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Noninvasive imaging of spontaneous retinoblastoma pathway-dependent tumors in mice.

Identification of the critical pathways involved in tumorigenesis should ultimately lead to the design of better anticancer agents that target specific components of the disrupted pathways. Murine models of spontaneous cancer in which tumor formation is dependent on defined genetic alterations provide a powerful test system for evaluating the therapeutic efficacy of pathway-specific antineoplastics. We have generated a conditional mouse model for retinoblastoma-dependent sporadic cancer that permits noninvasive monitoring of pituitary tumor development in live animals via in vivo bioluminescence imaging of luciferase expression. We show that the high sensitivity of bioluminescence imaging can be used for noninvasive detection of luciferase expression in pituitary glands from tumor-free animals and for in vivo quantitation of tumor burden over a large dynamic range. This mouse model permits longitudinal monitoring of tumor onset, progression, and response to therapy and may be used effectively for testing cancer prevention and treatment strategies based on therapeutics that specifically target the retinoblastoma pathway.

Animals↗

Case management: a new practice model for ET nurses.

An examination of wound, ostomy, and continence nursing practice provides ideas for improving patient care and for role development of the ET nurse. During this period of rapid health care reform, opportunities to expand ET nursing practice must be explored. For many ET nurses, care of the patient with an ostomy remains a primary focus. The fitting of prosthetic equipment and patient education concerning ostomy care may not, however, be enough to demonstrate the impact of ET nursing care on the outcome of patients with an ostomy. Caring for the patient undergoing gastrointestinal surgery by means of a case management model is a new option for ET nurses. Nurse case managers focus on the patient and the impact of illness from admission until discharge. They are accountable for coordinating the multidisciplinary team who cares for the patient and for the evaluation of outcomes. ET nurses must evaluate the outcomes of their care to demonstrate the continued need for our specialty practice. This article describes the efforts of ET nurses at a tertiary care center in the Midwest to develop a case management system for patients undergoing gastrointestinal surgery within their practice. The process of developing a critical pathway, or care map, is also described.

Case Management↗

Defining pathways.

AIMS AND BACKGROUND: The term 'clinical pathway' is internationally accepted in all settings of healthcare management. The way in which clinical pathways have been developed in the United Kingdom differs from that in the USA. Besides the international differences in the purpose, many alternative names also can be found. These have led to confusion. There is no single, widely accepted definition of a clinical pathway. The aim of the study was to survey the definitions used in describing the concept and to derive key characteristics of clinical pathways. METHOD: Using the PubMed, we conducted a review of literature published between January 2000 and December 2003 using the following terms: critical pathway, clinical pathway, integrated care pathway, care pathway and care map. All reports reviewed had to use the concept, as defined by the Medical Subject Headings term, to be considered. To assess all definitions, the concept analysis method was used. RESULTS: In 82 of the 263 eligible articles, the definition of pathway was given. Totally, we found 84 different definitions. Each definition was rephrased by taking into consideration the following three features inherent to pathways: nouns, characteristics and aims and outcomes. Every feature was further divided into categories. CONCLUSIONS: A clinical pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time. A clinical pathway explicitly states the goals and key elements of care based on Evidence Based Medicine (EBM) guidelines, best practice and patient expectations by facilitating the communication, coordinating roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; by documenting, monitoring and evaluating variances; and by providing the necessary resources and outcomes. The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction and increase the efficiency in the use of resources.

Critical Pathways↗

[Clinical pathways: bases, description and potential uses in neurology].

Over the last 10 years, we have witnessed the introduction of different procedures for coordinating clinical care, often shown as new tools in the hospital administration setting. Clinical or critical pathways are among these standardization methods of health care. In this article, we describe the characteristics of the clinical pathways and review their potential uses in neurology, especially in common conditions like stroke. In the following, we describe a clinical pathway for treating acute episodes in patients with relapsing-remitting of secondarily progressive forms of multiple sclerosis which was developed in the Son Dureta Hospital, in Palma de Mallorca, Spain. We carry out a critical assessment of this and other standardization methods.

Critical Pathways↗

Orthotopic neobladder reconstruction after radical cystectomy.

Urinary diversion with continent urinary reservoirs to the urethra offer major advantages to patients with invasive bladder carcinoma. Multiple configurations for pouch creation have been described, however, there are unifying concepts between all types of continent diversions which should be adhered to in order to optimize outcome. These general concepts are discussed and the author's technique for small and large intestinal neobladder construction is presented. Perioperative management is delivered using a collaborative care critical pathway technique and has resulted in excellent outcomes.

Anastomosis, Surgical↗

Functional significance of Tie2 signaling in the adult vasculature.

