Tesis: "Patient Pathways"

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Debbage, Samantha D. "Do integrated care pathways improve patient outcomes?" Thesis, University of Sheffield, 2009. http://etheses.whiterose.ac.uk/14949/.

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The purpose of the study was to determine if the use of an Integrated Care Pathway (ICP) was associated with more positive outcomes than traditional methods of care. The effectiveness of the ICP had not previously been tested (in relation to traditional methods of care) to determine if it made any difference, at a patient, staff or system (healthcare organisation) level. In February 2001 (as part of the NHS modernisation agenda) the gynaecology services within one UK city were re-organised and two separate units were merged into one new larger unit. Prior to the reorganisation, the two units offered similar treatments and were managed collectively; however, one site had developed and implemented ICPs and the other site had continued to use traditional methods of care delivery. ICPs are multidisciplinary plans for organising and delivering patient care. The plan of care is outlined in a sequential manner including all interventions with expected patient outcomes. The literature suggests that ICPs result in improved patient outcomes and lower hospital costs by decreasing length of stay and improving observations i.e. detecting signs of infection in a timelier manner. ICPs are recognised to facilitate the multidisciplinary partnerships in planning of patient care. However the literature was primarily anecdotal or non generalisable, and therefore additional local research was deemed essential. To ensure the research problem could be answered, three specific research questions were developed for testing: (1) What effect does an /~ / ICP have on the outcomes of gynaecological patients attending for major abdominal surgery? (2) What factors, including the use of an ICP contribute to the variance in length of stay for gynaecological patients? (3) What are the opinions of the staff who have used the ICP, of the ICP itself? Relevant directional hypothesis were derived from each research question. A quasi-experimental design was used to answer the first research question. Subjects were attached to one of two groups, a treatment group, which used the ICP, and a comparison group, which continued to deliver care based on traditional methods. Descriptive correlation was used to answer research question two and for the third research question descriptive exploration was used. Variables of interest from a patient, staff and system (health care organisational) level were collected to determine the effectiveness of the ICP compared with traditional methods. One of the difficulties faced with ICP research is the number of variables that can potentially influence patient care. Holzemer's model (1994, based on the work of Donabedian, 1966) was used to conceptualise the variables (and therefore the data collection instruments) into the category of structure, process or outcome at either a patient, provider or systems (health care organisation) level. This in turn helped to theorise the linkage between the variables within this study, identifying conceptual and functional relationships. The abdominal surgery ICP supported improvements in cost and efficiency through a reduction in length of stay (treatment site = 5.29 days, comparison site = 6.16 days) and a positive return to patients' perception of health. However, there was a reduction in patient satisfaction with nursing care with the introduction of the ICP and this needs further study. Involving patients in future developments and evaluations could promote long-term patient satisfaction.

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2

Zulkepli, Jafri. "A theoretical framework for hybrid simulation in modelling complex patient pathways". Thesis, Brunel University, 2012. http://bura.brunel.ac.uk/handle/2438/6448.

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Providing care services across several departments and care givers creates the complexity of the patient pathways, as it deals with different departments, policies, professionals, regulations and many more. One example of complex patient pathways (CPP) is one that exists in integrated care, which most literature relates to health and social care integration. The world population and demand for care services have increased. Therefore, necessary actions need to be taken in order to improve the services given to patients in maintaining their quality of life. As the complexity arises due to different needs of stakeholders, it creates many problems especially when it involves complex patient pathways (CPP). To reduce the problems, many researchers tried using several decision tools such as Discrete Event Simulation (DES), System Dynamic (SD), Markov Model and Tree Diagram. This also includes Direct Experimentation, one of techniques in Lean Thinking/Techniques, in their efforts to help simplify the system complexity and provide decision support tools. However, the CPP models were developed using a single tools which makes the models have some limitations and not capable in covering the entire needs and features of the CPP system. For example, lack of individual analysis, feedback loop as well as lack of experimentation prior to the real implementation. As a result, ineffective and inefficient decision making was made. The researcher also argues that by combining the DES and SD techniques, named the hybrid simulation, the CPP model would be enhanced and in turn will help to provide decision support tools and consequently, will reduce the problems in CPP to the minimum level. As there is no standard framework, a framework of a hybrid simulation for modelling the CPP system is proposed in this research. The researcher is much concerned with the framework development rather than the CPP model itself, as there is no standard model that can represent any type of CPP since it is different in term of its regulations, policies, governance and many more. The framework is developed based on several literatures, selected among developed framework/models that have used combinations of DES and SD techniques simultaneously, applied in a large system or in healthcare sectors. This is due to the condition of the CPP system which is a large healthcare system. The proposed framework is divided into three phases, which are Conceptual, Modelling and Models Communication Phase, and each phase is decomposed into several steps. To validate the suitability of the proposed framework that provides guidance in developing CPP models using hybrid simulation, the inductive research methodology will be used with the help of case studies as a research strategy. Two approaches are used to test the suitability of the framework – practical and theoretical. The practical approach involves developing a CPP model (within health and social care settings) assisted by the SD and DES simulation software which was based on several case studies in health and social care systems that used single modelling techniques. The theoretical approach involves applying several case studies within different care settings without developing the model. Four case studies with different areas and care settings have been selected and applied towards the framework. Based on suitability tests, the framework will be modified accordingly. As this framework provides guidance on how to develop CPP models using hybrid simulation, it is argued that it will be a benchmark to researchers and academicians, as well as decision and policy makers to develop a CPP model using hybrid simulation.

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Gaddari, Abdelhamid. "Analysis and Prediction of Patient Pathways in the Context of Supplemental Health Insurance". Electronic Thesis or Diss., Lyon 1, 2024. http://www.theses.fr/2024LYO10299.

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Ce travail de thèse s'inscrit dans la catégorie de la recherche en informatique de santé, en particulier l'analyse et la prédiction des parcours patients, qui sont les séquences des actes médicaux consommés par les patients au fil du temps. Notre objectif est de proposer une approche innovante pour l'exploitation des données de parcours de soins afin de réaliser non seulement une classification binaire, mais aussi multi-label. Nous concevons également une nouvelle approche de vectorisation et représentation sémantique exclusivement pour le domaine médical français, qui permettra d'exploiter un autre aspect des parcours patients afin d'améliorer la performance prédictive de notre approche proposée. Notre recherche s'inscrit dans le cadre des travaux de CEGEDIM ASSURANCES, une business unit du groupe CEGEDIM qui fournit des logiciels et des services pour les secteurs de l'assurance maladie complémentaire et de la gestion des risques en France. En analysant le parcours de soins et en utilisant l'approche que nous proposons, nous pouvons extraire des informations précieuses et identifier des patterns dans les parcours médicaux des patients afin de prédire des événements médicaux potentiels ou la consommation médicale à venir. Cela permettra aux assureurs de prévoir les futures demandes de soins de santé et donc de négocier de meilleurs tarifs avec les prestataires de soins de santé, ce qui permettra une planification financière précise, des modèles de tarification équitables et une réduction des coûts. En outre, ça permettra aux assureurs privés de concevoir des plans de santé personnalisés qui répondent aux besoins spécifiques des patients, en veillant à ce qu'ils reçoivent les soins adéquats au bon moment afin de prévenir la progression de la maladie. Enfin, l'offre de programmes de soins préventifs et de produits et services de santé personnalisés renforce les relations avec les clients, améliore leur satisfaction et réduit l'attrition. Dans ce travail, nous visons à développer une approche permettant d'analyser les parcours patients et de prédire les événements médicaux ou les traitements à venir, sur la base d'un large portefeuille de remboursements. Pour atteindre cet objectif, nous proposons tout d'abord un nouveau modèle basé sur les LSTM qui tient compte de la notion temporelle et qui permet de réaliser de la classification binaire et multi-label. Le modèle proposé est ensuite étendu par un autre aspect des parcours de soins, à savoir des informations supplémentaires provenant d'un clustering flou du même portefeuille. Nous démontrons que l'approche proposée est plus performante que les méthodes traditionnelles et d'apprentissage profond dans la prédiction médicale binaire et multi-label. Par la suite, nous améliorons la performance prédictive de l'approche proposée en exploitant un aspect supplémentaire des parcours patients, qui consiste en une description textuelle détaillée des traitements médicaux consommés. Ceci est réalisé grâce à la conception de F-BERTMed, une nouvelle approche de vectorisation et de représentation sémantique de phrases pour le domaine médical français. Celle-ci présente des avantages significatifs par rapport aux méthodes de l'état de l'art du traitement automatique du langage naturel (TAL). F-BERTMed est basé sur FlauBERT, dont le pré-entraînement utilisant la tâche MLM (Modélisation Masqué du Langage) a été étendu sur des textes médicaux français avant d'être fine-tuné sur les tâches NLI (Inférence du Langage Naturel) et STS (Similarité Sémantique Textuelle). Nous démontrons enfin que l'utilisation de F-BERTMed pour générer une nouvelle représentation des parcours patients améliore les performances prédictives de notre modèle proposé pour les tâches de classification binaire et multi-label
This thesis work falls into the category of healthcare informatics research, specifically the analysis and prediction of patients’ care pathways, which are the sequences of medical services consumed by patients over time. Our aim is to propose an innovative approach for the exploitation of patient care trajectory data in order to achieve not only binary, but also multi-label classification. We also design a new sentence embedding framework exclusively for the french medical domain, which will harness another view of the patients’ care pathways in order to enhance the predictive performance of our proposed approach. Our research is part of the work of CEGEDIM ASSURANCES, a business unit of the CEGEDIM Group that provides software and services for the french supplementary healthcare insurance and risk management sectors. By analyzing the patient care pathway and leveraging our proposed approach, we can extract valuable insights and identify patterns within the patients’ medical journeys in order to predict potential medical events or upcoming medical consumption. This will allow insurers to forecast future healthcare claims and therefore negotiate better rates with healthcare providers, allowing for accurate financial planning, fair pricing models and cost reductions. Furthermore, it enables private healthcare insurers to design personalized health plans that meet the specific needs of the patients, ensuring they receive the right care at the right time to prevent disease progression. Ultimately, offering preventive care programs and customized health products and services enhances client relationship, improving their satisfaction and reducing churn. In this work, we aim to develop an approach to analyze patient care pathways and predict medical events or upcoming treatments, based on a large portfolio of reimbursed medical records. To achieve this goal, we first propose a new time-aware long-short term memory based framework that can achieve both binary and multi-label classification. The proposed framework is then extended with another aspect of the patient healthcare trajectories, namely additional information from a fuzzy clustering of the same portfolio. We show that our proposed approach outperforms traditional and deep learning methods in medical binary and multi-label prediction. Subsequently, we enhance the predictive performance of our proposed approach by exploiting a supplementary view of the patient care pathways that consists of a detailed textual description of the consumed medical treatments. This is achieved through the design of F-BERTMed, a new sentence embedding framework for the french medical domain that presents significant advantages over the natural language processing (NLP) state-of-the-art methods. F-BERTMed is based on FlauBERT, whose pre-training using MLM (Masked Language Modeling) was extended on french medical texts before being fine-tuned on NLI (Natural Language Inference) and STS (Semantic Textual Similarity) tasks. We finally show that using F-BERTMed to generate a new representation of the patient care pathways enhances the performance of our proposed medical predictive framework on both binary and multi-label classification tasks

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NEVES, MARIANA GUERRA BARSTAD CASTRO. "THE DOCTOR-PATIENT RELATIONSHIP FROM THE ATTACHMENT THEORY S PERSPECTIVE: THINKING PATHWAYS". PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO, 2018. http://www.maxwell.vrac.puc-rio.br/Busca_etds.php?strSecao=resultado&nrSeq=34746@1.

