Auswahl der wissenschaftlichen Literatur zum Thema „Ross Valley Medical Clinic“

Nagwakas ang araw Lupa’t dagat, langit, pumanaw Tahan na, Humimlay Siyanawa — JF Lapeña, Tahan Na, Humimlay The continuing COVID-19 pandemic has directly or indirectly claimed the lives of countless colleagues, friends, and family. I personally thought my tears had run dry as people I knew and loved died throughout the past year, but the wells of grief run deep, even as the plague continues its scourge as of this writing. Especially when fellow front-liners fall, the haunting bugle call echoes the finality of death: “day is done, gone the sun, from the lake, from the hills, from the sky.”1 Of my original fellow office-bearers in the Philippine Association of Medical Journal Editors (PAMJE), two have passed on: Dr. Gerard “Raldy” Goco and Jose Ma. “Joey” Avila.2 Even in our Philippine Society of Otolaryngology - Head and Neck Surgery, I do not recall us dedicating so many passages in issues past as we do now, with tributes to Dr. Elvira Colmenar, Dr. Ruben Henson Jr., Dr. Marlon del Rosario, and Dr. Oliverio Segura. Our Philippine Medical Association Central Tagalog Region (PMA-CTR) has lost more than its share of physicians: Dr. Joseph Aniciete, Dr. Patrocinio Dayrit, and Dr. Rhoderick Presas of the Caloocan City Medical Society; Dr. Mar Cruz, Dr. Mayumi Bismarck, and Dr. Edith Zulueta of the Marikina Valley Medical Society; Dr. Kharen AbatSenen of the Valenzuela City Medical Society; Dr. Romy Encanto and Dr. Cosme Naval of the San Juan Medical Society; Dr. Roberto Anastacio and Dr. Encarnacion Cabral of the Makati Medical Society; and Dr. Amy Tenedero and Dr. Neil Orteza of the Pasay Parañaque Medical Society. The rest of the PMA has lost over 145 physicians due to, or during, the pandemic. As healthcare workers, how do we deal with their deaths, the inevitability of more deaths, and the very real prospect of our own deaths during these trying times? How do we continue our work of saving lives in our overcrowded hospitals and community-based clinics while dealing with grief and facing our own fears for ourselves and our families? Over 50 years ago, Elisabeth Kübler-Ross formulated a model of dying with five stages of coping with impending loss of life (denial, anger, bargaining, depression and acceptance) based on her work with dying patients at the University of Chicago, and these have become widely considered as phases of grief that people go through when faced with the prospect of their own death (or as a response to any major life change).3 By focusing “on dying, rather than death,” her work “shifted attention of religious thinkers, pastors, and authors of personal testimonies onto the themes and framework she offered” and “her legacy was to offer a fresh way to think and speak about dying, death and grieving.”4 Whether, and how we might appropriate her framework in order to cope with our personal and collective experiences during this pandemic, a pandemic that is arguably worse than any worst case scenario ever imagined, is another matter altogether. Does the framework even apply? The very nature of the COVID-19 pandemic is changing how people die -- in ambulances, makeshift tents and long queues outside overflowing hospitals, or en route to distant hospitals with vacancies (with patients from the National Capitol Region travelling to as far away as Central and Northern Luzon or Southern Tagalog and Bicol), or in their own homes (as people with “mild” symptoms are encouraged to monitor themselves at home, often rushing in vain to be admitted in hospitals with no vacancies when it is already too late) -- and “we have to make difficult decisions regarding resuscitation, treatment escalation, and place of care,”5 or of death. The new normal has been for COVID-19 patients to die alone, and rapidly so, within days or even hours, with little time to go through any process of preparation. Friends and family, including spouses, parents, and children, are separated from the afflicted, and even after death, the departed are quickly cremated, depriving their loved ones of the usual rites and rituals of passage. In most cases, wakes and novenas for the dead can only be held virtually, depriving the grieving loved ones of the support and comfort that face-to-face condolences bring. Indeed, the social support systems that helped people cope with death have been “dismantled, and the cultural and religious rituals that help us process grief also stripped away.”5 Amidst all this, “we must ensure that humanity, community, and compassion at the end of life are sustained,” and that “new expressions of humanity help dispel fear and protect the mental health of bereaved families.”6 What these expressions might be, and whether they can inspire hope in the way that community pantries7 have done remains to be seen. But develop these expressions we must, for our sakes as for the sake of our patients. The “hand of God” -- two disposable latex gloves filled with warm water and tied around the hand of a woman with COVID-19 to alleviate her suffering by nurse technician Araújo Cunha at the Vila Prado Emergency Care Unit in São Paulo is one such poignant expression.8 Ultimately, we must develop such expressions for and among ourselves as well. As healthcare workers, our fears for ourselves, our colleagues, and our own loved ones “are often in conflict with professional commitments” and “given the risks of complicated grief,” we “must put every effort into (our) own preparation for these deaths as well as into (our) own healthy grieving.”9 We cannot give up; our profession has never been as needed as it is now. True, we can only do so much, and so much more is beyond our control. But to this end, let us imagine the soothing, shushing “tahan na” (don’t cry) we whisper to hush crying infants, coupled with the calming invitation “humimlay” (lay down; rest; sleep). Yes, the final bugle call may echo the finality of death, but it can simultaneously reassure us that “all is well, safety rest, God is nigh!”1

