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At least 1,369 records · Page 76Linked to original sources
PubMed1998

Differential projections from gustatory responsive regions of the parabrachial nucleus to the medulla and forebrain.

The present study combined extracellular electrophysiology with anterograde and retrograde tracing techniques to determine efferent projections from taste responsive sites within the parabrachial nucleus (PBN). Taste activity was recorded from two distinct regions of the PBN, the waist region consisting of the ventrolateral (VL) and central medial (CM) subnuclei, and the external region, consisting of the external medial (EM) and external lateral (EL) subnuclei. Ascending and descending projections from these two regions differed. Small biotinylated dextran injections placed in taste responsive sites in the waist area produced a prominent descending projection to the medullary parvocellular reticular formation, a projection nearly non-existent from the external region. Differences in ascending projections were more subtle. Projections to the thalamus were bilateral in all cases, however, the waist region had a larger ipsilateral thalamic projection than the external region and the external region had a larger contralateral projection compared to the waist. Central nucleus of amygdala (CNA) projections from the waist area were primarily from posterior tongue responsive sites in VL and terminated in the central medial and lateral CNA subnuclei; external region projections were distributed to the capsular region of CNA. Both the external and waist region projected to substantia innominata (SI). Different efferent projections from the two gustatory responsive regions of the PBN may reflect functional specialization of PBN subnuclei. Descending projections from orally responsive sites in the waist area project to the lateral parvocellular reticular formation, a region implicated in brainstem circuitry underlying consummatory components of ingestive function. The external region, contains cells responsive to pain and oral aversive stimuli, but does not apparently contribute directly to local brainstem functions. Rather, forebrain pathways appear critical to the expression of external region functions.

Animals↗
PubMed1997

The path to a clinical pathway: collaborative care for the patient with an ostomy.

A colostomy and ileostomy clinical pathway was developed at a southeastern teaching hospital in 1990 in response to excessive lengths of stay and costs at our hospital compared with national data for this patient group. A multidisciplinary clinical pathway team was formed and charged with the development, implementation, and ongoing monitoring of the clinical pathway tool and its effect on the outcomes of the population of patients with colostomies and ileostomies. Through this multidisciplinary collaboration, length of stay and cost have been reduced while quality care indicators have been maintained. This article presents the sample pathway we developed and describes the pathway development process, documentation, the variance analysis process, and the outcomes achieved with implementation. A urostomy/urinary diversion pathway that was developed after variance analysis review of the colostomy and ileostomy clinical pathway is also presented.

Analysis of Variance↗
PubMedDate not supplied

Development, implementation, and ongoing monitoring of pathways for the treatment of gastrointestinal cancer at a comprehensive cancer center.

The purpose of this article is to explain the process used in the development and implementation of care pathways in a comprehensive cancer center in the Southwest. The pathways are a major component of the disease management process that defines a multidisciplinary standard of practice for a specific episode of care and measure outcomes as a basis for quality and cost improvement. Patients may be on several pathways as they progress through cancer treatment.

Cancer Care Facilities↗
PubMed1997

Spine update. Clinical pathways.

Health care providers are becoming increasingly involved with the development of clinical pathways as they take on more of the responsibilities of quality management and resource use. Although clinical pathways that are developed at the national, regional, or specialty organization level provide a framework for reference, locally developed pathways tailor care to patients who are served within an agency or community. As multidisciplinary teams develop pathways for patients with back and spine disorders, they create tangible definitions of quality. Variance tracking systems used in conjunction with pathways provide feedback on patient progress and outcomes. These guidelines have significant potential for the future.

Critical Pathways↗
PubMedDate not supplied

An interdisciplinary, evidence-based process of clinical pathway implementation increases pathway usage.

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.

Aged↗
PubMed2005

In-hospital care pathway delays: gender and myocardial infarction.

AIM: This paper reports the in-hospital findings of a study identifying gender specific care pathway delays or treatment opportunities amongst Irish women and men hospitalized with myocardial infarction. BACKGROUND: Reperfusion therapy is of optimum benefit when administered early, yet research shows that women continue to experience greater in-hospital delays to treatment than men. METHOD: A 1-year prospective census was carried out from December 2001 to November 2002 with 277 (31%) female and 613 (69%) male patients with myocardial infarction who were consecutively admitted to the six major teaching hospitals in Dublin, Ireland. RESULTS: Women experienced greater 'Triage to first medical assessment' delays than men (P=0.001), and waited a median of 30 minutes for their first medical contact, compared with 20 minutes for men (P<0.0001). The median 'door to needle' time for women was 70 minutes in comparison with 52 minutes for men (P=0.02). Women waited longer than men for aspirin (P=0.02), whilst men received a bed in the coronary care unit almost 1 hour sooner than women (P<0.0001). Despite these delays to treatment, women and men experienced similar rates of reperfusion treatment. CONCLUSIONS: In-hospital treatment delays experienced by women may limit their potential to achieve the maximum benefits from reperfusion therapies. Triage nursing provides the first entry point to hospital care for the majority of female patients with myocardial infarction, and therefore Accident and Emergency Department nurses are in an optimum position to influence positively the pathway of care for this group.

