Symptomatic palliative care for children with neurodisability

Paediatric palliative care and neurodisability are two relatively new, evolving paediatric sub-specialities that have increasing relevance in the current paediatric landscape. For many people palliative care has been synonymous with end of life care, but in paediatrics it encompasses much more and is for all children with life-threatening or life-limiting conditions, from the point of diagnosis. This breadth of focus is demonstrated well through the interface between paediatric palliative care and paediatric neurodisability. In this article we explore this unique interface through the three domains of complex symptom management, advanced care planning and end of life care. We describe the practicalities involved in all three areas and highlight the importance of early referral and the process of “dual” or “parallel” planning. We cover in more depth the specific management of the symptoms: dystonia/abnormalities of muscle tone, seizures, pain, agitation, secretions, respiratory failure, and gut failure.     

Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia

IntroductionA significant proportion of women report a reduction of symptoms over time—even without treatment—yet the natural progression of vulvodynia and which factors may explain decrease vs persistence of pain remain unclear.AimTo identify subgroups of pain trajectories in women with vulvodynia and to predict these different trajectories by treatments undertaken, pain characteristics, and psychosocial factors.MethodsData on pain intensity, treatments undertaken, pain characteristics, and psychosocial factors were collected 3 times over a 7-year period from 173 women who screened positive for vulvodynia. Latent class growth analysis was conducted to identify homogeneous subgroups with distinct pain trajectories. A multivariate binomial logistic regression was used to examine whether treatments, pain characteristics, and psychosocial factors predicted these trajectories.Main Outcome MeasureThe main outcome was pain intensity (0–10), measured at 3 time points with the numerical rating scale.Results2 pain trajectories were identified: 1 where pain persisted (28.9%), and 1 where pain decreased over time (71.1%). Whether a treatment had been undertaken was not predictive of the course of pain over time. Women who were older at first pain onset, had pain at another location than the entrance of the vagina, and reported more anxiety were more likely to have a persistent pain trajectory relative to the decreased pain trajectory.Clinical ImplicationsFindings suggest that the evolution of pain differs among women with vulvodynia depending on pain characteristics and anxiety.Strengths & LimitationsStrengths of the study include the 7-year longitudinal design to examine the natural history of provoked vestibulodynia and the inclusion of biopsychosocial factors as predictors of pain trajectories. However, women with major medical and psychiatric illnesses or deep dyspareunia were not included, and, thus, these factors could not be examined as predictors.ConclusionAssessing baseline characteristics associated with different pain trajectories during medical visits could have positive implications for the management of vulvodynia.Pâquet M, Vaillancourt-Morel M-P, Jodouin J-F, et al. Pain Trajectories and Predictors: A 7-Year Longitudinal Study of Women With Vulvodynia. J Sex Med 2019;16:1606–1614.     

Intraoperative Practice Variability in Total Knee Arthroplasty

BackgroundConsiderable practice variability exists among orthopedic surgeons performing total knee arthroplasty (TKA). The purpose of this study is to understand what TKA surgical and perioperative techniques are standard among high-volume academic knee arthroplasty surgeons.MethodsA written survey with 59 questions regarding management preferences in TKA was distributed by the 2018 John N. Insall Traveling Fellows to all arthroplasty-trained attending physicians at 13 medical centers, with 45 responses recorded.ResultsSurveyed surgeons performed unicompartmental knee arthroplasty (88%) and bilateral TKA (87%). Most surveyed surgeons rarely or never performed outpatient primary TKA (71%). Conventional alignment guides and cemented implants were used by 80% of respondents. Most surgeons used posterior-stabilized implants (67%), followed by cruciate-retaining (20%), ultracongruent (20%), and medial congruent or medial pivot designs (17.8%). Surveyed surgeons frequently or always resurfaced the patella (73%), used a tourniquet for the entire case (73%), and used tranexamic acid for all TKAs (91%). The most common locations for intra-articular anesthetic injection were the arthrotomy (91%), the periosteum (84%), and the medial posterior capsule (82%). Saline (62%) and dilute iodine (47%) were the most common irrigation fluids. The arthrotomy was most commonly closed with running barbed suture (60%) followed by interrupted vicryl (40%). Skin closure was predominantly with running monocryl (60%) followed by staples (29%). Anticoagulation for TKA was primarily aspirin 81 mg BID (60%).ConclusionThere was considerable variability among surgeons polled although a strong preference for more conventional and less developmental techniques prevailed.     

护理质量控制中心在提升基层医院护理管理质量中的作用

[目的]探讨护理质量控制中心在提升基层医院护理质量和管理水平的作用。[方法]护理质量控制中心指导基层医院建立完善的质量控制标准、质量评价体系,协助制订护士培训、检查、考核计划,并行使护理质量控制中心的监督、管理职责,促使各项制度得到有效落实。[结果]在护理质量控制中心的指导下,基层医院的护理管理体系、管理制度、评价体系逐步完善,护理人员业务水平、病人满意度及健康知识知晓率得到提升(P<0.05)。[结论]护理质量控制中心能在基层医院的护理质量管理中发挥积极作用。     

DRG支付方式改革下医院财务管理应对策略

通过探讨DRG支付方式改革下医院财务管理的应对策略,可以有效地降低医疗支付方式改革对医院财务管理的负面影响,促使医院财务管理在"危"与"机"的转换中抢抓机遇,促进医院财务管理提质增效。     

Avanzando en la sistematización del benchmarking en servicios de salud pública

Continuous management improvement should be an aspiration for all public sector organizations. External comparison or benchmarking identifies good practices in similar organizations. For public health services, it is not easy to obtain such indicators. The objectives of this paper are to describe the process of conducting a benchmarking exercise for a public health agency, and to share its results. For this purpose, agencies that may be compared were identified, and their websites were searched for annual reports or other documents with indicators of the activities or results of public health services. Limitations and contextual aspects of the indicators of the different organizations were identified, as well as ways to improve their comparability. Finally, a set of 19 indicators is proposed, as an initial core for quality management comparisons.