Medical Management Protocol Research Articles

Using Medical Words with Family Caregivers

Although there is poor communication about pain management between informal caregivers and hospice providers, little research has examined these interactions. This study explored communication between informal caregivers and hospice team members by investigating the use of medical words in care planning discussions. Transcripts of clinical communication between caregivers and hospice team members were reviewed for use of medical words, word placement (statement or question), whether or not the word was explained, and the caregiver's response to the word. As part of an ongoing randomized clinical trial in the midwestern United States, informal hospice caregivers participated in recorded hospice care planning discussions. A selection of videorecorded interactions from an ongoing study was analyzed. Hospice team members used six times as many medical words compared to caregivers. The majority of medical words used by caregivers and team members were drug names. Medical words were predominantly used as statements rather than questions that sought clarification. Three-fourths of medical words used by team members were not explained to caregivers. Caregivers provided little response to medical word use, indicating a lack of understanding. The propensity to use medical words during clinical communication with family caregivers is cautioned. In order to recognize the caregiver as a contributing team member, clinicians should limit the use of medical words, provide lay explanation alongside medical terminology, and use questions to check for understanding. More research is needed to determine assessment tools to capture the caregiver's level of understanding of medication and pain management protocol.

Assessment of medical wastes management protocols in Jordanian healthcare institutions

Successful and effective medical waste management strategy requires adopting clear and distinct protocols that will guarantee the appropriate and correct execution of this strategy. This study presents the results of a survey that has been conducted among the nursing staff working in different Jordanian hospitals in the northern, middle and southern parts of Jordan. The survey contained questions about medical waste administrative procedures and collection protocols. The results showed that the southern part of Jordan has the least proper way of administrative procedures and collection protocols of medical waste. However, other parts still need more attention to reach safe handling and treatment of medical wastes.

Efectividad de un programa de conciliación perioperatoria de la medicación crónica en pacientes de cirugía programada

Evaluation of the effectiveness of a perioperative medication reconciliation program in patients scheduled for elective surgery on perioperative medication management protocol adherence.Ambispective cross-cohort study: prospective cohort (Group A), and retrospective control cohort (Group B) without intervention. Forty eight hours before admission a pharmacist generates a proposal on medication active prior to admission to be maintained/discontinued during the perioperative period according to the hospital protocols. The Pharmacy proposal is validated/modified by an anesthesiologist 24h before admission. At the time of admission, after checking with the patient the medication list, the nurse initiates scheduled medication administration pre and postoperatively. The indicator for program effectiveness assessment is the degree of compliance with perioperative medication management protocols at 24, 48 and 72h of admission for intervention and control cohorts.Five hundred and three patients were included. One thousand two hundred and eleven pharmacy medication management recommendations were performed in Group A (intervention), of which 94.9% agreed with protocol. In Group B (control before program implementation) action taken by physicians agreed with protocol only in 32.4% of all cases.The medication reconciliation program significantly increased compliance with the recommendations on chronic medication perioperative management.

Serie de feocromocitomas durante 15 años en Navarra

The pheochromocytoma is a catecholamine secreting tumour derived from chromaffin cells of the sympathetic nervous system. Eighty to eighty-five percent of these tumours are localized in the adrenal medulla. When pheocromocytomas are found outside the adrenal gland they are referred to as extra-adrenal pheochromocytomas or paragangliomas. The diagnosis is confirmed by elevation of catecholamines and the metanephrines in blood plasma and urine. Localization of the tumour should be done following biochemical diagnosis by means of CT scan and/or MRI. The treatment of choice is tumour resection by laparoscopic surgery. A review was made of all patient medical histories diagnosed with pheochromocytoma confirmed by the pathology reports of Pathological anatomy of the Navarre hospital Complex (Anatomía patológica del Complejo hospitalario de Navarra A y B) between 1996 to 2010. Descriptive analysis was made using the IBM SPSS statistics program. Our series consists of 43 patients diagnosed with pheochromocytoma over a span of 15 years. The average age on presentation was 47 years. Among the younger patients specific genetic syndromes were found. Computerized tomography was the most widely used method of localization. Contradictory results were found regarding perioperative medical management protocols. All pheocromocytoma tumours in this series were benign. It is advisable to carry out a genetic study on patients under twenty. The biochemical indicators with the greatest diagnostic sensitivity were the levels of normetanephrine and metanephrine in urine. Surgery was the only treatment option.