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PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO
COORDENAÇÃO DE APERFEIÇOAMENTO DO PESSOAL DE ENSINO SUPERIOR
PROGRAMA DE SUPORTE À PÓS-GRADUAÇÃO DE INSTS. DE ENSINO
PROGRAMA DE SUPORTE À PÓS-GRADUAÇÃO DE INSTITUIÇÕES COMUNITÁRIAS DE ENSINO PARTICULARES
A relação médico-paciente consiste numa díade que é hierarquicamente assimétrica. Uma parte cuida e a outra recebe cuidado, análogo ao que ocorre nas relações de apego. O médico teria o papel de figura de apego, possibilitando ativar o seu sistema de cuidado. O objetivo deste estudo é analisar como o sistema de cuidado está inserido na relação médico-paciente, analisando o estilo de apego do médico, além de relacioná-lo à capacidade de cuidado que o médico tem com seu paciente. Foram entrevistados onze hematologistas do Rio de Janeiro e São Paulo com experiência no SUS utilizando um roteiro de entrevista semiestruturado e foi aplicado o instrumento de autorrelato EVA (Escala de Vinculação do Adulto). Após análise de conteúdo das entrevistas e análise por clusters do EVA, os médicos entrevistados apresentaram apego seguro, com aspectos defensivos evitativos e amedrontados. Quatro categorias também foram estabelecidas: experiências pessoais com medicina e/ou hematologia; especificidade da hematologia; como lidar com as questões sobre perdas; e cuidado com o outro. Conclui-se que o presente trabalho prioriza o lado do médico nesta relação, e a importância do atendimento às suas necessidades psicológicas e relacionais. Com isso, intervenções podem ser propostas à equipe de saúde, de forma a cuidar de maneira consistente destes profissionais e aprimorar sua relação com o paciente e seus familiares.
The doctor-patient relationship consists of a hierarchically asymmetrical dyad. One side cares and the other receives care, analogous to the attachment relationship. The doctor would have the attachment figure s role, being able to activate his or her caregiving system. The purpose of this study is to analyze how the care system is inserted in the doctor-patient relationship, analyzing the attachment style of the physician in addition to relating it to the care ability that the doctor has with his/her patient. Eleven hematologists from Rio de Janeiro and São Paulo with experience in SUS were interviewed using a semi-structured interview script and the self-report instrument AAS-R (Adult Attachment Scale-Revised) was applied. After content analysis of the interview and a cluster analysis of the AAS-R, all the doctors presented secure attachment, with avoidant-dismissing and avoidant-fearful defensive aspects. Four categories were also analyzed: personal experiences with medicine and/or hematology; hematology s specificity; how to deal with loss; and caring towards other. We concluded that the present it is important to prioritize the doctor s stance in the relationship, and to attend their psychological and relational needs. In that manner, interventions in the healthcare team can be proposed, providing the proper care to the healthcare professional, and, hence, improve their relationship with patients and their family members.

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Smeds, Magdalena. "Managing care pathways for patients with complex care needs". Licentiate thesis, Linköpings universitet, Logistik- och kvalitetsutveckling, 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-156836.

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One of the central challenges for the healthcare system today is how to manage care for patients with complex needs. This patient group is not well-defined but covers patients with serious diseases and comorbidities, or with a limited ability to perform basic daily functions due to physical, mental or psychosocial challenges. This group has a high service and resource utilisation resulting in high costs for the healthcare system and, typically, poor health outcomes. To improve care for these patients, it is necessary to implement strategies to manage the differentiated care needs, the additional support needs, the uncertainty in care delivery, and the coordination needs of the involved providers and the patient. Care pathways are increasingly used internationally to make care more patient-centred and to structure and design care processes for individual patient groups. Important elements in care pathways include structuring care activities, by defining their content and sequence; coordinating between providers and professionals; and involving patients in their care process. In this thesis, care pathways are proposed as the overall strategy for managing care for patients with complex care needs. The purpose of this thesis is thus to contribute with knowledge on how care pathways can be managed for patients with complex care needs. This is achieved by analysing how the practices coordination, standardisation, customisation and personalisation can support management of care pathways and by discussing how these practices influence quality of care. The quality of care dimensions discussed are accessible, timely, equitable, and patient-centred care. The empirical context in this thesis is the Standardised Cancer Care Pathways (CCPs) which were implemented in Sweden from 2015 to 2018. CCPs is the umbrella term for the national initiative to shorten waiting times, decrease regional differences and reduce fragmentation in care processes. CCPs include elements such as diagnosis-specific pathways and guidelines, introduction of CPP coordinators, and mandatory reporting of waiting times. Focus has been on implementing care pathways for 31 cancer diagnoses in all Swedish healthcare regions. Both qualitative and quantitative research methods have been used. A case study was conducted to examine standardised and customised care pathways, and coordination and multidisciplinary work in care pathways. A document study of regional reports on CCPs was analysed to study effects of care pathways on accessibility, timeliness and equitability. Finally, a national survey was conducted to deepen the understanding of the role of coordination, as performed by coordinators, in care pathways. This thesis argues that standardised and customised care pathways should be combined to manage care for patients with complex care needs. The customised pathway in particular benefits patients with serious unspecific symptoms, unknown primary tumour or more complex care needs, while patients with care needs that can be treated independently of the main diagnosis benefit from following a standardised care pathway. Coordinators are an important means to manage coordination, customisation and personalisation in the care pathway. The coordinators’ role is twofold: the first role is to manage care pathways by customising the care pathway and coordinating involved providers; the second role is to support and guide patients through the care pathway. This can be achieved by adapting interpersonal communication with patients through personalisation. This thesis further argues that care pathways have most potential to positively influence accessibility, timeliness, equitability, and patient-centredness. Accessibility has been positively influenced, especially for patients with ambiguous symptoms where symptoms indicating cancer have improved their chances of accessing cancer diagnostics. A negative aspect of prioritising patients who follow CCPs has been the potentially longer waiting times for other patient groups in equal need of urgent care. Notwithstanding, prioritised access to care is perceived to positively influence timeliness for patients following CCPs. Care pathways are perceived to have positively influenced patient-centredness by shifting the focus from what to deliver to how to deliver it.

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Bhattacharya, Abhik. "Development of a framework to identify patient pathways through a segment of the health care cycle". [Tampa, Fla] : University of South Florida, 2009. http://purl.fcla.edu/usf/dc/et/SFE0002866.

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Pelletier, Lori Rebecca. "Information-Enabled Decision-Making in Health Care: EHR-Enabled Standardization, Physician Profiling and Medical Home". Digital WPI, 2010. https://digitalcommons.wpi.edu/etd-dissertations/166.

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Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.

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Namaki, Araghi Sina. "A methodology for business process discovery and diagnosis based on indoor location data : Application to patient pathways improvement". Thesis, Ecole nationale des Mines d'Albi-Carmaux, 2019. http://www.theses.fr/2019EMAC0014.

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Dans chaque organisation, les processus métier sont aujourd’hui incontournables. Cette thèse vise à développer une méthode pour les améliorer. Dans le domaine de la santé, les organisations hospitalières déploient beaucoup d’efforts pour mettre leurs processus sous contrôle, notamment à cause de la très faible marge d’erreur admise. Les parcours des patients au sein des structures de santé constituent l’application qui a été choisie pour démontrer les apports de cette méthode. Elle a pour originalité d’exploiter les données de géolocalisation des patients à l’intérieur de ces structures. Baptisée DIAG, elle améliore les parcours de soins grâce à plusieurs sous-fonctions : (i) interpréter les données de géolocalisation pour la modélisation de processus, (ii) découvrir automatiquement les processus métier, (iii) évaluer la qualité et la performance des parcours et (iv) diagnostiquer automatiquement les problèmes de performance des processus. Cette thèse propose donc les contributions suivantes : la méthode DIAG elle-même qui, grâce à quatre différents états, extrait les informations des données de géolocalisation ; le méta-modèle DIAG qui a deux utilités : d’une part, interpréter les données de géolocalisation et donc passer des données brutes aux informations utilisables, et, d’autre part contribuer à vérifier l’alignement des données avec le domaine grâce à deux méthodes de diagnostic décrites plus bas ; deux algorithmes de découverte de processus qui utilisent la stabilité statistique des logs d’évènements ; une nouvelle approche de process mining utilisant SPC (Statistical Process Control) pour l’amélioration ; l’algorithme proDIST qui mesure les distances entre les modèles de processus ; deux méthodes de diagnostic automatique de processus pour détecter les causes des déviations structurelles dans des cas individuels et pour des processus communs. Le contexte de cette thèse confirme la nécessité de proposer de telles solutions. Une étude de cas dans le cadre de ce travail de recherche illustre l’applicabilité de la méthodologie DIAG et des fonctions et méthodes mentionnées
Business processes are everywhere and, as such, we must acknowledge them. Among all of them, hospital processes are of vital importance. Healthcare organizations invest huge amount of efforts into keeping these processes under control, as the allowed margin of error is so slight. This research work seeks to develop a methodology to endorse improvement of patient pathways inside healthcare organizations. It does so by using the indoor location data of patients. This methodology is called DIAG (Data state, Information state, Awareness, Governance). It is constructed of several different functions. The most important ones are as follows: (i) location data interpreting, (ii) automatic discovery of business process models, (iii) business process analyzing for evaluating the performance and quality of processes, and finally, (iv) automatic diagnosing of business processes. Along the former functions, the contribution of this thesis are: The DIAG methodology which, through four different states, extracts knowledge from location data; the DIAG meta-model which supports both the interpretation of location data (from raw data to usable information) and the alignment of the domain knowledge (which are used for the diagnosing methods); two process discovery algorithms which explore statistical stability in event logs, application of Statistical Process Control (SPC) for the “enhancement notation” of Process Mining; the ProDIST algorithm for measuring the distance between process models; two automatic process diagnosing methods to detect causes of structural deviations in individual cases and common processes. The state of the art in this dissertation endorses the necessity for proposing such solutions. A case study within this research work illustrates the applicability of the DIAG methodology and its mentioned functions and methods

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Lea, Troy William. "Spiritual Pathways to Healing and Recovery: An Intensive Single-N Study of a Patient with an Eating Disorder". BYU ScholarsArchive, 2016. https://scholarsarchive.byu.edu/etd/6022.

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This study presents an in-depth case study of eight sessions of spiritually integrated psychotherapy with a 20-year-old woman recovering from an Eating Disorder. The inclusion and utility of session-to-session outcome data as well as systematic follow up data in conjunction with in-depth qualitative interviews are shown. The therapist and client's perspectives are highlighted over the course of treatment. Three clinical areas of focus (renewing identity, reducing self-contempt, and fostering hope) are extracted from the qualitative interviews and the therapeutic process of weaving them together is highlighted. The Tau-U and SMA single case study statistical analyses are used to highlight clinical gains and maintenance.

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Hajdarevic, Senada. "Patient and health care delays in malignant melanoma". Doctoral thesis, Umeå universitet, Dermatologi och venereologi, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-54392.