Purpose: Engagement of patients in the HIV care continuum and adherence to antiretroviral therapy (ART) continue to limit successful viral suppression. Innovative practices to improve this continuum and ameliorate potential physician shortages are needed. The objective of this evaluation was to determine the clinical benefits of incorporating pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV. Methods: A single-center pre–post cohort pilot evaluation was conducted at the Tennessee Valley Healthcare Systems VA Medical Center. Patients were enrolled in an HIV pharmacotherapy clinic implemented by an ambulatory care pharmacy resident. The primary end point of the evaluation was the percentage of patients achieving an undetectable plasma HIV viral load after enrollment. Secondary end points included change from baseline in CD4 T-cell count and self-reported adherence. Results: A total of 55 patients were seen in the HIV pharmacotherapy clinic over a 28-week evaluation period. Of those patients with detectable viral load at enrollment, 70% reached viral suppression during follow-up, with a significant 0.75 log10 decrease in the median viral load ( P < .0001 for both). The median CD4 T-cell count increased from 464 to 525 cells/mm3 ( P = .01). Reported adherence, assessed using the Visual Analogue adherence Scale (VAS) increased significantly ( P = .0001). Conclusion: After enrollment in an HIV pharmacotherapy clinic, a significant decrease in viral load was seen, as were improvements in secondary end points of CD4 T cells and adherence. These data demonstrate the clinical benefits of pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.

Background National guidelines for the provision of HIV pre-exposure prophylaxis (PrEP) to reduce a person’s risk of acquiring HIV were made available in 2014. We created a pharmacist-managed HIV PrEP clinic in a community pharmacy setting at Kelley-Ross Pharmacy in Seattle, WA, USA. Methods: The clinic operates under a collaborative drug therapy agreement based on these guidelines. This allows pharmacists to initiate and manage tenofovir disoproxil fumarate/emtricitabine under the supervision of a physician medical director. Results: Between March 2015 and February 2018, 714 patients were evaluated and 695 (97.3%) initiated PrEP. Five hundred and thirteen (74%) patients began medication the same day as their initial appointment. Of the prescriptions filled in our pharmacy, 90% of patients had a mean proportion of days covered (PDC) greater than 80%, and 98% had a zero-dollar patient responsibility per month, including uninsured individuals. 19% of patients were lost to follow up, with an effective drop-out rate of 25%. Two hundred and seven diagnoses of sexually transmissible infections were made. There were no HIV seroconversions in the service. Conclusion: The pharmacist-managed PrEP clinic proved to be a successful alternative model of PrEP care, with high initiation rates and low drop-out and lost-to-follow-up rates. This may benefit individuals who do not access PrEP in traditional health care settings or where PrEP access is scarce. Financial sustainability of the model was dependent on the ability of pharmacists in the clinic to bill insurance plans for their services in accordance with Washington State legislative changes requiring commercial insurances to recognise pharmacists as providers.

