bluuebunny/crossref_metadata_2025 huggingface dataset:
Therapy of Sustained Ventricular Arrhythmias With Amiodarone: Prediction of Efficacy With Serial Electrophysiologic Studies
Authors: Nasir Nadim , Swarna Udaya S. , Boahene Kwabena A. , Doyle Timothy K. , Pacifico Antonio
Published: January 2017

Background: Programmed electrical stimulation early during amiodarone therapy has poor prognostic capabilities; and persistent inducibility has been associated with a favorable outcome in a majority of patients. These observations result from studies that differed significantly in methodology.

Methods and Results: The authors prospectively enrolled 121 patients in a standardized amiodarone dosing protocol in which amiodarone was the only antiarrhythmic agent. Electrophysiologic testing was done after 2 and 6 weeks to determine noninducibility, predictive value, and the significance of drug-induced prolongation of tachycardia cycle length. The mean age of the patients in the study was 63.2 ± 11.5 years, and their ejection fraction was 32.8 ± 11.9%. Coronary artery disease was present in 103 (85%). At 2 weeks 17 patients (14%) were no longer inducible, whereas 101 patients (86%) remained inducible. Patients in these groups were similar in age and ejection fraction. During follow-up evaluation, recurrences (35% vs 24%; P =.44) and sudden death (12% vs 13.5%) were similar in the two groups. Thirty-five of 95 patients (32%) with sustained monomorphic ventricular tachycardia had more than 100 ms prolongation of their cycle length, which was hemodynamically well tolerated (partial response), but 60 did not (nonresponse). Patients with a partial response were older (66.5 vs 61.1 years; P =.02) and had longer QRS durations (143.2 vs 129.4 ms; P =.03). They also had increased recurrences (37% vs 17%; P =.01) and more sudden deaths (23% vs 8%; P =.02). At 6 weeks 11 of 76 patients studied were noninducible. They had a lower recurrence rate than those who remained inducible (8% vs 27%; P =.02) but a similar number of sudden deaths (8% vs 16%; P =.27). Thirty-two patients partially responded, and 31 patients did not respond. During follow-up examination these two groups had a similar number of recurrences (25% vs 29%; P =.76) and sudden deaths (16% vs 16%). Conclusions: Noninducibility at 2 or 6 weeks of amiodarone therapy did not identify patients at low risk of sudden death. In inducible patients, tachycardia cycle length prolongation, even when well tolerated, was not a marker for favorable outcome. Electrophysiologically guided therapy. therefore. offers little benefit over empiric amiodarone.

Conclusions: Noninducibility at 2 or 6 weeks of amiodarone therapy did not identify patients at low risk of sudden death. In inducible patients, tachycardia cycle length prolongation, even when well tolerated, was not a marker for favorable outcome. Electrophysiologically guided therapy. therefore. offers little benefit over empiric amiodarone.
Sudden Death During Flecainide Therapy for Atrial Fibrillation Complicating Wolff-Parkinson-White Syndrome
Authors: Chun Sung , Singh Bramah N.
Published: January 2017

The Wolff-Parkinson-White syndrome can be complicated by atrial fibrillation that may increase morbidity and mortality. Different pharmacologic therapy, inlcuding class IA, IC, and III agents, has been used in such cases with variable success. We now use less pharmacologic intervention with development of an electrode catheter ablation for accessory pathways. However, antiarrhythmic agents are still being used, especially when an electrode catheter ablation is unavailable or if a patient refuses such a procedure. Therefore, it is prudent that one understands each antiarrhythmic agent's electrophmacologic properties as well as its potential proarrhythmic effect in order to accurately assess each drug's risk-benefit ratio. We present a case that illustrates electropharmacologic properties of quinidine. flecainide, sotalol, and amiodarone on various cardiac tissues, as well as possible proarrhythmic effect of flecainide on a structurally normal heart.
Differential Electrophysiologic Effects of Chronically Administered Amiodarone on Canine Purkinje Fibers versus Ventricular Muscle
Authors: Papp Julius Gy. , Németh Mikós , Krassói Irén , Mester Lajos , Hála Ottó , Varró András
Published: January 2017

Background: Acute and chronic treatment with amiodarone has been reported to cause different electrocardiographic changes in patients. The cellular electrophysiologic effects of chronic administration (50 mg/kg/day orally for 6 weeks) and acute superfusion (5 μM in the tissue bath) of amiodarone were therefore studied in dog cardiac ventricular muscle and Purkinje fibers using conventional microelectrode techniques.

