Update on Randomized Clinical Trials Impacting Clinical Care in Pediatric Cardiac Intensive Care

Clinical trials addressing the management of infants and children with congenital heart disease are challenged by low numbers of patients with a similar diagnosis (inadequate power), variation in management strategies between institutions (difficulty developing multicentered protocols), a rapidly evolving field (equipoise), and insufficient funding. This article summarizes the challenges and the results of some single‐center and multicenter trials evaluating perioperative care of infants and children undergoing surgery for congenital heart disease.     

The Perspective of Patients with Congenital Heart Disease: Does Health Care Meet Their Needs?

Objective. A first step in the delivery of tailored care is answering the following question: does health care meet the needs of patients? Therefore patients' perspective on health care use and their needs was examined. The design used was cross‐sectional questionnaire study. Patients. A total of 1109 adult congenital heart defect (CHD) patients attending one of eight Dutch hospitals were randomly selected from a national database (10% of all registered patients). Main Outcome Measures. Patient reported questionnaires on in‐ and outpatient health care use during the past year and need for additional care. Results. A total of 66% and 40% of patients had contact with their cardiologist and general practitioner, respectively. Six to 10 percent were hospitalized, operated upon, or visited the emergency room. For the majority, the amount of contact was sufficient. Most patients indicated that the communication skills and expertise of the cardiologist and general practitioner were sufficient, and health care improvements were not necessary. Frequent health care users had a poor functional status and frequent contact with their cardiologist and general practitioner. Patients who want more contact with their cardiologist rated the communication skills of the cardiologist as insufficient. Conclusions. For most patients, the amount and quality of care are both sufficient. Patients who rate the communication skills of the cardiologist as insufficient have need more contact. In addition to the recommended training program as described in the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines, we recommend the incorporation of communication training. This is the first study to provide insight into health care use and needs of CHD patients in countries with a compulsory health insurance system from the patient perspective.     

Echocardiography and Management of Sick Neonates in the Intensive Care Unit

To evaluate the influence of echocardiographic examination in the clinical management of the sick neonate, 241 patients, admitted to the neonatal intensive care unit of a tertiary referral center that had echocardiograms with data available for review, were enrolled in a retrospective study. Asymptomatic murmurs (45%) followed by extracardiac anomalies/dysmorphic features (24%) were the most common clinical indications for requesting an echocardiogram. Congenital structural abnormalities (33%), hemodynamically significant patent arterial duct (3%), persistent pulmonary hypertension of the newborn (6%), and left ventricular dysfunction (3%) were the echocardiographic findings that subgrouped as structural or functional abnormalities. Patent oval foramen and hemodynamically nonsignificant patent arterial duct (20%) and physiologic pulmonary artery stenosis (1%) were categorized as normal structural group. Thirty‐four percent of neonates had normal heart anatomy. This investigation changed the clinical management in at least 66% of newborns scanned, including emergency surgical intervention for 7%, medical treatment for 22%, and routine cardiologic follow‐up for 37% of patients. Asymptomatic murmur in our critically ill neonates has been associated with a higher incidence of cardiac disease. Hence, echocardiography is an important tool for diagnosis of cardiac abnormalities that can influence the management and outcome of the sick newborn in the intensive care unit. A preliminary echocardiogram performed by the neonatologist under the supervision of a pediatric cardiologist for interpretation and review is an alternate when there is not a cardiologist “in house.”     

Three-Year Chemical Dependency and Mental Health Treatment Outcomes Among Adolescents: The Role of Continuing Care

Background: Few studies have examined the effects of treatment factors, including the types of services [chemical dependency (CD), psychiatric, or both], on long‐term outcomes among adolescents following CD treatment, and whether receiving continuing care may contribute to better outcomes. This study examines the effect of the index CD and ongoing CD and psychiatric treatment episodes, 12‐step participation, and individual characteristics such as CD and mental health (MH) severity and gender, age, and ethnicity, on 3‐year CD and MH outcomes. Methods: Participants were 296 adolescents aged 13 to 18 seeking treatment at 4 CD programs of a nonprofit, managed care, integrated health system. We surveyed participants at intake, 1 year, and 3 years, and examined survey and administrative data, and CD and psychiatric utilization. Results: At 3 years, 29.7% of the sample reported total abstinence from both alcohol and drugs (excluding tobacco). Compared with girls, boys had only half the odds of being abstinent (OR = 0.46, p = 0.0204). Gender also predicted Externalizing severity at 3 years (coefficients 18.42 vs. 14.77, p < 0.01). CD treatment readmission in the second and third follow‐up years was related to abstinence at 3 years (OR = 0.24, p = 0.0066 and OR = 3.33, p = 0.0207, respectively). Abstinence at 1 year predicted abstinence at 3 years (OR = 4.11, p < 0.0001). Those who were abstinent at 1 year also had better MH outcomes (both lower Internalizing and Externalizing scores) than those who were not (11.75 vs. 15.55, p = 0.0012 and 15.13 vs. 18.06, p = 0.0179, respectively). Conclusions: A CD treatment episode resulting in good 1‐year CD outcomes may contribute significantly to both CD and MH outcomes 3 years later. The findings also point to the value of providing a continuing care model of treatment for adolescents.     

