Seval Kul

Effects of care pathways on the in-hospital treatment of heart failure: a systematic review

BackgroundCare pathways have become a popular tool to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. We performed a disease specific systematic review to determine how care pathways in the hospital treatment of heart failure affect in-hospital mortality, length of in-hospital stay, readmission rate and hospitalisation cost when compared with standard care.MethodsMedline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched from 1985 to 2010. Each study was assessed independently by two reviewers. Methodological quality of the included studies was assed using the Jadad methodological approach for randomised controlled trials, controlled clinical trials and the New Castle Ottawa Scale for case–control studies, cohort studies and time interrupted series.ResultsSeven studies met the study inclusion criteria and were included in the systematic review with a total sample of 3,690 patients. The combined overall results showed that care pathways have a significant positive effect on mortality and readmission rate. A shorter length of hospital stay was also observed compared with the standard care group. No significant difference was found in the hospitalisation costs. More positive results were observed in controlled trials compared to randomized controlled trials.ConclusionBy combining all possible results, it can be concluded that care pathways for treatment of heart failure decrease mortality rates and length of hospital stay, but no statistically significant difference was observed in the readmission rates and hospitalisation costs. However, one should be cautious with overall conclusions: what works for one organization may not work for another because of the subtle differences in processes and bottlenecks.

Effect of Ramadan fasting on maternal oxidative stress during the second trimester: A preliminary study

Aim:  To evaluate whether fasting during Ramadan has any significant effects on maternal oxidative stress or fetal health in healthy, pregnant women with an uncomplicated, second‐trimester, singleton pregnancy.

The Efficacy of Ankaferd Blood Stopper for the Management of Bleeding Following Total Thyroidectomy

ABSTRACT Purpose: Postoperative hematoma remains an uncommon but potentially life-threaten complication of thyroid surgery. The aim of this study is to assess the efficacy of Ankaferd Blood Stopper (ABS) in comparison to hemostasis by conventional technique (HCT) for the controlling of oozing-type bleeding following total thyroidectomy. Methods: We randomized 61 patients with benign euthyroid multinodular goiter who underwent total thyroidectomy subject to one of the two different hemostasis techniques. There were 31 patients in the HCT group and 30 patients in the ABS group. The study was designed prospectively to compare ABS and HCT groups in terms of operation time, postoperative drainage, duration of postoperative stay, and complications. Results: Mean postoperative drainage from the closed suction drains at first 24 hr were 24.6 ± 8.6 ml and 12.0 ± 9.2 ml (p = .001) and mean total postoperative drainage were 38.5 ± 13.2 ml and 20.6 ± 12.2 ml (p = .001) in the HCT and ABS groups, respectively, indicating statistically significant differences. Conclusions: On the basis of the results of this trial, the use of ABS seems to be more effective than HCT to control hemorrhage following total thyroidectomy.

Diagnostic dilemma of paraneoplastic arthritis: case series.

Paraneoplastic arthritis (PA) may mimic rheumatic diseases. While presenting the demographic and laboratory features of the patients diagnosed with PA, this study also aims to provide possible appropriate tools to differentiate the PA cases from early rheumatoid arthritis (ERA).

The Care Process Self-Evaluation Tool: a valid and reliable instrument for measuring care process organization of health care teams

BackgroundPatient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table.MethodsThe psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated.ResultsCFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated.ConclusionsThe CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams.

The use of survival analysis for clinical pathways

Although clinical pathways have been popular for many years, predominant approaches to the analysis of pathways have been based on frequently used statistical methods (i.e. comparison of two groups with parametric and non-parametric tests). More discussions on using advanced statistical methods to analyse clinical pathway data and the statistical framework of clinical pathways are necessary. Survival analysis is one advanced statistical method, which is a collection of statistical procedures for data analysis for which the outcome variable of interest is time until an event occurs. Survival analysis can be used in many applied fields, such as medicine, biology, public health and epidemiology. Clinical pathways also produce data suitable for application to survival analysis when the primary variable of the research is time until the predefined event occurs. In this study, survival analysis and how it can be used to analyze clinical pathways are explained in the application of real pathway data.

Comparison of pre-emptive tonsillar lodge infiltration with ropivacaine versus intravenous tramadol in pediatric tonsillectomies: a randomized placebo-controlled study.