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Background: Unlike other cancers, malignant melanoma (MM) is generally visible and can be easily and effectively cured if treated in time. Optimal cure of MM requires early detection, diagnosis, and treatment, which improves prognosis. However, patients as well as the health care organization and its professionals contribute to delayed treatment in various ways. Aims and objectives: The general aim of this PhD thesis was to explore reasons for delay in care seeking, diagnosis, and treatment of malignant melanoma. The specific objectives to be addressed were To explore patients’ decision making about seeking care for malignant melanoma To identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men To compare self-reported decision making coping styles between men and women in various ages, who live with or without a partner and are diagnosed with various stages of malignant melanoma in northern Sweden. To describe and compare patients diagnosed with MM, depending on their initial contact with care, and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals between clinics from the initial contact to diagnosis and treatment. Methods: In studies I and II, 21 and 30 patients, respectively, were interviewed about their decision making to seek care for MM. Study II focused on gender patterns in this decision making. The interviews were analysed using Grounded Theory (I) and qualitative content analysis (II). Study III included 270 people with MM who completed a translated questionnaire (Melbourne Decision Making Questionnaire) about coping styles in decision making. In study IV the pathways and time delay in health care for 71 people with MM were explored. Studies I and II were qualitative, whereas studies III and IV were quantitative. Results: In study I, the insights into severity and feelings of fear and existential threat were identified as key motivators for patients to decide to seek care for a suspected melanoma. Results in study II showed that gender constructions influenced the care-seeking behaviour. Women acknowledged the skin changes and attempted self-care first. They delayed care seeking due to family responsibilities. Men seldom acknowledged the suspicious skin change, but sought care immediately after prompting, and most often complied with relatives’ advice to seek care. Study III showed that men generally scored higher in buck-passing, while women and those living without a partner scored higher in hypervigilance. Participants with nodular melanoma (NM), a rapid-growing form of MM, scored higher in vigilance than those diagnosed as in situ melanoma. No correlation was found between tumour thickness and coping styles. Some differences concerning treatment of MM were found in study IV between people who initially had sought care at primary health care centres (PHC) and those who had sought care at dermatological and specialist clinics (Derm). Thicker tumours as well as NM were more common in the PHC group. A larger proportion of patients from PHCs were primarily excided within the primary health care; however, almost all of them were later referred to surgical clinics for wide excision. Patients within the PHC group also had to wait longer for the registered results of histopathological assessments. In general, women waited a shorter time for primary excision, and older people waited longer for wide excision. Conclusions: Time delay of diagnosis and treatment of MM is still common, and crucial to decrease. Future interventions should include gender aspects to influence people to seek care earlier. In health care, time delay could be decreased by facilitating access for patients with suspected skin melanomas, but also by reducing unnecessary referrals. Moreover, organizational changes whereby general practitioners and primary health care nurses are supported in using new technology for faster diagnoses and management of MM in collaboration with specialist clinics should be considered. Easy access and frequently used guidelines for MM could further decrease delay. Lastly, more efficient transfer and registration of laboratory results and referrals could decrease delay and improve patient safety.
Bakgrund: Malignt melanom (MM) är till skillnad från andra cancerformer ofta synlig och kan enkelt och kostnadseffektivt botas om det behandlas i tid. En optimal prognos av MM förutsätter tidig upptäckt, diagnos och behandling. Patienter, samt hälso- och sjukvården, dess organisation och dess personal kan på olika sätt bidra till fördröjning av behandlingen av MM. Syfte: Det övergripande syftet med denna avhandling var att undersöka orsaker till fördröjning att söka vård, diagnosticera och behandla malignt melanom. Specifika delsyften var: Att utforska patienternas beslutsfattande process att söka vård för MM Att identifiera specifika mönster i beslutsfattande-processen att söka vård för misstänkt MM utifrån kvinnors och mäns egna berättelser Att jämföra självrapporterade coping-stilar i den beslutsfattande processen mellan män och kvinnor i olika åldrar, boende med eller utan partner, och diagnosticerade med MM i olika stadier från norra Sverige Att beskriva och jämföra patienter med MM utifrån deras primära vårdkontakt samt utifrån ålder, kön, MM-typ och tjocklek. Ytterligare att utforska vård- och remissvägar samt tidsintervaller mellan olika kliniker från första kontakt till diagnos och behandling. Metod: I studie I och II, intervjuades 21 respektive 30 patienter om den beslutsfattande processen att söka vård för MM. Genuskonstruktioner i relation till den beslutsfattande processen var i fokus i studie II. Intervjuerna analyserades med hjälp av Grounded Theory (I) och kvalitativ innehållsanalys (II). I studie III inkluderades 270 patienter med MM som besvarade ett instrument (MDMQ) avseende coping-stilar i beslutsfattande processen. I studie IV undersöktes övergångar mellan olika kliniker och remissvägar för 71 patienter med MM samt eventuell tidsfördröjning inom hälso- och sjukvården. Resultat: I studie I, identifierades insikt i allvarlighetsgrad samt rädsla och existentiellt hot till följd av tillståndet vara nyckel-motivatorer för att bestämma sig för att söka vård för misstänkt hudmelanom. Resultat från studie II påvisade att genuskonstruktioner påverkar hur personer söker vård för MM. Kvinnor upptäckte själv sina melanom och försökte tillämpa egenvård i början. De kunde dröja att söka vård pga. ansvar för familjen. Män upptäckte sällan suspekta melanom själva men följde oftast anhörigas råd att söka vård och sökte vård omedelbart efter påstötning. Resultaten från studie III visade att män i högre grad använde en avvaktande startegi (buck-passing) medan kvinnor och de som bodde utan partner var överdrivet vaksamma (hypervigilance). Deltagare med nodulärt melanom (NM), en snabbt växande form av MM, var mer vaksamma (vigilance) jämfört med de med melanom in situ, en mycket tidig form av melanom. Några korrelationer mellan tumörtjocklek och coping-stilar hittades ej. Vissa skillnader avseende typer av MM samt vårdens handläggning beroende på var patienter initialt sökt vård identifierades i studie IV. Bland patienter som initialt sökt vård på hälsocentralerna var tjockare tumörer vanligare jämfört med dem som hade sökt vård på hud- och andra specialistklinker. Dessa patienter hade också som regel genomgått den primära excisionen på hälsocentralerna och en majoritet blev senare remitterade till kirurgisk klinik för utvidgad excision. Hälsocentralernas patienter fick vänta längre på att det histopatologiska svaret registrerades i journalen än sjukhusklinikernas patienter. Kvinnor fick generellt vänta kortare tid på primär excision och äldre patienter fick vänta längre för utvidgad excision. Slutsatser: Tidsfördröjning av diagnos och behandling av MM är fortfarande vanlig och därför viktig att minska. Framtida interventioner för att påverka människor att söka vård tidigare bör inkludera genusaspekter. Inom hälso- och sjukvården kan tidsfördröjning minskas genom förbättrad tillgänglighet för patienter med misstänkta hudmelanom, men också genom minskning av onödig remittering. En förändrad organisation där sjuksköterskor och primärvårdsläkare i samarbete med specialistkliniker stöttas att använda ny teknologi för snabbare diagnosticering och omhändertagande av MM bör övervägas. Ökad kännedom bland hälso- och sjukvårdspersonal om riktlinjer for MM-vård kan vidare minska fördröjning. Till sist, mer effektiva och förbättrade arbetssätt kring registrering och överföring av laboratoriska svar och remisser skulle kunna minska fördröjning och därmed öka patientsäkerheten.

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11

Bailey, Janelle Lee. "Language Pathways Defined in a Patient with Left Temporal Lobe DamageSecondary to Traumatic Brain Injury: A QEEG & MRI Study". BYU ScholarsArchive, 2014. https://scholarsarchive.byu.edu/etd/4363.

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Though the current understanding of language processing is incomplete, it has been established that the left hemisphere is dominant for language in the majority of the population. Damage to language centers of the brain and to white matter tracts connecting these language centers results in a language deficit known as aphasia. Neuroplasticity in the brain can often compensate for these language deficits by strengthening neuronal connections between the right and left hemisphere, or by enhancing the neuronal connectivity of undamaged areas in the left hemisphere. Thus the brain can compensate for damaged language centers by using alternative cortical areas. These compensatory language areas may be homologous areas of the right hemisphere, or other undamaged portions of the left hemisphere. Various imaging techniques have been used to demonstrate this phenomenon. The current neuroimaging technique known as quantitative electroencephalographic brain imaging allows investigators to evaluate the functional anatomical location of language processing. When this mapping is overlaid on a magnetic resonance image, investigators are able to locate areas in the brain of the participant that are electrically activated during elicited speech tasks. This method was used in a single case study to examine the brain of an individual with a unique traumatic brain injury in which the anterior portion of the individual's left temporal lobe was surgically removed and considerable recovery of language subsequently occurred. The stimulus for the quantitative electroencephalography included identifying syntactically incorrect sentences. Imaging results from the participant with traumatic brain injury were compared to imaging results obtained from an age-matched control. Differences in quantitative electroencephalography between the two participants included a delayed P1-N1-P2 response and an absent P600 in the participant with traumatic brain injury. Behavioral results include an increased number of incorrect responses from the participant with traumatic brain injury as compared to the control participant. These results imply an interesting cortical distribution of language processing that could be further assessed by functional magnetic resonance imaging.

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12

Nakajima, Aya. "Radiation sensitivity assay with a panel of patient-derived spheroids of small cell carcinoma of the cervix". Kyoto University, 2015. http://hdl.handle.net/2433/199178.

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13

Duarte, Anette. "Standardvårdplaner – till vilken nytta?" Thesis, Halmstad University, School of Social and Health Sciences (HOS), 2010. http://urn.kb.se/resolve?urn=urn:nbn:se:hh:diva-5836.

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Standardvårdplaner är vanligt förekommande inom hälso- och sjukvård och är under ständig utveckling. Standardvårdplaner är i olika grad evidensbaserade och framtagna med skiftande kvalitet. Standardvårdplaner används som ett hjälpmedel för effektivisering och kvalitetshöjning av vården för en specifik patientgrupp och är en på förhand formulerad vårdplan. Behov av ytterligare forskning efterfrågas om standardvårdplaner faktiskt minskar mängden dubbeldokumentation, leder till ökad tidsvinst och ökad vårdkvalitet. Syftet med föreliggande litteraturstudie var att göra en beskrivning av de effekter som användande av standardvårdplaner leder till. I litteraturstudien bearbetades 10 vetenskapliga artiklar som grund för resultatredovisningen. Resultatet visar att standardvårdplaner kan höja vårdkvaliteten, minska mängden dubbeldokumentation och leda till att tid frigörs till patientnära arbete. Det finns emellertid studier som visar på det motsatta. Standardvårdplanen kan ses som ett verktyg som underlättar en jämlik, högkvalitativ vård till alla patienter oavsett vem som vårdar. Utveckling av standardvårdplaner i vården bör ske på ett strukturerat och vetenskapligt sätt och tid till detta bör prioriteras. Litteraturstudien redovisar motstridiga resultat vilket indikerar behovet av fortsatt forskning av vilka effekter standardvårdplaner har för vården, både sett ur patientperspektiv, personalperspektiv samt ur ett organisatoriskt perspektiv.

Standardized care plans are commonly used in health care and are under constant development. Standardized care plans are to varying degrees evidence-based and designed with varying quality. Standardized care plans are used as a tool for improving the quality of care and are seen as a pre-formulated treatment plan. Research is needed into whether standardized care plans reduce the amount of redundant documentation, save time and increase quality of care. The aim of this literature study was to describe the situation regarding effects of using standardized care plans. In this study 10 scientific articles were analyzed. Results show that standardized care plans can improve quality of care, reduce redundant documentation and decrease time spent on documentation. However, there are studies that demonstrate the opposite. Standardized care plans can be seen as a tool for providing high-quality basic care for all patients. Scientific evidence should be used for development of standardized care plans and therefore priority should be given to making resources for this work available. There is a need for further research to validate the effects of standardized care plans as the results from this literature study are ambiguous. It would also be interesting to compare the views from patients, staff and management on the effects of using standardized care plans.

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14

Steen, Scott. "Understanding the processes involved in implementing an improving access to psychological therapies service : an exploratory study that investigates practitioner and client experience regarding its effect on patient pathways, service design and overall outcomes". Thesis, University of Chester, 2015. http://hdl.handle.net/10034/620323.