重症监护病房医院感染临床分析

目的:为防治ICU的医院感染提供临床依据.方法:对我院ICU收治的住院时间大于3 d的796例患者的病历资料进行回顾性分析.结果:796例中,发生医院感染201例(25.3%).其中APACHEⅡ＞20分者341例,发生医院感染172例(50.4%);APACHEⅡ＜20分者455例,发生医院感染29例(6.4%).医院感染发生在患者不同性别间无差异(P＞0.05),而在不同年龄、病情危重度间差异有显著性(P均＜0.01),201例感染者中,99例为下呼吸道感染(占49.2%),其中呼吸机相关肺炎68例,占肺部感染中68.7%,54例为胃肠道感染(26.9%),泌尿道29例(14.4%),其他19例(9.5%);最常见的病原菌依次为肺炎克雷伯杆菌(28.5%)、鲍曼不动杆菌(26.4%)、铜绿假单胞菌(18.3%)、嗜麦芽窄食单胞菌(8.2%)、葡萄球菌(6.7%)、肠杆菌(6.1%)、其他(5.8%).各病原菌对抗菌药物的耐药性均较严重,肺炎克雷伯菌对MERO、IMP和CFS敏感率分别为54.8%、59.9%、44.7%,其余耐药率均较高,而鲍曼不动杆菌对抗菌药物的敏感情况同肺炎克雷伯菌相似,铜绿假单胞菌对CAZ、IMP耐药率日渐增高.结论:ICU内医院感染发生率较高,与年龄、病情危重度相关;尽早控制病情、严格无菌操作、合理应用抗生素是防止耐药菌产生、控制和降低医院感染的关键.     

Innovation and Consumer Directed Care: Identifying the challenges

Our aim was to report clinician and researcher observations about the practical difficulties with achieving the articulated objectives of Consumer Directed Care (CDC). The methods used were as follows: identification of key client community services issues through analysis of qualitative data related to a PhD project; review of the summary of these issues by the supervising academic; presentation of the issues to five clinicians involved with a community service clinical trial; verification of the findings through discussions with a senior community service provider. There is anecdotal evidence that the current overlay of CDC in the existing community‐based home services sector for people who are older will continue to prevent its effective implementation. The existing culture and underlying philosophies related to this sector maybe unable to support the level of innovative change required. Research is needed into how the stated objectives of CDC can be achieved in Australia and how this can best be managed.     

Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions

Purpose

Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs.

The American Heart Association's Recent Scientific Statement on Cardiac Critical Care: Implications for Pediatric Practice

A writing group sponsored by the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the Council on Quality of Care and Outcomes Research of The American Heart Association has recently formulated a roadmap to meet the changing needs of the patient with cardiovascular disease requiring critical care. Although this roadmap has been formulated primarily to address the care needs of the adult with critical cardiovascular disease, it contains useful lessons pertinent to the care of the patient with pediatric and congenital cardiovascular disease. In this document, we have examined The Statement and applied its framework to the evolving field of pediatric cardiac critical care.     

湖北省重症医学科发展现状调查

目的:调查湖北省重症医学科的发展现状。方法:采用网络结合纸质调查模式,由湖北省二级及以上医院ICU医师填写。结果:①湖北省ICU主要分布于少数大城市及三级医院中;②湖北省ICU床位数偏少,医护人员数未达标,三级及二级医院ICU分别以封闭、半封闭式管理为主;③基本技术技能掌握较好,先进技术技能水平不高;部分基础设施配备率未达标,先进设备配备率较低。结论:湖北省ICU已初具规模,但未完全达到国家标准,二级医院与三级医院ICU水平存在较大差距。     

Utilization of Primary Care by Veterans with Psychiatric Illness in the National Department of Veterans Affairs Health Care System

BACKGROUND

Psychiatric illness is associated with increased medical morbidity and mortality. Studies of primary care utilization by patients with psychiatric disorders have been limited by nonrepresentative samples and confounding by medical co-morbidity.

