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Those study- ing sleep electro-encephalographies say that those suffering from bed-wetting have a higher incidence of increased slow brain-wave activity cheap tamoxifen 20mg mastercard. Nevertheless discount tamoxifen 20mg with mastercard, parents of these children often say their child is a heavy sleeper buy discount tamoxifen 20 mg line. They began the study by allowing the children to get used to sleeping with the headphones on cheap tamoxifen 20 mg visa. The study showed that the children in the bed-wetting group were dramatically more difficult to wake up than normal controls, thus confirming what parents have known for years. According to modern Western medicine, the ability to wake from sleep to the sensation of a full or contracting bladder involves many interconnected anatomic areas in the human body, including the cerebral cortex, reticular activating system (RAS), locus ceruleus (LC), hypothalamus, pontine micturition center (PMC), spinal cord, and bladder. The RAS controls depth of sleep, the LC controls arousal, and the PMC initiates the command for a detru- sor contraction. The variety of neurotransmitters involved in this process include noradrenaline, serotonin, and antidiuretic hor- mone (ADH). The abnormally deep sleep that parents say those 22 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine with enuresis suffer from is so resistant to arousal that their brains cannot automatically keep the bladder shut during sleep. Some believe that this deep sleep is the inherited factor dis- cussed above in the section on genetics. Parents often report that their children wet the bed earlier as opposed to later in the night, and some older studies (11,12) sug- gest that these episodes occur during slow-wave deep sleep. However, more recent research (13) shows this condition may occur at different stages of sleep. A possible explanation of this is, perhaps, when sleep- ing in a strange bed away from home, they do not sleep quite as deeply. Clinically, however, this is an excellent sign that the child should be able to be cured. It is also possible that these children may be consciously or subconsciously thinking about staying dry through the night when they are away from home. Whether proven through medical testing or by speaking to par- ents of bed-wetting children, it is evident that bed-wetters are often deep sleepers. Due to being deep sleepers, they do not wake up to the stimulus of a full bladder and often not even to the sound of an alarm or alarm therapy. Therefore, the cause of enuresis may also be related to the blunting of the arousal mecha- nism of the human body that wakes the individual when they need to urinate. In modern TCM journals, most patients are screened using a combination of the tests below prior to beginning treatment. As mentioned before, only 1-3% of enuresis sufferers have an organic cause. Urinalysis is considered the most important screening test in modern Western medicine for individ- uals with nocturnal enuresis. It is rare that a child with ordinary enuresis needs to have further testing. Further testing may be indicated if the child has new or persistent daytime wetting, uri- nary tract infections, bowel difficulties, or problems urinating. Physical examination A comprehensive physical examination is used by practitioners of modern Western medicine to rule out the presence of physical or structural causes of enuresis even though no abnormal physical findings are usually found in patients when nocturnal enuresis is the only symptom. Abnormal physical findings may or may not be present in children with urge syndrome/dysfunctional voiding. Abnormal physical findings are more likely in children with cystitis, constipation, neurogenic bladder, urethral obstruction, ectopic ureter, OSA, and hyperthyroidism. Palpation in the renal and suprapubic areas to look for enlarged kidneys or bladder. Thorough neurological examination of the lower extremities including gait, muscle power, tone, sensation, reflexes, and plantar responses. It is noted that a spinal defect, such as a dimple, hair tuft, or skin discol- oration, may be visible in approximately 50% of patients with an intraspinal lesion.