Methods and Results: During stimulation at 1 Hz, chronic amiodarone treatment lengthened the ventricular muscle action potential duration (APD) (from 227.8 ± 6.3 ms (n = 20) to 262.3 ± 5.2 ms (n = 21; P < .01), but shortened that of Purkinje fibers from 337.6 ± 9.2 (n = 21) to 308.3 ± 7.1 (n = 19; P < .05). Acute superfusion of 5 μM amiodarone in cardiac tissue obtained from chronically treated dogs did not change ventricular muscle APD but shortened Purkinje fiber AP from 309.7 ± 13.6 ms to 281.9 ± 11.9 ms (n = 8; P < −05). Neither the chronic nor the acute amiodarone exposure prevented the APD shortening in ventricular muscle evoked by 10 μM pinacidil, suggesting that amiodarone does not interfere with the ATP-dependent potassium channels. The normal difference in APD between ventricular muscle and Purkinje fibers in untreated, control preparations was 110 ms but decreased to 46 ms in fibers obtained from dogs chronically treated with amiodarone and increased to 185 ms in the presence of 30 μM sotalol, a class III antiarrhythmic drug used for comparison. Amiodarone (5 μM) applied directly abolished early afterdepolarizations (EADs) (induced by 1 μM dofetilide + 20 μM BaCl2 + 2 mM CsCI) in 5 of 6 experiments and caused strong use-dependent Vmax block with relatively fast onset kinetics (nte constant = 1.23 ± 0.13 AP-1, n = 5) and offset (time constant = 364 ± 62.5 ms, n = 5). After chronic amiodarone treatment, in contrast with acute sotalol application (30 μM), no reverse use-dependent effect was observed on the APD in Purkinje fibers.

Conclusions: These results provide further evidence that amiodarone differs from other recognized class III antiarrhythmic drugs (ie, it is a mixed type agent with acute fast kinetic class I [type B] and a unique class III antiarrhythmic action characterized by decreased dispersion of APDs between ventricular muscle and Purkinje fibers). Amiodarone can abolish EADs unlike other class III agents that are usually associated to induction of EADs. These features might be responsible not only for the antiarrhythmic efficacy, but also for the relative safety (low incidence of torsade de pointes) of amiodarone in clinical settings.
Effect of Dofetilide and d-Sotalol on the ATP-Sensitive Potassium Channel of Rabbit Ventricular Myocytes
Authors: West Paul D. , Bursill Jane A. , Wyse Kenneth R. , Martin Donald K. , Campbell Terence J.
Published: January 2017

Background: The ability of dofetilide and d-sotalol to maintain their class III action during ischemia is uncertain. We investigated the effect of these two drugs on the ATP-sensitive potassium channel (IKATP), which plays a major role in ischemia-induced action potential duration shortening.

Methods and Results: The activity of (IKATP) channels was studied in excised membrane patches of single ventricular myocytes, obtained by standard enzymatic dissociation techniques from New Zealand white rabbits. Dofetilide demonstrated a dose-dependent block of (IKATP) with an EC50 of 51 ± 1 μM in inside-out patches. Its ability to block the channel was substantially less when applied to the external membrane surface. d-Sotalol significantly blocked (IKATP) (42% reduction) at a concentration of 10 μM but not at 1 μM. As with dofetilide, its ability to block (IKATP) was reduced when applied externally.

Conclusions: We conclude that dofetilide and d-sotalol block the ATP-sensitive potassium channel. but dofetilide does so only at concentrations much greater than those rcquired for block of the delayed rectifier potassium channel. d-Sotalol in contrast shows modest blockade of (IKATP) at concentrations in the tipper range of those seen during its clinical use.
Biological Aspects of Schizophrenia
Authors: Spitzer Vicki M.
Published: January 2017

Schizophrenia is a serious mental disorder that affects more than 2 million people in the United States. The pathophysiology of schizophrenia was originally linked to dysregulation of the dopaminergic pathways in the brain, but more recently has been linked to dysregulation of other neurotransmitter pathways as well particularly the serotonergic pathways. The positive symptoms of schizophrenia, which include hallucinations and delusions, are thought to be associated with disturbances in the mesolimbic dopaminergic system. Negative symptoms, including apathy and social withdrawal are believed to arise from alterations in the mesocortical system. The delicate interplay between the neurotransmitters dopamine and serotonin is now believed to be associated with the symptoms of schizophrenia. Structural brain abnormalities, including enlarged ventricles and cortical atrophy, may also play a role in schizophrenia.
Maximizing Psychosocial Interventions
Authors: Littrell Kimberly H. , Freeman Lisa Y.
Published: January 2017

Although many patients with schizophrenia benefit from pharmacologic treatment, a patient's quality of life cannot be improved through drug therapy alone. Pharmacologic treatment must be integrated with psychosocial interventions to achieve the greatest level of recovery and prevent relapse. Patient outcomes can be maximized by drawing on the skills of a multidisciplinary team, consisting of a psychiatrist, nurse, psychologist, social worker, and pharmacist, among others. Through the team approach, the patient benefits from the full range of therapeutic options offered by each team member. The active participation of the patient's family members in the treatment program cannot be overlooked. Family members can be instrumental in helping the patient reintegrate into society.
Child Sexual Abuse: A Case of Intrafamilial Abuse
Authors: Johnson Leayn , Cheffer Natalie D.
Published: January 2017