OBJECTIVE

To determine whether patients with psychiatric disorders use primary care services differently than patients without these disorders, after controlling for medical co-morbidity.

DESIGN

Data from the 1999 Large Health Survey of Veterans (LHS) ( = 559,985) were linked to VA administrative data in order to identify veterans who received primary care. After adjusting for sociodemographic and clinical characteristics, medical co-morbidity, and facility characteristics, multivariate logistic regression was used to evaluate whether seven psychiatric diagnoses were associated with an increased or decreased likelihood of any primary care visit over 12 months.

RESULTS

Veterans with either schizophrenia, bipolar disorder or a drug use disorder were less likely to have had any primary care visit during the study period: [OR 0.61, 95% CI 0.59 to 0.63], [OR 0.63, 95% CI 0.60 to 0.67] and [OR 0.88, 95% CI 0.83 to 0.92], respectively, than veterans without these diagnoses, even after controlling for medical co-morbidity. Among patients with any primary care utilization, those with six of the seven psychiatric diagnoses had fewer visits in the study period.

CONCLUSIONS

Patients with schizophrenia, bipolar disorder or drug use disorders use less primary care than patients without these disorders. Interventions are needed to increase engagement in primary care by these vulnerable groups.Key Words: primary care, psychiatric illness, Axis I psychiatric disorders, Veterans Affairs Health Care System     

全程关护理念对扩张型心肌病患者康复的影响

目的探讨全程关护理念在扩张型心肌病中的应用及护理。方法对52例扩张型心肌病患者展开预防、筛查、监测、诊断、治疗与护理、健康管理等环节,对患者纳入信息化管理。结果 52例患者有22例发生心律失常,发生率为42.3%,8例治愈,42例好转出院,2例死于严重心力衰竭。结论正确地全程关护能及时发现并有效控制扩张型心肌病的恶性心律失常的发生,降低致残率和死亡率。     

Direct Medical Care Costs Associated With Patients Diagnosed With Chronic HCV

Background

HCV virus (HCV) is a significant global problem with wide-ranging socio-economic impacts. Because of the high morbidity and mortality associated with end-stage liver disease, cirrhosis, and hepatocellular carcinoma (HCC), the economic burden of HCV infection is substantial.

Objectives

This study aimed to estimate the direct medical care costs of chronic HCV infection.

Patients and Methods

For this cross-sectional study, 365 courses of HCV treatment were extracted from medical records of 284 patients being referred to Tehran HCV clinic, a clinical clinic of Baqiyatallah Research Center for Gastroenterology and Liver diseases, from 2005 to 2010. All the patients had been diagnosed with HCV. Direct medical care costs for each course of HCV treatment have been calculated based on Purchasing Power Parity Dollar (PPP$).

Results

Average direct medical costs for the courses treated with conventional interferon plus ribavirin (INF-RBV) were 4,403 PPP$, and 20,010 PPP$ for peg-interferon plus ribavirin (PEG-RBV) courses. There was an increase of the direct costs in both courses of treatment to achieve Sustain Viral Response (SVR). The costs amounted to 10,072 PPP$ in (INF-RBV) treatment and 34,035 PPP$ in (PEG-RBV). The significant difference between the costs of these two courses of treatment is attributable to high cost of Peg-interferon. This indicates that the medication costs are the dominant costs.

Conclusions

According to the results, total direct medical costs for HCV patients in Iran exceeded 12 billion PPP$ in (INF-RBV) treatment and 55 billion PPP$ in (PEG-RBV).     

中英性病艾滋病防治合作项目的政策影响评估

目的了解艾滋病防治项目对政府的政策影响。方法对北京的20位艾滋病领域专家进行问卷调查和深入访谈。结果中英项目在同时期项目运作中效果最好、力度最大,对地方政策制定起到指导和先锋作用,同时给国家的政策决策者以循证。其中,对高危行为人群的干预活动政策影响力最大,而针对机会性感染的治疗和自愿检测措施影响力不足,效果不显著。结论中英项目在科学的指导原则下,采用以试点为基础的项目管理机制和“边实践、边总结”的做法,为国家艾滋病防治提供了很好的最佳实践经验。然而,项目经验的可持续发展问题受到挑战。