Angioplasty, Balloon, Coronary↗
PubMed2000

A pathway for patients who die within a week of hospice admission.

Care pathways have recently been developed for hospice patients who die within one week of admission. This development was motivated by a number of factors. First, under managed care cost constraints, it is sometimes difficult to obtain early hospice admission approval because of certain reimbursement regulations. Second, patient and family wishes change during the illness trajectory as patients move through the stages of death and dying. Third, and most important to the caregiver, is that the philosophy adopted within care pathways advocates that patients should not suffer at the end of life. This article outlines the rationale for the formation of care pathways and describes a care pathway developed for a specific group of patients.

Attitude of Health Personnel↗
PubMed1998

The role of clinical pathways in reducing the economic burden of stroke.

Clinical pathways are a potentially beneficial, but largely untested, management strategy for both improving healthcare efficiency and decreasing costs while also maintaining or improving quality of care. Although relatively few clinical pathways for stroke have been described in the medical literature and although the reported benefits have been mixed, more and more hospitals are adopting clinical pathways as a management strategy for patients with stroke. In published clinical pathways for acute stroke, the following benefits have been reported: (i) reduced use of expensive diagnostic studies; (ii) fewer complications (particularly the frequency of urinary tract infections and aspiration pneumonia); (iii) reduced duration of hospital stay; (iv) reduced patient charges; and (v) lower mortality. However, these reported benefits are not consistent across all studies and some outcomes are highly correlated. Despite potential benefits, many clinical pathway programmes fail because of inadequate planning and shortcomings of implementation. Effective implementation of clinical pathways requires strong administrative and medical staff leadership, active participation of all clinical disciplines involved in the care of patients on the pathway, provision of regular feedback to clinicians, sufficient resources, improved documentation, incorporation of the entire episode of care into the pathway, integration with ongoing quality and utilisation management programmes, and periodic evaluation and modification.

Cerebrovascular Disorders↗
PubMed1997

The value of clinical pathways in home care.

Providing cost-effective, high-quality care can pose a challenge in this era of managed care. One agency successfully established and implemented multidisciplinary teams to organize and optimize care. Two case studies compare the nursing process of traditional versus well-managed care and show that clinical pathways can be effective tools to enhance the nursing process in home care.

Cost-Benefit Analysis↗
PubMed1998

Supportive care pathway comforts the terminally ill.

The supportive care pathway at Brookwood Medical Center in Birmingham, AL, is a different kind of pathway, de-emphasizing length of stay in favor of streamlining the care of terminally ill patients. The path differs from traditional pathway efforts in four respects: lack of tests and interventions, focus on both the patient and the family, utilization of phases of the dying process rather than days or hours, and a focus on the psychosocial, spiritual, and emotional aspects of care for the patient and family. The three phases of the pathway are admission (decision is made for palliative care), transition (symptom management), and terminal (peaceful death).

Alabama↗
PubMed1999

Development of clinical pathways for stroke management: an example from Saint Luke's Hospital, Kansas City.

Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. It evolved through the collaboration of a multidisciplinary team of clinical experts and is still evolving. Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.

Case Management↗
PubMed2001

Clinical pathways set to experience 'technological rebirth'.

The state of the art in case management care plans is automation. Larger hospital systems are at the beginning of a technological rebirth, and that includes acute care clinical pathways, according to case managers at New York University Medical Center in New York City and Emory University Hospital in Atlanta. Despite some minor glitches, and the perennial issue of getting physician support for pathways, the systems are up and running. Users are hopeful that pathway technology will continue to improve and someday be linked electronically to outcomes software.

Academic Medical Centers↗
PubMed2003

Protocol-based care: 1. How integrated care pathways work.

This paper opens a series on protocol-based care by introducing the concept, revisiting its definitions and components, and considering the factors that influence the development of protocols. Part one discusses the aims of integrated care pathways implemented by multidisciplinary teams and reflects on their benefits to patients, staff and organisations.

Clinical Protocols↗
PubMed2006

IT support for clinical pathways--lessons learned.

