Quality assurance and quality management in medical rehabilitation

External quality assurance in medical rehabilitation is characterized by the programs of Germany??s two largest providers of rehabilitation (the German pension insurance and the statutory health insurance). The programs were developed with considerable input from scientific institutes. Their strengths lie in measuring several relevant dimensions of quality, the comprehensive implementation for nearly all illnesses treated, integration of the patient perspective, and realization of prospective study designs with follow-up. Weaknesses include low relevance for patient allocation and compensation, the absence of systematic evaluations, and a lack of published patient information on the results of the quality measurements. Internal quality management in medical rehabilitation is regulated by sweeping legal guidelines. Since 2009, a statutory agreement has been in effect which includes a provision that all inpatient rehabilitation centers must be certified by October 2012. Areas for potential improvements in internal quality management processes include an improved theoretical basis, higher specificity for rehabilitation, and a more transparent, methodically improved structure of certification procedures.     

Glutamate cysteine ligase catalytic subunit promoter polymorphisms and associations with type 1 diabetes age-at-onset and GAD65 autoantibody levels.

The purpose of this study was to test the hypothesis that glutamate cysteine ligase catalytic subunit (GCLC) promoter polymorphisms are susceptibility factors for type 1 diabetes (T1D), T1D age-at-onset and T1D autoantibodies. T1D patients and control subjects from the Swedish Childhood Diabetes Registry and the Swedish Diabetes Incidence Study registry were genotyped for two GCLC promoter polymorphisms; the GCLC -129 C to T single nucleotide polymorphism (GCLC -129 SNP) and the GCLC GAG trinucleotide repeat polymorphism (GCLC TNR). Glutamate decarboxylase antibody (GAD65Ab) positive T1D patients with the GCLC -129 SNP C/T genotype have increased GAD65Ab levels (p-value, <0.05) compared to the GCLC -129 SNP C/C genotype. T1D patients with an age-at-onset of 14-35 years who possess the GCLC -129 SNP T/T genotype have a higher GAD65Ab index than T1D patients with the GCLC -129 SNP C/C genotype (p-value <0.05). In addition, T1D patients with an age-at-onset of 14-35 years possess the GCLC TNR 7/8 genotype at a lower frequency than the control subjects (OR, 0.33, 95% CI, 0.13-0.82). The GCLC -129 SNP and GCLC TNR appear to be in linkage disequilibrium (p-value<0.0001). These results suggest that GCLC promoter polymorphisms may influence GAD65Ab levels and may influence the age at which T1D is diagnosed.     

Intraoperative US diagnosis of pylephlebitis (portal vein thrombosis) as a complication of appendicitis: a case report

We report a case of infectious thrombosis of the superior mesenteric vein (pylephlebitis) that was suspected preoperatively with computed tomography and confirmed at intraoperative ultrasonography as confined to the extrahepatic portal vein and superior mesenteric vein. Intraoperative ultrasonography revealed intraluminal echogenic thrombus material in the dilated superior mesenteric and extrahepatic portal veins, slightly dilated open splenic vein, and numerous venous collaterals in the hepatoduodenal ligament. When preoperative imaging studies are inconclusive, intraoperative sonography can confirm the correct diagnosis of pylephlebitis and may give valuable information about the extent of the thrombosis. Received: 19 December 1995/Accepted: 31 January 1996     

Multifocality in Small Bowel Neuroendocrine Tumors

Background

Neuroendocrine tumors (NETs) account for 30% of small bowel (SB) neoplasms. The objectives of this study were to evaluate the incidence of multifocality in primary small bowel neuroendocrine tumors (SBNETs) and to examine the associated outcomes.

Methods

Patients with multifocal SBNET were compared to those with a solitary lesion. Only patients who underwent diagnostic workup and surgical intervention at our institution were included in this study. The primary aim of our study was surgical outcomes and mortality and recurrence. The second aim of our study was to evaluate the utility of double-balloon enteroscopy (DBE) and capsule endoscopy.

Results

Of 178 patients with SBNETs during the study period, 85 met inclusion criteria. The mean age was 61.0 ± 12.6 years and 44.7% were male. The ileum was the primary tumor site for 66 patients (77.7%). Of DBE patients, 28 (62.2%) had additional lesions identified, of which 23 (82.1%) had NET confirmed on pathology. Average tumor size was 1.8 cm and most were well differentiated (89.9%), with Ki-67 of ≥ 2% (65.8%); 74.4% had nodal metastases and 51% of patients had stage IV disease. Forty-six patients (54.1%) had multifocal disease, of whom 37 (80.5%) had an ileal primary. No differences in survival or recurrence were seen for multifocal versus solitary disease.

