participated in the pretest survey (translation and cultural adaptation process), and 84 patients were analyzed in the cultural validation study. Issues most selected were: fear of cancer returning, dry mouth, chewing/eating, speech/voice/being understood, swallowing, dental health/teeth, anxiety, fatigue/tiredness, taste, and fear of adverse events. The three specialists most selected by the patients for further consultation were speech therapist, dentist and psychologist. Statistically significant relationships between PCI and UW-QOL were found. Conclusion: The translation and cultural adaptation of the PCI into Brazilian Portuguese language was successful, and the results demonstrate its feasibility and usefulness, making this a valuable tool for use among the Brazilian head and neck cancer population.

Resumo Objetivo: O objetivo deste estudo foi traduzir, adaptar culturalmente e avaliar o Inventário de Preocupações dos Pacientes - Cabeça e Pescoço (IPP-CP) em uma série consecutiva de pacientes brasileiros. Método: Este estudo incluiu pacientes adultos tratados por câncer do trato aerodigestivo superior (TADS). A tradução e a adaptação cultural do IPP-CP seguiram diretrizes internacionalmente aceitas e incluíram uma amostra piloto de pacientes que completaram a primeira versão em português do IPP-CP. O uso, a viabilidade e a aceitabilidade do IPP-CP foram testados posteriormente, em uma série consecutiva de pacientes com câncer do TADS que completaram a versão final em português do PCI e uma versão em português do questionário de qualidade de vida da Universidade de Washington (UW-QOL). As associações entre os escores físicos e socioemocionais do UW-QOL e do IPP foram analisadas. Resultados: Vinte pacientes participaram da pesquisa piloto (processo de adaptação cultural e tradução), e 84 pacientes foram analisados no estudo de validação cultural. As questões mais selecionadas foram: medo de o câncer voltar, boca seca, mastigação/comer, fala/voz/ser compreendido, deglutição, saúde dental/dentes, ansiedade, fadiga/cansaço, paladar e medo de eventos adversos. Os três especialistas mais selecionados foram fonoaudiólogo, dentista e psicólogo. Relações estatisticamente significativas entre IPP e UW-QOL foram encontradas. Conclusão: A tradução e a adaptação cultural do IPP para o português foram bem-sucedidas, e os resultados demonstram a viabilidade e a utilidade da ferramenta, tornando-a valiosa para uso na população brasileira com câncer de CP.

Early Neurologic Deterioration after Stroke Depends on Vascular Territory and Stroke Etiology / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Early neurologic deterioration (END) occurs in up to one-third of patients with ischemic stroke and is associated with poor outcomes. The purpose of the present study was to determine which stroke etiologies and vascular distributions pose a greater threat of END in stroke patients. METHODS: Using a single-center registry of prospectively maintained clinical data, adult ischemic stroke patients admitted (July 2008 to June 2014) within 48 hours of symptom onset were evaluated according to stroke etiology and vascular distribution using diffusion-weighted MRI. Major stroke etiologies were divided into cardioembolic, large vessel, small vessel, other, unknown source, and multiple possible etiologies. END was defined as a worsening of 2 or more points on the National Institutes of Health Stroke Scale during a 24-hour period of hospitalization. Crude and backward stepwise regression models were generated to associate stroke etiology and vascular distribution with END. RESULTS: Of the included 961 patients (median age 65 years, 47% female, 72% non-White), 323 (34%) experienced END. Strokes involving the internal carotid artery (ICA) were associated with a threefold higher odds of END in stepwise regression models (OR 3.0, 95% CI 1.4-6.6, P=0.006). Among stroke etiologies, those with unclear mechanisms had the lowest odds of END in the fully adjusted model (OR 0.6, 95% CI 0.4-1.0, P=0.029). CONCLUSIONS: In our single-center cohort of patients, ICA infarctions were independently associated with END whereas strokes of unknown etiology were least often associated with END. Larger cohorts are necessary to determine which steps, if any, can be taken to prevent END in these vulnerable populations.

A importância do desfecho em ortopedia e traumatologia: traduzindo pesquisa em prática clínica / Outcomes in orthopedics and traumatology: translating research into practice

A pesquisa clínica tem como objetivo final gerar evidência factível paraa aplicação cotidiana. No entanto, traduzir os resultados de pesquisabaseada em evidências em prática clínica pode ser desafiador. Opresente estudo tem como objetivo salientar estes desafios, sugerire revisar ferramentas metodológicas de boas práticas, tendo comoexemplo tratamentos com plasma rico em plaquetas para lesões musculotendínease também o atual estado da arte do tratamento daslesões osteocondrais. Exploramos estudos e revisões sistemáticasenvolvendo os seguintes conceitos: diferenças clinicamente relevantes,erros sistemáticos, cálculo amostral, validade interna e externa. Autorese clínicos devem considerar estes conceitos para a execução e aplica-ção das melhores evidências. Deve-se contrabalancear os resultadosde pesquisa por meio de uma análise ponderada de sua robustezmetodológica e aplicabilidade prática. Nível de Evidência V, EstudosTerapêuticos - Investigação dos Resultados do Tratamento...

