L’iatrogénie médicamenteuse à l’hôpital est un problème majeur de santé publique dont les causes sont multiples. La diffusion de recommandations de bonnes pratiques de prescription pourrait permettre de diminuer ce phénomène. L’objectif de cette thèse est de modéliser un vecteur possible des bonnes pratiques de prescription, celui des interventions pharmaceutiques. Ce travail se décline en trois séquences : 1.contexte et justification, 2.développement d’un outil de documentation et d’analyse des interventions pharmaceutiques, 3.évaluation d’un modèle de diffusion des recommandations associant l’intervention d’un pharmacien clinicien intégré dans l’unité de soins à un rappel informatique de l'intervention au moment de la prescription. L’ensemble de ces données assoit la pertinence d’une diffusion des interventions pharmaceutiques basée sur les outils technologiques et les activités de pharmacie clinique. / Medication errors in hospitals have become a major public health problem with multiple causes. The diffusion of prescription guidelines could reduce this phenomenon. The objective of this thesis is to modelize a potential vector of prescription guidelines: the pharmacists’ interventions. This work is declined in three sequences: 1.context and justification, 2.development of a tool for the documentation and the analyse of pharmacists’ interventions, 3.assessment of a model of prescription guidelines diffusion combining intervention of a clinical pharmacist integrated into clinical ward with a computerized reminder of the intervention. Our data supports the relevance of pharmacists’ interventions diffusion based on technological tools and clinical pharmacy activities.

Purpose/Aims: The American Thoracic Society (ATS) published recommendations for alpha-1 antitrypsin deficiency (AATD) testing in 2003. This descriptive project evaluates the outcomes of ATS AATD guideline use in the setting of the pulmonary function testing (PFT) lab.The specific aims met by this descriptive project describe the prevalence of AATD cases and carriers in the sample, examine to what degree the established clinical guideline promoted accurate patient selection for the alpha-1 test in the sample, and aimed to determine whether alpha-1 antitrypsin blood levels are reduced in current smokers compared to former or never smokers.Background: Alpha-1 antitrypsin prevents lung tissue breakdown by attenuating excess elastase released from neutrophils during the inflammatory response. Smoking impairs alpha-1 antitrypsin protection at the site of lung inflammation promoting emphysema development. In the case of genetic mutation, protective alpha-1 antitrypsin levels are reduced, causing emphysema even in non-smokers. Significantly reduced protective levels of alpha-1 antitrypsin increase the odds for morbidity and early mortality from emphysema. The literature provides support for targeted testing in the population most affected.Sample/Methods: The sample population included adults 21 through 79 years completing pulmonary function testing over 18 months in a metropolitan pulmonary medicine practice and was retrospectively reviewed.Of the 521 in the sample, 190 were tested for AATD, and 24 were found to carry an abnormal genotype. However, using Table 11 from the ATS CPG failed to provide structured, consistent guidance in selecting patients for AATD testing. Still, the prevalence of the abnormal genotypes MS, MZ, SZ, and ZZ was increased in this pulmonary population compared to the published estimated prevalence for the general population.A structured decision-tree, developed from the original guideline for diagnostic testing, may provide superior guidance for AATD test patient selection in this setting. Increased case finding by targeted testing of patients in the setting of the pulmonary function lab can serve to integrate this clinical practice guideline in a consistent streamlined fashion.In this sample, no difference between AAT blood levels among ever, never, and current tobacco smokers was detected. A more powerful sample is needed.

No description available.