Background: Chronic kidney disease (CKD) patients who live far (>30 miles) from their nephrologist experience lower rates of clinic visit adherence, limited access to treatment, and higher rates of hospitalization and mortality than patients who live in close proximity to their nephrologist. Strategies to minimize disparities between urban and remotely located CKD patients are needed. The purpose of this study was to determine whether adherence to clinic visits and clinical outcomes in the remote management of CKD via telenephrology is comparable to in-person conventional care. Methods: Renal clinic adherence and composite outcomes of death, end-stage renal disease (ESRD), or doubling of serum creatinine (Cr) were measured in geographically remote Hudson Valley VA Medical Center (HVVAMC) CKD patients enrolled in telenephrology (n = 112) and CKD patients enrolled in the Bronx VAMC renal clinic (n = 116). Results: Prior to implementing the telenephrology service, 53.1% of scheduled visits of rural HVVAMC patients to the Bronx VAMC renal clinic were either cancelled or were “no-shows.” This was reduced by nearly half (28.5%) after instituting telenephrology (p < 0.001). Moreover, the frequency of attending appointments was greater in the telenephrology (71.9%) vs. in-person Bronx VA cohort (61.0%). The incidence of the composite outcome of death, ESRD, or doubling of Cr was similar between both groups (p = 0.96) over 2 years of follow-up. Conclusions: Remote CKD care delivered through telenephrology improves renal clinic visit adherence while delivering comparable renal outcomes. Application of this technology is a promising method to provide access to care to rural CKD patients and to minimize the disparity between urban/rural patients.

Objective: To determine the prevalence of depression–anxiety disorders and the degree to which physicians prescribed antidepressants for Aboriginal and non-Aboriginal populations living in a remote rural community in British Columbia in 2001. Methods: To obtain data for our main outcome measures, we retrospectively reviewed the charts of 2375 patients living in the Bella Coola Valley as of September 2001 and attending the Bella Coola Medical Clinic. Results: The 2001 prevalence rate of depression–anxiety disorders in the Bella Coola Valley was 7.5% (177/2375). Depression was the most common problem (86%) in these patients. Women had a higher rate of depression–anxiety disorders (10.3%) than did men (4.7%) ( P < 0.001). Non-Aboriginal people had a slightly higher rate (8.5%) than did Aboriginal people (6.3%); however, the difference was not statistically significant. Antidepressant medications were commonly prescribed for chronic pain and insomnia. The general pattern of antidepressant medication use in 2001 among both Aboriginal and non-Aboriginal people living in the Bella Coola Valley was as follows: peak use of antidepressants was in the middle to late years; the rate for women was roughly double the rate for men; and proportionately more Aboriginal people, especially the women, were taking antidepressants. Conclusions: Depression–anxiety disorder prevalence rates for Aboriginal and non-Aboriginal populations are similar. When using antidepressant medication prescriptions as a community health indicator, health care administrators should be aware that antidepressant medications are commonly prescribed for conditions other than depression–anxiety disorder.

Healthcare services and the expected need for expansion has fueled the need to take a look into the immediate future for the Roanoke valley. Building a healthy environment for the citizens of the valley does not only include bricks and mortar. The facilities are very important, but a healthy community begins from within. Roanoke county has taken the initiative to institute a wellness center for our 900 plus employees. We have always been supportive of our local healthcare providers, Carilion Clinic and Lewis-Gale Medical Center, but taking a pro-active part will lead to many positive results. We have already realized a reduction in healthcare claims and a corresponding decrease in the overall payment of these. Our wellness center operation has resulted in less time loss from work due to illness, an overall healthy workforce and most importantly an educated employee regarding their personal healthcare situation. We realize that a healthy workforce is a more productive one.Healthcare education and preventive care programs such as eating healthy foods and exercise translates into lower health insurance premiums for individuals as well as the County.