Medical waste management at the Oncology Institute of Vojvodina: possibilities of successful implementation of medical waste regulation in Serbia

Implementation of National waste management strategy, which included most of Healthcare facilities (HCF) in Serbia, began in 2009. The present study aimed to evaluate the medical waste management strategy protocol at Oncology Institute of Vojvodina, which is the first institution in Vojvodina and one of the first institutions in Serbia which has implemented the recomended medical waste management protocol. Segregation, storage, transportation and treatment were all evaluated and that was all performed according to National strategy. Biohazard generation rate was 0,17 kg/bed/day, which correspods with values in the HCF in Eastern Europe. The results show that the methods for safe management of medical waste are acceptable, affordable, and economically justifable to accomplish the reduction in the financial costs in HCF business, and can serve as representative of proper medical waste management practice for other HCF.

Personal and organizational predictors of physicians’ knowledge, attitudes and practices related to medical waste management in Mazandaran province (northern Iran)

Medical waste management (MWM) is an important public health concern worldwide. Although physicians must participate in medical waste management, their personal and organizational predictors in this process are unknown. This study aimed to the determinants of physicians' knowledge, attitudes and practices related to MWM in eight hospitals of Mazandaran province, northern Iran. A validated, reliable self-administered questionnaire was used including 30 questions about the respondents' knowledge, attitudes and practices (KAP) and personal and professional variables. Of a total of 200 physicians, 150 persons completed the questionnaire (response rate of 75%). The average score (± SD) for physicians' knowledge was 6.50 (± 1.50) out of 10, whereas those for attitudes and practices were 4.44 (± 0.88) and 4.02 (± 1.35) out of 5, respectively. Surgeons and orthopaedists had the lowest scores, whereas para-clinical specialists and internal medicine specialists had the highest scores. The score of knowledge showed significant differences among speciality groups and the various speciality groups' scores differed significantly only for knowledge (P = 0.024) and the mean of total KAP was significantly different between educational and non-educational hospitals (P < 0.05). As hospital type and physician speciality was related to the KAP concerning MWM, therefore it is recommend that all hospitals should develop appropriate protocols for medical waste management based on the this variables using a participatory process with teamwork and continuous training.

Abstract 141: Impact of an Aggressive Medical Management Protocol on Early Risk Factor Measures in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) Trial

Purpose: SAMMPRIS is the first stroke prevention trial to include protocol-driven aggressive management of multiple vascular risk factors. We sought to determine the impact of this protocol on early risk factor control in the trial. Materials and Methods: SAMMPRIS randomized 451 patients with symptomatic 70%-99% intracranial stenosis to aggressive medical management or stenting plus aggressive medical management at 50 USA sites. For the primary risk factor targets (SBP &lt; 140 mm/Hg (&lt;130 if diabetic) and LDL &lt; 70 mg/dL), the study neurologists follow medication titration algorithms and risk factor medications are provided to the patients. Secondary risk factors (diabetes, non-HDL, weight, exercise, and smoking cessation) are managed with assistance from the patient’s primary care physician and a lifestyle modification program (provided). Sites receive patient-specific recommendations and feedback to improve performance. Follow-up continues, but the 30-day data are final. We compared baseline to 30-day risk factor measures using paired t-tests for means and McNemar tests for percentages. Results: The differences in risk factor measures between baseline and 30 days are shown in Table 1. Conclusions: The SAMMPRIS protocol resulted in major improvements in controlling most risk factors within 30 days of enrollment, which may have contributed to the lower than expected 30 day stroke rate in the medical group (5.8%). However, the durability of this approach over time will be determined by additional follow-up.

