Follow-up Care Of Patients Research Articles

Interdisciplinary Team Evaluation: An Effective Method for the Diagnostic Assessment of Autism Spectrum Disorder.

The objective of this research is to assess the feasibility of an interdisciplinary team diagnostic assessment model for autism spectrum disorder (ASD). Medical records from 366 patients evaluated for ASD at the Seattle Children's Autism Center (SCAC) were reviewed. ASD diagnostic outcomes, provider satisfaction, engagement in follow-up care, billed time, and reimbursement amounts were compared in patients evaluated through an interdisciplinary team approach (n = 91) with those seen in multidisciplinary evaluations led by either a psychologist (n = 165) or a physician (n = 110). Diagnostic determination was made in 90% of patients evaluated through the interdisciplinary team model in a single day. Rates of ASD diagnosis were similar across the 3 tracks, ranging from 61% to 72%. Demographic characteristics did not impact the likelihood of ASD diagnosis. Rates of patient follow-up care and provider satisfaction were significantly higher in interdisciplinary versus multidisciplinary teams. Interdisciplinary team evaluations billed 1.8 fewer hours yet generated more net hourly clinic income compared with psychology-led multidisciplinary evaluations. An interdisciplinary team approach, focusing on ruling-in or ruling-out ASD, was sufficient to determine ASD diagnosis in most patients seen at the SCAC Interdisciplinary teams generated more clinic income and decreased the time spent in evaluation compared with a psychology-led approach. They did so while maintaining consistency in diagnostic rates, demonstrating increased provider satisfaction and an increased likelihood of engagement in follow-up care.

Screening for childhood adversity among adult primary care patients.

Over half of Americans reports a history of adverse childhood experiences (ACEs), which have been associated with many chronic health conditions. Yet primary care providers infrequently screen patients for ACEs and fail to consider the relationship between ACEs and adult health. Therefore, the purposes of this study were to test the effectiveness and feasibility of a screening interview for ACEs and to confirm the prevalence of ACEs among individuals with chronic health conditions. Screening interviews were conducted with 71 adults in a primary care setting. Patients' ACE history, nurse practitioner comfort with screening, time to screen, and patient follow-up care recommendations were gathered through questionnaires. Adverse childhood experience prevalence was analyzed by descriptive statistics. Relationships between ACEs, number of clinic visits, time to screen, and follow-up care recommendations were analyzed by bivariate statistics. Over half of participants reported more than four ACEs, with ACEs common among participants with chronic health conditions (93%). Adverse childhood experience scores were positively correlated with number of clinic visits, time to screen, and recommendations for follow-up care. Findings support screening primary care patients for ACEs. Adverse childhood experiences are prevalent among primary care patients with chronic conditions. Using interviews to screen for ACEs in primary care settings is effective and feasible.

Increased long-term mortality after myocardial infarction in patients with schizophrenia

BackgroundIschemic heart disease increases mortality in patients with schizophrenia. This nationwide study explored short-term and long-term mortality rates in patients with schizophrenia experiencing myocardial infarction (MI) compared to controls from the general population experiencing MI, as well as patients with schizophrenia and people from the general population not experiencing MI. MethodA Danish nationwide cohort study including incident patients diagnosed with schizophrenia between 1980 and 2015, matched 1:5 on year of birth and gender to controls from the general population. Primary outcome was all-cause mortality. Data were analysed utilizing Cox regression models, Kaplan-Meier estimates and standardized mortality ratios (SMR). ResultsPatients with schizophrenia experiencing MI had an increased mortality rate (Hazard rate ratio (HR) 9.94, 95%CI(8.71–11.35)), as well as schizophrenia controls (HR 4.50, 95%CI(4.36–4.64)) and MI controls (HR 3.27, 95%CI(3.03–3.52)) with controls not experiencing MI serving as reference in a model adjusted for age at entry, gender and calendar year. No difference in 30-day mortality was observed between groups experiencing MI, but increased mortality rates were shown in patients with schizophrenia at 1-year and 5-year follow-up. Trends in SMR declined in MI controls, while patients with schizophrenia showed an unchanged SMR over time. ConclusionsPatients with schizophrenia have not experienced a decline in mortality rate following MI compared to the general population in long-term follow-up. This finding highlights the need for research in MI follow-up care for patients with schizophrenia.

