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PubMedDate not supplied

Factors associated with nonprescription of evolving modes of therapy--a model for drug use evaluation in hospitalized medical patients.

OBJECTIVE: To measure the rate of inappropriate underuse of drug therapy among hospitalized patients and to identify factors associated with nonprescription of two effective modes of therapy. DESIGN: A survey was conducted by retrospective chart extraction to measure the rates of nonprescription of two therapeutic modalities--aspirin and angiotensin converting enzyme inhibitors. Stepwise logistic regression was used to determine which factors were significantly associated with nonprescription of either drug. SETTING: Two internal medicine departments in a major community and referral hospital in Israel. PATIENTS: Those who were hospitalized through 1990 with a diagnosis on their discharge sheet of angina pectoris or congestive heart failure. A random sample selection was made to define the study population. RESULTS: The rates of nonprescription among patients in whom there are no drug contraindications were 54% (95% CI 47-62) for aspirin and 34% (95% CI 27-41) for angiotensin converting enzyme inhibitors. Three variables correlated independently with nonprescription of both drugs: hospitalization in ward B, nonuse of the drug prior to hospitalization, and secondary priority of the diagnosis angina pectoris or congestive heart failure on discharge sheet. CONCLUSIONS: Nonprescription of essential drugs is a common phenomenon that varies significantly among physicians. Inconsistency in application of knowledge to clinical practice, as well as a diversity of approaches toward interpretations of clinical study results, significantly influences the prescription rates of evolving modes of therapy.

Angina Pectoris↗
PubMedDate not supplied

Evolving challenges in prehospital trauma services. Current issues and suggested evaluation tools.

For the past two decades, prehospital trauma care has been addressed almost generically in terms of the related approaches to epidemiology, research, and management. However, evolving directions in research have helped emergency medical services (EMS) practitioners to delineate more focused treatment strategies according to the mechanisms of injury, anatomic involvement, and the patient's clinical condition. Recent studies in the areas of trauma-associated circulatory arrest, severe blunt head injury, and post-traumatic hemorrhage following penetrating truncal injury suggest that current standard approaches to patient care should be reconsidered. In turn, this need for re-examination of trauma management strategies calls for the development of appropriate evaluation tools within EMS systems. Proper research design is dependent upon several key issues including: 1) the type of study (system study versus examination of a specific intervention); 2) the population under study; 3) physiological and anatomical scoring method; 4) prospective definitions of interventions and meaningful outcome variables (both morbidity and mortality); 5) relative outcome compared to known standards; and 6) prospective determination of statistical requirements.

Clinical Trials as Topic↗
PubMed1996

The evolving role of the health care supervisor: shifting paradigms, changing perceptions, and other traps.

As health care comes under mounting pressure to reduce costs, organizations are restructuring. Delivery systems are changing. As layoffs occur and changes are made in numbers and responsibilities of managers, supervisors find themselves in dramatically changing roles. Job security has become as illusory in health care as elsewhere. Morale among health workers is sagging, and motivational concerns are increasing. The supervisor has been put in the position of having to do more with less and to do it in the face of demoralized forces. The paradigms that were once operational are shifting, and the evolving role of the health care supervisor suggests that a completely new set of paradigms is taking over that suggests the supervisor's future security lies in the ability to learn new things and to shift and change with the environment.

Employment↗
PubMedDate not supplied

Measuring and improving quality and performance in an evolving health-care sector.

How can the challenges of quality measurement, assurance, and improvement be met at the national, state, and community levels? Can we sustain high levels of quality of care in an evolving health sector that wants to control costs and needs to extend access to millions of people? Can we find new ways to measure clinical practice performance and improve quality that will work more effectively in both the private and public sectors? All these questions demand answers in the context of contemporary circumstances.

Cost Control↗
PubMed1997

Effective managed care marketing strategies for evolving markets.

In a world of increased competition and changing consumer expectations, one of the keys to a fiscally sound health plan is having a dynamic marketing strategy that takes into account the shifting attitudes of consumers as managed care markets mature. The primary goal of any health plan marketing strategy should be the acquisition and retention of members. Providing cost-efficient and convenient service for enrollees, offering low or no deductibles, having convenient office locations, and minimizing paper-work are important elements of such a marketing strategy. Factors such as brand awareness and the perceived image of a health plan also are important considerations in acquiring and retaining market share. The relative importance of these consumer satisfaction criteria change as a managed care market evolves and matures. Financial and marketing managers, thus, should ascertain their market's stage of development and respond with appropriate marketing strategies.