This article presents a historic perspective of child abuse, reviews the existing literature, presents a case study, and describes a treatment plan using the nursing process. The case study describes the sexual abuse of a young girl by her stepfather and presents therapeutic interventions using the nursing process as a decision making tool to assess, plan, intervene, and evaluate. Child sexual abuse continues to be a major problem in our society. Nurses, both advanced practice nurses including clinical nurse specialists and nurse practitioners and the registered nurse working with families and children, can use the nursing process as a decision making tool The nursing process, when used to evaluate and plan care, can help to alleviate the pain and confusion that families experience when child abuse occurs.
Katalin Ehling: Interpreter of the American Southwest
Authors: Augusta Holly
Published: January 2017

Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editors, publishers, or Association. The Editors, publisher, and Association disclaim any responsibility orliability for such material and do not guarantee, warrant, or endorse any product or service advertised in this publication, nor do they guarantee any claim made by the manufacturer of such product or service.
Transitional Objects, Phenomena, and Relatedness: Understanding and Working with Individuals with Borderline Personality Disorder
Authors: Amey Stephanie E.
Published: January 2017

Transitional objects, transitional phenomena, and transitional relatedness are concepts that can be helpful both in clarifying normal aspects of development and in understanding individuals with borderline personality disorder. Valued objects of childhood and the mature interests of adulthood are useful in providing soothing comfort and feelings of self enhancement. Individuals with borderline personality disorder may use childhood transitional objects or pathologic transitional phenomena to soothe or comfort themselves. Nurse therapists can learn to both recognize these types of phenomena and apply this awareness in their therapeutic interactions to help explore traumatic past events, current insecurities, and new self-soothing methods, and thereby enhance treatment efficacy.
Depression and HIV+ Disease: A Critical Review
Authors: Morris Nanci J.
Published: January 2017

Major depression is thought to be one of the most common psychiatric disorders in HIV-infected persons. Research on aspects of HIV disease and depression is critically reviewed with the aim of synthesis and evaluation. Consideration is given to the clinical/psychiatric aspects of HIV infection, previous psychopathology in HIV-infected individuals, cognitive/neurologic manifestations, diagnosis, and treatment approaches. Directions for future research are offered, and finally, implications for clinical practice are specified.
Staffing of Inpatient Psychiatric Units and Assault by Patients
Authors: Lanza Marilyn Lewis , Kayne Herbert L. , Gulliford Dorothy , Hicks Carol , Islam Shaheen
Published: January 2017

BACKGROUND: Assault by a patient is a serious problem for patients, staff, and hospitals. There is disagreement in the literature about the relationship between the number of staff on psychiatric units and the assault rate.

OBJECTIVE: The purpose of this study was to determine the relationship between the number of and characteristics of nursing staff and the occurrence of assault on inpatient psychiatric units.

STUDY DESIGN: This was a comparative study of assaults over a 6-month time period. The primary unit of analysis was the unit shift.

RESULTS: When comparing shifts with an assault to shifts without an assault, the statistical resultsfor each of thefour dependent variables (number of registered nurses, number of staff patient/staff ratio, and staff gender) were not significant. There was a significant (p < .001) interaction among three factors: assault status, unit, and time. Although the number of registered nurses (RNs) was not significantly related to assault occurrence, examination of individual units by time of day (shift) revealed surprising and important results. Some units had more assaults when there were fewer RNs, and some units had more assaults when there were more RNs.

CONCLUSION: The difference between shifts with an assault and shifts without an assault depended on the particular unit and the particular time of day. The findings cannot be generalized across units and must be examined in detail at the unit level A most importantfinding in need offurther investigation is the inconsistent pattern of number of RNs related to assault occurrence both among units and within each unit.
Diagnosis, Neurobiology, and Treatment of First-episode Schizophrenia
Authors: Jarboe Kathleen S. , Kilts Clinton D.
Published: January 2017

Early detection, intervention, and treatment infirst-episode schizophrenia is becoming increasingly recognized as offering many patients thepossibility of improvedprognosis and quality of life. However, there are many obstacles to early detection treatment, specificaly, common signs leading to early detection are often misleading resulting in identification problems, and many common prodromal diagnoses suggest otherpotential illnesses. Because afirst-episode schizophrenia diagnosis is difficult, it is imperative that awareness be increased about warning signs among primary care clinicians, families, and school systems. In addition to psychoeducationalprograms, the new atypical antipsychotics offer the best hope to date for improved long-term outcome.
Treatment-refractory Schizophrenia: Update on Concepts and Interventions
Authors: Littrell Kimberly H. , Littrell Steven H.
Published: January 2017

Until recently, clinicians have had little reason for enthusiasm in the treatment of a significant proportion of the population with schizophrenia. Approximately 15% of these patients are unresponsive to traditional antipsychotic therapy. Defining this severely ill, treatment-refractory group of patients can be a difficult task. Despite the complexity of the undertaking, it is important that such patients be identified so that their treatment can be optimized. There is increasing evidence that new, atypical antipsychotic agents can not only ameliorate both positive and negative symp- toms of schizophrenia, but can also improve patients' vocational social, and cognitive functioning as well as their overall quality of life. Free of the limitations imposed by conventional antipsychotics, patients are now able to effectively partake in many available treatments. Psychiatric rehabilitation now becomes an achievable reality. The advent of atypical antipsychotics has clearly shown that there is a much greater potentialfor recovery from schizophrenia than we had previously thought possible.
Empowerment Through S elf Regulation: Group Approach for Survivors of Incest
Authors: DiVitto Sharon
Published: January 2017

