Ambulatory Program Research Articles

New Yorkers to Find ‘No Wrong Door’ to Public-Health Facilities

New Yorkers to Find ‘No Wrong Door’ to Public-Health Facilities

The number of included older people in recent pre-approval trials

chronic heart failure due to coronary arteria disease and activating the implanted ICD the therapy with amiodarone was doubled to 400mg/day. In the next week the patient developed a progressive weakness with inability to walk and to climb stairs. He admitted to the department of cardiology, where a rhadomyolysis was diagnosed.Maximumof creatinine kinasewas10.138U/L andmyoglobin 7.405ug/L. Parameters of infection and immune response were negative. Drug history revealed no use of thyroid drugs or statins, but the long-term use of bisoprolol, enalapril, torasemide and aspirin without any change prior to the occurrence of rhabdomyolysis. After 4weeks of in-patient rehabilitation the patient was discharged home without any ADL independence. An ambulatory training program was recommended. Conclusion.– Pubmed research and discussion with the manufacturer of amiodarone arise no association with the drugs used for heart failure therapy, so it seems possible that the rhabdomyolysis in this case is dose dependent.

PP224—Views of clinical and non-clinical professionals on information about older patients needed for rational drug prescription at time of authorisation

chronic heart failure due to coronary arteria disease and activating the implanted ICD the therapy with amiodarone was doubled to 400mg/day. In the next week the patient developed a progressive weakness with inability to walk and to climb stairs. He admitted to the department of cardiology, where a rhadomyolysis was diagnosed.Maximumof creatinine kinasewas10.138U/L andmyoglobin 7.405ug/L. Parameters of infection and immune response were negative. Drug history revealed no use of thyroid drugs or statins, but the long-term use of bisoprolol, enalapril, torasemide and aspirin without any change prior to the occurrence of rhabdomyolysis. After 4weeks of in-patient rehabilitation the patient was discharged home without any ADL independence. An ambulatory training program was recommended. Conclusion.– Pubmed research and discussion with the manufacturer of amiodarone arise no association with the drugs used for heart failure therapy, so it seems possible that the rhabdomyolysis in this case is dose dependent.

Resultados a medio plazo de un programa de insulinización en régimen de Hospital de Día para pacientes con diabetes tipo 2

Background and objectiveThe profile of the patient with type 2 diabetes mellitus (DM2) who requires insulin therapy is very diverse as are the results of this intervention and short/middle-term patient management. We evaluated the midterm results of an outpatient program starting insulin therapy with≥2 insulin injections/day in terms of metabolic control in different groups of patients. Patients and methodWe analyzed prospectively 131 patients with DM2, without previous insulin treatment, who were prescribed treatment with≥2 insulin injections/day and who were enrolled in a specific ambulatory program in order to start insulin therapy in a Day Hospital for 6 months. ResultsThe initial glycosylated hemoglobin (HbA1c) was 11.3 (2.3) % and decreased to 6.3 (1.4) % in 6 months, with HbA1c<7% in 72.5% of them. The group of recently diagnosed patients (<3 months, symptomatic severe hyperglycemia, D-group) were younger (57.1 [10.8] vs 64.2 [12.1] years; P<.01) and had a higher starting HbA1c (12.1 [1.8] vs 10.5 [2.5] %; P<.001) than patients included in the program for oral antidiabetic drugs’ failure (F-group). At the end of the program 50% of D-group patients did not need insulin (6.3% on F-group [P<.001]). There were no significant differences in either of 2 groups at study ends according to the final treatment scheme. ConclusionsCounselling patients with DM2 to start insulin with more than one injection per day in Day Hospital setting achieves and maintains a good metabolic control in the medium term in different patient profiles. Among symptomatic and recently diagnosed patients, insulin therapy can be stopped in 50% of them at the medium term.

Evaluation of the Child with Sleep-Disordered Breathing Scheduled for Adenotonsillectomy

The primary treatment of pediatric obstructive sleep apnea syndrome (OSAS) is adenotonsillectomy, and the safety of ambulatory adenotonsillectomy programs is predicated on the admission of the child with severe OSAS. The challenge is to identify the child with severe OSAS in the preoperative period. Preoperative evaluation with a combination of sleep-disordered breathing questionnaires plus an assessment with nocturnal oximetry has several advantages. It aligns with the diagnostic approach recommended by sleep physicians. It provides a useful prediction of perioperative respiratory adverse events and the medical interventions required to manage them.

