The Creation and Implementation of Guidelines for the Appropriate Termination of Patient-Provider Relationships

Primary care providers have terminated patient-provider relationships when they deem them no longer therapeutic. Healthcare providers are increasingly considering this an acceptable practice. However, the criteria for this decision remain unclear. As providers discharge challenging or difficult patients from their practices, questions to support this decision arise. Discharged patients face displacement and healthcare is disrupted. This project will (a) describe problematic patient-provider relationships and its effects, (b) identify possible alternatives to the firing of patients, (c) list appropriate reasons for termination, and (d) present recommended procedures to avoid allegations of medical abandonment. The project\u27s product is an Appropriate Discharge or Transfer of Care Packet (ADTP) containing a questionnaire, a sample discharge letter, and the organization\u27s written policy for termination. The project was designed as a resource to guide clinicians when the decision to fire a patient becomes necessary. The project was introduced by means of a PowerPoint presentation to two community clinics in Sacramento, California. After the presentation, the ADTP was introduced. Outcome measures were pre- and post-tests that assessed the knowledge of primary care providers on the necessary elements that should be established prior to the firing of a patient. Change was measured by comparing pre- and post-test scores for each attendee and revealed improved provider knowledge. A survey was distributed to assess providers\u27 receptiveness to the use of the ADTP packet. A positive overall response was received. The Medical Director decided to adopt the use of the ADTP with revision for use in three clinics

Alternativas na Colocação de Cateteres em Hemodiálise

Background: Although vascular access is essential for adequate haemodialysis delivery, the systematic use of a patient's venous patrimony may eventually lead to exhaustion of suitable sites for placement of a new vascular access. Case Report: We present two cases of such patients. In the first one we inserted a 55cm catheter through the left external iliac vein, and a 40cm translumbar catheter was placed in the second one. Both interventions were performed percutaneously under radiological guidance. Both patients were anticoagulated after the procedure. Conclusion: Unusual sites for haemodialysis catheter placement may be life saving in selected situations and offer safe and viable alternatives for adequate haemodialysis delivery

Quantitative evaluation of geodiversity : development of methodological procedures with application to territorial management

Although geodiversity is considered the setting for biodiversity, there is still a huge gap in the social recognition of these two concepts. The concept of geodiversity, less developed, is now making its own way as a robust and fundamental idea concerning the abiotic component of nature. From a conservationist point of view, the lack of a broader knowledge concerning the type and spatial variation of geodiversity, as well as its relationship with biodiversity, makes the protection and management of natural or semi-natural areas incomplete. There is a growing need to understand the patterns of geodiversity in different landscapes and to translate this knowledge for territorial management in a practical and effective point of view. This kind of management can also represent an important tool for the development of sustainable tourism, particularly geotourism, which can bring benefits not only for the environment, but also for social and economic purposes. The quantification of geodiversity is an important step in all this process but still few researchers are investing in the development of a proper methodology. The assessment methodologies that were published so far are mainly focused on the evaluation of geomorphological elements, sometimes complemented with information about lithology, soils, hidrology, morphometric variables, climatic surfaces and geosites. This results in very dissimilar areas at very different spatial scales, showing the complexity of the task and the need of further research. This current work aims the development of an effective methodology for the assessment of the maximum elements of geodiversity possible (rocks, minerals, fossils, landforms, soils), based on GIS routines. The main determinant factor for the quantitative assessment is scale, but other factors are also very important, such as the existence of suitable spatial data with sufficient degree of detail. It is expected to attain the proper procedures in order to assess geodiversity at different scales and to produce maps with the spatial representation of the geodiversity index, which could be an inestimable contribute for land-use management

Renal Pathology in Portuguese HIV-Infected Patients

HIV-infected patients may be affected by a variety of renal disorders. Portugal has a high incidence of HIV2 infection and a low prevalence of HIV-infected patients under dialysis treatment. The aim of this study was to characterise the type of renal disease in Portuguese HIV-infected patients and to determine if HIV2 infection is associated to renal pathology. Only 60 of the 5158 HIV-infected patients followed in our hospital underwent renal biopsy. Clinical and laboratory data and the type of renal disease were reviewed. Male gender was predominant (76.7%), as was Caucasian race (78.3%). Mean age was 37.9±10.6 years. The majority had criteria for AIDS, 66% were on combined antiretroviral therapy and 18.3% were on dialysis. The predominant lesions were immunecomplex glomerulonephritis (n=19), tubulointerstitial nephropathy (n=12), focal segmental glomerulosclerosis(n=11), followed by HIVAN (n=8). Other patterns(amyloidosis, vasculitis, minimal change lesion) were observed. Only three patients were HIV2 infected, and presented diabetic nephropathy, acute tubular necrosis and tubulointerstitial nephritis. No correlations between clinical findings and renal pathology were found. In conclusion, renal disease in HIV patients has a broad spectrum, and renal biopsy remains the gold standard for establishing the diagnosis and guide treatment. Renal disease is not frequent in HIV2-infected patients, and, when present, is probably not directly associated with HIV infection

Cavernous Sinus Thrombosis in a Patient with Nephrotic Syndrome

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Efficacy of Percutaneous Transluminal Angioplasty on Dysfunctional Fistulae Because of Inflow Stenosis

PURPOSE: Autogenous fistulas are the preferential vascular access for hemodialysis. The aim of this retrospective study was to determine the efficacy of angioplasty for dysfunctional fistulas because of inflow dysfunction. 
 METHODS: We reviewed all the angiographic procedures performed on our institution between April 2007 and April 2009. Procedures performed in dysfunctional fistulas because of inflow stenoses were analyzed. Fistulas with stenoses out of these areas were excluded. The following data were collected: patient age and sex, fistula age at the time of intervention, location of fistula, number and location of stenosis, angiography referral criteria, clinical findings (presence or absence of thrills, bruits and pulsatility) and date of reintervention or failure. 
 RESULTS: During the study period 215 fistulas were submitted to angiography of which, seventy-one presented inflow stenosis (33%). Mean follow-up was 21.72±9.26 months, and average age was 7.03 months. Two groups were considered: 31 fistulas comprising ≤6 months old, and 40 fistulas >6 months old. Primary patency rates±SE for older fistulas at 6, 12, 18 and 24 months, respectively, was 91.3%± 0.04%, 80.7%± 0.07%, 53.8% ±0.10% and 34.2±0.1% versus 91.7±0.08%, 57.1±0.14%, 23±0.14%, 11.4%± 0.1% for younger fistulas (P=0.04). Fistulas ≤6 months old and multiple stenosis were associated with a poorer primary patency rate (P=0.005).
 CONCLUSIONS: Inflow stenosis is frequently associated with fistula dysfunction. In this study we only analyzed AVF with inflow stenosis and we have shown that angioplasty can have great patency results, particularly for single lesions in matured fistulas.info:eu-repo/semantics/publishedVersio