Review Article: Ambulatory Treatment of the Psychotic Crisis

Current efforts to improve the community-based care of psychiatric patients often include attempts to encourage the ambulatory treatment of acute psychosis by non-psychiatrists. New therapies and revisions of older methods now allow this to be done with many patients for whom, 15 years ago, state hospitalization would have been the first step in treatment, and often the last.Many techniques applicable to the ambulatory treatment of acute psychotic crises can be used effectively by non-psychiatrists. This review describes ambulatory treatment programs for the more commonly encountered acute psychoses. It emphasizes methods which have only recently become available and those which can be used effectively and safely by the non-specialist. With the skillfully combined use of pharmacotherapy, environmental modification, office psychotherapy, legal aids and community resources, the interested nonpsychiatrist can undertake the ambulatory treatment of many psychotic crises.     

Development of a Soviet diagnostic kit for determining class M immunoglobulins to the hepatitis A virus by immunoenzyme analysis (a test system for anti-HAV IgM)

A new test system Diagn-A-Hep for the laboratory diagnosis of hepatitis A (HA) by means of the enzyme immunoassay has been developed at the Institute of Poliomyelitis and Viral Encephalitides (Moscow). The sensitivity and specificity of the newly developed test system have proved to be similar to those of the well-known commercial diagnostic system HAVAB manufactured by Abbott Laboratories (USA). Diagn-A-Hep permits the diagnosis of HA with 96-100% effectiveness both in patients with the acute form of the disease and in patients with its anicteric or inapparent forms. This system is simple and convenient, it may be employed in inadequately equipped laboratories or even under field conditions. The rules for the selection of immunobiological preparations to be included in the test system have been worked out.     

Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

ObjectiveHypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.MethodsThe development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assem bled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incor porated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommen dations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines—2010 update.ResultsTopics addressed include the etiology, epide miology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.ConclusionsFifty-two evidence-based recommenda tions and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medi cal practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpa tient clinical situations. The standard treatment is replace ment with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.     

NEW: an interactive data management system for monitoring ambulatory patients

Biobehavioral monitoring is a method of gathering daily biological and behavioral measurements from ambulatory patients so that hospital-based care can be extended to the home. Such data can also serve many other purposes such as peer review and assesing the outcome of treatment. To assist in handling the increased information about patients, NEW, a system of three interactive APL Plus computer program packages, has been developed. The program packages, NEWDATA, EVALUATION, and WARNINGS, form an interactive data management system to provide: a rapid means of entering and verifying each patient's data from either a single day or a group of days; a flexible and simple means of retrieving and analyzing the data for an individual patient or for groups of patients; and a means of reviewing, detecting, and signaling trends in the data that deviate from present clinical criteria.     

Role of 24-hour ambulatory electrocardiographic monitoring in a general hospital.

During 1976, 24-hour ambulatory electrocardiographic (ECG) monitoring was available to all physicians at this hospital, and 281 patients were investigated by 322 recordings. Cardiac arrhythmias requiring treatment were detected in 100 patients (36%). Some presented after symptoms such as faintness, giddiness, palpitations, collapse, or fits, but ominous arrhythmias were also found in asymptomatic patients. A demand pacemaker was implanted for episodic sinoatrial or atrioventricular conduction disorder in 30, while 70 patients (25%) required antiarrhythmic drug treatment for ventricular or atrial tachyarrhythmias. Facilities for ambulatory 24-hour ECG monitoring are necessary in any large hospital, and precise diagnosis in most of our patients studied could not have been achieved by any other investigation.     

Evolving residency requirements for ambulatory care training for five medical specialties, 1961 to 1989.

Recent changes in the patient population of teaching hospitals, spurred by technologic advances and economic forces, have jeopardized the traditional hospital-based model of residency training. In consequence, there has been increasing attention paid to the need for ambulatory care experience. A primary force in shaping the content of postgraduate medical education is "The Essentials of Accredited Residencies," published in the Directory of Graduate Medical Education Programs. We reviewed recommendations and requirements for ambulatory settings and outpatient experience as specified in the Directory during the years 1961 to 1988 and investigated pending changes in requirements for five major specialties: internal medicine, pediatrics, family practice, general surgery, and obstetrics and gynecology. Increases in the amount of time residents spend in ambulatory care training recently have been mandated in internal medicine and are under consideration in two other specialties, indicating probable major shifts in the locus of postgraduate medical training.     