SAFER-OPIOIDS

Chronic noncancer pain (CNCP) affects a considerable and increasing number of Canadians.1 Opioids have been demonstrated to reduce pain intensity in CNCP conditions; however, their use also presents risks and potential adverse effects.1 The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain recognizes that pharmacists need to take responsibility for assessing risks of opioid therapy and minimizing harm.1 Recent attention in the media about these risks reinforces the need for pharmacists to be proactive in assessing and monitoring opioid therapy.2 The removal of OxyContin from the market has also prompted a call to action for pharmacists and physicians to work collaboratively around dose changes and to reduce prescription fraud.1,3 Use of a structured approach for pharmacists to assess all patients on opioid therapy is important to ensure comprehensiveness and to avoid specific patients feeling targeted. Patients on opioid therapy may feel stigmatized because of recent increased media coverage about its harms, including the risk of addiction. Patients should play an active role in facilitating the safest possible use of opioids, and pharmacists can reinforce patient education with accurate information.1 Clinical pharmacists from the University Health Network (UHN) and the Centre for Addiction and Mental Health (CAMH) work collaboratively in an ambulatory program to provide detailed medication assessments focused on opioid therapy. They found that, when contacted for information, pharmacists in the community often reported that they were concerned about their patients’ opioid therapy; however, they felt that they did not have enough information about the indication or treatment plan to complete an assessment. These subjective reports are consistent with survey results from 2011 about Ontario pharmacists’ experiences dispensing opioids; of 642 respondents, most (86%) reported that they were concerned about the prescription opioid use of several or many of their patients.4 Respondents from this survey felt that physicians often failed to recognize that pharmacists can help with opioid management; 56% reported that physicians were unwilling to communicate their therapeutic plans to the pharmacists; and 61% reported that physicians sometimes or frequently did not respond to their concerns.4 Based on the structure of standardized assessments performed in the ambulatory clinic, a mnemonic to trigger identification of key information and a thorough and efficient assessment of patients’ opioid therapy was created to help pharmacists take responsibility for opioid management in their practice. Components of the tool were based on the pharmaceutical care process but, to facilitate a simple mnemonic phrase (SAFER-OPIOIDS; Box 1), they are not in the recommended order for consideration of indication, efficacy, safety and convenience.5 Box 1 SAFER-OPIOIDS mnemonic tool Side effects Aberrant behaviours Function Effect on pain Collaborative Relationship with physician Over the watchful dose of 200 mg morphine equivalents Pill count Interactions Opioid treatment agreement Indication Psychiatric Diagnosis Substance use

Single-Incision Laparoscopic Cholecystectomy for Day Surgery Procedure: Are We Prepared?

Single-incision laparoscopic surgery (SILS) for cholecystectomy is a well-established procedure and represents the next step in developing the concept of fast track surgery. This report describes our experience with SILS cholecystectomy in patients that stay overnight. Between February 2009 and July 2010, patients referred for cholecystectomy to the day surgery unit who agreed to undergo SILS were included in a prospective study. All operations were performed by the same surgical team specially trained in this type of surgery and the same operative technique was used in all cases. Postoperative pain and nausea were assessed using a 10-cm visual analogue scale on a self-completion questionnaire on the night of operation and the morning of discharge. A total of 107 patients (58% women, mean age 56 years) with symptomatic gallstones were included in the study. SILS was successfully performed in all patients and no patient required conversion to an open procedure. There were no significant differences in the median visual analogue scale for postoperative pain and nausea between the night of surgery and the next morning. The mean length of hospital stay was 23 hours, and 98 per cent of patients were satisfied with the results of surgery and would be willing to undergo the same procedure again. SILS cholecystectomy is a valid alternative to standard laparoscopic cholecystectomy as an outpatient surgery or overnight stay procedure. According to these promising results, SILS cholecystectomy could be included in a major ambulatory surgery program.