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The English Improving Access to Psychological Therapies (IAPT) programme is a government-funded initiative that aims to provide timely and equitable access to evidence-based psychotherapeutic interventions, within a primary care setting. Despite the many achievements of the programme, there are several issues regarding research to clinical gaps, as well as a high rate of variation between sites concerning outcomes and attrition. This thesis explores the implementation process of the IAPT delivery model to understand which factors are influential in the successful uptake and integration of evidence-based psychotherapeutic interventions. The aims of this thesis are:  To explore, identify and analyse the implementation process involved in establishing and delivering an IAPT service.  To uncover the factors that either facilitate or impede its development to provide a more in-depth and detailed account of the implementation and operation of services.  To develop an understanding regarding the applicability of evidence-based practice and the IAPT delivery model in a clinical setting, for the provision of psychological therapies. I conducted a series of semi-structured interviews with practitioners delivering and implementing services, across seven sites, and clients, across three sites. The design and analysis followed an Interpretative Phenomenological Analysis, focusing on personal meaning and sense-making processes. The objective of the interview was to understand the implementation process regarding the IAPT delivery model, exploring how this influences personal experiences and client engagement. Additionally, participant narrative was set in context using open-access data collected and published by the programme. The analysis generated three master themes for practitioners delivering and implementing services including: ‘A Call to Action’ describing how participants regarded this process as a genuine opportunity to make a real impact in mental healthcare; ‘Contextual Influences on Service Operation’ which explores the activities in becoming a locally determined, adaptable and relevant service; and a ‘Focus on Relationships’ outlining the relational and collaborative work involved during implementation. For the client group, three master themes were generated including: ‘A Personal Journey: From Discovery to Advocacy’ illustrating the changing experiences involved during service access and engagement; ‘Perception of Self’ which portrays how individuals made sense of their engagement by judging what it meant to them; 5 and ‘Outside Factors’ which explores the role of others and the physical journey made in getting to services. The analysis suggested that both groups made sense of their experiences in complex and varied ways. Heavily influencing the implementation of the IAPT delivery model is the over-arching need to boost throughput and quantity, possibly at a cost of quality. Additionally, it is argued that the use of routine outcome monitoring in services is useful for reflecting on the implementation process and engaging clients. The key to successful implementation appears to be about achieving integration, requiring a whole-systems based approach that considers the mediating pathways into and out of services. In light of the findings and literature, the thesis proposes several recommendations for future practice and further research.

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15

Dehghan, Azad. "Mining patient journeys from healthcare narratives". Thesis, University of Manchester, 2015. https://www.research.manchester.ac.uk/portal/en/theses/mining-patient-journeys-from-healthcare-narratives(69ebfa6d-764a-4dfe-bbf8-6aab1905a6f3).html.

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The aim of the thesis is to investigate the feasibility of using text mining methods to reconstruct patient journeys from unstructured clinical narratives. A novel method to extract and represent patient journeys is proposed and evaluated in this thesis. A composition of methods were designed, developed and evaluated to this end; which included health-related concept extraction, temporal information extraction, and concept clustering and automated work-flow generation. A suite of methods to extract clinical information from healthcare narratives were proposed and evaluated in order to enable chronological ordering of clinical concepts. Specifically, we proposed and evaluated a data-driven method to identify key clinical events (i.e., medical problems, treatments, and tests) using a sequence labelling algorithm, CRF, with a combination of lexical and syntactic features, and a rule-based post-processing method including label correction, boundary adjustment and false positive filter. The method was evaluated as part of the 2012 i2b2 challengeand achieved a state-of-the-art performance with a strict and lenient micro F1-measure of 83.45% and 91.13% respectively. A method to extract temporal expressions using a hybrid knowledge- (dictionary and rules) and data-driven (CRF) has been proposed and evaluated. The method demonstrated the state-of-the-art performance at the 2012 i2b2 challenge: F1-measure of 90.48% and accuracy of 70.44% for identification and normalisation respectively. For temporal ordering of events we proposed and evaluated a knowledge-driven method, with a F1-measure of 62.96% (considering the reduced temporal graph) or 70.22% for extraction of temporal links. The method developed consisted of initial rule-based identification and classification components which utilised contextual lexico-syntactic cues for inter-sentence links, string similarity for co-reference links, and subsequently a temporal closure component to calculate transitive relations of the extracted links. In a case study of survivors of childhood central nervous system tumours (medulloblastoma), qualitative evaluation showed that we were able to capture specific trends part of patient journeys. An overall quantitative evaluation score (average precision and recall) of 94-100% for individual and 97% for aggregated patient journeys were also achieved. Hence, indicating that text mining methods can be used to identify, extract and temporally organise key clinical concepts that make up a patient’s journey. We also presented an analyses of healthcare narratives, specifically exploring the content of clinical and patient narratives by using methods developed to extract patient journeys. We found that health-related quality of life concepts are more common in patient narrative, while clinical concepts (e.g., medical problems, treatments, tests) are more prevalent in clinical narratives. In addition, while both aggregated sets of narratives contain all investigated concepts; clinical narratives contain, proportionally, more health-related quality of life concepts than clinical concepts found in patient narratives. These results demonstrate that automated concept extraction, in particular health-related quality of life, as part of standard clinical practice is feasible. The proposed method presented herein demonstrated that text mining methods can be efficiently used to identify, extract and temporally organise key clinical concepts that make up a patient’s journey in a healthcare system. Automated reconstruction of patient journeys can potentially be of value for clinical practitioners and researchers, to aid large scale analyses of implemented care pathways, and subsequently help monitor, compare, develop and adjust clinical guidelines both in the areas of chronic diseases where there is plenty of data and rare conditions where potentially there are no established guidelines.

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16

Jones, Karen. "The remodelling of patient care pathway for e-health". Thesis, Brunel University, 2009. http://bura.brunel.ac.uk/handle/2438/3975.

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The interdependencies within the health care system are seldom taken into account prior to implementation of e-health projects, and there tends to be little change management as part of the plan. Our proposal offers a systems analysis model that gives e-health a framework to consider and manage the introduction, changes and outcomes. This research describes the use of a modified Patient Care Pathway as a method to design and implement e-health projects, presenting as a case study the pre-implementation phase of a teleradiology project in rural Thailand. The proposal is that a modified version of Patient Care Pathways can be used as a prospective design model for e-health services. The method adopts systems engineering principles and applies a ―whole systems approach‖ thereby providing a much richer schematic representation of the patient care pathway illustrating both the patient‘s journey through the system and also the information flow. Our method was applied to the design of a new teleradiology service that was to be established in Thailand, to connect GP‘s in a rural hospital to the radiology department in a tertiary hospital with a further connection to a specialist radiologist in a medical school in Bangkok. By comparing the pre-implementation Patient Care Pathway with the proposed pathway using the teleradiology, a systems analysis model was developed to identify critical points in the system and identify and anticipate how the system would support the changes in clinical practices. The method produced a valuable framework to better understand and thereby manage the implications of change prior to implementation of an e-health project.

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17

Barker, Tina M. "The Use of Clinical Pathways in Patients with Thoracic Injuries". Kent State University / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=kent1586891718248184.

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Alassiri, Mohammed. "Characterising the PEPITEM pathway in patients with atherosclerosis". Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/7065/.

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Atherosclerosis is an asymptomatic disease which is regarded as one of the most fatal diseases. However, the mechanism of the immune response is not well understood. There is accumulated evidence supporting the idea that inflammatory response initiates the disease. A new novel peptide has been discovered in our lab which down-regulates T cell recruitment during inflammation called PEPITEM (Peptide Inhibitor of Trans Endothelial Migration). We are interested in testing the action of PEPITEM on PBL isolated from atherosclerosis patients. We first demonstrated that PEPITEM did not affect the levels of adhesion of PBL from either diseased or healthy donors. Interestingly however, we did observe that PBL isolated from atherosclerosis patients adhere more readily than those isolated from healthy control subjects. Therefore, we studied the surface expression of certain adhesion molecules and chemokine receptors on the PBL of atherosclerosis patients. We found significantly higher surface expression of Beta-receptor family (Beta-1 and Beta-2) and PSGL-1 receptors in some PBL subsets in atherosclerosis patients. In addition, we looked at the effect of PEPITEM and adiponectin (AQ) treatment on the migration of PBL and we revealed for the first time based on our knowledge that there was no effect of treatment on PBL isolated from atherosclerosis patients. These observations will contribute to understanding the potential therapeutic applications of PEPITEM on atherosclerosis.

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19

Lewis, William. "Changes in Language Pathways in Tuberous Sclerosis Complex Patients with Autism". Thesis, Harvard University, 2014. http://etds.lib.harvard.edu/hms/admin/view/45.

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Tuberous sclerosis complex (TSC) is an autosomal-dominant neurocutaneous disease caused by loss of the TSC1 (encoding hamartin) or TSC2 (encoding tuberin) genes. Neurologic symptoms are common and varied in TSC and include epilepsy and behavioral conditions like autism spectrum disorders (ASD). Between 17 and 61% of children with TSC exhibit symptoms of ASD. The purpose of this study was to investigate a potential correlate of poor neurological outcome in TSC by assessing the integrity of brain language pathways and the relationship to ASD. 42 patients with TSC and 42 age-matched control subjects were scanned with advanced diffusion-weighted MRI. White matter language pathways were identified with a validated automatic method and analyzed for microstructural characteristics, including fractional anisotropy (FA) and mean diffusivity (MD). Well-defined white matter pathways in the brain are characterized by high FA and low MD. During normal development, brain white matter pathways increase in FA and decrease in MD. Out of 42 patients with TSC, 12 had ASD (29%). After controlling for age, TSC patients without ASD showed a small decrease in FA of the arcuate fasciculus compared to control subjects, and TSC patients with ASD had much lower FA than both control subjects and TSC patients without ASD. Similarly, while TSC patients without ASD had only a small increase in MD compared to control subjects in the arcuate fasciculus, TSC patients with ASD had much higher MD than control subjects and TSC patients without ASD. A new method for assessing the microstructure of young patients showed similar results with decreased compactness in language pathways of TSC patients with ASD. Another new method designed to better analyze regions with crossing pathways showed modifications in language pathway microstructure that correlated with ASD diagnosis in the TSC patients. Preliminary analysis of neuropsychiatric data also showed a trend toward an association of arcuate fasciculus MD with verbal IQ, although the result was not significant after multiple comparisons correction. It remains unclear why some patients with TSC develop ASD, while others have better language outcomes. Our results suggest that aberrant development of language pathways may act as a marker for poor neurological outcome in TSC patients. The impaired microstructure in language pathways of TSC patients may be responsible for the development of ASD, although prospective studies examining the development of language pathways and subsequent ASD diagnosis in this patient population remain essential. It is also possible that a primary problem with language leads to decreased use and subsequent poor development of language pathways. Early diagnosis of ASD is crucial for improving the outcomes of affected children.

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20

Brown, Helen Gaenor. "Transient Ischaemic Attack (TIA) Management study". Thesis, Griffith University, 2011. http://hdl.handle.net/10072/366821.

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BACKGROUND: There is increasing evidence of a high early risk of stroke following TIA. Patients presenting after a TIA offer a unique opportunity for the urgent initiation of proven secondary preventive measures known to reduce the risk of a subsequent stroke. Despite this many TIA patients remain under-investigated and under-treated. OBJECTIVE: The aim of this study was to assess whether a structured treatment pathway would improve patient management and outcomes. The clinical pathway categorizes patients with TIA into high or low-risk for stroke according to the ABCD2 prognostic scoring system so as to guide their treatment accordingly. It was hoped that the use of the clinical pathway would result in improved medical management and investigation for patients with TIA and ultimately reduce their risk of subsequent stroke and other adverse events at 90 days.
Thesis (Masters)
Master of Philosophy (MPhil)
School of Medicine
Griffith Health
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Henriksson, Gert. "Clinical, immunological and olfactory aspects of sinusitis and nasal polyposis : with special reference to patients with cystic fibrosis /". Stockholm, 2004. http://diss.kib.ki.se/2004/91-7140-151-2/.