Patients at high risk are flooding today's short-stay psychiatric inpatient units, presenting with suicidality and other self-destructive behaviors. Many of these patients are unable to regulate their internal experience and their behavior. The Self-Regulation Program described in this article uses cognitive-behavioral techniques that appear to empower patients to control the intensity of feelings, to change irrational thinking patterns, and to develop constructive behavioral responses. As a result of participating in this program, there appeared to be improvement in patients' coping strategies. The patients reported both increased feelings of empowerment and decreased engagement in self-destructive behaviors.
Cytochrome P450 Isoenzymes: Nursing Considerations
Authors: Applegate Maureen
Published: January 2017

Recent studies in pharmacology have focused on liver enzyme activity in the biotransformation of drugs. Among the 34 hepatic cytochrome P450 isoenzymes identifed to date, several have been found to be important in the metabolism of many psychoactive drugs and other agents. This article describes the role of cytochrome P450 isoenzymes in drug metabolism and potential drug-drug interactions and addresses nursing issues related to assessment, treatment, and patient education and safety.
The Business of Psychiatric Nursing: Cents and Sensibility Part I: Establishing an Independent Practice
Authors: Moller Mary D.
Published: January 2017

This two-part article discusses issues related to establishing and maintaining a successful outpatient private practice. Part one describes elements essential to making an independent nurse-managed outpatient clinic operational; including a mission statement and organizational objectives, organizational structure, daily operations, start-up and ongoing operational costs, personnel requirements, third-party reimbursement issues, public relations, monitoring outcomes, and maintaining one's own mental health. Establishing reimbursement rates for advanced practice nurses and billing for services are described The complex array of managed behavioral health care services are delineated as are issues related to scheduling, taking call, and allowing personal time off.
The Relationship Between Medication Noncompliance and Cognitive Function in Patients With Schizophrenia
Authors: Jarboe Kathleen S. , Schwartz Sarah K.
Published: January 2017

BACKGROUND:The relatively high rate of medication noncompliance in patients with schizophrenia may be in part the result of cognitive impairments frequently associated with the disorder.

OBJECTIVE: The purpose of this study was to determine whether baseline performance on specific neurocognitive tests predicts a patient's level of medication compliance. The question of whether improvement on these same tests after 3 months of antipsychotic treatment would correlate with medication compliance was also examined in this study.

DESCRIPTVE CORRELATIONAL DESIGN: Patients' medication compliance (on a percentage basis) was correlated with their baseline and 3-month posttreatment scores on four neurocognitive tests.

RESULTS: A statistically significant relationship exists between medication compliance and patients'performance on tests of attention and immediate visual recall

CONCLUSION: The results of this study support the implementation of interventions that ameliorate specific neurocognitive deficits that, in turn may facilitate improved medication compliance.
Managing Aggression in Schizophrenia
Authors: Robinson Lea , Littrell Steven H. , Littrell Kimberly
Published: January 2017

Agitation and aggression are frequent behavioral manifestations of persons diagnosed with a psychiatric illness. Data from the Epidemiological Catchment Area study indicate that persons with schizophrenia have afour-fold increase for the risk of violent behavior in a 1-year period. Additional research indicates that acute psychosis is a consistent riskfactorfor the occurrence of violence; approximately 10% ofpatients diagnosed with schizophrenia display assaultive behavior within 2 weeks before hospital admission. In addition, 20% to 30% ofpatients who display psychotic symptoms engage in threats, verbal aggression, and property damage within the same period. Once hospitalized, 10% to 15% of these patients become physically assaultive, and 30% to 35% engage infear-inducing behaviors. Clearly, the management of aggression in patients with schizophrenia is an important consideration for nurses working with this population.
Sexual Rights of People With Serious and Persistent Mental Illness: Gathering Evidence for Decision Making
Authors: Torkelson Diane J. , Dobal May T.
Published: January 2017

Management of sexual relationships between adults with serious and persistent mental illness in residential care is a complex issue. The Omnibus Budget Reconciliation Act of 1987 is afederal law that defines the needfor long-term care facilities to protect the privacy and visitation rights of residents. State interpretations of the Omnibus Budget Reconciliation Act of 1987 and patient advocacy groups may exert pressure on administrators to consider the need to allow consensual sexual activity between residents. This research review of sexual behavior of people with serious and persistent mental illness provides evidence to guide decision making for policy formation, clinical practice, and research.
Purse-String Suture for Round and Oval Defects: A Useful Technique in Dermatologic Surgery
Authors: Zhu Jian-Wei , Wu Xian-Jie , Lu Zhong-Fa , Cai Sui-Qing , Zheng Min
Published: January 2017

Background:

Round and oval skin wounds, like facial pigmented nevi after excision, are traditionally sutured linearly for closure, leaving significant scars, which greatly influences their appearance.