Der Schweizer Weg der kardiologischen Rehabilitation

Structured cardiac rehabilitation goes back to the late 1960s also in Switzerland and in the beginning was only available in rehabilitation clinics. In 1972 the first ambulatory rehabilitation programs became available to patients in Zurich and Bern. In the following years, in addition to the increasing number of rehabilitation centers for inpatients, more and more ambulatory rehabilitation programs were developed, especially in the larger Midlands population area in German and French-speaking Switzerland. In 1985 the Swiss Working Group of Cardiac Rehabilitation (SAKR) was initiated as an official working group of the Swiss Society of Cardiology and one of its first tasks was to establish a list of the institutions for cardiac rehabilitation in Switzerland. At that time there were 42 rehabilitation programs for a population of approx. 6.5 million, 21 for inpatients and 21 ambulatory; however, 90% of the patients were in inpatient programs. In 1992 the SAKR group defined the quality criteria which were to be applied for official recognition of institutions for cardiac rehabilitation in Switzerland. Due to these criteria, plus the fact that an increasing number of rehabilitation clinics in the mountains had been closed down, the number of inpatient rehabilitation centers decreased from 21 to 11 between 1989 and 2011, whereas the number of ambulatory programs increased from 21 to 51. The ambulatory rehabilitation centers are partially organized by local medical groups; however, most have integrated their activities into the local hospitals. The trend shows a developing preference for ambulatory rehabilitation. More and more elderly, polymorbid patients, however, will still need care in inpatient programs.

Structured assessment of protective factors: a German pilot study in sex offenders

The present study investigated the relationship between risk and protective factors in sex offenders and tested the feasibility of the instrument in an outpatient setting using the German version of the Structured Assessment of PROtective Factors (SAPROF) for violence risk. The study was conducted with 30 clients in the FORensic Ambulatory program for Sex offenders (FORAS) at the Institute for Sex Research and Forensic Psychiatry (ISF) in Hamburg, Germany. Correlations between the assessment data collected using the SAPROF, SVR-20, and Static-99 were analyzed. Both risk judgments and sum scores of the SVR-20 and the SAPROF showed a significantly negative correlation, whereas there was no significant link found between the SAPROF and the Static-99. The connection of the SAPROF to the SVR-20 but not to the Static-99 reflects the dynamic characteristic of the instrument. Despite the limited generalizability due to the small sample size, the German SAPROF seemed to be helpful for the structured assessment of protective factors.

PRS8 Cost-Effectiveness of an Ambulatory program of Pulmonary rehabilitation following Acute Exacerbations of Copd in Colombia

PRS8 Cost-Effectiveness of an Ambulatory program of Pulmonary rehabilitation following Acute Exacerbations of Copd in Colombia

Early Phase 2 Inpatient Rehabilitation after Acute Coronary Syndrome Treated with Primary Percutaneous Coronary Intervention

The aim of this study was to assess the 1-yr follow-up effects of inpatient rehabilitation and its prolongation with an ambulatory training program on blood pressure and metabolic risk factors in patients after an acute coronary syndrome. A controlled (n = 20) prospective study was undertaken. The study group consisted of 54 consecutive patients participating in a 3-wk inpatient rehabilitation. Of these, 14 chose to continue the training for 3 mos (CR_In+Amb group) and 40 declined (CR_In group). Body mass index increased in the CR_In and control groups. The magnitude of change was greater in controls (2.2 ± 2.14 vs. 0.7 ± 1.70 kg/m; P < 0.05). Waist circumference increased only in the control group, and at 12 mos, it was higher than in the CR_In and CR_In+Amb groups (P < 0.05). Mean systolic and diastolic blood pressure increased in the CR_In (from 121/76 to 130/82 mm Hg; P < 0.01) and control (from 122/74 to 139/87 mm Hg; P < 0.01) groups. At 12 mos, blood pressure in the CR_In group was lower than in the control group but higher than in the CR_In+Amb group (119/77 mm Hg; P < 0.05). Total cholesterol, low-density lipoprotein cholesterol level, and triglyceride level at 12 mos were higher in the control group than in the CR_In and CR_In+Amb groups (P < 0.05). C-reactive protein decreased in the CR_In and CR_In+Amb groups (P < 0.01). Inpatient rehabilitation was associated with beneficial effects on blood lipids and C-reactive protein in coronary patients and attenuated the rise in blood pressure and adiposity indices observed in nonparticipants. Prolongation of rehabilitation with an ambulatory program improved blood pressure control.