The development of a medical home is an integral component in decreasing health disparities among disenfranchised communities. Mobile health clinics contribute to increasing access to health services, promoting health education, and improving care coordination especially among low income rural patients. This problem based solution, case study describes the experience of a University-community based partnership in the development of a mobile clinic model within ambulatory Community Medical Health. In 2014, a university based, nursing program initiated, mobile health unit was created to offer basic medical care to rural health areas in the Central Valley. The following case describes how this was accomplished, what outcomes were tracked and what lessons were gleamed as a means of improving the process for future endeavors or as a model to others looking to develop a similar project. Over the past two years the mobile health unit has shown the increased need for medical services as evident by an increase of patient visits in these areas. In addition, implementation results and considerations are discussed including key process indicators, limitations and future model directions.

191 Background: Advance directives (AD) are critical to understanding a patient’s wishes should they be unable to communicate. Lacking these documents may lead to decreased knowledge regarding end-of-life wishes, and hinder end-of-life care. Having an AD uploaded into the electronic medical record (EMR) ensures these documents are available to all providers. This project sought to improve, from a cohort of patients with documented discussions regarding ADs, the proportion with the document in the EMR. At Valley-Mount Sinai Comprehensive Cancer Care, baseline data analysis shows only 20% of clinic patients for whom an AD was documented had an AD uploaded to their EMR. Methods: This project was created through the ASCO Quality Training Program and sought to increase the proportion of AD’s in patient’s EMR's. The current workflow of obtaining AD's at Valley-Mount Sinai was first identified. In our setting, the medical assistant (MA) asks new patient if they have an AD and uploads the AD into the chart if available. Following a structured cause and effect exercise, two Plan-Do-Study-Act (PDSA) cycles were prioritized. The first, beginning 10/15/18, required that the new patient nurse navigator discuss the value of AD’s with the patient when scheduling initial visits. The second PDSA, completed 11/12/18 for the MA’s, was an educational session reviewing AD’s and how to discuss them. Results: Pre- and post-intervention data is depicted in the Table. At baseline, 20% of the 114 patients with existing AD discussions had these documents uploaded into their EMR. After PDSA-2, 37.1% of the 78 patient cohort had an AD uploaded. Conclusions: Through clinical education and revising the current process, this project increased uploading AD’s into EMR’s from 20% to 37.1%. This demonstrates that small but effective interventions can increase the proportion of patients with AD’s in their charts. Future PDSA’s will focus on patient and RN education to further improve these numbers. [Table: see text]

Background: Mental health and its related problems are growing concerns over the world. The early onset of emotional and behavioral problem in the young children is related to a variety of health and behavior problems in adolescence. It is a challenging all over the world to determine the epidemiology of childhood mental disorders. Objective: The aim of this study is to sort out the prevalence and predominance of mental illness and their onset of age and sex among the child and adolescent who attended in the child guidance clinic in TUTH. Methodology: A retrospective study of a total of 539 consecutive cases of child and adolescent attended in Child Guidance Clinic TUTH. Diagnosis was made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision. Result: The cases from the age of 0.4 year to 21 years with mean age 8.85±4.08 years. Significantly majority were boys (n=343, 63.6%) and most of from out of the Kathmandu valley (n=300, 53.2%). Significantly most case referred from ENT OPD of TUTH (n=97, 18%) and mental retardation was the commonest (n=81, 15%) followed by conversion disorder (n=77, 14.3%) and anxiety spectrum disorder (n=63, 11.7%) Conclusion: Boys are common in mental illness among child and adolescents. The common diagnoses among child and adolescent are mental retardation, conversion disorder, anxiety spectrum disorders and Autism spectrum disorder. Journal of Nobel Medical College Vol. 2, No.1 Issue 3 Nov.-April 2013 Page 55-63 DOI: http://dx.doi.org/10.3126/jonmc.v2i1.7677

