Ashish Joshi

Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass

OBJECTIVES Less-invasive options are available for surgical treatment of multivessel coronary artery disease. We hypothesized that stenting combined with grafting of the left anterior descending artery with the left internal thoracic artery through a minithoracotomy (hybrid procedure) would provide the best outcome. METHODS Patients with equivalent numbers of coronary lesions (2.8 +/- 0.4) underwent either hybrid (n = 15) or off-pump coronary artery bypass through a sternotomy (n = 30). Early and 1-year outcomes were compared. Blood drawn from the aorta and coronary sinus immediately postoperatively was analyzed for activation of coagulation (prothrombin fragment 1.2 and activated Factor XII), myocardial injury (myoglobin), and inflammation (interleukin 8) by using an enzyme-linked immunosorbent assay. Target-vessel patency was determined by means of computed tomographic angiographic analysis. RESULTS The hybrid procedure was associated with significantly shorter lengths of intubation and stays in the intensive care unit and hospital and perioperative morbidity (P < .05). Intraoperative costs were increased but postoperative costs were reduced for the hybrid procedure compared with off-pump coronary artery bypass through a sternotomy. As a result, overall total costs were not significantly different between the groups. After adjusting for potential confounders, assignment to the hybrid group was an independent predictor of shortened time to return to work (t = -2.12, P = .04). Patient satisfaction after the hybrid procedure, as judged on a 6-point scale, was greater versus that after off-pump coronary artery bypass through a sternotomy. Finally, the hybrid procedure showed significantly reduced transcardiac gradients of markers of coagulation, myocardial injury, and inflammation and a trend toward significant improvement in target-vessel patency. CONCLUSIONS Perhaps because of reduced myocardial injury, inflammation, and activation of coagulation, patients undergoing the hybrid procedure had better perioperative outcomes and satisfaction, with excellent patency at 1 years follow-up. These promising preliminary findings warrant further investigation of this procedure.

Posterior cruciate-retaining versus posterior-stabilized total knee arthroplasty: a meta-analysis.

The objective of this meta-analysis was to compare outcomes of posterior cruciate-retaining and posterior stabilized prostheses. A computerized literature search was conducted to identify randomized controlled trials comparing the clinical outcomes of cruciate-retaining and posterior-stabilized designs. The table of contents of four major Orthopaedic journals and the references section of two arthroplasty text books were reviewed to identify other relevant studies. Ultimately, 1114 patients (1265 knees) were compared. Statistical analysis revealed a significant difference in flexion and range of motion in favor of posterior-stabilized knees, but no difference in complication rates. The clinical importance of this remains unknown. The decision to use one design versus the other should rest with the surgeons preference and comfort with a particular design.

Renal Impairment Following Total Joint Arthroplasty

Postoperative renal impairment is a serious complication of major surgeries that leads to increased morbidity and mortality. The objective of our study was to identify the risk factors for renal impairment following total joint arthroplasty. Among 17 938 total joint arthroplasties performed between 2000 and 2007, patients developing renal complications were identified. For performing univariate and multivariate analyses, patients with renal impairment were matched in a 1:2 ratio with control group who did not develop renal impairment. Ninety-eight (0.55%) patients developed either acute renal failure or acute renal injury. We identified the following as independent risk factors: elevated body mass index; elevated preoperative serum creatinine; and history of chronic obstructive pulmonary disease, liver disease, congestive heart failure, hypertension, and underlying heart disease. Renal impairment was significantly associated with increased duration of hospital stay and with in-hospital and 1-year all-cause mortality. In high-risk patients, preoperative optimization might be considered in an attempt to reduce the incidence of such a complication.

