Outpatient Clinical Practice Research Articles

Short-Term Impact of a Combined Nutraceutical on Cognitive Function, Perceived Stress and Depression in Young Elderly with Cognitive Impairment: A Pilot, Double-Blind, Randomized Clinical Trial.

The prevalence of senile dementia is increasing worldwide, especially in the developed countries. Nevertheless, drug therapy isn't often enough to treat this condition. Researchers are evaluating the possible impact of a preventive approach, based on an improvement of lifestyle and the intake of micronutrients. Moreover, there is an increasing interest for combined nutraceuticals that can act as memory and learning enhancers, with a significant and beneficial potential on the cognitive disorders. To evaluate the effects of a rational assemblage of nutraceuticals on cognitive functions in a sample of 30 elderly subjects. Double bind, cross-over designed trial versus placebo Setting: outpatient clinical practice. 30 elderly subjects with basal Mini-Mental State Examination score between 20 and 27 and self-perceived cognitive decline. Treatment with a combination of nutraceuticals based on Bacopa monnieri, L-theanine, Crocus sativus, copper, folate and vitamins of B and D group. After2 months of treatment or placebo. Patients were evaluated with Mini-Mental State Examination (MMSE), Perceived Stress Questionnaire (PSQ) and Index and Self-Rating Depression Scale (SRDS). MMSE and PSQ Index significantly improved in the active treatment arm, both versus baseline and versus the parallel arm. Both groups experienced a significant improving in the SRDS scores. We obtained a good and significant improvement of the cognitive functions tested with the MMSE, PSQ-Index and SRDS score, after 2 months of combined therapy of nutraceuticals. Further confirmation will be needed to verify these observations on the middle and long term in a larger number of subjects.

Wearing off: A complex phenomenon often poorly recognized in Parkinson's disease. A study with the WOQ-19 questionnaire.

'Wearing off' refers to the phenomenology of movement disorders in Parkinson's disease (PD) that appears early and is much commoner than generally believed. It may be present in the form of either motor symptoms or non-motor symptoms. To investigate the utility of wearing-off questionnaire (WOQ-19, Italian version) in the outpatient clinical practice to assess the suitability of different combinations of treatment, in various stages of PD. 73 consecutive patients (58% male and 42% female) suffering from PD were recruited through the Santorso Hospital and San Martino Hospital from September 2012 to March 2014. The patients were asked to indicate whether or not they experienced any of the 19 symptoms listed in the questionnaire during the day; if one or more of these referred symptoms relating to PD improved after taking an additional dose of levodopa; and, if these variations were present routinely. Furthermore, we also evaluated the possible correlation between the presence of motor and non-motor symptoms that were listed in the WOQ 19 with the motor impairment assessed by the Hoehn and Yahr stage (HY) and the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor section, in the whole patient cohort as well as in different subgroups undergoing therapy. Among the 73 patients, 22% were receiving levodopa (a mean daily dose of 300 ± 121.3 mg), 38.3% levodopa and dopamine agonists, 12.3% levodopa/rasagiline, 8.2% levodopa/selegiline, and 19.2% a combination of levodopa/dopamine agonists (DA)/monoamine oxidase inhibitors (MAOI). The most prevalent symptoms were the non-motor symptoms included in the WOQ-19. A significant correlation between the scores obtained on the different motor and non-motor items recorded by the WOQ-19 and the UPDRS motor section and HY scores was found. The therapeutic benefit was especially related to the motor symptoms. In clinical practice, this simple and easily administered questionnaire may be useful for the early detection of fluctuations in symptomatology in patients with PD. It will, therefore, help to improve the quality of the global care of patients with PD detected in various stages of the disease.

Evaluation of the knowledge and behavior of patients at a university hospital outpatient clinic regarding blood donation

Aim: This study aims to determine the knowledge, and behavior of patients at a university hospital’s family practice outpatient clinic regarding blood donation. Material and method: In this cross-sectional study, the authors administered a questionnaire to patients (400 people) at the university hospital’s family practice outpatient clinic for three months. The study data were entered into the SPSS package program, and the author performed the statistical analyses using this program. Results: The mean age of the participants was 28.70±10.81. Of them, 86% knew their blood type, and 53.8% had a document showing their blood type. Only 21.8% of the participants had previously donated blood. Blood donation was evaluated according to gender; men had offered to donate blood more than women; when evaluated according to marital status those who were married were found to donate blood more than singles. 63.3% of the participants who donated blood said they did so to help other people. Of those who did not donate blood before, 29.1% now consider donating?? In response to the question, how much a person is supposed to weigh in order to donate blood, 47.0% said a person should weigh at least 50 kilograms. When asked how often you could donate blood, 23.8% said every three months. Conclusion: The participants’ attitudes and behavior regarding blood donation were positive. Knowledge of participants is not enough. They are moderately well informed about this issue. People should be continuously provided with training about blood donation to increase their awareness.

