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PubMed1996

Clinical pathway effects on treatment of the alcohol withdrawal syndrome.

We investigated whether initiating a clinical pathway, that incorporated the use of an alcohol withdrawal assessment scale, would decrease length of stay (LOS) for and/or amount of benzodiazepine prescribed during uncomplicated alcohol detoxification. We retrospectively reviewed alcohol detoxification admissions on an inpatient unit: 66 admissions before, 56 after, and 75 admissions 1-year after initiation of the pathway. Admissions were grouped into completers and non-completers. Comparison of group means before and after pathway implementation demonstrated a significant decrease in LOS for completers of the detoxification service from 7.35 to 4.77 days, and from 6.67 to 4.31 days for all admissions. Similarly, total benzodiazepine exposure decreased to a third of the mg amount given per admission prior to the pathway. There were no increases in the "irregular" discharge rate or complication rate. These findings suggest that a clinical pathway, with an incorporated withdrawal assessment scale, can decrease LOS and benzodiazepine prescribing on an alcohol detoxification unit.

Alcohol Withdrawal Delirium↗
PubMed2004

Comparison of functional aspects of the coagulation cascade in human and sea turtle plasmas.

Functional hemostatic pathways are critical for the survival of all vertebrates and have been evolving for more than 400 million years. The overwhelming majority of studies of hemostasis in vertebrates have focused on mammals with very sparse attention paid to reptiles. There have been virtually no studies of the coagulation pathway in sea turtles whose ancestors date back to the Jurassic period. Sea turtles are often exposed to rapidly altered environmental conditions during diving periods. This may reduce their blood pH during prolonged hypoxic dives. This report demonstrates that five species of turtles possess only one branch of the mammalian coagulation pathway, the extrinsic pathway. Mixing studies of turtle plasmas with human factor-deficient plasmas indicate that the intrinsic pathway factors VIII and IX are present in turtle plasma. These two factors may play a significant role in supporting the extrinsic pathway by feedback loops. The intrinsic factors, XI and XII are not detected which would account for the inability of reagents to induce coagulation via the intrinsic pathway in vitro. The analysis of two turtle factors, factor II (prothrombin) and factor X, demonstrates that they are antigenically/functionally similar to the corresponding human factors. The turtle coagulation pathway responds differentially to both pH and temperature relative to each turtle species and relative to human samples. The coagulation time (prothrombin time) increases as the temperature decreases between 37 and 15 degrees C. The increased time follows a linear relationship, with similar slopes for loggerhead, Kemps ridley and hawksbill turtles as well as for human samples. Leatherback turtle samples show a dramatic nonlinear increased time below 23 degrees C, and green turtle sample responses were similar but less dramatic. All samples also showed increased prothrombin times as the pH decreased from 7.8 to 6.4, except for three turtle species. The prothrombin times decreased, to varying extents, in a linear fashion relative to reduced pH with the rate of change greatest in leatherbacks>green>>loggerhead turtles. All studies were conducted with reagents developed for human samples which would impact on the quantitative results with the turtle samples, but are not likely to alter the qualitative results. These comparative studies of the coagulation pathway in sea turtles and humans could enhance our knowledge of structure/function relationships and evolution of coagulation factors.

Animals↗
PubMed1995

Ras is not required for the interleukin 3-induced proliferation of a mouse pro-B cell line, BaF3.

It has been demonstrated that Ras is involved in interleukin 3 (IL-3)-stimulated signal transduction in various hematopoietic cultured cells (Satoh, T., Nakafuku, M., Miyajima, A., and Kaziro, Y. (1991) Proc. Natl. Acad. Sci. U.S.A. 88, 3314-3318; Duronio, V., Welham, M. J., Abraham, S., Dryden, P., and Schrader, J. W. (1992) Proc. Natl. Acad. Sci. U.S.A. 89, 1587-1591). However, it has not been fully understood which of IL-3-promoted cellular responses, i.e. proliferation, survival, and differentiation, requires Ras function. We employed a system of inducible expression of the dominant-negative (S17N) or dominant-active (G12V) mutant of Ras in BaF3 mouse pro-B cell line to analyze the role of Ras in IL-3-stimulated signal transduction. Induction of the dominant-negative Ras(S17N) effectively inhibited the IL-3-induced activation of c-Raf-1 and mitogen-activated protein kinase (MAPK). Furthermore, the activation of fos gene promoter following IL-3 stimulation was almost completely abolished when Ras(S17N) was induced. Under these conditions, Ras(S17N) exhibited no inhibitory effect on IL-3-dependent proliferation assessed by the increase of cell numbers and a mitochondrial enzyme activity. The results indicate that Ras-dependent pathways, including the Raf/MAPK/Fos pathway, are dispensable for IL-3-induced growth stimulation. When BaF3 cells were treated with a tyrosine kinase inhibitor, herbimycin A, IL-3-dependent proliferation of the cells was impaired, suggesting that tyrosine kinase-mediated pathways are critical for growth promotion. On the other hand, apoptotic cell death caused by deprivation of IL-3 was prevented by the induction of the activated mutant Ras(G12V), although the rate of cell number increase was markedly reduced. Thus, it is likely that Ras-independent pathways play important roles to facilitate the proliferation although they may not be essential for IL-3-stimulated antiapoptotic signal transduction.