An Overview of Chronic Disease Models: A Systematic Literature Review

Aims: The objective of our study was to examine various existing chronic disease models, their elements and their role in the management of Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Cardiovascular diseases (CVD). Methods: A literature search was performed using PubMed and CINHAL during a period of January 2003- March 2011. Following key terms were used either in single or in combination such as “Chronic Disease Model” AND “Diabetes Mellitus” OR “COPD” OR ‘CVD”. Results: A total of 23 studies were included in the final analysis. Majority of the studies were US-based. Five chronic disease models included Chronic Care Model (CCM), Improving Chronic Illness Care (ICIC), and Innovative Care for Chronic Conditions (ICCC), Stanford Model (SM) and Community based Transition Model (CBTM). CCM was the most studied model. Elements studied included delivery system design and self-management support (87%), clinical information system and decision support (57%) and health system organization (52%). Elements including center care on the patient and family (13%), patient safety (4%), community policies (4%), built integrated health care (4%) and remote patient monitoring (4%) have not been well studied. Other elements including support paradigm shift, manage political environment, align sectoral policies for health, use healthcare personnel more effectively, support patients in their communities, emphasize prevention, identify patient specific concerns related to the transition process, and health literacy between visits and treatments have also not been well studied in the existing literature. Conclusions: It was unclear to what extent the results generated is applicable to different populations and locations and therefore is an area of future research. Future studies are also needed to test chronic disease models in settings where more racially and ethnically representative patients receive chronic care. Future program development should also include information on other barriers including transportation issues, finances and lack of services.

Role of mobile phone technology in health education in Asian and African countries: a systematic review

The objective of this systematic review was to explore the role of mobile phone technologies in delivering health education programs in Asian and African countries. The search engine used was Pubmed during 2008-2011. Randomised controlled trials or controlled studies that improved health outcomes through delivery of health educational interventions using cell phone or text messaging were included in the review. Results showed studies from six Asian and African countries including Philippines, China, Kenya, South Korea, Taiwan and India. Mobile phone technology has shown to improve health outcomes for chronic disease conditions such as diabetes, heart disease and hypertension. Additional conditions include obesity and cardiopulmonary resuscitation guidance. Other studies have shown improvement in self management of breast cancer and post-hospitalisation HIV and pharmaceutical care. Overall results of the present review showed that mobile phone technologies can be a possible solution to improve healthcare outcome.

Prospective tracking of a pediatric emergency department e-kiosk to deliver asthma education

The study objective was to describe the prospective use of an interactive Patient Education and Motivation Tool (PEMT) placed within a pediatric emergency department (ED). A touch screen computer was utilized to deliver asthma education to children and their parents/guardians during their acute asthma visit between November 2006 and April 2007. Ninety-nine participants were enrolled in this prospective non-randomized pre—post study. PEMT comprised three key components: screening, learning and evaluation. The tool tracked the date the system was used, user characteristics, asthma knowledge, amount of time spent on each screen, and navigational patterns of individuals using the program. The results showed that baseline asthma knowledge had positive association with age and negative association with time spent in the learning module. There was negative association between age and time spent in the learning module. Thus PEMT was effective in improving the asthma knowledge of young patients and those having lower baseline knowledge.

Impact of water, sanitation, and hygiene interventions on improving health outcomes among school children.

Purpose. This review was done to explore the impact of water treatment, hygiene, and sanitary interventions on improving child health outcomes such as absenteeism, infections, knowledge, attitudes, and practices and adoption of point-of-use water treatment. Methods. A literature search was conducted using the databases PubMed and Google scholar for studies published between 2009 and 2012 and focusing on the effects of access to safe water, hand washing facilities, and hygiene education among school-age children. Studies included were those that documented the provision of water and sanitation in schools for children less than 18 years of age, interventions which assessed WASH practices, and English-language, full-text peer reviewed papers. Results. Fifteen studies were included in the final analysis. 73% (n = 11) of the studies were conducted in developing countries and were rural based (53%, n = 8). The childs age, gender, grade level, socioeconomic index, access to hygiene and sanitary facilities, and prior knowledge of hygiene practices were significantly associated with the outcomes. Nutrition practices which are key factors associated with the outcomes were rarely assessed. Conclusion. Further research is required to assess the long-term impact of such interventions in different settings.

