Pharmacy claims data as a tool to measure adherence

Abstract Medication possession ratio (MPR) was introduced as a uniform methodology for estimating medication adherence from pharmacy claims data, but it does not provide accurate information on the continuity of medication usage and the measurement of medication persistency and identification of eventual gaps in medication supply. The combination of an MPR and a persistency metric could provide timely information on the dynamics of patient medication adherence.     

Postoperative digestive fistulas. Etiopathogenic considerations

The digestive fistula is one of the most serious complications that might appear following different types of resectional digestive surgery. This condition still carries a considerable morbidity and mortality rate and therefore all surgical and ICU staff pay a great deal of attention and intensify their care to avoid the fatalities. The postoperative digestive fistulas, through their physiopathological and clinical complexity induce the disturbance of the biological equilibrium with vital consequences. The trend of the last decades is the increasing of digestive fistulas incidence with a variable mortality rate after different authors. A therapeutic algorithm is needed. The mortality rate due to digestive fistulas, two decades ago was, around 60%; at the present there is a decrease of the mortality rate, which is around 10%. The explanation is the introduction of the new methods of treatment such as lactic acid lavage aspiration for alkaline fistulas or total parenteral nutrition, continuous enteral nutrition and antiexocrine chemotherapy. A fistula is a communication between two epithelial or endothelial surfaces, lined by granulation tissue. It can be a life-threatening condition.     

Further psychometric analysis of the Florida Obsessive-Compulsive Inventory

This study examined the psychometric properties of the Florida Obsessive-Compulsive Inventory (FOCI [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851-859]). Participants were 89 adults with OCD presenting for treatment at a specialty clinic. A trained clinician administered the Yale-Brown Obsessive Compulsive Scale and patients completed the FOCI, Obsessive-Compulsive Inventory-Revised, Beck Depression Inventory-Second Edition, and State Trait Anxiety Inventory at baseline and following 14 weekly or daily cognitive behavioral therapy sessions. The internal consistency of FOCI Symptom Checklist and Severity Scale were good, and the concurrent and divergent validity of the FOCI Symptom Checklist and Severity Scale was supported through its associations with clinician-rated OCD symptom severity, and self-reported OCD, depressive, and anxiety measures. In addition, sensitivity to cognitive-behavioral treatment effects was shown as the Severity Scale scores were significantly lower following treatment compared to baseline. These findings not only replicate Storch et al. [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851-859] but also add unique construct validity data in support of the psychometrics of the FOCI.     

The use of extracorporeal membrane oxygenation in patients with therapy refractory cardiogenic shock as a bridge to implantable left ventricular assist device and perioperative right heart support

Implantation of left ventricular assist device (LVAD) as a bridge to recovery or transplantation is a widely accepted treatment modality. Preexisting organ dysfunction is thought to unfavorably affect patient survival after implantation of a ventricular assist device (VAD). We present our experience using extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock to stabilized organ function prior to LVAD implantation. Between September 2006 and March 2008, five patients in cardiogenic shock with preexisting organ dysfunction (impaired liver and kidney function) were supported with ECMO before LVAD implantation. ECMO-LVAD interval was 8 ± 4 days. All patients were transferred to a LVAD. At the LVAD implantation time, glutamic-oxaloacetic transaminase (GOT) decreased from 206.25 ± 106.93 Ul ⁻¹ to 70.6 ± 32.9 U l⁻¹, glutamic-pyruvic transaminase (GPT) decreased from 333.5 ± 207.3 U l⁻¹ to 77.8 ± 39.7 U l⁻¹, and creatinine decreased from 2.2 ± 0.9 mg dl⁻¹ to 1.2 ± 0.2 mg dl⁻¹. One patient died while on LVAD support due to not device related sepsis. One patient received successful heart transplantation. Overall survival was 80%. In all patients, we removed the ECMO 3 days after LVAD implantation. After removal of the ECMO there was no right heart failure. ECMO support can immediately stabilize circulation and provide organ perfusion in patients with cardiogenic shock. After improvement of organ function, LVAD implantation can be performed successfully in this patient collective. To avoid right ventricular failure, the ECMO should not be removed at the time of LVAD implantation, and used as a right ventricular support for the immediate postoperative period.     

Mobile and Fixed Computer Use by Doctors and Nurses on Hospital Wards: Multi-method Study on the Relationships Between Clinician Role,Clinical Task,and Device Choice

Background

Selecting the right mix of stationary and mobile computing devices is a significant challenge for system planners and implementers. There is very limited research evidence upon which to base such decisions.

Objective

We aimed to investigate the relationships between clinician role, clinical task, and selection of a computer hardware device in hospital wards.

Methods

Twenty-seven nurses and eight doctors were observed for a total of 80 hours as they used a range of computing devices to access a computerized provider order entry system on two wards at a major Sydney teaching hospital. Observers used a checklist to record the clinical tasks completed, devices used, and location of the activities. Field notes were also documented during observations. Semi-structured interviews were conducted after observation sessions. Assessment of the physical attributes of three devices—stationary PCs, computers on wheels (COWs) and tablet PCs—was made. Two types of COWs were available on the wards: generic COWs (laptops mounted on trolleys) and ergonomic COWs (an integrated computer and cart device). Heuristic evaluation of the user interfaces was also carried out.

Results

The majority (93.1%) of observed nursing tasks were conducted using generic COWs. Most nursing tasks were performed in patients’ rooms (57%) or in the corridors (36%), with a small percentage at a patient’s bedside (5%). Most nursing tasks related to the preparation and administration of drugs. Doctors on ward rounds conducted 57.3% of observed clinical tasks on generic COWs and 35.9% on tablet PCs. On rounds, 56% of doctors’ tasks were performed in the corridors, 29% in patients’ rooms, and 3% at the bedside. Doctors not on a ward round conducted 93.6% of tasks using stationary PCs, most often within the doctors’ office. Nurses and doctors were observed performing workarounds, such as transcribing medication orders from the computer to paper.

Conclusions

The choice of device was related to clinical role, nature of the clinical task, degree of mobility required, including where task completion occurs, and device design. Nurses’ work, and clinical tasks performed by doctors during ward rounds, require highly mobile computer devices. Nurses and doctors on ward rounds showed a strong preference for generic COWs over all other devices. Tablet PCs were selected by doctors for only a small proportion of clinical tasks. Even when using mobile devices clinicians completed a very low proportion of observed tasks at the bedside. The design of the devices and ward space configurations place limitations on how and where devices are used and on the mobility of clinical work. In such circumstances, clinicians will initiate workarounds to compensate. In selecting hardware devices, consideration should be given to who will be using the devices, the nature of their work, and the physical layout of the ward.     

Mustard oil enhances spinal neuronal responses to noxious heat but not cooling

The TRPA1 agonist mustard oil (allyl isothiocyanate = AITC) induces heat hyperalgesia and mechanical allodynia in human skin and sensitizes rat spinal wide dynamic range (WDR) neuronal responses to noxious skin heating. We presently used electrophysiological methods to investigate if AITC affects the responsiveness of individual spinal WDR neurons to intense skin cooling. Recordings were made from cold-sensitive WDR neurons in lamina I and deeper dorsal horn; 21/23 also responded to noxious skin heating. Topical application of AITC excited 8/18 units and significantly enhanced their responses to noxious heat while not significantly affecting responses to the cold stimulus. Vehicle (mineral oil) had no effect on thermal responses. The data confirm a role for the TRPA1 agonist AITC in enhancing heat nociception without significantly affecting cold sensitivity.