Animals↗
PubMed2000

Immune cell activation by bacterial CpG-DNA through myeloid differentiation marker 88 and tumor necrosis factor receptor-associated factor (TRAF)6.

Transition of immature antigen presenting cells (APCs) to the state of professional APCs is essential for initiation of cell-mediated immune responses to pathogens. Signal transduction via molecules of the Toll-like receptor (TLR)/interleukin 1 receptor (IL-1R) pathway is critical for activation of APCs either by pathogen-derived pattern ligands like lipopolysaccharides (LPS) or by CD40 ligation through T helper cells. The capacity of bacterial DNA (CpG-DNA) to induce APCs to differentiate into professional APCs represents an interesting discovery. However, the signaling pathways involved are poorly understood. Here we show that CpG-DNA activates the TLR/IL-1R signaling pathway via the molecules myeloid differentiation marker 88 (MyD88) and tumor necrosis factor receptor-associated factor 6 (TRAF6), leading to activation of kinases of the IkappaB kinase complex and the c-jun NH(2)-terminal kinases. Moreover, cells of TLR2- and TLR4-deficient mice are activated by CpG-DNA, whereas cells of MyD88-deficient mice do not respond. The data suggest that CpG-DNA initiates signaling via the TLR/IL-1R pathway in APCs in a manner similar to LPS and to T helper cell-mediated CD40 ligation. Activation of the TLR/IL-1R signaling pathway by foreign bacterial DNA may be one way to initiate innate defense mechanisms against infectious pathogens in vivo.

Adaptor Proteins, Signal Transducing↗
PubMed2002

Impact of a clinical pathway on the postoperative care of children undergoing surgical closure of atrial septal defects.

The purpose of this study was to impact of a clinical pathway on the postoperative management of children undergoing surgical closure of atrial septal defects (ASDs). Three groups of children were studied: group 1 (14 patients), before introduction of an intensive care team, minimally invasive surgery, and the clinical pathway; group 2 (17 patients), after the introduction of the intensive care team and minimally invasive surgical techniques but before the pathway; and group 3 (30 patients), after implementation of the clinical pathway. Average hospital length of stay fell from 118.52 +/- 19.83 hours (4.9 +/- 0.83 days) in group 1 to 95.92 +/- 66.48 hours (3.99 +/-2.77 days) in group 2 and declined further to 54.29 +/- 20.17 hours (2.26 +/- 0.84 days) in group 3 (p <.05). There were statistically significant decreases in laboratory resource utilization (p <.05). The addition of a dedicated intensive care team and utilization of minimally invasive surgical techniques reduced mean length of stay (by 20%) and resource utilization (by 50%). However, only the implementation of the pathway provided the consistency necessary for maximal quality management, cost saving, and reduction in length of stay (additional 44% reduction in mean length of stay and 40% reduction in resource utilization). These results show the incremental advantage of implementing a defined clinical pathway for postoperative management of children with atrial septal defects.

Adolescent↗
PubMed2002

Streamlining the care of patients with hypertrophic pyloric stenosis: application of a clinical pathway.

