Care Maps, Clinical Paths/Pathways, Critical Paths/Pathways 1999 citations/Oct 99

     1.    Rymer, M. M., Summers, D., & Soper, P. (1999). Development of Clinical Pathways for Stroke Management: An Example from Saint Luke's Hospital, Kansas City. Clin Geriatr Med, 15(4), 741-764.
Abstract: Clinical pathways for stroke are important tools for improved case management and outcome assessment. The clinical path created at St. Luke's Hospital in Kansas City is described here. It evolved through the collaboration of a multidisciplinary team of clinical experts and is still evolving. Ideally, a clinical path should be used as a guide rather than a standard of care, which is to be individualized for each patient. This article describes the methods for writing the pathways and how they are used for documentation. It also summarizes how the pathway data support stroke outcome assessment.

     2.    Pitt, H. A., Murray, K. P., Bowman, H. M., Coleman, J., Gordon, T. A., Yeo, C. J., Lillemoe, K. D., & Cameron, J. L. (1999). Clinical pathway implementation improves outcomes for complex biliary surgery [In Process Citation]. Surgery, 126(4), 751-6; discussion 756-8.
Abstract: BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

     3.    Holmboe, E. S., Meehan, T. P., Radford, M. J., Wang, Y., Marciniak, T. A., & Krumholz, H. M. (1999). Use of critical pathways to improve the care of patients with acute myocardial infarction [In Process Citation]. Am J Med, 107(4), 324-31.
Abstract: PURPOSE: While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction. SUBJECTS AND METHODS: A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality. RESULTS: Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant. CONCLUSIONS: Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

     4.    Chang, P. L., Wang, T. M., Huang, S. T., Hsieh, M. L., Tsui, K. H., & Lai, R. H. (1999). The implementation of clinical paths for six common urological procedures, and an analysis of variances. BJU Int, 84(6), 604-609.
Abstract: OBJECTIVE: To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths. PATIENTS AND METHODS: The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation. RESULTS: The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0.01), but the mortality and readmission rate did not increase. CONCLUSIONS: The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

     5.    Tolson, D. (1999). Practice innovation: a methodological maze. J Adv Nurs, 30(2), 381-90.
Abstract: Practice innovation is an inevitable feature of a health culture preoccupied with evidence-based practice. The cyclical process of defining best practice, implementing and evaluating change represents an unparalleled opportunity for nurse researchers to engage in, and develop, practice through 'realistic evaluation'. However, the methodological dilemmas and challenges inherent in evaluation research which informs policy should not be under-estimated. This paper seeks to introduce and wrestle with some of the political tensions and methodological issues surrounding practice innovation when it is undertaken within an evaluative research framework. A critical pathway is presented to stimulate discussion and guide novice evaluators through this often perplexing methodological maze. A case study in audiological rehabilitation in elder care is used to illustrate the issues raised.

     6.    Firilas, A. M., Higginbotham, P. H., Johnson, D. D., Jackson, R. J., Wagner, C. W., & Smith, S. D. (1999). A new economic benchmark for surgical treatment of appendicitis. Am Surg, 65(8), 769-73.
Abstract: Cost reduction in the management of common surgical diseases such as appendicitis has become paramount for the survival of children's hospitals. We designed a clinical pathway to treat appendicitis with the goal of reducing cost and hospital length of stay (LOS) while maintaining quality of care. From September 1995 through December 1996, patients with nonperforated appendicitis (NPApp) and perforated appendicitis with peritonitis (PApp) were enrolled into a clinical pathway. NPApp patients were discharged when tolerating a regular diet. PApp patients were discharged if the following criteria were met: temperature < 38.5 degrees C for 24 hours, WBC < 14,000 on postoperative day 3, tolerating diet, and transition to oral analgesics accomplished. Hospital LOS and actual hospital costs in pathway patients were compared with those of historic controls. Patients with appendicitis from the Pediatric Health Information Systems (PHIS) database, a consortium of 20 children's hospitals in the United States, served as concurrent controls. Hospital LOS and hospital charges in PHIS NPApp and PApp patients from our institution were compared with national PHIS database patients. Mean LOS and hospital costs for both NPApp and PApp pathway patients were significantly decreased compared with historic controls (P < 0.05). Mean LOS and hospital charges in our institution's PHIS NPApp and PApp patients were also significantly decreased compared with the national PHIS database (P < 0.05). Innovative approaches such as these are necessary for the survival of children's hospitals in an increasingly cost competitive healthcare market.

     7.    Correa, A. J., Reinisch, L., Paty, V. A., Sanders, D. L., & Duncavage, J. A. (1999). Analysis of a critical pathway in osteoplastic flap for frontal sinus obliteration. Laryngoscope, 109(8), 1212-6.
Abstract: OBJECTIVES: A critical pathway was applied to patients undergoing osteoplastic flap (OPF) for frontal sinus obliteration to determine whether efficiency could be improved. STUDY DESIGN: A retrospective review of consecutive OPF procedures (n = 51) performed between 1992 and July 1997 was conducted. METHODS: The patient groups were subdivided into those who underwent OPF alone and those who had endoscopic sinus procedures performed in addition to OPF. Comparisons were made between the precritical pathway and post-critical pathway groups, specifically noting operative time, total operating room (OR) time, estimated blood loss (EBL), length of hospital stay, and costs. We used a critical pathway that was developed for endoscopic sinus procedures at our institution through a multidisciplinary team approach. Preoperative evaluation and testing, intraoperative equipment and medications, and postoperative care including follow-up clinic visits were all standardized. An unpaired, two-tailed Student t test was used to evaluate the data. RESULTS: Statistically significant (P<.05) reductions in operative times, total OR time, EBL, and length of hospital stay were observed in the post-critical pathway group who underwent endoscopic sinus procedures as well as OPF. Costs to the OR were reduced 29% and 15% for OPF and for OPF with endoscopic surgery, respectively. Patient costs were reduced 5% and 4% in these groups, respectively. CONCLUSIONS: With implementation of effective critical pathways, significant decreases in length of stay are seen, and cost reductions can be realized through the improved efficiency, shortened OR times, and decreases in redundancy of ordering materials.

     8.    McAlister, F. A., Taylor, L., Teo, K. K., Tsuyuki, R. T., Ackman, M. L., Yim, R., & Montague, T. J. (1999). The treatment and prevention of coronary heart disease in Canada: do older patients receive efficacious therapies? The Clinical Quality Improvement Network (CQIN) Investigators. [Review] [74 refs]. Journal of the American Geriatrics Society, 47(7), 811-8.
Abstract: OBJECTIVES: To review the evidence for clinical efficacy and cost-effectiveness of proven medications in the treatment and prevention of myocardial infarction (MI) in older patients; to summarize Canadian data on treatment patterns and clinical outcomes for younger and older patients with coronary heart disease; to explore the reasons for gaps between best care, based on the evidence of efficacy from trials, and usual care, based on the population effectiveness audits; and to explore potential approaches to closing the care gaps. DESIGN: Review of the recent clinical trial literature on the management of MI, highlighting results in older patients. Review of medication utilization and outcomes data from a series of large, consecutively enrolled patient cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10 centers in five Canadian provinces, including university-based teaching hospitals, community hospitals, cardiologist and family physician out-patient clinics) from 1987 to 1996. RESULTS: There is no qualitative interaction of cardiac therapies: thrombolytics, beta-blockers, acetylsalicylic acid (ASA), and statins are efficacious in all clinically relevant patient subgroups, including older people. However, there are consistent gaps between usual care and best care, particularly among older patients (in whom there is also a concomitantly higher mortality risk). Repeated multivariate analyses confirm older age to be an independent contributor to increased risk. Use of efficacious medications is, in contrast, consistently associated with increased survival. Analysis of temporal trends suggests beneficial changes in practice patterns and outcomes are possible to achieve. However, "best care" has not been rapidly or completely achieved. Review of strategies to close these care gaps suggests that audit and feedback, critical pathways, and multifactorial interventions involving patients and other members of the healthcare team as well as physicians may be the most efficacious strategies for change. CONCLUSIONS: Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population. [References: 74]

     9.   Koyama, T., Okudera, H., Gibo, H., & Kobayashi, S. (1999). Computer-generated microsurgical anatomy of the basilar artery bifurcation. Technical note. J Neurosurg, 91(1), 145-52.
Abstract: The authors' goal was to develop a computer graphics model to represent the microsurgical anatomy of the basilar artery (BA) bifurcation and surrounding structures to simulate surgery of a BA bifurcation aneurysm performed via the transsylvian approach. The source of the input data was a variety of publications that showed detailed anatomy of the area. A computer graphics model of the area near the BA bifurcation including relevant structures, such as perforating branches or cranial nerves, was depicted in detail. A BA bifurcation aneurysm was added to the computer graphics model and it was rotated to simulate the transsylvian approach. After the internal carotid artery was displaced using a virtual retractor, the aneurysm was exposed, thus providing an understanding of the three-dimensional surgical orientation of the area. Designing a standard anatomical model on the basis of data culled from a variety of publications and adding morphological changes by using a virtual retractor to displace structures that obstruct the view along a critical path at the base of the brain are useful strategies of computer manipulation for surgical simulation in open microneurosurgery. This methodological tool would be useful in teaching surgical microanatomy and in introducing a new navigational system for virtual reality. Both concept and technical details are discussed.

   10.    Murphy, M., Noetscher, C., & Lagoe, R. (1999). A multihospital effort to reduce inpatient lengths of stay for pneumonia.  Journal of Nursing Care Quality, 13(5), 11-23.
Abstract: Three large hospitals in the metropolitan area of Syracuse, New York, implemented a cooperative project to reduce hospital stays and resource utilization without adversely affecting patient outcomes for community acquired pneumonia. The project occurred under the leadership of nurse case managers and nurse managers. It was supported by active physician involvement. The project was implemented over a three-year period. It resulted in reductions of hospital stays through the standardization of patient care for pneumonia throughout the community

   11.    Jacobsen, T., & Hill, M. (1999). Achieving information systems support for clinical integration. Journal of Nursing Administration, 29(6), 31-9.

   12.    Chang, P. L., Wang, T. M., Huang, S. T., Hsieh, M. L., Tsui, K. H., & Lai, R. H. (1999). Effects of implementation of 18 clinical pathways on costs and quality of care among patients undergoing urological surgery. Journal of Urology, 161(6), 1858-62.
Abstract: PURPOSE: We evaluated the effects on the costs and quality of care of implementation of 18 clinical pathways for urological operations. MATERIALS AND METHODS: From April 1997 to March 1998 patients undergoing 1 of 18 urological operations were treated according to clinical pathways. The outcomes in terms of length of hospital stay and admission charges of these patients were compared with those of patients treated between April 1996 and March 1997 before clinical pathways were implemented. We also selected 7 clinically relevant quality indicators to assess the quality of care before and after clinical pathway implementation. RESULTS: Of the 1,784 patients undergoing urological surgery from April 1997 to March 1998, 1,382 (77.5%) were treated according to 1 of the 18 clinical pathways. Before implementation 1,279 of 1,615 patients (79.2%) underwent these procedures. The length of hospital stay decreased from 5.5 to 4.9 days (p < 0.01) and the average hospital admission charges decreased by 12.9% (p < 0.01) after implementation. Five of the quality indicators, including the rate of surgical complications, were significantly improved after pathway implementation. The hospitalization rate was not affected (1.3 before versus 0.8% after implementation, p = 0.18). Variations from the clinical pathways occurred in 543 cases (39.3%) and affected the length of hospital stay only (11.6%) or the admission charge only (12.9%) more often than both (7.8%, p < 0.01) or neither (7.0%, p < 0.01). The most common variances in these patients were patient related (30.8%). CONCLUSIONS: Implementation of multiple clinical pathways in a urology department can improve urological practice by decreasing the length of hospital stay, admission charges and rate of surgical complications, and by improving the quality of care

   13.    Chan, S. W., & Wong, K. F. (1999). The use of critical pathways in caring for schizophrenic patients in a mental hospital. Archives of Psychiatric Nursing, 13(3), 145-53.
Abstract: To provide quality health care and at the same time, to control cost, literature suggests that using critical pathways as a tool can enhance resource management, increase collaborative practice, and benefit patient care. This study describes the processes of developing a critical pathway in caring for schizophrenic patients in a mental hospital in Hong Kong. The perceived benefits and difficulties in using the critical pathway are discussed from a nursing perspective. Nurses believed that the use of critical pathways could improve the coordination and effectiveness of care. Also, nurses' autonomy and professional status improved. However, inadequate knowledge and resistance from other disciplines were barriers to the implementation. Recommendations are given to overcome the barriers

   14.    Caplan, G., Board, N., Paten, A., Tazelaar-Molinia, J., Crowe, P., Yap, S. J., & Brown, A. (1999). Decreasing lengths of stay: the cost to the community. Australian & New Zealand Journal of Surgery, 69(6), 433-7.
Abstract: BACKGROUND: Patients who are discharged earlier from hospital frequently require support from professional and unpaid carers at home after discharge. Hospitals save money per patient by discharging earlier, but it is not known whether the costs to community services and unpaid caters outweigh the savings to the hospital. METHODS: We prospectively studied the total costs, patient satisfaction, time off work and pain scores of 224 patients who underwent elective herniorrhaphy or laparoscopic cholecystectomy and who lived locally before and after re-engineering the elective surgical service. The components of the re-engineered surgical service were a peri-operative unit, pre-admission anaesthetic assessment based on self-reported questionnaires, day of surgery admissions, enhanced patient education, clinical pathways, and post-acute care. RESULTS: The patients treated through the re-engineered surgical service had a significantly shorter length of stay (LOS) (mean LOS: 2.2 vs 3.2 days; P < 0.001) but neither they nor their carers required more time off work. Significant determinants of time off work were smoking, heavy lifting at work and a higher pain score at day 7. Patients treated through the re-engineered surgical service recorded significantly higher satisfaction with their treatment. The cost saving to the hospital outweighed the cost of increased services provided in the community, so that the overall cost of providing treatment was over $200 less per patient through the re-engineered service. Conclusions: This study demonstrates that changes in care provision that result in shorter LOS and greater cost effectiveness may better meet patients' needs than existing systems

   15.    Gore, M. J., & Smith, L. W. (1999). Perspectives. Reports from the field suggest some quality tools work best at local level. Medicine & Health, 53(22), suppl 1-4.

   16.    Read, H. (1999). Documentation in the outpatient setting. Nursing Standard, 13(34), 41-3.
Abstract: Record keeping in the outpatient department can be problematic. In this article, the author explains how her department developed a generic record keeping system.  (7 ref)

   17.    Pederson, C., & Bjerke, T. (1999). Pediatric pain management: a research-based clinical pathway. DCCN - Dimensions of Critical Care Nursing, 18(3), 42-51.
Abstract: Nurses want to provide pain management for pediatric patients, but different approaches lead to inconsistent pain management. This article presents a pediatric pain management clinical pathway developed as a result of research in the pediatric intensive care unit and based on pain management research. Using this pathway can help nurses deliver consistent pain management to pediatric patients.  (18 ref)

   18.    Cervizzi, K., & Edwards, P. A. (1999). Current issues. Where is rehabilitation nursing documentation going? Rehabilitation Nursing, 24(3), 92.

   19.    Cardozo, L., & Aherns, S. (1999). Assessing the efficacy of a clinical pathway in the management of older patients hospitalized with congestive heart failure. J Healthc Qual, 21(3), 12-6; quiz 16-7.
Abstract: Congestive heart failure (CHF) is the most common cause for hospitalization in older patients, and the prevalence of this condition is expected to rise as the population ages. The high cost of care has resulted in an increased emphasis on cost-effective approaches in patient management. One way to achieve this is the use of clinical pathways. This article compares outcomes in a group of older hospitalized patients managed on a CHF pathway with those of a historical cohort managed in the traditional manner. The patients on the pathway had significant reductions in length of stay and cost of care as well as more effective delivery of processes of care. Mortality rates were unchanged, at 3.5%. However, readmission rates showed a significant increase, from 9.25% to 13.5%, for patients on the pathway.

   20.    Callender, D. (1999). Pediatric practice guidelines: implications for nurse practitioners. Journal of Pediatric Health Care, 13(3 part 1), 105-11.
Abstract: Practice guidelines are promoted as an important means of achieving high-quality, cost-effective health care. Nurse practitioners must understand what practice guidelines are and how they are developed and be willing to put them into practice. This discussion begins with a description of practice guidelines specific to pediatrics. The terminology used in reference to these "clinical tools" are differentiated and their historic and contemporary influences are summarized. The complexity of guideline development and attributes of a quality practice guideline are described. Finally, the pivotal roles nurse practitioners can play in putting guidelines into practice are suggested.  (32 ref)

   21.    Warren, R. L. (1999). Critical analysis of two decades of experience with postinjury emergency department thoracotomy in a regional trauma center [letter]. Journal of Trauma-Injury Infection & Critical Care, 46(5), 983.

   22.    Sprague, T. E., Wren, K. R., Corpe, R. S., Philpot, T. E., Chaney, S. A., Bentz, H. L., & Bandy, L. C. (1999). Critical pathways: a means of managing the operating room. CRNA - the Clinical Forum for Nurse Anesthetists, 10(2), 65-70.
Abstract: Critical pathways help institutions in efficient and appropriate resource use to increase the quality of health care and minimize health care costs. However, many opportunities for pathway development and implementation are unexplored. This article delineates the development process for critical pathways and discusses the outcomes realized from use of the total joint pathway at the Medical College of Georgia, Augusta, GA. Copyright (c) 1999 by W.B. Saunders Company  (8 ref)

   23.    Schellenberg, D. M., Acosta, C. J., Galindo, C. M., Kahigwa, E., Urassa, H., Masanja, H., Aponte, J. J., Schellenberg, J. R., Fraser-Hurt, N., Lwilla, F., Menendez, C., Mshinda, H., Tanner, M., & Alonso, P. L. (1999). Safety in infants of SPf66, a synthetic malaria vaccine, delivered alongside the EPI. Tropical Medicine & International Health, 4(5), 377-82.
Abstract: The most likely mechanism to deliver a malaria vaccine in African countries is through the Expanded Program of Immunization (EPI). So far only SPf66, a multistage synthetic peptide, has shown any evidence of protection in Phase III field trials. In Tanzania, SPf66 reduced the risk of clinical malaria by 31% in children aged 1-5 years. In order to progress in the critical path of vaccine development and testing towards the implementation of a new vaccine in malaria control programs, we carried out a randomized double-blind placebo controlled efficacy trial of SPf66 when given alongside the EPI scheme. Monitoring of safety and reactogenicity during this trial included detailed clinical and laboratory assessments on 98 infants and assessment of adverse effects within 1 h of vaccination for all 1207 children vaccinated. Surveillance systems monitored attendances as outpatients, admissions to hospital and fatal events in the community. No serious adverse effects were detected more frequently amongst SPf66 recipients compared to placebo. This first assessment in very young infants of a synthetic vaccine provides evidence of a good safety profile

   24.    Sagehorn, K. K., Russell, C. L., & Ganong, L. H. (1999). Implementation of a patient-family pathway: effects on patients and families. Clinical Nurse Specialist, 13(3), 119-22.
Abstract: The purpose of this study was to discover whether implementation of a patient-family pathway with patients and families undergoing coronary artery bypass graft (CABG) surgery impacted anxiety, information with care planning, and patient length of stay. Using an experimental design, a sample of 60 patients and family members was studied. Each patient and his or her designated family member received either the patient-family pathway or the hospital's standard care planning. Findings indicated no statistically significant differences in state anxiety or information with care planning between patients and family members receiving the patient-family pathway and those receiving standard care planning. There was no statistically significant difference in length of stay between the two patient groups. The results indicate that the CABG patient-family pathway has limited value to patients and families as measured in this study. Resources can be reallocated to other uses that may have a more positive impact on the patient and family experience.  (8 ref)

   25.    Podore, P. C., & Throop, E. B. (1999). Infrarenal aortic surgery with a 3-day hospital stay: A report on success with a clinical pathway. Journal of Vascular Surgery, 29(5), 787-92.
Abstract: PURPOSE: This paper reports on an experience with a clinical pathway for elective infrarenal aortic surgery (AS) that targeted hospital discharge on postoperative day (POD) 3. The pathway incorporated early feeding, early ambulation, and selective use of the intensive care unit (ICU). METHODS: A review of 50 consecutive hospital discharges after AS (aneurysm repair and aortofemoral bypass grafting) by a single surgeon performed from April 1996 through June 1998 with this clinical pathway is reported. The data collected included morbidity rate, mortality rate, length of stay (LOS), and number of hospital readmissions. RESULTS: The average LOS for all patients was 3.0 days. Only six patients (12%) were admitted to the ICU. Discharge on POD 3 was achieved in 80% of the group (40 of 50), and increasing experience improved compliance, with 92% of the most recent 25 patients (23 of 25) being discharged by POD 3. Eleven of these 25 patients (44%) were discharged on POD 2. No patient was readmitted to the hospital within a 30-day period after discharge. There was no mortality after AS during this period. CONCLUSION: Factors that limit the discharge of patients recovering from AS include the ability to ambulate independently and to tolerate a diet. Ambulation and feeding on POD 1 were well tolerated by most patients, which shortened the period of hospitalization. Admission to the ICU was infrequently required when a monitored surgical step-down unit was available. Discharge by POD 3 for AS has been proven to be routinely achievable, safe, and well accepted by patients and to reduce the cost of hospitalization

   26.    Jacavone, J. B., Daniels, R. D., & Tyner, I. (1999). CNS facilitation of a cardiac surgery clinical pathway program. Clinical Nurse Specialist, 13(3), 126-32.
Abstract: In this collaborative project, the Clinical Nurse Specialist (CNS) worked with various members of the healthcare team using a clinical pathway group work process to implement changes in the nursing, medical, and respiratory care of cardiac surgery patients. The patient population (N = 598) comprised cardiac surgery patients undergoing coronary artery bypass graft, mitral valve replacement, or aortic valve replacement. The practice changes implemented were earlier extubation, earlier ambulation, the administration of fentanyl and propofol, and the administration of gastrointestinal (GI) prophylactic medications. The overall outcomes were decreased incidence of pneumonia, earlier increase in level of consciousness, improved ambulation abilities, and improved nausea levels. Pneumonia decreased significantly, from 2.49% to 1.67% (p = 0.05). For patients who met early extubation criteria, mean time on the ventilator decreased from 17 hours to 8 hours, and length of stay decreased from 8 days to 7 days in a subgroup of patients (diagnosisrelated group (DRG) 105). The overall annual charge savings was approximately $201,000. These results add to the belief that CNS-guided patient care in collaboration with the healthcare team has positive benefits.  (22 ref)

   27.    Hardin, W. D. Jr, Stylianos, S., & Lally, K. P. (1999). Evidence-based practice in pediatric surgery. Journal of Pediatric Surgery, 34(5), 908-12; discussion 912-3.
Abstract: BACKGROUND/PURPOSE: The current medical environment demands the provision of quality healthcare at an affordable cost. Both payors and regulators are committed to lowering cost through initiation of best practice strategies that include practice guidelines, clinical pathways, and standards of care. The only practical way to join this debate is through the use of objective, unbiased clinical data. This study was undertaken to review the current state of the pediatric surgery literature and its value in determining best clinical practice. METHODS: The National Library of Medicine Medline database was accessed using the Ovid Internet client software. All references, abstracts, and keyword indexes from the core pediatric surgery literature, the Journal of Pediatric Surgery, the European Journal of Pediatric Surgery, Pediatric Surgery International, Zeitschrift fur Kinderchirurgie, and Seminars in Pediatric Surgery were downloaded and reviewed. Search criteria were defined to identify prospective, randomized, controlled studies. References were then categorized as case reports; retrospective case series; prospective case series; randomized, controlled studies; laboratory studies; review articles; or miscellaneous studies. RESULTS: As of March 1, 1998, there are 9,373 references, excluding citations of letters or comments, contained in the core pediatric surgery literature, as provided through Medline. Of these, 485 were identified as studies for review, possible prospective case series or prospective, randomized, controlled studies. After review, 34 studies (0.3%) were classified as prospective, randomized, controlled studies, whereas 139 (1.48%) were classified as prospective studies. There were 3,241 (34.6%) case reports, 5,619 (59.9%) retrospective case series, 1,109 (11.8%) laboratory studies, 195 (2.1%) review articles, and 36 (0.3%) miscellaneous studies that did not fit into other categories. When analyzed by decade of publication, prospective studies and prospective, randomized, controlled studies (n = 173) numbered 103 in the 1990s, 63 in the 1980s, and seven in the 1970s. CONCLUSIONS: There is a paucity of scientifically rigorous data on which to base clinical practice in pediatric surgery. The increasing numbers of prospective, case-controlled studies or the more sound prospective, randomized, controlled trials in the 1990s suggests that pediatric surgeons are aware of the need to generate unbiased data to support current clinical practice and the development of practice guidelines. Limitations exist in conducting prospective, randomized, controlled trials because of the rare nature of many pediatric surgical conditions and the lack of clinical "equipoise" over available treatment options. The authors encourage the use of multiinstitutional trials and the prospective, randomized, controlled study methodology to develop data that can be used to guide clinical practice in our evolving healthcare environment

   28.    Darrikhuma, I. M. (1999). Development of a renal transplant clinical pathway: one hospital's journey. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 10(2), 270-84.
Abstract: Mounting pressures to resolve multiple challenges related to quality, cost, and access in a resource-driven, customer-focused health care environment have compelled clinicians to develop innovative strategies to provide cost-effective, state-of-the-art care. Targeted patient groups include those associated with high cost, high volume, or high resource use. Patients undergoing renal transplantation fall into one or more of these categories. Recently, the management of patients with end-stage renal disease (ESRD) has come under national focus, as evidenced by the fact that Health Care Financing Administration (HCFA) has commissioned an ESRD managed care demonstration project. The purpose of this article is to describe how one case management tool--the clinical pathway can be used to decrease costs and improve outcomes associated with renal transplantation. This discussion will include a review of the origins and components of clinical pathways and a description of how one institution developed, implemented, evaluated, and refined a renal transplantation clinical pathway.  (22 ref)

   29.    Cappelletty, D. M. (1999). Critical pathways or treatment algorithms in infectious diseases: do they really work? Pharmacotherapy, 19(5), 672-4.