Early and personalized ambulatory follow-up to tailor furosemide and fluid intake according to congestion in post-discharge heart failure

Congestive heart failure (CHF) worsening is a worldwide cause of rehospitalization and mortality, specially during the early period after hospitalization. Fluid accumulation plays a key role in the pathophysiology of both acute heart decompensation and disease progression. The effective use of drugs to maintain restored clinical stabilization in recently discharged patients is a difficult task, and it relies on matching the most appropriately tailored therapy to specific clinical profiles. However, no successful treatment has been shown to reduce post-discharge readmission. We evaluated in a case-control study the effectiveness of an early and personalized congestion-guided ambulatory program on medium-term (6months) compensation in recently discharged CHF patients. Group A (22 patients) underwent a post-discharge close follow-up consisting of: an early clinic visit within 10days; a second visit within 10days after the first; and the other visits at month 1, 2, 3 after discharge. Controls (Group B, 21 patients) underwent a conventional ambulatory follow-up only at month 1, 2, 3 after discharge. The ambulatory approach in both groups was based on the monitoring of signs/symptoms of congestion and body weight, body hydration estimation by using bioelectrical impedance analysis (BIA) and laboratory data. This assessment was finalized to tailor furosemide and daily fluid intake at each visit to eliminate clinical or instrumental evidence of persistent congestion relieving the signs and symptoms. At 6 months, Group A was associated with a better clinical compensation (improved hydration state, lower BNP levels and congestion score), an improved quality of life, and reduced re-hospitalizations. We conclude that in CHF the early and personalized ambulatory follow-up based on congestion-guided treatment is effective to optimize management and maintain clinical stability in the post-discharge period.

Fatores intervenientes na terapia fonoaudiológica de crianças autistas

Estudos recentes mencionam que a incidência dos distúrbios do espectro autístico chega a 1%. Isso implica na necessidade de identificação urgente de modelos de intervenção eficazes, bem como dos fatores que podem interferir nesses processos. O objetivo deste artigo é descrever três anos de processos de terapia de linguagem de três crianças com diagnósticos incluídos no espectro do autismo com diferentes características de desenvolvimento e diferentes respostas ao processo terapêutico. Todas as crianças são atendidas em sistema ambulatorial, uma vez por semana, num serviço especializado, por fonoaudiólogas pós-graduandas na área há aproximadamente seis meses antes dos primeiros relatos apresentados. Os casos apresentados evidenciam a diversidade do fenótipo do autismo. Embora não fosse o objetivo deste estudo, fica aparente a referencia a três diferentes quadros incluídos no espectro do autismo. Desta forma, os processos de intervenção foram objeto de sutis ajustes às necessidades e possibilidades de cada uma das crianças. Todas as crianças tiveram progressos importantes em suas manifestações. A análise longitudinal individualizada de processos de intervenção terapêutica permite a abordagem de aspectos associados que podem ser determinantes nos resultados e que exigem abordagem consistente.

Enfoques y fundamentos para un modelo de rehabilitación ambulatoria en personas con lesión cerebral adquirida.

Introduction: A significant percentage of people who acquire a Brain Injury need outpatient rehabilitationprograms. In Chile the rehabilitation field is in a transitional stage. Even though the biomedical modelis predominant in rehabilitation, the clinical guidelines have begun to recommend an interdisciplinaryapproach that considers patients needs and their families. Now-a-days, there is a gap on how tooperationalize effective interventions responding to this paradigm.Objectives: To find evidence that sustains the development and assessment of outpatient neurorehabilitationapproaches of people with brain injury and, to describe the possible operationalization methodologies of these.Methodology: Inductive and conceptual review of literature.Results: In Chilean Literature does not exist empirical evidence nor systematic developments on thefoundations and effectiveness of outpatient rehabilitation programs for people with brain injury.International Literature describes three approaches: holistic, client centered, and goal-based. While suchapproaches can guide the team actions, the evidence of their effectiveness, based on expert criteria andsmall longitudinal studies and single case studies is still limited.Conclusions: For the development of a rehabilitation team identity, it is essential to determine theprinciples and approaches that support their work. Due to complexity and diversity of patients in theambulatory phase, it is crucial that teams have clear foundations to guide the constant decision making.The evaluation of the effectiveness of ambulatory programs in Chile is a necessity; also it is to developmethodologies according to the nature of the phenomenon.