PURPOSE: The purpose of this study was to evaluate the impact of a clinical pathway on infants admitted to a pediatric tertiary care center with the diagnosis of hypertrophic pyloric stenosis (HPS). METHODS: The records of 132 HPS patients were evaluated before and after implementation of a clinical pathway. Infants were excluded for prematurity, admission to nonsurgical services, or multiple diagnoses requiring prolonged hospitalization, resulting in 83 patients for analysis. Group I (prepathway, n = 40) and group II (postpathway, n = 43) infants were analyzed for time from admission to operation, operation to first feeding, operation to discharge, total length of stay, hospital charges, metabolic status at time of admission, and postoperative complications. The Mann-Whitney test was performed (statistical significance at P <.05). RESULTS: There was no significant difference between group I and group II patients in the length of preoperative hospitalization or metabolic status at the time of hospital admission. In comparison with group I patients, there was a significant reduction in time to resumption of oral feedings (4.6 +/- 1.9 hours v 7.5 +/- 3.2 hours; P <.001) for group II infants and a significantly earlier discharge (26.7 +/- 6.8 hours v 38.0 +/- 11.7 hours; P <.001). This resulted in a shortened length of stay (41.8 +/- 9.7 hours v 57.8 +/- 14.3 hours; P <.001) with an associated decrease in hospital charges ($4,555 +/- $464 v $5,400 +/- $1,017; P <.001). CONCLUSIONS: Elimination of practice variability by the use of a clinical pathway for HPS resulted in significant reduction of hospital stay and related charges. The impact of the pathway occurred in the postoperative period and is a consequence of a rapid and systematic return to oral feedings.

Breast Feeding↗
PubMed2003

Reducing clinical variations with clinical pathways: do pathways work?

OBJECTIVE: To test clinical pathways in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations. DESIGN: Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator. SETTING: We tested the clinical pathways in six sites, each with different clinical pathways. RESULTS: Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated. CONCLUSIONS: The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care.

Aged↗
PubMed2001

Development and implementation of a clinical pathway for spinal cord injuries.

The authors have developed a clinical pathway for the treatment of spinal cord injuries to help improve patient care. A clinical pathway for the treatment of patients with spinal cord injury was developed through a multidisciplinary approach. The control group (group 1) consisted of patients who were treated in the 2 years before the initiation of the pathway. Data from patients treated in conjunction with this pathway were collected prospectively (group 2). Thirty-six patients were treated in conjunction with the pathway compared with 22 in the control group. Group 2 had 6.8 fewer intensive care unit days, 11.5 fewer hospital days, 6 fewer ventilator days (p < 0.05), and a lower rate of complications. The use of a clinical care pathway for spinal cord injuries has resulted in improved patient care and fewer complications.

Adult↗
PubMed2004

Medical malpractice and head and neck cancer.

PURPOSE OF REVIEW: The purpose of this review is to evaluate medical malpractice involving patients with head and neck cancer. In the United States, problems associated with the medical malpractice environment are reaching proportions that threaten the delivery of health care. RECENT FINDINGS: Several methods to learn more about the trends and ramifications of litigation have been developed. Although patients with cancer of the head and neck bring suits rarely, when they do several themes seem prevalent. Delays in diagnosis are common allegations. Plaintiffs are frequently much younger than expected, and the oncologic outcome is frequently poor. Defendant physicians occasionally unwittingly add to the delay by not expecting the younger patient. The poor oncologic outcome may be related to the delay or to a biologically more aggressive disease. Relationships between these factors are explored. Consent issues are also relatively common. SUMMARY: Physicians must strive to know as much as possible about tort reform, and to contribute to the process. Litigation analysis and other tools to expand our understanding can be used to educate ourselves and the legal community. Scientific standards must be developed along with clinical pathways to guide ourselves to prevent litigation. They may also guide the legal community to establish more rational standards of care based on a consensus of expert opinions.

Critical Pathways↗
PubMedDate not supplied

Aortic stent grafting: a new approach to a deadly diagnosis: one hospital's findings in defining new care processes.

Ruptured abdominal aortic aneurysm (AAA) is the 13th leading cause of death in the United States. Diagnosis is the key to prevention of death from AAA. Millions of Americans harbor this silent, potentially lethal aneurysm. For over 50 years, conventional open surgical repair has been performed for ruptured aortic abdominal aneurysm. It is a major operation with an extended hospital stay and recovery period. An alternative approach to AAA repair has evolved over the past 10 years that combines advances in catheter and stent technologies. With the AAA aortic stent graft, patients usually do not require intensive care and are discharged home within 48 hours of the procedure. This article describes the AAA aortic stent graft procedure, in the formation of a case management team to develop a clinical pathway and standing orders for these patients and defines the outcomes of care.

Angioplasty↗
PubMedDate not supplied

Clinical pathways: improving patient education and influencing readmission rates.

Clinical pathways have long been used as a mechanism for implementing a managed care delivery system. They have been effective in highlighting lengths of stay, outcome variances, and systems problems. Clinical pathways play an important part in enhancing quality improvement activities, especially in accordance with the standards of the Joint Commission on Accreditation of Healthcare Organizations. This article addresses benefits of clinical pathways in general, and benefits at the authors' facility in particular, specifically, a clinical pathway's effectiveness in influencing readmissions of patients with atrial fibrillation.