   30.    Brye, P. E., Loharikar, R., & Duda, E. (1999). New picture archiving and communications system plus new facility equals critical path planning challenge. Journal of Digital Imaging, 12(2 Suppl 1), 130-3.
Abstract: The architectural design and construction of a new imaging department is one of the most complex challenges in healthcare architecture. When a client also plans a simultaneous change in basic operating system technology from film-based to filmless imaging, the challenge for both hospital management and the facility/technology design team is even more complicated. A purposeful planning process plus a carefully composed team of internal and external experts are the two essentials for success in executing this difficult conversion of both facility and technology

   31.    Holloway, R. G., Vickrey, B. G., Keran, C. M., Lesser, E., Iverson, D., Larson, W., & Swarztrauber, K. (1999). US neurologists in the 1990's: trends in practice characteristics. Neurology, 52(7), 1353-61.
Abstract: BACKGROUND: The American Academy of Neurology (AAN) conducts periodic surveys of its members to profile and monitor changes in the characteristics of US neurologists and their practices. OBJECTIVE: To assess neurologists' characteristics, geographic distribution, practice arrangements, professional activities, practice volume, procedures performed, sources of revenue, involvement with managed care and capitation, and other selected topics. METHODS: The AAN Member Census survey was sent to US neurologists in the fall of 1996 (response rate = 89%), and the Practice Profile survey was sent to a random sample of 1,986 US neurologists in the summer of 1997 (response rate = 55%) who had completed a Member Census survey. The results of the Practice Profile survey were compared with those of two prior surveys conducted in 1991 to 1992 and 1993 to 1994. RESULTS: The mean age of US neurologists is 48 years, 18% are women, 93% are US citizens, and 24% are international medical graduates. The proportion of neurologists in solo practices, group practices, and medical schools/universities has not changed. The weekly hours worked has remained stable (58 hours), but the time spent in administrative activities has increased (p < 0.001). The average number of patient visits per week to neurologists appears to have increased (p < 0.001), as has the proportion of neurologists performing procedures (p < 0.05). The majority of neurologists have contracts with managed care organizations (82%), and a minority (32%) have capitated payment arrangements. Medicare continues to be the largest source of clinical revenue. Nearly 50% of all respondents have experience in developing clinical practice guidelines or critical pathways, and >20% of respondents employed physician extenders to assist in their practices. CONCLUSION: Neurologists are spending more time in administrative activities, are performing or interpreting more procedures, and are seeing more patients. Neurologists' involvement with capitation is comparable with that in a nationally representative sample of physicians, and they are exploring innovative ways, such as developing practice guidelines and using physician extenders, to improve the quality and efficiency of providing neurologic care

   32.    Stomel, R., Grant, R., & Eagle, K. A. (1999). Lessons learned from a community hospital chest pain center. American Journal of Cardiology, 83(7), 1033-7.
Abstract: The iterative lessons from our studies suggest that creation of a chest pain center alone will not change the practice of chest pain management by most physicians. In 1993 we established a chest pain center; in mid-1995 we established a patient management algorithm directing intermediate-risk patients to the chest pain center rather than admit them to the hospital. The creation of a chest pain center did not reduce the rate of chest pain admission by mid-1995. After the patient management algorithm was created, admittances dropped by a rate of 21% (p <0.001) and chest pain center usage increased by +1,726% (p <0.001). Among the 473 patients treated and discharged in the chest pain center after mid-1995, 333 (70%) were considered intermediate risk. No patient died after discharge from the chest pain center and there was 1 non-Q-wave myocardial infarction. We conclude that a chest pain management algorithm in a chest pain center can be safe, yet effective, for identifying high-risk patients for admission and low-risk patients for discharge

   33.    Cole, L., & Houston, S. (1999). Linking outcomes management and practice improvement. Structured care methodologies: evolution and use in patient care delivery. Outcomes Management for Nursing Practice, 3(2), 53-60.

   34.    Winsett, R. P., & Hathaway, D. K. (1999). Predictors of QoL in renal transplant recipients: bridging the gap between research and clinical practice... the National Institute of Nursing Research (NINR) intervention study. Anna Journal, 26(2), 235-40.
Abstract: Previous research in quality of life (QoL) in renal transplant recipients has identified three factors predictive of improved QoL: reduction in adverse events, facilitation of employment, and enhancement of social support. After a decade of QoL outcome research, the researchers have proposed a multidisciplinary approach to posttransplant care by developing a clinical pathway using the three predictive factors. Putting into practice the research outcome, this pathway systematically addresses and evaluates each of the study arms and the impact on QoL. A clinical team has been instrumental in developing a model of practice that incorporates the research outcomes.  (47 ref)

   35.    Tarzian, A. J., Iwata, P. A., & Cohen, M. Z. (1999). Autologous bone marrow transplantation: the patient's perspective of information needs. Cancer Nursing, 22(2), 103-10.
Abstract: Phenomenologic inquiry was used to explore patients' experiences with autologous bone marrow transplantation (ABMT). Interviews were conducted before and after implementation of a clinical pathway that included a teaching protocol for ABMT. Texts were analyzed individually, compared for pre- and postpathway patients to determine if different themes emerged from these two groups, and then combined. Themes common to both groups included (a) a range of needs for information, (b) everybody's different: a fine balance (the challenge of finding a balance when giving information to patients who vary in the amount of information they desire), (c) someone who has been there (the value of talking to someone who has survived an ABMT), (d) and the burden of ABMT patients teaching family. One theme that reflected different experiences of pre- and postpathway patients was that of the need to know detailed information about the ABMT and the fear of knowing too much. Whereas postpathway patients reflected more on the burden of knowing too much, prepathway patients expressed more dissatisfaction about not being told enough about procedures and symptoms to be expected. Suggestions for teaching patients about ABMT include being generally realistic while focusing on the positive, and viewing patient education as a process individualized according to each patient's needs

   36.    Stratton, L. (1999). Evaluating the effectiveness of a hospital's pain management program. Journal of Nursing Care Quality, 13(4), 8-18.
Abstract: Nationally, the focus on facilities providing effective pain management has increased, yet no funds have been allocated to pain management programs. The article describes a 3-year study whose purpose was to evaluate the effect on nurses' attitudes and behavior of the institution of a multifaceted, low-cost hospital pain management program. The program utilized various instructional methods and implementation of policies, procedures, and documentation protocols. Nurses were surveyed before and after the pain management program using the 39-item Nurses' Knowledge and Attitudes Survey. Results demonstrated a statistically significant increase between pretest and posttest scores. Copyright (c) 1999 by Aspen Publishers, Inc.  (20 ref)

   37.    Rosenberger, J. M., & Wiemers, N. E. (1999). CAREMAPS in medical rehabilitation. Journal of Care Management, 5(2), 23-4, 26, 28 passim.
Abstract: This article describes the development of a stroke CAREMAP for use with an inpatient rehabilitation population. Successes, barriers, and lessons learned during the development process are described. The authors report that use of the CAREMAP has resulted in decreased LOS, lowered costs and improved patient outcomes.  (1 ref 9 bib)

   38.    Petterson, M. (1999). Integrated patient records benefit both patients and the healthcare team. Critical Care Nurse, 19(2), 120.

   39.    Morris, D. C., St, & Claire, D. Jr. (1999). Management of patients after cardiac surgery. [Review] [131 refs]. Current Problems in Cardiology, 24(4), 161-228.
Abstract: The postoperative care of the patient during removal of CPB is the epitomy of modern clinical medicine. Successful postoperative care speaks to the best of modern medicine, namely, sophisticated technology, utilization of a team of concerned medical and nursing specialists, application of clinical pathways, and continued refinement in the patient care based on the principles of continual quality improvement. This article outlines the disruptions of the patient's physiologic systems by the inflammatory state initiated by CPB as a means of alerting the physician to the physical stresses imposed on their patients. Second, it describes the cardiac and noncardiac complications that might arise as a consequence of these disruptions to allow the physician to be proactive in the therapeutic approach. Finally, we propose treatment schemes based on an understanding of the pathophysiologic consequences of CPB and refined by their repeated application in the clinical arena. [References: 131]

   40.    Matula, P. A., & Shollenberger, D. (1999). Total joint project: acute care to home care. MEDSURG Nursing, 8(2), 92-8.
Abstract: The advent of managed care, decreased reimbursement, and competition among providers has forced acute care institutions to examine care delivery. Clinical paths provide a method that manages patient care toward positive outcomes within a cost-effective environment. A collaborative project for total joint patients beginning with the office visit and continuing through the entire episode of care is described.  (5 ref)

   41.    Mathias, J. M. (1999). A vertical pathway for total joint replacement. Or-Manager, 15(4), 27, 29-30,32.

   42.    Lowers, J., & Gore, M. J. (1999). Reducing variation in care. Quality Letter for Healthcare Leaders, 11(4), 2-7.
Abstract: What care a patient receives reflects not only best practices and available technology but also geography, provider experience and patient preference. Spurred on by payers and a growing body of evidence-based methodology, providers are seeking to make patient care more consistently reflect best practices.  (Abstract by: Author)

   43.    Lin, P. C., Chuang, C. Y., Lu, C. L., Yen, P. C., Wang, J. L., & Chen, C. H. (1999). Application of clinical path methods in orthopedic unit [Chinese]. Journal of Nursing (China), 46(2), 45-54.
Abstract: The purpose of this project was to explore the effectiveness of clinical path methods for total knee and total hip replacement patients. Patient's length of stay, medical cost, quality of care, and patient satisfaction were evaluated. It was performed in a medical center's orthopedic units in Taipei, Taiwan. The process included preparation, implementation, and evaluation phases. The total sample size for total knee replacement was 187, and 64 for total hip replacement. The results showed that the patient's length of stay was significantly reduced, average charges were decreased, and quality of patient care was maintained. Patients were highly satisfied with these clinical path methods.  (7 ref)

   44.    Holmquist, M., Chabalewski, F., Blount, T., Edwards, C., McBride, V., & Pietroski, R. (1999). A critical pathway: guiding care for organ donors. [Review] [36 refs]. Critical Care Nurse, 19(2), 84-98; quiz 99-100.

   45.    Dufault, M. A., & Willey-Lessne, C. (1999). Using a collaborative research utilization model to develop and test the effects of clinical pathways for pain management. Journal of Nursing Care Quality, 13(4), 19-33.
Abstract: The article reports a study that tested a practical multidisciplinary approach to address the prevailing research-to-practice gap in pain management. By means of a collaborative research utilization model, academic scientists and students from two affiliating colleges of nursing were paired with clinicians from medicine, nursing, social work, pastoral care, and physical therapy to form three partnerships to develop and evaluate 14 pain management clinical pathways. Results showed that patients whose caregiver used the pathways had less pain across their hospital stay, less interference by pain in nearly all quality of life indicators, and greater satisfaction with caregiver responsiveness to their pain. Each of these improvements reversed after discharge, however

   46.    Cabello, C. C. (1999). Six stepping stones to better management. Nursing Management, 30(4), 39-40.
Abstract: Clinical pathways can help nurse managers develop clinical staff, guide quality improvement, enhance interdisciplinary practice, standardize care delivery, control the budget, and increase patient satisfaction

   47.    Brugler, L., DiPrinzio, M. J., & Bernstein, L. (1999). The five-year evolution of a malnutrition treatment program in a community hospital. Joint Commission Journal on Quality Improvement, 25(4), 191-206.
Abstract: BACKGROUND: Studies suggest that 30%-55% of hospitalized patients are at risk for malnutrition, an avoidable comorbidity contributing to increases in hospitalization and readmission, length of stay, complications, and mortality. Yet a variety of issues have impeded many hospitals' implementation of effective nutrition intervention programs. BENCHMARKING STUDY: St Francis Hospital (SFH), a 395-bed community acute care facility in Wilmington, Delaware, participated in a nationwide benchmark study in fall 1993. In comparison with the 12-hospital means, data for SFH showed both delays in initiating a nutrition care plan for acutely ill patients and a significantly higher risk for malnutrition. NUTRITION SCREENING PILOT: A pilot study was implemented in 1994 to identify nutrition needs within 48 hours of admission as a first step in the improvement process. Although interventions occurred earlier for a greater number of high-risk patients, nutrition intervention was not being provided in a uniform and timely manner. THE MALNUTRITION CLINICAL PATHWAY: A free-standing hospital committee, the Nutrition Care Committee (NCC), with guidance from the care management department, began developing a malnutrition pathway that would serve as an integrated plan for providing nutrition care to high-risk patients. The original pathway was organized into four stages that outlined the progression and timing of care--identification of the patient at high risk for malnutrition, nutrition care decisions, treatment in progress (the remainder of the patient's hospitalization), and discharge planning. OUTCOME STUDIES: Outcome studies were conducted in 1996 and again in 1998 to assess the malnutrition treatment pathway's impact on patient health outcomes and the cost of care. The 1996 outcome study indicated significant improvements in the identification of high-risk patients (from 25.9% to 86%) and the timeliness of nutrition intervention (from 6.9 days to 2.4 days). A second outcome study was conducted in 1998, following revision of the pathway. Comparison of the 1996 after-pathway patient population with a matched study group in 1998 indicated reductions in average length of stay from 10.8 to 8.1 days; the incidence of major complications from 75.3% to 17.5%; and 30-day readmission rates from 16.5% to 7.1%. DISCUSSION: The performance improvement project described in this article began with SHF's voluntary participation in an interdisciplinary benchmarking study and continued when it was apparent that SFH had an opportunity for performance improvement. Forming an NCC at SFH was the first step in a process that gained the administrative support necessary to fully develop the program. SUMMARY AND CONCLUSIONS: SFH has developed and implemented a malnutrition treatment program that is integrated into the care plan of all acute care patients and is included in the discharge planning process. Outcome studies have demonstrated the effect of the malnutrition treatment program on patient recovery and cost of care

   48.    Beger, D., Messenger, F., & Roth, S. (1999). Self-administered medication packet for patients experiencing a vaginal birth. Journal of Nursing Care Quality, 13(4), 47-59.
Abstract: A patient satisfaction survey at Missouri Baptist Medical Center revealed that patients experiencing a vaginal delivery needed to wait for their medications and did not consistently receive adequate information about medications. Furthermore, a chart review noted that physicians ordered a wide variety of medications for their patients but that the patients did not always use all their medications. A review of patients' accounts determined that their medications were costly. A multidisciplinary team using the FOCUS-PDCA quality improvement model designed and implemented a self-administered medication packet. Outcomes included continued patient satisfaction with decreases in cost, narcotic use, and medication errors. Copyright (c) 1999 by Aspen Publishers, Inc.  (7 ref)

   49.    Rosenstein, A. H. (1999). Measuring the benefits of clinical decision support: return on investment. [Review] [26 refs].  Health Care Management Review, 24(2), 32-43.
Abstract: In an effort to provide high quality care in a more cost-effective manner, health care providers have found it necessary to implement a series of decision support strategies designed to improve outcomes of care. While each of these strategies has measurable benefits, they each come along with additional costs. This article will describe a methodology for measuring the costs and direct and indirect benefits from decision support activities. [References: 26]

   50.    Swain, L. M. (1999). Learning is fundamental: the impact of education on successful clinical pathway implementation. Journal for Healthcare Quality, 21(2), 11-5; quiz 15-48.
Abstract: Successful implementation of a clinical pathway program is a complex, multifaceted task. Medical and hospital staff education is often overlooked or minimized during the implementation process. Even with a clinically sound pathway and a state-of-the-art variance-tracking system, implementation can fail miserably if the medical and hospital staff do not completely understand and support the pathway initiative. A well-developed plan for education provides staff members with the foundation they need to be successful within the pathway program.  (Abstract by: Author)

   51.    Gordon, S. (1999). Information systems & technology. Valuing investments in clinical information systems. Nursing Economics, 17(2), 108-11.

   52.   Stephens, S. A., & Mason, S. (1999). Putting it together: a clinical documentation system that works. Nursing Management, 30(3), 43-7.
Abstract: To save caregivers' time and institutional dollars, designs a clinical documentation system that integrates data from initial assessment, care planning, charting, and clinical pathways

   53.    Spath, P. (1999). Guest column. Small hospitals benefit from program investments: but you must consider managed care goals first. Hospital Case Management, 7(3), 45-48,60.

   54.    Lusky, K. F. (1999). >From assessment to outcomes: dynamic care planning. Provider, 25(3), 28-30, 33, 35-39.

   55.    Harlan, K., & Meiring, A. (1999). Critical path network. Total knee arthroplasty clinical pathway. Hospital Case Management, 7(3), 49-52, 60.