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One group of physicians in a large healthcare delivery system might have developed an effective method to achieve high levels of colorectal can- cer screening (Stroud cheap 20mg tamoxifen with mastercard, Felton generic 20mg tamoxifen amex, and Spreadbury 2003) generic tamoxifen 20 mg on-line, but the opportunity to describe tamoxifen 20 mg line, champion, and implement such process redesign across dozens of other groups within the system is much more challenging and typically will require incremental resource commitment. Large organizations tend to have rigid frameworks or bureaucracies; change is slow and requires per- severance and the ability to make clear to skeptics and enthusiasts alike the value of the new procedure in their group and across the system. Small practices may be equally difficult, especially if only one or two physicians or decision makers are involved and they are unwilling or uninterested in pursuing quality improvements. Irrespective of organizational size, there is often a complex matrix of demands for quality improvement and change agents, so simply changing one process in one location will not necessar- ily result in quality improvement, especially throughout an organization. Large organizations also create the potential for multiple layers of quality assessment. The Baylor Health Care System (BHCS), located in the Dallas–Fort Worth area, includes 11 hospitals with 83,000 admissions per V ariation in Medical Practice and Implications for Quality 49 year and 47 primary care and senior centers with more than 500,000 vis- its annually. Consequently, BHCS evaluates its quality improvement efforts at both the hospital level and an outpatient level. Obviously, inpatient and outpatient processes of care differ; quality improvement efforts may be widely applicable for inpatient services at all 11 hospitals, but such process redesigns might not necessarily be applicable to the 47 outpatient clinics and senior centers. Value- based purchasing is increasing, whereby consumers and insurers utilize those healthcare facilities that embrace quality improvement efforts and hence provide better processes of care and, arguably, outcomes. The Joint Commission, CMS, and Medicare have established minimum standard lev- els of quality and linked reimbursement schemes to achieving these goals. Although all healthcare organizations are obligated to meet these stan- dards, a number of hospitals and delivery systems chose to use these stan- dards before they were mandatory or have set higher threshold levels because of the compelling business case to do so. Increasing numbers of healthcare organizations fund these efforts internally, both for inpatients and outpa- tients, because it makes sense to do so in terms of outcomes, patient sat- isfaction, and long-term financial picture (happy patients return for additional care or recommend that friends and relatives use the same services) (Ballard 2003; Leatherman et al. Planning the collection and analysis of suitable data for quality meas- ures requires significant forethought, particularly when considering strate- gies to assess true variation and minimize false variation, and includes using appropriate measures, controlling case mix and other variables, minimiz- ing chance variability, and using high-quality data (Powell, Davies, and Thomson 2003). The initial results of a study that compared generalists to endocri- nologists in providing care to patients with diabetes showed what most people might expect, that specialists provided better care. Adjusting for patient case-mix bias and clustering (physician-level variation) substantially altered the results: there was no difference between generalists and endocri- nologists in providing care to diabetes patients. Studies must be designed with sufficient power and sophistication to account for a variety of con- founding factors and require sufficient numbers of physicians and patients per physician to avoid distorting differences in quality of care between physician groups (Greenfield et al. Another study evaluated the rela- tionship of complication rates of carotid endarectomy to processes of care 50 The Healthcare Quality Book and reported findings similar to the original diabetes survey. Initial analy- sis showed that facilities with high complication rates likely had substan- dard processes of care. By repeating the study at the same location but at a different time, researchers found substantially different complication rates and concluded that the inability, in practice, to estimate complication rates at a high degree of precision is a fundamental difficulty for clinical policy making (Samsa et al. Physicians and administrators alike may challenge results they do not like on the grounds that they con- sider the data suspect because of collection errors or other inaccuracies. Patient socioeconomic status, age, gender, and ethnicity also influence physician profiles in medical prac- tice variation and analysis efforts (Franks and Fiscella 2002). Keys to Successful Implementation and Lessons Learned from Failures Despite the inherent appeal in improving quality, considerable limits and barriers to the successful implementation of quality improvement projects exist. These barriers are subject to or the result of variation in culture, infra- structure, and economic influences across an organization, and overcom- ing them requires a stable infrastructure, sustained funding, and the testing of sequential hypotheses as to how to improve care. Administrative and Physician Views Issues that must be addressed to implement quality improvements include organizational mind-set, administrative and physician worldviews, and patient knowledge and expectations. In one example in a primary care setting, screening for colorectal cancer improved steadily from 47 percent to 86 percent over a two-year period (Stroud, Felton, and Spreadbury 2003). This evolutionary change minimized the barriers of revolutionary change, especially physician and administrator push-back, as well as other personal issues that are difficult to identify and alter (Eisenberg 2002). Success in adjusting culture to embrace quality improvement requires a long view that is sympathetic to V ariation in Medical Practice and Implications for Quality 51 converting daily practice into an environment that adapts accordingly. Many decision makers expect immediate and significant results and are sensitive to short-term variation in results that might suggest the improvements are inappropriate or not cost effective. A monthly drop in screening rates, for example, could be viewed as an indication that the screening protocol is not working and should be modified or abandoned altogether to conserve scarce resources. Then again, the observed decrease could be random vari- ation and no cause for alarm or change (Wheeler 2000). Cultural tolerance to variation and change is a critical issue when considering successful fac- tors to implementing quality improvement efforts, and it can be addressed by systemic adjustments and educational and motivational interventions (Donabedian and Bashur 2003; Palmer, Donabedian, and Povar 1991).