Evaluation of the appropriateness of the preclinical phase (stage A and stage B) of heart failure Management in Outpatient clinics in Italy rationale and design of the 'VASTISSIMO' study.

Early detection of heart failure, when still preclinical, is fundamental. Therefore, it is important to assess whether preclinical heart failure management by cardiologists is adequate. The VASTISSIMO study ('EValuation of the AppropriateneSs of The preclInical phase (Stage A and Stage B) of heart failure Management in Outpatient clinics in Italy') is a prospective nationwide study aimed to evaluate the appropriateness of diagnosis and management of preclinical heart failure (stages A and B) by cardiologists working in outpatient clinics in Italy. Secondary goals are to verify if an online educational course for cardiologists can improve management of preclinical heart failure, and evaluate how well cardiologists are aware of patients' adherence to medications. The study involves 80 outpatient cardiology clinics distributed throughout Italy, affiliated either to the Hospital Cardiologists Association or to the Regional Association of Outpatient Cardiologists, and is designed with two phases of consecutive outpatient enrolment each lasting 1 month. In phase 1, physicians' awareness of the risk of heart failure and their decision-making process are recorded. Subsequently, half of the cardiologists are randomized to undergo an online educational course aimed to improve preclinical heart failure management through implementation of guideline recommendations. At the end of the course, all cardiologists are evaluated (phase 2) to see whether changes in clinical management have occurred in those who underwent the educational program versus those who did not. Patients' adherence to prescribed medications will be assessed through the Morisky Self-report Questionnaire. This study should provide valuable information about cardiologists' awareness of preclinical heart failure and the appropriateness of clinical practice in outpatient cardiology clinics in Italy.

Validation of a pain mechanism classification system (PMCS) in physical therapy practice

The objective of this study was to validate the clinical application of a pain mechanism classification system (PMCS) in clinical practice. We analyzed data abstracted from the medical records of patients who were treated in the outpatient clinics of a large urban rehabilitation hospital in Chicago. We hypothesized that there would be good agreement between the PMCS determined by trained therapists and the PMCS category assigned based on a computer-generated statistical model using patients’ signs and symptoms. Using cluster analysis, when we assumed five groups, 97% of patients could be classified. Sensitivity and specificity results with 95% confidence intervals were calculated for the categories using the physical therapist assigned categories (PMCS) as the criterion standard. Sensitivity for four of the five categories (inflammatory, ischemia, peripheral neurogenic, and other ranged from 72·0 to 83·1%). For the central mechanism, sensitivity was much lower at 15%. Specificity for the five categories ranged from 72·4% (ischemia) to 98·8% (central). This study provides empirical support for recent findings in the literature that the peripheral components of a PMCS can be implemented consistently in an outpatient pain clinical practice.

Breast cancer chemoprevention in primary care: Assessing readiness for change.

1547Background: Despite FDA approval of medications for breast cancer risk reduction and professional organizations’ (ASCO, USPSTF & NCCN) chemoprevention recommendations, chemoprevention use has not increased substantially. Barriers and facilitators to primary care providers’ (PCP) incorporation of breast cancer chemoprevention could inform efforts to increase uptake. Methods: We conducted an online survey of PCPs’ regarding awareness and use of breast cancer chemoprevention, and perceived barriers/solutions. All eligible PCPs at Geisinger Health System (family physicians, internists, residents, physician assistants, nurse practitioners) who practice ≥ one-half day per week in a family practice, internal medicine or OB-GYN outpatient clinic were invited to participate via email (four attempts total). Results: Of 492 invited providers, 195 (40%) participated (mean age 41 years, 61% female, 70% MD/DO, 45% ≥ 10 years in practice). Of the 195 participants, 74 (38%) used the Gail model for breast cancer risk ...

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 4: Acting on Patient Satisfaction Results.

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 4: Acting on Patient Satisfaction Results

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 3: Patient Satisfaction and Your Practice.

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 3: Patient Satisfaction and Your Practice

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 2: History of Patient Satisfaction in Health Care.

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 2: History of Patient Satisfaction in Health Care

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 1: Current Medicare Physician Quality Reporting Programs.