   56.    Esquivel, J., Farinetti, A., & Sugarbaker, P. H. (1999). [Elective surgery in recurrent colon cancer with peritoneal seeding: when to and when not to proceed]. [Italian]. Giornale Di Chirurgia, 20(3), 81-6.
Abstract: Peritoneal carcinomatosis occurs in about 10% of patients with colon cancer. Patients with progressive disease develop complications, with a median survival of 9 months. Our goal is to present a new quantitative scoring system by which to evaluate patients with peritoneal carcinomatosis. The Peritoneal Cancer Index and Completeness of Cytoreduction Score represent quantitative and prognostic indicators that permit the creation of a clinical pathway. Based on the scores, patients can undergo systemic chemotherapy, exploratory laparotomy or cytoreductive surgery. If there is a complete cytoreduction, perioperative intraperitoneal chemotherapy is given and these patients are considered potential long-term survivors

   57.    Barber, D. B., Rogers, S. J., Chen, J. T., Gulledge, D. E., & Able, A. C. (1999). Pilot evaluation of a nurse-administered carepath for successful colonoscopy for persons with spinal cord injury. Sci Nursing, 16(1), 14-5, 20.
Abstract: Due to ongoing improvements in medical care, the life expectancy of persons with spinal cord injury (SCI) continues to improve and approach that of the able bodied population. As the SCI population ages, cancer would be expected to increase as a cause of death. When a patient presents with occult fecal blood and anemia, colonscopy to the cecum is often pursued. It has been our experience that 80 percent of patients are found to have inadequate bowel preps resulting in suboptimal colonoscopy when the prep is attempted at home. Because of this, we developed a nurse-administered carepath necessitating a 48-hour admission for bowel prep and colonoscopy. The bowel prep consists of magnesium citrate, polyethylene glycol-electrolyte solution, and sodium phosphate/biphosphate enemas. Throughout hospitalization, the patient receives a clear liquid diet. Eighteen patients have been placed on the carepath. At the time of colonoscopy, all 18 were noted to have received an acceptable bowel prep allowing vizualization to the cecum. A description of the carepath and its benefits is presented.  (4 ref)

   58.    Goldman, L. (1999). The impact of hospitalists on medical education and the academic health system. Annals of Internal Medicine, 130(4 Pt 2), 364-7.
Abstract: Hospitalism as a career option is likely to reinforce the emphasis of traditional medical residency programs on inpatient care; may become an alternative area of emphasis in many subspecialty fellowship programs; and may even generate its own specific types of advanced training and certification. In the academic setting, subspecialists and their trainees are concerned that hospitalists may request fewer consultations, which could adversely affect subspecialists and the education of both fellows and residents. However, the focus and expertise of hospitalists is likely to improve inpatient education for students and residents and is appealing because it has the potential to improve the quality of inpatient care. Perhaps the major effect of the hospitalist movement on academic centers will be the creation of a cadre of physicians committed to critical pathways; clinical guidelines; quality assurance; risk management; clinical re-engineering; and the use of the inpatient service as a laboratory for developing, evaluating, and implementing initiatives to improve patient care. Although any fundamental change in the organization of clinical services brings with it the risk that essential components of the current system will be jeopardized, the hospitalist movement may have great benefits if it can develop safeguards to ensure seamless patient care and the appropriate use of subspecialty expertise

   59.    Bates, D. W., Pappius, E., Kuperman, G. J., Sittig, D., Burstin, H., Fairchild, D., Brennan, T. A., & Teich, J. M. (1999). Using information systems to measure and improve quality. International Journal of Medical Informatics, 53(2-3), 115-24.
Abstract: Information systems (IS) are increasingly important for measuring and improving quality. In this paper, we describe our integrated delivery system's plan for and experiences with measuring and improving quality using IS. Our belief is that for quality measurement to be practical, it must be integrated with the routine provision of care and whenever possible should be done using IS. Thus, at one hospital, we now perform almost all quality measurement using IS. We are also building a clinical data warehouse, which will serve as a repository for quality information across the network. However, IS are not only useful for measuring care, but also represent powerful tools for improving care using decision support. Specific areas in which we have already seen significant benefit include reducing the unnecessary use of laboratory testing, reporting important abnormalities to key providers rapidly, prevention and detection of adverse drug events, initiatives to change prescribing patterns to reduce drug costs and making critical pathways available to providers. Our next major effort will be introduce computerized guidelines on a more widespread basis, which will be challenging. However, the advent of managed care in the US has produced strong incentives to provide high quality care at low cost and our perspective is that only with better IS than exist today will this be possible without compromising quality. Such systems make feasible implementation of quality measurement, care improvement and cost reduction initiatives on a scale which could not previously be considered

   60.    Zevola, D. R., & Maier, B. (1999). Improving the care of cardiothoracic surgery patients through advanced nursing skills. Critical Care Nurse, 19(1), 34-6, 38-44.
Abstract: Nurses at this institution were able to improve care of cardiothoracic surgery patients and reduce costs by designing a clinical pathway that allowed nurses to extubate patients and remove their pulmonary artery catheters. Policies and procedures, education program, and quality assurance efforts are all discussed.  (16 ref)

   61.    Walji, S., Peterson, R. J., Neis, P., DuBroff, R., Gray, W. A., & Benge, W. (1999). Ultra-fast track hospital discharge using conventional cardiac surgical techniques. Annals of Thoracic Surgery, 67(2), 363-9; discussion 369-70.
Abstract: BACKGROUND: Recent introduction of minimally invasive adult cardiac surgical techniques has emphasized the advantage of early hospital discharge. However, we chose an alternative approach to determine the safety, efficacy, and feasibility of ultra-fast track protocols while retaining both standard surgical exposure (median sternotomy) and conventional cardiac surgical techniques (hypothermia, cardiopulmonary bypass with cardiac arrest, and optimal myocardial protection). METHODS: From September 1995 to January 1998, a total of 258 consecutive patients underwent cardiac procedures by a single surgeon. Acceleration of clinical pathways was used to initiate earlier discharges. Stringent postdischarge follow-up was implemented. Prospectively entered data were then analyzed retrospectively. RESULTS: A variety of isolated as well as combined coronary and valve procedures were performed. Of the 258 patients operated on during this entire study period, a total of 144 patients (56%) were discharged within postoperative days 1 to 4 (ultra-fast track discharge). Over the past 12 months, this incidence increased to 70% (76 of 108 patients). Approximately 50% of these patients were operated on urgently or emergently. To date, there have been no deaths in this ultra-fast track group. There were eight brief readmissions, of which one was for rewiring of a noninfected sternal dehiscence, and the remaining were for cardiac diagnostic studies or a noncardiac problem altogether. CONCLUSIONS: Conventional cardiac operation can allow ultrafast hospital discharges while retaining the advantage of time-tested techniques and providing wider application without requiring new or additional training or equipment

   62.    Scranton, P. E. Jr. (1999). The cost effectiveness of streamlined care pathways and product standardization in total knee arthroplasty. Journal of Arthroplasty, 14(2), 182-6.
Abstract: The orthopaedic department at Providence Medical Center, Seattle, Washington, instituted a streamlined care pathway and product standardization for total knee arthroplasty (TKA) in July 1995. The goal was to reduce operating room time and to streamline the care pathway for a safe, expedited hospitalization of patients. The hospital staffs standardized nursing orders, cut the instrument systems from 13 to 4 sets, and coordinated the expedited care pathway. Fifty-two consecutive primary TKAs were compared prepathway to 77 consecutive primary TKAs postpathway. The average length of stay declined 1.9 days from 5.1 to 3.2. The tourniquet time declined from 61 minutes to 56 minutes. The average dollar charges were $1,063 less. There were no infections in either group. The manipulation rate for adhesions declined 37%

   63.    Rosenstein, A. H. (1999). Inpatient clinical decision-support systems: determining the ROI. Healthcare Financial Management, 53(2), 51-5.
Abstract: Healthcare providers faced with increasing pressure to provide high-quality, cost-effective care have implemented clinical decision-support programs to drive the appropriate process improvement activities needed to achieve successful care outcomes. Each of these activities requires the commitment of the necessary technology and human resources. To measure the return on investment (ROI) of decision-support activities, providers need to establish a methodology for capturing the costs and benefits of implementing decision-support-directed process-improvement activities.  (Abstract by: Author)

   64.    Riegler, A. (1999). Clinical pathways and the elderly. Home Healthcare Nurse, 17(2), 74.

   65.    Price, M. B., Jones, A., Hawkins, J. A., McGough, E. C., Lambert, L., & Dean, J. M. (1999). Critical pathways for postoperative care after simple congenital heart surgery. American Journal of Managed Care, 5(2), 185-92.
Abstract: OBJECTIVE: To evaluate the clinical, financial, and parent/patient satisfaction impact of critical pathways on the postoperative care of pediatric cardiothoracic patients with simple congenital heart lesions. STUDY DESIGN: Critical pathways were developed by pediatric intensive care nurses and implemented under the direction of pediatric cardiothoracic surgeons. PATIENTS AND METHODS: Critical pathways were used during a 12-month study on 46 postoperative patients with simple repair of atrial septal defect (ASD), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). Using the study criteria, a control group of 58 patients was chosen from 1993. Prospective and control group data collected included postoperative intubation time, total laboratory tests, arterial blood gas utilization, morphine utilization, time in the pediatric intensive care unit, total hospital stay, total hospital charges, total hospital cost, and complications. Variances from the critical pathway and satisfaction data were also recorded for study patients. RESULTS: Resource utilization was reduced after implementation of critical pathways. Significant reductions were seen in total hours in the pediatric intensive care unit, total number of laboratory tests, postoperative intubation times, arterial blood gas utilization, morphine utilization, length of hospitalization (ASD, 4.9 to 3.1 days; CoA, 5.2 to 3.2 days; and PDA, 4.1 to 1.4 days; all P < 0.05), total hospital charges (ASD, $16,633 to $13,627; CoA, $14,292 to $8319; and PDA, $8249 to $4216; all P < 0.05), and total hospital costs. There was no increase in respiratory complications or other complications. Patients and families were generally satisfied with their hospital experience, including analgesia and length of hospitalization. CONCLUSIONS: Implementation of critical pathways reduced resource utilization and costs after repair of three simple congenital heart lesions, without obvious complications or patient dissatisfaction.  (Abstract by: Author)

   66.    Nemeth, L. (1999). Leadership for coordinated care: role of a project manager. Critical Care Nursing Quarterly, 21(4), 50-8.
Abstract: The use of clinical pathways as a method to improve outcomes for specific populations within health care organizations has become widely adopted. This article focuses on the role of a project manager in facilitating a wide range of outcomes. Through a quality improvement framework, interdisciplinary collaboration, and data-driven decision making, organizational performance can be enhanced. An advanced practice nurse is well suited to lead organizational improvement efforts aimed at optimizing the care delivery system to effectively meet expectations of all constituents. Copyright (c) 1999 by Aspen Publishers, Inc.  (10 ref)

   67.    Lopopolo, R. B. (1999). Hospital restructuring and the changing nature of the physical therapist's role. Physical Therapy, 79(2), 171-85.
Abstract: BACKGROUND AND PURPOSE: This study was conducted to identify role behavior changes of acute care physical therapists and changes in the organizational and professional context of hospitals following restructuring. METHODS: A Delphi technique, which involved a panel of 100 randomly selected acute care physical therapy managers, was used as the research design for this study. Responses from rounds 1 and 2 were synthesized and organized into exhaustive and mutually exclusive categories for round 3. Data obtained from round 3 were used to develop a comprehensive perspective on the changes that have occurred. RESULTS: Changed role behaviors in patient care and professional interaction, including increased emphasis on evaluation, planning, teaching, supervising, and collaboration, appeared to be extensions of unchanged role behaviors. Reported changes in the structural and professional context of physical therapy services included using critical pathways to guide care, providing services system-wide, and using educational activities and meetings to maintain a sense of community. The importance of professionalism to physical therapists' work was identified and related to specific role behavior changes. CONCLUSION AND DISCUSSION: The changing role of physical therapists in acute care hospitals includes an increased emphasis on higher-level skills in patient care and professional interaction and the continuing importance of professionalism

   68.    Lock, J., & Walsh, M. (1999). Development and implementation of depression care along the health care continuum. Journal of Nursing Care Quality, 13(3), 13-22.
Abstract: Depression is a common cause of illness with significant social, vocational, and economic consequences. As one of the most treatable forms of mental illness, depression often is underrecognized and undertreated. The annual cost of depression to the United States economy is approximately $43.7 billion, with 55 percent (or $23.8 billion) accounting for missed work and lowered productivity. The prevalence rate of depression is estimated at 12-20 percent. The depressed patient utilizes two to three times more health services. There is little in the literature to demonstrate the care of the depressed person across the continuum in an integrated health care system. This article reviews the development and implementation of the treatment of depression care across multiple sites along the continuum. The care management depression team utilized the principles of performance improvement; Plan, Do, Check, Act framework for the initiative

   69.    Levine, S. R., & Gorman, M. (1999). "Telestroke" : the application of telemedicine for stroke. [Review] [74 refs]. Stroke, 30(2), 464-9.
Abstract: BACKGROUND: Time is of the essence for effective intervention in acute ischemic stroke. Efforts including stroke teams that are "on call" around-the-clock are emerging to reduce the time from emergency room arrival to evaluation and treatment. SUMMARY OF COMMENT: Based on the results of the NINDS rt-PA Stroke Trial, which demonstrated both clinical effectiveness in reducing neurological deficits and disability and cost savings to health care systems, many community hospitals and managed-care organizations are exploring methods to enhance and expedite acute stroke care in their local communities. Only a small fraction of acute stroke victims is currently treated with thrombolytics (<1.5% nationally), and few benefit from the expertise and experience of the stroke teams. It is essential to develop new paradigms to improve acute stroke care in all settings, rural and urban. Rapid linkages to expert stroke care can help the underserved areas. Telemedicine for stroke, "Telestroke, " uses state-of-the-art video telecommunications that may be a potential solution and may maximize the number of patients given effective acute stroke treatment across the country and across the world. Telestroke could facilitate remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient. This model also has the potential to enhance patient entry into clinical trials. Telestroke would enhance stroke education through the use of Internet-based interactives for health-care professionals and patients. Education would be facilitated through the creation of telecommunication-linked classes providing interactive information on stroke care and prevention to places where they are otherwise not available. Health-care professionals will gain experience and expertise through the interaction with a remote expert--telementoring. Telestroke provides an excellent medium for data collection and an unprecedented opportunity for quality assurance. Monitoring of an entire tele-interaction can offer real-time assessments, which can then be analyzed in-depth at a later date for unique insights into health-care delivery. Prehospital use of telemedicine for stroke is already being piloted, linking patients in the ambulance to the emergency department. Legal and economic parameters must be established for telemedicine in the areas of reimbursement, liability, malpractice insurance, licensing, and credentialing. Issues of protection of privacy and confidentiality, informed consent, product liability, and industry standards must be addressed to facilitate the use of this new and potentially useful technology. CONCLUSIONS: Computer-based technology can now be used to integrate electronic medical information, clinical assessment tools, neuroradiology, laboratory data, and clinical pathways to bring state-of-the-art expert stroke care to underserved areas. [References: 74]

   70.    LeMaitre, G. D. (1999). Regarding "Impact of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass" [letter; comment]. Journal of Vascular Surgery, 29(2), 385-6.
Notes: Comments: Comment on: J Vasc Surg 1998 Jun;27(6):1056-64; discussion 1064-5

   71.    Latamore, B. (1999). Hospital uses IT to gain competitive edge in tight market... information technology. Executive Solutions for Healthcare Management, 2(2), 18-20.

   72.    Kline-Rogers, E., Martin, J. S., & Smith, D. D. (1999). New era of reperfusion in acute myocardial infarction. [Review] [41 refs]. Critical Care Nurse, 19(1), 21-31; quiz 32-3.

   73.    Jones, A. (1999). Pathways of care in the inpatient treatment of schizophrenia: an experimental project. Mental Health Care, 2(6), 194-7.
Abstract: Pathways of care originate in the US, in the healthcare reforms of the 1980s, as a way to rationalise and control costs of medical care. Predominantly applied to inpatient medical and surgical treatments, there is little research on their use with mental health disorders. ADRIAN JONES describes a one-year project in a UK hospital to develop a working care pathway for the inpatient treatment of schizophrenia.  (40 ref)

   74.    Iorio, R., Healy, W. L., & Richards, J. A. (1999). Comparison of the hospital cost of primary and revision total knee arthroplasty after cost containment. Orthopedics (Thorofare, NJ), 22(2), 195-9.
Abstract: Revision total knee arthroplasty (TKA) consumes more time, more work, and more supplies than primary TKA. This study compared the hospital cost of primary and revision TKA after the introduction of cost-containment programs (implant standardization, clinical pathway, and competitive bid implant purchasing) at our hospital. Hospital financial records of 207 primary unilateral TKA operations and 32 revision TKA operations performed from October 1993 through September 1995 were analyzed. A cost-accounting system provided actual hospital cost data for each procedure. Accurate calculation of hospital income or loss was determined for all 239 procedures. The average hospital length of stay was 4.7 days for primary unilateral TKA and 5.1 days for revision TKA. There were 26 three-component revision operations and 6 one- or two-component revision operations. The average hospital cost was $10,421 for primary TKA and $11,906 for revision TKA. The average net hospital income (hospital revenue - hospital expense) was $3211 for primary TKA and $1853 for revision TKA. The payer mix included indemnity insurance, Medicare, Medicaid, managed care, and workmen's compensation. All payers were profitable except for Medicaid and selected managed care contracts for both primary and revision TKA. As a result of cost-containment programs, revision TKA can be profitable at our institution

   75.    Grinslade, S., & Buck, E. A. (1999). Diabetic ketoacidosis: implications for the medical-surgical nurse. [Review] [23 refs]. MEDSURG Nursing, 8(1), 37-45.
Abstract: Diabetic ketoacidosis (DKA) is an acute complication associated with type 1 diabetes mellitus. DKA accounts for a significant portion of annual health care expenditures and is considered a medical emergency. Previously treated in the ICU, DKA is now treated on general medical-surgical nursing units. To manage this crisis successfully, medical-surgical nurses must have a comprehensive knowledge and understanding of the pathophysiologic mechanisms, clinical manifestations, and treatment protocols. A critical pathway is presented to guide clinical care. [References: 23]

   76.    Bumgarner, S. D., & Evans, M. L. (1999). Clinical care map for the ambulatory laparoscopic cholecystectomy patient. Journal of Perianesthesia Nursing, 14(1), 12-6.
Abstract: Shortened hospital stays, expectations of quick recovery, and rapid turnaround times in surgical services challenge perioperative nurses to be creative and innovative providers of essential and appropriate patient education. Nurses need approaches that enable them to meet these challenges. One such approach is the adaptation of a clinical care map to the development of a perioperative patient care guide. This article describes the rationale behind the use of this approach and its application to the education of the patient undergoing laparoscopic cholecystectomy. Steps in the process are described. Nurses can use these steps to develop patient care guides suited to their specific practice setting. Copyright (c) 1999 by American Society of PeriAnesthesia Nurses  (16 ref)

   77.    Bowden, T. A. Jr. (1999). Gastrointestinal conditions. [Review] [66 refs]. Journal of the American College of Surgeons, 188(2), 127-35.

   78.    Baker, B., Fillion, B., Davitt, K., & Finnestad, L. (1999). Ambulatory surgical clinical pathway. Journal of Perianesthesia Nursing, 14(1), 2-11.
Abstract: The purpose of this report is to describe the design, implementation, and advantages of a clinical pathway for patients undergoing ambulatory surgery. The primary purpose of the pathway is to dovetail the preoperative, intraoperative, and postoperative care of the ambulatory surgical patient. The pathway provides a mechanism to collect data and evaluate patient outcome. This is a US government work. There are no restrictions on its use.  (20 ref)

   79.   Kitchiner, D. J., & Bundred, P. E. (1999). Clinical pathways [editorial; comment]. [Review] [12 refs]. Medical Journal of Australia, 170(2), 54-5.
Notes: Comments: Comment on: Med J Aust 1999 Jan 18;170(2):59-62

   80.    Dowsey, M. M., Kilgour, M. L., Santamaria, N. M., & Choong, P. F. (1999). Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study [see comments]. Medical Journal of Australia, 170(2), 59-62.
Notes: Comment in: Med J Aust 1999 Jan 18;170(2):54-5
Abstract: OBJECTIVE: To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty. DESIGN AND SETTING: Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital. PARTICIPANTS: 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients). MAIN OUTCOME MEASURES: Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay. RESULTS: Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation (P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients. CONCLUSION: Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty

   81.    Messer, M., & Ozmar, B. (1999). Use of evidence-based practice management guidelines in trauma care. International Journal of Trauma Nursing, 5(1), 17-8.
Abstract: A PMG is a tool developed by a consensus process, with the input of all trauma care practitioners who are involved in the care of a patient with a specific clinical issue. The group that develops the PMG uses current, evidence-based data, carefully introduces and monitors the PMG in the clinical setting, and evaluates the success of the PMG in accomplishing the goals identified at the beginning of the process. The ultimate goal of a PMG is to eliminate unnecessary practice variations, with the end point of achieving quality care. Participating in the development of a guideline with a review of the literature serves as an excellent educational process for all practitioners

   82.    Bradshaw, M. J. (1999). Clinical pathways: a tool to evaluate clinical learning. Journal of the Society of Pediatric Nurses, 4(1), 37-40.
Abstract: Clinical pathways are a means by which an instructor can objectively and effectively evaluate student learning and progress toward clinical outcomes. An advantage to use of pathways in one-time experiences is that the pathway serves as a criterion-based frame of reference for both student and instructor, since the criteria are the same as for other clinical experiences in that course. The faculty member thus has an objective measure of student learning and performance, and the student always knows the measure on which she or he will be evaluated. Clinical pathways are limited to brief experiences and are not designed to show professional growth and progress in learning over time. A pathway could be designed, however, to appraise critical thinking and professional behaviors associated with spontaneous incidents, such as a problem patient. Nurse educators can use pathways as a creative means to address student responses in a variety of situations

   83.    Welsh, K. M., Magnusson, M., & Napoli, L. (1999). Updates & kidbits. Asthma clinical pathway: an interdisciplinary approach to implementation in the inpatient setting. Pediatric Nursing, 25 (1), 79-80, 83-87.
Abstract: Asthma is a leading cause of admission to the pediatric inpatient setting. Despite advances in the treatment of this chronic condition, morbidity and mortality continue to increase. It is also a source of significant variation in clinical practice and redundancy of care elements across various disciplines involved in the management of patients with asthma. A clinical pathway was developed and implemented by a multidisciplinary team at The Children's Hospital of Philadelphia. The unique approach used to strategize implementation combined the expertise of registered nurses, respiratory therapists, medical staff, and case managers and was a significant factor in the pathway's ultimate success. The result was a more standardized and efficient approach to care. Outcome measurements revealed decreased length of stay with no increase in the re-admission rate and cost savings.  (8 ref)

   84.    Pulde, M. F. (1999). Physician-centered management guidelines. Physician Executive, 25(1), 40-4.
Abstract: The "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between a satisfied work force and productivity, service quality, and, ultimately, organizational success. If health care organizations hope to recruit and retain the quality workforce upon which their core competency depends, they must develop a vision strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care. This article outlines a conceptual framework for effective physician management, a "critical pathway," that will enable health care organizations to add their name to the list of "most admired." The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost-effectiveness.  (Abstract by: Author)

   85.    North, M. C., Harbin, C. B., & Clark, K. G. (1999). A patient education MAP: an integrated, collaborative approach for rehabilitation. Rehabilitation Nursing, 24(1), 13-8.
Abstract: Because Roosevelt Warm Springs Institute for Rehabilitation has been faced with decreasing patient lengths of stay, increasing patient acuity, and changes in the nurse staffing mix, nurses wanted to ensure that patients and their families were receiving appropriate education and learning the skills required to provide safe and competent self-care in the home. As a result, they developed a patient education action plan. This multidiscipline action plan (MAP) involved changing from a multidisciplinary to an interdisciplinary approach toward patient and family education. This plan provides a framework that is linked to expected outcomes for education during a patient's stay, reduces the redundancy of patient education by professionals from different disciplines, and increases collaboration. Teaching modules that outline and provide all of the information an educator needs to effectively teach a patient or group of patients make up the basis for the MAP system. This article describes the MAP system and the related continuous quality improvement activities, offers documentation forms, and identifies a structural path

   86.    Johnson, K., & Schubring, L. (1999). The evolution of a hospital-based decentralized case management model. Nursing Economics, 17(1), 29-35, 48.
Abstract: The authors present a case study of a highly integrated case management program and the redefinition of the clinical practice model that evolved across the continuum of care as the integration process was achieved. The central leadership role of the clinical care coordinator (an advanced staff nurse role) as the front-line link between the case manager and the staff nurses was seen as one key in the model's success. Success was further enhanced by: development of objectivebased versus time-oriented pathways; involvement of home health earlier, especially in the more complex discharge plans; and a refocus of the patient education process. Future initiatives include refocusing the patient education component as part of a "Steps to Recovery" approach that includes appropriate aspects of the objective-based clinical pathways and expanding the number of case management models to include currently underrepresented patient populations.  (10 ref)

   87.    Sikka, R., Waters, J., Moore, W., Sutton, D. R., Herman, W. H., & Aubert, R. E. (1999). Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes. Diabetes Care, 22(1), 1-6.
Abstract: OBJECTIVE: To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS: We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated. RESULTS: At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively). CONCLUSIONS: We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways

   88.    Rutkowski, K. C., & Easterling, A. D. (1999). Fast-tracking clinical pathway redesign, Part II. Hospital Case Management, 7(1), 9-12.