Bakgrund: Våld mot kvinnor i nära relation är ett globalt hälsoproblem. Ett svenskt universi- tetssjukhus har tagit fram en handlingsplan för omhändertagande av våldsutsatta kvinnor och det finns evidens för att avdelningschefer spelar en stor roll för implementeringen av hand- lingsplaner. Syfte: Syftet med föreliggande studie är att undersöka avdelningschefers erfarenheter av att implementera en handlingsplan om våldsutsatthet; “Våldsutsatta kvinnor - en handlingsplan för omhändertagande”, samt att undersöka vilka hinder och underlättande faktorer som ligger bakom implementeringen. Metod: Studien genomfördes med en kvalitativ metod i form av semistrukturerade intervjuer. Sju avdelningschefer från sju olika avdelningar inom fem divisioner intervjuades vid ett svenskt universitetssjukhus som har en handlingsplan för omhändertagande av våldsutsatta kvinnor. Intervjuerna genomfördes med stöd av en intervjuguide, och resultatet analyserades med hjälp av en kvalitativ innehållsanalys. Huvudresultat: Majoriteten av informanterna hade inte implementerat handlingsplanen. För- sök till implementering hade genomförts dels genom att föra in frågan om våld i ett inskriv- ningsformulär eller genom att ta upp handlingsplanen på arbetsplatsträffar eller andra perso- nalmöten. De rapporterade hinder och underlättande faktorer som finns i samband med im- plementeringen av handlingsplanen för våldsutsatta kvinnor berodde på avdelningsschefen själv, verksamheten, dokumentationen och olika resurser. Slutsats: Idag går det inte att implementera handlingsplanen full ut. Informanterna upplevde detta som frustrerande och menar att en tydlig struktur av handlingsplanen från sjukhusled- ningen krävs för att kunna förankra handlingsplanen i verksamheten. Fler studier bör genom- föras på fler avdelningar då verksamhetens patientgrupp påverkade hur informanterna förhöll sig till handlingsplanen. / Background: Intimate partner violence against women is a global health problem. A Swedish university has developed a guideline for the care of abused women and there is evidence that nurse managers play a major role in the implementation of guidelines. Aim: The aim of the present study is to investigate the nurse managers' experiences of im- plementing a guideline on domestic violence; "Abused women - a guideline for disposal" and to explore the barriers and facilitating factors behind the implementation. Method: A qualitative study was conducted. Seven nurse managers from seven different wards within five divisions were interviewed at a Swedish university hospital that has a guideline for the care of abused women. Data were collected through semi-structured intervi- ews using an interview guide, and the results were analyzed using a qualitative content analy- sis. Main result: The majority of respondents had not implemented the guideline. Attemts to im- plement the guideline had been carried out, partly by bringing in the issue of violence in an enrollment form, or by taking up the guideline at workplace meetings and other staff mee- tings. The reported barriers and facilitating factors that are associated with the implementation of the guideline for abused women was due to the nurse manager, operations, documentation and various resources. Conclusion: Today it is not possible to implement the guideline completley. The informants experienced this as frustrating and believes that a clear structure of the guideline from the hospital management is required to anchor the guideline into the wards activity. More intervi- ews should be conducted in other wards as the group of patients, treated at the ward, affected how informants conducted the guideline.

Background: The goal of the study was to evaluate the masticatory efficacy in patients who had been provided with resection prostheses after tumor removal in the maxillary/ mandibular region. These patients complained of impairment of masticatory function. Patients and Methods: 3 groups of patients were compared under clinical-experimental conditions. A uniform chewing material was masticated by the participants under standardized conditions. A sieving procedure was used to evaluate the masticatory efficacy. Analysis of the particle sizes and particle masses obtained was performed with the aid of computers. Results: The results showed that the masticatory efficacy of the patients with resection prostheses was the lowest of the 3 groups compared. The number of existing supporting zones and the location of the defect were found to be important influencing factors. Recording of the dietary habits of all patients was performed using a standardized dietary questionnaire. These data were analyzed using the corresponding software of the German Nutrition Society. With regard to the patients with resection prostheses, it was revealed that they often switched to food that did not require