Articles: adult.
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Int J Evid Based Healthc · Jun 2009
Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?
Aim Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings. ⋯ 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.
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Journal of neurotrauma · May 2009
The effect of hypothermia on the expression of TIMP-3 after traumatic brain injury in rats.
To investigate the effect of hypothermia on the expression of apoptosis-regulating protein TIMP-3 after fluid percussion traumatic brain injury (TBI) in rats. 210 adult male Sprague Dawley rats were randomly assigned to the groups of TBI with hypothermia treatment (32 degrees C), TBI with normothermia (37 degrees C), and sham injured control. TBI model was induced by fluid percussion TBI device. Mild hypothermia (32 degrees C) was achieved by partial immersion in a water bath (0 degrees C) under general anesthesia for 4 hours. ⋯ In contrast, post-traumatic hypothermia significantly attenuated such an increase. According to the RT-PCR and western blot analysis, the maximum mRNA levels of TIMP-3 were reduced to 60.60%+/-2.30, 55.83%+/-1.80, 66.03%+/-2.10 and 64.51%+/-1.50 of the corresponding values in the normothermic group in injured and uninjured hemispheres (cortex and hippocampus) by hypothermia treatment, respectively (p < 0.01), while the respective maximum protein levels of TIMP-3 were reduced to 57.50%+/-1.50, 52.67%+/-2.20, 60.31%+/-2.50and 54.76%+/-1.40 (p < 0.01). Our data suggests that moderate F-P brain injury would significantly upregulate TIMP-3 expression, while such an increase could be efficiently suppressed by hypothermia treatment.
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Despite enhanced interest in manifestations of pain in adults with intellectual and developmental disabilities (IDD), the characteristics of pain behavior in this group have seldom been examined. The aim of the present study was to provide a sensitive pain behavior scale for adults with IDD. The participants, 228 adults (mean age, 38.7 years) with different levels of IDD, were videotaped before and during an influenza vaccination and scored using the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R). Observed pain behaviors not captured by the NCCPC-R, was also registered. Sensitivity to pain of all 27 items was examined by Signed Rank test, internal consistency by Cronbach's alpha, and sensitivity to change of the total scale by Standardized Response Mean (SRM). Thirteen items were excluded from the original NCCPC-R scale; 4 new items were added, making a modified scale of 18 items. This scale, named the Non-Communicating Adults Pain Checklist-Revised (NCAPC), was rescored and examined for psychometric properties in a random sample (N = 89). Sensitivity to pain of all items (P < .05) and high internal consistency (alpha = 0.773) were demonstrated. Large sensitivity to pain at all levels of IDD was shown (SRM, 1.20 to 2.07). Better psychometric properties were demonstrated for NCAPC than NCCPC-R in the target population. ⋯ This article presents initial psychometric properties of a new measure, the NCAPC, evaluating pain behavior in adults with IDD. This measure could help clinicians to better capture pain expressions in this population and contribute to better pain management for this group of patients.
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Rev Bras Ter Intensiva · Mar 2009
Therapeutical hypothermia after cardiopulmonary resuscitation: evidences and practical issues.
Cardiac arrest survivors frequently suffer from ischemic brain injury associated with poor neurological outcome and death. Therapeutic hypothermia improves outcomes in comatose survivors after resuscitation from out-of-hospital cardiac arrest. Considering its formal recommendation as a therapy, post-return of spontaneous circulation after cardiac arrest, the objective of this study was to review the clinical aspects of therapeutic hypothermia. ⋯ When temperature increases to more than 35º C, sedation, analgesia, and paralysis could be discontinued. The expected complications of hypothermia may be pneumonia, sepsis, cardiac arrhythmias, and coagulopathy. In spite of potential complications which require rigorous control, only six patients need to be treated to save one life.