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Phethi, T. S. "Help-seeking pathways followed by patients with chronic diseases:the case of ga-Dikgale". Thesis, University of Limpopo, 2014. http://hdl.handle.net/10386/1229.

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Thesis (M.A. (Clinical Psychology)) --University of Limpopo, 2014
The aim of the study was to investigate help-seeking pathways that are followed by patients with chronic disease in one rural community in Limpopo Province. Specifically, the objectives of the study were: a). to investigate help-seeking pathways that were followed by patients with chronic diseases before and after they were diagnosed with their condition; b). to explore the treatment modalities that were used by the patients before they started receiving hospital treatment for their chronic conditions; and, c). to determine whether or not the patients received other forms of treatment in addition to their treatment for the chronic diseases. Through snowball sampling, 10 participants (female = 6; male = 4) drawn from Ga-Dikgale community (Limpopo Province) were selected and requested to participate in the present study. The ages of the participants ranged from 42 to 96 years. Data were collected using semi-structured interviews and analyzed using interpretative phenomenological analysis (IPA) The results of the study are presented under the following themes: a). participants‟ understanding of chronic disease; b). participants‟ view or understanding of factors that could have led to their chronic disease ; c). the help-seeking pathways that were followed by patients with chronic diseases before and after they were diagnosed with their condition; d). the treatment modalities that were used by the patients before they started receiving hospital treatment for their chronic conditions; and, e) whether or not the patients received other forms of treatment in addition to their treatment for the chronic diseases. The study found that different treatment agencies are consulted by patients with chronic diseases. These agencies include: spiritual leaders, traditional healers, to mention few. Based on the findings of the present study, it is concluded that help-seeking pathways are mainly determined by the perceived causes of the disease, which are culturally rooted.

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Bouyssou, Isabelle. "Deciphering Plasmodium vivax invasion pathway(s) in Duffy-negative patients". Electronic Thesis or Diss., Sorbonne université, 2023. https://accesdistant.sorbonne-universite.fr/login?url=https://theses-intra.sorbonne-universite.fr/2023SORUS180.pdf.

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Le paludisme à Plasmodium vivax est une maladie infectieuse causée par le parasite protozoaire Plasmodium vivax et transmise par les moustiques femelles Anopheles. Cette maladie est prévalente en Amérique, Asie, Moyen-Orient, Pacifique, Afrique du Nord-Est et Afrique du Sud mais demeure rare en Afrique sub-saharienne. Historiquement, la maladie était considérée bégnine et peu dangereuse du fait de l'observation de faibles parasitémies chez les patients Duffy-positifs et de l'absence virtuelle d'infections chez les individus Duffy-négatifs. Des études ont montré que les individus d'origine africaines ou afro-américaines étaient naturellement résistants à P. vivax. Les parasitologistes pensaient que cela était dû à l'absence de récepteurs Duffy Antigen Receptor for Chemokines (DARC) à la surface de leurs érythrocytes. Ensuite, l'identification du ligand P. vivax Duffy Binding Protein (PvDBP) spécifique à DARC et la preuve de l'importance de l'interaction PvDBP-DARC dans le mécanisme d'invasion ont conduit à l'établissement d'un paradigme scientifique selon lequel les mérozoïtes de P. vivax envahissent exclusivement les érythrocytes Duffy-positifs. La recherche sur le paludisme à P. vivax a donc longtemps été négligée et d'importantes lacunes demeurent. Cependant, le nombre de cas de paludisme à P. vivax stagne dans certains pays et un nombre croissant de cas d'infection chez des patients Duffy-négatifs est reporté en Afrique. Cela a soulevé des interrogations quant aux mécanismes d'invasion de P. vivax. Une première hypothèse est que le parasite a évolué vers un nouveau mécanisme d'invasion outrepassant la Duffy-négativité. Alternativement, une seconde hypothèse est que les populations Duffy-négatives ont toujours représenté un réservoir silencieux et insidieux d'infection. Mon projet de thèse vise à décrypter les mécanismes d'invasion de P. vivax chez les patients Duffy-négatifs. 1.Etude bibliographique: comprendre le contexte et les enjeux liés à l'émergence du paludisme à P. vivax en Afrique sub-saharienne et étudier les connaissances actuelles sur les mécanismes d'invasion de P. vivax obtenues grâce aux technologies omiques. 2.Etude d'épidémiologie moléculaire: comprendre l'épidémiologie du paludisme à P. vivax en Ethiopie, disséquer le génome d'isolats de P. vivax circulant en Afrique sub-saharienne et rechercher une signature moléculaire de l'invasion via des techniques de séquençage. 3.Etude fonctionnelle: caractériser les érythroblastes Duffy-négatifs pendant leur différentiation et évaluer la capacité des mérozoïtes de P. vivax à les envahir via des essais fonctionnels in vitro. Les résultats de l'étude bibliographique ont montré que, malgré de récentes avancées, la recherche sur le paludisme à P. vivax est entravée par le manque de données scientifiques et de techniques expérimentales. Par ailleurs, les résultats des études d'épidémiologie moléculaire ont révélé que les souches de P. vivax se regroupent en clusters géographiques. Mais ils n'ont pas permis d'identifier une association entre la diversité génétique des souches de P. vivax et une adaptation aux hôtes humains Duffy-négatifs. Ce qui suggère que les parasites P. vivax n'ont pas évolué vers une voie d'invasion alternative pour infecter les patients Duffy-négatifs. En fait, les résultats de l'étude fonctionnelle ont démontré qu'une sous-population d'érythroblastes Duffy-négatifs est capable d'exprimer la protéine fonctionnelle DARC, et que les mérozoïtes P. vivax sont capables de les envahir. Ainsi, l'ensemble de ces travaux de recherche va à l'encontre du paradigme scientifique établi selon lequel les mérozoïtes de P. vivax envahissent exclusivement les érythrocytes Duffy-positifs et supporte l'hypothèse que les populations africaines Duffy-négatives représentent un réservoir silencieux et insidieux d'infection. Ce qui entraine d'importantes conséquences pour le contrôle et l'éradication du paludisme à P. vivax en Afrique sub-saharienne
Vivax malaria is an acute debilitating illness caused by the parasitic protozoan Plasmodium vivax and transmitted by female Anopheline mosquitoes. It is mainly prevalent in America, South-East Asia, Middle East, Western Pacific, Eastern Africa, and Southern Africa but considered rare in Sub-Saharan Africa. Historically, the disease has often been regarded as a benign self-limiting infection. This is due to the observation of low parasitemia in Duffy-positive patients and virtual absence of infections in Duffy-negative individuals. Indeed, previous studies showed that individuals with African and African American origins were naturally resistant to P. vivax. Parasitologists thought that this resistance was due to the absence of Duffy Antigen Receptor for Chemokines (DARC) on the surface of their erythrocytes. Subsequently, the identification of the ligand P. vivax Duffy Binding Protein (PvDBP) specific to DARC and the evidence that the interaction PvDBP- DARC was crucial for invasion led to a scientific paradigm by which P. vivax merozoites exclusively invade Duffy-positive erythrocytes. Consequently, research on vivax malaria has long been neglected and many knowledge and tool gaps remain to be filled. However, since a few years, the stagnating burden of the disease in many countries associated with the increasing report of P. vivax infections in Duffy-negative patients raised questions about P. vivax invasion pathways. A first hypothesis was that P. vivax may have evolved to a new invasion pathway that would overcome Duffy-negativity. Alternatively, a second hypothesis was that Duffy-negative populations may have always been a silent and insidious reservoir of infection which had previously gone unnoticed. My thesis project aimed at deciphering Plasmodium vivax invasion pathways in Duffy-negative patients. 1.Bibliographical study: understand the global context and key issues of the presence of vivax malaria in Sub-Saharan Africa and review current knowledge on P. vivax invasion pathways through the lens of omics technologies. 2.Molecular epidemiological study: understand vivax malaria epidemiology in Ethiopia, dissect the genome of P. vivax strains circulating in Sub-Saharan Africa and search for potential molecular signature in genes encoding proteins involved in P. vivax invasion pathways using next generation sequencing techniques. 3.Functional study: characterize Duffy-negative erythroblasts during terminal erythroid differentiation and assess the ability of P. vivax merozoites to invade Duffy-negative erythroblasts by developing reproducible in vitro functional assays. Findings of the bibliographical study showed that despite the recent advances of omics technologies, key knowledge and tool gaps remain in vivax malaria research. Besides, findings of the molecular epidemiological studies revealed that P. vivax strains cluster in distinct geographic clusters. However, these findings did not reveal any association between genetic diversity and adaptation to Duffy-negative human hosts. This suggests that the parasites did not evolve towards an alternative invasion pathway. In fact, findings of the in vitro functional study demonstrated that a subset of Duffy-negative erythroblasts can express functional DARC during terminal erythroid differentiation and that P. vivax merozoites can invade them. Taken together, these findings contrast with the established scientific paradigm by which P. vivax merozoites exclusively invade Duffy-positive erythrocytes and support the assumption that African Duffy-negative populations may be a silent and insidious reservoir of infection, with all the consequences that this entails for the control and eradication of vivax malaria in Sub-Saharan Africa

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DiRocco, Dianne Boyer. "The effect of critical pathways on length of stay for cerebrovascular accident patients". FIU Digital Commons, 1995. http://digitalcommons.fiu.edu/etd/2823.

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The purpose of this study was to (a) determine the effect of a critical pathway on the length of hospital stay for patients diagnosed with cerebrovascular accident, and (b) identify the variances associated with delayed length of stay for patients admitted after the implementation of the critical pathway. The sample included 34 patients (Male = 14; Female = 20) diagnosed with either hemorrhagic cerebrovascular (n = 4) or non-hemorrhagic (n = 30) accidents. The mean age was 68 years. A t-test comparing the length of stay for patients admitted to the hospital before (Mean = 8.59, SD = 4.95) and after the implementation of the critical pathway (Mean = 8.71, SD = 3.18) indicate that the critical pathway did not reduce the length of stay, t(32) = -.08, p > .05. Variances associated with extended length of stay for patients admitted after the implementation of the critical pathway included delays in discharge due to patient (23.5%), placement (17.6%), and provider (11.8%).

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25

Jury, Elizabeth Carole. "Dysregulated intracellular signalling pathways in T lymphocytes from patients with systemic lupus erythematosus". Thesis, University College London (University of London), 2004. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.411032.

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Leurs, Paul B. "Tissue factor pathway inhibitor in patients with diabetes mellitus an epiphenomenon? /". Maastricht : Maastricht : UPM, Universitaire Pers Maastricht ; University Library, Maastricht University [Host], 2001. http://arno.unimaas.nl/show.cgi?fid=6971.

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27

Taylor, Clare Joanne. "The clinical pathway of patients with heart failure in primary care". Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6557/.

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Background: Heart failure is a common clinical syndrome associated with major adverse symptoms and poor outlook for patients, and high costs for healthcare systems globally. This thesis examines four aspects of the clinical pathway of patients with heart failure in primary care. Methods: Routinely collected GP records are used to estimate the number of newly diagnosed heart failure cases by year. A qualitative interview study explores the patient experience of the diagnostic pathway. Survival analysis is used to determine prognosis of patients following a first diagnostic label. Finally, a screening study examines who develops heart failure over time. Results: The incidence of heart failure has been static at 2.3 cases per 1,000 person-years since 2006. Patients initially normalise their symptoms so delay seeking help, GP access is challenging and communication in secondary care, particularly delivery of diagnosis, could be improved. Survival rates are 81.5%, 51.6% and 29.5% at 1, 5 and 10 years, respectively, and have not changed over time. Screening provides an alternative pathway to identify patients with heart failure. Conclusions: Strategies to reduce the number of new cases of heart failure, enhance patient experience, improve survival and explore new diagnostic pathways should be important priorities for the NHS.

