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PubMed2005

Thromboembolism and anticoagulant management in hemodialysis patients: a practical guide to clinical management.

The need for anticoagulation in dialysis patients is common and the incidence of venous thromboembolism (VTE) and atrial fibrillation in this population is high. While direct data are lacking on the management of anticoagulation in dialysis patients, careful weighing of risks and benefits on the basis of evidence from other populations is crucial. VTE should be managed with adjusted dose warfarin for most patients. Placement of an inferior vena cava filter is a reasonable option for those patients with unacceptable bleeding risks. Studies are ongoing to assess the safety of some low-molecular-weight heparins (LMWH), which may potentially be useful for long-term anticoagulation in hemodialysis patients. In atrial fibrillation the available data on risk of bleeding, risk of stroke, and patient preferences should all be taken into account when considering long-term anticoagulation. We have constructed an evidence model to help quantitate the risks and benefits for an individual patient. The impact of dialysis on risk of bleeding is such that the risk of bleeding will outweigh the benefit in many patients, and anticoagulation will not be used: in some of these patients aspirin therapy may be an alternative. Finally, in the area of prevention of graft and access thrombosis, some randomized controlled trials are available, but none have to date shown benefit from anticoagulation for primary or secondary prevention of thrombosis, and the risk of bleeding in these studies was high.

Anticoagulants↗
PubMed2004

Aspects of decision support in water management--example Berlin and Potsdam (Germany) II--improvement of management strategies.

Methods related to partial order theory such as the Hasse diagram technique (HDT) are increasingly used in the field of multi-criteria decision support. The HDT has the advantage of being a transparent evaluation tool, supported by several data analysis tools such as the concept of antagonistic indicators. However, the evaluation usually does not lead to a clear decision, because more than one possible solution is offered. In the example presented here, three of the nine water management strategies (scenarios) evaluated by HDT were identified as winners. However, these strategies were not comparable with each other because of the conflicting evaluation of at least two different indicators. Such antagonisms describe the advantage and disadvantage of each scenario. Based on this background information, a new innovative approach is demonstrated, enabling the stakeholders to design new, modified management strategies, with reduced negative effects. After improvement of the three potential solutions, one clear winner scenario could be identified.

Decision Support Techniques↗
PubMed1982

Hepatic hemangioma in childhood: medical management or surgical management?

Between 1955 and 1980 there were 14 patients treated at The Hospital for Sick Children with hemangiomas of the liver. Eight were seen at birth and 13 within the first 6 wk of life. The presenting clinical feature was that of massive hepatomegaly. Two children who had presented in the neonatal period were found to have had cardiac failure. Six patients were anemic and required blood transfusions. Before 1976 all patients who did not have cutaneous hemangiomas underwent laparotomy. Since 1976 only one laparotomy was done, the remaining 5 patients all having been treated symptomatically without operation. All the tumors involuted in the first year of life. Follow-up ranged from 1 to 20 yr and all are living and without symptoms. We recommend no active treatment if complications are absent. Steroids and radiotherapy are not used. If anemia and/or cardiac failure supervene, appropriate nonoperative management is necessary. Surgical treatment is indicated only if medical management fails or for rupture of the lesion.

Child↗
PubMed1995

Breast cancer management--a look forward. A view of breast cancer management in the United Kingdom in 1995 and the year 2000.

This paper endeavours to contrast the modes of presentation and techniques used in diagnosis and management policies of a 40-year-old woman with breast cancer at present, and as it is likely to be in the year 2000. An attempt is made to review the situation as it occurs across the UK at present, followed by an attempt to forecast how a similar patient is likely to be managed in the year 2000. The nature of the task inevitably involves generalizations, suppositions, hypotheses, informed guesswork and sheer speculation. The challenge is to stimulate thought and discussion among breast clinicians, so that appropriate and desirable changes may be anticipated, and consensus sought in utilising resources to move toward them.

Adult↗
PubMed2000

Crisis resource management among strangers: principles of organizing a multidisciplinary group for crisis resource management.

Patient safety depends on the skills, vigilance, and judgment of trained individuals working as members of a clinical team that includes anesthesiologists, surgeons, nurses, and technicians. Now, as never before, safe outcome depends both on better knowledge and better management. This requires organization of caregivers, who may be strangers from diverse disciplines, into teams. One can drill an individual to work safely alone. One can rehearse a series of scenarios with small groups (who regularly work together) to improve performance. But what does one do with an unrehearsed group, called together in an emergency from several different disciplines, usually including Anesthesia. These people may not know each other, their roles, their special skills, and may even be hazy about each other's goals. Rapid organization of such an ad hoc team becomes a critical priority where patient safety is at stake. The way by which such an ad hoc team from several disciplines can rapidly be helped to function effectively together is by teaching all the "strangers" the principles of Crisis Resource Management. These principles are not as well-presented in a written text or lecture format, as one cannot introduce the sense of urgency that emotionally charges and changes the impact. We believe the best teacher is experience gained in a realistic simulated environment using a model driven, full human simulator. This simulated environment is safe for both patient and trainee.