Objective:

This article provides an overview of our experience using intradermal purse-string suture for round and oval defects in the faciocervical region to ascertain whether purse-string suture closure for such defects can result in good functional and cosmetic outcomes.

Methods and Results:

We present 63 cases with different skin lesions in the faciocervical area. The defects of the lesions after excision were closed using intradermal purse-string suture. The wounds showed good final healing without obvious adverse events postoperatively. The result of scar assessment using the Vancouver Scar Scale was satisfying, with a total score of only 1.11. The final cosmetic appearance of the healed wounds seemed to be excellent and acceptable as they were always smaller than the original defects, with minimal scarring.

Conclusion:

Purse-string suture enabled us to repair small, circular wounds easily after excision of skin lesions. It is an excellent alternative to other reconstructions and a rapid, simple method to close skin defects with minimal scarring, achieving an excellent long-term cosmetic and functional outcome.
Comparative Study of IQ-Ultra and Finn Chambers Test Methodologies in Detecting 10 Common Standard Allergens that Cause Allergic Contact Dermatitis
Authors: Doumit Joseph , Pratt Melanie
Published: January 2017

Background:

Patch testing is routinely used in contact dermatitis clinics because it is the gold standard for the evaluation of potential allergic contact dermatitis.

Objective:

The study was undertaken to evaluate possible differences in reactivity between the Finn Chamber and IQ-Ultra patch-testing methodologies.

Methods:

Patients were patch-tested simultaneously with the Finn Chamber and IQ-Ultra patch tests. Ten standard allergens set by the North American Contact Dermatitis Group were used for both techniques.

Results:

Both patch tests had a significant agreement in detecting all of the allergens. An “almost perfect agreement” was noted for ethylenediamine dihydrochloride, quaternium-15, mercapto mix, black rubber mix, balsam of Peru, and nickel sulfate; “substantial agreement” for formaldehyde, bisphenol A epoxy resin, and 4-tert-butylphenol formaldehyde resin; and “moderate agreement” for potassium dichromate.

Conclusion:

The Finn Chamber and IQ-Ultra patch tests had a good agreement in the detection of the 10 standard allergens that were tested.
Local Side Effects Caused by Hair Dye Use in Females: Cross-sectional Survey
Authors: Alghamdi Khalid M. , Moussa Noura A.
Published: January 2017

Background:

Despite its association with a number of side effects, hair dye use is common worldwide.

Objective:

To explore the local side effects of hair dye use and to relate these effects to features of hair dyeing.

Methods:

A questionnaire about hair dye use was distributed to a random sample of 650 female patients at various outpatient clinics in 2008.

Results:

A total of 567 females returned the questionnaire (87.2% response rate). Of these respondents, 82.6% (464 of 562) had used hair dye products in the past. The mean age at first use was 22.23 ± 7.05 years, and the median time between two consecutive dyes was 6 months. Of these respondents, 76.8% (354 of 461) used permanent dyes. Participants reported that they suffered skin redness caused by hair dyes (15.1%, 65 of 431), had scaling (14.4%, 60 of 417), or had itchiness (31.3%, 134 of 428). In addition, 74% (262 of 354) of the participants reported that they had issues with the texture or condition of hair following hair dye use; 77.7% (314 of 404) reported split ends, whereas 69.6% (273 of 392) reported hair dryness, 69.4% (256 of 369) lusterless hair, 77.2% (308 of 399) excessive hair loss, and 53.6% (210 of 392) excessive hair graying. Furthermore, 55.1% (196 of 356) of the participants reported a slowing of hair growth. The total number of hair dyeing events was associated with increased hair loss (p = .04) and excessive graying (p < .001) after controlling for all relevant variables.

Conclusion:

Hair dye is associated with local side effects to the skin and hair. Increased public awareness of these risks could help inform consumer choices and reduce excessive use.
Mycophenolate Mofetil and Erythromycin for Bullous Lupus Erythematosus of Childhood
Authors: Pehr Kevin
Published: January 2017

Background:

Bullous lupus erythematosus is a rare disease that is extremely rare in childhood (with only seven previous reports) and difficult to control.

Objective:

Herein is presented the youngest patient reported with this condition, and a novel, safe, and effective treatment regimen is described.

Methods:

Through study, perseverance, serendipity, and creativity, a safe and effective regimen was developed.

Results:

The combination of mycophenolate mofetil and erythromycin (plus sun protection) was found to be efficacious.

Conclusion:

It is proposed that the two medications act synergistically, with the “antibiotic” acting as a antiinflammatory agent, but at a different point in the inflammatory cascade than mycophenolate mofetil. This suggests the approach of using common, inexpensive, and benign antibiotics to potentiate, and perhaps decrease the use of, immunomodulatory agents in autoimmune and autoinflammatory diseases.
Do Clinical Practice Guidelines Reflect Research Evidence?
Authors: Savoie Isabelle , Kazanjian Arminée , Bassett Ken
Published: January 2017

Objectives:

To examine whether existing clinical practice guidelines (CPGs) for cholesterol testing reflect research evidence and hence may control or reduce costs while maintaining or improving the quality of care.