OBJECTIVE To investigate the placebo controlled effect of pre-emptive local infiltration of ropivacaine and intravenous tramadol in postoperative pain and nausea-vomiting in pediatric tonsillectomy cases. METHODS 90 children at ASA I-II physical status, who are between 2 and 9 years old, underwent tonsillectomy were included to the study. Patients were randomized into one of three study groups. Group I was i.v. saline group (placebo group), Group II was preemptive 1.5 ml 0.75% ropivakain to the tonsil lodge and Group III was preemptive 1mg/kg i.v. tramadol. Hemodynamic parameters and synchronized Maunuksela pain scores were evaluated in the post anesthetic care unit. RESULTS There was no difference in age, weight, sex and hemodynamic parameters of children included to the study groups. Postoperative nausea vomiting was significantly lower in Group II and pain scores at resting and swallowing are significantly lower than the other study groups. Maunuksela pain scores at 2nd, 3rd, 6th and 9th hours while resting were significantly lower in Group II compared with Groups I and III (p<0.001). The comparison of scores between groups I and III were similar. Maunuksela pain scores during swallowing were significantly lower in Group II compared with Group I and III at 2nd, 3rd, 6th, 9th, 12th, 21st and 24th hours postoperatively (p<0.001). While comparing Maunuksela pain scores of Groups I and III, significantly lower scores are determined at 2nd and 24th hours in Group III (p<0.001). Analgesic needs were significantly low in Group II at postoperative period (150 ± 30 mg paracetamol) (p<0.05). It was similar in Groups I and III (Group I: 400 ± 40 mg, Group III: 360 ± 40 mg paracetamol). CONCLUSION This study showed that peritonsillar ropivacaine infiltration might produce an effective postoperative analgesia probably due to a preventing effect on sensitization of the pain pathways.

Polymorphism of CYP3A4 and ABCB1 genes increase the risk of neuropathy in breast cancer patients treated with paclitaxel and docetaxel

Background Interindividual variability of pharmacogenetics may account for unpredictable neurotoxicities of taxanes. Methods From March 2011 to June 2015, female patients with operable breast cancer who had received docetaxel- or paclitaxel-containing adjuvant chemotherapy were included in this study. All patients were treated with single-agent paclitaxel intravenously (IV) 175 mg/m2 every 3 weeks for four cycles, or IV 80 mg/m2 weekly for 12 cycles, and IV 100 mg/m2 docetaxel for four cycles as adjuvant treatment. We evaluated the relationship between neurotoxicity of taxanes and single-nucleotide polymorphisms of ABCB1, CYP3A4, ERCC1, ERCC2, FGFR4, TP53, ERBB2, and CYP2C8 genes. Taxane-induced neurotoxicity during the treatment was evaluated according to the National Cancer Institute Common Toxicity Criteria version 4.03 prior to each cycle. Chi-squared tests were used to compare the two groups, and multivariate binary logistic regression models were used for determining possible risk factors of neuropathy. Results Pharmacogenetic analysis was performed in 219 females. ABCB1 3435 TT genotype had significantly higher risk for grade ≥2 neurotoxicity (odds ratio [OR]: 2.759, 95% confidence interval [CI]: 1.172–6.493, P: 0.017) compared to TC and CC genotype, and also CYP3A4 392 AA and AG genotype had significantly higher risk for grade ≥2 neurotoxicity (OR: 2.259, 95% CI: 1.033–4.941, P: 0.038) compared to GG genotype. For FDGF4 gene with AG and GG genotype, OR was 1.879 (95% CI: 1.001–3.525, P: 0.048) compared to AA genotype with regard to any grade of neuropathy risk. We could not find any other association of other genotypes with neurotoxicity grades. Conclusion ABCB1 3435 TT genotype and CYP3A4 392 AA/AG genotypes may be used as predictors of neurotoxicity during taxane chemotherapy.

Intraclass correlation coefficients for cluster randomized trials in care pathways and usual care: hospital treatment for heart failure

BackgroundCluster randomized trials are increasingly being used in healthcare evaluation to show the effectiveness of a specific intervention. Care pathways (CPs) are becoming a popular tool to improve the quality of health-care services provided to heart failure patients. In order to perform a well-designed cluster randomized trial to demonstrate the effectiveness of Usual care (UC) and CP in heart failure treatment, the intraclass correlation coefficient (ICC) should be available before conducting a trial to estimate the required sample size. This study reports ICCs for both demographical and outcome variables from cluster randomized trials of heart failure patients in UC and care pathways.MethodsTo calculate the degree of within-cluster dependence, the ICC and associated 95% confidence interval were calculated by a method based on analysis of variance. All analyses were performed in R software version 2.15.1.ResultsICCs for baseline characteristics ranged from 0.025 to 0.058. The median value and interquartile range was 0.043 [0.026-0.052] for ICCs of baseline characteristics. Among baseline characteristics, the highest ICCs were found for admission by referral or admission from home (ICC = 0.058) and the disease severity at admission (ICC = 0.046). Corresponding ICCs for appropriateness of the stay, length of stay and hospitalization cost were 0.069, 0.063, and 0.001 in CP group and 0.203, 0.020, 0.046 for usual care, respectively.ConclusionReported values of ICCs from present care pathway trial and UC results for some common outcomes will be helpful for estimating sample size in future clustered randomized heart failure trials, in particular for the evaluation of care pathways.

Endothelial nitric oxide synthase gene polymorphisms in preeclampsia with or without eclampsia in a Turkish population.

Aim:  To evaluate endothelial nitric oxide synthase (eNOS) gene polymorphisms in preeclampsia with or without eclampsia in a Turkish population.