Communication↗
PubMed2001

Comparative effectiveness of an integrated pest management system and other control tactics for managing the spider mite Tetranychus ludeni (Acari: Tetranychidae) on eggplant.

The effect of an integrated pest management (IPM) package, host plant resistance, Chrysoperla carnea predation and neem oil were evaluated against the spider mite Tetranychus ludeni on eggplant (Solanum melongena L.) fields in 1996 and 1997, by estimating the mite population density and yield levels. Compared with the IPM package (Panruti local, C. carnea plus neem oil), the standard (susceptible) eggplant variety (MDU1) grown by farmers and treated with an acaricide (dicofol) had significantly higher mite densities. The predator C. carnea was recorded in significantly lower numbers in plots with the standard variety compared to a resistant variety (panruti local) with the full IPM package. Eggplant yield level and crop value were highest in the IPM-treated plots followed by Panruti local plus C. carnea. The standard variety treated with an acaricide had the lowest yield and value. These results indicated the usefulness of host plant resistance complemented by biorational control agents, such as C. carnea and neem oil, that these are suitable components in an IPM programme for managing the spider mite in endemic areas.

Animals↗
PubMed1998

Staged diabetes management: computerizing a disease state management program.

Recently, the Diabetes Control and Complication Trial (DCCT) and other similar studies have demonstrated that near-normalization of blood glucose in diabetes will reduce complications up to 75% but translation of these results into practice has been difficult. In an attempt to help provide the best possible control of patients with diabetes, we have produced an attempt to help provide the best possible control of patients with diabetes, we have produced a new disease state management system for diabetes, called "Staged Diabetes Management" (SDM), implemented it in over 100 sites worldwide, and developed a computer program to simplify its use. SDM, designed to change the way we deal with patients with diabetes, is based upon five principles: (1) community involvement in setting care guidelines; (2) negotiation of goals with patients; (3) appropriate timelines for therapeutic success; (4) use of flowcharts for medical decisions; and (5) evaluation of the program. SDM is designed to be altered by a community to meet its needs and resources. It encourages primary care physicians to deliver better diabetes care using a team approach and to refer patients with diabetes to specialists when appropriate. It has a complete set of materials for communities, individual health care providers and patients. SDM has been tested for changes in structure, process and outcomes. A meta-analysis of seven clinical trials with over 500 patients has shown a time-weighted average fall in hemoglobin A1c of 1.7 points (equivalent to a drop in mean blood glucose of about 3.5 mM or 60 mg/dL). Preliminary pharmacoeconomic analysis demonstrates a lifetime cost saving of over $27,000 per patient. A computer program has been developed for the Microsoft Windows environment that contains a client-server database, based upon DiabCare, for the data file structure.

Adult↗
PubMed1997

Terror management and cognitive-experiential self-theory: evidence that terror management occurs in the experiential system.

The authors hypothesized, on the basis of terror management theory and cognitive-experiential self-theory, that participants in an experiential mode of thinking would respond to mortality salience with increased worldview defense and increased accessibility of death-related thoughts, whereas participants in a rational mode would not. Results from 3 studies provided convergent evidence that when participants were in an experiential mode, mortality salience produced the typical worldview defense effect, but when participants were in a rational mode it did not. Study 4 revealed that mortality salience also led to a delayed increase in the accessibility of death-related thoughts only when participants were in an experiential mode. These results supported the notion that worldwide defense is intensified only if individuals are in an experiential mode when considering their mortality. Discussion focuses on implications for understanding terror management processes.

Adaptation, Psychological↗
PubMed1999

Dimensions of choice in the assessment and care management process: the views of older people, carers and care managers.

The aim of promoting the maximum possible choice for service users and carers is - together with the goal of greater independence - central to recent community care policies. This paper sets out a typology of those key choices which users and carers are expected to be able to make within each stage of the assessment and care management process: choices about what services, when to receive them (i.e. at what times and for what duration) and from whom (i.e. which provider organization and which individual care worker). Drawing on interviews with 28 older service users, 20 informal carers and 22 care managers across four local authority areas in England, the paper goes on to describe the extent to which such choices - both at the strategic/macro and operation/micro level - have increased or decreased in practice. The evidence confirms that of other recent studies that the gap between the 'ideal' of user and carer involvement and the 'reality' of everyday practice is still considerable.

Journal Article↗
PubMed2003

Diagnosis and management of the painful shoulder. Part 2: examination, interpretation, and management.