Gallium poisoning: A rare case report

The authors present a case of a college student who suffered acute gallium poisoning as a result of accidental exposure to gallium halide complexes. This is extremely rare and has never been reported in the literature. Acute symptoms after the incident, which initially presented as dermatitis and appeared relatively not life-threatening, rapidly progressed to dangerous episodes of tachycardia, tremors, dyspnea, vertigo, and unexpected black-outs. Had there been effective emergency medical care protocols, diagnostic testing, treatment and antidotes, the latent manifestations of irreversible cardiomyopathy may have been prevented. Given how quickly exposure led to morbidity, this article aims to raise an awareness of the toxic potential of gallium. This has particular relevance for workers involved in the production of semiconductors where there is a potential for accidental exposure to gallium by-products during device processing. It may also have implications for dentists who use gallium alloys to replace mercury containing amalgam. In the absence of threshold limit values and exposure limits for humans, as well as emergency medical guidelines for treatment of poisoning, the case calls on the National Institute for Occupational Safety and Health and the Occupational Safety and Health Administration to establish guidelines and medical management protocols specific for gallium.

A novel solution approach and protocol design for bio-telemetry applications

In this contribution a novel model-based solution approach is introduced for medical networks and biotelemetric applications. Medical networks are communication networks that serve for the purpose of monitoring and protecting human health. These networks are designed to use biotelemetric ways to transmit the vital data to health observers such as doctors, nurses, first-aid teams, hospitals, and health agencies. These networks are also used in collective damages that may occur in situations such as flood, earthquake, war and terror and for treatments and follow-up of patients and to organize health teams more effective and efficiently. Implementations using this model presented here provides a reference design. In addition MCP (Medical Communication Protocol) and MMP (Medical Management Protocol) are designed to reveal how communications between modules designed. In this way, communication rules explained clearly on developed solution based on the model.

Bodies in Doubt: An American History of Intersex by Elizabeth Reis

Health & History ● 12/1 ● 2010 141 Right continues to press for the removal of comprehensive sex education in schools. The book involves a certain amount of repetition, suggesting the potential for tighter organisation. There is also a tendency to describe issues as ‘complex’, and then move on without affording full explanations. On the other hand, Lord often affords an entertaining narrative. As one would imagine, the subject provides scope for plenty of pithy word play: Lord writes under headings such as ‘In Bed with the Fed’ and ‘Rooted in Abstinence’. Condom Nation effectively mines the enormous chasm between Americans’ public views on sex education and their sexual behaviour. MICHAEL STURMA MURDOCH UNIVERSITY Elizabeth Reis, Bodies in Doubt: An American History of Intersex (Baltimore: Johns Hopkins University Press, 2009). ISBN 9780801891557 (HC). 15 halftones, 240 pp. Intersex is a contemporary term used to describe that which has historically been referred to as hermaphroditism. Elizabeth Reis traverses an epoch of American intersex that is book-ended by the seventeenth century ‘monstrous sign of providence’ and the twentyfirst century activist. Within each century, an intersex zeitgeist has reinforced a personhood or, as the case may be, a persona non grata. True hermaphroditism in humans is routinely written about as an impossibility. Those people with ambiguous or doubtful bodies have been met by a cultural milieu determined to find a place for them, that, more often than not, is a place of annihilation. Thus if there is a singular feature of an American history of intersex it is denial of existence. Early colonial references to bodies in doubt were dismissed as myth and fantasy, and the United States harbours a silence that is written into twenty-first-century medical management protocols, which surgically alter ambiguous genitalia to look acceptable. The protocols are inherited from John Money (and John and Joan Hampson) who, between the 1950 and 1970s decreed that if intersex individuals knew about their intersex status, they would at best lead unhappy lives and at worst commit suicide. Bodies in Doubt offers much-needed voice to the much-silenced lives of intersex Americans, and Reis eloquently writes the unwritten 142 BOOK REVIEWS history of intersex in the United States. Reis captures their stories as told by a plethora of masculinist and authoritative treatises, including autopsies, legal records, and medical texts, and to a lesser extent autobiographies. We witness the lives of these people as they were viewed, regulated, and categorised within the dominant discourses of their times that were bound to a need to similarly hide intersex and perpetuate social constructions of sex and gender. From this work we have an unprecedented view of not only the lives of intersex individuals, but also the cultural norms surrounding them. Through the social sanctioning of intersex we garner glimpses of women, heterosexuality, marriage, and the ubiquity of the notion that there are only two sexes and genders. Additionally, threaded throughout the piece are references to other social axes, namely vocation, property, class, and race. An American history of intersex is also marked by deceit. In the early centuries, intersex individuals were policed for the truth of their bodies. When bodies were in doubt and did not coincide with sex and gender, intersex individuals were accused of intentionally deceiving intimates (e.g., marital partners) and society (e.g., the law and medicine). When sex and gender was assigned, rarely were the person’s desires or wishes listened to. Medicine knew best, and the medical management protocols today continue to deny intersex as a viable ontology. The medical profession is still influenced by Money and also many theories that attempted to annihilate intersex and deny it existence. Reis does more than analyse the past; the epilogue documents what is unfolding in the first decade of the new millennium. Reis is aware that the history of American intersex continues with our own cultural stamp. We must concede that ‘our contemporary standpoint is no less fraught with cultural biases than our predecessors’ (p. 153). The terms ‘hermaphrodite’and ‘intersex’have a historical component, and remain controversial and thus culturally significant. The Chicago Consensus Conference in 2005 (where only two intersex adults were invited) posited ‘Disorders of sex development’(DSD...