Clinical research is focused in generating evidence that is feasible tobe applicable to practitioners. However, translating research-focused evidenceinto practice may be challenging and often misleading. This articleaims is to pinpoint these challenges and suggest some methodologicalsafeguards, taking platelet-rich plasma therapies and knee osteochondralinjuries as examples. Studies and systematic reviews involving the followingconcepts will be investigated: clinically relevant outcomes, systematicerrors on sample calculation, internal and external validity. Relevant studieson platelet-rich plasma for muscle-tendon lesions and updates on osteochondrallesions treatment were included in this analysis. Authors andclinicians should consider these concepts for the implementation andapplication of dissemination of the best evidence. Research results shouldbe challenged by a weighted analysis of its methodological soundnessand applicability. Level of Evidence V, Therapeutic Studies - Investigatingthe Results of Treatment...

Diseño a doble ciego y el uso de placebos psicológicos en investigación de resultados en psicoterapia: Es posible? Un estudio piloto de viabilidad / Double blind design and the use of psychological placebos in outcomes research in psychotherapy: Is it possible? A pilot feasibility study

El uso de placebos y diseños a doble ciego ha cumplido un papel crucial en la investigación clínica en Medicina. Su aplicación a la investigación de resultados en psicoterapia ha sido controversial. Muchos autores niegan la posibilidad de su aplicación debido a que el terapeuta debería conocer la condición del procedimiento aplicado. Se presenta detalladamente un estudio en el que se utilizó un procedimiento placebo correspondiente a EMDR (Eye Movement Desensitization and Reprocessing- Desensibilización y Reprocesamiento por Movimientos Oculares) con un Diseño Experimental de Caso Único. Los objetivos fueron los siguientes: poner a prueba la viabilidad de la implementación de un placebo de tipo psicológico en EMDR y la aplicación de un diseño a doble ciego en el estudio de resultados en EMDR. Se seleccionaron tres pacientes que sufrían de Trastorno por Estrés Postraumático. Se estableció una línea de base de la sintomatología presentada. Luego, los sujetos fueron asignados aleatoriamente a tres condiciones experimentales durante tres sesiones: (a) aplicación del protocolo EMDR sin ningún tipo de estimulación con auriculares en silencio (placebo 1), (b) aplicación del protocolo EMDR con estimulación bilateral auditiva simultánea (no alternada) (placebo 2) y (c) aplicación del protocolo estándar de EMDR con estimulación auditiva bilateral alternada (tratamiento activo). Tales procedimientos resultaron igualmente creíbles para el paciente y para el terapeuta. Esto permitió el desarrollo de un diseño de investigación a doble ciego para la investigación de resultados en EMDR. Finalmente, se discuten algunas posibles aplicaciones e implicancias de la introducción del uso de placebos psicológicos y diseño a doble ciego en la investigación en psicoterapia.