The Advantages and Challenges of Measuring Patient Experience in Outpatient Clinical Practice. Part 1: Current Medicare Physician Quality Reporting Programs

Faculty Communication Knowledge, Attitudes, and Skills Around Chronic Non-Malignant Pain Improve with Online Training.

Many physicians struggle to communicate with patients with chronic, non-malignant pain (CNMP). Through the use of a Web module, the authors aimed to improve faculty participants' communication skills knowledge and confidence, use of skills in clinical practice, and actual communication skills. The module was implemented for faculty development among clinician-educators with university faculty appointments, outpatient clinical practices, and teaching roles. Participants completed the Collaborative Opioid Prescribing Education Risk Evaluation and Mitigation Strategy (COPE-REMS®) module, a free Web module designed to improve provider communication around opioid prescribing. Main study outcomes were improvements in CNMP communication knowledge, attitudes, and skills. Skills were assessed by comparing a subset of participants' Observed Structured Clinical Exam (OSCE) performance before and after the curriculum. Sixty-two percent of eligible participants completed the curriculum in 2013. Knowledge-based test scores improved with curriculum completion (75% vs. 90%; P < 0.001). Using a 5-point Likert-type scale, participants reported improved comfort in managing patients with CNMP both immediately post-curriculum and at 6 months (3.6 pre vs. 4.0 post vs. 4.1 at 6 months; P = 0.02), as well as improvements in prescribing opioids (3.3 vs. 3.8 vs. 3.9, P = 0.01) and conducting conversations about discontinuing opioids (2.8 vs. 3.5 vs. 3.9, P < 0.001). Additionally, CNMP-specific communication skills on the OSCE improved after the curriculum (mean 67% vs. 79%, P = 0.03). Experienced clinician-educators improved their communication knowledge, attitudes, and skills in managing patients with CNMP after implementation of this curriculum. The improvements in attitudes were sustained at six months. A Web-based curriculum such as COPE-REMS® may be useful for other programs seeking improvement in faculty communication with patients who have CNMP.

Implementation of a new patient health questionnaire into standard practice in outpatient cancer clinics to improve patient care and quality of treatment.

214 Background: Patient socio-demographic, lifestyle, and risk factor information at the Princess Margaret Cancer Centre (PM) is routinely collected for clinical purposes. The only standardized patient information presently being gathered in the outpatient cancer clinics at the PM is symptom management data, which is linked directly into the electronic medical records. Collecting and recording additional data can improve the quality of patient care, help identify risk factors, and guide treatment options. Our aim was to determine the feasibility of collecting this additional information in a clinical setting. Methods: This pilot cohort study was implemented in the thoracic outpatient oncology clinic at the PM. It involved developing a questionnaire utilizing literature sources, expert review, and pilot testing. Adult cancer patients completed the questionnaire and a complementary acceptability survey during their first clinic visit. Results: 170 patients with thoracic tumours, primarily lung cancer, took part in the feasibility study. Of these, 51% were female, 67% were Caucasian, and the median age was 65 (range 32 to 88) years old. The acceptability survey demonstrated that: 76% of respondents found that the questionnaire did not make their clinic visit more difficult, 68% found that it asked the right questions, 79% thought the questionnaire contained pertinent information for their doctor and other healthcare providers to know, and 51% found that it was time consuming to complete. Conclusions: This study determined that it is feasible to implement a standardized questionnaire that gathers patient socio-demographic, lifestyle, and risk factor information in routine clinical cancer care. Since half of the study population found the questionnaire time consuming to complete it should be administered prior to patient visits, in an electronic format, and with greater explanation/education. The next phase is converting the questionnaire into an electronic version, which aligns with the preferences of study participants and will allow the information to be more easily accessible by clinicians/researchers.

Relational ecologies of psychotherapy: The influence of administrative attachment on therapeutic alliance

