Class of 2011 Abstract / OBJECTIVES: The objective of this study was to compare patient clinical outcomes, vascular access line administration complications, and piperacillin-tazobactam costs before and after implementation of an extended infusion piperacillin-tazobactam protocol in adult patients at an academic medical center. METHODS: In this IRB-approved retrospective project, the effect of the implementation of a piperacillin- tazobactam extended infusion protocol at a tertiary care, academic medical center was accessed. The use of piperacillin-tazobactam was accessed during 3 one-month time periods in 2010: Time Period 1 (pre-education and implementation of protocol), Time Period 2 (post-education of pharmacists and infectious disease physicians), and Time Period 3 (post-education of healthcare professionals and implementation of extended-infusion piperacillin- tazobactam protocol). Patients were excluded if piperacillin-tazobactam therapy was prescribed for less than 72 hours. Data collected in each one-month period included demographic data, culture results, number of piperacillin-tazobactam grams prescribed per day, percentage of patients who received extended-infusion piperacillin-tazobactam, other antimicrobial therapy prescribed, medications prescribed with intravenous incompatibilities with piperacillin-tazobactam, number of intravenous line lumens before and after start of piperacillin-tazobactam therapy, length of stay, and all-cause 30 day mortality. RESULTS: During a three step process, the use of extended infusion piperacillin-tazobactam was implemented at an academic medical center after administration approval, education of healthcare professionals, and development of an electronic piperacillin-tazobactam order set. Use of extended-infusion piperacillin-tazobactam protocol significantly decreased the average daily piperacillin-tazobactam dose per patient. CONCLUSION: Implementation of extended-infusion piperacillin-tazobactam protocol for adult patients did significantly decrease the average daily dose of piperacillin-tazobactam per patient (reduced drug cost) but increased vascular access requirements.

Unauthorized reproduction of this article is prohibited. Background:Mental health conditions are common among persons with HIV (PWH). An understanding of factors associated with prescription medication use for these conditions and clinical impact of the prescription medications may improve care of mental health disorders in PWH.Methods:Psychotropic medication use was examined among PWH within the AIDS Clinical Trials Group A5322 (HAILO) study. Multivariable logistic models and Cox regression models estimated the association between psychotropic medications (any/none) with baseline and incident slow gait (>1 s/m) and neurocognitive impairment (NCI) for more than 4 years.Results:Of 1035 participants, the median age was 51 years.81% were men, 30% black, non-Hispanic, and 20% Hispanic. Psychotropic medication use was similar between men (34%) and women (38%; P = 0.19). PWH using psychotropic medications had greater odds of baseline slow gait {odds ratio 1.61, [95% confidence interval (CI): 1.23 to 2.10]; P < 0.001}. Men but not women using psychotropic medications had an increased risk of developing slow gait [hazard ratio 1.85; (1.29 to 2.65) vs 0.77; (CI: 0.35 to 1.68), P interaction = 0.045]. The sex-specific odds ratios for medication use and NCI were qualitatively but not statistically different [men: 1.79; (1.14-2.80); women: 1.27; (0.56-2.90); P interaction = 0.47]. Psychotropic medication use was associated with an increased risk of incident NCI [hazard ratio 2.18; (95% CI: 1.23 to 3.84), P = 0.007] in both men and women.Conclusions:Psychotropic medications are associated with impairment in functional outcomes of aging, with a greater risk of baseline NCI and incident slow gait among men. Further investigation is needed to optimize outcomes in PWH and prescription of psychotropic medications among both men and women.