Abundant data now demonstrate that the growth of new blood vessels, termed angiogenesis, plays both pathological and beneficial roles in human disease. Based on these data, a tremendous effort has been undertaken to understand the molecular mechanisms that drive blood vessel growth in adult tissues. Tie2 recently was identified as a receptor tyrosine kinase expressed principally on vascular endothelium. Disrupting Tie2 function in mice resulted in embryonic lethality with defects in embryonic vasculature, suggesting a role in blood vessel maturation and maintenance. Based on these studies, we undertook a series of studies to probe the function of Tie2 in adult vasculature that will form the focus of this chapter. Consistent with a role in blood vessel growth in adult vasculature, Tie2 was upregulated and activated in the endothelium of rat ovary and in healing rat skin wounds, both areas of active angiogenesis. Moreover, Tie2 was upregulated in the endothelium of vascular "hot spots" in human breast cancer specimens. Surprisingly, Tie2 also was expressed and activated in the endothelium of all normal rat tissues examined, suggesting a role in maintenance of adult vasculature. To determine the functional role of Tie2 in tumor vasculature, a soluble Tie2 extracellular domain (ExTek) was designed that blocked the activation of Tie2 by its activating ligand, angiopoietin 1 (Ang1). Administration of recombinant ExTek protein or an ExTek adenovirus inhibited tumor growth and metastasis in rodent tumor models, demonstrating a functional role for Tie2 in pathological angiogenesis in adult tissues. To begin to understand the endothelial signaling pathways and cellular responses that mediate Tie2 function, we identified signaling molecules that are recruited to the activated, autophosphorylated Tie2 kinase domain. Two of these molecules, SHP2 and GRB2, are part of the pathway upstream of mitogen-activated protein kinase (MAPK) activation, a pathway that may be responsible for morphogenetic effects of Tie2 on endothelial cells. Another signaling molecule, p85, is responsible for recruitment of phosphatidylinositol 3 kinase (PI3-K) and activation of the Akt/PI3-K pathway. Akt/PI3-K has emerged as a critical pathway downstream of Tie2 that is necessary for cell survival effects as well as for chemotaxis, activation of endothelial nitric oxide synthase, and perhaps for anti-inflammatory effects of Tie2 activation. Taken together, these studies and many others demonstrate that the Tie2 pathway has important functions in adult tissues, in both quiescent vasculature and during angiogenesis, and help to validate the Tie2 pathway as a therapeutic target.

Animals↗

Effect of posterior hypothalamic injection of procaine on the hippocampal theta rhythm in freely moving cats.

Earlier in vivo studies conducted on freely moving and anesthetized rats demonstrated that the posterior hypothalamus (PH) comprises pathways critical for producing the synchronous hippocampal formation (HPC) theta rhythm. In addition, these findings suggested that the frequency of the HPC theta was encoded in the PH and then was fed via the medial forebrain bundle to the medial septum and HPC. In the present study we attempted to verify this hypothesis with use of a different in vivo model--freely moving cats. The microinjection of the local anaesthetic, procaine, into the PH region reversibly suppressed the spontaneous as well as sensory and electrically induced HPC theta. However, in contrast to rats, in freely moving cats microinjection of procaine into the PH reduced the amplitude of the HPC theta but had no effect on theta frequency. We conclude that in freely moving cats the PH region comprises a critical part of the ascending brainstem pathway, for production of the HPC theta rhythm. In contrast to rats, in freely moving cats ascending inputs from the brainstem to the PH contribute mainly to the amplitude of the HPC theta rhythm.

Anesthetics, Local↗

Effect of feedback on resource use and morbidity in hip and knee arthroplasty in an integrated group practice setting.

OBJECTIVE: To assess the effect of a structured program of feedback about resource utilization and morbidity on resource consumption and complications in an orthopedic surgical practice. DESIGN: We prospectively analyzed use and outcomes before and after an intervention (departmental data presentation). MATERIAL AND METHODS: Feedback on resource utilization and morbidity for 2,820 patients who underwent a primary total hip or knee arthroplasty for a diagnosis of osteoarthritis between Jan. 1, 1990, and Dec. 31, 1992, was provided to members of the orthopedic department of an academic medical center. Data were adjusted for severity of disease. RESULTS: On reassessment 18 months after the beginning of the feedback program, total charges and length of hospital stay for hip or knee arthroplasty were significantly reduced. Interpractitioner variability was also reduced but not significantly. The feedback process was instrumental in identifying a specific complication--pulmonary embolism after bilateral total knee replacement--which was significantly reduced by addition of warfarin prophylaxis. CONCLUSION: The intervention was successful in reducing resource use (length of hospital stay) and complications (pulmonary embolism). In addition, total charges for hip and knee arthroplasty declined significantly at a time when medical center charges overall were increasing. Efforts to maintain continuous improvement will primarily focus on the development of critical pathways.