Methods:

A systematic search for published and unpublished cholesterol testing CPGs and independent critical appraisal of the CPGs by two researchers using a standard checklist.

Results:

In four of the five CPGs analysed, the link between the research evidence and the recommendations was not maintained. The appraisal, local experience and the literature all suggest that panel composition is an important explanation, in that the greater the involvement of clinical experts in the development process of the CPGs, the less the recommendations reflected the research evidence. Even though their participation is important for CPG uptake, clinical expert panels appear to have difficulty limiting CPGs to research-based recommendations.

Conclusions:

Existing cholesterol testing CPGs are unlikely to improve the quality of care while controlling or reducing costs. The problem lies not with guideline implementation but with the guidelines themselves. It is unclear how best to ensure that recommendations reflect research evidence but this is likely to require significant and progressive changes to the current guideline development process, including a redefinition of the clinical experts' role.
Weights for Waits: Lessons from Salisbury
Authors: Lack Alastair , Edwards Rhiannon Tudor , Boland Angela
Published: January 2017

Objectives:

This paper describes a waiting list patients' points scheme under development in Salisbury, UK, for the fair management of elective inpatient and day case waiting lists. The paper illustrates how points can be assigned to patients on a waiting list to indicate their relative unmet need, and illustrates the impact on case mix and resource use of the implementations of the points system versus ‘first come, first served’. The paper explores a range of philosophical and technical questions raised by the points system.

Methods:

The Salisbury Priority Scoring System enables surgeons to assign relative priority to patients at the time they are placed on a waiting list for elective health care. Points are assigned to patients to reflect the rate of progress of their disease, pain or distress, disability or dependence on others, loss of usual occupation and time already waited. In recognition of the need for resource planning alongside the prioritisation of elective inpatients and day case waiting lists, a range of iso-resource groups has been developed for all procedures on these lists. These categorise procedures in terms of their resource use (i.e. bed days and theatre time required).

Results:

In a modelling exercise, application of the Salisbury Points Scheme to a ‘first come, first served' orthopaedic waiting list produced considerable changes in the order of patients to be treated. Only seven patients appeared in the first 20 patients to be treated under both regimes. The Salisbury Scheme required fewer resources to treat its first 20 patients than ‘first come, first served' and met more Salisbury-defined ‘need’;, but eliminated fewer days of waiting from the list.

Conclusions:

Development of a points scheme and iso-resource groupings opens up opportunities for more sophisticated purchasing, based on treating patients in order of unmet need rather than according to arbitrary maximum waiting time guarantees, as has been the dominant policy on waiting lists pursued in the UK, Australia, and Sweden, to date. However, such schemes raise three issues: first, the necessity of defining need as a composite of clinical and social factors; second the necessity to determine the acceptability of explicit prioritisation to both health care professionals and patients; third, the thorny issue of whether such prioritisation schemes will lead to ‘gaming’ by well-meaning general practitioners and specialists, aiming to secure the priority of their own patients and clinical specialty. Rigorous piloting of schemes, such as that developed at Salisbury, will be required to identify their dynamic effect over time on case mix, waiting time and resource use.
Cost Containment of Pharmaceutical Use in Iceland: The Impact of Liberalisation and User Charges
Authors: Almarsdóttir Anna Birna , Morgall Janine Marie , Grímsson Almar
Published: January 2017

Objectives:

Iceland was the first Nordic country to liberalise its drug distribution system, in March 1996. Subsequent regulation in January 1997 increased patients' share of drug costs. The objectives of this study were to test the assumptions that liberalising community pharmacy ownership would lower reimbursement costs for the state's Social Security Institute and that increasing patient charges would reduce use and, therefore, lower the cost to the Institute.

Methods:

Based on the assumptions, we built and tested two models using interrupted time series designs that contrast the monthly reimbursement costs before and after the legislation and regulation took effect. A control variable (the number of office visits to general practitioners) was tested to assess other events in the health care arena. Monthly data on these variables were provided by the Icelandic State Social Security Institute for January 1993 to August 1998 for reimbursement costs and to December 1998 for office visits to general practitioners.

Results:

Reimbursement costs have risen steadily throughout the period under study. The interrupted time series analysis did not show a substantial effect from the legislative change in March 1996 or from the regulatory intervention in January 1997.

Conclusions:

The main argument used for liberalising community pharmacy ownership in Iceland was built on false assumptions regarding the effect on drug reimbursement costs to the state. It will be necessary to find more promising interventions to halt the rapidly increasing cost of drugs.
Quantifying Patient Preferences for Out-of-Hours Primary Care
Authors: Morgan Anne , Shackley Phil , Pickin Mark , Brazier John
Published: January 2017

Objective:

To quantify public preferences for different attributes of out-of-hours primary medical care.

Methods

This study applies a technique called conjoint analysis. A focus group was convened to identify the most important attributes for inclusion in the study, followed by a postal questionnaire asking people to choose between hypothetical services containing different mixes of these attributes. Multi-variate regression analysis estimated the relative importance of different attributes to respondents. The respondents were 436 adults who were among respondents to an earlier postal survey of 25 090 randomly selected Sheffield residents.

