A patient classification system for emergency events in home care

The purpose of this article is to describe the development of a uniform classification system that provides a way for home care agencies to classify patient priority needs for evacuation, transport, supportive care, and use of staffing resources in an emergency/disaster situation/bioterroristic event.     

Discrepant perceptions about end-of-life communication: a systematic review

Little research has compared the perceptions of health professionals (HPs), patients, and caregivers about the communication of prognostic information. The objectives of this literature review were to determine 1) patient and caregiver perceptions of levels of information received about prognosis and end-of-life (EoL) issues regarding a life-limiting illness; 2) patient perceptions of and factors related to their understanding and awareness of prognosis; 3) HPs' perceptions of patients' wishes about disclosure of prognosis and factors related to their decision whether to disclose; and 4) concordance between HPs and patients/caregivers regarding the information given by HPs about prognostic and EoL issues. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO, Cochrane Register of Controlled Trials [Central]) up to November 2004. The reference lists of identified studies were hand searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Fifty-one studies were identified. There was a large discrepancy between patients/caregivers and HPs regarding the amount of information they believed had been given. Patients' understanding and awareness of information received conflicted with the HPs' perceptions of patients' understanding and awareness of the information that had been given. HPs tended to underestimate patients' need for information and overestimate patients' understanding and awareness of their prognosis and EoL issues. HPs need to repeatedly check patients' understanding and preferences for information.     

Rehabilitation of a glenohumeral instability utilizing the body blade

Traditional rehabilitation for shoulder dislocation has a success rate of only 20%. The body blade has been hypothesized to strengthen the muscles stabilizing the shoulder girdle by training the contractile tissues directly and also indirectly affecting the joint and surrounding noncontractile tissues when responding to rapid positional changes and mechanical energy. Shoulder dislocation negatively affects both the active (musculature) and passive (joint and ligaments) stabilizers of the glenohumeral joint. Therefore, the purpose of this case report was to evaluate the efficacy of therapeutic exercise using the body blade in the conservative management of an individual with glenohumeral instability. The patient, an 18-year-old male, dislocated his left shoulder after a wave crashed on top of him. Intervention included therapeutic exercise using the body blade. Measures were taken at examination, re-evaluation (6th visit), and discharge (11th visit). According to the 11-point numeric pain rating scale, worst pain was reduced from 4 to 0. Glenohumeral ROM measures at discharge were all within normal range except external rotation (deficit of 10 degrees), compared to the initial ROM deficits of 10-35% of noninvolved values. Post intervention strength, as assessed by handheld dynamometry, revealed deficits only in scapular retraction compared to the uninvolved side (21% compared to an initial deficit of 39%). Other muscle groups showing deficits from 20% to 40% at initial examination exceeded the comparative strength of the other limb at discharge. The SPADI and WOSI scores were reduced from 13 to 0 and 482 to 46, from initial examination to discharge, respectively. Furthermore 6 months post episode of care the patient reported no recurrent dislocation of the involved shoulder. The success rate of an exercise program with individuals who have dislocated their glenohumeral joint is poor. After 11 visits of physical therapy using the body blade the patient improved in ROM, strength, and function.     

Morphine treatment accelerates sarcoma-induced bone pain, bone loss, and spontaneous fracture in a murine model of bone cancer

Metastatic bone cancer causes severe pain that is primarily treated with opioids. A model of bone cancer pain in which the progression of cancer pain and bone destruction is tightly controlled was used to evaluate the effects of sustained morphine treatment. In cancer-treated mice, morphine enhanced, rather than diminished, spontaneous, and evoked pain; these effects were dose-dependent and naloxone-sensitive. SP and CGRP positive DRG cells did not differ between sarcoma or control mice, but were increased following morphine in both groups. Morphine increased ATF-3 expression only in DRG cells of sarcoma mice. Morphine did not alter tumor growth in vitro or tumor burden in vivo but accelerated sarcoma-induced bone destruction and doubled the incidence of spontaneous fracture in a dose- and naloxone-sensitive manner. Morphine increased osteoclast activity and upregulated IL-1 beta within the femurs of sarcoma-treated mice suggesting enhancement of sarcoma-induced osteolysis. These results indicate that sustained morphine increases pain, osteolysis, bone loss, and spontaneous fracture, as well as markers of neuronal damage in DRG cells and expression of pro-inflammatory cytokines. Morphine treatment may result in "add-on" mechanisms of pain beyond those engaged by sarcoma alone. While it is not known whether the present findings in this model of osteolytic sarcoma will generalize to other cancers or opioids, the data suggest a need for increased understanding of neurobiological consequences of prolonged opioid exposure which may allow improvements in the use of opiates in the effective management of cancer pain.     

Quantification of the left atrium applying cardiovascular magnetic resonance in clinical routine

Objectives. In recent years the impact of the left atrium (LA) has become more evident in different cardiovascular pathologies. We aim to provide LA parameters in healthy volunteers for cardiovascular magnetic resonance (CMR) using a fast approach. Design. We analyzed 203 healthy volunteers (mean age 44.6 years (y), range 19y–76y) at 1.5 and 3.0 Tesla (T) using steady-state free precession (SSFP) cine in routine long axis view. Left atrial enddiastolic volume (LA-EDV), endsystolic volume (LA-ESV), stroke volume (LA-SV) and ejection fraction (LA-EF) were quantified and indexed to body-surface-area (BSA). Dependency on age and sex was analyzed. Results. 21 subjects had to be excluded. In the remaining, there was no significant difference between 1.5 T and 3.0 T. Absolut LA-EDV and LA-ESV were larger in men than in women (LA-EDV: male 70?±?19?ml vs. female 61?±?16?ml (p?=?.001); LA-ESV: male 24?±?9?ml vs. female 21?±?8?ml (p?=?.01)). These differences disappeared after indexing to BSA (LA-EDV/BSA: male 34?±?10?ml/m² vs. female 33?±?9?ml/m² (p?=?.65) and LA-ESV/BSA: male 12?±?4?ml/m² vs. female 11?±?4?ml/m² (p?=?.71)). LA-EDV/BSA decreased with older age. Conclusions. Reference values for LA size and function based on a fast approach are provided. LA size decreases with older age. Normalization to body size overcomes sex-dependency. Reports should be related to body size.     

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution

Background

The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution.

Methods

Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann–Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost.

Results

There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost.

Conclusions

Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.