Adult Obesity and Office‐based Quality of Care in the United States

Nationally representative data on the quality of care for obese patients in US‐ambulatory care settings are limited. We conducted a cross‐sectional analysis of the 2005 and 2006 National Ambulatory Medical Care Survey (NAMCS). We examined obesity screening, diagnosis, and counseling during adult visits and associations with patient and provider characteristics. We also assessed performance on 15 previously published ambulatory quality indicators for obese vs. normal/overweight patients. Nearly 50% (95% confidence interval (CI): 46–54%) of visits lacked complete height and weight data needed to screen for obesity using BMI. Of visits by patients with clinical obesity (BMI ≥30.0 kg/m²), 70% (66–74%) were not diagnosed and 63% (59–68%) received no counseling for diet, exercise, or weight reduction. The percentage of visits not being screened (48%), diagnosed (66%), or counseled (54%) for obesity was also notably higher than expected even for patients with known obesity comorbidities. Performance (defined as the percentage of applicable visits receiving appropriate care) on the quality indicators was suboptimal overall. In particular, performance was no better than 50% for eight quality indicators, which are all related to the prevention and treatment of obesity comorbidities, e.g., coronary artery disease, hypertension, hyperlipidemia, asthma, and depression. Performance did not differ by weight status for any of the 15 quality indicators; however, poorer performance was consistently associated with lack of height and weight measurements. In conclusion, many opportunities are missed for obesity screening and diagnosis, as well as for the prevention and treatment of obesity comorbidities, in office‐based practices across the United States, regardless of patient and provider characteristics.     

Patient satisfaction and quality in home health care of elderly islanders

Patient satisfaction has been a widely investigated subject in health care research. Quality of care from the patient perspective, especially in home health care, however has been investigated only very recently. Home health care is a system of care provided by skilled practitioners to patients in their homes under the direction of a physician. Multidisciplinary nature of home health care services present challenges to quality measurement that differ from those found in a more traditional hospital settings. The aim of the study was to investigate the satisfaction of elderly patients living on islands with home health care. Participants receiving skilled nursing care in their homes, for any diagnosis, who met selection criteria, were surveyed about their perception of the quality of health care. The research was conducted during the year 2010 among the residents of Kvarnerian islands (Krk, Cres and Mali Losinj) under the authority of Croatian Institute for Health Insurance that approved the protocols employed in the investigation. Most older patients (96.2%) reported high levels of satisfaction with health services delivery. Common leading diagnosis among home health care patient include diseases of circulatory system (28.9% of patients), nutritional and metabolic disease (14.5%), malignant diseases (13.2%), musculoskeletal and connective tissue disease (11.8%), diseases of the nervous system (9.2%), followed by injury and poisoning (7.9%). Provision of home health care was well received by elderly patients. Home health care providers seek to provide high quality, safe care in ways that honour patient autonomy and accommodate the individual characteristics of each patients home and family. The demographics of an aging society will sustain the trend towards home-based care. Therefore, research on effective practices, conducted in home health care settings, is necessary to support excellent and evidence-based care.     

Developing a systematic approach to the diagnosis and classification of mitochondrial disease

The accurate diagnosis and classification of mitochondrial diseases are essential first steps in understanding the natural history and true health care burden imposed by these protean and devastating disorders. Epidemiologic studies place the incidence of genetic forms of mitochondrial disease between 1 in 2000 and 1 in 5000 live births. Symptoms may not appear for years after birth, even when inherited. Once they occur, however, the course is often relentlessly progressive. Diagnosis requires a combination of clinical and laboratory studies that are applied systematically. DNA analysis and respiratory chain studies remain the mainstays of diagnosis, but several other disciplines may contribute to achieving diagnostic confidence when a single study is suggestive but inconclusive. A comprehensive classification system for mitochondrial diseases has not yet been developed. The current International Classification of Diseases, 10th Revision (ICD-10) includes just 10 codes for mitochondrial disorders. Supplementary data of 347 proposed ICD-10 codes is included to assist with the development of a more comprehensive system for the diagnosis and classification of mitochondrial disease.     