Results:

The doctor's manner (whether the doctor takes time to listen), the type of consultation (whether the patient receives a home visit, telephone advice, sees an accident and emergency doctor or attends a primary care treatment centre) and waiting time for consultation best predicted the public's preferences for out-of-hours care. Another three attributes - ease of access; seeing a familiar doctor; and the doctor's shift arrangements - were not statistically significant.

Conclusions:

By asking people to make simple choices between hypothetical services, it is possible to quantify their strength of preference for different aspects of a service. This has important implications for the planning of services. Specifically, for out-of-hours services, more consideration should be given to the doctor's manner and waiting times rather than familiarity of doctor.
Does Length of Questionnaire Matter? A Randomised Trial of Response Rates to a Mailed Questionnaire
Authors: Iglesias Cynthia , Torgerson David
Published: January 2017

Objective:

To assess whether length of questionnaire affects response rates.

Methods:

A quasi-randomised trial of women aged 70 years and over in a general practice in England. Three questionnaires of different lengths: a clinical questionnaire (four pages); the same questionnaire plus the EuroQol (five pages); the same questionnaire plus the SF-12 (seven pages). The impact of length on the proportion of returned questionnaires and item completion rates was assessed.

Results:

In total, 847 questionnaires were mailed; response rates were 49%, 49% and 40% to the short, medium and long questionnaires, respectively. This difference was statistically significant when the short questionnaire was compared against the longest instrument (9% difference; 95% confidence interval (CI) of difference=0.3% to 16.6%). Item completion rates for the clinical questionnaire did not differ. Respondents did not differ in age or self-reported health status between the three groups.

Conclusions:

Increasing the length of a questionnaire from five to seven pages reduces response rates from women aged 70 years and over. However, lengthening a questionnaire does not seem to affect the quality of responses to questions near the front of the questionnaire.
Do Managers Pay Their Way? The Impact of Management Input on Hospital Productivity in the NHS Internal Market
Authors: Söderlund Neil
Published: January 2017

Introduction:

Levels of management staffing in the UK National Health Service (NHS) have received considerable political and media attention in the last four years or so. Both the previous and current governments committed themselves to reducing management expenditure in the health service, and significant cuts appear to have been made in this area in the last year or so. Few systematic evaluations have been undertaken of the value of general management input, however, and policy changes appear to have been largely determined by popular opinion. This study attempts to quantify the effect of management input on hospital productivity for the first three years of the NHS internal market (1991/2–1993/4).

Methods:

An average cost function was used to model the effect of management inputs on hospital costs after adjustment for the levels of outputs produced, input costs, and internal and external exogenous constraints on hospital functioning. Two measures of management input were used: the proportion of total spending consumed by top level management, and the proportion consumed by all administrative activities. Cross-sectional and longitudinal models with contemporaneous and lagged management input effects were estimated.

Results:

Higher spending on top level management was associated with poorer productivity levels in most instances. Total administrative inputs had a weaker, but still generally negative, association with productivity.

Conclusions:

No evidence was found that increasing management inputs was associated with improved productivity. On the contrary, spending more on top level managers appeared in fact to be associated with lower productivity levels. Results would thus appear to be in line with decisions to reduce the level of expenditure on management in NHS hospitals. Quality differences could not be measured, however, and it is possible that management input is associated with quality improvements which might reduce or reverse observed productivity losses.
Effect of Japanese Government Policy on Hospital Pharmaceutical Profit Levels
Authors: Oliver Adam James , Ikegami Naoki , Ikeda Shunya
Published: January 2017

Objectives:

Our main objective is to examine whether the Japanese government's pharmaceutical price reduction policy has reduced the size of pharmaceutical profit traditionally enjoyed by health care providers. We discuss alternative measures that the government could introduce in an attempt to control drug costs.

Methods:

We review Japan's pharmaceutical reimbursement system. We then analyse published and unpublished data in an attempt to reach our main objective. Calculations are made from raw data, provided by the National Hospital Federation of Japan, in order to discover the extent to which hospitals are experiencing financial difficulties.

Results:

Due to pharmaceutical product shifting by hospitals from older, less profitable drugs to newer, more profitable ones, drug profit margins may not have fallen to the extent that is often reported in the Japanese press. Furthermore, increased prescribing, possibly due to the ageing of the population, may have maintained the total drug profits of hospitals, to a large extent, despite any reduction in profit margins.