mastication. Conclusions: A nutritional guideline for patients with resection prostheses was developed, which is available for downloading free of charge on the Internet. / Hintergrund: Ziel der Untersuchung war die Prüfung der Kaueffektivität bei Patienten, die mit Resektionsprothesen nach Tumorentfernung im Kieferbereich versorgt worden waren. Diese Patienten klagten über eine Einschränkung der mastikatorischen Funktion. Patienten und Methoden: Unter klinisch xperimentellen Bedingungen erfolgte der Vergleich von 3 Patientengruppen. Unter standardisierten Bedingungen zerkleinerten die Patienten einheitliches Kaugut. Zur Bewertung der Kaueffektivität wurde ein Siebverfahren eingesetzt. Die Auswertung der ermittelten Partikelgrößen und Partikelmassen erfolgte computergestützt. Ergebnisse: Die Ergebnisse zeigten, dass im Vergleich der 3 Gruppen die Kaueffektivität der Patienten mit Resektionsprothesen am geringsten war. Die Zahl der vorhandenen Stützzonen des Restgebisses und die Defektlokalisation wurden als bedeutsame Einflussfaktoren ermittelt. Die Erfassung der Ernährungsgewohnheiten aller Patienten erfolgte mittels eines standardisierten Ernährungsfragebogens. Diese Daten wurden mit der zugehörigen Software der Deutschen Gesellschaft für Ernährung ausgewertet. Bei den Patienten mit Resektionsprothesen zeigte sich, dass diese auf Nahrungsmittel ausweichen, die kein Kauen erfordern. Schlussfolgerungen: Es wurde eine Ernährungsrichtlinie für Patienten mit Resektionsprothesen abgeleitet, die zum kostenfreien Herunterladen im Internet zur Verfügung steht. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation. Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing. Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial. Methods Phase I: Intervention Development 1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes. 2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted. 3. Four units were randomized to control or experimental groups. 4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use. Phase II: Evaluation 5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score. 6. Qualitative interviews evaluated the intervention and leadership behaviours. Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings. Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders. Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.

Coronary artery disease (CAD) is the leading cause of death worldwide. Treatment with coronary interventions, long-term treatment and life style changes can reduce symptoms and improve prognosis. The aim of this thesis was to investigate aspects of invasive treatment for multivessel coronary artery disease, and to investigate adherence to prevention guidelines one year after myocardial infarction.  We used the national quality registry SWEDEHEART to collect data on long term treatment one year after myocardial infarction for 51 620 patients < 75 years of age. For 17 236 of the patients, we collected LDL-cholesterol measurements from SWEDEHEART and defined use of lipid lowering drugs from the Prescribed Drug Register. We developed a questionnaire for post-PCI-patients to investigate patients’ understanding of cause and treatment of coronary artery disease. For 23 342 PCI-patients with multivessel coronary artery disease, SWEDEHEART-data was linked to Swedish health data registries to determine one year outcome for patients undergoing incomplete vs. complete revascularization.   Lipid control (LDL-cholesterol < 1.8 mmol/L) was attained by one in four patients one year after myocardial infarction, whereas blood pressure control (< 140 mmHg) was attained by two thirds of patients. Lipid and blood pressure control was lower for women but there was no gender difference in smoking cessation rate: 56 %. Over 90 % of patients were treated with a statin after myocardial infarction but treatment was intensified for only one in five patients with LDL-cholesterol above target. The questionnaire study revealed that non-modifiable factors such as age and heredity were more often seen as cause of coronary artery disease than modifiable life style factors. Only one in five patients perceived CAD as a chronic illness, requiring life style changes. Two thirds of PCI-patients with multivessel disease underwent incomplete revascularisation, and this was associated with a twofold risk for the combination of death, myocardial infarction and repeat revascularization up to one year, compared to patients who underwent complete revascularization. We conclude that  long term treatment after myocardial infarction is suboptimal in relation to guideline recommendations. Assessment of patients’ views on CAD and better health education post PCI may facilitate life style changes. Further studies need to investigate whether complete revascularization will improve outcome for PCI-patients with multivessel disease.

