放射治疗流程再造及质量控制

目的对放射治疗流程进行再造与优化并对放射治疗的各个环节进行全面质量控制,使放射治疗的效率提高、差错率降低。方法通过对放射治疗各环节进行分析,对放射治疗流程进行再造。结果实施放射治疗流程再造及质量控制后,每月工作量与上年同期对比增长60%,放射治疗综合满意度提高了25.8%。结论放射治疗流程再造及质量控制,可以使放射治疗的效率提高、差错率降低。     

Computed tomography for preoperative planning in minimal-invasive total hip arthroplasty: Radiation exposure and cost analysis

Computed tomography (CT) was used for preoperative planning of minimal-invasive total hip arthroplasty (THA). 92 patients (50 males, 42 females, mean age 59.5 years) with a mean body-mass-index (BMI) of 26.5 kg/m² underwent 64-slice CT to depict the pelvis, the knee and the ankle in three independent acquisitions using combined x-, y-, and z-axis tube current modulation. Arthroplasty planning was performed using 3D-Hip Plan^® (Symbios, Switzerland) and patient radiation dose exposure was determined. The effects of BMI, gender, and contralateral THA on the effective dose were evaluated by an analysis-of-variance. A process-cost-analysis from the hospital perspective was done. All CT examinations were of sufficient image quality for 3D-THA planning. A mean effective dose of 4.0 mSv (SD 0.9 mSv) modeled by the BMI (p < 0.0001) was calculated. The presence of a contralateral THA (9/92 patients; p = 0.15) and the difference between males and females were not significant (p = 0.08). Personnel involved were the radiologist (4 min), the surgeon (16 min), the radiographer (12 min), and administrative personnel (4 min). A CT operation time of 11 min and direct per-patient costs of 52.80 € were recorded. Preoperative CT for THA was associated with a slight and justifiable increase of radiation exposure in comparison to conventional radiographs and low per-patient costs.     

Alcohol-related effects on automaticity due to experimentally manipulated conditioning

Background: The use of alcohol is associated with various forms of automatic processing, such as approach tendencies and attentional biases, which may play a role in addictive behavior. The development of such automaticity has generally occurred well before subjects perform tasks designed to detect them. Although it seems plausible that this development involves some form of alcohol‐related conditioning, this process is not usually included in the experimental procedure. Methods: The development of automaticity involving alcoholic or nonalcoholic stimuli was experimentally manipulated via a conditioning task. Subjects were presented with pairs of stimuli from a set of 4 stimuli: 2 pictures of alcoholic beverages, and 2 pictures of nonalcoholic beverages. One of the alcoholic and 1 of the nonalcoholic beverages was associated with reward, the other stimuli with punishment. Subjects had to learn to select the rewarded stimuli from pairs of 1 rewarded and 1 punished stimulus. The task, thus experimentally established reward versus punishment stimulus–response–outcome associations, for alcoholic and for nonalcoholic stimuli. Subsequently, a cued reversal task was used to test automaticity involving alcoholic versus nonalcoholic, and rewarded versus punished stimuli. Results: An association was found between heavier drinking and an alcohol‐related conditioning bias: heavier drinkers had more difficulty overcoming a conditioned response when it involved selecting a previously punished nonalcoholic stimulus over a previously rewarded alcoholic stimulus. Conclusions: The study provided novel information on secondary reinforcement involving alcoholic stimuli: heavier drinkers may more easily develop automaticity related to alcohol‐reward contingencies. This may have implications for interventions and the interpretation of findings concerning alcohol‐related automatic processing.     

What is the patient acceptability of real time 1:1 videoconferencing in an orthopaedics setting? A systematic review

Background

Real time 1:1 videoconferencing (VC) has the potential to play an important role in the management of orthopaedic pathologies. Despite positive reporting of telemedicine studies uptake in clinical practice remains low. Acceptability to patients is an important element of system take-up in telemedicine and a focus towards qualitative methodology may explore the underlying reasons behind its acceptability. In this paper we have systematically reviewed qualitative studies that include evidence about patient responses to VC services in an orthopaedic setting.

Nursing clinical practice changes to improve self‐management in chronic obstructive pulmonary disease

Aim

To propose nursing clinical practice changes to improve the development of patient self‐management.

Background

Chronic obstructive pulmonary disease is one of the main causes of chronic morbidity, loss of quality of life and high mortality rates.

Introduction

Control of the disease's progression, the preservation of autonomy in self‐care and maintenance of quality of life are extremely challenging for patients to execute in their daily living. However, there is still little evidence to support nursing clinical practice changes to improve the development of self‐management.

Methods

A participatory action research study was performed in a medicine inpatient department and the outpatient unit of a Portuguese hospital. The sample comprised 52 nurses and 99 patients. For data collection, we used interviews, participant observation and content analysis.

Results

The main elements of nursing clinical practice that were identified as a focus for improvement measures were the healthcare model, the organization of healthcare and the documentation of a support decision‐making process. The specific guidelines, the provision of material to support decision‐making and the optimization of information sharing between professionals positively influenced the change process. This change improved the development of self‐management skills related to the awareness of the need for ‘change’, hope, involvement, knowledge and abilities.