   89.    Rebidas, D., Smith, S. T., & Denomme, P. (1999). Redesigning medication distribution systems in the OR. AORN Journal, 69(1), 184-6, 188, 190 passim.
Abstract: Detroit Riverview Hospital's surgery suite recently converted to an automated medication distribution system. Focusing on control, access, documentation, and charging, the redesign has benefited pharmacists, nurse anesthetists, and OR nurses. Automation reduced nursing labor associated with ordering and restocking medications, counting narcotics, and investigating discrepancies. Storage and dispensing options, including innovative anesthesia trays, facilitate caregiver productivity, quality initiatives, and clinical pathways. System documentation pinpoints questionable events and patterns to ensure that all medications dispensed were administered to patients. Charges are captured and posted automatically. Overall, automated medication distribution has helped the OR improve clinical care quality and patient service

   90.    Rauh, R. A., Schwabauer, N. J., Enger, E. L., & Moran, J. F. (1999). A community hospital-based congestive heart failure program: impact on length of stay, admission and readmission rates, and cost. American Journal of Managed Care, 5(1), 37-43.
Abstract: OBJECTIVE: To do an analysis of patients with a primary diagnosis of congestive heart failure at discharge before (n = 407) and after (n = 347) the implementation of a comprehensive inpatient and outpatient congestive heart failure program consistent with the guidelines of the Agency for Health Care Policy and Research. STUDY DESIGN: A retrospective analysis of the impact of the congestive heart failure program on length of stay, admission and readmission rates, and costs to both patient and provider. The program, which used a multidisciplinary team approach, included an intensive education program focusing on diet, compliance, and symptom recognition, as well as the use of outpatient infusions. It also incorporated aggressive pharmacologic treatment for patients with advanced congestive heart failure. RESULTS: Our analysis revealed significant decreases in length of stay, admission and readmission rates, and costs to the patient and provider (P < or = .05). The mean cost per admission decreased 17% ($1118), and a substantial 77% ($718,468) net reduction in nonreimbursed (lost) hospital revenue was noted. CONCLUSION: A multidisciplinary, comprehensive congestive heart failure program can improve patient care in a community-hospital setting while significantly reducing costs to both the patient and the institution.  (Abstract by: Author)

   91.    Mathias, J. M. (1999). Closing pathway loop with automation, teamwork. Or-Manager, 15(1), 1-13-6.

   92.    Mathias, J. M. (1999). Clinical pathways. Closing pathway loop with automation, teamwork. Or-Manager, 15(1), 3-6.

   93.    Gandhi, R. R., Keller, M. S., Schwab, C. W., & Stafford, P. W. (1999). Pediatric splenic injury: pathway to play? Journal of Pediatric Surgery, 34(1), 55-8; discussion 58-9.
Abstract: BACKGROUND: Nonoperative management of blunt splenic injury (BSI) remains a "gold standard" in pediatric trauma care. Controversy exists regarding the minimal hospital stay necessary for the care of these patients and the appropriate duration of reduced activity required after discharge. METHODS: A clinical pathway was developed in an attempt to standardize the hospital and outpatient management of children with BSI cared for at the Children's Hospital of Philadelphia. From July 1, 1996 to September 30, 1997, all children with BSI were treated using this pathway (pathway group). To better evaluate outcome, data were compared with an historical control of consecutive children treated at our institution during the previous 2 years (control group). RESULTS: Twenty-eight children in the control group and 21 children in the pathway group comprise the study population. Average age, injury mechanism, grade of splenic injury, injury severity score, length of intensive care unit stay, and number of transfusions were not significantly different between the two groups (P<.05). As expected, there was a significant decrease in the length of stay on the general care units (5.3+/-1.2 v 2.9+/-0.9 days, control v pathway, P<.05), which, in turn, resulted in a significant decrease in the total length of hospitalization (6.7+/-1.4 v 3.9+/-1.2 days, P<.05) and estimated hospital charges. During follow-up, no complications or missed injuries were identified at a standard 3-week and the 3-month office visit. CONCLUSION: Hemodynamically stable children with isolated blunt splenic injuries may be treated safely with a 4-day hospital stay followed by 3 weeks of quiet activities at home and 3 months of light activity before return to full, unrestricted activity

   94.    Droste, T. (1999). Coordinating patient care improves quality of care, efficiency. Executive Solutions for Healthcare Management, 2(1), 10-12.

   95.    Dorfman, G. S. (1999). Utilization of diagnostic tests: assessing appropriateness. Academic Radiology, 6(Suppl 1), S40-6; discussion S47-51.

   96.    Cannon, C. P., Johnson, E. B., Cermignani, M., Scirica, B. M., Sagarin, M. J., & Walls, R. M. (1999). Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction. Clinical Cardiology, 22(1), 17-20.
Abstract: BACKGROUND: Rapid time to treatment with thrombolytic therapy is an important determinant of survival in acute myocardial infarction (AMI). HYPOTHESIS: We hypothesized that establishment of an AMI thrombolysis critical pathway in the Emergency Department could successfully reduce the "door-to-drug" time, the time between patient arrival and start of thrombolysis. METHODS AND RESULTS: Before establishment of the AMI critical pathway, median door-to-drug time was 73 min, which was reduced to 37 min after critical pathway implementation (p < 0.05). The percentage of patients treated within 30 min rose from 0% prior to establishment of the pathway to 43% (p = 0.03). Similarly, the percentage treated in within 45 min rose from 0 to 67% (p = 0.0005). Door-to-drug times were longer for women than for men (median 105 min for women vs. 70 min for men before pathway implementation). The pathway reduced door-to-drug time for both genders, but the median door-to-drug times were higher for women than for men (Mann-Whitney p = 0.013). The difference between men and women was 35 min before establishment of the pathway to 10 min by the end of the study period. CONCLUSIONS: Our critical pathway was successful in reducing door-to-drug times. We observed a "gender gap" in door-to-drug times, with longer mean times for women, which was reduced by the AMI critical pathway. Thus, our data provide support for the use of critical pathways to reduce door-to-drug times, as recommended by the National Heart Attack Alert Program

   97.    Brown, D. L., & Smith, D. J. (1999). Bacterial colonization/infection and the surgical management of pressure ulcers. [Review] [60 refs]. Ostomy Wound Management, 45(1A Suppl), 109S-118S; quiz 119S-120S.
Abstract: The purpose of this paper is to review the current recommendations and guidelines for the care and treatment of pressure ulcers with specific reference to the control of infection within these wounds and surgical management. After reviewing the literature published between May 1993 and April 1998, it is our contention that no significant changes in the clinical management of this problem are warranted. This may signal the need for further study in this area. Recommendations for the optimal care of clean and infected pressure ulcers are included. [References: 60]

   98.    Bing, M., Abel, R. L., Pendergrass, P., Malone, M., Sabharwal, K., & McCauley, C. (1999). Aspirin administration for cardiac-related acute chest pain/angina: increased use in Medicare patients. Southern Medical Journal, 92(1), 23-7.
Abstract: BACKGROUND: Coronary heart disease (CHD), the leading cause of death in the United States, accounted for approximately 490,000 deaths in 1993. Angina pectoris, a manifestation of CHD, accounted for 13,586 Medicare discharges in 1993 in Texas. A pilot project showed aspirin prophylaxis that reduces cardiovascular morbidity and mortality in individuals with acute angina is underused. Texas Medical Foundation collaborated with 10 acute-care facilities to improve aspirin prophylaxis. METHODS: Collaborators assessed processes of care and implemented clinical pathways to improve aspirin administration. Data were abstracted from medical records before and after pathway implementation to evaluate impact. RESULTS: Aspirin administration during hospital stay increased 10.8%, aspirin administration on discharge increased 11.7%, and average time from arrival to aspirin administration decreased 2.9 hours. CONCLUSIONS: Results suggest collaborator-implemented clinical pathways significantly improved care received by Medicare patients admitted for cardiac-related acute chest pain/angina. Data suggest room for further improvement

   99.    Bergman, D. A. (1999). Evidence-based guidelines and critical pathways for quality improvement. Pediatrics, 103(1 Suppl E), 225-32.
Abstract: Clinical practice guidelines have a long and distinguished tradition in pediatrics. Currently, the American Academy of Pediatrics has developed more than 15 practice guidelines and more than 250 clinical policy statements. In the past, practice guidelines have been used to improve care through the dissemination of evidence-based, clinically effective practices to pediatric practitioners. In the current environment this purpose has been broadened to include cost reduction, standardization of practice, and reduction of medical liability. This has led to both confusion and distrust on the part of the pediatrician. Practice guidelines are best understood as a tool to insure that children receive evidence-based care. They are best used in association with a set of outcome and performance measures that provide feedback to clinicians and allow for modification of the guidelines to meet the needs of the local patient population. The quality of practice guidelines is directly dependent on the quality of the medical evidence supporting the recommendation. Unfortunately only a small percentage of the evidence supporting practice guidelines comes from randomized clinical trials with the majority of the evidence coming from expert clinical panels. The success of practice guidelines in improving care for children has yet to be convincingly demonstrated. Currently, there is a dearth of well designed studies that document the effectiveness of practice guidelines. Their ultimate effectiveness will depend on both an improved evidence base and effective strategies for rapid dissemination of the recommendations. The development of evidence-based practice guidelines does not insure that it will have a major impact on physician practice. In the past, effective dissemination of new knowledge has been a long process, often taking years. This cycle time can be dramatically shortened through the development of networks of practice sites that share knowledge and experience in the implementation of practice guidelines and the use of strategies that take advantage of key groups in the dissemination process. When used appropriately, practice guidelines can provide an important adjunct to clinical research by facilitating the dissemination of new clinical findings and can provide an important platform for encouraging innovations in patient care

100.    Yutani, C., Imakita, M., Ishibashi-Ueda, H., Tsukamoto, Y., Nishida, N., & Ikeda, Y. (1999). Coronary atherosclerosis and interventions: Pathological sequences and restenosis. Pathology International, 49(4), 273-290.
Abstract: The primary cause of cardiac morbidity and mortality in developed countries is ischemic (coronary) heart disease. The incidence of this disease is virtually all due to atherosclerosis, and ischemic heart disease is also the most prevalent disease in the industrialized world, causing over 40% of all deaths in the United States and Western Europe. In Japan, the incidence of ischemic heart disease due to coronary atherosclerosis is gradually increasing as well. Compared with the classical nomenclature of atherosclerosis; that is, fatty streak, fibrous plaque and complicated lesions, the term Stary's classification has been universally accepted because it reflects the more recently acquired knowledge about the morphological and biochemical details of the processes in coronary atherosclerosis, which have been obtained by new strategies such as angioscopy, intravascular ultrasound and molecular biological methods. The term Stary's classification has been applied for the coronary atherosclerosis of patients with acute coronary syndrome at the National Cardiovascular Center, for the analysis of predisposing atherosclerosis of these patients. The recent findings regarding acute coronary syndrome resulting from a rupture of coronary atherosclerotic plaques indicate that this syndrome is probably the most important mechanism underlying the sudden onset. It has been found that the risk of plaque rupture may depend more on plaque composition than on plaque size. Plaques rich in soft extracellular lipids and macrophages are possibly more vulnerable to plaque rupture. Two of the goals of the present review are to clarify how plaque disruption occurs and to elucidate the relationship between plaque disruption and coronary risk factors in elderly Japanese patients with acute coronary syndrome. Coronary stents have been shown to be efficacious in the treatment of acute and threatened closure complicating percutaneous transluminal coronary angioplasty (PTCA) and have produced encouraging initial results in the prevention of restenosis. In the autopsy study of restenosis after PTCA, it was observed that dense caps of collagen fibers in the adventitia in the vicinity of the disrupted internal elastic laminae were present in all of the remodeling lesions. It is suggested that remodeling, which resulted in adventitial scarring, is one of the major causative factors of restenosis after PTCA. The long-term success of stenting, however, remains limited by the occurrence of late in-stent restenosis, with an incidence of 20-42% depending on the stent design and the patient population studied. Another aim of the present review is to describe the pathological mechanism of restenosis after PTCA and/or stent replacement and, consequently, the vascular remodeling that occurs around adventitial tissue after PTCA and intimal hyperplasia that is chronically irritated by a foreign body granulomatous reaction after stenting. Finally, the results of the investigation of the effect of a tissue factor pathway inhibitor on the prevention of interventional restenosis is described.  [References: 126]

101.    Yoshida, T., Ikeda, H., Hiraki, T., Kubara, I., Ohga, M., & Imaizumi, T. (1999). Detection of concealed left sided accessory atrioventricular pathway by P wave signal averaged electrocardiogram. Journal of the American College of Cardiology, 33(1), 55-62.
Abstract: Objectives. The purpose of this study was to examine whether P wave signal-averaged electrocardiogram (P-SAECG), which detects subtle changes in P wave, detects the concealed accessory atrioventricular pathway (AP). Background. It is difficult to differentiate atrioventricular reciprocating tachycardia (AVRT) due to the AP from atrioventricular nodal reentrant tachycardia (AVNRT) when the ventricular preexcitation is absent on 12-lead electrocardiograms. By electrophysiological studies, the anterograde conduction in the concealed AP is shown to be blocked near the AP-ventricular interface during sinus rhythm. Methods. P-SAECG during sinus rhythm was performed in 20 normal volunteers (control), 21 patients with AVRT due to the concealed AP, 19 with AVNRT, 22 with paroxysmal atrial fibrillation (PAF), and 7 with automatic atrial tachycardia (AT). The filtered P wave duration (FPD) and AR20 (power spectrum area ratio of 0-20 to 20-100 Hz) were measured and repeated in AVRT, AVNRT and AT groups at one week after catheter ablution. Results. The anterograde conduction in the concealed left-sided AP was confirmed in all cases by an electrophysiological study. The FPD in AVRT group was more prolonged than that in controls or AVNRT group. Although the FPD was similar between AVRT and PAF groups, AR20 differentiated between the two groups. Ablation of the concealed AP shortened FPD in AVRT group but that of the slow pathway or the atrial focus did not shorten in the AVNRT or AT groups, respectively. The changes in FPD after ablation were correlated with those in the duration of atrial activity by an electrophysiological study (r = 0.67). Conclusions. Our findings suggest that P-SAECG detects the concealed left-sided AP, providing a clinical tool in noninvasively assessing atrial activation patterns.  [References: 39]

102.    Wilson, J. (1999). President's letter. AUSTRALAS PSYCHIATRY, 7(1), 33.

103.    Wilson, A., Tobin, M., Ponzio, V., Moffit, C., Hudson-Jessop, P., & Chen, L. (1999). Developing a clinical pathway in depression: Sharing our experience. AUSTRALAS PSYCHIATRY, 7(1), 17-19.
Abstract: The Second National Mental Health Plan [1] has as one of its key themes, a focus on the quality and effectiveness of services with an emphasis on outcomes for consumers and carers. This focus on quality and outcomes results in an increasing interest in clinical practice guidelines, benchmarking of services and the development and evaluation of models of best practice. One way to progress these issues within clinical services is to develop clinical pathways for groups of patients with similar conditions. Clinical pathways have been defined as 'clinical management tools that organise, sequence and time the major interventions of professionals for a particular case type, subset or condition' [2]. Simplistically, a timeline is plotted on one axis with interventions on the other.  [References: 11]

104.    Wakita, Y., Wada, H., Nakase, T., Nakasaki, T., Shimura, M., Hiyoyama, K., Mori, Y., Gabazza, E. C., Nishikawa, M., Deguchi, K., & Shiku, H. (1999). Aberrations of the tissue factor pathway in patients positive for lupus anticoagulant. CLIN APPL THROMB HEMOST, 5(1), 10-15.
Abstract: To evaluate the relationship between the tissue factor (TF) pathway and lupus anticoagulant (LA), in the present study, we measured the plasma levels of TF antigen and TF pathway inhibitor (TFPI) antigen in patients positive for LA. Plasma TF and TFPI levels in LA-positive patients were significantly higher than levels in healthy volunteers (p < 0.01). In LA-positive patients, there were no significant differences in plasma TF and TFPI levels between patients with and without thrombosis. In patients with thrombosis, there was no significant difference in the plasma TF level between LA-positive and LA- negative patients; however, the plasma TFPI level in LA-positive patients was significantly lower than that in LA-negative patients (p < 0.01). We also examined the TF pathway in human umbilical venous endothelial cells (HUVEC) incubated with plasma of LA-positive patients, LA-negative patients, and healthy volunteers. TF activity was significantly higher (p < .05) in HUVECs incubated with the plasma of LA-positive patients than in cells incubated with the plasma of the other two groups (p < .01). However, there was no significant difference in TFPI antigen levels among the media of HUVECs incubated with the plasma of all groups. The viability of HUVEC incubated with the plasma of LA-positive patients with thromboses, LA-positive patients without thromboses, and LA-negative patients with thromboses were significantly lower than that of HUVECs incubated with the plasma of healthy volunteers (p < .01). These findings suggest that abnormalities of the TF pathway plays an important role in the mechanism of hypercoagulability in LA- positive patients. LA may affect vascular endothelial cells causing thrombogenesis.  [References: 39]

105.    Velthuis, B. K., Rinkel, G. J. E., Ramos, L. M. P., Witkamp, T. D., & Van Leeuwen, M. S. (1999). Perimesencephalic hemorrhage: Exclusion of vertebrobasilar aneurysms with CT angiography. Stroke, 30(5), 1103-1109.
Abstract: Background and Purpose - It is important to recognize a perimesencephalic pattern of hemorrhage in patients with subarachnoid hemorrhage (SAH), because in 95% of these patients the cause is nonaneurysmal and the prognosis is excellent. The purpose of this study was to investigate whether CT angiography can accurately exclude vertebrobasilar aneurysms in patients with perimesencephalic patterns of hemorrhage and therefore replace digital subtraction angiography (DSA) in this setting. Methods - In 40 patients with posterior fossa SAH as shown on unenhanced CT, 2 radiologists independently evaluated unenhanced CT for distinguishing between perimesencephalic and nonperimesencephalic pattern of hemorrhage and assessed CT angiography for detection of aneurysms. All patients subsequently underwent DSA or autopsy. Results - Observers agreed in 38 of 40 patients (95%) in differentiating perimesencephalic and nonperimesencephalic patterns of hemorrhage on unenhanced CT. On the CT angiograms, both observers detected a vertebrobasilar aneurysm in 16 patients and no aneurysm in 24 patients. These findings were confirmed by DSA or autopsy. No patients with a perimesencephalic pattern of hemorrhage were found to have an aneurysm on either CT angiography or DSA. Conclusions - Good recognition of a perimesencephalic pattern of hemorrhage is possible on unenhanced CT, and CT angiography accurately excludes and detects vertebrobasilar aneurysms. DSA can be withheld in patients with a perimesencephalic pattern of hemorrhage and negative CT angiography.  [References: 30]

106.    Van Dreden, P., Grosley, M., & Cost, H. (1999). Letter to the editor: Total and free levels of tissue factor pathway inhibitor: A risk factor in patients with factor V Leiden? [3]. Blood Coagulation & Fibrinolysis, 10(2), 115-116.

107.    Tuchnitz, A., Schmitt, C., Von Bibra, H., Schneider, M. A. E., Plewan, A., & Schomig, A. (1999). Noninvasive localization of accessory pathways in patients with Wolff- Parkinson-White syndrome with the use of myocardial Doppler imaging. Journal of the American Society of Echocardiography, 12(1), 32-40.
Abstract: This study sought to examine the diagnostic accuracy of noninvasive prediction of accessory pathway localization in patients with manifest Wolff- Parkinson-White syndrome with the use of myocardial Doppler imaging as a new noninvasive mapping procedure. Myocardial Doppler imaging measures myocardial velocities and therefore can determine the site of earliest ventricular activation in patients with accessory bypass tracts. Twenty-five patients with manifest preexcitation were studied with the use of pulsed wave and M- mode myocardial Doppler imaging for the evaluation of the shortest electromechanical time interval in 9 basal myocardial segments. The new diagnostic test was compared with 3 electrocardiographic algorithms. An invasive mapping procedure served as reference standard. Abnormally short electromechanical time intervals were found in preexcited segments (27 +/- 12 ms vs 64 +/- 27 ms). Myocardial Doppler imaging correctly localized 84% of the accessory pathways and electrocardiographic algorithms only 48% to 60% of cases. Noninvasive prediction of accessory pathway localization by myocardial Doppler imaging is accurate and proved to be superior to prediction based on electrocardiographic algorithms.  [References: 30]

108.    Toy, P. (1999). Guiding the decision to transfuse: Interventions that do and do not work. Archives of Pathology & Laboratory Medicine, 123(7), 592-594.
Abstract: Guiding the decision to transfuse can improve transfusion practices. Effective processes must first identify problem(s) in transfusion practice and then include the attending physician as an educational target. Process improvements that have been shown to be effective include the following: (1) briefly meeting one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds of patients who receive transfusion, (4) concurrently reviewing orders for transfusion before issue of the blood product, and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements.  [References: 32]

109.    Thomas, L., Cullum, N., McColl, E., Rousseau, N., Soutter, J., & Steen, N. (1999). Guidelines in professions allied to medicine. The Cochrane Library (Oxford) , (2).
Abstract: (Date of most recent substantive amendment: 24 November 1998). Background and objectives: To identify rigorous evaluations of the introduction of clinical practice guidelines in nursing (including health visiting), midwifery and other professions allied to medicine. Both hospital and community sectors were included. To determine the effectiveness and efficiency of introducing clinical practice guidelines targeting nursing, midwifery and professions allied to medicine to promote improved professional practice and patient outcomes. Search strategy: Relevant studies were located using a variety of electronic databases (eg Medline [1975-1996], Embase [1980 -1996], Cinahl [1982-1996]) and personal contact with content area experts. Selection criteria: Study design: randomised controlled trials (RCTs); interrupted time series (ITS) studies and controlled before and after (CBA) studies. Participants: any of the following health care disciplines: nursing, midwifery, health visiting, chiropody, speech and language therapy, physiotherapy, occupational therapy, dietetics, clinical psychology, pharmacy and radiography. Interventions: the introduction of clinical practice guidelines. Outcomes: any measure of professional performance or patient outcomes. Data collection and analysis: Comparisons: all studies that evaluated the effectiveness of guidelines plus dissemination/implementation strategies against a non-intervention control (comparison 1), or that evaluated different dissemination and implementation strategies (comparison 2). During the review, we identified a subset of studies that evaluated role substitution supported by clinical guidelines; they were included as a post-hoc comparison in the review (comparison 3). Data extraction and quality assessment were undertaken independently by two reviewers using a data checklist following standard methods described by the Cochrane Effective Practice and Organisation of Care Group (EPOC). Data on methods, participants, interventions and outcomes were extracted. It was impractical to examine the impact of interventions quantitatively in specific subgroups of studies because of the heterogeneity of clinical area, study design, source and format of interventions, processes and outcomes measured and participating health professionals. We therefore opted to report effects on process and outcome of care in the same way they were reported in the original papers. Main results: Eighteen studies met all inclusion criteria including 13 RCTs, three ITS studies and two CBA studies. The reporting of study methods was inadequate for all studies. In all but one study, nurses were the targeted professional group; one study was aimed solely at dieticians. Various behaviours were targeted included the management of hypertension, low back pain and hyperlipidaemia. Nine studies examined comparison 1: three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care. Only one study included a formal economic evaluation, with equivocal findings. Three studies examined comparison 2; it was difficult to draw firm conclusions from the identified studies because of poor methods. Six studies examined comparison 3: these studies generally supported the hypothesis of no difference between nurse-protocol driven and physician care. Reviewers' conclusions: Findings from the 18 studies identified provide some evidence that guideline-driven care can be effective in changing the process and outcome of care provided by professions allied to medicine. Significant improvements in the outcome of care were found in six out of eight studies comparing the introduction of guidelines to a no guideline control. The three studies comparing two or more dissemination and implementation strategies were compromised by poor methods; as a result it is difficult to draw firm conclusions from these studies. The findings from the six studies that examined the ability of clinical guidelines to enable role substitution generally support the effectiveness of this intervention. However, caution is needed in generalising findings to other professions and settings. [CINAHL Note: The Cochrane Collaboration systematic reviews contain interactive software that allows various calculations in the MetaView.]