Introduction: Proton pump inhibitors (PPI) may impair the biotransformation of clopidogrel leading to increased major adverse cardiac events (MACE). Available studies have focused solely on patients receiving clopidogrel following a cardiac event. Given the widespread use of this combination, (about 64% in a recent study), this represents a major interaction that deserves further study. The objective of this thesis was to determine if the potential interaction between PPIs and clopidogrel leads to an increase in MACE in high-risk atherosclerotic patients receiving clopidogrel and PPIs as compared to clopidogrel alone. Methods: We conducted a retrospective chart review of patients in the University Hospital System who received clopidogrel between January 1, 2007 and April 30, 2009. Patients were included if they were hospitalized for acute coronary syndromes, stroke/TIA, revascularization (coronary, cerebral or peripheral arteries), or aspirin allergy. The primary outcome was the composite of myocardial infarction (MI), stroke/transient ischemic attack (TIA), coronary artery revascularization, or death (all cause) during the first year following discharge. Secondary outcomes included the composite of MI, stroke /TIA, revascularization (coronary, cerebral or peripheral arteries), or death. Bivariate analyses were conducted using Student’s t test, Mann Whitney U and Chi-square tests where appropriate. Multivariate analysis was conducted to adjust for baseline differences. Results: Overall, 1700 charts were reviewed and 572 patients met study criteria. The median follow-up was 332 days. The most common indication for clopidogrel use was coronary artery revascularization (66%). There were 201 patients in the clopidogrel with PPI group and 371 patients in the clopidogrel without PPI group. Baseline characteristics were evenly matched between both groups except for smoking, liver disease, and prior receipt of a PPI. The primary endpoint occurred in 21 patients in the clopidogrel with PPI group and 38 patients in the clopidogrel without PPI group (10% vs. 10%, p = 0.9, OR 1.02, 95% CI 0.58 – 1.80). The primary endpoint was unchanged after multivariate adjustments for baseline differences (adjusted OR 0.98, 95% CI 0.54 – 1.75). Likewise, there was no difference in the secondary endpoint (14% vs. 15%, p = 0.8, OR 1.02; 95% CI 0.58 – 1.80). The secondary endpoint was also unchanged after multivariate adjustments for baseline differences (adjusted OR 1.04, 95% CI (0.61 – 1.75) Conclusion: Patients receiving clopidogrel with a PPI demonstrated similar rates of MACE when compared to patients receiving clopidogrel without a PPI. / text

Background and aims: Hypertension is a public health problem and a major reason for hospitalisation and death. In Mozambique, low levels of detection, treatment and control have been described. However, data on target-organ damage and associated clinical conditions is lacking. We therefore aimed at characterising the clinical profile of patients with severe hypertension, describing the pattern of target organ damage and determining the outcomes at 6-month follow-up. Methods: We designed a prospective descriptive cohort study to assess adult patients with severe hypertension defined according to the Joint National Committee VII guidelines. The study was conducted from July 2015 to May 2017 at Mavalane General Hospital in Maputo-Mozambique. Patients were characterized through physical examination, laboratory profile, electrocardiography, and echocardiography, and followed for six months to assess occurrence of complications such as hypertensive heart failure, stroke, renal failure, hospital admission and death. Data were analysed using SPSS software version 20.0. The study was approved by the National Bioethics Committee for Health of Mozambique. Results: We studied 116 subjects (111 [95.7%] black; women 81 [70%]). Women were slightly younger than men (mean 57 years vs 59 years); 18 (15.5%) patients were younger than 44 years. The risk profile of the studied population included obesity (46; 42.5%); dyslipidaemia (59; 54.1%); diabetes (10; 8.6%) and smoking (8; 6.9%). At baseline, mean values for systolic and diastolic blood pressure were 192.3 ± 23.6 and 104.2 ± 15.2, respectively. The most frequent target-organ damage were left atrial enlargement in 91 (88.3%) with atrial fibrillation in 9 (7.9%); left ventricular hypertrophy in 57 (50.4%); hypertensive retinopathy in 30 (26. 3%) and renal damage in 29 (25.7%) subjects. Major events during 6-month follow-up were hospitalisations (12; 10.3%) and death (10; 8.6%). Renal damage (4; 4.2%), stroke (4; 3.4%) and heart failure (2; 1.7%) were the most common complications occurring over the follow up period. Conclusion: Severe and complicated hypertension affects young people with higher incidence of obesity, diabetes and smoking than that found in general population. High occurrence of target organ damage is found at baseline, particularly heart damage, renal lesion and stroke. On follow up, severe hypertension is associated with high number of hospitalisations and high case-fatality rate. Moreover, renal damage, stroke and hypertensive heart disease were common complications on follow up. Further research is needed to understand the determinants of these poor outcomes.