Ambulatory surgery in urology: first numbers of a successful program

The ambulatory surgery includes those surgical procedures that require a small period of post-operative recovery so that the patients will be discharged from the hospital in the same day of the surgical intervention. In Urology, the vast amount of pathology that allows the cure with medium and low complexity surgical procedures makes this specialty a privileged one in which ambulatory surgery is concerned. In this paper the authors propose to describe how their Urology group works in the ambulatory field. 472 patients where reviewed in an evaluation period from January 2006 to April 2008. The medical appointment protocol is summarized as well as the most common surgical procedures and complications. Annually we operate an average of 200 ambulatory patients and this represents about 22% of the hole surgical activity of the Urology group. The majority of the surgeries are circumcisions and vasectomies (always associated with other small procedures). There is a 5 hours weakly period where a total of 5 to 6 patients are operated. Surgical complications represented 1.6% of total procedures, all of them late ones. With this specific ambulatory program our service managed to reduce drastically the waiting time for this kind of procedures (now-a-days is about 3-4 weeks), with a satisfaction rate of about 95%. According to the great outcomes, low complications rate and great acceptance of the patients, the development of this unit is without doubt a winning project in patients care.

Ambulatory pulmonary rehabilitation programme in patients suffering from chronic obstructive pulmonary disease (COPD): a preliminary study

Ambulatory pulmonary rehabilitation programme in patients suffering from chronic obstructive pulmonary disease (COPD): a preliminary study

Long- but not short-term multifactorial intervention with focus on exercise training improves coronary endothelial dysfunction in diabetes mellitus type 2 and coronary artery disease

Patients with type 2 diabetes mellitus (T2DM) suffer from accelerated coronary artery disease. We assessed the effects of a multifactorial intervention with focus on exercise training on coronary endothelial function, vascular structure, and inflammation in serum and skeletal muscle biopsies, including mRNA expression of diabetes candidate genes. Twenty-three patients were randomized to either 4 weeks in-hospital exercise training (6 x 15 min bicycle/day, 5 days/week) and a hypocaloric diet, followed by a 5 months ambulatory program (30 min ergometer/day, 5 days/week, plus 1 h group exercise/week), or a control group. At the beginning of the study, at 4 weeks, and after 6 months changes in diameter of coronary arteries in response to acetylcholine and mean peak flow velocity were invasively measured; intramural plaques were assessed by intravascular ultrasound. Six months of intervention led to significant improvement of coronary endothelial function, whereas intramural plaque burden remained unchanged. After 4 weeks, endothelial function remained unchanged, however, lowest values for fasting glucose, HbA1c, high-sensitive C-reactive protein, total and LDL-cholesterol, and highest values for mRNA expression in skeletal muscle of p22, gp91, haem oxygenase 1, peroxisome proliferator activator receptor (PPAR) alpha and gamma were observed. There was a continuous increase for AdipoR1, AdipoR2, Glut4, interleukin-6, endothelial nitric oxide synthase, and PPARgamma-coactivator-1alpha mRNA expression in skeletal muscle. This is the first study to demonstrate improvement in coronary endothelial function by a multifactorial intervention which focused on exercise training in patients with T2DM. This coincided with improved markers of hyperglycaemia, insulin sensitivity, and inflammation both in serum and skeletal muscle biopsies.

Mejora a corto plazo del peso y la calidad de vida de mujeres obesas posmenopáusicas mediante un programa ambulatorio de ejercicio físico