Thesis (Ph.D. in Clinical Sciences) -- University of Colorado at Denver and Health Sciences Center, 2005. / Typescript. Includes bibliographical references (leaves 100-112). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

O câncer representa um importante problema de saúde pública no mundo, devido ao aumento da sua prevalência, além do grande impacto individual, institucional e social. Assim, merece uma abordagem ampliada, integral e interdisciplinar, a fim de minimizar as seqüelas decorrentes da doença ou do seu tratamento, visando à cura com manutenção da qualidade de vida (QV). Dessa forma, este trabalho teve como objetivos descrever o perfil sócio-demográfico e de saúde bucal de pacientes com câncer de cabeça e pescoço assistidos no HNSC, Porto Alegre – RS e, verificar o impacto na QV destes de um protocolo de cuidados odontológicos sistemático, antes, durante e depois da terapia oncológica. O estudo, delineado como um Ensaio Clínico Randomizado, teve a participação de 46 sujeitos com diagnóstico de neoplasia primária de cabeça e pescoço, captados por conveniência, consecutivamente e distribuídos aleatoriamente em dois grupos. No grupo controle, os pacientes foram examinados e orientados sobre os possíveis efeitos do tratamento oncológico e encaminhados aos serviços de atenção básica de referência para atendimento odontológico. No grupo intervenção, os pacientes foram examinados e orientados, sobre os possíveis efeitos do tratamento oncológico. Os sujeitos incluídos neste grupo receberam um protocolo de cuidados odontológicos na instituição, com acompanhamento profissional sistemático antes, durante e depois da terapia oncológica. Também foram fornecidas, aos cuidadores e pacientes, em ambos os grupos, orientações sobre os possíveis efeitos secundários da terapia oncológica e de ações para minimizar estes problemas. Os dados coletados referem-se a condições sócio-demográficas e de saúde bucal e também de avaliação da QV através de dois questionários - EORTC (específico para pacientes com câncer de cabeça e pescoço) e WHOQOL (avaliação geral da QV), aplicados em dois momentos distintos: antes e quinze dias depois da terapia oncológica concluída. Os resultados mostraram uma maior prevalência do câncer de cabeça e pescoço em homens, de baixo nível educacional e sócio-econômico, com pobre condição oral e média de idade de 54,2 anos. O diagnóstico histopatológico mais freqüente foi o carcinoma epidermóide, sendo as localizações preferenciais a língua e orofaringe. Mais de 60% dos diagnósticos foram realizados nas fases avançadas (III e IV – TMN) e os principais tratamentos realizados a cirurgia e a radioterapia. Apesar das características basais serem desfavoráveis, o grupo intervenção apresentou melhora na avaliação geral de QV e manutenção da específica após o tratamento oncológico, enquanto que o grupo controle mostrou piora em ambos, porém não houve diferença significativa entre os grupos. Entretanto, a variação das medidas (delta) no grupo intervenção, quando comparadas as características basais e finais, mostra uma projeção que tendencia uma melhoria significativa ao longo do tempo. Verifica-se também uma redução de candidíase (p<0,05) e mucosite no grupo intervenção. Conclui-se que os pacientes assistidos no Serviço de Oncologia do HNSC apresentaram o perfil típico dos tumores de localização de cabeça e pescoço no país, com maior prevalência de homens, tabagistas, de baixo nível sócio-econômico e educacional e pobre saúde oral. O protocolo de cuidados odontológicos desenvolvido foi capaz de reduzir danos decorrentes da terapia oncológica, além de poder contribuir para uma melhoria da QV ao longo do tempo aos pacientes com câncer de cabeça e pescoço. / Cancer represents a major public health problem all over the world due to the increase in its prevalence, besides its great individual institutional, and social impact. Thus, it deserves a wide, integral, and interdisciplinary approach in order to minimize the sequelae resulting from the disease or its treatment, and aiming to the healing with maintenance of the quality of life (QoL). This way, this study aimed to describe the social-demographic and oral health profile of head and neck cancer patients treated in Hospital Nossa Senhora da Conceição (HNSC), Porto Alegre, Brazil, and to check the impact of a systematic dental care guideline on the QoL before, during, and after the oncological therapy. The study, designed as a Randomized Clinical Trial, had the participation of 46 subjects with diagnosis of head and neck primary neoplasy, captured by convenience, consecutively, and randomly distributed in two groups. In the control group, patients were examined and advised about the possible effects of the