Problem: While the educational preparation of students in a tertiary nursing programme was the general focus of the study, the specific concern was with the degree to which students in the first and third year of the programme implemented all aspects of the nursing process in their delivery of patient care. The study developed out of a need to evaluate the effectiveness of theoretical teaching in regard to the students' ability to implement theoretical principles in clinical practice. The desired outcome of the study is that the data will be useful in developing more appropriate and effective teaching approaches that will result in improved clinical nursing practice. Methodology A survey of patients receiving nursing care from students in the first and third year of their programme was conducted on completion of a one week block of clinical experience for both groups of students. A questionnaire was the instrument of data collection. Factors included in the study were the patients' perceptions of the students' attention to four of the five phases of the nursing process: assessment, diagnosis, planning and evaluation. Questions addressing the degree of patient involvement in all of these phases were included throughout the questionnaire. Questionnaires were returned from twenty nine of the thirty one patients surveyed in the first year student group and from thirty of the thirty one patients surveyed in the third year student group; constituting a 93.5 percent and a 96.7 percent response respectively. Results The scores achieved by each group of students were compared against scores determined by the researcher to indicate realistic educational and professional standards of practice in each specified section and comparisons were also made between the two students groups to identify development of practice over the education programme. Scores indicated that: 1. Within each section of the study both student groups scored below the expected level on certain items, the most notable deficiencies being related to the aspects of patient empowerment through informing and involving. 2. The third year student group scored overall higher than the first year students in regard to attention to the more 'technical' aspects of the nursing process, but did not give the same degree of attention to the 'human' aspects, scoring equal to, or lower than their less experienced colleagues. Conclusions: 1. There are apparent philosophical differences between the graduates of the 'old style' training system and those involved in the tertiary nursing programme in regard to the individualization of patient care and the allocation of priorities within a time frame. 2. Clinical application of theoretical principles relies heavily on the reinforcement of these principles by the clinical teacher/supervisor. There is a need for these clinical supervisors to have: (a) a better understanding of the educational objectives for students in the clinical settings, and (b) assistance towards developing teaching/organizational strategies that will guide the student towards objective attainment when such abilities are not developed. Recommendations: Among the recommendations presented were: 1. that the nursing discipline within the university make formal and informal opportunities to inform all clinicians of the changes in nursing education and the implications these changes have on the overall approach to the delivery of patient care. 2. that there is an increased emphasis on the educational preparation of the clinical supervisors and that their commitment to the students' achievement of the clinical objectives is enhanced through involvement in programme planning and evaluation.

Abstract available in the JACC Cardiovascular Interventions.

No description available.

The number of patients electing to undergo total hip arthroplasty (THA) in the United States has been projected to double by the year 2030, with a growing number of these patients below the age of 65 years. This cohort of patients not only desires to return to pain free daily activity, but wishes to participate in recreation and sporting activities. However, many of these patients report pain, impairments, and functional limitations following THA. The number one deficit observed for patients who fail conventional post-operative rehabilitation is persistent weakness of the hip abductor muscles. In order to safely progress these patients back to their desired activity level, appropriate postoperative rehabilitation programs need to be developed. The primary objective of this dissertation was to examine the effectiveness of a hip abductor strengthening program on subjective and objective outcomes following THA. The secondary aims of this study were to document hip muscle activation and lower extremity movement patterns during functional exercises; and to compare shortterm subjective and objective clinical outcomes for subjects following THA compared to controls. Several observations were made from our results. First, the lunge, single leg squat, and step-up and over exercises may be appropriate to include in post-operative rehabilitation programs to transition THA subjects from static strengthening exercises to dynamic activities. Second, subjects at 6- and 12-weeks following THA continue to exhibit strength and functional deficits, which contributes to decreases in activity level. Third, the addition of an exercise program targeting the hip abductor muscles following THA may help to improve subjective and objective outcomes compared to conventional post-operative rehabilitation. Finally, findings from our results are summarized and we propose a model to develop patient-specific rehabilitation programs.