Conclusions:

Although drug price reduction policy has had some success in controlling pharmaceutical expenditure, there is little evidence to suggest that total pharmaceutical profits for the provider units have been seriously undermined, despite the prevalence of this notion among hospital administrators. Nevertheless, in order to promote the more efficient and effective manufacture and utilization of pharmaceuticals, the government should seriously consider alternative methods for controlling pharmaceutical costs.
The Case for Combining Qualitative and Quantitative Approaches in Health Services Research
Authors: Barbour Rosaline S.
Published: January 2017

A judicious combination of qualitative and quantitative methods can play a valuable role in health services research. This paper reviews the main reasons for combining methods: for different stages in a project; to compensate for the shortcomings of individual methods; and for the purpose of ‘triangulation’. It examines the potential for qualitative approaches to contribute to quantitative work — by providing insights into the process of data construction, identifying relevant variables to be studied, furnishing explanations for unexpected or anomalous findings, and generating hypotheses or research questions for further investigation. Similarly, qualitative work can be enhanced by using quantitative techniques — albeit often in a modified form — in analysing data, developing sampling strategies, and amalgamating findings from separate qualitative studies. Although there is potential to develop multi-method approaches, there remains an important role for rigorous studies employing either qualitative or quantitative methods.
Pre-Hospital Diagnosis of Myocardial Ischaemia by Telecardiology: Safety and Efficacy of a 12-Lead Electrocardiogram, Recorded and Transmitted by the Patient
Authors: Schwaab Bernhard , Katalinic Alexander , Riedel Jens , Sheikhzadeh Abdolhamid
Published: January 2017

We compared a 12-lead electrocardiogram (ECG) recorded by the patient and transmitted to a cardiology call centre via telephone (tele-ECG) with a standard 12-lead ECG recorded from the same patient at the same time. In 158 patients, tele-ECGs were compared with standard ECGs by two cardiologists and one internist, independently and blindly. In 14 patients peripheral electrodes were displaced, and in 12 patients there were baseline artefacts. These technical errors were corrected by telephone communication in all but two individuals. One patient could not use the tele-ECG device because of disability. Hence, in 155 of 158 patients (98%), the quality of the tele-ECG was adequate for diagnosis. Reliability coefficients ( R) for PQ, QRS and QT intervals between tele- and standard ECG were high, with R values of 0.73, 0.75 and 0.79, depending on the physician. Negative T-waves could be detected with very good agreement in the tele-ECG as compared with the standard ECG (kappa values of 0.97, 0.95 and 0.94). The agreement between tele- and standard ECG concerning: alterations of the ST segment was very good (kappa = 0.99 for all investigators). Residual signs of myocardial infarction could be detected by tele-ECG, with very good agreement for anterior as well as for posterior localizations (kappa = 0.99 and 1.00). The tele-ECG technique seems a promising approach to reducing pre- and in-hospital time delays to the initiation of thrombolytic therapy.
A Home Telecare Management System
Authors: Rodríguez M J , Arredondo M T , del Pozo F , Gómez E J , Martínez A , Dopico A
Published: January 2017

The increasing tendency to discharge chronic patients from hospital, as well as the growing expectation of improved quality of life for elderly and disabled people at home, was the original motivation for the development of a home telecare management system. The system allows a service centre to perform remote monitoring of biological signals and other data via the public telephone network, as well as to manage different emergency situations arising at home. The system is part of the EU-funded EPIC project (European Prototype for Integrated Care). It was tested in Belfast (Northern Ireland) and is currently being installed in Torre del Mar (Spain). This paper describes the system design and preliminary evaluation. The results indicate that the system operators find it highly acceptable in terms of efficiency, effectiveness, helpfulness, control and learnability. Integration of home telecare data with community-care information systems is essential if data captured at home are to be incorporated into the care process effectively.
Broadband Telemedicine: Teaching on the Information Superhighway
Authors: Jameson D G , O'Hanlon P , Buckton S , Hobsley M
Published: January 2017

The INSURRECT project uses the SuperJANET network to link six sites in the UK for interactive teaching and learning in surgery, an area of higher education where visual information is critical to the learning process. Collaboration between the six universities allows students access to a larger pool of surgical expertise and case studies than any single institution could provide. The project expects to improve the time that medical students can devote to surgery by up to 50%, by providing both supervised and unsupervised access to important visual information and case studies. Finally, the reduction in student numbers in operating theatres should reduce the infection risk to patients. A key component of the project is the central image resource, located in London, but allowing students and surgeons access from anywhere on the network. This paper describes the development of the interactive surgical teaching system and our experience with it during the first 18 months. One subjective observation, noticed after just one term's teaching, was the improved quality of the teaching.
Telemedicine and Developing Countries
Authors: Wright David , Androuchko Leonid
Published: January 2017

A committee was established by the International Telecommunication Union in 1994 to study telemedicine, with particular reference to developing countries. A questionnaire was used to gather data. Fifty-eight responses were received, two-thirds from developing countries. In most developing countries the user did not pay for the telemedicine service, at least not directly. There were few instances of a commercial telemedicine service, and in most countries the telemedicine service was subsidized by the government or another party. The telemedicine ‘value chain’ describes how equipment suppliers, telecommunications operators and health-care professionals deliver their products or services to the client, who is eventually the ultimate user. Quite different configurations are conceivable, and an analysis of what could be a sustainable, cost-effective value chain in developing countries is required. It is clear that the rapidly growing interest in telemedicine challenges the leaders of the medical establishment to rethink the ways they provide their services and to address the medical needs of areas where such services are absent or in short supply.