Clinical pathways are an effective instrument to decrease undesired practice variability and improve clinician performance. IT applications embedded into clinical routine work can help to increase pathway compliance. Successfully implementing such applications requires both a responsive IT infrastructure and a participatory and iterative design process aimed at achieving user acceptance and usability. Experiences from the implementation and iterative improvement of an online surgical pathway at Marburg University Medical Centre have shown that pathway conformance actually could be improved by the use of IT. An analysis of the iterative design process has shown that future pathway projects can benefit from the lessons learned during this project. Based on these lessons a method for developing well adapted interaction mechanisms is presented, which is aimed at improving process alignment. Our goal is to build up a library of tested reusable components to reduce the number of iterations for pathway implementation.

Academic Medical Centers↗
PubMed1998

Transcranial magnetic stimulation in study of the visual pathway.

The authors critically reviewed experiments in which transcranial magnetic stimulation (TMS) and repetitive TMS (rTMS) of the higher visual pathway were used. Topics include basic mechanisms of neural excitation by TMS and their relevance to the visual pathway (excitatory and inhibitory effects), TMS and rTMS of calcarine cortex (suppression, unmasking, and phosphenes), TMS of V5 (suppression), TMS and rTMS of higher level temporoparietooccipital areas (perceptual errors, unmasking, and inattention), the role of frontal lobe output in visual perception, and vocalization of perceived visual stimuli (role of consciousness of linguistic symbols).

Attention↗
PubMed1991

Surgical interruption of postganglionic innervation of the sinoatrial nodal region.

Recent experiments have revealed synapses that selectively mediate right and left vagal regulation of sinoatrial function in the fat pad overlying and surrounding the right pulmonary vein complex. However, precise vagal postganglionic pathways to the sinoatrial region have remained obscure. Such pathways, including critically important neural inputs to sinoatrial and atrioventricular nodal regions, may be vulnerable to surgical approaches to atrial or intracardiac repair. The present experiments seek to delineate specific autonomic pathways to the sinoatrial region of the canine heart. The distal ends of the cut right and left cervical vagi and the right and left ansae subclaviae were electrically stimulated (10 to 20 Hz, 1 msec, 2 to 3 V) before and after surgical incisions were placed. Cut No. 1 was made longitudinally along the ventral caval surface from the pericardial reflection caudally to the pulmonary vein fat pad, cut No. 2 was made from the caudal end of cut No. 1 transversely across the sulcus terminalis to a point midway across the anterior (ventral) surface of the right atrium. Each incision was closed with 4-0 silk, with care being taken to avoid injury to either the sinoatrial nodal or the pulmonary fat pad regions. In four of seven animals, these two incisions totally interrupted vagal input to the sinoatrial node, whereas in the remaining three dogs a residual inhibitory influence remained. These residual fibers were surgically ablated by excision of globular fat pads situated on the rostrodorsal surfaces of the right superior pulmonary vein, suggesting a dorsorostral route into the interatrial septum and thence to the sinoatrial node. There was little or no interruption of either right or left vagal input to the atrioventricular nodal region; sympathetic supplies to both sinoatrial nodal and atrioventricular nodal regions remained essentially intact after the two incisions. Thus the major parasympathetic postganglionic projections to the sinoatrial node in the dog heart are by way of the free wall of the right atrium and are vulnerable to surgical interventions in this portion of the heart.

Animals↗
PubMed2001

Critical role of cAMP-GEFII--Rim2 complex in incretin-potentiated insulin secretion.

Incretins such as glucagon-like peptide-1 and gastric inhibitory polypeptide/glucose-dependent insulinotropic peptide are known to potentiate insulin secretion mainly through a cAMP/protein kinase A (PKA) signaling pathway in pancreatic beta-cells, but the mechanism is not clear. We recently found that the cAMP-binding protein cAMP-GEFII (or Epac 2), interacting with Rim2, a target of the small G protein Rab3, mediates cAMP-dependent, PKA-independent exocytosis in a reconstituted system. In the present study, we investigated the role of the cAMP-GEFII--Rim2 pathway in incretin-potentiated insulin secretion in native pancreatic beta-cells. Treatment of pancreatic islets with antisense oligodeoxynucleotides (ODNs) against cAMP-GEFII alone or with the PKA inhibitor H-89 alone inhibited incretin-potentiated insulin secretion approximately 50%, while a combination of antisense ODNs and H-89 inhibited the secretion approximately 80-90%. The effect of cAMP-GEFII on insulin secretion is mediated by Rim2 and depends on intracellular calcium as well as on cAMP. Treatment of the islets with antisense ODNs attenuated both the first and second phases of insulin secretion potentiated by the cAMP analog 8-bromo-cAMP. These results indicate that the PKA-independent mechanism involving the cAMP-GEFII--Rim2 pathway is critical in the potentiation of insulin secretion by incretins.

Animals↗