An Intervention for Treating Alcohol Dependence: Relating Elements of Medical Management to Patient Outcomes With Implications for Primary Care

Alcohol dependence, frequently seen in medical settings, is a major problem that affects the health and well-being of many individuals and their families. The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors specifically associated with a medically oriented intervention given for the treatment of alcohol dependence. The intervention was developed for the National Institute on Alcohol Abuse and Alcoholism-sponsored COMBINE Study, a randomized controlled trial combining 2 medications, naltrexone and acamprosate, with Medical Management, with or without specialty alcohol treatment. We examined the effect of patient adherence to treatment (number of Medical Management visits, total minutes in treatment, alliance or therapeutic relationship with the clinician, patient satisfaction with treatment, and clinician adherence to the Medical Management protocol) on abstinence from alcohol, amount of heavy drinking, and clinical improvement during treatment. More Medical Management visits attended and less total time spent in Medical Management treatment was associated with more days of abstinence from alcohol, reductions in heavy alcohol drinking, and a higher likelihood of clinical improvement. The patients' positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment. Two clinician factors clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were also associated with better patient outcomes. Medically trained clinicians with minimal specialty training in alcohol dependence treatments were able to deliver a brief and effective medication management intervention that was designed to be consistent with primary care practice.

Pharmacist membership in a medical group’s diabetes health management program

An evaluation of the effectiveness of a program at achieving improved glycemic control, lipid levels, and adherence to preventive care measures in diabetes mellitus patients was conducted. An interdisciplinary diabetes health management program (DHMP) was implemented, which included physicians, clinical pharmacists, registered nurses, and registered dieticians. The patients are seen by a clinical pharmacist with the option of individual or group visits with other members of the multidisciplinary team. Clinical pharmacist interventions include education and comprehensive medication management through collaborative practice agreements held with physicians. The collaborative agreements allow the clinical pharmacist to initiate, adjust, or discontinue pharmacotherapy and order pertinent laboratory tests and podiatry referrals that are within the scope of the medication management protocol. A retrospective review was conducted of the 707 patients enrolled in the program between April 2002 and April 2004. The mean +/- S.D. number of days between baseline and follow-up values was 140 +/- 62. Eighty-four percent of the enrolled patients were diagnosed with type 2 diabetes mellitus, 69% met the National Cholesterol Education Program's criteria for metabolic syndrome, and 51% were male. The mean glycosylated hemoglobin (HbA(1c)) value dropped significantly, and the percentage of patients who were at or below the American Diabetes Association's established HbA(1c) goal of < or = 7% increased significantly. Lipid values for enrolled patients improved, with the percentage achieving a low-density-lipoprotein cholesterol concentration of <100 mg/dL increasing from 25% to 44% [corrected] Adherence to preventive care measures (e.g., annual eye and foot examinations) also significantly improved from baseline to follow-up. Involvement of pharmacists in an interdisciplinary DHMP has improved patient care.