110.    Teich, J. M., Glaser, J. P., Beckley, R. F., Aranow, M., Bates, D. W., Kuperman, G. J., Ward, M. E., & Spurr, C. D. (1999). The Brigham integrated computing system (BICS): Advanced clinical systems in an academic hospital environment. INT J MED INFORM, 54(3), 197-208.
Abstract: The Brigham integrated computing system (BICS) provides nearly all clinical, administrative, and financial computing services to Brigham and Women's Hospital, an academic tertiary-care hospital in Boston. The BICS clinical information system includes a very wide range of data and applications, including results review, longitudinal medical records, provider order entry, critical pathway management, operating-room dynamic scheduling, critical-event detection and altering, dynamic coverage lists, automated inpatient sumaries, and an online reference library. BICS design emphasizes direct physician interaction and extensive clinical decision support. Impact studies have demonstrated significant value of the system in preventing adverse events and in saving costs, particularly for medications.  [References: 31]

111.    Taylor, M. D., & Bernstein, M. (1999). Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: A prospective trial of 200 cases. Journal of Neurosurgery, 90(1), 35-41.
Abstract: Object. Awake craniotomy was performed as the standard surgical approach to supratentorial intraaxial tumors, regardless of the involvement of eloquent cortex, in a prospective trial of 200 patients surgically treated by the same surgeon at a single institution. Methods. Patient presentations, comorbid conditions, tumor locations, and the histological characteristics of lesions were recorded. Brain mapping was possible in 195 (97.5%) of 200 patients. The total number of patients sustaining complications was 33 for an overall complication rate of 16.5%. There were two deaths in this series, for a mortality rate of 1%. New postoperative neurological deficits were seen in 13% of the patients, but these were permanent in only 4.5% of them. Complication rates were higher in patients who had gliomas or preoperative neurological deficits and in those who had undergone prior radiation therapy or surgery. No patient who entered the operating room neurologically intact sustained a permanent neurological deficit postoperatively. Of the most recent 50 patients treated, three (6%) required a stay in the intensive care unit, and the median total hospital stay was 1 day. Conclusions. Use of awake craniotomy can result in a considerable reduction in resource utilization without compromising patient care by minimizing intensive care time and total hospital stay. Awake craniotomy is a practical and effective standard surgical approach to supratentorial tumors with a low complication rate, and provides an excellent alternative to craniotomy performed with the patient in the state of general anesthesia because it allows the opportunity for brain mapping and avoids general anesthesia.  [References: 36]

112.    Suzuki, M., Kudo, A., Otawara, Y., Hirashima, Y., Takaku, A., Ogawa, A., Kassell, N. F., Vapalahti, M., Langmoen, I. A., & Butler, W. E. (1999). Extrinsic pathway of blood coagulation and thrombin in the cerebrospinal fluid after subarachnoid hemorrhage. Neurosurgery, 44(3), 487-494.
Abstract: OBJECTIVE: The involvement of thrombin in the pathophysiology of subarachnoid hemorrhage (SAH) was investigated by comparing thrombin expression and extrinsic pathway activation in the cerebrospinal fluid (CSF) and blood of patients with SAH with the neurological grades, outcome, and presence of delayed cerebral vasospasm. METHODS: Blood and CSF samples were obtained from 38 patients with SAH on Days 3 through 5, 7 through 9, and 12 through 14 after the onset of SAH. CSF samples were also obtained from control patients. Thrombin-antithrombin III complex, prothrombin fragment F1+2, tissue factor, and tissue factor pathway inhibitor were analyzed using enzyme-linked immunosorbent assay. RESULTS: No markers in the blood or CSF were correlated with neurological grades and outcome. Thrombin-antithrombin III complex and prothrombin fragment F1+2 levels were significantly higher in the CSF of patients with SAH than in the blood or the CSF of control patients and were significantly higher in patients with vasospasm than in patients without vasospasm on Days 7 through 9. Tissue factor levels were significantly higher in the CSF of patients with SAH than in the blood, but the levels were close to those in the CSF of control patients. Tissue factor pathway inhibitor levels in the CSF of patients with SAH and control patients were under the detection limit. CONCLUSION: Thrombin in the blood may not reflect the pathophysiology of SAH. Imbalance between tissue factor and tissue factor pathway inhibitor in the CSF may tend to thrombin generation under normal physiological conditions and also after SAH. Thrombin in the CSF may be involved in the pathophysiology of vasospasm.  [References: 42]

113.    Su, L. T., & Carpenter, J. P. (1999). Decreasing carotid endarterectomy length of stay at a university hospital. Cardiovascular Surgery, 7(3), 292-297.
Abstract: In 1995, a clinical pathway for carotid endarterectomy patients was instituted at the authors' institution. The effect of this program on length of stay and patient outcomes was investigated. Records of 152 consecutive carotid endarterectomies performed by a single surgeon over a 45-month period with identical technique (general anesthesia, routine shunting, closure with a dacron patch) were reviewed. Comparison of patients treated under the pathway (n = 119) and those prior to that policy (n = 33) revealed no significant differences (P>0.05) in age, sex, co-morbid conditions, or surgical indication. No difference (P > 0.05) was found for occurrence of complications, which included two fatal perioperative strokes (1.3%) and two myocardial infarctions (1.3%) (one fatal). No complications occurred after discharge and no patients required readmission to the hospital. Average length of stay was reduced from 6.0 to 3.3 days, with 78% of patients discharged within 48 h. Preoperative hospitalization decreased from 100 to 21%. A decrease in the use of preoperative arteriography from 100 to 10% was noted. The cost of vascular studies decreased from $2451 to $1228. Cost- saving measures, including early discharge of stable patients, elimination of preoperative hospitalization and decreased use of arteriography, can be accomplished while maintaining acceptable complication rates following carotid endarterectomy in a university hospital setting.  [References: 13]

114.    Stiefelhagen, P. (1999). Progress and education in medicine. Part II: Depressive disorders, possibilities for prenatal therapy, autoimmune diseases and drug therapy. Internist, 40(6), 686-691.

115.    Stewart, A. (1999). Evidence-based medicine: A new paradigm for the teaching and practice of medicine. Annals of Saudi Medicine, 19(1), 32-36.
Abstract: Physicians have long used evidence to support clinical decisions. However, both the nature and quantity of evidence have changed drastically in the last 20 years. The proponents of evidence-based medicine argue that only through the development of skills in information management can individual clinicians be confident that they are providing their patients with the best possible care. Since first espoused in 1992, EBM has taken a foothold in North America and Europe. Its impact is seen across the spectrum of healthcare providers, from physiotherapists and dentists to nurses, physicians and beyond. Medical educators have recognized the importance of producing a generation of physicians skilled in information management, and for whom a career in medicine is synonymous with lifelong learning. Hospitals, through the use of clinical pathways and guidelines, are applying the principles of EBM in concerted efforts to improve quality of care and to curb costs. Likewise, health policymakers have seriously undertaken to put weighting of evidence at the forefront of decision-making in an attempt to distribute shrinking resources wisely. The greatest challenge may lie with individual physicians who are outside of academic medical centers, many of whom feel the rhetoric is inapplicable to their own practice. It is to this majority that we must strongly address the message, for they represent the vast bulk of practicing physicians, and thus have the greatest impact on the provision of quality care. Finally, the practice of EBM is especially relevant to regions such as the Middle East, where health care delivery systems are evolving, where the educational and management tools exist and where resources, though finite, are sufficient to implement it. It is incumbent on academic centers and healthcare policymakers to adopt and disseminate the philosophy of EBM sooner rather than later. Embracing an EBM philosophy now may be the pivotal step towards provision of 'best care' in the new millennium.  [References: 26]

116.    Stahl, S. M. (1999). Why settle for silver, when you can go for gold? Response vs. recovery as the goal of antidepressant therapy. Journal of Clinical Psychiatry, 60(4), 213-214.

117.    Soejima, H., Ogawa, H., Yasue, H., Kaikita, K., Nishiyama, K., Misumi, K., Takazoe, K., Miyao, Y., Yoshimura, M., Kugiyama, K., Nakamura, S., Tsuji, I., & Kumeda, K. (1999). Heightened tissue factor associated with tissue factor pathway inhibitor and prognosis in patients with unstable angina. Circulation, 99(22), 2908-2913.
Abstract: Background - This study was designed to evaluate the plasma levels of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in patients with unstable angina and investigate whether there is a relationship between these levels and unfavorable outcome. Methods and Results - The plasma TF and free TFPI antigen levels were determined in plasma samples taken from 51 patients with unstable angina, 56 with stable exertional angina, and 55 with chest pain syndrome. The plasma TF and free TFPI antigen levels were higher in the unstable angina group than in the stable exertional angina and chest pain syndrome group. There was a good correlation between TF and TFPI. We established borderline as maximum level in the patients with chest pain syndrome. Seven patients (of the 22 in the high TF group) required revascularization to control their unstable angina during in-hospital stay. On the other hand, only 1 of the 29 patients in the low TF group required myocardial revascularization. Four patients of the 14 patients in the high free TFPI group required myocardial revascularization during in-hospital stay, and 4 of the 37 patients in the low free TFPI group required myocardial revascularization. We compared the TF and free TFPI levels between the cardiac event (+) group and cardiac event (-) group. TF levels were significantly higher in the cardiac event (+) group than in the cardiac event (-) group. Conclusions - We have demonstrated that not only the plasma TF levels but also the plasma-free TFPI levels are elevated in patients with unstable angina. Patients with unstable angina and heightened TF and free TFPI are at increased risk for unfavorable outcomes. The heightened TF level was a more important predictor in patients with unstable angina.  [References: 22]

118.    Smith, D. M., & Gow, P. (1999). Towards excellence in quality patient care: A clinical pathway for myocardial infarction. Journal of Quality in Clinical Practice, 19(2), 103-105.
Abstract: A major initiative to implement a clinical pathway for myocardial infarction has provided a model on which to further develop pathways within our organization. Two of the primary objectives were to reduce time to thrombolysis and length of stay. Two years after the implementation of the myocardial infarction pathway there has been a reduction in the thrombolysis times from 80 to 49 min and in length of stay from 7.28 to 6.13 days. These results highlight significant improvements in patient and process outcomes. There is heightened awareness about best practice for patients who have sustained myocardial infarctions.  [References: 6]

119.    Simos, P. G., Breier, J. I., Maggio, W. W., Gormley, W. B., Zouridakis, G., Willmore, L. J., Wheless, J. W., Constantinou, J. E. C., & Papanicolaou, A. C. (1999). Atypical temporal lobe language representation: MEG and intraoperative stimulation mapping correlation. Neuroreport, 10(1), 139-142.
Abstract: FUNCTIONAL brain imaging techniques hold many promises as the methods of choice for identifying areas involved in the execution of language functions. The success of any of these techniques in fulfilling this goal depends upon their ability to produce maps of activated areas that overlap with those obtained through standard invasive procedures such as electrocortical stimulation. This need is particularly acute in cases where active areas are found outside of traditionally defined language areas. In the present report we present two patients who underwent mapping of receptive language areas preoperatively through magnetoencephalography (MEG) and intraoperatively through electrocortical stimulation. Language areas identified by both methods were located in temporoparietal regions as well as in less traditional regions (anterior portion of the superior temporal gyrus and basal temporal cortex). Importantly there was a perfect overlap between the two sets of maps. This clearly demonstrates the validity of MEG-derived maps for identifying cortical areas critically involved in receptive language functions.  [References: 19]

120.   Shuttleworth, A. (1999). Finding new clinical pathways in the changing world of district child psychotherapy. J CHILD PSYCHOTHER, 25(1), 29-49.
Abstract: This paper discusses the changing working environment of child psychotherapists in the public sector in the UK whose responsibility is to play a part in providing a general service to a local community. It suggests they operate with a kind of dual citizenship, owing allegiance both to the psychoanalytic community and to the public sector. Transitions between one and the other are demanding, requiring careful thought and management. This has become more demanding because of changes occurring within the public sector as a whole and within multi-disciplinary, multi-approach child and adolescent mental health teams. The nature of these changes is outlined. It is suggested that their cumulative effect is radical and irreversible and that, if district child psychotherapy is to be sustained, it will need to adapt to them in ways that are understood by and are acceptable to both the psychoanalytic and the public-sector communities. Hard thinking will be needed to carry forward into the next fifty years the achievements of district child psychotherapy in the UK in its first fifty years.  [References: 17]

121.    Shimura, M., Wada, H., Nakasaki, T., Hiyoyama, K., Mori, Y., Nishikawa, M., Deguchi, H., Deguchi, K., Gabazza, E. C., & Shiku, H. (1999). Increased truncated form of plasma tissue factor pathway inhibitor levels in patients with disseminated intravascular coagulation. American Journal of Hematology, 60(2), 94-98.
Abstract: To evaluate that the relationship between the truncated form of tissue factor pathway inhibitor (TFPI) and the stage of disseminated intravascular coagulation (DIC), we measured the plasma levels of tissue factor (TF) antigen and the intact and truncated forms of TFPI antigens in 41 patients with DIC, 12 with pre-DIC, and 20 with non-DIC. The plasma TF and total TFPI antigen levels were significantly higher in patients with DIC than in non- DIC patients. Plasma levels of intact TFPI antigen in the pre-DIC groups were significantly lower than in the non-DIC and DIC groups. The truncated form of TFPI antigen levels in DIC patients were significantly increased compared with those in non-DIC and pre-DIC patients. The fact that the intact form of TFPI was decreased in pre-DIC patients compared with that in non-DIC patients, suggests that it is consumed in the pre-DIC state and that hypercoagulability occurs in pre-DIC patients. The increased level of the truncated form of TFPI in DIC patients may be attributed to proteolysis of the intact form of TFPI in these patients. The increased level of the truncated form of TFPI may be a useful index for the diagnosis of DIC.  [References: 27]

122.    Shigemori, M., & Tokutomi, T. (1999). Standards and guidelines for the management of severe head injury. Japanese Journal of Neurosurgery, 8(2), 84-91.
Abstract: To standardize the care and management of patients with severe head injury may reduce inappropriate care and improve patient outcomes. The optimum guidelines also may reduce the cost of medical care and enhance quality of the management. Recently 2 major sets of guidelines were presented using a different approach. One from the Brain Trauma Foundation of the United State in 1995 and the other from the European Brain Injury Consortium in 1997. The former was developed by evaluating the scientific evidence (evidence-based guideline) and the latter was based on the expert opinion and committee consensus (consensus-based guideline). The major topics of these guidelines are trauma care system, prehospital care and ICU managements, which are deemed to have an impact on outcomes of patients with Glasgow Coma Scale (GCS) score of 8 or less in adults. Despite the contrasting methods used to develop these guidelines, they are nearly the same in essence. In this article, each topics of both guidelines are generally reviewed. Our updating protocol for the management of severe head injury including hypothermia therapy and the preliminary result are described. In addition, controversies on management guidelines are also discussed.  [References: 14]

123.    Schmidt, C., Reibe, F., Guntert, B., Kuchler, T. h., & Henne-Bruns, D. (1999). Quality of life as an outcome parameter in medicine. GESUNDHOKON QUALMANAGE, 4(3), 85-91.
Abstract: Assessment of health outcome in today's Quality Management is not clone in terms of postoperative survival and complications only but also in terms of Quality of Life (QoL) after therapy. To measure QoL, suitable instruments are necessary. Especially in oncology, valid, internationally standardized and therefore comparable instruments were developed by the EORTC (European Organization for Research and Treatment of Cancer, Brussel). Official EORTC therapy and disease specific modules with international evaluation exist in addition to Ad-Hoc modules without the international testing. In the USA and Europe QoL Research has become an important issue. Decisions for or against a specific therapy and evaluation of new drugs are increasingly clone on basis of QoL. Furthermore, studies for Cost-Benefit-Analysis are clone by measuring QoL and Costs. QoL has developed to a cornerstone of Outcome Research, Quality Assurance and documentation of customer demands. To intensify research in Germany a Reference Center for Quality of Life was founded with financial support of the German Cancer Help in Kiel.  [References: 45]

124.    Schjetlein, R., Abdelnoor, M., Haugen, G., Husby, H., Sandset, P. M., & Wisloff, F. (1999). Hemostatic variables as independent predictors for fetal growth retardation in preeclampsia. Acta Obstetricia Et Gynecologica Scandinavica, 78(3), 191-197.
Abstract: Background. Preeclampsia is a major contributor to perinatal disease and fetal growth retardation (FGR). It has been suggested that increased intravascular coagulation, fibrin deposition in spiral arteries and hypoperfusion of the placenta are involved in these pregnancy complications. Methods. Multiple variables of the hemostatic system and lipid metabolism as well as clinical features, were entered into univariate and multivariate models in order to examine the association with preeclampsia and FGR. Results. Two hundred women with preeclampsia and 97 normotensive pregnant women were examined. Plasma levels of the thrombin-antithrombin complex (TAT), tissue factor pathway inhibitor free antigen (TFPI-Fag), protein S free antigen, plasminogen activator inhibitor type-1 (PAI-1) activity and serum levels of triglycerides were significantly increased, whereas plasma levels of antithrombin (AT), fibrinogen, C4b-binding protein (C4b-BP), PAI-2 antigen and serum HDL-cholesterol levels were decreased in the presence of preeclampsia. In the multivariate regression analysis, high TFPI-Fag plasma levels were associated with the presence of preeclampsia. The presence of FGR was in the univariate analysis associated with decreased PAI-1 activity and lower concentrations of fibrin, fibrinogen, factor VII antigen and PAI-2 antigen, as well as with evidence of macroscopic placental infarction. In a multivariate regression model, low maternal weight, placental infarction and low PAI-2 levels were predictors for low birth weight. In a logistic regression model, with the presence or absence of FGR as the dependent variable, male sex of the infant, placental infarction, low PAI-1 activity and factor VII antigen or PAI-2 antigen levels were independent predictors. Conclusions. Our results are consistent with activated coagulation in the placental vessels in preeclampsia. A low concentration of PAI-2 antigen in plasma emerged as the most consistent risk factor for preeclampsia and FGR.  [References: 23]

125.    Schatzberg, A. F., Nemeroff, Evans, Gorman, & Shelton. (1999). Antidepressant effectiveness in severe depression and melancholia. Journal of Clinical Psychiatry, 60(SUPPL. 4), 14-22.
Abstract: While outcome has improved in patients with depressive disorders since the introduction of the newer antidepressants, some physicians still treat severely depressed patients with the older tricyclic antidepressants because of conflicting reports about the efficacy of the newer agents, particularly the selective serotonin reuptake inhibitors, in severe depression. However, a standardized operational definition of severe depression is lacking, and treatment studies are difficult to evaluate due to variation in methodology. Remission rates are relatively low in many of the short-term clinical trials of the newer antidepressants in severe depression, but may improve if the research design were to include a longer trial and aggressive dosing. There is some evidence that venlafaxine, a serotonin-norepinephrine antidepressant, may offer some advantage for severely depressed patients.  [References: 35]

126.    Schaefer, F., Straube, E., Oh, J., Mehls, O., & Mayatepek, E. (1999). Dialysis in neonates with inborn errors of metabolism. Nephrology, Dialysis, Transplantation, 14(4), 910-918.
Abstract: Background. Certain inborn errors of metabolism become manifest during the neonatal period by acute accumulation of neurotoxic metabolites leading to coma and death or irreversible neurological damage. Outcome critically depends on the immediate elimination of the accumulated neurotoxins. Recent technological progress provides improved tools to optimize the efficacy of neonatal dialysis. Methods. We report our experience with continuous venovenous haemodialysis (CVVHD) in six neonates with hyperammonaemic coma due to urea-cycle disorders or propionic acidaemia and in one child with leucine accumulation due to maple-syrup urine disease (MSUD), in comparison with five patients managed by peritoneal dialysis (PD) (2 hyperammonaemia, 3 MSUD). Application of a new extracorporeal device specifically designed for use in small children permitted the establishment of stable blood circuits utilizing small-sized catheters, and the tight control of balanced dialysate flows over wide flow ranges. Results. Plasma ammonia or leucine levels were reduced by 50% within 7.1 +/- 4.1 h by CVVHD and within 17.9 +/- 12.4 h by PD (P < 0.05). Also, total dialysis time was shorter with CVVHD (25 +/- 21 h) than with PD (73 +/- 35 h, P < 0.02). A comparison of the CVVHD results with published literature confirmed superior metabolite removal compared to PD, and suggested comparable efficacy as achieved with continuous haemofiltration techniques. Apart from accidental pericardial tamponade during catheter insertion in one case, no major complications were noted with CVVHD. In three of the five PD patients, dialysis was compromised by mechanical complications. None of the MSUD patients but four children with urea-cycle disorders died, two during the acute period and two later during the first year of life, with signs of severe mental delay. Of the eight children presenting with hyperammonaemic coma, the four with the most rapid dialytic ammonia removal rate (50% reduction in < 7 h) survived with no or moderate mental retardation, whereas slower toxin removal was always associated with a lethal outcome. Simulation studies showed that the efficacy of neonatal CVVHD is limited mainly by blood-flow restrictions. Conclusions. While CVVHD is the potentially most efficacious dialytic technique for treating acute metabolic crises in neonates, utmost care must be taken to provide an adequately sized vascular access.  [References: 32]

127.    Rosomoff, H. L., & Rosomoff, R. S. (1999). Low back pain: Evaluation and management in the primary care setting. Medical Clinics of North America, 83(3), 643-662.
Abstract: The primary care physician plays a major role in the identification of low back pain and the entry of the patient into the health care system. Acute low back pain remits within a short period of time in most patients, and major diagnostic studies are not required. If the pain persists beyond the treatment parameters of the primary care physician, consultation is necessary. A basic component of the initial evaluation is the identification of myofascial syndromes that mimic so-called root syndromes. Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected. When the initial attempts at treatment fail, the patient should be referred to a multidisciplinary comprehensive pain center so as to avoid or limit chronicity, the earlier, the better. Practitioners should feel comfortable in asking the centers to which they make a referral for outcome data. If these are not available, the choice should be made elsewhere. Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value. The criteria for selection and referral of patients to multidisciplinary pain centers have been presented, including specific considerations for the geriatric age group. The overwhelming cost of low back pain to the economy can be decreased along with suffering and the adverse impact that pain has on all social strata.  [References: 24]