Community Participation↗
PubMed1997

Evolving therapy for Helicobacter pylori infection: efficacy and economic impact in the treatment of patients with duodenal ulcer disease.

Helicobacter pylori infection is present in most patients with duodenal ulcer disease, and cure of H pylori infection has been shown to dramatically reduce ulcer recurrence. Therapeutic strategies for duodenal ulcer disease have rapidly evolved over the past several years in an effort to consistently cure H pylori infection in a safe, cost-efficient manner. This paper reviews the effectiveness of treatments for H pylori infection in patients assessed with duodenal ulcer disease. The impact of clinical success on economic effectiveness has been determined in a recent prospective outcomes trial. Treatments with clarithromycin plus omeprazole or clarithromycin plus ranitidine-bismuth-citrate (RBC) provide consistent cure of H pylori infection, with eradication rates of 70% to 80%. Recent studies suggest that higher rates of eradication are possible with triple combination therapy (e.g., clarithromycin plus a second antibiotic and a proton pump inhibitor or RBC), but the optimal triple therapy regimen (including the combination of drugs, dosage, and duration of treatment) has not yet been defined. A recent 1-year prospective outcomes trial has demonstrated that eradication therapy with clarithromycin and omeprazole, compared with standard antisecretory therapy, provides measurable savings in utilization of ulcer-related health-care resources. Combination therapy with clarithromycin plus omeprazole, clarithromycin plus RBC, or clarithromycin plus lansoprazole and amoxicillin have been approved for the treatment of H pylori infection in patients with duodenal ulcer disease. Economic analysis has confirmed that cure of H pylori infection not only contributes to the clinical resolution of duodenal ulcer disease, but also provides economic advantages by reducing costs associated with recurrence.

Anti-Bacterial Agents↗
PubMedDate not supplied

Evolving patterns of resistance to respiratory pathogens in Canada.

Active surveillance of changing resistance patterns is difficult but important for rational therapeutic choices. In Canada, penicillin resistance in Streptococcus pneumoniae has evolved more slowly than in other countries (in Europe and Israel rates exceed 50%). Currently, penicillin resistance is found in roughly 21% of Canadian isolates, and cross-resistance is becoming common. Beta-lactamase production is now found in approximately 28% of Haemophilus influenzae isolates, although more recently, rates over 30% have been found in some areas of Canada. In Moraxella catarrhalis, beta-lactamases are produced by 80% to 90% of bacteria, with resistance to trimethoprim/sulphamethoxazole also found. To date, there have been only a few reports of resistance to the fluoroquinolones. The apparent increase in the rate of development of resistance and cross-resistance will lead to new therapeutic challenges.

Anti-Bacterial Agents↗
PubMedDate not supplied

Mission committees' role evolves from operations to oversight.

Originally established in the 1970s to ensure that sisters serving in the health care ministry had input into governing board decisions, mission committees in the Holy Cross Health System, South Bend, IN, have evolved through three stages of development. In their early years, mission committees searched for an identity, struggling to define their roles and purpose. In the committees' second stage, activities were the dominant focus as organizations created an array of audiovisual presentations and educational programs. In the early 1980s lay employees began to assume their distinctive role in promoting the religious institute's mission, and the committees moved from an emphasis on operations to one on oversight and policy direction. Today the mission committees' membership includes not only governing board and congregational members but also the chief executive officer, the chief human resource office, and physicians. The system has strengthened the committees' role by charging them with responsibility for the human resources function. Although no single structure can ensure that an organization's identity is an integral part of the religious institute's mission, the mission committees' work in directing how the organization selects, orients, evaluates, and manages its employees gives clear evidence of the vitality of its mission objectives.

Catholicism↗
PubMed1988

The evolving role of health care organizations in research.

Many hospitals and health care organizations are contending with fierce financial and competitive pressures. Consequently, programs that do not make an immediate contribution to master strategy are often overlooked in the strategic management process. Research programs are a case in point. Basic science, clinical, and health services research programs may help to create a comprehensive and fundamentally sound master strategy. This article discusses the evolving role of health care organizations in research relative to strategy formulation. The primary costs and benefits from participating in research programs are examined. An agenda of questions is presented to help health care organizations determine whether they should incorporate health-related research as a key element in their strategy.