Diagnosis, interpretation and subsequent management of shoulder pathology can be challenging to clinicians. Because of its proximal location in the schlerotome and the extensive convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns can be broadly distributed to the deltoid, trapezius, and or the posterior scapular regions. This pain behavior can make diagnosis difficult in the shoulder region, as the location of symptoms may or may not correspond to the proximity of the pain generator. Therefore, a thorough history and reliable physical examination should rest at the center of the diagnostic process. Effective management of the painful shoulder is closely linked to a tissue-specific clinical examination. Painful shoulder conditions can present with or without limitations in passive and or active motion. Limits in passive motion can be classified as either capsular or noncapsular patterns. Conversely, patients can present with shoulder pain that demonstrates no limitation of motion. Bursitis, tendopathy and rotator cuff tears can produce shoulder pain that is challenging to diagnose, especially when they are the consequence of impingement and or instability. Numerous nonsurgical measures can be implemented in treating the painful shoulder, reserving surgical interventions for those patients who are resistant to conservative care.

Journal Article↗
PubMed2002

Randomized, controlled trial of integrated heart failure management: The Auckland Heart Failure Management Study.

AIMS: To determine the effect of an integrated heart failure management programme, involving patient and family, primary and secondary care, on quality of life and death or hospital readmissions in patients with chronic heart failure. METHODS AND RESULTS: This trial was a cluster randomized, controlled trial of integrated primary/secondary care compared with usual care for patients with heart failure. The intervention involved clinical review at a hospital-based heart failure clinic early after discharge, individual and group education sessions, a personal diary to record medication and body weight, information booklets and regular clinical follow-up alternating between the general practitioner and heart failure clinic. Follow-up was for 12 months. One hundred and ninety-seven patients admitted to Auckland Hospital with an episode of heart failure were enrolled in the study. There was no significant difference between the intervention and control groups for the combined end-point of death or hospital readmission. The physical dimension of quality of life showed a greater improvement in the intervention group from baseline to 12 months compared with the control group (-11.1 vs -5.8 respectively, 2 P=0.015). The main effect of the intervention was attributable to the prevention of multiple admissions (56 intervention group vs 95 control group, 2 P=0.015) and associated reduction in bed days. CONCLUSIONS: This integrated management programme for patients with chronic heart failure improved quality of life and reduced total hospital admissions and total bed days.

Adult↗
PubMed2005

[Consequence of evidence-based medicine and individual case appraisal of the Robodoc method for the MDK, and the malpractice management of insurance funds and the principles of managing innovations].

PURPOSE: Robots in Total Hip Replacement were introduced to utilize the precision of an industrial robot for reaming the femur. This method has been discussed controversially from the beginning of its clinical application in Germany. Criticism increased recently especially in respect of alleged malpractice. Aim of this study was to describe the consequences of the results of a systematic review and the evaluation of malpractice accusations for statutory health insurance and medical advisory services. METHOD: Robot-assisted total hip replacement was evaluated by a Health Technology Assessment report, especially concerning proof of clinical benefit and specific complications of this method. 44 cases of alleged malpractice reported to health insurance were assessed as well and compared with the results of the systematic review. RESULTS: The HTA report showed no proof of clinical benefit but pointed to increased rates of complications. In the 44 evaluated cases the entire range of endoprosthesis- but no robot-specific complications could be identified. CONCLUSION: Patients must be informed about risks, complications, benefits and especially alternatives to a robot-assisted operation. The prospective procedure of management of assumed malpractice concerning Robodoc can not be standardised, but each case must be evaluated individually. Consequently, implementation of a structured malpractice management system for health insurance and medical advisory services should be useful. Additionally, health service should implement an "early warning system" for innovative procedures.

Arthroplasty, Replacement, Hip↗
PubMed2000

Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries.

Two alternative treatment methods for preventive interventions for pressure ulcers, tele-rehabilitation and contingency management, are discussed. Telerehabilitation uses a videophone that transmits both audio and still images over a telephone line. Using this technology, the WOC nurse can interview a patient who cannot be present at a clinic because of physical condition or distance. Telerehabilitation allows the nurse to assess a patient's pressure ulcer, consult with appropriate caregivers, and make recommendations for treatment. Contingency management procedures are designed for patients with high rates of noncompliance in skin care. The patients are seen as outpatients and are compensated systematically for appropriate skin care (ie, the lack of pressure ulcers). Examples of each of these patient interventions is described, discussed, and contrasted.

Ambulatory Care↗
PubMed2003

Self-management: its place in the management of chronic illnesses.

Self-management programs are now regarded as important facets in the overall care of people with chronic illnesses. They are seen as producing long-lasting benefits both to participants and to the health system in terms of reduced hospitalisations and reduced lengths of stay, as well as decreasing medication usage. In this article we examine what constitutes self-management and the evidence supporting the views that the benefits are unequivocal. We argue that greater attention to research design is required before the benefits can be assessed. We also argue that greater attention must be paid to access issues for people from culturally and linguistically diverse backgrounds (CALD) and lower socioeconomic status.