128.    Ramsey, S. D., Neil, N., Sullivan, S. D., & Perfetto, E. (1999). An economic evaluation of the JNC hypertension guidelines using data from a randomized controlled trial. Journal of the American Board of Family Practice, 12(2), 105-114.
Abstract: Background: We wanted to determine the clinical cost of managing hypertension when following the Joint National Committee on Hypertension (JNC) guidelines, including drug therapy, the cost of monitoring for and treating side effects, compliance, and the cost of switching after therapeutic failures. Methods: The base-case analysis considers antihypertensive agents from four therapeutic classes that were recently evaluated in large randomized trial: enalapril, amlodipine, acebutolol, and chlorthalidone. Clinical evaluation, therapy, and monitoring for hypertension are modeled with an incidence-based Markov model. Clinical inputs include agent efficacy, side effects, and compliance with dosing schedules. JNC- recommended clinical and laboratory monitoring schedules are followed for each agent. Switches between classes occur for therapeutic failures. Drug and medical care costs are valued in 1995 US dollars. Results: Although patients whose hypertension was initially treated with amlodipine achieved control more readily than patients who were given the other agents, the initial costs to achieve and maintain hypertension control were lowest for chlorthalidone ($641), followed by acebutolol ($920), amlodipine ($946), and enalapril ($948). Maintenance costs were lowest for chlorthalidone. For all agents except chlorthalidone, drug costs were the largest component of overall costs, followed by the costs of office visits, laboratory monitoring, and switching between classes for therapeutic failures. Conclusions: By following JNC guidelines, a slightly higher percentage of patients will achieve hypertension control with a newer class calcium channel blocker (amlodipine) but at a substantially higher cost than with a generic diuretic (chlorthalidone).  [References: 23]

129.    Plomp, J. J., Molenaar, P. C., O'Hanlon, G. M., Jacobs, B. C., Veitch, J., Daha, M. R., Van Doorn PA, Van der Meche, F. G. A., Vincent, A., Morgan, B. P., & Willison, H. J. (1999). Miller fisher anti-GQ1b antibodies: alpha-Latrotoxin - Like effects on motor end plates. Annals of Neurology, 45(2), 189-199.
Abstract: In the Miller Fisher syndrome (MFS) variant of the Guillain-Barre syndrome, weakness is restricted to extraocular muscles and occasionally other craniobulbar muscles. Most MFS patients have serum antibodies against ganglioside type GQ1b of which the pathophysiological relevance is unclear. We examined the in vitro effects of MFS sera, MFS IgG, and a human monoclonal anti-GQ1b IgM antibody on mouse neuromuscular junctions (NMJs). It was found that anti-GQ1b antibodies bind at NMJs where they induce massive quantal release of acetylcholine from nerve terminals and eventually block neuromuscular transmission. This effect closely resembled the effect of the paralytic neurotoxin alpha-latrotoxin at the mouse NMJs, implying possible involvement of alpha-latrotoxin receptors or associated downstream pathways. By using complement-deficient sera, the effect of anti-GQ1b antibodies on NMJs was shown to be entirely dependent on activation of complement components. However, neither classical pathway activation nor the formation of membrane attack complex was required, indicating the effects could be due to involvement of the alternative pathway and intermediate complement cascade products. Our findings strongly suggest that anti-GQ1b antibodies in conjunction with activated complement components are the principal pathophysiological mediators of motor symptoms in MFS and that the NMJ is an important site of their action.  [References: 46]

130.    Peters, J. A., Djurdjinovlc, L., & Baker, D. (1999). The genetic self: The human genome project, genetic counseling, and family therapy. FAM SYST HEALTH, 17(1), 5-25.
Abstract: In the ideal world, genetic counseling, family therapy, and primary healthcare should blend into a seamless network of psychosocial services for families with genetic conditions. The discussions presetered here was inspired by two interdisciplinary workshops titled 'The Genetic Self'. This paper introduces family therapists and primary care practitioners to the Human Genome Project and current applications in genetic counseling. The practical goal is to foster interdisciplinary teams and referral networks for management of families with or at risk for genetic disorders. Families with genetic conditions may need access to genetic diagnosis, possible genetic testing, tailored medical management, crisis interventions, follow-up at appropriate developmental stages, family therapy, individual psychotherapy, or pastoral counseling for dealing with spiritual issues elicited by genetic conditions. We also hope to stimulate collaborative research on the impact of genetic conditions in families, to form advocacy partnerships on behalf of these families, and ultimately, to influence public policy.  [References: 76]

131.    Opal, S. M., & Cross, A. S. (1999). Clinical trials for severe sepsis: Past failures, and future hopes. Infectious Disease Clinics of North America, 13(2), 285-297.
Abstract: Recent clinical trials with experimental immunotherapeutic agents fur severe sepsis and septic shock have been largely unsuccessful despite seemingly convincing preclinical evidence of significant benefit of these antisepsis therapies. This article reviews basic therapeutic rationale, preclinical evaluation, and clinical trial design of past clinical trials of innovative sepsis treatments. Lessons learned from past failures should provide insights into the design and implementation of successful clinical trials for new anti-sepsis agents in the future.  [References: 57]

132.    O'Rourke, R. A. (1999). Management of patients after cardiac surgery. Current Problems in Cardiology, 24(4), 167-228.
Abstract: The postoperative care of the patient during removal of CPB is the epitomy of modern clinical medicine. Successful postoperative care speaks to the best of modern medicine, namely, sophisticated technology, utilization of a team of concerned medical and nursing specialists, application of clinical pathways, and continued refinement in the patient care based on the principles of continual quality improvement. This article outlines the disruptions of the patient's physiologic systems by the inflammatory state initiated by CPB as a means of alerting the physician to the physical stresses imposed on their patients. Second, it describes the cardiac and noncardiac complications that might arise as a consequence of these disruptions to allow the physician to be proactive in the therapeutic approach. Finally, we propose treatment schemes based on an understanding of the pathophysiologic consequences of CPB and refined by their repeated application in the clinical arena. We acknowledge the input of Dr Jerrold Levy, Professor, Department Chair of Anesthesiology at Emory Healthcare Hospital, for his original creation of the algorithm for postoperative bleeding and coagulopathy after cardiac surgery (Fig 7).  [References: 131]

133.    Niaudet, P., Dudley, J., Soto, B., May, A., Levy, M., Gubler, M. C., & Weiss, L. (1999). Factor h deficiency and renal involvement. Annales De Pediatrie, 46(2), 99-103.
Abstract: Factor H is a regulatory protein of the alternate complement activation pathway. Factor H deficiency manifesting as permanent alternate pathway activation has been reported in patients with hemolytic uremic syndrome (HUS), collagen III glomerulopathy, IgA nephropathy, systemic lupus erythematosus with C2 deficiency, and membranoproliferative glomerulonephritis. Six pediatric cases of factor H deficiency are reviewed. Three (cases 1-3), all boys, presented with atypical HUS characterized by hemolytic anemia, severe hypertension, and progression to end-stage renal failure. Recurrent infections occurred in cases 1 and 2, both of whom had repeatedly low factor H levels with low C3 levels. Case 3 had C3 levels in the low-to-normal range and normal factor H levels with reduced factor H activity. Cases 4 and 5 were brothers born to consanguineous parents and presented with recurrent macroscopic hematuria in the absence of significant proteinuria or renal function impairment. Renal biopsy demonstrated mesangial proliferation with dense C3 deposits in both cases. Case 6 was a 12-month- old girl presenting with macroscopic hematuria, nephrotic syndrome, anemia, and glomerular filtration rate (GFR) reduction. Renal biopsy demonstrated proliferative crescentic glomerulonephritis with C3 deposits. Following a course of steroid therapy, proteinuria decreased and both GFR and factor H returned to normal. These six cases illustrate the diversity of clinical and histological manifestations seen in factor H-deficient patients. The exact pathogenic role of factor H deficiency remains to be determined.  [References: 16]

134.    Moore, C. E., Ross, D. A., & Marentette, L. J. (1999). Critical pathways in anterior cranial base surgery. Otolaryngology & Head & Neck Surgery, 121(1), 113-118.
Abstract: New advances in anterior cranial base surgery have dictated the need for a comprehensive, multidisciplinary approach in the treatment of lesions of this area, necessitating multiple modes of diagnostic and surgical techniques. Traditional consideration of the complex problems presented by neoplastic involvement of the anterior cranial base predicated on isolated syndrome analysis is no longer sufficient to adequately assess tumor pathology. To address these complex problems, we discuss a method of localization of pathology based on anatomic structure and function as well as the corresponding surgical approach to the anterior cranial base.  [References: 9]

135.    Merritt, T. A., Gold, M., & Holland, J. (1999). A critical evaluation of clinical practice guidelines in neonatal medicine: Does their use improve quality and lower costs? Journal of Evaluation in Clinical Practice, 5(2), 169-177.
Abstract: Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.  [References: 42]

136.    Mehdirad, A. A., Fatkin, D., DiMarco, J. P., MacRae, C. A., Wase, A., Seidman, J. G., Seidman, C. E., & Benson, D. W. (1999). Electrophysiologic characteristics of accessory atrioventricular connections in an inherited form of Wolff-Parkinson-White syndrome. Journal of Cardiovascular Electrophysiology, 10(5), 629-635.
Abstract: Introduction: A familial form of Wolff-Parkinson-White syndrome (WPW) occurs in association with hypertrophic cardiomyopathy and intraventricular conduction abnormalities. This syndrome, demonstrating autosomal dominant inheritance and segregating with a high degree of penetrance but variable expressivity, has been genetically linked to chromosome 7q3. The purpose of this study is to detail the electrophysiologic characteristics of accessory atrioventricular connections (AC) in four members of a kindred with this syndrome. Methods and Results: We clinically evaluated 32 members of a single kindred and identified 20 individuals with ventricular preexcitation, abnormal intraventricular conduction including complete AV block and/or ventricular hypertrophy. Genetic linkage analysis mapped the disease gene in this kindred to the chromosome 7q3 locus (maximum logarithm of the odds score = 6.88, theta = 0); recombination events in affected individuals reduced the genetic interval from 7 centimorgans (cM) to 5 cM. Electrophysiologic study of four individuals with preexcitation, identified seven AC (1 right sided, 3 septal, and 3 left sided). All four individuals had inducible orthodromic tachycardia; while three had multiple AC. Bidirectional conduction was demonstrated in 6 of 7 AC. Successful ablation was accomplished in 5 of 7 AC. Conclusion: The electrophysiologic characteristics and location of AC in family members having this complex cardiac phenotype are similar to those seen in individuals with isolated WPW. Identification of WPW in more than one family member should prompt clinical evaluation of relatives for additional findings of ventricular hypertrophy or conduction abnormalities.  [References: 23]

137.    McCullough, P. A., & O'Neill, W. W. (1999). Early use of coronary angiography and intervention. Cardiology Clinics, 17(2), 373-386.
Abstract: In this article we have outlined the current rationale and role of invasive management in ACS. For the majority of patients with ACS, who are either at high risk or unstable, invasive management is a critical element in breaking the sequence of recurrent ischemia leading to early cardiac events (Fig. 11). Secular trends in the care of cardiovascular patients predict even more sophisticated, invasive methods of treating coronary occlusion in the future. A futurist's view on this subject may envision the following type of scenario. A patient with prior CAD experiences persistent chest pain and notifies the emergency medical system. The paramedics arrive, and perform a rapid fingerstick cardiac biomarker panel and ECG. The results are interpreted by an emergency physician via a telecommunication system, and the patient is determined to be at high risk. He or she is triaged to a center capable of angioplasty and bypass surgery. On the way to the hospital, the patient is treated with aspirin, IV heparin, and an IV glycoprotein IIb/IIIa inhibitor. The patient undergoes triage angiography within 1 hour of hospital arrival, culprit lesion(s) are identified, and a revascularization plan is made - setting a critical pathway that is definitive. This vision is not far off on the horizon. We anticipate additional clinical trial results will help form the decision points in this optimal treatment scenario, which for a large proportion of patients will involve invasive management.  [References: 72]

138.    Matz, P. G., Cobbs, C., & Berger, M. S. (1999). Intraoperative cortical mapping as a guide to the surgical resection of gliomas. Journal of Neuro-Oncology, 42(3), 233-245.

139.    Mattson, J. (1999). Case management: A historical and future perspective of its influence on outcome for persons who have sustained spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 4(4), 30-37.
Abstract: With the development of model systems in the 1970s, dedicated teams of rehabilitation professionals initiated the concept of case management. This occurred at about the same time that casualty insurers began using independent case managers. Since then, it is believed that persons with spinal cord injury (SCI) who have had the benefit of a case manager achieve and maintain better outcomes regarding health status, return to work, and modification and removal of architectural barriers. In general, these individuals have reported less depression and a more fulfilling lifestyle. The growth of managed care, with resultant abbreviated length of stay and diminished hands-on case management, may have a noticeably negative impact on adherence to clinical pathways and consequent successful outcomes. It is hypothesized that, despite technological advances, without comprehensive case management during all phases of SCI care, many individuals will not reach or maintain community reintegration and autonomy.  [References: 12]

140.    Lowson, S. M., & Sawh, S. (1999). Adjuncts to analgesia: Sedation and neuromuscular blockade. Critical Care Clinics, 15(1), 119-141.
Abstract: This article provides an overview of some of the current issues involved in sedation and anxiolysis in the intensive care unit. The problems involved in trying to monitor sedation levels are discussed, as are some of the newer options available for physiologic monitoring of the central nervous system. The problem of abnormal mental states in the intensive care unit and the range of antidepressant therapy now available are also covered. The importance of sleep deprivation and the properties of the neuromuscular blockers are also discussed.  [References: 132]

141.    Lock, J. (1999). How clinical pathways can be useful: An example of a clinical pathway for the treatment of anorexia nervosa in adolescents. CLIN CHILD PSYCHOL PSYCHIATRY, 4(3), 331-340.
Abstract: This article reports on the development of a clinical pathway for the treatment of acutely ill adolescents with anorexia nervosa in a hospital setting. The role of clinical pathways in standardizing health care and in controlling costs is reviewed. The evolution of the clinical pathway for treating adolescents with anorexia nervosa is described. The pathway's utility in describing changes in clinical practice is also reported.  [References: 27]

142.    Leibel, S. A. (1999). ACR appropriateness criteria. International Journal of Radiation Oncology, Biology, Physics, 43(1), 125-168.

143.    Lee, K. L., Chun, H. M., Liem, L. B., & Sung, R. J. (1999). Effect of adenosine and verapamil in catecholamine-induced accelerated atrioventricular junctional rhythm: Insights into the underlying mechanism. Pacing & Clinical Electrophysiology, 22(6 I), 866-870.
Abstract: Accelerated AV junctional rhythm is postulated to be due to enhanced automaticity of a high AV junctional focus. The adenosine response of this rhythm was tested in 17 patients (7 males, 12-83 years). The indications of electrophysiology study were nonspecific palpitation (n = 5), unexplained syncope (n = 6), postablation of accessory pathways (n = 4), and postmodification of AV nodal reentry tachycardia (n = 2). The sinus node and AV nodal functions were normal. Pacing and programmed electrical stimulation failed to induce any arrhythmia at baseline. The accelerated junctional rhythm (cycle length = 553 +/- 134 ms) was initiated spontaneously in all patients after isoproterenol infusion (1-2 mug/min). It was not suppressible by overdrive pacing. Cessation of isoproterenol infusion terminated the rhythm in all patients. Adenosine (6 mg) reproducibly terminated the accelerated junctional rhythm in all patients. In six patients, adenosine suppressed the junctional rhythm without producing AV nodal block. In the other 11 patients, the junctional rhythm was terminated prior to the occurrence of AV nodal block. Verapamil was tested in ten patients and 5 mg of intravenous verapamil terminated the junctional rhythm in all patients. In conclusion, the mechanism of catecholamine-induced accelerated AV junctional rhythm is most likely enhanced automaticity, and catecholamine-induced accelerated AV junctional automaticity is sensitive to adenosine and verapamil. Adenosine appears to have differential effects on catecholamine- enhanced AV junctional automaticity and AV nodal conduction. This suggests that, under catecholamine stimulation, adenosine may have different mechanisms of action on A V nodal conduction and automaticity.  [References: 8]

144.    Lawrence, D. (1999). Delivery of quality patient care through clinical pathways. CLIN MANAGE, 8(2), 76-80.
Abstract: The white paper, The New NHS: Modern and Dependable, sets out to establish standards for healthcare provision combined with a firm commitment to quality improvement. How the management tools of critical pathway analysis, total quality management, and control of variance can be applied to existing best clinical practice is described. The management of diabetes in general practice is used as an example of this principle to define standards and quality issues through a collaborative teamworking approach that encompasses the primary healthcare team as well as the patients and their carers. This embodies the definition of clinical governance which is a mechanism to promulgate and guarantee best clinical practice for the benefit of healthcare professionals and the public.  [References: 9]

145.    Kobayashi, Y., Hayashi, M., Miyauchi, Y., Kawaguchi, N., Ogura, H., Saitoh, H., Ino, T., Atarashi, H., Kishida, H., & Hayakawa, H. (1999). Uncommon atrial flutter originating in the left atrioventricular groove: Emergence after successful catheter ablation for a left concealed accessory pathway. Japanese Circulation Journal, 63(5), 416-420.
Abstract: This report describes a 49-year-old male with concealed Wolff- Parkinson-White syndrome in whom a true uncommon atrial flutter suddenly emerged 2 weeks after successful catheter ablation of a left-sided accessory pathway. The earliest atrial activation during the atrial flutter was recorded at the posterolateral mitral annulus 2 cm proximal to the previous successful ablation site for the accessory pathway. Two applications of radiofrequency (RF) current directed at the supravalvular mitral annulus could not terminate the atrial flutter. A subsequent delivery of RF current directed at the subvalvular annulus, where a local fragmented potential preceded the earliest atrial activation, eliminated the atrial flutter.  [References: 9]

146.    Khanal, S., Ribeiro, P. A., Platt, M., & Kuhn, M. A. (1999). Right coronary artery occlusion as a complication of accessory pathway ablation in a 12-year-old treated with stenting. Catheterization & Cardiovascular Diagnosis, 46(1), 59-61.
Abstract: We describe a complication of radiofrequency ablation of a posteroseptal pathway that resulted in acute occlusion of a distal right coronary artery in a pediatric patient. The complication was treated with coronary stenting after unsuccessful angloplasty.  [References: 14]

147.    Kawabata, M., Hirao, K., Toshida, N., Suzuki, F., & Hiejima, K. (1999). The response of the slow atrioventricular nodal pathway to temperature. Japanese Circulation Journal, 63(6), 427-432.
Abstract: The present study attempted to determine the lowest temperature at which the slow atrioventricular nodal pathway responds to heating and the temperature necessary for successful ablation of the slow pathway in patients with atrioventricular nodal reentrant tachycardia (AVNRT). The study group comprised 23 consecutive patients (14 women, 9 men) with symptomatic AVNRT. Radiofrequency current was delivered at the slow pathway potential recording site using a HAT 200S catheter ablation system. Successful radiofrequency ablation of the slow pathway was achieved in all 23 patients. Junctional beats, suggesting the response of the slow pathway to temperature, were detected in 62 of the total 136 applications. The temperature measured at the first junctional beat was 45.4+/-4.2 [degree] C. The maximum temperature required for the successful ablation of AVNRT ranged from 45 to 88 [degree] C. There were no complications except for 1 patient with transient atrioventricular (AV) block. There were no recurrences of AVNRT during follow-up. The lowest temperature at which the slow pathway was responsive to heat was quite similar to that for accessory pathways or the AV junction. However, the temperature required for the successful ablation of AVNRT differed markedly among the patients.  [References: 30]

148.    Kaiser, H. J. (1999). Diplopia, from the symptom to the diagnosis. Klinische Monatsblatter Fur Augenheilkunde, 214(5), 346-350.
Abstract: Background This overview gives a rough frame how to proceede to a quick diagnosis and possible differential diagnosis in patients with diplopia. Method: A thourough interview concerning the onset of symptoms, invariability, and subjective perception is mandatory. The first step before examining ocular motility is to verify monocular or binocular double vision. When the reported diplopia is binocular, the examiner can carry out the red- glas test to determine the site of the double image. In a next step monocular range of movement in the 9 directions of gaze is evaluated to search for incomitance. Results: The main causes of diplopia are palsies of the oculomotor nerves, mechanical restriction-posttraumatic or inflammatory -, supranuclear lesions and disturbed neuromuscular junction. Conclusion: With a simple and clear diagnostic diagram ist is easy to work out the underlying cause of diplopia.  [References: 8]

149.    Jones, A., Hawkins, J. A., McGough, E. C., Lambert, L., & Dean, J. M. (1999). Erratum: Critical pathways for postoperative care after simple congenital heart surgery (American Journal of Managed Care (1999) 5 (185- 192)). American Journal of Managed Care, 5(4), 538.