Abstract P5-17-01: Lobular breast cancer alliance - Advocates advancing research, screening, treatment and follow-up care for lobular breast disease

Abstract Introduction Thirty patient advocates attended the First International Invasive Lobular Breast Cancer Symposium in 2016 at the University of Pittsburgh Cancer Center. The conference underscored that invasive lobular breast cancer (ILC) and other lobular pathologies are understudied. Specifically: ILC is the sixth most prevalent cancer of women and the second most frequently diagnosed histological subtype of breast cancer impacting up to 34,000 patients a year in the US. ILC is a molecularly distinct breast cancer with unique subtypes and variants with differences in presentation and behavior, including physical findings of thickening and a tendency to metastasize to unique locations. While ILC is frequently associated with a good initial prognosis, recent analysis suggests that long-term outcomes of ILC may be worse than those stage-matched to ductal breast cancer. Current imaging tools are less reliable for early detection of lobular disease and detection of distant recurrence. Standard of care chemotherapy and endocrine therapies may have different effectiveness applied to ILC and IDC. Challenges Growing interest in ILC research requires improved methods to identify, communicate with and link patients with ILC to clinical trials and research. Advocates with advanced science training are needed as partners for research proposals and grant reviews. Lobular breast cancer is under-represented in key meetings and literature. Encouraging opportunities to share ILC research as agenda topics and fostering collaborations between researchers, clinicians and advocates can accelerate progress and refine clinical practices for screening, treatment and follow-up. Patients living with ILC lack a central on-line source of lobular breast cancer information and resources. This information gap is a barrier to help patients recognize signs of lobular breast cancer's unique presentation and metastatic behaviors. Results The Lobular Breast Cancer Alliance (LBCA) was formed by patient advocates who attended the First International ILC Symposium in response to advocate-identified opportunities to advance research, refine treatments and enhance patient education. LBCA's mission is to bridge patients, clinicians and researchers to increase our knowledge of lobular breast disease and promote research that leads to advancements in prevention, diagnosis, treatment and patient follow-up care. Conclusions LBCA is driving an increased awareness of lobular breast cancer with specific goals: Build a clinically accurate, patient centered website devoted to lobular breast cancer at www.LobularBreastCancer.org. Elevate lobular research and foster opportunities for researcher, advocate and clinician collaborations at prominent conferences and meetings. Identify barriers to conduct research on ILC and metastasis and link patients and advocates to ILC tumor research and clinical trials. Initiate peer-to-peer clinician outreach strategy through targeted literature, meetings and education services to share information on ILC presentation, metastatic patterns and screening and treatment challenges of patients with ILC. Build partnerships with existing breast cancer organizations to integrate ILC into existing information resources and work on common goals. Citation Format: Petitti L, Axelrod J, Campbell-Kotler M, Frank E, Jaremek J, Levine J, McWilliams M, Migyanka F, Ryan N, Viggiano E, Metzger-Filho O, Oesterreich S, Pate L. Lobular breast cancer alliance - Advocates advancing research, screening, treatment and follow-up care for lobular breast disease [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-17-01.

Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany: Major impact of early information.

BackgroundUp to 3.5% of the population experience anaphylactic reactions in response to Hymenoptera stings. Current guidelines are in place for the diagnostic workup and follow-up care of patients with Hymenoptera venom anaphylaxis (HVA). However, little is known about the degree of implementation of the recommendations and patient attitudes toward the recommendations in the general patient population.MethodsFor the analysis of the follow-up care in real life, a retrospective questionnaire-based study was conducted in unselected patients who had received treatment from an emergency medical response team for HVA, as documented in records of three regional Medical Emergency Response Centers.ResultsFrom over 125,000 cases, a filtered list of 1895 patients that coded for anaphylaxis was generated and examination of paper records identified 548 patients with a documented insect sting anaphylaxis. Patients were sent a standardized questionnaire addressing different aspects of diagnostics and follow-up care. Almost 40% of the patients did not receive a referral to an allergist at the emergency center, over 50% did not consult an allergy specialist at any time after the index sting, 25% did not receive any form of diagnostic workup, over 30% did not receive any information about venom immunotherapy (VIT) as treatment option, and only 50% were eventually started on VIT. Emergency medication was prescribed in 90% of the cases, 77% including an adrenalin auto injector, of which 47% were expired at the time of the survey. Patients who were informed about diagnostic and treatment options early during the index event, i. e., during the stay in the emergency department, displayed a higher rate of referral to an allergist (70% vs. 17%), higher rate of diagnostic workup (88% vs. 59%), and a higher rate of initiation of VIT (89% vs. 64%), as compared to patients who did not.ConclusionOur results demonstrate that there are missed opportunities for secondary and tertiary prevention of anaphylaxis due to insect venom allergy and that early information on required diagnostics and treatment options has a major impact on the degree of proper follow-up care in line with current guideline recommendations.