Australia↗
PubMedDate not supplied

A framework for managing system disturbances and insights from air traffic management.

System disturbances are likely to be a key factor affecting the acceptance and safety of future automation. Since hardware and software are rarely totally reliable, humans are always required in socio-technical command and control environments such as air traffic management (ATM). Unfortunately, human-automation interaction is known to be problematic, particularly when the human assumes a monitoring or back-up role. Hence an understanding of how humans manage system disturbances is required, together with a method of looking at the problem for new systems. In this paper we outline a contextual framework of the process by which people recover from system disturbances, together with literature data and findings from 31 interviews with ATM personnel. The framework describes the context and causes of a problem, the problem itself, the effect and exposure, the recovery process, and the outcome. The framework, together with the research findings and operational experience, is also the basis for a performance prediction tool called the Recovery from Automation Failure Tool (RAFT).

Aircraft↗
PubMed1995

The MRI study as a diagnostic and therapeutic indicator in the non-surgical management of temporomandibular joint disorders: phase I management--a case report.

The dental profession frequently points to occlusion, muscle disorders or psychological stress as principal causes of temporomandibular joint (TMJ) disorders. Diagnosis and management is confusing, and no general consensus exists. Recent advances in magnetic resonance imaging (MRI) have allowed a means of evaluating large numbers of patients for internal derangements in an objective non-invasive fashion. This has unequivocally confirmed prior arthrographic and surgical observation that partial or complete dislocation of the articular disk with condylar compression of sensitive superior posterior joint space neurovascular elements is the principal pathophysiologic mechanism of TMJ disorders. TMJ disorders have been shown to be a general progression of degenerative joint disease characterized by joint space compression with displacement and degeneration of articular hard and soft tissues, most commonly the result of trauma. This article illustrates how the author has combined several different dental and medical diagnostic procedures with clinical therapeutic measures to manage patients to improved function and remission of symptoms by controlling the position of the joint hard structures in an objective fashion.

Adult↗
PubMedDate not supplied

Chronic pain management: a qualitative study of elderly people's preferred coping strategies and barriers to management.

Although the majority of pain complaints, in Australia, are among the elderly population, the focus of treatment is not on this age group. In order to achieve effective management of elderly people's chronic pain, their perspective of pain and coping strategies used needs to be understood. This qualitative study explored the preferred strategies of elderly people and the barriers they encountered in trying to manage their pain. Elderly people (n = 72) with chronic pain, over 65 years of age and living in the community, were interviewed for the study. Data were collected using six focus group and 12 in-depth interviews and a biographical questionnaire. Preferred coping strategies were those that could be self-administered and included both physical and cognitive elements. Elderly people wished to be active in their treatment, make informed choices and were willing to try new methods. Least-preferred strategies were the conventional treatments of medications, exercise and physiotherapy. Many barriers have to be overcome to achieve relief for their pain such as cost, access to health care, related disorders, attitudes of health professionals, lack of communication and fear of losing independence. Health professionals need to be aware of elderly people's perspective of pain and their preferred strategies and reasons for these choices. Health services must meet their specific needs.

Adaptation, Psychological↗
PubMed2003

Economics versus alleles: balancing integrated pest management and insect resistance management for rotation-resistant western corn rootworm (Coleoptera: Chrysomelidae).

Western corn rootworm, Diabrotica virgifera virgifera LeConte, has overcome crop rotation in several areas of the central United States. We expanded a simple model of adult behavior and population genetics to explain how rotation resistance may have developed and to study ways to manage the western corn rootworm in a landscape of corn, soybean, and winter wheat where evolution of resistance may occur. We modeled six alternative management strategies over a 15-yr time horizon, as well as a strategy involving a 2-yr rotation of corn and soybean in 85% of the landscape, to investigate their effectiveness from both a biological and economic perspective. Generally, resistance to crop rotation evolves in fewer than 15 yr, and the rate of evolution increases as the level of rotated landscape (selection pressure) increases. When resistance is recessive, all six alternative strategies were effective at preventing evolution of rotation resistance. The two most successful strategies were the use of transgenic rotated corn in a 2-yr rotation and a 3-yr rotation of corn, soybean, and wheat with unattractive wheat (for oviposition) preceding corn. Results were most sensitive to increases in the initial allele frequency and modifications of the density-dependent survival function. Economically, three alternative strategies were robust solutions to the problem, if technology fees were not too high. Repellant soybean, attractive rotated corn, and transgenic rotated corn, all in 2-yr rotations, were economically valuable approaches. However, even the currently common 2-yr rotation was economical when resistance was recessive and the actual costs of resistance would not be paid until far in the future.

Agriculture↗