150.    Jacobsen, E. M., Sandset, P. M., & Wisloff, F. (1999). Do antiphospholipid antibodies interfere with tissue factor pathway inhibitor. Thrombosis Research, 94(4), 213-220.
Abstract: This study was conducted to investigate whether antiphospholipid antibodies (APA) can interfere with the phospholipid-dependent inhibition of coagulation exerted by tissue factor pathway inhibitor (TFPI). Eleven patients with APA and eleven healthy controls matched for age and gender were enrolled. Blood samples were drawn before and 5 minutes after an intravenous injection of unfractionated heparin 5000 IE, which is known to cause TFPI release in healthy individuals. The preheparin samples showed significantly higher TFPI free antigen levels in the APA positive patients than in the controls (21.7 vs. 14.2 ng/ml, p=0.03). TFPI activity as measured in a chromogenic substrate assay also was higher in patients, but this difference was not statistically significant (1.13 vs. 1.01 U/ml, p=0.2). The TFPI levels showed a considerable rise in both patients and controls after heparin injection. In both assays, the postheparin levels were significantly higher in patients than in controls (TFPI antigen: 179 vs. 153 ng/ml, p=0.05; TFPI activity: 3.26 vs. 2.51 U/ml, p=0.03). A modified diluted prothrombin time assay (dPT) was used to measure TFPI anticoagulant activity. In this assay, samples from the patients with the strongest effect of lupus anticoagulants (LAs) on preheparin coagulation times showed little or no increase after heparin injection. This result may reflect an inhibition of TFPI anticoagulant activity by strong LAs. In conclusion, we have found that patients with APA have higher TFPI amidolytic activity/antigen level both before and after heparin stimulation of TFPI release. These observations do not explain the higher thrombotic risk in these patients but may reflect an upregulated tissue factor activity, which has been demonstrated in these patients. TFPI anticoagulant activity, however, as measured in a dPT assay, may be inhibited by strong LAs.  [References: 31]

151.    Irizarry, J. M., Graham, M. H., & Cordts, P. R. (1999). Use of a critical pathway to move laparoscopic cholecystectomy to the ambulatory surgery arena. Military Medicine, 164(7), 531-534.
Abstract: Critical pathways are being implemented in health care facilities across the nation as a cost-containment tool. When developed using best practice based on a literature review and the collaboration of a multidisciplinary team, critical pathways can be very successful in maintaining or increasing the quality of care while controlling the cost of the care provided. The Department of Defense Utilization Management Plan strongly encourages the use of pathways. Here we discuss the development and implementation of a critical pathway for laparoscopic cholecystectomy patients, with the goal being to transfer the medical care from the inpatient setting to the ambulatory surgery arena. The use of this pathway resulted in almost a 50% increase in patients treated in the ambulatory surgery arena.  [References: 4]

152.    Hwang, C., Karagueuzian, H. S., & Chen, P. S. (1999). Idiopathic paroxysmal atrial fibrillation induced by a focal discharge mechanism in the left superior pulmonary vein: Possible roles of the ligament of marshall. Journal of Cardiovascular Electrophysiology, 10(5), 636-648.
Abstract: Introduction: The origin of double potentials inside the left superior pulmonary vein and their relation to the mechanisms of idiopathic paroxysmal focal atrial fibrillation (AF) are unclear. Methods and Results: A total of 40 patients were studied. Group I included 15 patients who underwent radiofrequency catheter ablation of accessory pathway. Double potentials were found inside the left superior pulmonary vein during sinus rhythm in 10 patients and during premature atrial contractions in the remaining five patients. Group II included 25 patients with idiopathic paroxysmal AF. Double potentials were also identified in the left superior pulmonary vein. In 15 patients (Group IIA), the earliest automatic discharge during premature atrial contractions and at the onset of AF was within the left superior pulmonary vein. AF was ablated by radiofrequency energy application at the site registering double potentials. Radiofrequency ablation in the remaining 10 patients failed to terminate AF (Group IIB). The patients in Group IIA had significantly more male patients and more frequent premature atrial contractions and atrial tachycardia on 24-hour Holter recordings prior to the procedure than patients in Group IIB. Conclusions: Double potentials are present at the left superior pulmonary veins in patients with and without a history of AF. The first potential is due to the activation of atrial myocardium and the second is due to the activation of a different muscular structure. Rapid discharge of this structure triggers episodes of paroxysmal AF. Patients with focal AF originating from the left superior pulmonary vein can be identified by Holter recordings.  [References: 15]

153.    Huvers, F. C., De Leeuw, P. W., Houben AJHM, De Haan, C. H. A., Hamulyak, K., Schouten, H., Wolffenbuttel, B. H. R., & Schaper, N. C. (1999). Endothelium-dependent vasodilatation, plasma markers of endothelial function, and adrenergic vasoconstrictor responses in type 1 diabetes under near-normoglycemic conditions. Diabetes, 48(6), 1300-1307.
Abstract: It is unknown whether and to what extent changes in various endothelial functions and adrenergic responsiveness are related to the development of microvascular complications in type 1 diabetes. Therefore, endothelium- dependent and endothelium-independent vasodilatation, endothelium-dependent hemostatic factors, and one and two adrenergic vasoconstrictor responses were determined in type 1 patients with and without microvascular complications. A total of 34 patients with type 1 diabetes were studied under euglycemic conditions on two occasions (11 without microangiopathy, 10 with proliferative and preproliferative retinopathy previously treated by laser coagulation, 13 with microalbuminuria, and 12 healthy volunteers also were studied). Forearm vascular responses to brachial artery infusions of N(G)- monomethyl-L-arginine (L-NMMA), sodium nitroprusside, acetylcholine (ACh), clonidine, and phenylephrine were determined. The ACh infusions were repeated during coinfusion of L-arginine. Furthermore, plasminogen activator inhibitor type 1 (PAI-1) activity, tissue plasminogen activator antigen levels, von Wille-brand factor antigen levels, tissue factor pathway inhibitor (TFPI) activity, and endothelin-1 levels were measured. No differences in endothelium-dependent or endothelium-independent vasodilatation or adrenergic constriction were observed between the diabetic patients and the healthy volunteers. In comparison to the first ACh infusion, the maximal response to repeated ACh during L-arginine administration was reduced in the diabetic patients, except in the patients with proliferative and preproliferative retinopathy previously treated by laser coagulation. In these patients, the combined infusion of L-arginine and ACh resulted in an enhanced response. TFPI activity was elevated, and PAI-1 activity was reduced in the type 1 diabetic patients. Furthermore, PAI-1 activity was positively correlated with urinary albumin excretion (r = 0.48, P < 0.01) and inversely correlated with the vasodilatory response to the highest ACh dose (r = -0.37, P < 0.05). The response to the highest ACh and L-NMMA dose were positively correlated with mean arterial blood pressure (r = 0.32, P < 0.01; r = 0.41, P < 0.01, respectively). Forearm endothelium-dependent and endothelium-independent vasodilatation and adrenergic responsiveness were unaltered in type 1 diabetic patients with and without microvascular complications. Relative to healthy control subjects, endothelium-dependent vasodilatation was depressed during a repeated ACh challenge (with L-arginine coinfusion) in the diabetic patients without complications or with microalbuminuria. In contrast, this vasodilatation was enhanced in the patients with retinopathy. Elevation of TFPI was the most consistent marker of endothelial damage of all the endothelial markers measured.  [References: 43]

154.    Hluchy, J., Schlegelmilch, P., Schickel, S., Jorger, U., Jurkovicova, O., & Sabin, G. V. (1999). Radiofrequency ablation of a concealed nodoventricular Mahaim fiber guided by a discrete potential. Journal of Cardiovascular Electrophysiology, 10(4), 603-610.
Abstract: Introduction: We present the case of a 17-year-old woman who underwent an electrophysiological study and radiofrequency (RF) ablation of supraventricular tachycardia refractory to medical treatment. Two right- sided, concealed, nondecremental atrioventricular accessory pathways (AV- APs) involved in orthodromic circus movement tachycardias were identified. After RF ablation of both AV-APs, evidence of bidirectional dual AV nodal conduction was demonstrated and regular narrow complex tachycardia was induced. Methods and Results: During the tachycardia, retrograde slow and fast AV nodal pathway conduction with second-degree ventriculoatrial (VA) block and VA dissociation were observed. During the tachycardia with second- degree VA block, ventricular extrastimuli elicited during His-bundle refractoriness advanced the next His potential or terminated the tachycardia. Mapping the right atrial mid-septal region, a distinct high-frequency activation P potential was recorded in a discrete area, two thirds of the way from the His bundle toward the os of the coronary sinus. Detailed electrophysiologic testing with the recordable P potential demonstrated that the tachycardia utilized a concealed nodoventricular AP arising from the proximal slow AV nodal pathway. Conclusion: The tachycardia with slow 1:1 VA conduction could be reset by ventricular extrastimuli elicited during His- bundle refractoriness advancing the subsequent activation P potential and atrial activation. RF ablation guided by recording of the activation P potential resulted in elimination of both the slow AV nodal pathway and the nodoventricular connection with preservation of the normal AV conduction system.  [References: 24]

155.    Hiltke, T. J., Bauer, M. E., Klesney-Tait, J., Hansen, E. J., Munson, R. S. Jr, & Spinola, S. M. (1999). Effect of normal and immune sera on Haemophilus ducreyi 35000HP and its isogenic MOMP and LOS mutants. Microbial Pathogenesis, 26(2), 93-102.
Abstract: A bactericidal assay was developed in order to test the effect of hyperimmune rabbit sera on the viability of serum-resistant Haemophilus ducreyi 35000HP. Testing of several lots of rabbit complement and time course experiments showed that the serum-sensitive H. ducreyi CIPA77 was killed efficiently by 25% complement at 35 [degree] C in 3 h. We hypothesized that incubation of 35000HP under these conditions with the appropriate bactericidal antibody would kill this strain. A panel of high titre rabbit antisera was developed and tested against 35000HP. The panel included antisera raised to whole cells, total membranes, Sarkosyl-insoluble outer membrane proteins, the H. ducreyi lipoprotein, and the peptidoglycan-associated lipoprotein. None of the antisera convincingly showed bactericidal activity. The bactericidal assay was also used to determine the effect of normal human serum (NHS) on isogenic mutants of 35000HP. 35000HP-RSM2, an Omegakan insertion mutant that expresses a truncated lipooligosaccharide, was as resistant to NHS as its parent. A mutant deficient in expression of the major outer membrane protein (35000.60) was sensitive to NHS. We conclude that 35000HP is relatively resistant to normal and hyperimmune sera, and that the major outer membrane protein contributes to this resistance.  [References: 43]

156.    Higenbottam, T., Stenmark, K., & Simonneau, G. (1999). Treatments for severe pulmonary hypertension. Lancet, 353(9150), 338-340.

157.    Heila, H., Isometsa, E. T., Henriksson, M. M., Heikkinen, M. E., Marttunen, M. J., & Lonnqvist, J. K. (1999). Suicide victims with schizophrenia in different treatment phases and adequacy of antipsychotic medication. Journal of Clinical Psychiatry, 60(3), 200-208.
Abstract: Background: To investigate clinical characteristics and adequacy of antipsychotic treatment in different phases of illness and treatment among suicide victims with schizophrenia. Method: As part of the National Suicide Prevention Project, a nationwide psychological autopsy study in Finland, all DSM-III-R schizophrenic suicide victims with a known treatment contact (N = 88) were classified according to the phase of illness (active/residual) and treatment (inpatient/recent discharge/other). Characteristics of victims in terms of known risk factors for suicide in schizophrenia, as well as adequacy of the neuroleptic treatment, were examined. Results: Fifty-seven percent of suicide victims with active phase schizophrenia were prescribed inadequate neuroleptic treatment or were noncompliant, and 23% were estimated to be compliant nonresponders. Inpatient suicide victims had the highest proportion of negative or indifferent treatment attitudes (81%), whereas recently discharged suicide victims had the highest prevalence of comorbid alcoholism (36%), paranoid subtype (57%), and recent suicidal behavior or communication (74%), as well as the highest number of hospitalizations during their illness course and shortest last hospitalization. Conclusion: Suicide risk factors in different treatment phases of schizophrenia may differ. Substantial numbers of suicide victims with schizophrenia are receiving inadequate neuroleptic medication, are noncompliant, or do not respond to adequate typical antipsychotic medication. Adequacy of psychopharmacologic treatment, particularly in the active illness phase, may be an important factor in suicide prevention among patients with schizophrenia.  [References: 68]

158.    Hautzinger, M. (1999). Mindless confrontation. Psychotherapeut, 44(2), 122-123.

159.    Hauser, H., Bohndorf, K., Mirvis, S., Shanmuganathan, K., Pinto, F., Bode, P. J., Linsenmaier, U., & Pfeifer, K. J. (1999). Radiological emergency management of multiple trauma patients. Emergency Radiology, 6(2), 61-76.
Abstract: In recent years there has been major improvement in the management of patients with serious injuries. The initial imaging technique for multiple trauma patients is also undergoing change. In addition, other innovations including specialisation in training (casualty surgery), preclinical services (emergency medical care/ambulance system), optimisation of early clinical procedures (guidelines for action) and modification of clinical treatment strategies (conservative/operative/interventional) have altered the management of these patients. Conventional X-ray diagnosis, which has played a major role to date, is now increasingly giving way to modern cross- sectional imaging, in particular CT. This tendency has been seen in Germany particularly since the introduction of spiral CT. However, to minimise any risk to critically injured patients, standards must be defined with regard to physical structure, emergency room equipment and quality. The basic principles, the current situation and suggestions for improvement with regard to the emergency management of multiple trauma patients are put forward and discussed from the radiologic point of view.

160.    Harris, G. M., Stendt, C. L., Vollenhoven, B. J., Gan, T. E., & Tipping, P. G. (1999). Decreased plasma tissue factor pathway inhibitor in women taking combined oral contraceptives. American Journal of Hematology, 60(3), 175-180.
Abstract: Use of combined oral contraceptives (OC) is associated with a significant risk of thrombosis. The mechanisms of this effect are not clearly defined. Tissue factor pathway inhibitor (TFPI) is a circulating anti- coagulant that inhibits the earliest steps in activation of the extrinsic coagulation pathway. It plays a central role in control of coagulation but its contribution to the thrombotic risk associated with OC has not been assessed. Plasma TFPI antigen and activity, factor VIIa, prothrombin fragments 1 and 2, von Willebrand antigen, fibrinogen, and low density lipoprotein cholesterol were measured by standard assays in women taking OC (aged 16 to 45 years, n = 40) and age-matched women not taking OC (controls, n = 40). Plasma TFPI antigen did not vary significantly across the menstrual cycle in controls. Women on OC had a 25% reduction in plasma TFPI antigen (median 51.0 ng/ml; 95% confidence intervals [CI] 37.5 to 85.5; control 68.0 ng/ml, CI 61.0 to 95.0; P< 0.001) and a 29% reduction in TFPI activity (78.5 U/ml, CI 57.5 to 107.5; control 111.0 U/ml, CI 79.5 to 171.0; P < 0.001) compared to controls. Plasma factor VIIa activity and prothrombin fragments 1 and 2 were also significantly increased in women using OC (both P < 0.001), indicating activation of the extrinsic coagulation pathway. These results demonstrate that normal cyclic variations in estrogen and/or progesterone do not significantly alter plasma TFPI levels. However, estrogens and/or progestogens in OC result in activation of the extrinsic coagulation pathway and significantly reduce plasma TFPI, its major circulating inhibitor. Reduced plasma TFPI levels may underlie the thrombotic effects of OC.  [References: 29]

161.    Hanly, C. (1999). On subjectivity and objectivity in psychoanalysis [In Process Citation]. J Am Psychoanal Assoc, 47(2), 427-44.
Abstract: Epistemological subjectivism has found its way into psychoanalysis along several theoretical and clinical paths. It has developed out of the clinical interest in transference and countertransference and, in particular, from the broadly generalized definition of countertransference now popular. The clinically necessary attention to analyst-analysand interaction has been turned into interactionism or intersubjectivism and a denial of epistemological subject-object differentiation. These perspectives transform a clinical focus on the here and now of the analytic relation into the determination of the past by the present and a teleological reversal of causality. Once this reversal is made, narrative in the analytic situation becomes the co-creation of the analysand's past by the present analyst-analysand relation. Psychoanalysis, on this view, can at best substitute a coherent, novelistic account for the life history of a person. Some of the problems of subjectivism are examined here with a view to restoring to psychoanalysis the epistemology of science and common sense.

162.    Gori, A. M., Pepe, G., Attanasio, M., Falciani, M., Abbate, R., Prisco, D., Fedi, S., Giusti, B., Brunelli, T., Comeglio, P., Gensini, G. F., & Neri Serneri, G. G. (1999). Tissue factor reduction and tissue factor pathway inhibitor release after heparin administration. Thrombosis & Haemostasis, 81(4), 589-593.
Abstract: Elevated plasma levels of tissue factor (TF) and tissue factor pathway inhibitor (TFPI) and large amounts of monocyte procoagulant activity (PCA) have been documented in unstable angina (UA) patients. In in vitro experiments heparin is able to blunt monocyte TF production by inhibiting TF and cytokine gene expression by stimulated cells and after in vivo administration it reduces adverse ischemic outcomes in UA patients. TF and TFPI plasma levels and monocyte PCA have been investigated in 28 refractory UA patients before and during anticoagulant subcutaneous heparin administration (thrice daily weight- and PTT-adjusted for 3 days) followed by 5000 IU x 3 for 5 days. After 2-day treatment, immediately prior to the heparin injection, TF and TFPI plasma levels [(median and range): 239 pg/ml, 130-385 pg/ml and 120 ng/ml, 80-287 ng/ml] were lower in comparison to baseline samples (254.5 pg/ml, 134.6-380 pg/ml and 135.5 ng/ml, 74-306 ng/ml). Four h after the heparin injection TF furtherly decreased (176.5 pg/ml, 87.5-321 pg/ml; -32.5%, p < 0.001) and TFPI increased (240.5 ng/ml, 140-450 ng/ml; +67%, p < 0.0001). After 7-day treatment, before the injection of heparin, TF and TFPI plasma levels (200 pg/ml, 128-325 pg/ml and 115 ng/ml, 70-252 ng/ml) significantly decreased (p < 0.05) in comparison to the pre-treatment values. On the morning of the 8th day, 4 h after the injection of heparin TF plasma levels and monocytes PCA significantly decreased (156.5 pg/ml, 74-259 pg/ml and from 180 U/105 monocytes, 109-582 U/105 monocytes to 86.1 U/105 monocytes, 28-320 U/105 monocytes; -38% and -55% respectively) and TFPI increased (235.6 ng/ml, 152-423 ng/ml; +70%, p < 0.001). In conclusion, heparin treatment is associated with a decrease of high TF plasma levels and monocyte procoagulant activity in UA patients. These actions of heparin may play a role in determining the antithrombotic and antiinflammatory properties of this drug.  [References: 39]

163.    Gordon, T. A., Bowman, H. M., Bass, E. B., Lillemoe, K. D., Yeo, C. J., Heitmiller, R. F., Choti, M. A., Burleyson, G. P., Hsieh, G., & Cameron, J. L. (1999). Complex gastrointestinal surgery: Impact of provider experience on clinical and economic outcomes. Journal of the American College of Surgeons, 189(1), 46-56.
Abstract: Background: Commonly performed elective gastrointestinal surgical procedures are carried out with low morbidity and mortality in hospitals throughout the United States. Complex operative procedures on the alimentary tract are performed with a relatively low frequency and are associated with higher mortality. Volume and experience of the surgical provider team have been correlated with better clinical and economic outcomes for one complex gastrointestinal surgical procedure, pancreaticoduodenectomy. This study evaluated whether provider volume and experience were important factors influencing clinical and economic outcomes for a variety of complex gastrointestinal surgical procedures in one state. Study Design: Complex high-risk gastrointestinal surgical procedures were defined as those with statewide in-hospital mortality of >= 5%, frequency of greater than 200 per year in the state, and requiring special surgical skill and expertise. Six procedures met these criteria. Using publicly available discharge data, all patients discharged from Maryland hospitals from July 1989 to June 1997 with a primary procedure code for one of the six study procedures were selected. Hospitals were classified into one of six groups based on the average number of study procedures per year: 10 or less; 11 to 20; 21 to 50; 51 to 100; 101 to 200; and 201 or more procedures per year. A hospital was included if at least one procedure was performed there during the study period. No providers fell within the 51 to 100, and 101 to 200 groups, so all analyses were performed for the remaining four volume groups that were classified, respectively, as minimal (10 or fewer procedures), low (11 to 20 procedures), medium (21 to 50 procedures), and high-volume groups (201 or more procedures). Poisson regression was used to assess the relationship between in-hospital mortality and hospital volume after casemix adjustment. Multiple linear regression models were used to assess differences in average length- of-stay and average total hospital charges among hospital volume groups. We further analyzed mortality, length-of-stay, and charges at the procedural level to understand these subgroups of complex gastrointestinal patients. We also examined the relationship between provider volume and outcomes for malignant versus benign diagnosis groups. Results: Complex gastrointestinal surgical procedures were performed on 4,561 patients in Maryland from July 1989 through June 1997. The study population averaged 61.6 years of age, was 55% male, 71% Caucasian, and had predominantly Medicare as a payment source. After casemix adjustment, patients who underwent complex gastrointestinal surgical procedures at the medium-, low-, and minimal-volume provider groups had a 2.1, 3.3, and 3.2 times greater risk of in-hospital death, respectively, than patients at the high-volume provider (p < 0.001 for all comparisons); longer lengths-of-stay, 16.1, 15.7, and 15.5 days at the low-, medium-, and minimal-volume groups, respectively, versus 14.0 days for the high-volume provider (p < 0.001 for all comparisons). Similarly, adjusted charges at the high-volume provider were, on average, 14% less than those of the low-volume group, which had the next lowest charges. Although mortality rates differed by procedure type, for each procedure, mortality increased as provider volume decreased, following the pattern found in the aggregate analysis. After casemix adjustment, the risk of in-hospital death for patients with malignant diagnoses was significantly higher for the medium-, low-, and minimal-volume groups compared with patients at the high-volume provider, relative risk of 3.1, 4.0, and 4.2, respectively, (p < 0.001 for all comparisons). Conclusions: This study demonstrates that increased hospital experience is associated with a marked decrease in hospital mortality. The decreased mortality at the high-volume provider was also associated with shorter lengths-of-stay and lower hospital charges. These findings were more pronounced for malignant diagnoses than for benign conditions. Characteristics of the high-volume provider thought to contribute to improved outcomes include overall experience level of the physicians and staff; specialized staff, facilities, and equipment in the operating rooms and intensive care units; and the use of critical pathways and detailed care management plans.  [References: 26]

164.    Glenn, D. M., & Macario, A. (1999). Management of the operating room: A new practice opportunity for anesthesiologists.  Anesthesiology Clinics of North America, 17(2), 365-394.
Abstract: The goals of this article are to review the history of the financing and delivery of health care in the United States, to introduce important aspects of management of the operating room as a new practice opportunity, and to provide a few analytical tools for the operating room manager. A basic tenet of health economics and operating room management is that costs can be controlled and reduced while preserving optimum health care.  [References: 41]

165.   Gibney, M., Cohen, E., & Roman, S. H. (1999). Inpatient diabetes care: Strategies for disease management. DIS MANAGE, 2(1-2), 13-23.
Abstract: Diabetes is a chronic condition with high morbidity, mortality, and prevalence rates that results in high human and financial costs. Coordinating diabetes care with a disease management approach that stresses comprehensive, proactive, and evidence-based strategies is essential if the human and financial costs of diabetes are to be reduced. Most patients do not receive the essential care processes recommended by the American Diabetes Association (ADA) that could reduce the human and financial costs. One reason the ADA standards are not being met is the tendency of our healthcare system to utilize resources for acute events, rather than the management of chronic diseases. We believe that the frequent episodes of hospitalization for patients with diabetes represent missed opportunities to improve their overall diabetes care. This is a descriptive report involving a large tertiary medical center in New York City, where the disease management approach has been used to develop diabetes-related inpatient interventions. The inpatient disease management tools described are a blood glucose monitoring form with color-coded algorithms, an inpatient type 2 diabetes clinical pathway for diabetes as a secondary diagnosis, an inpatient brochure, and a patient follow-up letter reporting hemoglobin A(1c) levels measured during hospitalization. These tools have the potential to achieve 2 important goals: improved glycemic management for patients while hospitalized and the provision of a critical link between inpatient and ambulatory diabetes care. These tools will help achieve the ADA standards and may reduce the morbidity of diabetes.  [References: 20]

166.    Gheiler, E. L., Lovisolo, J. A., Tiguert, R., Tefilli, M. V., Grayson, T., Oldford, G., Powell, I. J., Famiglietti, G., Banerjee, M., Pontes, J. E., & Wood, D. P. Jr. (1999). Results of a clinical care pathway for radical prostatectomy patients in an open hospital - multiphysician system. European Urology, 35(3), 210-6.
Abstract: OBJECTIVES: The object of this study was to evaluate the results of a comprehensive clinical care pathway (CCP) aimed at reducing the length of hospitalization and overall cost for patients undergoing radical prostatectomy in a setting including both academic and private physicians. METHODS: The clinical records of 1,129 consecutive patients who underwent radical prostatectomy by 24 urologists between July 1, 1990, and December 31, 1996, were reviewed. The factors considered were length of stay, morbidity and mortality, readmission rates, and average cost. The CCP was implemented on January 1, 1994. Its scope was to minimize preoperative evaluation, eliminate the preoperative hospital stay, standardize postoperative care and provide intensive patient education. RESULTS: The average length of stay decreased significantly after implementation of the CCP (8.1 vs. 4.9 days, p = 0.0001). In 1990, there was a large difference in length of stay between academic and private physicians (8.3 vs. 12.6 days) (p = 0. 02) but by 1 year after implementation of the CCP there was virtually no difference (4.69 vs. 4.71 days) (p > 0.05). Complication rates were similar before and after implementation of the CCP. Using the average 1993 cost/case as the baseline preCCP figure, the average cost of radical prostatectomy decreased by 16% in 1994 and by 22% in 1995. CONCLUSIONS: It is possible to successfully implement a CCP in a multi-physician system to reduce length of stay and cost of radical prostatectomy without subjecting the patient to a greater risk of complication

167.    Finkel, T. (1999). Thinking globally, acting locally: The promise of cardiovascular gene therapy. Circulation Research, 84(12), 1471-1472.