Improving Inferior Vena Cava Filter Retrieval Rate With the Implementation of a Registry and Nurse Navigator at a Large Academic Hospital After 4-Year Retrospective Inferior Vena Cava Filter Retrieval Chart Review

SESSION TITLE: Venous Thromboembolism SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Utilization of inferior vena cava filters (IVCF) for venous thromboembolisms (VTE) have exponentially increased after the advent of retrievable IVCF (RIVCF) and the expansion of accepted indications of use. A RIVCF should be removed once the risk for VTE resolves or when anticoagulation therapy can be resumed. Unretrieved IVCFs may result in filter migration, fracture, embolization, caval thrombosis, and IVC perforation. However, several single-center studies demonstrated retrieval rates (RR) of only between 14 and 45%. Thus, we first set out to ascertain our retrieval rate and then implement a system to improve it. METHODS: A four-year (January 1st 2012 to July 29th 2016) retrospective chart review of the medical records of patients who underwent IVCF placement and retrieval procedures at an interventional radiology section of a large academic hospital was conducted and IVCF retrieval rate was ascertained. An IVCF registry was created while conducting the chart review. After the conclusion of the retrospective chart review, a nurse navigator was put in charge to continue to update the registry and tract for potential IVC filter retrieval. RESULTS: A total of 387 IVCFs were placed during the four-year span of the review. The mean patient age was 60.8 years and the mean filter dwell time was 812 days. The number of IVCFs removed was 24. The number of potential retrieval opportunity was 166 (42.9%). Complication rate of retrieval was 0.775%. Adjusted for patient death, loss to follow-up, and permanent indications, the adjusted IVCF RR was 12.6%. Since January of 2017, 12 patients with the registry and coordination of a nurse navigator were identified for IVCF retrieval and had them successfully removed. CONCLUSIONS: The adjusted IVCF RR of 12.6% was lower than the range of RRs (14-45%) from several other single-center retrospective studies. Most of the studies found rates closer to 20%. Such variations may be attributed to differences in hospital operations, patient populations, or the specialty performing the procedure. However, the chart review established a baseline RR and allows us to compare it to future RRs and quantity retrieval improvements with implementation of IVCF registry and a nurse navigator. Since the implementation of those two factors, 12 IVCF were removed compared to 24 IVCF that were removed in the last 4 years without the two factors. Thus, a total of 12 patients, who otherwise most likely would have unnecessarily kept their IVCFs, benefitted from its retrieval and have their potential complications removed. CLINICAL IMPLICATIONS: Patient follow-up care is one of the most neglected part of healthcare improvement efforts which may stem from the fact that the medical reimbursement in most cases are not linked to patient’s health outcome after leaving the hospital. Nevertheless, striving to continue to make improvements in post-treatment patient care is vital for any medical field. As the median age of our patient population and the use of RIVCF continues to increase and retrieval of RIVCF remain low, we are wary of possible large influx of indwelling IVCF complications. To minimize this risk and prevent adverse health outcomes of our patients, we find value in making this improvement. DISCLOSURE: The following authors have nothing to disclose: Daniel Lee, Hanzhou Li, Hoang-Anh Vo, Ana Rita No Product/Research Disclosure Information

313 - Shared Care for Follow-Up of Patients with Continuous Flow Left Ventricular Assist Device Implantation

313 - Shared Care for Follow-Up of Patients with Continuous Flow Left Ventricular Assist Device Implantation

Cost-effectiveness of Memory Assessment Services for the diagnosis and early support of patients with dementia in England.