A dual-sensor diagnostic pacemaker for ambulatory cardiac monitoring

Unexplained blackouts are a very common medical problem. Some patients presenting themselves at hospital with such symptoms have underlying bradycardia or extreme tachycardia with a profound decrease in cardiac output. Modern treatment of these patients may be highly effective but accurate diagnosis of their exact condition may be needed. A novel ambulatory dual-sensor diagnostic pacemaker has been developed to meet this requirement. The device monitors intracardiac ECG and intraventricular pressure through a special lead introduced perveneously into the right ventricle and detects and counts events such as bradycardia, tachycardia, pauses in the electrical or pressure signals and electrical interference. Analogue recordings of the electrical and pressure waveforms of 16 of these events can be made during the operating period of 3 weeks and pacing is incorporated via a specially-adapted commerical pacemaker if a prolonged episode of bradycardia or a pause is sensed. The device forms part of a complete diagnostic system also incorporating a computer which is used to set up the parameters of the diagnostic pacemaker and to display and analyse the recorded data.     

Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services

Background

This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.

Methods

Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1^st, 2004 and September 30^th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.

Results

Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.

Conclusion

A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.     

Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial

ABSTRACT: BACKGROUND: The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany. New models of healthcare provision need to be developed, tested and implemented on the population level. Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness. These studies have been conducted in different healthcare systems, however, so it is unclear whether these results extend to the specific context of the German healthcare system. The objective of this population-based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home. Methods and study design The study was designed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home (DelpHi cohort). These people are screened for eligibility to participate in a trial of dementia care management (DelpHi trial). The trial is a cluster-randomised, controlled intervention trial with two arms (intervention and control) designed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home. This subsidiary support system is initiated and coordinated by a dementia care manager: a nurse with dementia-specific qualifications who delivers the intervention according to a systematic, detailed protocol. The primary outcome is quality of life and healthcare for patients with dementia and their caregivers. This is a multidimensional outcome with a focus on four dimensions: (1) quality of life, (2) caregiver burden, (3) behavioural and psychological symptoms of dementia and (4) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication. Secondary outcomes include the assessment of dementia syndromes, activities of daily living, social support health status, utilisation of health care resources and medication. DISCUSSION: The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs. Qualification requirements will be evaluated, and the results will help to modify existing guidelines and treatment paths. Trial registration NCT01401582.     

Concerns about increasing use of ambulatory care raised at QMA annual meeting.

Quebec Health Minister Dr. Jean Rochon is pushing for a regionalized health care system that favours ambulatory care, day surgery and home care over hospital admissions and acute care in hospital. The Quebec Medical Association is concerned these changes will lower the quality of care in the province.     

Trial of a Soviet diagnostic kit for determining class M immunoglobulins to the hepatitis A virus by immunoenzyme analysis (an anti-HAV IgM test system)

The authors have studied the effectiveness of the first Soviet test system for the diagnosis of hepatitis A by means of the enzyme immunoassay (Diagn-A-Hep), developed at the Institute of Poliomyelitis and Viral Encephalitides, Moscow, under the conditions of different epidemic situations. In the process of this trial the high specificity and sensitivity of this test system, established earlier in the certification and commission trials, have been confirmed. Diagn-A-Hep has proved to be highly effective in the diagnosis of acute forms of hepatitis A and permitted its detection in patients during the incubation period, as well as in patients with anicteric and asymptomatic subclinical forms. Besides clinical diagnosis, the kit Diagn-A-Hep may be used in large-scale seroepidemiological surveys of the immune structure of the population, as well as in detection of HAV in different material under test.     