168.    Finke, J., & Teusch, L. (1999). Outlines of a manual-directed client-centered therapy of depressive disorders. Psychotherapeut, 44(2), 101-107.
Abstract: The fundamental principles of a therapy manual for client-centered therapy of depressive disorders are presented. Specific procedures are outlined depending on the type of disorder concerning the psychopathological symptoms, characteristics of the subjective experience and conflicts and difficulties in interpersonal relationships. Interventions are adapted to the phase of symptoms, to the phase of relationship and conflict and to the phase of parting. Two case studies are presented to demonstrate, how intervention techniques relate to the individual focus of the patient. The rules how to handle therapeutic techniques are discussed with regard to the need of individual variability.  [References: 19]

169.    Fedi, S., Gori, A. M., Falciani, M., Cellai, A. P., Aglietti, P., Baldini, A., Vena, L. M., Prisco, D., Abbate, R., & Gensini, G. F. (1999). Procedure-dependence and tissue factor-independence of hypercoagulability during orthopaedic surgery. Thrombosis & Haemostasis, 81(6), 874-878.
Abstract: The increased risk for deep vein thrombosis (DVT) after orthopaedic surgery has been well documented as well as hypercoagulable state during both total hip arthroplasty (THA) and total knee replacement (TKR). To investigate the influence of the surgical procedure [posterolateral (PL) or lateral (L) approach for THA, use of tourniquet (TQ) or not use of TQ for TKR] on the hypercoagulability and the role of extrinsic pathway activation and endothelial stimulation during orthopaedic surgery we have examined 40 patients (20 patients undergoing primary THA - 10 with PL approach and 10 with L approach - and 20 patients undergoing TKR - 10 with TQ application and 10 without TQ). Thrombin-antithrombin complexes (TAT), tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombomodulin (TM) and von Willebrand factor antigen (vWF:Ag) were analyzed before and during the orthopaedic surgery. During THA, TAT plasma levels increased more markedly in patients assigned to the L than PL approach (p < 0.05); during TKR an elevation of TAT of higher degree (p < 0.05) was observed when TQ was not applicated. Blood clotting activation was significantly (p < 0.001) more relevant during THA than TKR. No changes in TF and vWF:Ag plasma levels were observed in all patients undergoing THA and TKR. TFPI plasma levels significantly (p < 0.05) decreased 1 h after the end of the THA in group PL and group L, whereas they remained unaffected in the two groups of patients undergoing TKR. Similarly TM plasma levels significantly decreased during THA, but not during TKR. In conclusion, these results show that: 1) the site of surgical procedures and the type of approach affect the degree of hypercoagulability, 2) the blood clotting activation takes place in the early phases of orthopaedic surgery, without signs of extrinsic pathway and endothelial activation.  [References: 32]

170.    Eccles, M., Freemantle, N., & Mason, J. (1999). North of England evidence-based guideline development project: Summary version of guidelines for the choice of antidepressants for depression in primary care. Family Practice, 16(2), 103-111.

171.    Dorostkar, P. C., Silka, M. J., Morady, F., & Dick, I. I. M. (1999). Clinical course of persistent junctional reciprocating tachycardia. Journal of the American College of Cardiology, 33(2), 366-375.
Abstract: OBJECTIVE: The purpose of this study is to review the clinical course of persistent junctional reciprocating tachycardia (PJRT) in 21 patients spanning a wide age range to examine the electrophysiologic characteristics of the conduction system in these patients with PJRT, particularly in regards to its incessant nature and to evaluate the long-term response to radiofrequency ablation. BACKGROUND: Persistent junctional reciprocating tachycardia is uncommon, occurring in 1% of patients with supraventricular tachycardia. Its presentation, course and treatment are incompletely characterized. METHODS: The clinical, electrocardiographic, electrophysiologic and echocardiographic data of 21 patients with PJRT were reviewed. RESULTS: In 9 of these 21 patients, the mean tachycardia cycle length increased significantly (p < 0.0001) as the patients grew, from a mean tachycardia cycle length of 308 +/- 64 ms in the patients less than 2 years, 414 +/- 57 ms in the patients between 2 years and 5 years, to 445 +/- 57 ms in the patients greater than 5 years, primarily due to slowing of retrograde conduction in the accessory pathway. Persistent junctional reciprocating tachycardia was associated with impaired ventricular function in 11, improving spontaneously in 4 and, after successful ablation of the accessory pathway, in 7. All patients except one were uncontrolled on one or more medications. Ablation of the accessory pathway was successful in 19 of 21 patients. CONCLUSIONS: We conclude that PJRT is characterized by an onset in early childhood and by an age-related prolongation of the tachycardia cycle length mediated primarily through conduction delay in the concealed, retrogradely conducting accessory pathway. Ablation of the accessory pathway provides definitive treatment for PJRT.  [References: 23]

172.    Dietrich, E. S. (1999). Fundamentals and limits of pharmacoeconomics. Pz Prisma, 6(1), 61-68.

173.    Dhanasekaran, N., Wu, Y. K., & Reece, E. A. (1999). Signaling pathways and diabetic embryopathy [In Process Citation]. Semin Reprod Endocrinol, 17(2), 167-74.
Abstract: Diabetic embryopathy is the leading cause of neonatal death and/or congenital malformations in infants of diabetic mothers. Because the development of the embryo critically depends on the maternal and the embryonic signaling pathways, a defective signaling mechanism between the maternal and the embryonic tissues appears to be involved in the etiology of diabetic embryopathy. Analyses of the recent studies from different laboratories suggest a "multifactorial" basis for diabetic embryopathy. These studies suggest that a wide variety of signal-transducers converge towards the regulation of elcosanoid signaling pathyway which appears to be the critical pathway involved in diabetic embrhyopathy. The characterization of the regulatory components of this pathway is likely to identify the signaling loci susceptible for the therapeutic intervention.

174.    Denton, M., Wentworth, S., Yellowlees, P., & Emmerson, B. (1999). Clinical pathways in mental health. AUSTRALAS PSYCHIATRY, 7(2), 75-77.

175.    Deakin, M. (1999). Valuation, appraisal, discounting, obsolescence and depreciation: Towards a life cycle analysis and impact assessment of their effects on the environment of cities. INT J LIFE CYCLE ASSESS, 4(2), 87-93.
Abstract: Previous editions of this Journal have drawn attention to the critical role valuation plays in life cycle analysis and environmental impact assessment (see for example VOLKWEIN and KLOPFFER [1]). In particular, the critical role of valuation has been highlighed in a number of discussions on 'valuation step' within life cycle costing, 'hedonic and contingency' assessments of environmental impact and both the utility and welfare of 'pathway' analysis/assessment (KREWITT, MAYERHOFER, TRUKENMULLER and FRIEDRICH, 1998; POWELL, PEARCE and CRAIGHILL, 1997; VOLKWEIN, GIHR and KLOPFFER, 1996 [2-4]). Focusing on the utility of market valuation, this paper examines the critique of discounting environmentalists have made in relation to property valuation, investment appraisal and the application of the principle in the income based net annual return model of land use time- horizons and the spatial configuration of building programmes - a criticism implict in 'valuation step', 'hedonic, contingency' and 'pathway' analysis/assessments. It examines the argument put forward regarding the link between the selection of a discount rate, the valuation of property, appraisal of investment and inter-generational downloading of costs associated with the use of land, repair, maintenance and refurbishment of buildings: the downloading of costs, seen by some, to have an adverse impact and work against the introduction of experimental designs aimed at energy saving, clean air environments.  [References: 22]

176.    Davidson, J. (1999). Revised standards for the treatment of type 2 diabetes in Texas [4]. Diabetes Care, 22(7), 1219-1220.

177.    Cunningham, M. A., Ono, T., Hewitson, T. D., Tipping, P. G., Becker, G. J., & Holdsworth, S. R. (1999). Tissue factor pathway inhibitor expression in human crescentic glomerulonephritis. Kidney International, 55(4), 1311-1318.
Abstract: Background. Tissue factor (TF) pathway inhibitor (TFPI), the major endogenous inhibitor of extrinsic coagulation pathway activation, protects renal function in experimental crescentic glomerulonephritis (GN). Its glomerular expression and relationship to TF expression and fibrin deposition in human crescentic GN have not been reported. Methods. Glomerular TFPI, TF, and fibrin-related antigen (FRA) expression were correlated in renal biopsies from 11 patients with crescentic GN. Biopsies from 11 patients with thin basement membrane disease and two normal kidneys were used as controls. Results. TFPI was undetectable in control glomeruli but was detectable in interstitial microvessels. In crescentic biopsies, TFPI was detected in cellular crescents and was more prominent in fibrous/fibrocellular crescents, indicating a correlation with the chronicity of crescentic lesions. TFPI appeared to be associated with macrophages but not endothelial or epithelial cells. TFPI was generally undetectable in regions of the glomerular tuft with minimal damage. In contrast, TF and FRA were strongly expressed in regions of minimal injury, as well as in more advanced proliferative and necrotizing lesions. Despite prominent TF expression, FRA was less prominent in fibrous/fibrocellular crescents in which TFPI expression was maximal. Conclusions. These data suggest that TFPI is strongly expressed in the later stages of crescent formation and is inversely correlated with the presence of FRA in human crescentic GN. This late induction of TFPI may inhibit TF activity and favor reduced fibrin deposition in the chronic of crescent formation.  [References: 24]

178.    Crane, M., Werber, B., & Lavery, L. A. (1999). Critical pathway approach to diabetic pedal infections in a multidisciplinary setting. Journal of Foot & Ankle Surgery, 38(1), 82-83.

179.    Chou, S. C., & Boldy, D. (1999). Patient perceived quality-of-care in hospital in the context of clinical pathways: Development of an approach. Journal of Quality in Clinical Practice, 19(2), 89-93.
Abstract: Clinical pathways have been introduced in many hospitals with the aims of improving efficiency, reducing costs, and improving the quality and outcomes of care. However, there is a shortage of research evidence regarding the extent to which they do in fact achieve such aims. This paper describes the development and testing of a patient-perceived quality-of-care questionnaire for use in relation to the assessment of clinical pathways. Issues of validity and reliability are addressed and illustrative examples of results for two pilot hospitals are presented.  [References: 12]

180.    Carbon, C., Guillemot, D., Regnier, B., Schlemmer, B., Taboulet, F., Tremolieres, F., Wong, O., Rozet, K., Denis, C., Zagury, P., Cavalie, P., Pigeon, M., Golinelli, D., Davy, O., Rostoker, G., & Fleurette, F. (1999). Antibiotic prescription and use in ambulatory patients. Revue De Pneumologie Clinique, 55(2), 65-74.
Abstract: Objective. This study was conducted to describe changes in prescription practices outside the hospital, to evaluate the adaptation of such prescriptions to current scientific knowledge, and to compare medical practices in France with those in other European countries. Methods. Data were collected from several sources: analysis of the literature, surveys conducted in the Loiret department and in the Rhone-Alps region, ten-year health surveys (INSEE), data from the Sentinel network, sales statements from pharmaceutical firms, the Permanent Survey of Medical Prescription (EPPM) of the Medical Information and Statistics (IMS) firm. Comparisons between France, the United Kingdom and Germany were conducted by the French Medicine Agency's Pharmaco-economic Studies and Information Department using data furnished by the IMS firm and by pharmaceutical firms. Results. In France, antibiotic sales increased by a mean annual rate of 2.1%, expressed in antibiotic units, and 2.6%, expressed in turnover (manufacturer price) between 1991 and 1996. The majority of these antibiotics were prescribed for respiratory and ENT infections with a presumed viral etiology such as rhino- pharyngitis and acute bronchitis. The results of the different surveys were in agreement showing that antibiotic prescriptions are made in approximately 40% of all consultations for rhino-pharyngitis and in 80% of those for acute bronchitis. Antibiotics were prescribed in more than 90% of cases of pharyngitis whatever the age of the patient. The situation was different for acute middle ear infections as the number of consultations has remained relatively unchanged over the last 10 years while antibiotic prescriptions have strongly increased, reaching 80% of the consultations. The number of consultations for pharyngitis and acute rhino-pharyngitis appears to be greater in France than in the United Kingdom and in Germany. Likewise, the proportion of patients using antibiotics after consulting for presumed viral conditions would be higher in France with different antibiotic classes being used. Conclusions. There is a gap between official guidelines (product description documents, therapeutic information documents, good practice guidelines, consensus conferences) and the state of current practices. Excessive and poorly-adapted antibiotic prescription favors the disturbing phenomenon of resistance which is all the more alarming because the emergence of resistant strains is difficult to predict and concerns bacteria causing the most common infections. To improve medical practices and achieve a persistent reduction in the use of antibiotics for vital infections, validated recommendations should be distributed to physicians. An effort should be made to prescribe the most appropriate active substance at optimal dose and treatment duration to limit the development of bacterial resistance. In addition, patients and the general public should be informed of the absence of any beneficial effect and the individual and collective risks involved in using antibiotics for vital infections in order to help them better understand and comply to their physician's prescription.  [References: 14]

181.    Caplan, G., & Brown, A. (1999). Clinical pathways (multiple letters) [5]. Medical Journal of Australia, 170(11), 568.

182.    Calkins, H., Yong, P., Miller, J. M., Olshansky, B., Carlson, M., Saul, J. P., Huang, S. K. S., Liem, L. B., Klein, L. S., Moser, S. A., Bloch, D. A., Gillette, P., & Prystowsky, E. (1999). Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: Final results of a prospective, multicenter clinical trial. Circulation, 99(2), 262-270.
Abstract: Background - The purpose of this study was to evaluate the safety and efficacy of a temperature-controlled radiofrequency catheter ablation system. Methods and Results - The patient population included 1050 patients who had undergone ablation of atrioventricular nodal reentrant tachycardia (AVNRT), an accessory pathway (AP), or the atrioventricular junction (AVJ). Ablation was successful in 996 patients. The probability of success was highest among patients who had undergone ablation of the AVJ, lowest in patients who had undergone ablation of an AP, and in between for patients who had undergone ablation of AVNRT. A major complication occurred in 32 patients. Four variables predicted ablation success (AVJ, AVNRT, or left free wall AP ablation and an experienced center). Four factors predicted arrhythmia recurrence (right free wall, posteroseptal, septal, and multiple APs). Two variables predicted development of a complication (structural heart disease and the presence of multiple targets), and 3 variables predicted an increased risk of death (heart disease, lower ejection fraction, and AVJ ablation). Conclusions - These findings may serve as a guide to clinicians considering therapeutic options in patients who are candidates for ablation.  [References: 36]

183.    Cacabelos, R., Takeda, M., & Winblad, B. (1999). The glutamatergic system and neurodegeneration in dementia: Preventive strategies in Alzheimer's disease. International Journal of Geriatric Psychiatry, 14(1), 3-47.

184.    Bower, K., & Zander, K. (1999) The Center for Case Management [Web Page]. URL http://www.cfcm.com/ [1999].
Abstract: This website provides information about the products and services of The Center for Case Management. Recent articles from The New Definition (their free newsletter) are reproduced on the website.  

185.    Bender, A. D., Motley, R. J., Pierotti, R. J., & Bischof, R. O. (1999). Quality and outcomes management in the primary care practice. Journal of Medical Practice Management, 14(5), 236-240.
Abstract: In response to the trend away from thinking of health care as a commodity to one in which quality is a differentiating feature among providers, primary care practices must focus on outcomes management. This article reviews the various clinical and office-based processes that influence practice outcomes. These include patient management, chart management, practice guidelines, clinical pathways, case management, and patient information. The key to a quality program and successful outcomes management is a commitment on the part of physicians to managing these processes so that best outcomes are achievable.  [References: 18]

186.    Bellantuono, C., Rizzo, R., & Vampini, C. (1999). Guidelines for drug treatment of depression in primary care. Rivista Di Psichiatria, 34(3), 117-125.
Abstract: Depression represents one of the major health problems, with its prevalence ranging from 2.6% to almost 30%, according to the investigated population. Many of these cases are first seen by the general practitioner. Therefore, clearcut guidelines are needed to avoid unnecessary prescription. Such guidelines could only stem from modern psychiatric practice, that is based upon extensive double-blind drug trials that clearly demonstrate the superiority of drugs over placebo. It has been shown that patients who most benefit from drug treatment are those with severe symptoms, rather than those who belong to a given diagnostic subgroup. Drug resistance should prompt for a visit to a psychiatrist. Drugs that proved to be most effective comprise TCAs, SSRIs, SNRIs, MAOI and some newer antidepressants like nefazodone, mianserine, mirtazapine, and trazodone. Interactions with cytochrome P450 isoenzymes should be taken into account when patients are treated with drugs for other medical conditions. Dosages should be individualized to avoid toxicity and unresponsiveness. With equally effective drugs, priority should be given to drug tolerance, rather than to drug cost. The treatment of the acute phase should last for not less than two months and should lead to the continuation phase, for three to six months; during these two phases, the drug should be used at full therapeutic doses. The purpose of the continuation phase is to prevent relapse. Treatment may be continued for some years at reduced dosage to prevent recurrence.  [References: 17]

187.    Ariens, R. A. S., Alberio, G., Moia, M., & Mannucci, P. M. (1999). Low levels of heparin-releasable tissue factor pathway inhibitor in young patients with thrombosis. Thrombosis & Haemostasis, 81(2), 203-207.
Abstract: An association between deficiency of tissue factor pathway inhibitor (TFPI) and thrombosis has not been clearly demonstrated in humans, but previous studies have focused on the measurement of plasma TFPI, which is only a small part of the total body TFPI. The major fraction of this natural anticoagulant can be measured in plasma after release by heparin injection. To investigate if deficiency of heparin-releasable TFPI is associated with thrombosis, we measured TFPI activity in plasma before and 10 min after intravenous injection of 7500 IU unfractionated heparin in 64 young patients with venous thrombosis, 49 young patients with arterial thrombosis and 38 healthy individuals. Post-heparin TFPI activity levels were significantly lower in the group of patients with venous thrombosis than in controls (mean +/- SD: 230% +/- 39 vs 260% +/- 34, p = 0.0002), whereas there was no difference for patients with arterial thrombosis. Defining the normal range as the mean +/- 2 SD of TFPI activity in controls, twelve patients had low postheparin TFPI activity levels, seven with venous and five with arterial thrombosis. Low levels of TFPI activity were confirmed by immunoassay in six of the seven patients with venous thrombosis and two of the five patients with arterial thrombosis, and were present also in at least one first degree relative of six patients, suggesting that the defect might be inheritable. However, the causative role of low heparin-releasable TFPI remains uncertain, because co-segregation of the defect with thrombotic symptoms could not be demonstrated in the small number of families studied.  [References: 24]

188.    Beitel, J. (1998). Positioning and intracranial hypertension: implications of the new critical pathway for nursing practice. Off J Can Assoc Crit Care Nurs, 9(4), 12-6; quiz 17-8.
Abstract: Evidence based practice in nursing requires careful scrutiny of research studies to determine if there is support to continue existing protocols or if a change in clinical practice is warranted. Current nursing practice in critical care includes the routine elevation of the head of the bed (HOB) to 30 degrees or 45 degrees for patients with cerebral edema. Intracranial hypertension is a common complication of cerebral edema. New guidelines for medical management of intracranial hypertension have been developed and presented in a critical pathway. Positioning of patients with intracranial hypertension must be re-evaluated in light of the changing goals of medical management outlined in the critical pathway. The author of this article will critically appraise the research examining the impact of elevating the HOB on patients with intracranial hypertension within the context of the critical pathway parameters. Recommendations for positioning, in keeping with the new critical pathway for intracranial hypertension, will be suggested. Future research directions will be identified.

189.    Henneman, E. (1998). From the UCLA Medical Center: a clinical pathway for gastrointestinal bleeding. Cost Qual Q J, 4(4), 26-31.

190.    DeLong, J. F., Allman, R. M., Sherrill, R. G., & Schiesz, N. (1998). A congestive heart failure project with measured improvements in care. Eval Health Prof, 21(4), 472-86.
Abstract: This project was designed to improve the in-hospital management of Medicare beneficiaries with congestive heart failure (CHF). Eleven hospitals were studied using two indicators: (a) assessment of left ventricular (LV) function, and (b) use of angiotensin converting enzyme (ACE) inhibitors in patients with systolic dysfunction. Baseline performance rates were obtained for 990 cases with the Diagnosis Related Group (DRG) 127 for CHF discharged January 1994 to December 1994. Baseline data feedback presentations in 1995 spurred quality improvement plans with interventions such as physician education, critical care maps, and standing orders. Follow-up abstractions were performed on 612 discharges October 1995 through April 1997. The study demonstrated 12% improvement (53% to 65%, p < .01) in assessing LV function and 20% improvement (54% to 74%, p < .01) in appropriate ACE inhibitor use. Projects emphasizing Health Care Quality Improvement Program (HCQIP) principles can successfully affect health care management for the Medicare population.

191.    Hassaballa, H., Payne, J., McFolling, S., & Marder, R. J. (1998). Enhancing clinical pathway placement. Qual Manag Health Care, 7(1), 13-7.
Abstract: Soaring health care costs have fueled the immense growth in managed care. To contain these costs, health care organizations have turned to clinical pathways. However, clinical pathways cannot do an effective job if health care personnel are not aware of their existence. The article presents a simple, effective, and efficient method to increase placement of clinical pathways in inpatient medical records.

192.    Cardozo, L., Ahrens, S., Steinberg, J., Lepczyk, M. B., Kaplan, C., Burns, J., LaPlante, J., Wright, C., Spybrook, K., Racine, E., & Valade, T. (1998). Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital. Qual Manag Health Care, 7(1), 1-12.
Abstract: Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.