Teaching self-management of diabetes via telehomecare

This study demonstrates that telehomecare is an effective way to improve patient education and self-management outcomes. The cost effectiveness of this technology makes it an attractive medium for reaching patients who require close monitoring, reinforced teaching, and reassurance. telehomecare can also support caregivers and connect socially isolated individuals to their care providers. The possibilities for using telehomecare are just beginning to be realized. With the advent of PPS, telehomecare may be an effective substitute for visits that focus on teaching and monitoring. It is a new tool in the arsenal for the home care nurse to use for monitoring patients and promoting knowledge and behavior change. The video visits are short, focused opportunities for increased patient teaching; the one-on-one focus, audio-visual aids, and opportunities for patients to use the machines to self-monitor are all positive aspects.     

Coagulopathies in trauma patients

Coagulopathy after traumatic injury has multiple etiologies. It may result from overwhelming activation of tissue factor, consumption of circulating coagulation proteins, massive transfusion, metabolic alterations, hypothermia, or any combination of these factors. Despite advances in trauma resuscitation, the problem of persistent, life-threatening coagulopathy continues to pose a significant challenge for the healthcare team, and sometimes is an insurmountable obstacle in the path to recovery of the patient with trauma. Development of a coagulopathy has a significant impact on the morbidity and mortality of the patient with trauma. This article describes the relevant pathophysiology as it relates to the development of a coagulopathy, prevention strategies, and management principles applied in caring for the patient with trauma and a coagulopathy.     

The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate

OBJECTIVES: To describe the development of the Amputee Mobility Predictor (AMP) instrument designed to measure ambulatory potential of lower-limb amputees with (AMPPRO) and without (AMPnoPRO) the use of a prosthesis, and to test its reliability and validity. DESIGN: Measurement study using known groups method and concurrence with existing measures. SETTING: Academic medical center. PARTICIPANTS: A convenience sample of 191 lower-limb amputee subjects who had completed prosthetic training, 24 in the reliability study (mean age +/- standard deviation, 68.3+/-17.9y, range, 28-99y) and 167 in the validity study (mean age, 54.8+/-18.6y; range, 18-100y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Intra- and interrater reliability; construct validity by known groups method; concurrent validity by comparisons with 6-minute walk test, Comorbidity Index, age, and time since amputation; predictive validity by comparison with 6-minute walk test after controlling for other factors. RESULTS: Interrater reliability was.99 for subjects tested with and without their prosthesis; intrarater reliability was.96 and.97. Both the AMPnoPRO (P<.0001) and the AMPPRO scores (P<.0001) distinguished among the 4 Medicare functional classification levels. The AMP correlated strongly with 6-minute walk scores (AMPnoPRO r=.69, P<.0001; AMPPRO r=.82, P<.0001) and the amputee activity survey (AMPnoPRO r=.67, P<.0001; AMPPRO r=.77, P<.0001), and negatively correlated with age (AMPnoPRO r=-.69, P<.0001; AMPPRO r=.56, P<.0001) and comorbidity (AMPnoPRO r=-.43, P<.0001; AMPPRO r=.38, P<.0001). CONCLUSION: The AMP with and without a prosthesis are reliable and valid measures for the assessment of functional ambulation in lower-limb amputee subjects.     

Professional responsibility in relation to cervical spine manipulation

Manipulation of the cervical spine is one of the few potentially life-threatening procedures performed by physiotherapists. Is it worth the risk? A comparison of risks versus benefits indicates that at present, the risks of cervical manipulation outweigh the benefits: manipulation has yet to be shown to be more effective for neck pain and headache than other interventions such as mobilisation, whereas the risks, although infrequent, are serious. This analysis is of particular concern because the conditions for which manipulation is indicated are benign and usually self-limiting. Because physiotherapists have legal and ethical obligations to the community to avoid foreseeable harm and provide optimum care, it may be prudent to determine who in our profession should perform cervical manipulation. That is, the profession could restrict the practice of cervical spine manipulation. Although all registered physiotherapists in Australia are entitled to perform cervical manipulation, few choose to use this intervention. Therefore, it might be feasible to encourage those practitioners who wish to use cervical manipulation to undertake formal education programs. Such a requirement could be embodied in a code of practice that discourages those without formal training from performing cervical manipulation. By taking such measures, we could ensure that our profession exercises wisdom in its monitoring and use of cervical manipulation.     

A longitudinal evaluation of patients' perceptions of Parkinson's disease

PURPOSE: Parkinson's disease (PD) is a chronic progressive neurological disorder that frequently results in nearly total disability. This study examined changes over 3 years in patients' experiences living with PD, and explored how participants' health perceptions and predicted mortality at baseline related to their actual death by Year 3. DESIGN AND METHODS: Data were obtained from a local sample of 109 participants by in-home interviews. RESULTS: The collected results (1) suggested a disconnection between the participants' responses to open-ended questions about the disorder, compared with their responses to questions structured by the investigators; (2) demonstrated changes in responses to structured and open-ended questions; and (3) demonstrated that respondents who declined to predict whether they would be living in 10 years were three times more likely to die by Year 3 than those who answered the question. IMPLICATIONS: Results demonstrate the importance of identifying the most important issues for the individual with PD and suggest that these issues may change over time. Results also raise issues surrounding how patients' perceptions influence the course of their disease.     

Monocytes and peritubular capillary C4d deposition in acute renal allograft rejection

BACKGROUND: Peritubular capillary (PTC) deposition of complement split factor C4d in renal allografts has been shown to be closely associated with circulating antidonor antibodies and a marker for relatively poor graft survival. Monocyte/macrophage (MO) infiltration of renal allografts has been shown to adversely affect graft survival. The purpose of this study was to assess whether the two phenomena are related. METHODS: Twenty-three biopsies (from 15 patients) demonstrated diffuse strong staining of PTC for C4d (C4d+ group) and acute tubular injury with or without significant cellular rejection, while 28 biopsies (with acute rejection) but negative for PTC C4d served as controls (C4d- group). RESULTS: The C4d+ group demonstrated significantly greater glomerular and interstitial MO infiltration than did the C4d- group [3.4 +/- 2.0 vs. 0.2 +/- 0.3 MO/glomerulus, P < 0.0001; 12.9 +/- 9.2 vs. 6.5 +/- 5.0 MO/high power field (hpf), P = 0.0030]. Neutrophilic (PMN) infiltration of glomeruli and PTC was also significantly greater in the C4d+ group than in the C4d- one (0.8 +/- 0.6 vs. 0.3 +/- 0.3 PMN/glomerulus, P = 0.0003; 0.9 +/- 0.8 vs. 0.4 +/- 0.3 PTC PMN/hpf, P = 0.0035). CONCLUSION: The results indicate a close association between PTC C4d deposition and MO infiltration, particularly glomerular, and confirm previous observations regarding the correlation of PTC C4d staining and PMN infiltration.