Cost-Benefit Analysis↗
PubMed1981

The evolving role of the medical director.

The role of the medical director is one that has been evolving for several decades in response to changing circumstances within the hospital environment. This article traces the development of that role and attempts to clarify significant issues surrounding the role such as how the person in that post functions within the governance structure of the hospital.

Hospital Administration↗
PubMed1998

Evolving Concepts about Aortic Stenosis.

Concepts about the management of aortic stenosis have evolved over the last several years. Concerns about the safety of exercise, positive inotropic drugs, and afterload reduction have been based on the expected exponential relationship of pressure and flow predicted by the Gorlin equation. However, in most patients, even those with severe stenosis, transvalvular pressure gradient increases much less than predicted with increases in cardiac output. Furthermore, data show that exercise testing usually can be performed safely and often provides helpful information about functional status and symptoms. In addition, positive inotropes and afterload-reducing drugs, when initiated cautiously, are often beneficial for these patients. Based on newly available data, physicians are encouraged to wait until symptoms develop before replacing the aortic valve in patients with severe stenosis. Patients with severe aortic stenosis but low transvalvular gradients because of left ventricular dysfunction should have functional testing with dobutamine or nitroprusside. If an increase in flow produces only a minimal increase in transvalvular velocity or pressure gradient, the patient is less likely to benefit from surgery. Risk for noncardiac surgery may not be as high as previously reported in most patients with aortic stenosis; again, functional testing can play an important role in their clinical assessment.

Journal Article↗
PubMed1999

Primary Parkinson's disease: the use of Tuina and acupuncture in accord with an evolving hypothesis of its cause from the perspective of Chinese traditional medicine--Part 2.

In Part II of this series, the author continues the discussion of a hypothesis based on acupuncture channel theory regarding the cause of Parkinson's disease (PD). A system of Yin-type Tuina, termed FSR (forceless spontaneous response) evolved from this theory; its clinical application has resulted in various degrees of relief from PD symptoms, (e.g., tremor, rigidity, decreased dyskinesia; improved balance, circulation) regardless of the stage of the disease, and in several cases enabled a reduction of conventional medication. This installment includes basic instruction in the technique, and a discussion of the dyskinesia which occurs during restoration of Qi to the Large Intestine and Stomach channels during treatment. A case study chronicles the weekly changes in symptoms typically experienced by patients during FSR therapy.

Acupuncture Therapy↗
PubMed1999

[Primary antiphospholipid syndrome evolving into systemic lupus erythematosus: a report of 3 new cases and a review of the literature].

The antiphospholipid syndrome (APS) is characterized by the presence of venous and arterial thrombosis, fetal losses, and thrombocytopenia, associated with the presence of antiphospholipid antibodies (aPL). This syndrome may be "primary" or associated with other diseases, particularly systemic lupus erythematosus (SLE). There is considerable debate on the interrelations between primary APS and SLE as well as on the value of the American College of Rheumatology (ACR) criteria to distinguish between both entities. Several authors have suggested that some patients with primary APS may ultimately develop SLE. Likewise, some authors have proposed exclusion criteria for primary APS. The presence of any of these criteria in a patient with the initial diagnosis of APS might indicate progression of SLE. Three new cases are here reported in whom the diagnosis evolved into SLE some years after the initial diagnosis of primary APS was made. Similar cases previously reported in the literature are reviewed.

Adult↗
PubMed1999

The evolving role of advanced practice nursing within the new Veteran's Health Administration.

The Veteran's Health Administration (VHA) is experiencing profound change in focus and organization of service delivery. The focus of the evolving VHA system includes improvements in performance outcomes, such as actual costs, better access, higher levels of customer satisfaction, and improved functional status of patients. Given the changing nature of service delivery in the VHA system and the contributions of the Advanced Practices Nurses (APNs), this article explores the expanding role of the APN within the VHA and presents a best practice model for achieving the full potential of advanced nursing practice.

Hospitals, Veterans↗
PubMed1999

Hormone-refractory prostate cancer: an evolving standard of care.

The treatment of advanced prostate cancer has evolved rapidly in the last several years. Therapeutic options for patients with advanced disease, once limited to the use of androgen deprivation, have expanded to include a number of interventions, including secondary hormonal manipulations, chemotherapy, and a variety of investigational approaches.