Atrial Fibrillation↗
PubMed1998

Clinical pathways--the new paradigm in healthcare?

A clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other healthcare professionals for a particular diagnosis or procedure. It is a relatively new clinical process improvement tool that has been gaining popularity across hospitals in the USA, Australia and United Kingdom. Clinical pathways are developed through collaborative efforts of clinicians, nurses, pharmacists, physiotherapists and other allied healthcare professionals with the aim towards improving the quality of patient care. Clinical pathways have been shown to reduce unnecessary variation in patient care, reduce delays in discharge through more efficient discharge planning, and improve the cost-effectiveness of clinical services. The approach and objectives of clinical pathways are consistent with those of total quality management (TQM) and continuous quality improvement (CQI) and is essentially the application of these principles to the patient's bedside. This article examines the proliferation in the use of clinical pathways, its benefits to the healthcare organisation, its application as a tool for CQI activities in direct relation to patient care and the medico-legal implications involved.

Critical Pathways↗
PubMed2001

Clinical pathway for evaluating women with abnormal uterine bleeding.

OBJECTIVE: To devise a clinical pathway for evaluating women with abnormal uterine bleeding. STUDY DESIGN: One thousand women with the complaint of abnormal uterine bleeding were enrolled. All would have undergone endometrial biopsy based on older recommendations. The patients followed a clinical pathway to determine if an endometrial biopsy was necessary. The pathway divided women into the categories of premenopausal, postmenopausal, low risk and high risk. If one risk factor was present, the patient underwent endometrial biopsy. If there were no risk factors, the patient continued down the pathway with medical therapy. RESULTS: Five hundred seventy endometrial biopsies were performed. Five cases of endometrial cancer and three of complex atypical hyperplasia, both in the postmenopausal, high-risk group, were discovered. Subsequent reviews revealed that no cases of endometrial cancer were missed or developed in the two years following the initial complaint. CONCLUSION: Utilization of a clinical pathway reduced the number of endometrial biopsies by 50%. The introduction of clinical pathways at our institution was done successfully in the evaluation of abnormal uterine bleeding.

Adult↗
PubMed1997

Clinical pathways and coronary artery bypass surgery.

Use of a multidisciplinary clinical pathway helps eliminate variations in patients' care. Organizing the care delivered each day of the patient's hospitalization may lead to fewer complications, a quicker recovery, and an earlier discharge. In today's healthcare arena, much attention is being focused on improving the quality of care and decreasing the need for acute care. Clinical pathways facilitate patients' outcomes and earlier discharge and thus reduce the cost of care.

Adult↗
PubMed1992

Two-dimensional echocardiographic phase analysis. Its potential for noninvasive localization of accessory pathways in patients with Wolff-Parkinson-White syndrome.

BACKGROUND: In patients with the preexcitation syndrome who are undergoing transcatheter or surgical ablation, accurate localization of accessory pathways is critical. Because preexcitation is known to alter ventricular activation sequence and result in focal areas with presystolic contraction, we investigated whether phase analysis applied to two-dimensional echocardiographic cine loops objectively identifies these focal areas and can be used to localize ventricular insertion sites of accessory pathways. METHODS AND RESULTS: We prospectively obtained phase images in 17 patients (11 males; age range, 11-35 years) during minimal preexcitation in normal sinus rhythm and during maximal preexcitation induced by right atrial pacing. A group of 11 normal subjects (six men; age range, 26-37 years) served as controls. Pathway locations predicted from phase imaging were compared with those predicted from routine 12-lead ECGs, from visual inspection of cine loop images, and from catheter-mounted electrode endocardial mapping. Cross-sectional views in a digital cine loop format were mathematically transformed using a first harmonic Fourier algorithm to obtain the corresponding phase images. Phase angle histograms were derived in eight wall segments. Mean and earliest phase angles were derived by computer analysis to quantitate contraction sequence. We found that during right atrial pacing, phase angles in focal areas markedly deviated from normal--mean phase angles from 33 degrees to 164 degrees, and earliest phase angles from 50 degrees to 180 degrees. Accessory pathways could be precisely localized in 53% of the patients by 12-lead ECG, in 59% by visual inspection of cine loop images, in 82% by phase imaging, and in 94% by a combination of the three methods. CONCLUSIONS: Our results suggest that phase imaging, especially when used in combination with cine loop and 12-lead ECG, can be used to localize ventricular insertion sites of accessory pathways and may be clinically useful as a noninvasive adjunct to endocardial mapping in patients with Wolff-Parkinson-White syndrome.

Adult↗