Double blind design and placebos have been of crucial importance in medical clinical research. Their use in outcomes research in the field of psychotherapy has been controversial, though. Their feasibility in such case has been denied by many authors based on the assumption that the psychotherapist would need to know the nature of the applied procedure. In view of this, the author has conducted a pilot feasibility study on three subjects within the context of his doctoral dissertation. Said dissertation aims at establishing the role of alternating bilateral auditory stimulation in the processing of traumatic memories as used in the EMDR (Eye Movement Desensitization and Reprocessing) technique. To such end, the EMDR basic principles and procedures are introduced -with particular attention to alternating bilateral auditory stimulation- and a pilot study using placebos during EMDR administration is presented in detail. The goals of this study are testing the feasibility of: (a) using a psychological placebo in EMDR therapy, and (b) applying a double blind design study in EMDR outcomes research. A single case experimental design was performed on three different patients suffering from PTSD (Posttraumatic Stress Disorder). A symptomatology baseline was established through out three weekly sessions using the DTS (Davidson Trauma Scale) and the OQ-45.2 (Outcomes Questionnaire 45.2). First, three CDs were recorded -one with no sound at all (CD-1, silence condition); another one with auditory stimulation consisting of a tic-tac sound recorded in monaural condition, and reproduced simultaneously over both earphones at a rate of one beat per second (CD-2, monaural condition) and a third one with alternating bilateral auditory stimulation consisting of the exact same sound recorded in stereophonic condition, and reproduced alternatively over the left and right earphones (CD-3, stereo condition)-. At a second stage, these three experimental conditions were assigned randomly to the three subjects, who were administered: (a) EMDR protocol without any type of stimulation, with no sound coming out of the earphones using CD-1 (placebo 1), (b) EMDR protocol with simultaneous bilateral auditory stimulation using CD-2 (placebo 2), and (c) EMDR protocol with alternating bilateral auditory stimulation using CD-3 (active treatment). In all cases, the experimental conditions were implemented during three full sessions in which the CDs were reproduced for the subjects through earphones, instead of speakers, to ensure that the psychotherapist was unaware of the actual conditions. Subsequently, the standard EMDR protocol (i.e., with alternating bilateral auditory stimulation) was administered to each subject until the end of the treatment, determined either by the symptoms being resolved or the maximum of ten sessions being completed. As a result of this pilot study, the author concludes that the feasibility of using double blind studies and placebos in EMDR psychotherapy has indeed been established. Since no apparent difficulties in the administration of the placebos were detected during the study, the use of psychological placebos seems viable. Such procedure is equally credible for the patient as well as for the psychotherapist, which renders possible the development of a double blind design in EMDR outcomes research. It should be noted, though, that the credibility of the placebo was not formally assessed, but rather was perceived through the author’s informal observation. Developing assessment criteria and formal tools to evaluate the credibility of placebo procedures is advisable if future investigations on the subject are to be carried. Even though this study was conducted under a Single Case Experimental Design, the placebo procedure employed could be easily adapted for its use in between group’s designs. Finally, some of the possible applications and consequences regarding the introduction of placebos and double blind design in psychotherapy research are discussed.

Effects of Hospital Nurse Staffing on in-hospital Mortality, Pneumonia, Sepsis, and Urinary Tract Infection in Surgical Patients

PURPOSE: This study was done to examine relationships between nurse staffing level and postsurgical patient outcomes using inpatient database from the National Health Insurance. METHODS: Records of 111,491 patients who received one of 12 types of surgery between January and December, 2009 were identified and analyzed in this study. Nurse staffing level was measured using adjusted nurse staffing grades from 0 to 7. Patient outcomes were defined as in-hospital mortality, or pneumonia, sepsis, or urinary tract infection after surgery. Logistic regression analyses estimated by Generalized Estimation Model, were used to analyze the association between nurse staffing level and patient outcomes. RESULTS: An inverse relationship was found between nurse staffing and patient mortality. Compared with patients who were cared for in hospitals with the highest nurse staffing (Grades 0-1), increases in the odds of dying were found in those with Grades 6-7 [OR (odds ratio)=2.99, 95% CI (confidence interval)=1.94-4.60], those with Grades 4-5 (OR=1.78, 95% CI=1.24-2.57) and those with Grades 2-3 (OR=1.57, 95% CI=1.25-1.98). Lower nurse staffing level was also associated with higher number of cases in pneumonia and sepsis. CONCLUSION: Policies for providing adequate nurse staffing is required to enhance quality of care and lead to better perioperative patient outcomes.

Effect of Psychological Status on Outcome of Posterior Lumbar Interbody Fusion Surgery

STUDY DESIGN: Prospective longitudinal study. PURPOSE: To determine if preoperative psychological status affects outcome in spinal surgery. OVERVIEW OF LITERATURE: Low back pain is known to have a psychosomatic component. Increased bodily awareness (somatization) and depressive symptoms are two factors that may affect outcome. It is possible to measure these components using questionnaires. METHODS: Patients who underwent posterior interbody fusion (PLIF) surgery were assessed preoperatively and at follow-up using a self-administered questionnaire. The visual analogue scale (VAS) for back and leg pain severity and the Oswestry Disability Index (ODI) were used as outcome measures. The psychological status of patients was classified into one of four groups using the Distress and Risk Assessment Method (DRAM); normal, at-risk, depressed somatic and distressed depressive. RESULTS: Preoperative DRAM scores showed 14 had no psychological disturbance (normal), 39 were at-risk, 11 distressed somatic, and 10 distressed depressive. There was no significant difference between the 4 groups in the mean preoperative ODI (analysis of variance, p = 0.426). There was a statistically and clinically significant improvement in the ODI after surgery for all but distressed somatic patients (9.8; range, -5.2 to 24.8; p = 0.177). VAS scores for all groups apart from the distressed somatic showed a statistically and clinically significant improvement. Our results show that preoperative psychological state affects outcome in PLIF surgery. CONCLUSIONS: Patients who were classified as distressed somatic preoperatively had a less favorable outcome compared to other groups. This group of patients may benefit from formal psychological assessment before undergoing PLIF surgery.