Background: Many innovative ideas have been proposed to manage and improve the quality and cost of clinical care. For many innovations, like Total Quality Management (TQM), the &quotblack box&quot of implementation process is not well understood. Empirical work on the process of innovation implementation in health care is limited. Objective: This study was designed to explore how one organisation, Intermountain Health Care (IHC), an acute and primary health care provider in the USA, innovates in implementing TQM organisation-wide to improve and manage clinical quality. More broadly, the study aims to identify factors that contribute to innovation implementation in health care for clinical quality improvement, and to generate a model of innovation implementation in health care for clinical quality improvement. Method: This thesis takes a case study approach using multiple research methods. The main methods used comprise interviews with key personnel, assessment of organisational documents and a survey of clinicians' and managers' attitudes and beliefs. Findings: The main finding of the research is that innovation implementation at IHC was a journey, not a destination. Embedded in the journey were five periods and many actions and interactions, grouped into eleven elements. The five periods were: exposing to an innovative idea, embracing the idea, extending knowledge and experience on the idea, emerging of strategies to implement the idea organisation-wide, and enacting and adapting the strategies. The eleven elements were: gestation, shocks, plan, proliferation, fluid participation, setbacks, criteria shift, top executive involvement, relationships and infrastructure building, and adoption. To implement TQM organization-wide, integrated structures and systems were being instituted. The study found that resistance to change came from not only some physicians but also hospital administrators. The study also found that supportive environments played a critical role in the journey. While the TQM implementation at IHC resulted in some cost savings and some behavioural changes including clinical practice change, cultural change at the level of values and beliefs had yet to occur. Conclusion: A process-oriented integrative model of clinical service management is proposed. The elements of an innovation, the temporal change processes, lead to formation and changes of the ongoing organisational processes, which in turn evaluate and improve the important clinical processes. These processes integrate TQM with other quality improvement approaches; also ensure that quality is part of the dialogue between key stakeholders who are responsible for managing and improving clinical quality and costs. These processes also are capable of dealing with dilemmas faced in health care and the constantly created managerial ideas and clinical knowledge. Key Words: Innovation, Clinical Outcomes, Knowledge, Quality and Costs, TQM Management

ABSTRACT In the modern era, the most common post-operative complications following cardiopulmonary bypass (CPB) are neurocognitive deficits (NCD) and atrial fibrillation (AF). Both morbidities have been linked to inflammation resulting from surgery, anesthesia and CPB. Microemboli, inadequate oxygen delivery and the inflammatory response consequent to blood contacting artificial components of the CPB circuit have all been linked to postoperative NCD and to a lesser extent post-operative AF. The artificial components of the CPB circuit consist of stainless steel, polyvinylchloride (PVC), polycarbonate and other carbon-based plastics. In order to attenuate the negative sequelae of blood-circuit contact related inflammatory response, industry developed the biocompatible circuit (BCC) coating for the disposable CPB circuits. Four such coatings were studied and compared to an uncoated control group in a total of 101 patients undergoing routine CPB-assisted cardiac surgical procedures. Soluble adhesion molecule (SAM) activation was studied at different time points and common clinical outcomes such as white blood cell activation, serum renal function parameters urea and creatinine, postoperative bleeding, transfusion requirements, intensive care and hospital length of stay, CPB pump volume balances, changes in weight, postoperative serum lactate and glucose and the development of AF postoperatively, were compared. Additionally, postoperative neurocognitive testing was performed using a simple bedside neurocognitive test called the antisaccadic eye movement test. The patients in all groups were tested for comparison preoperatively and 72 hr postoperatively. Results: The mandate of BCC coating development and manufacture is to attenuate the well-documented and demonstrated inflammatory response consequent to the contact of blood with artificial CPB surfaces. The studied BCCs significantly decreased platelet transfusions in females. In addition, the BCCs decreased the concentrations of 2 SAMs when measured 6 hours after surgery and CPB. The difference in SAM expression seen between the coated and uncoated groups at 6 hr was no longer apparent at 72 hr. Very little difference was noted between the four BCC groups. Patients who developed AF postoperatively seemed predisposed to do so as the serum levels of soluble vascular cell adhesion molecule was significantly higher at baseline and remained so at 6 and 72 hr. The decreased platelet transfusions in females resulting from BCC use is a highly significant finding within this high-risk group of patients. As most platelet transfusions occur soon after the patient is disconnected from CPB, the short-term decrease in SAM activation can be linked to this improved clinical finding. The studied BCC coatings have achieved limited success in their intended mandate to attenuate inflammatory response in terms of improved clinical and laboratory desired outcomes.