There is now vast and multi-faceted empirical literature on the impact of relational dynamics in psychotherapy, and relationality is a central theme within contemporary psychoanalytic theories. Yet, there is virtually no literature addressing the relational dynamics around outpatient psychotherapy that influence the wider therapeutic alliance, that is the relational dynamics that unfold between clients and administrative office staff in making initial contacts and appointments, completing paperwork, negotiating payment, discussing insurance coverage, working through crisis calls, and the myriad of other forms of interaction which serve to form the relational ecology of psychotherapy. Milieu therapy or the use of supportive and structured therapeutic environments has been given significant attention in inpatient settings; however, administrative relational factors or administrative staff characteristics have seemingly been ignored in outpatient psychotherapy and psychoanalysis literatures. Many outpatient clinical practice settings involve multiple levels and dimensions of relationality between clients, administrative personnel, and therapists which shape the potential for secure continuous containment and various forms of attachment to psychotherapeutic space. In this paper, we describe several clinical illustrations of relational dynamics between clients and office staff which influence therapeutic alliance and outline the contours of our emerging idea of administrative hospitality based on relational psychoanalysis, attachment theory, symbolic anthropology, and stigma research. In doing so, we draw on our collective experience working in several outpatient clinics and insights from our current context in an urban outpatient training clinic which emphasises psychodynamic practice. Our goal is not a comprehensive analysis of the relational ecology of psychotherapy but to offer an initial exploratory account of some of the administrative relational dynamics in and around outpatient psychotherapy which go beyond the therapist-client dyad. The anthropological concept of liminality is connected to relational psychoanalytic theories to describe the important dynamics of transitional space in an overall process of relational transformation.

SHORT-TERM IMPACT OF A COMBINED NUTRACEUTICAL ON COGNITIVE FUNCTION, PERCEIVED STRESS AND DEPRESSION IN YOUNG ELDERLY WITH COGNITIVE IMPAIRMENT: A PILOT, DOUBLE-BLIND, RANDOMIZED CLINICAL TRIAL

Background: The prevalence of senile dementia is increasing worldwide, especially in the developed countries. Nevertheless, drug therapy isn’t often enough to treat this condition. Researchers are evaluating the possible impact of a preventive approach, based on an improvement of lifestyle and the intake of micronutrients. Moreover, there is an increasing interest for combined nutraceuticals that can act as memory and learning enhancers, with a significant and beneficial potential on the cognitive disorders. Objective: To evaluate the effects of a rational assemblage of nutraceuticals on cognitive functions in a sample of 30 elderly subjects. Design: Double bind, cross-over designed trial versus placebo Setting: outpatient clinical practice Participants: 30 elderly subjects with basal Mini-Mental State Examination score between 20 and 27 and self-perceived cognitive decline. Intervention: Treatment with a combination of nutraceuticals based on Bacopa monnieri, L-theanine, Crocus sativus, copper, folate and vitamins of B and D group. After2 months of treatment or placebo. Measurements: Patients were evaluated with Mini-Mental State Examination (MMSE), Perceived Stress Questionnaire (PSQ) and Index and Self-Rating Depression Scale (SRDS). Results: MMSE and PSQ Index significantly improved in the active treatment arm, both versus baseline and versus the parallel arm. Both groups experienced a significant improving in the SRDS scores. Conclusions: We obtained a good and significant improvement of the cognitive functions tested with the MMSE, PSQ-Index and SRDS score, after 2 months of combined therapy of nutraceuticals. Further confirmation will be needed to verify these observations on the middle and long term in a larger number of subjects.

Barriers to Drug Adherence

Barriers to Drug Adherence Abstract Objective: Lately, several phases to accomplish that patients continue therapy for chronic conditions for long periods has passed. Initially the patient was thought to be core of the problem of compliance. The role of the health care providers was also addressed soon. Now we acknowledge that a system approach is required. The idea of compliance is associated too closely with blame, be it of providers or patients and the concept of adherence is a better way for understanding the dynamic changes required to maintain health over long periods of time. This manuscript aims to uncover the patient side of the problem through indirect method of adherence measurement via patient questionnarie. Material and Method: 792 patients of family practice outpatient clinic ( 400 female and 392 male )were recruited and given a questionnarie as to list their reasons for drug inadherence Results: Reasons for inadherence were as follows; Unwillingness to use drugs (42,04%), Media effects (38,76%), Forgetfullness (34,59%), Poor communication with health care provider (33,58%), Drug side effects (24,11%), Refusing the disease (22,22%), Multiple drug use (19,06%), Concerns for accuracy of treatment (10,6%), and High costs of drugs (6,1%) Conclusion: Patients are explicitly effected by many factors for adherence. Improved adherence is primarily driven by improved management of diseases, including the increase awareness of issues surrounding adherence. That counts the physicians too. Inadherence warrants a bio-psychosocial approach and seemingly inadherent patients must be provided with a higher level of communication