Background Policy makers in England advocate referral of patients with suspected dementia to Memory Assessment Services (MAS), but it is unclear how any improvement in patients' health-related quality of life (HRQL) compares with the associated costs. Aims To evaluate the cost-effectiveness of MAS for the diagnosis and follow-up care of patients with suspected dementia. Method We analysed observational data from 1318 patients referred to 69 MAS, and their lay carers (n = 944), who completed resource use and HRQL questionnaires at baseline, three and six months. We reported mean differences in HRQL (disease-specific DEMQOL and generic EQ-5D-3L), quality-adjusted life years (QALYs) and costs between baseline and six months after referral to MAS. We also assessed the cost-effectiveness of MAS across different patient subgroups and clinic characteristics. Results Referral to MAS was associated with gains in DEMQOL (mean gain: 3.48, 95% confidence interval: 2.84 to 4.12), EQ-5D-3L (0.023, 0.008 to 0.038) and QALYs (0.006, 0.002 to 0.01). Mean total cost over six months, assuming a societal perspective, was £1899 (£1277 to £2539). This yielded a negative incremental net monetary benefit of -£1724 (-£2388 to -£1085), assuming NICE's recommended willingness-to-pay threshold (£30,000 per QALY). These base case results were relatively robust to alternative assumptions about costs and HRQL. There was some evidence that patients aged 80 or older benefitted more from referral to MAS (p < 0.01 from adjusted mean differences in net benefits) compared to younger patients. MAS with over 75 new patients a month or cost per patient less than £2500 over six months were relatively more cost-effective (p < 0.01) than MAS with fewer new monthly patients or higher cost per patient. Conclusions Diagnosis, treatment and follow-up care provided by MAS to patients with suspected dementia appears to be effective, but not cost-effective, in the six months after diagnosis. Longer term evidence is required before drawing conclusions about the cost-effectiveness of MAS.

Improving patient safety: The impact of an outpatients' electronic handover system in a tertiary dermatology department.

Electronic medical records (EMR) can improve quality healthcare, patient safety and streamline workflow to improve efficiency of a department. Despite the known benefits and difficulties of EMR systems, there is limited data on the impact and definable effectiveness it can have within a dermatology unit. We present an outpatients' EMR known as an electronic handover system (EHS) from its inception, delivery and audit of its use in evaluating the true impact. An audit of the EHS was conducted from 1 March to 31 August 2014. Quantitative data evaluating the type of jobs entered and completed, overdue tasks, patient workload and phone consultations were conducted. Qualitative data was assessed via a pilot survey assessing users' perspectives of the EHS evaluating communication, clinician-patient relationship and administrative tasks. Altogether 754 jobs were entered for 411 dermatology outpatients using the EHS. Most tasks concerned following up bloods and swabs (38%) or biopsies (36%). Overall, 51 jobs were not completed by the specified due dates and 188 phone consultations were performed. Compared with pre-EHS data, clinic review patients fell by 16%, with a modest increase (2%) in the number of new patients seen. The survey results show that most respondents believed that EHS improved communication, did not affect the clinician-patient relationship and they were more confident in their practice knowing there was a recording system for follow up. The dermatology EHS has provided a reliable system for following up all outpatient results. The potential benefits range from clinical, organisational and health research, which, from our experience, demonstrates improved patient follow-up care.

Influence of a Pay-for-Performance Program on Glycemic Control in Patients Living with Diabetes by Family Physicians in a Canadian Province.