Critical Pathways↗

Critical decision making in the management of patients with acute myocardial infarction and other acute coronary syndromes.

The decision-making process for emergency physicians in managing patients with signs or symptoms of AMI or unstable angina is quite different than that used by other specialists who might evaluate such patients in a less critical setting (e.g., a cardiologist seeing a private patient in an office or outpatient clinic environment). The emergency physician's evaluation must be highly focused and follow established principles of emergency medicine (Fig. 2). Although the evaluation and treatment of all patients must be individualized to some degree, increasing experience at high-volume centers nationally indicates that well-constructed institutional strategies, protocols, and critical pathways can help emergency physicians to provide consistent, cost-effective management of such patients.

Algorithms↗

Cognitive-behavioral interventions to manage depression in patients with cancer: research and theoretical initiatives.

The incidence of depression is rising worldwide, possibly due to urban crowding and insufficient resources. This pandemic raises the possibility that disabling depression among patients with cancer will increase. Already, about one-third of patients with cancer present with depression. Although many progressive cancer centers are instituting psychooncology services, the projected decline in numbers of psychiatrists in the coming decade suggests that these programs may flounder unless nurses are able to provide adjuvant support. Consequently, this article describes the theoretical and emerging research data base regarding the treatment of cancer-related depression with cognitive-behavioral therapy. Implications drawn from this review suggest that nurses can take an active role in preventing and managing cancer-related depression in direct care environments by developing critical pathways for screening, prevention, treatment, and outcomes assessment using theory-based research.

Adult↗

Factors that enhance or impede critical care nurses' discharge planning practices.

INTRODUCTION: Any illness that is serious enough to require admission to the critical care unit will intensify the physical and psychological effects that the patient and their significant others experience. Hence, the discharge needs of patients admitted to critical care are unquestionably complex, diverse and dynamic. METHODS: Utilising an exploratory descriptive approach 502 critical care nurses, identified from the Australian College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A 31-item questionnaire was developed and distributed. A total of 218 eligible participants completed the survey. One-to-one semi-structured interviews with 13 Victorian critical care nurses were also conducted. RESULTS: Participants reported that a lack of time was a barrier to discharge planning. Communication however, could enhance or impede the discharge planning process in critical care. Participants considered that the critical pathway, used in the care of cardiothoracic patients, did assist with communication of discharge planning processes, hence enhancing the process. CONCLUSIONS: While these findings provide some understanding of the factors that enhanced or impeded critical care nurses' discharge planning practices further research is indicated. The findings reported here may, however, provide a starting point for improving the discharge planning process in critical care.

Adult↗

Cost-effectiveness and cost-efficiency in vascular surgery.

Medical costs have been an increasing focus of attention in medicine in general, particularly in the United States health care environment. Because vascular disease is most prevalent in the elderly, the forecasted growth of this population over the next several decades will put increasing strains on health care financing. Costs will undoubtedly be a major component of any system of outcomes measurement, and it is important for vascular surgeons and others who specialize in vascular disease to be familiar with the definitions and methodology and cost-effectiveness analysis. Similarly, improving cost efficiency within the practice of vascular surgery will be mandated. The purpose of this article is to review systems of cost-effectiveness analysis as they pertain to vascular surgery, as well as to define critical pathway models that have been used to improve cost-efficiency in vascular surgery.

Cost-Benefit Analysis↗

Hematopoietic stem cell fate is established by the Notch-Runx pathway.

Identifying the molecular pathways regulating hematopoietic stem cell (HSC) specification, self-renewal, and expansion remains a fundamental goal of both basic and clinical biology. Here, we analyzed the effects of Notch signaling on HSC number during zebrafish development and adulthood, defining a critical pathway for stem cell specification. The Notch signaling mutant mind bomb displays normal embryonic hematopoiesis but fails to specify adult HSCs. Surprisingly, transient Notch activation during embryogenesis via an inducible transgenic system led to a Runx1-dependent expansion of HSCs in the aorta-gonad-mesonephros (AGM) region. In irradiated adults, Notch activity induced runx1 gene expression and increased multilineage hematopoietic precursor cells approximately threefold in the marrow. This increase was followed by the accelerated recovery of all the mature blood cell lineages. These data define the Notch-Runx pathway as critical for the developmental specification of HSC fate and the subsequent homeostasis of HSC number, thus providing a mechanism for amplifying stem cells in vivo.

Animals↗

Public trust and initiatives for new health care partnerships.

