Evidence-based Treatment Plan Research Articles

Treating Selective Mutism Using Modular CBT for Child Anxiety: A Case Study

Selective mutism is a rare, debilitating condition usually seen in children. Unfortunately, there is little research examining effective treatments for this disorder, and designing an evidence-based treatment plan can be difficult. This case study presents the evidence-based treatment of an 8-year-old Caucasian boy with selective mutism using an established treatment for anxiety—Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders (Chorpita, 2007). The treatment consisted of 21 sessions and included modules on psychoeducation, exposure, cognitive restructuring, social skills, and maintenance and relapse prevention. The client's symptoms were greatly improved by the end of treatment based on fear hierarchy ratings, self-report and parent-report questionnaires, and child and parent clinical interviews. In addition, at discharge the client no longer met criteria for selective mutism. Improvements were maintained when the client was reassessed at 1-month and 6-month follow-up appointments.

Management of Colorectal Trauma

Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century and the result has improved, compared to other injuries, problems, such as high septic complication rates and mortality rates, still exist, so standard management for colorectal trauma is still a controversial issue. For that reason, we designed this article to address current recommendations for management of colorectal injuries based on a review of literature. According to the reviewed data, although sufficient evidence exists for primary repair being the treatment of choice in most cases of nondestructive colon injuries, many surgeons are still concerned about anastomotic leakage or failure, and prefer to perform a diverting colostomy. Recently, some reports have shown that primary repair or resection and anastomosis, is better than a diverting colostomy even in cases of destructive colon injuries, but it has not fully established as the standard treatment. The same guideline as that for colonic injury is applied in cases of intraperitoneal rectal injuries, and, diversion, primary repair, and presacral drainage are regarded as the standards for the management of extraperitoneal rectal injuries. However, some reports state that primary repair without a diverting colostomy has benefit in the treatment of extraperitoneal rectal injury, and presacral drainage is still controversial. In conclusion, ideally an individual management strategy would be developed for each patient suffering from colorectal injury. To do this, an evidence-based treatment plan should be carefully developed.

Interprofessional collaboration among nurses and physicians: Making a difference in patient outcome

Deficiencies in collaboration and communication between healthcare professionals have a negative impact on the provision of healthcare and on patient outcomes. Policymakers and healthcare managers, as well as clinicians and practitioners, are aware of this and have a growing interest in improving these relationships. To establish new models of care delivery, it is necessary to determine the interventions that are most effective in furthering interprofessional collaboration. This article provides an overview of the evidence base for interprofessional collaboration involving doctors and nurses and new models of care in relation to patient outcomes. Two authors conducted independent literature searches in PubMed, CINAHL, and Cochrane Library and selected fourteen randomised controlled trials (RCT) for review. All of the RCTs originated from Western countries, and the majority tested collaborative care management models against usual care within the elderly population. The major components of the interventions involved individual evidence-based treatment plans, care coordination, health status monitoring, coaching in self-management and promotion of community-based services. They varied between a few days' and three years' duration. Outcome measures incorporated mortality, clinical, functional and social outcomes, and utilisation of medical services. Some studies also used patient-reported outcomes. While the results of the fourteen RCTs included were mixed, all but one study reported at least one statistically significant improvement in outcome following interventions based on interprofessional collaboration. More rigorous research in this field and expansion of areas of interprofessional collaboration are needed. Nevertheless, up to now the evidence base of interprofessional collaboration shows promising results in relation to patient outcomes.

Care Coaching

The management of chronic medical conditions is very costly because of poor response to evidence-based treatment plans. Behavioral health disorders have been shown to impact one's inability to adhere to treatment protocols, thus worsening the course of the comorbid state. Traditional management methods have been unsuccessful in diminishing the costs associated with increased utilization of healthcare services that result from poor adherence to treatment plans and treatment failures that ultimately produce poor clinical outcomes. This article examines the use of an alternative approach on an identified high-risk population of individuals with the primary goal of promoting patient-centric self-efficacy and optimal patient care, thereby improving clinical outcomes resulting in a reduction of overall healthcare utilization. Care coaches, in collaboration with primary care physicians, engaged in telephonic consultation with identified participants from one regional health plan to validate and modify treatment plans in order to conform to evidence-based guidelines. The approach used in this study demonstrated improved clinical outcomes through decreases in acute care facility admissions, lengths of stay in acute care facilities, and emergency department visits. In addition, a positive return on investment is presented as evidence of the efficacy of this alternative approach. Predictive modeling and risk stratification methodologies are useful in the identification of individuals at risk for treatment failure and poor outcomes. Individuals who suffer from multiple comorbidities with identified psychosocial issues/barriers have increased health risks and costs that are far greater than those who do not appear to have associated psychopathology or psychosocial factors. Examining the use of the study protocol from a lifetime perspective can further reduce costs in the future and still show a positive return on investment.