We evaluated the influence of the introduction of a pay-for-performance program implemented in 2010 for family physicians on the glycemic control of patients with diabetes. Administrative data for all 583 eligible family physicians and 83,580 adult patients with diabetes in New Brunswick over 10 years were used. We compared the probability of receiving at least 2 tests for glycated hemoglobin (A1C) levels and achieving glycemic control before (2005-2009) and after (2010-2014) the implementation of the program and between patients divided based on whether a physician claimed the incentive or did not. Patients living with diabetes showed greater odds of receiving at least 2 A1C tests per year if the detection of their diabetes occurred after (vs. before) the implementation of the program (OR, 99% CI=1.23, 1.18 to 1.28), if a physician claimed the incentive (vs. not claiming it) for their care (1.92, 1.87 to 1.96) in the given year, and if they were followed by a physician who ever (vs. never) claimed the incentive (1.24, 1.15 to 1.34). In a cohort-based analysis, patients for whom an incentive was claimed (vs. not claimed) had greater odds of receiving at least 2 A1C tests per year before implementation of the incentive, and these odds increased by 56% (1.49 to 1.62) following its implementation. However, there was no difference in A1C values among the various comparison groups. Introduction of the incentive was associated with greater odds of having a minimum of 2 A1C tests per year, which may suggest that it led physicians to provide better follow-up care for patients with diabetes. However, the incentive program has not been associated with differences in glycemic control.

Carnet de suivi national : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC)

In an attempt to harmonize clinical practices among French hematopoietic stem cell transplantation centers, the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held its sixth annual workshop series in September 2015 in Lille. This event brought together practitioners from across the country. Our article discusses the updates and modifications for the 2016 version of the national patient follow-up care logbook.

Effect of Policy Change on the Use of Long-distance Transport and Follow-up Care for Patients with Traumatic Finger Amputations: Level 3 Evidence

Effect of Policy Change on the Use of Long-distance Transport and Follow-up Care for Patients with Traumatic Finger Amputations: Level 3 Evidence

Implementation of non-vitamin K antagonist oral anticoagulants in daily practice: the need for comprehensive education for professionals and patients.

Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for the prevention and treatment of venous thromboembolism and for stroke prevention in patients with atrial fibrillation. NOACs do not require routine coagulation monitoring, creating a challenge to established systems for patient follow-up based on regular blood tests. Healthcare professionals (HCPs) are required to cope with a mixture of patients receiving either a vitamin K antagonist or a NOAC for the same indications, and both professionals and patients require education about the newer drugs. A European working group convened to consider the challenges facing HCPs and healthcare systems in different countries and the educational gaps that hinder optimal patient management. Group members emphasised the need for regular follow-up and noted national, regional and local variations in set-up and resources for follow-up. Practical incorporation of NOACs into healthcare systems must adapt to these differences, and practical follow-up that works in some systems may not be able to be implemented in others. The initial prescriber of a NOAC should preferably be a true anticoagulation specialist, who can provide initial patient education and coordinate the follow-up. The long-term follow-up care of patients can be managed through specialist coagulation nurses, in a dedicated anticoagulation clinic or by general practitioners trained in NOAC use. The initial prescriber should be involved in educating those who perform the follow-up. Specialist nurses require access to tools, potentially including specific software, to guide systematic patient assessment and workflow. Problem cases should be referred for specialist advice, whereas in cases for which minimal specialist attention is required, the general practitioner could take responsibility for patient follow-up. Hospital departments and anticoagulation clinics should proactively engage with all downstream HCPs (including pharmacists) to ensure their participation in patient management and reinforcement of patient education at every opportunity. Ideally, (transmural) protocols for emergency situations should be developed. Last but not least, patients should be well-informed about their condition, the treatment, possible risk scenarios, including the consequences of non-adherence to prescribed therapy, and the organisation of follow-up care.

Sliding traсheal plasty in children under extracorporeal membrane oxygenation (first experience in Russia)

To improve the results of surgical treatment of children with extended tracheal stenosis. Since 2013 slidingtraсheal plasty under extracorporeal membrane oxygenation was performed in 4 children aged 1 year 2 months - 4.5 years with extended tracheal stenosis in Children's City Clinical Hospital №13. Patients' weight was from 10,5 to 16 kg. Extended tracheal stenosis and complete cartilag inousrings were confirmed in all patients after peoperative survey. Indications for surgery were based on medical history data, the severity of respiratory failure and survey data. Sliding traсheal plasty by different approach esunder extracorporeal membrane oxygenation was applied in all patients. There were no intraoperative complications. In the study group 1 patient died in remote postoperative period after discharge due to deterioration of his condition caused by upper respiratory tract infection and acute respiratory failure. In immediate postoperative period 1 patient had pronounced growth of granulation tissue in the area of anastomosis followed laser photocoagulation and prolonged intubation. The average ICU-stay was 24 days, the duration of mechanical ventilation - 11 days. Follow-up carefor patients was conducted on terms of 4-6 and 12 months after surgery. In 2 patients moderate complaints of recurrent bronchitis without signs of respiratory insufficiency during 6-8 months postoperatively were observed. In one child complaints were completely absent.