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28

Mateu, Jiménez Mercè 1990. "Mechanisms and pathways involved in lung tumor development in patients with chronic respiratory conditions". Doctoral thesis, Universitat Pompeu Fabra, 2017. http://hdl.handle.net/10803/664501.

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Chronic respiratory diseases, especially chronic obstructive pulmonary disease (COPD), and several molecular mechanisms may predispose to lung cancer (LC) development. Hypothesis: We hypothesized that different biological mechanisms such as oxidative stress, inflammatory events and epigenetic alterations may alter key cellular processes that are strongly involved in tumor initiation and progression in COPD patients. Objectives: In tumor and non-tumor lungs and in blood, to explore potential differences between LC patients with and without COPD, in several biological mechanisms that underlie lung tumor development. To evaluate the different profile of these molecular mechanisms between tumor and non-tumor lungs in either LC or LC-COPD patients. Methods: In lung specimens (tumor and non-tumor), oxidative and nitrosative stress markers, antioxidant systems, Th1 and Th2 cytokines, M1 and M2 macrophages, epigenetic events and downstream biomarkers were determined in LC patients with and without COPD. Redox balance markers and Th1 and Th2 cytokines were also evaluated in the blood compartment of LC patients with and without COPD. Results: In tumor lungs and in the blood of LC patients with COPD, an increased oxidative and nitrosative stress was observed, and an upregulation of the Th1 inflammatory response. Expression of specific microRNAs, DNA methylation levels and downstream biomarkers were altered in the lung tumors of LC patients with COPD, which in turn, promoted an increase in cell proliferation, invasion and angiogenesis. In the tumor lungs of LC patients with and without COPD, redox and nitrosative imbalance was higher, Th1 and Th2 cytokines were greater and epigenetic events and downstream biomarkers were altered. Conclusions: A different expression profile of several molecular mechanisms, involved in tumor development, exist in lung tumors and in blood of LC patients with COPD, which may predispose COPD patients to a higher risk of developing LC.
Las enfermedades crónicas respiratorias, y en especial la enfermedad pulmonar obstructiva crónica (EPOC), así como diversos mecanismos moleculares, podrían ser factores de predisposición al desarrollo de cáncer de pulmón (CP). Hipótesis: La hipótesis de trabajo fue que diferentes mecanismos biológicos como el estrés oxidativo, los procesos inflamatorios y las modificaciones epigenéticas, podrían alterar diversos procesos celulares involucrados en el inicio y en la progresión tumoral en pacientes con EPOC. Objetivos: En tejido pulmonar (tumoral y no tumoral) y en sangre, explorar las diferencias potenciales entre pacientes con CP con y sin EPOC, en diversos mecanismos biológicos que subyacen el desarrollo del tumor pulmonar. Evaluar el perfil diferente de estos mecanismos moleculares entre el pulmón tumoral y no tumoral, tanto en pacientes con CP como en pacientes con CP y EPOC. Métodos: Se determinaron marcadores de estrés oxidativo y nitrosativo, sistemas antioxidantes, citosinas Th1 y Th2, eventos epigenéticos y sus biomarcadores efectores, en el pulmón tumoral y no tumoral de pacientes con CP, con y sin EPOC. También se evaluó el estrés oxidativo y nitrosativo, así como las citosinas Th1 y Th2, en la sangre de pacientes con CP, con y sin EPOC. Resultados: En el tumor pulmonar y en la sangre de los pacientes con CP y EPOC, se observó un aumento del estrés oxidativo y nitrosativo, así como un incremento de la respuesta inflamatoria Th1. La expresión de microRNAs específicos, los niveles de metilación del ADN, y los biomarcadores efectores se vieron alterados en el tumor pulmonar de pacientes con CP y EPOC, lo que a su vez promovió en estos pacientes un aumento de la proliferación celular, la invasión y la angiogénesis. En el tumor pulmonar de los pacientes con CP, con y sin EPOC, se observó un aumento del estrés oxidativo y nitrosativo, un incremento de las citosinas Th1 y Th2, así como alteraciones en los eventos epigenéticos y en los niveles de los biomarcadores efectores. Conclusiones: En los tumores pulmonares y en la sangre de los pacientes con CP y EPOC, existe un perfil de expresión diferente de diversos mecanismos moleculares implicados en el desarrollo tumoral, lo que podría predisponer a los pacientes con EPOC a un mayor riesgo de desarrollar CP.

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Chiu, Chim-keung y 趙漸強. "Pathways to care: help seeking pattern of thepeople with early psychosis". Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2003. http://hub.hku.hk/bib/B43895244.

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Huang, Norman Jason. "Graph-based Support Vector Machines for Patient Response Prediction Using Pathway and Gene Expression Data". Thesis, Harvard University, 2013. http://dissertations.umi.com/gsas.harvard:11072.

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Over the past decade, multiple function genomic datasets studying chromosomal aberrations and their downstream implications on gene expression have accumulated across a variety of cancer types. With the majority being paired copy number/gene expression profiles originating from the same patient groups, this time frame has also induced a wealth of integrative attempts in hope that the concurrent analysis between both genomic structures will result in optimized downstream results. Borrowing the concept, this dissertation presents a novel contribution to the development of statistical methodology for integrating copy number and gene expression data for purposes of predicting treatment response in multiple myeloma patients.

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Hodkinson, Peter William. "Developing a patient-centred care pathway for paediatric critical care in the Western Cape". Doctoral thesis, University of Cape Town, 2015. http://hdl.handle.net/11427/17259.

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Background: Emergency care of critically ill or injured children requires prompt identification, high quality treatment and rapid referral. This study examines the critical care pathways in a health system to identify preventable care failures by evaluating the entire pathway to care, the quality of care at each step along the referral pathway, and the impact on patient outcomes. Methods: A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation until paediatric intensive care unit admission or emergency centre death, using a modified confidential enquiry process of expert panel review and caregiver interview. Outcomes were expert panel assessment of quality of care, avoidability of death or PICU admission and severity at PICU admission, identification of modifiable factors, adherence to consensus standards of care, as well as time delays and objective measures of severity and outcome. Results: The study enrolled 282 children: 85% medical and 15% trauma cases (252 emergency admissions, and 30 children who died at referring health facilities). Global quality of care was graded poor in 57(20%) of all cases and 141(50%) had at least one major impact modifiable factor. Key modifiable factors related to access and identification of the critically ill, assessment of severity, inadequate resuscitation, delays in decision making and referral, and access to paediatric intensive care. Standards compliance increased with increasing level of healthcare facility, as did caregiver satisfaction. Children presented primarily to primary health care (54%), largely after hours (65%), and were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 74% of children, indicating room for improvement. Conclusions and Relevance: The study presents a novel methodology, examining the quality of paediatric critical care across a health system in a middle income country. The findings highlight the complexity of the care pathway and focus attention on specific issues, many amenable to suggested interventions that could reduce mortality and morbidity, and optimize scarce critical care resources; as well as demonstrating the importance of continuity and quality of care throughout the referral pathway.

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32

Yeung, Y. Y. Louisa y 楊月瑩. "Cantonese dichotic digit test: a comparison between normative and cleft palate groups". Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2006. http://hub.hku.hk/bib/B37990469.

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Bipath, Priyesh. "Tryptophan and the kynurenine pathway in chronic renal failure patients on dialysis". Diss., Pretoria : [s.n.], 2008. http://upetd.up.ac.za/thesis/available/etd-10212008-135418.

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Sun, Tingting [Verfasser]. "Genetic versus epigenetic BRCA1 silencing pathways: clinical effects in primary ovarian cancer patients / Tingting Sun". Berlin : Medizinische Fakultät Charité - Universitätsmedizin Berlin, 2019. http://d-nb.info/1189139227/34.

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35

Wang, Jing. "Genetic and functional analysis of pathways regulating sodium handling in patients with low renin hypertension". Thesis, University of Cambridge, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.611982.

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Yilma, Lemma. "Pathways to diagnosis and treatment : TB patients' experiences in London : a narrative enquiry and analysis". Thesis, London School of Hygiene and Tropical Medicine (University of London), 2011. http://researchonline.lshtm.ac.uk/1379947/.

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The purpose of this study was to understand TB patients' experiential accounts of access to TB diagnosis and treatment and more specifically about their experiences of medical help from health care professionals. METHOD: This narrative enquiry was undertaken in three boroughs of London, including two boroughs with the highest TB notification rates in the UK. The study involved pilot interviews with ten patients to develop the research question. In-depth narrative interviews with 32 additional patients were then undertaken. All participants were over eighteen years of age. The analysis of narratives involved descriptive; holistic-form and categorical content (themes) approaches to identify story 'plot' and 'subplots' and themes covering the whole of the patients' journeys to treatment. RESULTS: Seven narrative plots and thirty subplots were grouped into six categories of medical help and specific themes embedded in them were grouped in three stages of patients' pathways 'before' 'during' and 'after' diagnosis. These themes are listed below sequentially to illustrate these patients' pathways. 1. Symptoms were misinterpreted and misdiagnosed. 2. Kept on ineffective antibiotics/painkillers for many visits. 3. Referred quickly for suspected TB or other serious illnesses. 4. Referred only when critically ill. 5. Referred when antibiotics and pain killers not helping. 6. Referred only after pushing for referral. 7. Sought help from A&E. 8. Diagnosed immediately after TB testing. 9. Referred to wrong specialist and waited too long. 10. Had to fight for TB test. 11. Had lots of tests but no results. 12. Doubts about diagnosis. 13. Felt ignored and had no information. 14. Felt listened and cared for. 15. Quickly began my treatment. 16. Felt better after treatment, no side-effects. 17. Felt better after treatment with side-effects. 18. Felt needed longer treatment. CONCLUSIONS: The accounts of two thirds of the study participants suggest that their doctors' misunderstanding of their illness and miscommunication with them contributed to delayed diagnosis and treatment ranging from one month to twelve months. TB service providers and commissioners need to raise clinical staff awareness about TB and review the factors hindering doctor-patient communication about TB care. The findings in this research indicate that health service related delay is likely to contribute to increased TB transmission rates in the two research settings in London.

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Almotiri, Naif. "Teleconsultation perspective for cardiovascular patients in Saudi Arabia". Thesis, Brunel University, 2012. http://bura.brunel.ac.uk/handle/2438/7343.

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This research of teleconsultation services aims to improve the quality of diagnosis and treatment for rural cardiovascular patients through utilizing distant medical expertise. Equitable access to expert healthcare as well as improved medical management for these patients can assist in modifying cardiovascular disease (CVD) risk and reduce morbidity and mortality in Saudi Arabia. The objectives were to design and develop a new care pathway for cardiovascular disease patients by utilizing teleconsultation technology, investigate factors and issues that might act as barriers to its adoption, and then evaluate the impact of this model on the stakeholders. A small scale pilot project was used to determine the issues of technology, processes and human resources required to deliver an effective service with the context of the research setting. Four primary healthcare centres, two regional hospitals, fifteen patients and sixty other participant stakeholders were included in this study. An approach using (PCP) patient care pathways was used to introduce the teleconsultation technology and integrate it within the healthcare delivery system. Compared to the traditional PCP, the modified PCP utilising teleconsultation technology improved the quality of healthcare through:  Improved access to medical care and quality of diagnosis by obtaining the expertise of a distant specialist.  More efficient medical evaluation and management.  Enhanced role of primary healthcare centres and participating hospitals by providing all levels of health services for patients.  Evidence-based referral (reduced waiting time, reduced burden on outpatient clinics). The telconsultation adoption barriers included:  Inadequacy of finance  Limited infrastructure  Legal and regularity difficulties.  Organization issues.  Literacy on technology. This study recommends the following for telemedicine implementation in the country:  Promote perception and readiness for ICT services with the healthcare community.  Enhance structural readiness including appropriate infrastructure and adequate funding, human resources and equipment.  Proactive policies to encourage growth of the telecommunication sector and to address concerns regarding privacy and security.