Analysis of Nursing Records of Cardiac Surgery Patients Based on Nursing Process Focusing on Nursing Outcome / 대한의료정보학회지

OBJECTIVES: The objective of this study is to find out what nurses wrote in narrative nursing notes. METHODS: Forty-six patients' nursing notes were analyzed based on the nursing process. Eight patterns were extracted depending on the different combinations of the nursing process components. RESULTS: Of the 8 patterns, assessment only pattern was the most frequent comprising 45.8% and assessment or diagnosis-intervention-outcome patterns accounted for 25.9% of the total nursing phrases. The content of nursing notes was also classified into 15 categories. Out of these 15 categories, nursing outcomes were recorded more frequently in nursing care mainly driven by doctor's order such as diseases related symptom management, insomnia care, respiratory care and pain control than in independent nursing care such as education and emotional care. According to the survey on nurses' attitude toward nursing record, nurses did not document nursing outcome as much as they reported they did. The main reasons for this discrepancy were insufficient time for recording and lack of knowledge about why, how and what to evaluate. CONCLUSION: Even though there is room for improvement, nursing notes can be used a source for nursing contribution to patient outcomes.

Development of Nursing Information System for the Analysis of Nursing Intervention Effects on Patient Outcomes / 대한의료정보학회지

OBJECTIVE: Development of nursing documentation system is the first step as a way to do nursing effectiveness research and proving effectiveness of nursing care on patient outcomes to the other health care professionals as well as the public. METHODS: To develop nursing documentation system using nursing process model, the system incorporated standardized nursing terminologies of North American Nursing Diagnosis Association(NANDA), Nursing Interventions Classification(NIC), and Nursing Outcomes Classification(NOC). The system was developed under the hospital information system by TCP/IP protocol and used Oracle as DBMS under the Windows 98 environment. Power Builder 5.0 was used as a program language. RESULTS: First data model was created and served as the foundation for designing the user interface. And then the system was developed for collecting, storing, and retrieving nursing diagnoses, interventions, and outcomes and comparing the changes in patient outcomes before and after interventions performed. CONCLUSION: By developing nursing information system that includes nursing care sensitive patient outcomes, nurses can involve nursing effectiveness research and know how to improve nursing care quality provided for patients by analyzing patient outcome data. Further evaluation of this system should be followed.

Validation of Nursing Care Sensitive Outcomes related to Knowledge / 간호학회지

PURPOSE: The purpose of this study was to assess the importance and sensitivity to nursing interventions of four nursing sensitive nursing outcomes selected from the Nursing Outcomes Classification (NOC). Outcomes for this study were "Knowledge: Diet", "Knowledge: Disease Process", "Knowledge: Energy Conservation", and "Knowledge: Health Behaviors". METHOD: Data were collected from 183 nurses working in 2 university hospitals. Fehring method was used to estimate outcome and indicators' content and sensitivity validity. Multiple and stepwise regression were used to evaluate relationships between each outcome and its indicators. RESULT: Results confirmed the importance and nursing sensitivity of outcomes and their indicators. Key indicators of each outcomes were found by multiple regression. "Knowledge: Diet" was suggested for adding new indicators because the variance explained by indicators was relatively low. Not all of the indicators selected for stepwise regression model were rated for highly in Fehring method. The R2 statistics of the stepwise regression models were between 18 and 63% in importance by selected indicators and between 34 and 68% in contribution by selected indicators. CONCLUSION: This study refined what outcomes and indicators will be useful in clinical practice. Further research will be required for the revision of outcome and indicators of NOC. However, this study refined what outcomes and indicators will be useful in clinical practice.

Health-Related Quality of Life : An Overview / 薬剤疫学

Under the prevailing ”disease-oriented” paradigm of health, Quality of Life (QOL) has been treated with profound skepticism. Two facts, however, militate for taking QOL seriously into account : first, both social and clinical decision making today require evidence presented in the form of patient outcomes; second, of patient outcomes, one of the most important from the patient's standpoint is QOL. Giving several examples, the author discusses why traditional endpoints are insufficient and why patient-based outcomes are relevant in modern social and clinical decision making.<BR>And yet not all outcomes are relevant : for the purposes of assessment of health and medical care, QOL should be confined to its health-related elements, and instruments to measure health-related quality of life (HRQOL) should be rigorously tested with psychometric methods. Even more important, however, is the instrument's content validity : i. e., whether it measures what one wants to measure. This paper lists criteria for selection of appropriate instruments and describes the recent debate and moves to formulate guidelines on the use of HRQOL evidence in pharmaceutical product approvals and manufacturers' product efficacy claims. Finally, the author discusses the future of HRQOL research and uses of HRQOL in clinical practice.