Benefits of Comprehensive Inpatient Education and Discharge Planning Combined With Outpatient Support in Elderly Patients With Congestive Heart Failure

Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce readmission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse-driven home health care program. The comprehensive intervention resulted in a marked reduction in 6-month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow-up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.

Pre-eclampsia: Is it a different disease in primiparous and multiparous women?

The aim of this study was to evaluate differences in clinical and laboratory parameters and differences in the complication rates between pre-eclamptic primiparous and pre-eclamptic multiparous women. A prospective case series of 112 primiparous and 186 multiparous women with pre-eclampsia was conducted at Princess Badea Teaching Hospital; a large tertiary public health service hospital in Irbid, North Jordan. A uniform medical and surgical management protocol was implemented. The main outcome measures included antenatal, intrapartum and puerperal, maternal and foetal complications. Multiple maternal and foetal demographic, clinical and laboratory parameters were studied. As expected, the primiparous were younger than the multiparous women. After adjusting for maternal age, regression analysis revealed no difference in the systolic or diastolic blood pressure in the two groups. It was also demonstrated that there was no statistically significant difference in the clinical presentation, haematological and biochemical parameters or ultimate maternal outcome between the two groups. After adjusting for babies' sex and gestational age, it was demonstrated that there was no statistically significant difference in the following: gestational age at delivery, foetal weight, stillbirth, admission rate to neonatal intensive care unit, neonatal death rate within the first four weeks after birth and incidence of intrauterine growth restriction between the two groups.

Training, supervision and quality monitoring of the COMBINE Study behavioral interventions.

Current standards for clinical trials require that behavioral interventions be thoroughly specified, that clinicians be well trained and closely supervised and that performance be carefully monitored to ensure and document treatment fidelity. This article describes procedures developed and implemented for this purpose in the COMBINE Study, a multisite trial combining medications and behavioral interventions for alcohol dependence. Two behavioral treatments were tested in COMBINE: a Medical Management (MM) protocol to accompany the delivery of trial medications and a Combined Behavioral Intervention (CBI) designed as a comprehensive and flexible evidence-based psychotherapy. Information is provided concerning (1) screening and qualifications of practitioners, (2) training and certification in the interventions, (3) on-site supervision and coordination of the two treatments, (4) central monitoring and coding of treatment sessions and (5) maintenance and documentation of treatment fidelity. Both interventions were delivered with fidelity. Problems encountered and important choices made in the implementation of training and quality assurance for CBI and MM are briefly described.

Reduction in Anticoagulation-Related Adverse Drug Events Using a Trigger-Based Methodology

An initiative was undertaken by Novant Health System to address warfarin-related adverse drug events (ADEs) using lab-based patient-specific International Normalized Ratio (INR) triggers and pharmacy-based patient-specific Vitamin K triggers. The goal was to reduce ADEs related to the use of warfarin in both the inpatient and outpatient settings. Process improvements and medication management protocols were developed for patients managed with warfarin anticoagulation. During each month's seven-day sampling period, the hospital information system generated the lab and pharmacy triggers, and the clinical pharmacists used these patient-specific triggers to identify the patient charts for review. All triggered charts were reviewed. Preliminary harm classification based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was assigned by the clinical pharmacists and recorded for each patient. The system achieved reductions in ADEs related to warfarin administration on an inpatient management (45%) and outpatient management (52%) basis. Although based on inpatient facility-generated triggers, the initiative also served as a reasonable outpatient model, with improvements seen in the outpatient physician intervention groups.

Household exposure factors, asthma, and school absenteeism in a predominantly Hispanic community.