Objectives To evaluate the effects of an ambulatory physical exercise program on the quality of life, anthropometric and biochemical parameters in obese post-menopausal women. Methods One hundred and six obese post-menopausal women were randomized to take part in an ambulatory program of physical exercise (aerobic and anaerobic), or to receive conventional information about diet and exercise. After three months, effects on quality of life were evaluated (test Euroqol, Rosenberg and subjective evaluation of health), weight, BMI, waist perimeter and fat mass, and biochemical parameters. Results Mean age was 59.79 (8.02) years and BMI 37.51 (6.03) kg/m 2. Women included in the exercise group improved their quality of life after three months (EuroQol 0.48 (0.38) vs 0.66 (0.35); Rosenberg: 19.21 (5.05) vs 16.86 (4.94); subjective evaluation of health (%): 60.68 (19.99) vs 71.14 (17.28); p<0.01) and lost weight (90.95 (15.51) vs 88.72 (15.17); p<0.001), BMI (37.5 (5.68) vs 36.59 (5.72); p<0.001) and fat mass (46.28 (4.92)% vs 45.47 (4.88)%; p<0.01). No changes were observed in control group. 31 people withdrew the study before 12 weeks. Conclusions An ambulatory physical exercise program improves quality of life and reduces weight and fat mass, in a short period of time, in obese post-menopausal women. The high rate of withdrawal should be considered as an inconvenient in this type of programs.

Abstract 5147: A Cluster Randomised Controlled Trial to Evaluate an Ambulatory Primary Care Management Program for Patients with Dyslipidemia: TEAM Study

Dyslipidemia management in primary care is often sub-optimal. New Quebec (Canada) legislation increases the potential for family physician-community pharmacist collaborative care (PPCC). We hypothesized that PPCC can improve the management of dyslipidemia. In a randomized controlled trial, clusters of physicians and pharmacists within the same geographical area were randomly assigned to the PPCC or the usual care (UC) group. PPCC pharmacists attended a one-day workshop and successfully completed a clinical skills evaluation. In the PPCC intervention, the physicians are responsible for the diagnosis and the prescription of lipid-lowering pharmacotherapy, while the pharmacists initiate treatment; request appropriate laboratory tests; monitor effectiveness, safety, and adherence to treatment; and adjust medication dosage accordingly. In PPCC, physician-pharmacist communication procedures were pre defined to enhance professional collaboration. Moderate and high CHD risk patients initiating statin treatment or currently on treatment but inadequately controlled were recruited and followed-up for 1 year. The primary endpoint was the mean change difference in LDL between groups after 1 year. Secondary endpoints included the proportion of patients at or below their target LDL and TC/HDL ratio, as defined by the Canadian Lipid Guidelines, after 1 year. Multilevel and multivariate regression models were used. We enrolled 15 clusters of physicians and pharmacists (PPCC: 108 patients; UC: 117 patients). The mean change in LDL after 1 year was -1.11 mmol/L (95%CI: −1.26 to −0.96) and −0.89 mmol/L (−0.95 to −0.83) in PPCC and UC groups, respectively. The adjusted mean change difference in LDL between PPCC and UC groups was −0.11 mmol/L (−0.34 to 0.11). After 1 year, 80.6% of PPCC patients and 72.9% of UC patients were at or below their target lipid levels (adjusted OR 2.1; 1.2 to 3.8; p=0.008). PPCC patients had more lipid-lowering pharmacotherapy changes (OR: 2.0; 1.1 to 3.8) and were more likely to report lifestyle changes (OR: 3.9; 2.4 to 6.3). Our data shows that the Family physician-community pharmacist collaborative care improves the adherence to the Canadian Lipid Guidelines.( ISRCTN66345533 )

Breast milk composition in a cohort of pre‐term infants' mothers followed in an ambulatory programme in Colombia

Describing preterm breast milk evolution and composition according to gestational age (GA) and postnatal age (PNA) in a cohort of mothers cared for in an ambulatory Kangaroo Mother Care Program (KMCP) in a developing country. A cohort involving 113 mothers who delivered 'healthy' preterms adequate for GA was assembled. Mothers received intensive breastfeeding support before discharge. Samples of both fore- and hind milk were obtained at entry into KMCP and weekly thereafter, until term. Composition was described according to PNA and postconceptional age (PCA). Protein concentration varied inversely with both PCA and PNA. Fat concentration was consistently higher in hind milk than in fore milk samples of the same feed. Lactose increased steadily with PCA. Calcium/phosphorus ratios were stable, close to 2:1 and content of both was similar in samples of different PCA and PNA. Minerals concentration could be inadequate for preterms. Protein concentration decreases steadily to mature milk levels by the third week of PNA, regardless of birth GA. Therefore, from the third week of PNA onwards, protein content could be insufficient to satisfy needs of preterms born at 32 weeks or less. Feeding hind milk could increase caloric density and fat intake to better meet preterms' nutritional needs.