Barriers to Drug Adherence

Aim: This manuscript aims to investigate the patient’s side of the problem through indirect method of adherence measurement via patient questionnarie. Background: Lately, several phases to accomplish that patients continue therapy for chronic conditions for long periods has passed. Initially the patient was thought to be the core of the problem of compliance. The role of the health care providers was also addressed soon. Now we acknowledge that a system approach is required. The idea of compliance is associated too closely with blame, be it of providers or patients and the concept of adherence is a better way for understanding the dynamic changes required to maintain health over long periods of time. Methods: 792 patients of family practice outpatient clinic ( 400 female and 392 male )were recruited and given a questionnarie as to list their reasons for drug inadherence Results: Reasons for inadherence were as follows; Unwillingness to use drugs (42,04%), Media effects (38,76%), Forgetfullness (34,59%), Poor communication with health care provider (33,58%), Drug side effects (24,11%), Refusing the disease (22,22%), Multiple drug use already (19,06%), Concerns for accuracy of treatment (10,6%), and High costs of drugs (6,1%) Conclusion: Patients are explicitly effected by many factors for adherence. Improved adherence is primarily driven by improved management of diseases, including the increase awareness of issues surrounding adherence. That counts the physicians too. Inadherence warrants a bio-psychosocial approach and seemingly inadherent patients must be provided with a higher level of communication

Psychometric properties of three single-item pain scales in patients with rheumatoid arthritis seen during routine clinical care: a comparative perspective on construct validity, reproducibility and internal responsiveness

ObjectiveTo investigate the construct validity, reproducibility (ie, retest reliability) and internal responsiveness to treatment change of common single-item scales measuring overall pain in patients with rheumatoid arthritis (RA) and to...

Violence Risk Assessment and Management in Outpatient Clinical Practice.

The aims of this review were to highlight fundamental distinctions between risk assessment in forensic versus therapeutic settings, review the best available evidence regarding key risk and protective factors for violence of particular relevance to clinicians in outpatient therapeutic settings, and describe an approach to evaluating and managing violence risk in outpatient treatment. An integrative literature review was undertaken to examine violence risk and protective factors most relevant to outpatient clinicians in therapeutic settings. Based on the available research, the Integrative Outpatient Violence Risk Assessment and Management (IVRAM) model, a 5-step strategy for evaluating and managing violence risk in therapeutic contexts, is introduced. The IVRAM emphasizes the integration of nomothetic and idiographic data through a focus on empirically derived dynamic risk and protective factors in the context of an individualized anamnestic analysis. Clinicians working in forensic and therapeutic settings will increasingly benefit from the contributions of the other as the distinctions between risk assessment and risk management continue to decrease.

The Clinical Learning Dyad Model: An Innovation in Midwifery Education.

There is a national shortage of women's health and primary care providers in the United States, including certified nurse-midwives and certified midwives. This shortage is directly related to how many students can be trained within the existing system. The current model of midwifery clinical training is based on apprenticeship, with one-on-one interaction between a student and preceptor. Thus, the number of newly trained midwifery providers is limited by the number of available and willing preceptors. The clinical learning dyad model (CLDM), which pairs 2 beginning midwifery students with one preceptor in a busy practice, addresses this problem. In addition, this model brings in a senior midwife student as a near-peer mentor when the students are first oriented into outpatient clinical practice. The model began as a pilot project to improve the quality of training and increase available student spots in clinical education. This article discusses the origins of the model, the specifics of its design, and the results of a midterm and one-year postintervention survey. Students and preceptors involved in this model identified several advantages to the program, including increased student accountability, enhanced socialization into the profession, improved learning, and reduced teaching burden on preceptors. An additional benefit of the CLDM is that students form a learning community and collaborate with preceptors to care for women in busy clinical settings. Challenges of the model will also be discussed. Further research is needed to evaluate the effectiveness of the CLDM. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

The Morbidity and Mortality Conference in Gastroenterology and Hepatology: An Important Cornerstone of Patient Safety and Optimal Care

The morbidity and mortality (M&M) conference has evolved considerably in recent years. M&M was originally developed by surgeons and anesthesiologists to investigate negative “end results.” M&Ms were intended to be an open discussion promote and enhance patient safety, and to be engaged in projects to improve systems of care, decrease health care disparities and improve patient outcomes. Incorporation of these varied objectives and principles has led to a variety of innovations in M&M conferences that have been reported widely in general and emergency medicine, oncology, surgery, pediatrics, and obstetrics. The result is an evolution of the traditional M&M into a comprehensive and dynamic Quality and Patient Outcomes (QPO) conference, which fosters QI, patient safety, and medical education. The combination of high-volume diverse procedures, inpatient and outpatient clinical practice, and integration of hepatology and luminal gastroenterology each