Effective communication between doctor and patient is a critical component of high-quality care. The physician's credibility has a significant effect on treatment outcomes. Because changes in medicine and larger cultural trends challenge the ability of clinicians to engage their patients' trust, new kinds of partnerships must be created. To do this effectively, physicians have to sharpen their communication skills and devise strategies for assuring that their patients become informed allies in their own treatment. A number of innovations are helping to build these alliances: training in communication skills; creative uses of the Internet and videotape technologies; improved "customer service" programs; critical pathways for patients; and special educational aids. All these tools promise to be useful, but they require careful development and evaluation.

Clinical Competence↗

Tuberculin testing in patients with human immunodeficiency virus/acquired immune deficiency syndrome.

After declining for decades, the incidence of Mycobacterium tuberculosis is increasing. The Mantoux tuberculin skin test, which uses purified protein derivative (PPD) of tuberculin, has been used for years as a screening device to detect the presence of exposure and infection to tuberculosis. However, the advent of human immunodeficiency virus (HIV) has elicited many questions regarding the validity of traditional standards for PPD administration and interpretation. The uncertainties in interpreting tuberculin skin tests in immunocompromised individuals is part of the challenge that is being faced by the health-care profession in this 2nd decade of acquired immune deficiency syndrome. This article will help advanced practice nurses understand the relationship between the immune system, tuberculosis, and the PPD skin test; the problem of anergy with immunocompromised patients, particularly those who are HIV-infected; issues involved in placement and interpretation of the results of the PPD test; new Agency for Health Care Policy and Research (AHCPR) standards for PPD interpretation with HIV-infected persons; the "booster" effect and two-step PPD testing; concerns regarding bacille Calmette-Guérin vaccine; and the use of a critical pathway to aid in rapid identification and isolation of the patient with HIV admitted with a potential diagnosis of tuberculosis versus Pneumocystis carinii pneumonia.

AIDS-Related Opportunistic Infections↗

Evaluation of variances in patient outcomes.

New knowledge and understanding about improving the quality and reducing the costs of care will come from careful scrutiny of the variations in the outcomes of nursing interventions. Nurses need to systematically identify and measure outcomes, understanding the probabilistic nature of these patient responses to the care received. Using a formative evaluation process, nurses should measure degrees of patient outcomes over time to ascertain the effects of nursing care and analyze the variances in these observed outcomes from what was expected. Critical pathways are valuable tools for guiding evaluations of nursing care along a timeline and can lead to improvements in nursing care.

Analysis of Variance↗

Fast track recovery of elderly coronary bypass surgery patients.

BACKGROUND: To ascertain whether early extubation and fast-track treatment protocols are feasible in elderly patients, we analyzed 487 consecutive patients who had isolated coronary artery bypass grafting between January 1995 and June 1997, constituting the experience of a single surgeon. METHODS: Management consistently applied to all patients emphasized early extubation protocol, tepid cardioplegia and normothermic bypass to reduce pump times, early mobilization and chest tube removal, and protocol treatment of atrial fibrillation. Elderly patients at least 70 years old (n = 176, mean age 75 years) were compared with younger patients (n = 311, mean age 58 years). RESULTS: The hospital mortality rate was 0.8% (4 of 487 patients), and there was no difference in the operative mortality rate of the older cohort versus the younger cohort (0.6% versus 0.9%; p > 0.05). Older patients had a higher incidence of peripheral vascular disease, congestive heart failure, prior strokes, renal failure, and cerebrovascular disease (p < 0.05). Early extubation was achieved in 71% of younger patients versus 57% of older cohort (95% confidence interval, 14%+/-9%; p = 0.002). Older patients had significantly higher incidence of postoperative atrial fibrillation (27% versus 14%; 95% CI, 13%+/-7%; p < 0.001), a factor responsible for shorter length of stay among younger patients (5.6+/-2.8 days versus 7.2+/-3.7 days; 95% CI, 1.6+/-0.3 days; p < 0.001). Nonetheless discharge before the fifth postoperative day was achieved in 34% of the elderly patients. CONCLUSIONS: Although elderly patients have a higher acuity of illness, critical pathways for accelerated discharge are safe and feasible in most elderly patients.

Adult↗

Practice innovation: a methodological maze.

Practice innovation is an inevitable feature of a health culture preoccupied with evidence-based practice. The cyclical process of defining best practice, implementing and evaluating change represents an unparalleled opportunity for nurse researchers to engage in, and develop, practice through 'realistic evaluation'. However, the methodological dilemmas and challenges inherent in evaluation research which informs policy should not be under-estimated. This paper seeks to introduce and wrestle with some of the political tensions and methodological issues surrounding practice innovation when it is undertaken within an evaluative research framework. A critical pathway is presented to stimulate discussion and guide novice evaluators through this often perplexing methodological maze. A case study in audiological rehabilitation in elder care is used to illustrate the issues raised.

Aged↗