Discussion

The implemented changes have improved health‐related behaviours and clinical outcomes.

Conclusion

To support self‐management development skills, an effective nursing clinical practice change is needed. This study has demonstrated the relevance of a portfolio of techniques and tools to help patients adopt healthy behaviours.

Implications for nursing and/or health policy

The involvement and participation of nurses and patients in the conceptualization, implementation and evaluation of policy change are fundamental issues to improve the quality of nursing care and clinical outcomes.     

Does e-pain plan improve management of sickle cell disease associated vaso-occlusive pain crisis? A mixed methods evaluation

PurposeThere is limited application and evaluation of health information systems in the management of vaso-occlusive pain crises in sickle cell disease (SCD) patients. This study evaluates the impact of digitization of paper-based individualized pain plans on process efficiency and care quality by examining both objective patient data and subjective clinician insights.MethodsRetrospective, before and after, mixed methods evaluation of digitization of paper documents in Children's Hospital of Pittsburgh of UPMC. Subjective perceptions are analyzed using surveys completed by 115 clinicians in emergency department (ED) and inpatient units (IP). Objective effects are evaluated using mixed models with data on 1089 ED visits collected via electronic chart review 28 months before and 22 months after the digitization.ResultsSurveys indicate that all clinicians perceived the digitization to improve the efficiency and quality of pain management. Physicians overwhelmingly preferred using the digitized plans, but only 44% of the nurses had the same response. Analysis of patient records indicates that adjusted time from analgesic order to administration was significantly reduced from 35.50 to 26.77 min (p < .05). However, time to first dose and some of the objective quality measures (time from administration to relief, relief rate, admission rate, and ED re-visit rate) were not significantly affected.DiscussionThe relatively simple intervention, high baseline performance, and limited accommodation of nurses’ perspectives may account for the marginal improvements in process efficiency and quality outcomes. Additional efforts, particularly improved communication between physicians and nurses, are needed to further enhance quality of pain management.ConclusionThis study highlights the important role of health information technology (HIT) on vaso-occlusive pain management for pediatric patients with sickle cell disease and the critical challenges in accommodating human factor considerations in implementing and evaluating HIT effects.     

Attachment in mental health institutions: A critical review of assumptions,clinical implications,and research strategies

Attachment is relevant to institutionalized treatment and the therapeutic process in three identifiable ways: (1) patients bring their mental representations of previous and existing attachment relationships to the treatment; (2) attachment is relevant to the extent to which a therapeutic alliance is established and maintained, both in terms of the mental representations of attachment in the patient and in the therapist and how these influence interactive behaviour and expectations in each partner to the therapeutic work; (3) the outcome of the treatment may be related to attachment; for example, when institutional experiences have an enduring impact on attachment representations and the future attachment behaviour of the patient. However, this brief review of attachment concepts reveals that several theoretical, conceptual and empirical questions remain to be answered before evidence-based clinical attachment guidelines can be formulated concerning patient-staff relationships.     

Using a ‘talk’ model of shared decision making to propose an observation-based measure: Observer OPTION

Objective

To propose a revised Observer OPTION measure of shared decision making.

Methods

We analyzed published models to identify the core components of a parsimonious conceptual framework of shared decision making. By using this framework, we developed a revised measure combining data from an observational study of clinical practice in Canada with our experience of using Observer OPTION^{12 Item}.

Results

Our conceptual framework for shared decision making composed of justifying deliberative work, followed by the steps of describing options, information exchange, preference elicitation, and preference integration. By excluding items in Observer OPTION^{12 Item} that were seldom observed or not aligned to a robust construct, we propose Observer OPTION^{5 Item}.

Conclusion

Although widely used, Observer OPTION^{12 Item} did not give sufficient attention to preference elicitation and integration, and included items that were not specific to a core construct of shared decision making. We attempted to remedy these shortcomings by proposing a shorter, more focused measure.

Practice implications

Observer OPTION^{5 Item} requires evaluation; we hope that it will be useful as both a research tool and as a formative measure of clinical practice.     

Linking components of event-related potentials and autonomic measures of the orienting reflex

This study examined autonomic measures and event-related potentials (ERPs) associated with elicitation and habituation of the basic Orienting Reflex (OR). Subjects received 16 innocuous tones with intensity alternating between 60 and 80 dB, at long inter-stimulus intervals. There was no stimulus-related task, so we could examine the effects of stimulus novelty and intensity in the absence of task demands. Cardiac, respiratory, peripheral vasoconstriction, and electrodermal measures were recorded, as well as continuous EEG. Single-trial ERPs were obtained, and components extracted by Principal Components Analysis were examined for potential response fractionation in the central indices of stimulus processing. The predicted fractionation of autonomic measures was obtained: cardiac deceleration showed no systematic change with intensity or trials, respiratory pause showed a substantial main effect of trials but no intensity effects, peripheral vasoconstriction showed intensity but no trials effects, and electrodermal responses showed substantial main effects of trials and intensity. A range of intensity and novelty effects were obtained in components identified as the N1, P3a, P3b, Novelty P3, and the classic Slow Wave. The different stimulus–response profiles of the ERP components are discussed in relation to the autonomic response profiles within the context of a sequential processing theory of OR elicitation.