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George, Caroline L. "Controlling Time Spent with Patients: A Pathway for Nurses to Feel Competent While Minimizing Burnout". University of Cincinnati / OhioLINK, 2021. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1626356561343293.

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Roth, Erik y Johanna Holmbom. "Sjuksköterskors upplevelser av att vårda patienter i livets slutskede enligt Liverpool Care Pathway (LCP)". Thesis, Högskolan Dalarna, Omvårdnad, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:du-12576.

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Syfte: Att beskriva sjuksköterskors upplevelser av att vårda patienter i livets slutskede enligt en vårdplan utformad som en journal med riktlinjer för vård i livets slutskede, den så kallade Liverpool Care Pathway (LCP). Metod: Studien är utförd som en litteraturöversikt. Artiklarna söktes via databaserna CINAHL, PubMed, MedLine, SAGE Journals och Scopus. Tolv artiklar valdes ut för kvalitétsgranskning enligt en förutbestämd granskningsmall. Elva artiklar godkändes och utgjorde grunden för resultatet. Resultat: En tydlig effekt av införandet av LCP var att sjuksköterskorna upplevde ett ökat självförtroende och en ökad kunskap i vårdandet. Detta bidrog till förbättringar gällande symtomkontroll samt ifrågasättande av fortsatt rutinmässig behandling. LCP anågs vara en bra utgångspunkt för samtal och undervisning i möten med patienter och anhöriga. LCP upplevdes ge ramar och gemensamma utgångspunkter i teamarbetet runt patienten vilket bidrog till en bättre planering och tydligare mål i vårdandet. Trots alla positiva upplevelser kände en del sjuksköterskor att de kunde uppstå svårigheter i vårdandet enligt LCP. Brister i vårdmiljön ansågs av sjuksköterskorna göra att målen med vården inte kunde tillgodoses. Tidsbrist och underbemanning ledde ofta till att patienter i livets slutskede fick en lägre prioritet. Vidare ansågs kriterierna vara för hårda enligt vissa sjuksköterskor gällande införande av LCP.

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ZEMA, MADDALENA. "Design of clinical pathway management system for preventing adverse event". Doctoral thesis, Politecnico di Torino, 2016. http://hdl.handle.net/11583/2684403.

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A clinical pathway (CP) - also known as care map or integrated care pathway - is a collection of evidence-based recommendation on the sequence and timing of care interventions for a diagnosis. CP analysis has experienced increased attention over the years because it is useful both for the health-care management in general and for the administration, computerization and scheduling the best practice for individual patients. Indeed, significant improvement in the quality of almost all available clinical processes was observed after the CP development and implementation. In addition, reductions in health care macro-variation phenomena (length of stay, patient trajectories, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where CPs were implemented successfully. Moreover, CPs are helpulf for clinical risk management. For example, it is possible to discover a CP model from past clinical pathway instances (i.e., patient paths), detect the anomalies in clinical pathways and identify care points where patient trajectory deviate from expected and/or normative medical behaviors. Ideally a patient trajectory (PT), namely actual care events provided to a patient during diagnosis and treatment, should adhere to the corresponding CP. Deviation occurs when the care received by a patient differs from what was defined in the pathway. Differences are common in practice and they can have positive or negative implications on care delivery. In certain cases, deviations from CPs could be due to patient specific conditions or operational efficiency, but on the other hand they could indicate sub-optimal care, errors and potential adverse events. For this reason, it is important to measure variance from prescribed CPs because both these conditions could provide an opportunity for improvement in care delivery if early recognized. However, the measurement of deviations of trajectories representing the actual care received by patients is a non-trivial task because of the potentially complicated structure of clinical pathways themselves. CP management computerization can contribute to improve adherence to CPs and to measure deviations in a timely and efficient manner. Previous works demonstrated that an information technologhy (IT) application that support CPs -embedded into clinical routine work - can help to increase pathway compliance. The aim of this thesis is the design of a Clinical Pathway Management System (CPMS) able to track patient trajectory (PT) and identify deviations on actual PT from its corresponding CP and cases of missing records. Main expected benefits are an increased availability of information for healthcare staff, activities and responsabilities tracing along all phases of care path, greater clinical decision support for health workers and a better control over the process due to integration between services and resources. The ultimate goals are both the prevention of adverse events in clinical processes and a posteriori identificazion of errors to adopt corrective actions. Within the project, a methodology able to model and compare CPs and PTs has been developed, validated and integrated in the CPMS. The methodology consists of a set of models for the complete description of CPs and PTs and of an index for measuring deviations in PTs, called Clinical Pathway Deviation Index (CPDI). It can be applied for real-time evaluations, even when patient trajectory is still ongoing, in order to assess actual services - provided to a certain patient - and to generate alerts, if deviations have been found. In addition, it can be used by the Quality Manager to identify occurred adverse events, recognize an excessive variability among PTs, analyze trend and staff behavior and to identify possible improvements to be made to CP. CPMS was designed as multi-agent system (MAS) - due to the need to implement a scalable and flexible system, able to support different scenarios. The Prometheus methodology and the Prometheus Design Tool (PDT) were employed for MAS design. In addition, functional requirements were accurately described using the Unified Model Language (UML). A web application architecture was chosen in order to guarantee ease-of-installation, ease-of-deployment, ease-of-update, simplified access and scalability. A prototype was developed and tested.

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Acum, Michelle. "End of pathway cleft surgery : exploring the patient-reported outcomes and young people's decision making experiences". Thesis, University of East Anglia, 2018. https://ueaeprints.uea.ac.uk/68908/.

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Objective: Literature exploring how young people (YP) experience cleft surgery at the end of the treatment pathway is limited, both in terms of their reported outcomes and their experience of deciding whether to undergo surgery. This thesis aimed to add to the cleft field by reviewing the patient-reported outcomes (PROs) of end of pathway cleft surgery and exploring YP’s experiences of deciding whether to undergo orthognathic surgery (OS; an end of pathway cleft surgery). Design: A systematic literature search identified studies measuring the PROs of undergoing end of pathway cleft surgery. To explore OS decision making experiences a qualitative design was employed and interviews conducted with twelve YP. Results: The 22 studies measuring PROs varied in methodological quality; most were small scale and none utilised a measure validated in the cleft population, meaning it is hard to draw conclusions about end of pathway cleft surgery from the patient perspective. Thematic Analysis of YP’s accounts resulted in the development of four themes to depict YP’s decision making experiences: 1) Awareness of difference, 2) Committing to the process, 3) Others facilitating decision making and 4) Responsibility on my shoulders. Conclusions: This thesis reveals the difficulty in determining PROs of end of pathway cleft surgery due to the methodological challenges and the heterogeneity of what, how and when outcomes are measured. It demonstrates the contextual, social and personal complexities YP experienced in the process of deciding about OS during a period of developmental transition. Theoretical, clinical and research implications are discussed.

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42

Yan, Edwin B., Tony Frugier, Chai K. Lim, Benjamin Heng, Gayathri Sundaram, May Tan, Jeffrey V. Rosenfeld, David W. Walker, Gilles J. Guillemin y Maria C. Morganti-Kossmann. "Activation of the kynurenine pathway and increased production of the excitotoxin quinolinic acid following traumatic brain injury in humans". BioMed Central, 2015. http://hdl.handle.net/10150/610324.

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ABSTRACT: During inflammation, the kynurenine pathway (KP) metabolises the essential amino acid tryptophan (TRP) potentially contributing to excitotoxicity via the release of quinolinic acid (QUIN) and 3-hydroxykynurenine (3HK). Despite the importance of excitotoxicity in the development of secondary brain damage, investigations on the KP in TBI are scarce. In this study, we comprehensively characterised changes in KP activation by measuring numerous metabolites in cerebrospinal fluid (CSF) from TBI patients and assessing the expression of key KP enzymes in brain tissue from TBI victims. Acute QUIN levels were further correlated with outcome scores to explore its prognostic value in TBI recovery. METHODS: Twenty-eight patients with severe TBI (GCS ≤ 8, three patients had initial GCS = 9-10, but rapidly deteriorated to ≤8) were recruited. CSF was collected from admission to day 5 post-injury. TRP, kynurenine (KYN), kynurenic acid (KYNA), QUIN, anthranilic acid (AA) and 3-hydroxyanthranilic acid (3HAA) were measured in CSF. The Glasgow Outcome Scale Extended (GOSE) score was assessed at 6 months post-TBI. Post-mortem brains were obtained from the Australian Neurotrauma Tissue and Fluid Bank and used in qPCR for quantitating expression of KP enzymes (indoleamine 2,3-dioxygenase-1 (IDO1), kynurenase (KYNase), kynurenine amino transferase-II (KAT-II), kynurenine 3-monooxygenase (KMO), 3-hydroxyanthranilic acid oxygenase (3HAO) and quinolinic acid phosphoribosyl transferase (QPRTase) and IDO1 immunohistochemistry. RESULTS: In CSF, KYN, KYNA and QUIN were elevated whereas TRP, AA and 3HAA remained unchanged. The ratios of QUIN:KYN, QUIN:KYNA, KYNA:KYN and 3HAA:AA revealed that QUIN levels were significantly higher than KYN and KYNA, supporting increased neurotoxicity. Amplified IDO1 and KYNase mRNA expression was demonstrated on post-mortem brains, and enhanced IDO1 protein coincided with overt tissue damage. QUIN levels in CSF were significantly higher in patients with unfavourable outcome and inversely correlated with GOSE scores. CONCLUSION: TBI induced a striking activation of the KP pathway with sustained increase of QUIN. The exceeding production of QUIN together with increased IDO1 activation and mRNA expression in brain-injured areas suggests that TBI selectively induces a robust stimulation of the neurotoxic branch of the KP pathway. QUIN's detrimental roles are supported by its association to adverse outcome potentially becoming an early prognostic factor post-TBI.

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Pullen, Emma. "Sport and exercise medicine in NHS England : the pathways of sport-related injury patients and social costs". Thesis, Loughborough University, 2017. https://dspace.lboro.ac.uk/2134/24731.

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This thesis explores the general public s experiences of sport related injury (SRI) as they utilise Sport and Exercise Medicine services in NHS England. It focuses specifically on: the treatment pathways to, and utilisation of, one Sport and Exercise Medicine (SEM) clinic in NHS England; the social and economic costs incurred as a consequence of SRI; and the extent healthcare utilisation and costs coalesce to structure SRI experience. The study employs a qualitative methodology based on a two phase research design that retrospectively maps the pathways of patients (n=19) up until their treatment at the SEM clinic (focusing on social and economic costs ), and prospectively, as a number of patients (n=4) continue their treatment at the SEM clinic, thus illustrating how pathways and costs feed each other in problematic ways. Findings demonstrate that patient pathways to SEM are relatively lengthy and inefficient due to a lack of knowledge of SEM initiatives for SRI treatment amongst both GPs and patients. This leads to indirect referrals, increased workload in primary care and the utilisation of general orthopaedic secondary care services. It further highlights a number of social and economic costs incurred through SRI, such as diminished social wellbeing, increased emotional labour, poor health behaviours and workplace absenteeism, which are exacerbated through inefficient patient pathways and patient dissatisfaction with general orthopaedic treatment. The thesis is the first study to shed light on the pathways of SRI patients in the NHS and the treatment experience of SEM clinics in NHS England. It demonstrates the extent SEM initiatives justified on the basis of improving the efficiency of pathways and satisfaction of treatment for SRI patients could be more effectively implemented and identifies a number of important implications for the future sustainability of physical activity health promotion policy and the wider social and economic productivity of exercising public populations.