Building Caries Risk Assessment Models for Children

Despite the well-recognized importance of caries risk assessment, practical models remain to be established. This study was designed to develop biopsychosocial models for caries risk assessment in various settings. With a questionnaire, an oral examination, and biological (salivary, microbiological, and plaque pH) tests, a prospective study was conducted among 1782 children aged 3-6 years, with 1576 (88.4%) participants followed in 12 months. Multiple risk factors, indicators, and protective factors were identified. Various risk assessment models were constructed by the random selection of 50% of the cases and further validated in the remaining cases. For the prediction of a “one-year caries increment”, screening models without biological tests achieved a sensitivity/specificity of 82%/73%; with biological tests, full-blown models achieved the sensitivity/specificity of 90%/90%. For identification of a quarter of the children with high caries burden (baseline dmft > 2), a community-screening model requiring only a questionnaire reached a sensitivity/specificity of 82%/81%. These models are promising tools for cost-effective caries control and evidence-based treatment planning. Abbreviations: decayed, missing, filled teeth in primary dentition (dmft); receiver operation characteristics (ROC); relative risk (RR); confidence interval (CI); National Institutes of Health (NIH); World Health Organization (WHO); US Department of Health and Human Services (US/DHHS); American Academy of Pediatric Dentistry (AAPD).

Cardiovascular risk in minority and underserved women in Appalachian Tennessee: A descriptive study

The purposes of this study were to translate current knowledge regarding cardiovascular risk factors, screening, and prevention to a disparate population of women and to ascertain the cardiovascular health status and risk factors in a sample of minority and underserved Appalachian women. Demographic data were collected from a voluntary sample of women from a disparate population living in Appalachian Tennessee. A coronary risk profile recorded family health history, personal health history, and lifestyle habits affecting risk for cardiovascular disease. Physiologic measurements included body mass index, blood pressure, fasting glucose, cholesterol levels, ankle brachial index, and carotid artery stenosis. Women in Appalachia Tennessee from a disparate population have high risks for heart disease and stroke. This is a critical time to address any modifiable risk factors and aggressively treat underlying cardiovascular diseases such as hypertension and hypercholesterolemia. Nurse practitioners (NPs) often provide primary care to women who may not be aware of their cardiovascular risks or actual disease. NPs can ensure that their practice incorporates primary and secondary cardiovascular prevention through screening, individual health education, and aggressive evidence-based treatment plans for women.

Modeling Dose-Response in Amblyopia: Toward a Child-Specific Treatment Plan

This article describes an empirically derived mathematical model of the treatment dose-response of occlusion therapy for amblyopia based on outcome data obtained from the Monitored Occlusion Treatment for Amblyopia Study (MOTAS). The MOTAS protocol comprised three discrete phases: baseline, refractive adaptation, and occlusion. Only data from the occlusion phase were used in this dose-response model. Seventy-two participants, 3 to 8 years of age, mean +/- SD age 5.2 +/- 1.4 years (anisometropia [n = 18]); strabismus [n = 22]); both anisometropia and strabismus [n = 32]) completed the occlusion phase. All participants were prescribed 6-h/d patching, which was objectively monitored by an occlusion dose monitor (ODM). Simple normal linear regression modeling of the data on an interval-by-interval basis (interval between clinic visits) indicates that increasing cumulative dose within interval (hours) yields an increase in visual acuity (R2 = 0.918; 684 data points). Most of the children achieved their best visual acuity with 150 to 250 hours' cumulative dose. Specific patient characteristics (especially age) modify the steepness of this function. For example, a 0.20-logMAR (2-line logarithm of the minimum angle of resolution) gain in visual acuity requires a cumulative dose of 170 hours for children at age 48 months and 236 hours at age 72 months. Mathematical modeling of amblyopia therapy is a novel approach that elucidates the kinetics of the therapeutic response in humans. This response is age-influenced so that older children require a greater dose to achieve the same outcome--evidence of altered plasticity of the visual system. Fine-tuning the dose-response in amblyopia therapy will facilitate the development of child-specific, evidence-based treatment plans.

Designing Practical Evidence-Based Treatment Plans for Children With Prolonged Seizures and Status Epilepticus

The adverse effects of prolonged seizures and status epilepticus can be reduced through appropriate, prompt, and aggressive intervention. Because most prolonged seizures and status epilepticus episodes begin outside the hospital, it is important to design treatment interventions that can be rendered at home or in school that do not rely entirely on intervention by emergency medical personnel. Factors that make this new approach possible include the use of evidence-based guidelines to inform treatment decisions and the successful development, and government approval, of new formulations of commonly used medications, including rectal diazepam gel and the phenytoin prodrug fosphenytoin. A useful plan should be initiated at the 5-minute to 10-minute mark (not the 30-minute mark) and contain clear, easy-to-read directions that can be implemented by family, school personnel, or emergency medical services who have varying levels of medical sophistication. Four scenarios illustrating these considerations are included and provide examples of plans that fulfill these criteria.

