Implementation study of a clinical prediction score to rule out cardiogenic chest pain in community: Cluster randomized trial

1.1 Fundamentals Chest pain is a common complaint in primary care patients (1 to 3% of all consultations) (1) and its aetiology can be miscellaneous, from harmless to potentially life threatening conditions. In primary care practice, the most prevalent aetiologies are: chest wall syndrome (43%), coronary heart disease (12%) and anxiety (7%) (2). In up to 20% of cases, potentially serious conditions as cardiac, respiratory or neoplasic diseases underlie chest pain. In this context, a large number of laboratory tests are run (42%) and over 16% of patients are referred to a specialist or hospitalized (2).¦A cardiovascular origin to chest pain can threaten patient's life and investigations run to exclude a serious condition can be expensive and involve a large number of exams or referral to specialist -­‐ often without real clinical need. In emergency settings, up to 80% of chest pains in patients are due to cardiovascular events (3) and scoring methods have been developed to identify conditions such as coronary heart disease (HD) quickly and efficiently (4-­‐6). In primary care, a cardiovascular origin is present in only about 12% of patients with chest pain (2) and general practitioners (GPs) need to exclude as safely as possible a potential serious condition underlying chest pain. A simple clinical prediction rule (CPR) like those available in emergency settings may therefore help GPs and spare time and extra investigations in ruling out CHD in primary care patients. Such a tool may also help GPs reassure patients with more common origin to chest pain.

Efficacy of clinical guideline implementation to improve the appropriateness of chest physiotherapy prescription among inpatients with community-acquired pneumonia

BACKGROUND: Although there is no strong evidence of benefit, chest physiotherapy (CP) seems to be commonly used in simple pneumonia. CP requires equipment and frequently involves the assistance of a respiratory therapist, engendering a significant medical workload and cost. AIM: To measure and compare the efficacy of two modalities of chest physiotherapy (CP) guideline implementation on the appropriateness of CP prescription among patients hospitalised for community-acquired pneumonia (CAP). PATIENTS AND METHODS: We measured the CP prescription rate and duration in all consecutive CAP inpatients admitted in a division of general internal medicine at an urban teaching community hospital during three consecutive one-year time periods: (1) before any guideline implementation; (2) after a passive implementation by medical grand rounds and guideline diffusion through mailing; (3) after adding a one-page reminder in the CAP patient's medical chart highlighting our recommendations. Death and recurrent hospitalisation rates within one year after hospitalisation were recorded to assess whether CP prescription reduction, if any, impaired patient outcomes. RESULTS: During the three successive phases, 127, 157, and 147 patients with similar characteristics were included. Among all CAP inpatients, the CP prescription rate decreased from 68% (86/127) to 51% (80/157), and to 48% (71/147), respectively (P for trend <0.01 for trend). A significant reduction in CP duration was observed after the active guideline implementation (12.0, 11.0, 7.0days, respectively) and persisted after adjustment for length of stay. Reductions in CP prescription rate and duration were also observed among CAP patients with COPD CP prescription rate: 97% (30/31), 67% (24/36), 75% (35/47), respectively (P<0.01 for trend). The mean cost of CP per patient was reduced by 56%, from $709 to $481, and to $309, respectively. Neither the in-hospital deaths, the one-year overall recurrent hospitalisation nor the one-year CAP-specific recurrent hospitalisation significantly differed between the three phases. CONCLUSION: Both passive and active implementation of guidelines appear to improve the appropriateness of CP prescription among inpatients with CAP without impairing their outcomes. Restricting CP use to patients who benefit from this treatment might be an opportunity to decrease CAP medical cost and workload.

Improving Transition Outcomes: Resource Mapping Workshop: Community Organizations Survey

Community organizations survey tool from the Improving Transition Outcomes Resource Mapping Workshops

Improving Transition Outcomes: Resource Mapping Workshop: Community Members Survey

Community members survey tool from the Improving Transition Outcomes Resource Mapping Workshops

Improving Transition Outcomes: Community Demonstration Prototypes

Information on the Council Bluffs Youth Connections, Henry County Transition Partners, and CASE (Career And Self Awareness) community demonstration prototypes.

Ants and their effects on an insect herbivore community associated with the inflorescences of Byrsonima crassifolia (Linnaeus) H.B.K. (Malpighiaceae)

The effects of ants on the insect community on inflorescences of Byrsonima crassifolia (Malpighiaceae) were tested in an ant exclusion experiment in a cerrado vegetation in southeastern Brazil. Forty-four species of insects (23 families) and nine species of ants (6 genera and 3 subfamilies) were found on the inflorescences of B. crassifolia. The exclusion of ants, primarily Camponotus sericeiventris and Camponotus spp., reduced the treehopper population to 20% of the original abundance. Ant exclusion and time influenced the abundance of chewing (Exclusion, P<0.001; Time, P<0.002), and sucking insects (Exclusion, P<0.02; Time, P<0.01). Twice as many chewing and sucking insects were found on ant-excluded inflorescences as compared to control inflorescences (P<0.001). One and half more sucking insects were found on ant-excluded than on control inflorescences. Only time significantly influenced the richness of chewing and sucking insects associated with B. crassifolia inflorescences. Inflorescences on control branches were significantly less attacked by herbivores than inflorescences on ant-excluded branches (P<0.001). Therefore, these results suggest that the presence of ants alters the structure of insect herbivore community associated with B. crassifolia.

Improving Transition Outcomes: Announcement of Community Demonstration Prototypes

Announcement of the Improving Transition Outcomes Community Demonstration Prototypes with general information for each.

Improving Transition Outcomes: Announcement of Community Demonstration Prototypes #2

Announcement of the Improving Transition Outcomes Community Demonstration Prototypes with general information for each.

Improving Transition Outcomes: CASE (Career And Self Awareness) Prototype: Community Team Award

Promotional article recognizing an award presented to the CASE (Career And Self Awareness) team.

Improving Transition Outcomes: CASE (Career And Self Awareness) Prototype: Iowa Association of Community Providers Award

Promotional article recognizing an award presented to the CASE (Career And Self Awareness) team.

Audit report on Clarke Community School District in Osceola, Iowa for the year ended June 30, 2007

Audit report on Clarke Community School District in Osceola, Iowa for the year ended June 30, 2007

Audit report on Sheldon Community School District in Sheldon, Iowa for the year ended June 30, 2007

Audit report on Sheldon Community School District in Sheldon, Iowa for the year ended June 30, 2007

Audit report on Perry Community School District in Perry, Iowa for the year ended June 30, 2007

Audit report on Perry Community School District in Perry, Iowa for the year ended June 30, 2007

Audit report on KCCK-FM Radio, a public telecommunications entity operated by Kirkwood Community College in Cedar Rapids, Iowa for the year ended June 30, 2007

Audit report on KCCK-FM Radio, a public telecommunications entity operated by Kirkwood Community College in Cedar Rapids, Iowa for the year ended June 30, 2007

Audit report on Community Colleges for International Development, Inc., Cedar Rapids, Iowa for the year ended June 30, 2007

Audit report on Community Colleges for International Development, Inc., Cedar Rapids, Iowa for the year ended June 30, 2007