oncological treatment and referred to the basic health care services for dental care. In the test group, patients were examined and advised about the possible effects of oncological treatment. The subjects included in this group received a dental care guideline in the institution, with a systematic professional follow-up before, during, and after the oncological therapy. Also, both caretakers and patients from each group received guidance about the possible secondary effects of the oncological therapy and the actions to minimize these problems. Collected data refer to the social-demographic and oral health status, as well as the evaluation of QoL by means of two questionnaires - EORTC (specific for head and neck cancer patients), and WHOQOL (general evaluation of QoL). These were administered in two distinct moments: before the onset and fifteen days after the conclusion of the oncological therapy. Results showed a higher prevalence of head and neck cancer in men, with low educational and social-economic level, with a poor oral condition, and an average age of 54.2 years. The most frequent histopathological diagnosis was epidermoidis carcinoma, being the preferential sites the tongue and the oropharynx. More than 60% of the diagnosis was done in the advanced phases (III e IV – TMN), and the main treatments performed were surgery and radiotherapy. In spite of the unfavorable baseline characteristics, the test group showed an improvement in the general evaluation of QoL, and maintenance of the specific QoL after the oncological treatment. The control group showed a worsening in both of them, although there was no significant difference between the groups. However, the range of the measures (delta) in the test group, when compared to the baseline and final characteristics, shows a projection tending to a significant improvement along time. A decrease in candidiasis (p<0,05) and muccositis was also shown in the test group. It is concluded that the patients treated in the Oncology Service of HNSC have shown a profile that is typical of the head and neck tumors in the country, with higher prevalence in men, smokers, low social-economic and educational level, and poor oral health. The dental care guideline that was developed was able to decrease harm resulting from the oncological therapy, as well as to contribute for an improvement of QoL along the time for the patients with head and neck cancer.

The purpose of this study was to describe the characteristics and findings of antimalarial drug efficacy studies conducted in Ethiopia and to use the findings to formulate recommendations for antimalarial drug efficacy monitoring and use of evidence to inform antimalarial treatment policy for the Ethiopian setting. This study reviewed 44 antimalarial efficacy studies conducted in Ethiopia from 1974 to 2011. The analysis of results indicated that chloroquine as the first-line antimalarial drug for the treatment of malaria due to Plasmodium falciparum had a 22% therapeutic failure in 1985. Chloroquine was replaced with sulfadoxine-pyrimethamine in 1998, more than 12 years later, when its therapeutic failure had reached 65%. Sulfadoxinepyrimethamine at the time of its introduction had a treatment failure of 7.7%; it was replaced after seven years in 2004 by artemether-lumefantrine; by then its treatment failure had reached 36%. The WHO recommends the replacement of a first-line antimalarial drug when more than 10% of treatment failure is reported. The replacement drug should have a therapeutic efficacy of more than 95%; while the change itself should be completed within two years. The prolonged delay to replace failing antimalarial drugs in Ethiopia seems to have been influenced mainly by the lack of systematic antimalarial drug efficacy data collection and pragmatic use of the data and evidence gathered.Almost eight years after its introduction, isolated studies show that the efficacy of artemether-lumefantrine has decreased from 99% in 2003 to around 96.3% in 2008. Though this decrease is not statistically significant (chi-square 1.5; P=0.22) and has not reached the threshold of 10%, it is plausible that its efficacy may drop further. This is mainly due to regulatory provisions in the country that allow marketing of oral artemisinin mono-therapies that are not recommended for malaria treatment, use of less effective antimalarial combination drugs in the neighboring countries and widespread drug quality problems. The situation calls for and this study recommends the establishment of stringent drug efficacy monitoring and early warning system and alignment of the antimalarial drug regulatory practices with recommendations of the WHO. / Health Studies / D. Litt. et Phil. (Health Studies)