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44

Bluschke, Annet, der Hagen Maja von, Katharina Papenhagen, Veit Roessner y Christian Beste. "Conflict processing in juvenile patients with neurofibromatosis type 1 (NF1) and healthy controls – Two pathways to success". Saechsische Landesbibliothek- Staats- und Universitaetsbibliothek Dresden, 2017. http://nbn-resolving.de/urn:nbn:de:bsz:14-qucosa-227045.

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Neurofibromatosis Type 1 (NF1) is a monogenetic autosomal-dominant disorder with a broad spectrum of clinical symptoms and is commonly associated with cognitive deficits. Patients with NF1 frequently exhibit cognitive impairments like attention problems, working memory deficits and dysfunctional inhibitory control. The latter is also relevant for the resolution of cognitive conflicts. However, it is unclear how conflict monitoring processes are modulated in NF1. To examine this question in more detail, we used a system neurophysiological approach combining high-density ERP recordings with source localisation analyses in juvenile patients with NF1 and controls during a flanker task. Behaviourally, patients with NF1 perform significantly slower than controls. Specifically on trials with incompatible flanker-target pairings, however, the patients with NF1 made significantly fewer errors than healthy controls. Yet, importantly, this overall successful conflict resolution was reached via two different routes in the two groups. The healthy controls seem to arrive at a successful conflict monitoring performance through a developing conflict recognition via the N2 accompanied by a selectively enhanced N450 activation in the case of perceived flanker-target conflicts. The presumed dopamine deficiency in the patients with NF1 seems to result in a reduced ability to process conflicts via the N2. However, NF1 patients show an increased N450 irrespective of cognitive conflict. Activation differences in the orbitofrontal cortex (BA11) and anterior cingulate cortex (BA24) underlie these modulations. Taken together, juvenile patients with NF1 and juvenile healthy controls seem to accomplish conflict monitoring via two different cognitive neurophysiological pathways.

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45

Venchiarutti, Rebecca. "Pathways to diagnosis and treatment of head and neck cancer: outcomes and experiences of patients in NSW". Thesis, The University of Sydney, 2021. https://hdl.handle.net/2123/25061.

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Delayed diagnosis and treatment of cancer can lead to poor outcomes. These relationships have not been well explored in Australia for head and neck cancer (HNC) patients. This thesis examines pathways to diagnosis and treatment of patients with HNC in New South Wales (NSW) with focus on the impact of remoteness of residence. Three primary studies were conducted. A retrospective cohort study reports on 224 patients treated for oropharyngeal or oral cavity cancer at two centres from 2008-2013. Regional patients had longer times to treatment and post-operative radiotherapy (PORT) compared to metropolitan patients. Guideline adherence for timely treatment was generally poor regardless of residence. In a prospective cohort study conducted from 2018 to 2020, quantitative data from 100 patients showed regional patients still experience longer times to treatment, however time to PORT appears to be improving. Health literacy negatively correlated with several pre-treatment intervals as well as care coordination. Qualitative data showed facilitators to early diagnosis and treatment included availability of services, social capital, and experience with the health system; barriers included travel/distance to services, lack of emotional investment from healthcare providers (HCP), and symptom appraisal/interpretation by HCPs. A survey of general practitioners (GPs) showed 42% of regional GPs expected a patient to be seen by a specialist within two weeks of referral compared to 70% of metropolitan GPs. Service availability was a driver of regional GPs’ decision of where to refer to, though metropolitan GPs perceived patients’ symptoms as the driving factor. Lastly, a narrative systematic review addresses the question of how health systems can be redesigned to address diagnostic and treatment intervals. In summary, the pathways to diagnosis and treatment of HNC are complex, requiring multidisciplinary and multi-system interventions to address disparities.

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46

SIRONI, ALESSANDRA. "UNVEILING MOLECULAR PATHWAYS DISRUPTED IN SMS AND SMS-LIKE PATIENTS BY MEANS OF GENOMIC AND FUNCTIONAL APPROACHES". Doctoral thesis, Università degli Studi di Milano, 2020. http://hdl.handle.net/2434/700745.

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Smith Magenis Syndrome (SMS, OMIM#182290) is a complex genomic disorder with incidence of 1:15000-25000, clinically characterized by neurological abnormalities with variable intellectual disability (ID), craniofacial dysmorphisms, behavioral and sleep disturbances, and speech and motor delay. SMS is caused by haploinsufficiency of RAI1 (Retinoic Acid-Induced 1) gene to either large 17p11.2 deletion (90%) or point mutations/intragenic microdeletions (10%). RAI1 encodes a transcription factor, working as chromatin reader in a regulatory complex, that positively regulates the expression of many neurodevelopmental and circadian rhythm genes. However, only 50% of individuals with SMS clinical suspicion is confirmed by the genetic test, suggesting that other loci may be involved directly or indirectly in the same pathway of RAI1 gene, hence contributing to the SMS-like phenotype. In order to deepen the genetic mechanisms underlying the SMS spectrum, we analyzed a cohort of 30 patients with SMS clinical diagnosis through several genetic approaches. High resolution array-CGH, performed to pinpoint rare pathogenic CNVs containing dosage sensitive genes that might be implicated in RAI1 molecular pathways, disclosed 4 pathogenic CNVs. Further studies, namely RAI1 NGS sequencing, MLPA, and RT-qPCR revealed in one patient multiple peculiar molecular RAI1 defects consistent with SMS molecular diagnosis. Considering that sleep disturbance is a main feature of SMS and the circadian genes oscillatory expression can be observed in peripheral melatonin target tissues, an additional aim of this project was the evaluation of circadian rhythm genes expression in peripheral blood cells of selected 16 SMS/SMS-like patients through RT-qPCR analysis. Among the tested genes, CLOCK, BMAL2, PER2, and NR1D1 were found dysregulated in at least one patient analyzed. Thus, this study turned out to be an useful preliminary approach to evaluate any circadian dysfunctions in patients with sleep disturbance. Another crucial aim of this thesis was the investigation of candidate genes implicated in RAI1 molecular pathway through a functional approach. Considering that neurodevelopmental disorders (NDDs) are extraordinarily difficult to study, we used human iPSCs differentiated into neurons, in the attempt to elucidate the molecular alterations that give rise to SMS. A male patient of our cohort, bearing a rare 54 kb maternal deletion at Xq13.3 mapping 29 kb far from 5’UTR of ZDHHC15 gene that results downregulated in blood, was selected for iPSCs reprogramming and differentiation in cortical neurons. Starting from peripheral blood mononuclear cells we successfully obtained three and two genomic stable iPSCs clones of patient and his parents, respectively. Patient’s iPSCs were comparable to parents’ iPSCs for morphology, pluripotency-related markers expression, and capability of embryo body formation and spontaneous differentiation into the three germ layers. The subsequent iPSCs differentiation produced cortical neurons found positive to several specific neuronal markers. Although, we were unable to determine the amount of ZDHHC15 mRNA on mature cortical neurons, an altered functional activity of patient’s cultured iPSCs-derived neurons was disclosed. The evaluation of electrophysiological profiles of differentiated neurons revealed in the patient and his mother compared to the father the absence of a progressive increase in mEPSCs frequency and amplitude, resembling a defected excitatory synaptic development. To sum up, the present combined approach using both genomic and functional techniques resulted an efficient strategy to deepen the molecular and genetic mechanisms underlying SMS-like phenotype, and to increase the possibility to uncover the networks of genes underlying NDDs.

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47

Abd, kader Khaled. "Disruption of the JakSTAT cytokine signaling pathway in T cells from HIV-infected patients". Thesis, University of Ottawa (Canada), 2007. http://hdl.handle.net/10393/27566.

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HIV infection leads to a profound T cell dysfunction well before the clinical onset of AIDS. This study investigated whether alterations in the Janus kinase (Jak)/signal transducer and activator of transcription (STAT) pathway in CD4+ and CD8+ T cells from HIV-infected patients induced by the growth promoting cytokines IL-2, IL-4, IL-7, IL-10, and IL-15 may be involved. IL-2 and IL-15 induced STAT5 phosphorylation (P-STAT5) in CD4+ T cells but there was a clear separation of cells into P-STAT5- and P-STAT5+ populations to similar proportions in HIV- and HIV+ patients. In response to IL-7, the proportion of P-STAT5- cells was significantly higher in HIV+ patients compared to HIV- controls. The IL-7 dependent P-STAT5- CD4+ T cells appeared to correlate with a lack of IL-7Ralpha chain expression. However, the P-STATS- cells observed did not correlate significantly with other cytokine receptor components. Cytokine-induced P-STAT5 in the CD8+ T cells from HIV+ patients was clearly detected. However, IL-2 and IL-15 stimulation revealed a P-STATS- CD8+ T cell population, which was not detected in HIV- subjects. P-STATS- CD8+ T cells were observed in all HIV+ patients studied in response to IL-2 and IL-15, irrespective of HAART. Defects in the IL-2 and IL-15 mediated signaling pathways appeared to exist downstream of cytokine receptor expression. In response to IL-7, P-STATS- cells were observed in both HIV+ and HIV- patients. However, their proportion was higher in HIV+ patients and returned towards that of HIV- controls under HAART and correlated inversely with IL-7Ralpha chain expression. The presence of P-STATS- CD8+ T cells did not correlate with the expression of other cytokine receptor chains. The P-STAT5- T cells observed in response to these cytokines may represent cells at distinct differentiation stages and functional capacities that arise in response to chronic HIV infection and may contribute to the eventual insufficiency of the cell mediated immune response.

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48

Mendoza, Alonzo Jennifer Lorena. "Predicting the Clinical Outcome in Patients with Traumatic Brain Injury using Clinical Pathway Scores". Scholar Commons, 2013. http://scholarcommons.usf.edu/etd/4544.

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The Polytrauma/TBI Rehabilitation Center (PRC) of the Veterans Affairs Hospital (VAH) treats patients with Traumatic Brain Injury (TBI). These patients have major motor and cognitive disabilities. Most of the patients stay in the hospital for many months without major improvements. This suggests that patients, family and the VAH could benefit if healthcare provider had a way to better assess or "predict" patients' progression. The individual progress of patients over time is assessed using a pre-defined multi-component performance measure Functional Independence Measures (FIM) at admission and discharge, and a semi-quantitative documentation parameter Clinical Pathway (CP) at weekly intervals. This work uses already de-identified and transformed data to explore developing a clinical outcome predictive model for patients with TBI, as early as possible. The clinical outcome is measured as percentage of recovery using CP scores. The results of this research will allow healthcare providers to improve the current resource management (e.g. staff, equipment, space) through setting goals for each patient, as well as to provide the family more accurate and timely information about the status and needs of the patient.

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49

Pelligra, Amanda. "Surgical Pathway Implementation for Pediatric Patients with Multiple Chronic Conditions Undergoing Complex Hip Surgery". Kent State University / OhioLINK, 2021. http://rave.ohiolink.edu/etdc/view?acc_num=kent1617296741840046.

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50

Brunini, Tatiana Marlowe Cunha. "L-arginine-nitric oxide pathway in blood cells from chronic renal and heart failure patients". Thesis, University of Oxford, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.326115.

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