Conclusions

SBNETs have a high incidence of multifocality. DBE can be used in the preoperative assessment to detect multifocal NET. Multifocality has no impact on survival or recurrence outcomes.

     

The Effects of Non-Nutritive Sucking and Pre-Feeding Oral Stimulation on Time to Achieve Independent Oral Feeding for Preterm Infants

Background:

The survival rates of preterm infants has increased over the last years, but oral feeding difficulties are the most common problems encountered by them

Objectives:

This study aimed at comparing the effects of non-nutritive sucking (NNS) and pre-feeding oral stimulation on feeding skills, length of hospital stay and weight gain of 26-32 weeks gestational age preterm infants in NICU, to determine the more effective intervention.

Patients and Methods:

Thirty-two preterm infants were assigned randomly into three groups. One intervention group received pre-feeding oral stimulation program and the other received non-nutritive sucking stimulation, while the control group received a sham intervention. Gestational age of infants was calculated during 1, 4 and 8 oral feeding and discharge time from NICU. The infants’ weights were measured weekly from birth and at discharge time.

Results:

Mean gestational age on 8 time oral feeding per day, in 3 groups was not significant (P = 0.282). Although NNS and pre-feeding oral stimulation groups has fulfilled this criterion 7.55 and 6.07 days sooner than the control group, respectively (a result which is of great clinical and economic importance), but the difference did not reach statistical significance. Weight gaining at discharge time in NNS group was significantly higher than control and pre-feeding oral stimulation groups (P < 0.05).

Conclusions:

This study revealed that pre-feeding oral stimulation and NNS programs both were effective on oral feeding skills and weight gaining of the immature newborns. Yet, it seems that NNS program was more effective than pre-feeding oral stimulation on weight gaining.     

A systematic review of instruments measuring patients′ perceptions of patient‐centred nursing care

This systematic review identified and evaluated instruments measuring patients' perceptions of patient‐centred nursing care. Of 2629 studies reviewed, 12 were eligible for inclusion. Four instruments were reported: The Individualized Care Scale, the Client‐Centred Care Questionnaire, the Oncology patients' Perceptions of the Quality of Nursing Care Scale and the Smoliner scale. These instruments cover themes addressing patient participation and the clinician–patient relationship. Instruments were shown to have satisfactory psychometric properties, although not all were adequately assessed. More research is needed regarding test–retest reliability, convergent and discriminant validity, validity with known groups and structural validity using confirmatory factor analysis.     

Argon plasma coagulation in bronchology: a new method--alternative or complementary?

Argon plasma coagulation (APC) is a thermal coagulation technique that uses ionized argon to transmit high-frequency electrical current, contact free, to tissue. APC has been used in surgery for more than 20 years, particularly for the hemostasis of superficial bleeding. Although APC has become well established in gastrointestinal endoscopy since its introduction in 1991, very few reports of its use in bronchoscopy exist to date. From June 1994 to June 1998, 364 patients (80 women, 284 men), 88% with a confirmed malignant tumor, were treated prospectively in a total of 482 sessions. The single most common indication was recanalization of malignant airway stenoses (186 patients). The defined therapy objective was achieved with good results in 67% of patients. More than 90% of interventions were performed with rigid bronchoscopy. Despite less penetration compared with Nd:YAG laser, extensive bronchial tumors were treatable, in which coagulated tumor fractions were removed either with forceps or bronchoscope tip. The second indication was bleeding in the central airways (119 patients). Acute hemostasis was achieved in 118 patients, 20% in whom the flexible technique under local anesthesia was used. In 34 patients, APC was successfully used to recanalize occluded stents. Rare indications included benign endobronchial tumor, fistula conditioning before fibrin adhesion, and the treatment of scar tissue stenosis. Summarizing all complications, a rate of 3.7% "per treatment" was recorded. Two patients died within 24 hours; their deaths were not directly related to APC. APC is an effective and safe technique for the treatment of bronchologic tumor ablation and hemostasis and can be used with local anaesthetic with flexible bronchoscopy or rigid bronchoscopy with general anesthesia. Compared with Nd:YAG laser, APC is an economic alternative technique offering more effective hemostasis. Furthermore, APC is of particular value as a compliment to well-known techniques, increasing the options in interventional bronchoscopy.     

Individual and Combined Effects of Environmental Risk Factors for Esophageal Cancer Based on Results From the Golestan Cohort Study

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