The patient safety institute demonstration project: a model for implementing a local health information infrastructure

The increasing focus on patient safety has uncovered many unsafe conditions in the current US. healthcare system. One of the most glaring problems is the inability of a fragmented healthcare system to provide critical and timely clinical information at the point of care. The Institute of Medicine has called for the development of a National Health Information Infrastructure to rectify this deficiency. This NHII will be built on Local Health Information Infrastructures, or LHIIs. The Patient Safety Institute is a potential model for an LHII that was developed and implemented in Seattle using the Swedish Medical Centers and associated ambulatory clinics. This model was piloted and evaluated among 365 clinical users across three hospitals, three clinics, and family practice residency programs involving access of records of more than 5300 distinct patients within a five-month period and involved the collection of more than 23 million clinical data results. User responses revealed the technology was intuitive to learn, easy to use, easy to navigate, and helpful in clinical care. The PSI demonstration project has developed an approach to the creation and implementation of LHIIs that is potentially transferable to other local communities.     

Hoarseness in children: summer camp study

Ninety-six children attended an 8-week residential summer camp program and were evaluated for hoarseness using a 4 point integral scale. Eighteen percent were hoarse at the start of the camp season and 35% subsequently developed hoarseness during the camping season. Only 4.1% of the children in the first screening and 12.5% of those in the second screening had a moderate degree of hoarseness, while the majority of the hoarse children were judged as having only a mild degree. We believe that children should not be considered for voice screenings until 8 weeks after the start of the school term.     

A national sample of IAPSRS members' responses to the psychiatric rehabilitation beliefs, goals, and practices scale

This study reports on the convergent-discriminant validity of the Psychiatric Rehabilitation Beliefs, Goals, and Practices Scale (PRBGP) which purports to measure practitioners' knowledge of the current consensus in psychiatric rehabilitation. The sample comprised 478 IAPSRS members who represented practitioners from 39 states. The study found that the PRBGP variance among this sample was primarily associated with the number of 15 leading contributors to the psychiatric rehabilitation literature that these practitioners claimed to have read when education, discipline, role, experience, and agency area were controlled. Experience in the behavioral health field and the administrator role were also significantly related to the PRBGP, but these relationships may have also been a function of informational factors associated with IAPSRS membership. For a combined sample (n = 757), it was also found that the PRBGP is primarily related to the number of leading authors that these practitioners read. The PRGBP appears to measure knowledge of the current consensus on beliefs, goals, and practices in psychiatric rehabilitation, and is not a measure of these other responder characteristics.     

Frequency and imaging appearance of hepatic angiomyolipomas in pediatric and adult patients with tuberous sclerosis

OBJECTIVE: This study evaluates the frequency and imaging appearance of hepatic angiomyolipomas in pediatric and adult patients with tuberous sclerosis. CONCLUSION: Multiple hepatic angiomyolipomas are often found in patients with tuberous sclerosis, particularly in those with bilateral diffuse renal angiomyolipomas.     

Service utilization, incidents, and hospitalizations among people with mental illnesses and incarceration histories in a supportive housing program

This study compared the service utilization, incidents, and hospitalizations of forensic clients and non-forensic clients in a supportive housing program for the mentally ill. 28 forensic consumers were compared to 28 non-forensic consumers matched on age, sex, ethnicity, diagnosis, and hospitalization history across four quarters of services data via ANOVA with repeated measures and substance abuse history as a covariate. Multiple and logistic regression evaluated the contributions of age, sex, length of stay, type of case management, substance abuse history, and incarceration history to the variance of 123 clients for incidents and hospitalizations. Forensic clients modestly utilized more services during their first year in the residence. Incarceration history was the dominant predictor of incidents, but not hospitalizations. These findings may help in determining if a jail diversion program should include a specialized community-housing component.     

A randomized double-blind comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on ovulatory function in normal women

OBJECTIVE: To evaluate the ovarian follicular dynamics of cycle modification with the aromatase inhibitor letrozole compared with clomiphene citrate in normal ovulatory women. DESIGN: Randomized double-blind controlled trial. SETTING: Tertiary care hospital. PATIENT(S): Nineteen ovulatory female volunteers, ages 18-35 years. INTERVENTION(S): Subjects were monitored in one control cycle. Subjects then received either letrozole 2.5 mg daily or clomiphene citrate 50 mg daily on days 5-9 after menses. MAIN OUTCOME MEASURE(S): Number of mature follicles, endometrial thickness and endometrial pattern at ovulation, and follicular profiles of LH, FSH, and E(2). RESULT(S): The number of mature follicles at the LH surge in natural cycles was 1.0 with an exaggerated response seen for treatment both with clomiphene and letrozole. There was no difference in the endometrial thickness at midcycle during either the natural cycles or the medicated cycles. LH surges and spontaneous ovulation were documented in all natural and medicated cycles. When measured daily, follicular profiles of LH and FSH are similar between the groups in both the natural and medicated cycles. In the medicated cycles, clomiphene results in a significant increase in E(2) levels, while E(2) levels in letrozole-stimulated cycles appeared lower than in natural cycles. CONCLUSION(S): Transient inhibition of aromatase activity in the early follicular phase with the aromatase inhibitor letrozole results in stimulation of ovarian folliculogenesis similar to that seen with clomiphene citrate with no apparent adverse effect on endometrial thickness or pattern at midcycle.     

