A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Policy Points Improving health systems requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers - Quadruple Aim -. Reinforcing the recently defined Fifth Aim as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. Adding a Sixth Aim to take into account the increased health risks due to climate change. CONTEXT: Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. METHODS: A conceptual framework to provide additional ethical guardrails for health systems. RESULTS: Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. CONCLUSIONS: As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Concentrated topical epinephrine is safe in endoscopic sinus surgery.

BACKGROUND: The safety of topical epinephrine (1:1000 concentration) has recently been called into question. No objective data have been presented examining this issue. METHODS: We retrospectively reviewed all cases of endoscopic sinus surgery performed by the senior authors at their respective institutions. Perioperative records were reviewed for use of topical 1:1000 epinephrine and for any intraoperative or postoperative complications related to its use. RESULTS: During the study periods, 1998 cases of endoscopic sinus surgery were identified where topical 1:1000 epinephrine was used. Two complications were identified (0.1%), one at each institution. One patient suffered coronary artery vasospasm, attributed to the use of topical 1:1000 epinephrine during surgery. The other patient developed transient intraoperative hypertension immediately after inadvertent submucosal injection of concentrated epinephrine. This event was caused by an erroneous switch with the 1% lidocaine/1:100,000 solution. This error occurred early in the institution's experience with concentrated topical epinephrine. After implementation of additional preventative safeguards, no further errors or complications have occurred. CONCLUSION: Concentrated epinephrine has the potential for complications when used during endoscopic sinus surgery. Nevertheless, with appropriate safeguards described in this study, its topical use is safe.

Hematuria due to urolithiasis in a child with chronic immune thrombocytopenic purpura.

Hematuria is an uncommon manifestation of chronic immune thrombocytopenic purpura. The occurrence of urolithiasis in children with chronic immune thrombocytopenic purpura has not been described. We report a case of hematuria due to urolithiasis in an 8-year-old boy with chronic immune thrombocytopenic purpura. This child, who had a history of immune thrombocytopenic purpura of 1 year's duration, presented to the emergency department with gross hematuria. The cause of hematuria was initially attributed to his primary disease process. A careful history, examination, and pertinent investigations revealed that the hematuria was secondary to urolithiasis. This report highlights the need to keep an open mind and to search for specific causes of bleeding, even in children with known bleeding disorders.

Cutaneous sarcoidosis with tuberculoid granuloma.

Cutaneous sarcoidosis is not an uncommon clinical entity. We report a case of cutaneous sarcoidosis, the histology of which showed tuberculoid granuloma.