Experiences of Medical Advisors in the Workers' Compensation System in British Columbia

AbstractAttending physicians and medical advisors, physicians contracting their services to the Workers' Compensation Board, have key roles in assisting injured workers to return to work. A literature review of the role of the physician in the compensable return to work process reveals a lack of information regarding the experiences of medical advisors. This descriptive phenomenological study was undertaken to explore the lived experiences of four medical advisors in a northern rural service delivery location. The purpose of the research was to gain an understanding of the medical advisors' experiences in the compensable return to work process and in the compensation system. Analysis of the interview data revealed a central theme of commitment to quality medical care for injured workers, along with three major themes and several minor themes subsumed within the major concepts: providing medical opinions — requiring factual information, clarifying the diagnosis, no previous relationship with worker, categories of injuries; working with attending physicians and specialists — building relationships, evidence based treatment plans, role of the attending physician, role of the medical advisor; and, working within the workers' compensation environment — structure and policies, expedited services, and case management/team environment. This research report presents the central theme as the foundation through which the major themes are interconnected. This study does not generalise to all medical advisors, but relays stories that contain the essence of a lived experience.

Incidence and management of cutaneous toxicities associated with cetuximab

Cetuximab is a human/mouse chimeric monoclonal antibody that binds to the EGF receptor, competitively inhibiting ligand binding, and inducing receptor dimerization and downregulation. Cetuximab has been active in multiple tumors, including colorectal cancer (CRC), head and neck, pancreatic and lung cancers. Cetuximab has been approved by the FDA, in combination with irinotecan, for the treatment of metastatic CRC in patients refractory to irinotecan, and for use as a single agent in the treatment of recurrent metastatic CRC in patients intolerant of irinotecan-based chemotherapy. Most common toxicities are rash, diarrhea, fever, headache, nausea, hypomagnesemia and hypersensitivity reactions. Data from several clinical trials with cetuximab show a positive correlation between rash and response and/or survival. Rash occurred on 90% of patients treated with cetuximab monotherapy and grade 3 or 4 skin reactions occurred on as many as 16% of patients in the trials using cetuximab. A rash usually presents as pustular or maculopapular follicular eruption, often referred to as acneiform. Cetuximab will engage in productive dimerization complexes in human skin causing significant disruption of the normal development and maintenance of the hair follicle, which leads to follicular response and inflammatory response. At this time there are no standard or evidence-based treatment plans for the rash. Most of the evidence is based on institutional or personal experiences. The most commonly used agents are topical antibiotics, oral antibiotics, topical steroids, systemic immunomodulatory agents, topical immunomodulatory agents and anti-inflammatory preparations. As cetuximab is becoming widely used in general oncology practice, it is important to understand the toxicity of rash to develop practice guidelines for their management. This review addresses recommendations for toxicity management of rash caused by cetuximab in treatment of metatstatic CRC.

A Review of a Preventable Poison: Pediatric Lead Poisoning

A review of lead poisoning in pediatric populations enables nurses to increase their knowledge base about lead poisoning and to further the work on the Healthy People 2010 goal of eliminating childhood lead poisoning as a public health issue in the United States. Nurses should be aware of and use the variety of primary, secondary, and tertiary prevention strategies that are available to address pediatric lead poisoning. Prevention, education, and evidence-based treatment plans can decrease the occurrence of pediatric lead poisoning.

Prosthodontic Treatment Planning: Current Practice, Principles, and Techniques

In this series of articles, the faculty of the University of Southern California New Odontic Seminar have taken the 25 years of documented treatment of sample patient "A.K." and used it as a foundation on which to base discussion of the concepts and technology that have developed in prosthodontic treatment planning. Each of the contributing authors was asked, "What are your thoughts retrospectively if you were to treat the patient A.K. in your practice today?" And, since all dentists are challenged with evidence-based treatment planning, each author was also asked "On what evidence in the literature do you base your treatment planning for patients who need prosthetic therapy?" Dentistry's experience with long-term success of endodontics, periodontics, and implant dentistry is expressed in the presentations discussing when an implant may be better suited for a prosthetic abutment than a restored tooth.

To reflect or not? Reflective practice in radiation therapy

Therapy radiographers may be empowered to contribute more freely to the multi-disciplinary professional team if they critically reflect on their inherent clinical knowledge and perspectives. Critical reflection may help radiographers articulate the rationale behind professional decisions and proposed evidence-based treatment planning and delivery protocols, and reveal knowledge embedded in practice. Documentation of professional reflection may yet become a cornerstone for continuing professional development. Despite a paucity of rigorous empirical investigation, ‘reflective practice’ has become focal in nursing education. Three concepts appear confused, ill defined or interchangeable in the literature: ‘reflective practice’, ‘reflection’ and the ‘reflective practitioner’. Debate continues into the value of ‘reflective practice’ as a system: it remains problematic, it is difficult to conceptualise, it appears to have no clear or universal definition and no certain framework or guidelines for its implementation. In reflecting on action there may be strong hindsight bias which may invalidate conclusions reached. There are doubts raised about the benefits of structured models to implement reflective practice. Belonging to such an empirically based profession, it may be that educators and clinical therapy radiographers incorporate only those elements of systematised ‘reflective practice’ that can be empirically demonstrated to be beneficial to the profession, and will result in improved patient outcomes. There is no compelling evidence yet that any systematised ‘reflective practice’ is inherently more beneficial to therapy radiographers than radiographers continuing to reflect as they do now, with or without documentation.