Staphylococcus aureus is a common component of skin flora of healthy adults. However, it can cause serious infections such as bloodstream infections, pneumonia, or bone and joint infections. Methicillin-resistant Staphylococcus aureus (MRSA) is known to cause hospital- (HA-MRSA) and community-acquired (CA-MRSA) infections worldwide. Asia is reported to have highest prevalence rates of HA-MRSA and CA-MRSA. As there were very less number of epidemiological studies being done in Malaysia, this study aimed to determine the prevalence of MRSA infection among the healthcare undergraduates who will be engaging with patients soon. We analyzed nasal swabs of students from a private medical institution in Klang Valley, Malaysia. Methicillin-resistance was accessed by sensitivity to the Oxacillin and Cefoxitin disks. In a total of 151 healthcare undergraduates, 117 of them were found positive for Staphylococcus aureus. Among the latter, 21 samples (13.9%) were resistant to Oxacillin and Cefoxitin. Our data shows significant high percentage of MRSA infection and therefore prevention strategies for MRSA need to be developed for the healthcare students before they engage with patients in clinic setting. Keywords: MRSA, nasal swab, healthcare undergraduates, Oxacillin.

Objective. To assess the comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) by emergency medical services in the prehospital setting, and how the benefits and harms differ based on patient characteristics, techniques, and devices. Data sources. We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020 and reference lists, and posted a Federal Register notice request for data. Review methods. Review methods followed Agency for Healthcare Research and Quality Evidence-based Practice Center Program methods guidance. Using pre-established criteria, studies were selected and dual reviewed, data were abstracted, and studies were evaluated for risk of bias. Meta-analyses using profile-likelihood random effects models were conducted when data were available from studies reporting on similar outcomes, with analyses stratified by study design, emergency type, and age. We qualitatively synthesized results when meta-analysis was not indicated. Strength of evidence (SOE) was assessed for primary outcomes (survival, neurological function, return of spontaneous circulation [ROSC], and successful advanced airway insertion [for SGA and ETI only]). Results. We included 99 studies (22 randomized controlled trials and 77 observational studies) involving 630,397 patients. Overall, we found few differences in primary outcomes when airway management approaches were compared. • For survival, there was moderate SOE for findings of no difference for BVM versus ETI in adult and mixed-age cardiac arrest patients. There was low SOE for no difference in these patients for BVM versus SGA and SGA versus ETI. There was low SOE for all three comparisons in pediatric cardiac arrest patients, and low SOE in adult trauma patients when BVM was compared with ETI. • For neurological function, there was moderate SOE for no difference for BVM compared with ETI in adults with cardiac arrest. There was low SOE for no difference in pediatric cardiac arrest for BVM versus ETI and SGA versus ETI. In adults with cardiac arrest, neurological function was better for BVM and ETI compared with SGA (both low SOE). • ROSC was applicable only in cardiac arrest. For adults, there was low SOE that ROSC was more frequent with SGA compared with ETI, and no difference for BVM versus SGA or BVM versus ETI. In pediatric patients there was low SOE of no difference for BVM versus ETI and SGA versus ETI. • For successful advanced airway insertion, low SOE supported better first-pass success with SGA in adult and pediatric cardiac arrest patients and adult patients in studies that mixed emergency types. Low SOE also supported no difference for first-pass success in adult medical patients. For overall success, there was moderate SOE of no difference for adults with cardiac arrest, medical, and mixed emergency types. • While harms were not always measured or reported, moderate SOE supported all available findings. There were no differences in harms for BVM versus SGA or ETI. When SGA was compared with ETI, there were no differences for aspiration, oral/airway trauma, and regurgitation; SGA was better for multiple insertion attempts; and ETI was better for inadequate ventilation. Conclusions. The most common findings, across emergency types and age groups, were of no differences in primary outcomes when prehospital airway management approaches were compared. As most of the included studies were observational, these findings may reflect study design and methodological limitations. Due to the dynamic nature of the prehospital environment, the results are susceptible to indication and survival biases as well as confounding; however, the current evidence does not favor more invasive airway approaches. No conclusion was supported by high SOE for any comparison and patient group. This supports the need for high-quality randomized controlled trials designed to account for the variability and dynamic nature of prehospital airway management to advance and inform clinical practice as well as emergency medical services education and policy, and to improve patient-centered outcomes.