Inferior Vena Cava Filters in Trauma Patients: A National Practice Patterns Survey of U.S. Trauma Centers

Inferior vena cava filters (IVCFs) for thromboprophylaxis in trauma patients are being increasingly used despite a lack of strong clinical data in support of their efficacy and conflicting clinical practice guidelines. This national survey elucidates practice patterns of IVCF use across U.S. trauma centers. A web-based survey was administered to members of the Eastern Association for the Surgery of Trauma between September 2011 and October 2011. The survey queried: 1) background and professional practice; 2) trauma patient population; 3) IVCF placement; 4) IVCF retrieval and follow-up; and 5) pharmacologic prophylaxis. Two hundred eighty-one of 1059 eligible providers completed the survey (27%). Respondents were from a wide spectrum of training backgrounds and clinical practice settings. IVCFs were used by 98.9 per cent of respondents. IVCFs in patients without known venous thromboembolism were considered by 93.2 per cent of respondents. Indications and timing of IVCF retrieval vary. Follow-up care of patients with IVCFs was not uniform. An IVCF registry was maintained by 38 per cent of trauma programs. Adjunctive pharmacologic prophylaxis was used by 96.8 per cent of respondents. This study elucidates the gaps and variations in contemporary practices of IVCF use in trauma patients. Identification of best practices in IVCF use and retrieval awaits well-designed comparative effectiveness studies.

GW25-e4426 Community care follow-up of patients with chronic heart failure 5 years report

GW25-e4426 Community care follow-up of patients with chronic heart failure 5 years report

Unreserved application of epigenetic methods to define differences of DNA methylation between urinary cellular and cell-free DNA.

Urinary DNA is increasingly gaining importance in diagnosis of urological malignancies. Especially cell-free DNA originating from apoptotic and necrotic cells of the early tumor could become a key target for early stage tumor diagnosis. Aberrant DNA methylation forms tumor cell characteristic epigenetic profiles which are covalently established before any tumor related aberration at transcriptional or protein level has occurred. In addition, these epigenetic signatures are alterably adapted to and accompanying the individual stages of multistep, progressive tumorigenesis. Hence, they seem very promising for diagnosis as well as for monitoring the patient's follow-up care and even for decisions regarding personalized therapeutic options. The essential prerequisite at this approach will be a reliable methodological handling of the biological material of interest. In this study we present detailed analyses of LINE-1 DNA methylation profiles and demonstrate the sensitive detection of LINE-1 DNA methylation differences as well as between cancer patients and healthy individuals, between urinary cellular and cell-free DNA. In addition, we show methylome differences between both DNA fractions from a healthy individual and bladder cancer patients. In conclusion, we demonstrate here the unrestricted amenability of urinary cell-free DNA for both, a detailed characterization of a distinct DNA methylation alteration and its sensitive detection and a comprehensive global, array-based screening for DNA methylation differences.

Brace modifications that can result in improved curve correction in idiopathic scoliosis

Background and aimThe purpose of this paper is to share with scoliosis professionals the X-rays of different pad placement levels associated with improved curve correction in a case of idiopathic scoliosis (IS). Scoliosis braces of all types and brands utilize common principles of construction that ensure good fit and function. Equally important to the end result is good patient follow-up care and brace quality control by the orthotist.Design and methodsThis report reviewed the case of an 11-year-old girl diagnosed with IS, focusing on the in and out-of-brace x-rays, as well as the fit and function of the braces. The first brace was a TLSO-type, the second a Cheneau-type brace using a B1 model following the Rigo classification of scoliosis.ResultsThe first TLSO-type brace presented an in-brace X-ray that showed a curve increase. The Cheneau-type scoliosis brace reduced the Cobb angles over 50%.ConclusionsThe biomechanical changes consequent to modifications in brace design and pad placements appeared to have improved the scoliosis and reduced the Cobb angles in this case. An orthotist must provide optimal fit and function of the brace which was prescribed by the referring physician. Adherence to certain basic design principles, and close follow up by the orthotist-especially during growth spurts - are critical to its effectiveness. Specifically, a skilled orthotist must be experienced with the particular brace-type, apply these principles, maintain a good working relationship with both physician and patient to ensure timely brace adjustments essential to continued brace comfort and efficacy.