Because it is excreted almost entirely by slow repolarization generic 20mg tamoxifen with mastercard, and prolong the refractory period in both the kidney order tamoxifen 20 mg with mastercard, drug half-life is prolonged with renal impairment 766 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM and dosage must be reduced generic 20 mg tamoxifen amex. Thus tamoxifen 20 mg low cost, they reduce automaticity of the SA and AV nodes, tension and dysrhythmias. Diltiazem and verapamil are the only calcium channel The drug enhances the efficacy of cardioversion. Both structurally similar to sotalol but lacks clinically significant drugs may be given IV to terminate acute PSVT, usually within beta-blocking activity. Ibutilide is widely distributed and has 2 minutes, and in AF and flutter. When given IV, the drugs act metabolized, and the metabolites are excreted in urine and within 15 minutes and last up to 6 hours. Adverse effects include supraventricular and ventricu- be used in the chronic management of the aforementioned lar dysrhythmias (particularly torsades de pointes) and hypo- dysrhythmias. Ibutilide should be administered in a setting with the liver, and metabolites are primarily excreted by the kid- personnel and equipment available for emergency use. The drugs are contraindicated in digoxin toxicity be- Dofetilide is indicated for the maintenance of normal sinus cause they may worsen heart block. If used with propranolol rhythm in symptomatic clients who are in AF of more than or digoxin, caution must be exercised to avoid further im- one-week duration. Adverse effects increase with decreasing pairment of myocardial contractility. Do not use IV vera- creatinine clearance levels so renal function must be assessed pamil with IV propranolol; potentially fatal bradycardia and and initial dosage is dependent on creatinine clearance levels. High dosages in clients with renal dysfunction result in drug accumulation and prodysrhythmia (torsades de pointes). The drug has an elimination half-life of approximately 8 hours with Unclassified the kidneys being the major route of elimination. The drug should initially be administered in a setting with personnel and Adenosine, a naturally occurring component of all body equipment available for emergency use. Beta-blocking effects predominate duction at the AV node and is used to restore NSR in clients at lower doses and class III effects predominate at higher with PSVT; it is ineffective in other dysrhythmias. The drug is well absorbed after oral administration, has a very short duration of action (serum half-life is less than and peak serum level is reached in 2 to 4 hours. It must be ination half-life of approximately 12 hours, and 80% to 90% given by a rapid bolus injection, preferably through a central is excreted unchanged by the kidneys. If given slowly, it is eliminated before it can prevention or management of ventricular tachycardia and fib- reach cardiac tissues and exert its action. It has also been used, usually in smaller doses, to Magnesium sulfate is given IV in the management of sev- prevent or treat AF. However, it is less effective than amio- eral dysrhythmias, including prevention of recurrent episodes darone in the prophylaxis of AF. It is contraindicated in of torsades de pointes and management of digitalis-induced clients with asthma, sinus bradycardia, heart block, cardio- dysrhythmias. Its antidysrhythmic effects may derive from genic shock, heart failure, and previous hypersensitivity to imbalances of magnesium, potassium, and calcium. Dosage should be individualized, reduced with renal Hypomagnesemia increases myocardial irritability and is a impairment, and increased slowly (eg, every 2 to 3 days with risk factor for both atrial and ventricular dysrhythmias. Thus, normal renal function, at longer intervals with impaired renal serum magnesium levels should be monitored in clients at risk function). Dysrhythmogenic effects are most likely to occur and replacement therapy instituted when indicated. Heart in some instances, the drug seems to have antidysrhythmic failure may occur in clients with markedly depressed left ven- effects even when serum magnesium levels are normal. Like amiodarone, sotalol may be preferred over a class I agent because it is more effective in reducing recurrent ven- Nursing Process tricular tachycardia, ventricular fibrillation, and death. These include the following: of calcium into conductile and contractile myocardial cells.

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