The Passaic Asthma Reduction Effort (PARE) used an asthma symptom and household exposure factor questionnaire to screen 4634 elementary school children over a 4-year period in Passaic, New Jersey. During the first year, an additional 240 preschool children were also screened. Overall, 16% of the school children were reported by their parents to have been diagnosed with asthma. In all, 30% of responding families claimed to have at least one family member diagnosed with asthma and this was five times more likely if the target child had asthma. Exposures consistently associated with childhood asthma diagnosis included environmental tobacco smoke (ETS), presence of dampness/mold, roaches, and furry pets in the home. Diagnosis of asthma was primarily associated with all six symptoms used in the PARE questionnaire, and secondarily with environmental factors. Puerto Rican and black children had the highest asthma prevalence (26% and 33%), while Mexican children had the lowest (7%). Use of medications and school absenteeism among asthmatic children were associated with wheeze and night cough, but not with any specific environmental exposure. Increased school absenteeism by children undiagnosed with asthma was associated with ETS and dampness/mold in the home. Differences in asthma diagnosis and absenteeism in response to environmental factors were found across ethnic subgroups. Getting asthmatic children on medical management protocols and providing families with education about environmental risk reduction should aid in reducing morbidity in this ethnically complex population. Such coordinated efforts offer the promise of reducing school absenteeism.

Traumatic rupture of the aortic isthmus: program of selective management.

Two hypotheses were investigated: (1) helical computed tomography (CT) of the chest on victims of decelerating trauma can yield a diagnosis of, or "rule out," a traumatic rupture of the aorta (TRA) without the need for an aortogram; and (2) selective delay of aortic repair can be safely accomplished through a medical management protocol. Screening helical CT examinations were done on 6169 victims of blunt thoracic trauma; 47 were found to have TRA; in 8, indirect but nondiagnostic findings not clarified by an aortogram led to surgical exploration. The sensitivity of helical CT was higher than that of aortograms, and a "normal" helical CT scan was never associated with a proved TRA. It is estimated that the use of helical CT has resulted in at least a 40% to 50% decrease in the need for aortograms, in addition to yielding rapid, noninvasive valuable information about other injuries. Drugs (beta-blockers +/- vasodilators) to decrease the stress in the aortic wall were used in 93 patients when the diagnosis was suspected and were continued as necessary through the evaluation, stabilization, and until the aorta was cross-clamped at operation. Elective, delayed operation was done between 2 days and 25 months in 15 patients who were deemed to be excessive risks for emergency aortic repair; there were 2 deaths (13. 3%). Eleven patients never had aortic repair. No patient maintained on this protocol, whether repaired emergently, electively, or not at all, developed free rupture of the periaortic hematoma and death from TRA.

Consultant Attitudes on the Impact of Computers: Users Compared with Non‐Users

The attitudes of doctors towards Computer‐Based Information Systems (CBIS) are crucial to the successful implementation of medical audit, resource management and clinical protocols. We present the results of a postal questionnaire survey of 846 consultants (471 replies) on their attitudes towards computers. The survey revealed doctors′ requirements (demands) of CBISs and also their concerns (expectations) about the likely impact of these systems. Clear differences are found between the concerns of doctors who are computer users and those who are not. The latter displaying more negative attitudes. It is assumed that if the attitudes of the non‐users become like those of the user′s implementation of CBISs will be more successful. Requirements for CBISs were very similar between the two groups, suggesting that changes in attitudes are not required, but that systems should display the features listed in the demand section of the questionnaire. A strategy for the implementation of CBISs should have two strands. It should meet the demands and reduce the concerns of non‐users over computer systems. The findings of this survey present for the first time an empirical basis for the development of such a strategy.

Cocaine-packet ingestion. Diagnosis, management, and natural history.

We treated 50 patients who ingested packets of cocaine and developed a protocol for conservative medical management. Of the 50 patients, only 3 required emergency surgery. Surgery was precipitated by signs and symptoms of bowel obstruction in all cases. Six patients chose elective surgery. The rest of the patients passed the packets without signs of cocaine toxicity or other complications. This finding is in contrast to that of previous reports. Asymptomatic patients who have ingested packets of cocaine can be safely observed and managed conservatively.