Application of traditional Chinese medical continuing nursing care in follow-up of patients with gastrointestinal carcinoma

Objective To study the application value of traditional Chinese medical continuing nursing care in follow-up of patients with gastrointestinal carcinoma .Methods Sixty-four patients with advanced gastrointestinal carcinoma from September 2010 to January 2013 were randomly divided into the control group （n=31） and the experimental group （n =33）.The control group received the routine follow-up, while the experimental group received routine follow-up plus traditional Chinese medical continuing nursing care including pressing the auricular point by magnetic beads , foot bath in the traditional Chinese medicine , massage at the plantar reflex zone and oral shiquandabu decoction .The quality of sleep , the intensity of pain , appetite and cancer-related fatigue （ CRF ） were evaluated before and four weeks after the follow-up in two groups. Results Before the follow-up, Pittsburgh sleep quality index （PSQI） was （10.39 ±177;3.84） in the control group, and （10.15 ±177;3.73） in the experimental group; the score of pain numerical rating scale was （2.26 ±177; 1.03） in the control group, and （2.21 ±177;1.05） in the experimental group;the cases of the mild, moderate and severe according to CRF score were respectively 8, 20, 3 cases in the control group , and respectively 10, 21, 2 cases in the experimental group , and the differences in the three indexes between two groups were not statistically significant （P＞0.05）.Four weeks after the follow-up, PSQI was （10.10 ±177;3.35） in the control group, and （8.48 ±177;2.50） in the experimental group, and the difference was statistically significant （t =2.170,P＜0.05）;the score of pain numerical rating scale was （2.19 ±177;0.83） in the control group, and （1.76 ±177;0.75） in the experimental group, and the difference was statistically significant （t =2.201,P ＜0.05）;the cases of the mild, moderate and severe according to CRF score were respectively 11, 16, 4 cases in the control group , and respectively 20, 13, 0 cases in the experimental group , and the difference was statistically significant （Z =-2.330,P ＜0.05）.Conclusions The traditional Chinese medical continuing nursing care can improve the symptoms in the follow-up of patients with advanced gastrointestinal carcinoma . Key words: Carcinoma; Gastrointestinal tract; Follow up study; Continuing nursing care; Traditional Chinese medical nursing

Bridging Care Transitions

Academic medical centers face unique challenges to ensuring patient safety after a hospital discharge, including those related to providing patient follow-up care in practices staffed by residents who are not comfortable managing care transitions. In 2011, the authors designed a quality improvement program for early postdischarge follow-up (bridge visits) at a resident primary care outpatient practice, using existing resources. The authors added a unique appointment template to the outpatient electronic health record to guide residents during the visit. Residents completed both postvisit and postprogram surveys regarding their experience with the program, and patients completed postvisit phone surveys regarding their satisfaction with the program. Fifty-eight residents completed postvisit surveys, of which 31.0% (18/58) reported problems with medication reconciliation and 25.9% (15/58) with adherence to discharge medications. Of those residents who completed postprogram surveys, almost half (18/38; 47.4%) agreed that their experience changed the way they discharge patients. Nearly all patients who responded to the postvisit phone surveys reported that the program reinforced their discharge and medication instructions (44/46; 95.7%); 81.8% (18/22) of patients with established providers did not mind seeing an interim physician for expedited postdischarge care. An early postdischarge program at a resident outpatient primary care practice is valuable both in ensuring patient safety and as a model to promote experiential learning in medical education. Findings from this study will be used to develop a formal curriculum in care transitions for all residents.