Usability of a Patient Education and Motivation Tool Using Heuristic Evaluation

Background Computer-mediated educational applications can provide a self-paced, interactive environment to deliver educational content to individuals about their health condition. These programs have been used to deliver health-related information about a variety of topics, including breast cancer screening, asthma management, and injury prevention. We have designed the Patient Education and Motivation Tool (PEMT), an interactive computer-based educational program based on behavioral, cognitive, and humanistic learning theories. The tool is designed to educate users and has three key components: screening, learning, and evaluation. Objective The objective of this tutorial is to illustrate a heuristic evaluation using a computer-based patient education program (PEMT) as a case study. The aims were to improve the usability of PEMT through heuristic evaluation of the interface; to report the results of these usability evaluations; to make changes based on the findings of the usability experts; and to describe the benefits and limitations of applying usability evaluations to PEMT. Methods PEMT was evaluated by three usability experts using Nielsen’s usability heuristics while reviewing the interface to produce a list of heuristic violations with severity ratings. The violations were sorted by heuristic and ordered from most to least severe within each heuristic. Results A total of 127 violations were identified with a median severity of 3 (range 0 to 4 with 0 = no problem to 4 = catastrophic problem). Results showed 13 violations for visibility (median severity = 2), 38 violations for match between system and real world (median severity = 2), 6 violations for user control and freedom (median severity = 3), 34 violations for consistency and standards (median severity = 2), 11 violations for error severity (median severity = 3), 1 violation for recognition and control (median severity = 3), 7 violations for flexibility and efficiency (median severity = 2), 9 violations for aesthetic and minimalist design (median severity = 2), 4 violations for help users recognize, diagnose, and recover from errors (median severity = 3), and 4 violations for help and documentation (median severity = 4). Conclusion We describe the heuristic evaluation method employed to assess the usability of PEMT, a method which uncovers heuristic violations in the interface design in a quick and efficient manner. Bringing together usability experts and health professionals to evaluate a computer-mediated patient education program can help to identify problems in a timely manner. This makes this method particularly well suited to the iterative design process when developing other computer-mediated health education programs. Heuristic evaluations provided a means to assess the user interface of PEMT.

A pilot study to assess perceptions of using SMS as a medium for health information in a rural setting

BACKGROUND Information and Communication Technologies (ICTs) in health is not merely about technology but a means to reach various optimal outcomes across the entire health system. OBJECTIVE The objective of this pilot study is to assess the perceptions of receiving health messages through SMS among individuals living in rural Indian settings. METHODS A convenient sample of 100 individuals aged 18 years and above and living in rural settings of Kuthampakkam village in Chennai, a Southern part of India were enrolled during September 2013. Individuals having the mobile phone and agreeing to participate were enrolled in the study. Individuals with physical and mental challenges or involved in other clinical trials were excluded from the study. Information was gathered on the variables including socio-demographics, individual familiarity with use of technology, mobile phone usage and the perceptions of using SMS for obtaining health information. Information was gathered using a series of quantitative assessments. Descriptive analysis was performed to report means and standard deviations for the continuous variables and frequency analysis was reported for the categorical variables. Analysis of variance (ANOVA) was used to compare the means of the various continuous variables as compared to the chi-square analysis that was performed to compare the frequency distribution for the categorical variables. All analysis was performed using SAS v9.1. RESULTS A convenient sample of 100 rural individuals was enrolled. The average age of the study participants was 34 years (SD=17), with more than half of them being males (54%; n=54), and 47% (n=47) of them had education less than high school. Results showed that more than half of the individuals had no computers either at home (61%; n=61) or work (68%; n=68). 100{\%} of them had mobile phones in their household. Text messaging was common in more than half of the study participants. Results showed that the majority of the study participants agreed that receiving calls on the mobile phones for receiving health messages would be the most preferred method. Results showed that the individuals in the age group of 21-40 years, males, with some college education, and in the income category of 50,000-1,00,000 were most likely to obtain SMS based health messages. CONCLUSIONS ICT based health programs need to be established so that the audience receives the optimal technological platform program necessary to obtain health messages. This also suggests that future research is needed to determine the population that would actually adopt the use of SMS based health interventions rather than using SMS as a tool for delivery of health information to all.

Evaluation of a tele-education programme in Brazil

We evaluated a tele-education programme for primary care staff in Pernambuco State, Brazil. During 2008 and 2009, tele-education sessions occurred four times each week for one hour per day. The topics included public health, child and adolescent health, mental health and nursing. After each session, participants completed an evaluation questionnaire. A total of 73 municipalities and 141 health centres participated in the programme. There were 254 tele-education sessions scheduled during the 20-month study period; of these, 224 sessions were successfully performed and 30 were cancelled. We collected 3504 responses from the satisfaction survey. There was high acceptance of the programme: 97% rated it as excellent or good.