Influenza-Like-Illness and Clinically Diagnosed Flu: Disease Burden,Costs and Quality of Life for Patients Seeking Ambulatory Care or No Professional Care at All

This is one of the first studies to (1) describe the out-of-hospital burden of influenza-like-illness (ILI) and clinically diagnosed flu, also for patients not seeking professional medical care, (2) assess influential background characteristics, and (3) formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011–2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever), a longer duration of illness, more use of medication (especially antibiotics) and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5–6 symptoms over a 6-day period; required 1.6 physician visits and 86–91% took medication. An average episode amounted to €51–€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries.     

Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index.

The impact of multidisciplinary teams that incorporate nurse practitioners on total use of health services was measured with the new Utilization and Financial Index (UF-Index). The data from two studies, a randomized controlled trial and a before-and-after study, showed that, in spite of large increases in use of ambulatory services by practice populations served by family physician-nurse practitioner teams, the ultimate effect has been a substantial reduction in total use of health services. The effect was associated with major reductions in hospital care for the same populations. Such economic advantages to society proved feasible within a fee-for-service context and in settings where rigorous evidence demonstrated no concurrent deterioration in health status of patients or in quality of care.     

Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States

Objective

To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings.

Research Design and Methods

We used data from the 2005–2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures.

Results

Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs.

Conclusions

These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.     

Ambulatory measurement of ankle kinetics for clinical applications

This study aimed to design and validate the measurement of ankle kinetics (force, moment, and power) during consecutive gait cycles and in the field using an ambulatory system. An ambulatory system consisting of plantar pressure insole and inertial sensors (3D gyroscopes and 3D accelerometers) on foot and shank was used. To test this system, 12 patients and 10 healthy elderly subjects wore shoes embedding this system and walked many times across a gait lab including a force-plate surrounded by seven cameras considered as the reference system. Then, the participants walked two 50-meter trials where only the ambulatory system was used. Ankle force components and sagittal moment of ankle measured by ambulatory system showed correlation coefficient (R) and normalized RMS error (NRMSE) of more than 0.94 and less than 13% in comparison with the references system for both patients and healthy subjects. Transverse moment of ankle and ankle power showed R>0.85 and NRMSE<23%. These parameters also showed high repeatability (CMC>0.7). In contrast, the ankle coronal moment of ankle demonstrated high error and lower repeatability. Except for ankle coronal moment, the kinetic features obtained by the ambulatory system could distinguish the patients with ankle osteoarthritis from healthy subjects when measured in 50-meter trials. The proposed ambulatory system can be easily accessible in most clinics and could assess main ankle kinetics quantities with acceptable error and repeatability for clinical evaluations. This system is therefore suggested for field measurement in clinical applications.     

Renal transplantation in patients treated with haemodialysis and short term and long term continuous ambulatory peritoneal dialysis.

Forty two adult patients who had been treated with continuous ambulatory peritoneal dialysis for one to 142 weeks (mean (SD) 38 (36)) received a total of 44 allografted kidneys. Twenty one had been treated with continuous ambulatory peritoneal dialysis for less than 26 weeks (mean 11 (8)) and the other 21 for longer than 26 weeks (mean 64 (35)). These two groups were compared with 55 patients who had been treated with haemodialysis and received a total of 63 grafts. In the group of patients treated with continuous ambulatory peritoneal dialysis azathioprine and low dose prednisolone were used as the immunosuppressive regimen for 20 transplantations in 18 patients, and 24 patients receiving 24 grafts were treated with cyclosporin A and low dose prednisolone. In the group of patients treated with haemodialysis 38 patients receiving 43 grafts were treated with azathioprine and low dose prednisolone, and 20 patients receiving 20 grafts were treated with cyclosporin A and low dose prednisolone. Actuarial survival of patients and grafts at two years was 95% and 72%, respectively, in the continuous ambulatory peritoneal dialysis group compared with 89% and 58%, respectively, in the haemodialysis group. No difference was found in graft survival between short term treatment with continuous ambulatory peritoneal dialysis (72% graft survival) and long term treatment (65% graft survival). In conclusion, continuous ambulatory peritoneal dialysis is suitable treatment for patients awaiting renal transplantation.