Antineoplastic Agents, Hormonal↗
PubMed1999

Rapidly evolving adult respiratory distress syndrome with eosinophilia of unknown cause in previously healthy active duty soldiers at an Army training center: report of two cases.

BACKGROUND: Two previously healthy soldiers presented with rapidly evolving adult respiratory distress syndrome (ARDS) within days of their return from the National Training Center at Fort Irwin, California. There have been six similar cases reported in the National Training Center area, five with fatal outcomes. METHODS: Both patients were treated in an intensive care unit setting. Extensive diagnostic testing was performed, and patients were treated empirically with doxycycline, ceftriaxone, and ribavirin. RESULTS: Both patients had complete recovery. Intensive care unit course was notable for circulatory collapse, respiratory distress requiring ventilatory support, approximately 10% eosinophils on bronchoalveolar lavage, and dramatic peripheral eosinophilia. All cultures, including serology cultures for hantavirus, were negative. CONCLUSION: There have been no previously described syndromes comprising "viral" prodrome, rapid progression to ARDS, and eosinophilia. Based on the geographic, temporal, and clinical similarity of these two cases, we believe that they share a common, yet undetermined, cause. Both environmental exposures and any undescribed pathogens warrant further investigation.

Adult↗
PubMed2000

The bacterial replicative helicase DnaB evolved from a RecA duplication.

The RecA/Rad51/DCM1 family of ATP-dependent recombinases plays a crucial role in genetic recombination and double-stranded DNA break repair in Archaea, Bacteria, and Eukaryota. DnaB is the replication fork helicase in all Bacteria. We show here that DnaB shares significant sequence similarity with RecA and Rad51/DMC1 and two other related families of ATPases, Sms and KaiC. The conserved region spans the entire ATP- and DNA-binding domain that consists of about 250 amino acid residues and includes 7 distinct motifs. Comparison with the three-dimensional structure of Escherichia coli RecA and phage T7 DnaB (gp4) reveals that the area of sequence conservation includes the central parallel beta-sheet and most of the connecting helices and loops as well as a smaller domain that consists of a amino-terminal helix and a carboxy-terminal beta-meander. Additionally, we show that animals, plants, and the malarial Plasmodium but not Saccharomyces cerevisiae encode a previously undetected DnaB homolog that might function in the mitochondria. The DnaB homolog from Arabidopsis also contains a DnaG-primase domain and the DnaB homolog from the nematode seems to contain an inactivated version of the primase. This domain organization is reminiscent of bacteriophage primases-helicases and suggests that DnaB might have been horizontally introduced into the nuclear eukaryotic genome via a phage vector. We hypothesize that DnaB originated from a duplication of a RecA-like ancestor after the divergence of the bacteria from Archaea and eukaryotes, which indicates that the replication fork helicases in Bacteria and Archaea/Eukaryota have evolved independently.

Amino Acid Sequence↗
PubMed2000

Cancer-related depression: Part II--Neurologic alterations and evolving approaches to psychopharmacology.

PURPOSE/OBJECTIVES: To describe evolving psychopharmacologic options for managing depression related to cancer. DATA SOURCES: Literature review and case study. DATA SYNTHESIS: Optimal recovery from depression requires early detection and selection of psychopharmacologic agents--singly or in combination--to address each depressive symptom. CONCLUSIONS: Adequate psychopharmacologic management of depression requires consistent, informed involvement of healthcare professionals, patients, and caregivers. Patients and caregivers need to be prepared to assess responses to therapy, recognize adverse effects, manage minor side effects and threats to adherence, and seek appropriate assistance for adverse events, including drug-drug interactions. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses need to take an active role in assessing, documenting, and monitoring patients' responses to antidepressants, particularly during key phases (e.g., induction, substitutions, augmentation, withdrawal). Nurses also need to take an active role in screening patients for depression, preparing patients and caregivers for psychopharmacologic management of depression, and reinforcing these competencies regularly. Oncology nurses also can be instrumental in recognizing signs and symptoms of treatment resistance and addressing these issues appropriately. Because of the rapid pace of psychopharmacologic research, oncology nurses need to update knowledge continuously to provide safe care to depressed patients with cancer.

Antidepressive Agents↗