Unrelated marrow transplantation for children with acute lymphoblastic leukemia in second remission

Allogeneic bone marrow transplantation (BMT) may be curative for more patients than chemotherapy for the child with relapsed acute lymphoblastic leukemia. This study reviewed the outcomes of 363 children with acute lymphoblastic leukemia in second remission who received unrelated donor BMT from 1988 to 2000 in order to define prognostic factors that affect leukemia-free survival (LFS). Median patient age was 9 years (range, 0-19 years), and median follow-up 29 was months (range, 0-125 months). The median duration of first remission was 24 months (range, 0-109 months). Prognostic factors, including age, duration of first remission, HLA matching, and graft-versus-host (GVH) disease, were analyzed using both univariate and multivariate analyses. Overall survival was 38%, and LFS was 36% at 5 years. LFS was significantly worse for patients 15 years or older (log-rank, P =.009). HLA matching was associated with improved LFS. Acute GVH disease developed in 71%, with 29% having grades III-IV. The incidence of chronic GVH disease was 39% for patients who survived more than 80 days and was significantly higher for female patients receiving marrow from female donors (P =.0009). Transplantation-related mortality was 42% and was associated with HLA mismatches, age 15 years and older, and first remission less than 12 months. The 5-year estimate for relapse was 22%, with first remission at least 6 months associated with a lower risk. Results of unrelated donor BMT appear similar to multi-institutional studies of matched related donor BMT, and this approach appears to be curative for many patients. However, innovative approaches are needed for patients with initial remissions of less than 6 months and for older teenagers.     

Renal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement

BACKGROUND: Severe renal disease is a feature of anti-neutrophil cytoplasmic antibodies (ANCA)-associated small-vessel vasculitis. We evaluated patient and renal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement at diagnosis during long-term follow-up. METHODS: Eighty-five patients were diagnosed between 1982 and 1996 and followed until 2001 allowing >or=5 years of follow-up. All patients were treated with prednisolone and cyclophosphamide. Univariate and multivariate analyses with patient and renal survival as dependent variables were performed. RESULTS: Of the 85 patients in this study, 17 (20%) died within one year after diagnosis. Of the 25 patients (29%) who were dialysis dependent at diagnosis, two remained dependent and two again became dialysis dependent after less than one year; nine died early without renal recovery. Risk factors for death occurring within one year in univariate analysis (RR, 95% CI) were age>65 years (6.5, 1.6-13.7) and dialysis dependency at diagnosis (3.6, 1.0-13). Twenty patients died beyond one year during the long-term follow-up. Male gender (4.7, 1.6-10) and developing dialysis dependency during follow-up (4.1, 1.4-12) were associated with poor outcome. Risk factor for renal failure within one year was dialysis dependency at diagnosis (29, 3.6-229). Of 64 patients dialysis independent one year after diagnosis, 12 patients became dialysis dependent during follow-up. A renal relapse was strongly associated with development of renal failure in long-term follow-up (17, 3.5-81). CONCLUSIONS: Early death and failure to recover renal function in PR3-ANCA associated vasculitis is associated with age> 65 years and dialysis dependency at diagnosis. Long-term renal survival is determined by renal relapses during follow-up only. Slow, progressive renal failure without relapses is rarely observed in this group.     

Upper airway motion depicted at cine MR imaging performed during sleep: comparison between young Patients with and those without obstructive sleep apnea

PURPOSE: To compare the patterns of dynamic airway motion depicted on cine magnetic resonance (MR) images obtained during sleep between young patients with and those without obstructive sleep apnea (OSA). MATERIALS AND METHODS: Fast gradient-echo sequences were performed in the sagittal midline by using a 1.5-T unit to create cine MR images. Cine MR images obtained during sleep in 16 young patients with OSA were compared with those obtained in 16 young patients with no airway symptoms of airway disease. The nasopharynx, oropharynx, and hypopharynx were characterized in terms of airway motion as static patent (SP), dynamic patent, intermittent collapsed (IC), or static collapsed (SC); and the maximal diameter and greatest change in diameter (in millimeters) of these airways were calculated. Adenoid tonsil size and mouth position (ie, opened or closed) were determined. Differences in the frequency of MR imaging parameters in the different anatomic regions were evaluated by using Fisher exact, chi 2, and sample t tests. RESULTS: There were statistically significant differences in the following parameters between the two groups: nasopharynx SP (P <.001) and IC (P <.001); hypopharynx SP (P <.001) and IC (P <.001); and mean change in airway diameter of the nasopharynx (P <.001) and hypopharynx (P <.001). The mean adenoid tonsil size in the patients with OSA was larger (P =.006). CONCLUSION: There are significant differences in the patterns of dynamic airway motion between young patients with and those without OSA.