Does e-pain plan improve management of sickle cell disease associated vaso-occlusive pain crisis? A mixed methods evaluation

PurposeThere is limited application and evaluation of health information systems in the management of vaso-occlusive pain crises in sickle cell disease (SCD) patients. This study evaluates the impact of digitization of paper-based individualized pain plans on process efficiency and care quality by examining both objective patient data and subjective clinician insights.MethodsRetrospective, before and after, mixed methods evaluation of digitization of paper documents in Children's Hospital of Pittsburgh of UPMC. Subjective perceptions are analyzed using surveys completed by 115 clinicians in emergency department (ED) and inpatient units (IP). Objective effects are evaluated using mixed models with data on 1089 ED visits collected via electronic chart review 28 months before and 22 months after the digitization.ResultsSurveys indicate that all clinicians perceived the digitization to improve the efficiency and quality of pain management. Physicians overwhelmingly preferred using the digitized plans, but only 44% of the nurses had the same response. Analysis of patient records indicates that adjusted time from analgesic order to administration was significantly reduced from 35.50 to 26.77 min (p < .05). However, time to first dose and some of the objective quality measures (time from administration to relief, relief rate, admission rate, and ED re-visit rate) were not significantly affected.DiscussionThe relatively simple intervention, high baseline performance, and limited accommodation of nurses’ perspectives may account for the marginal improvements in process efficiency and quality outcomes. Additional efforts, particularly improved communication between physicians and nurses, are needed to further enhance quality of pain management.ConclusionThis study highlights the important role of health information technology (HIT) on vaso-occlusive pain management for pediatric patients with sickle cell disease and the critical challenges in accommodating human factor considerations in implementing and evaluating HIT effects.     

Patient participation during oncological encounters: Barriers and need for supportive interventions experienced by elderly cancer patients

ObjectiveTo enhance patient participation during (oncological) encounters, this study aims to gain insight into communication barriers and supportive interventions experienced by elderly patients with cancer.MethodA mixed method design, including both quantitative (secondary survey data analysis) and qualitative (interviews) methods Survey data were used to identify communication barriers and need for supportive interventions of elderly cancer patients, compared to younger patients. Next, interviews provided in-depth insight into elderly patients’ experiences and underlying mechanisms.ResultsA majority of the 70 participating elderly cancer patients (53%) felt confident in communicating and participating during medical encounters. However, 47% of patients experienced barriers to effectively communicate with their healthcare provider and felt the need for supportive interventions. The 14 interviewed patients mentioned barriers and facilitators related to attributes of themselves (e.g. feeling sick, self-efficacy), the provider (e.g. taking patient seriously) and the healthcare system (e.g. time constraints).ConclusionsAlthough many elderly cancer patients feel confident, offering support to patients who feel less confident in communicating with their provider is recommended.Practice implicationsThe outcomes of this study can be used as a first step for developing interventions for elderly cancer patients to overcome communication barriers, and help providers to facilitate this process.     

Ectopically located gonads in a patient with mixed gonadal dysgenesis: detection by diffusion-weighted MRI

We report a case of mixed gonadal dysgenesis in which diffusion-weighted magnetic resonance imaging played a major role in the detection of ectopically located gonads. Magnetic resonance imaging may have a potential in detecting ectopically located gonads and may provide important information for the management of patients with mixed gonadal dysgenesis.     

Evaluation of a nurse-led disease management programme for chronic kidney disease: A randomized controlled trial

Background

Patients with end stage renal failure require dialysis and strict adherence to treatment plans to sustain life. However, non-adherence is a common and serious problem among patients with chronic kidney disease. There is a scarcity of studies in examining the effects of disease management programmes on patients with chronic kidney disease.

Objectives

This paper examines whether the study group receiving the disease management programme have better improvement than the control group, comparing outcomes at baseline (O1), at 7 weeks at the completion of the programme (O2) and at 13 weeks (O3).

Methods

This is a randomized controlled trial. The outcome measures were non-adherence in diet, fluid, dialysis and medication, quality of life, satisfaction, symptom control, complication control and health service utilisation.

Results

There was no significant difference between the control and study group for the baseline measures, except for sleep. Significant differences (p < 0.05) were found between the control and study group at O2 in the outcome measures of diet degree non-adherence, sleep, symptom, staff encouragement, overall health and satisfaction. Sustained effects at O3 were noted in the outcome measures of continuous ambulatory peritoneal dialysis (CAPD) non-adherence degree, sleep, symptom, and effect of kidney disease.

Conclusions

Many studies exploring chronic disease management have neglected the group with end stage renal failure and this study fills this gap. This study has employed an innovative model of skill mix using specialist and general nurses and demonstrated patient improvement in diet non-adherence, CAPD non-adherence, aspects of quality of life and satisfaction with care. Redesigning chronic disease management programmes helps to optimize the use of different levels of skills and resources to bring about positive outcomes.     

Mixed Infection with Two Types of Hepatitis C Virus Is Probably a Rare Event

Summary A search for the simultaneous presence of two hepatitis C virus (HCV) types in sera of a group of chronically infected intravenous drug users, hemodialysis patients and hemophiliacs from Sweden and Russia was performed with two genotyping methods based on the use of type-specific primers from core and NS4 regions of the viral genome. An important feature of NS4 based assay is that type-specific primers are used in both rounds of nested PCR, thus providing the possibility of the identification not only of the abundant type, but also of the minor HCV type present in a particular serum. The experiments, however, did not reveal the simultaneous presence of two or more HCV types in any of the 40 samples. These results suggest that the frequency of mixed infections in serum with different HCV types is very low even in high-risk groups, at least in the geographic region studied. Received: January 3, 1999 · Accepted: July 20, 1999     

Dietary-induced thermogenesis in obesity. Response to mixed and carbohydrate meals

Summary The possibility that dietary-induced thermogenesis may be decreased in obesity has been proposed in recent years. However, the results of human studies so far obtained are conflicting. The present research was undertaken in order to clarify this question. We studied postprandial thermogenesis induced by ingestion of a mixed meal and of a carbohydrate mixture in 15 normal and 12 obese subjects. Blood glucose and plasma insulin levels were measured at the same time. The data obtained have shown that the mean resting metabolic rate (RMR) expressed as a function of body weight^3/4, is almost the same in obese as in normal-weight subjects (0.115±0.018vs 0.133±0.021 kj/min/kg^3/4, respectively). Moreover, the increment of mixed-meal induced thermogenesis (MM-IT) was 48±22% in normal and −0.8±12% in obese subjects, respectively (p<0.01). Carbohydrate induced thermogenesis (CHO-IT) appeared slightly higher in normal-weight than in obese subjects (159±66vs 98±46). After carbohydrate ingestion we observed a higher glycemic and insulinemic response in obesity. These results indicate that thermogenesis induced by ingestion of food is reduced in obese subjects; they are also compatible with the idea that insulin resistance could play a role in this phenomenon.