Biomedical subjects
Publications and source records attributed to P Curtis.
Bowel obstruction is a recognised complication in pregnancy, especially in those with adhesions from previous surgery. We report a case where the use of an elemental diet was successful in avoiding surgery in a pregnant patient with recurrent conservatively managed small bowel obstruction.
Nausea and emesis are common side effects of opioid drugs administered for pain relief in cancer patients. The aim of this study was to compare the anti-emetic efficacy and safety of ondansetron, placebo and metoclopramide in the treatment of opioid-induced nausea and emesis (OIE) in cancer patients. This was a multinational, multicentre, double-blind, parallel group study in which cancer patients who were receiving a full opioid agonist for cancer pain were randomised to receive one of oral ondansetron 24 mg once daily, metoclopramide 10 mg three times daily, or placebo. Study medication was started only if the patient experienced nausea and/or emesis following opioid administration. Efficacy and safety assessments were made over a study period of 24 h from the time of the first dose of anti-emetics/placebo. The study was terminated prematurely because of the difficulties in recruiting patients satisfying the stringent entry criteria. Ninety-two patients were included in the intent-to-treat population: 30 patients received placebo, 29 patients ondansetron and 33 patients metoclopramide. There was no statistically significant difference between the groups in the proportion achieving complete control of emesis (33% of patients on placebo, 48% on ondansetron and 52% on metoclopramide) or complete control of nausea (23% of patients on placebo, 17% on ondansetron and 36% on metoclopramide). Rescue anti-emetics were required in 8 of 33 patients on metoclopramide, 4 of 29 on ondansetron, and 3 of 30 on placebo. The incidence of adverse events was very low and similar in all treatment groups. Neither ondansetron 24 mg once daily nor metoclopromide 10 mg t.d.s. given orally was significantly more effective than placebo in the control of OIE in cancer patients.
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STUDY DESIGN: Randomized controlled study of standard manual therapy given by 31 generalist physicians to 295 patients, in primary care practice. OBJECTIVES: To determine whether training primary care physicians in techniques of limited manual therapy would result in improved outcomes for their patients with acute low back pain. SUMMARY OF BACKGROUND DATA: Controversy continues regarding the benefit of spinal manual therapy and the role of highly trained manual therapists in the care of low back pain. Continuing medical education in manual therapy is frequently offered to generalist physicians, but nothing is known of the value and effectiveness of this training. METHODS: Thirty-one primary care physicians were trained to provide optimal low back care (enhanced care) and a sequence of eight standard manual therapy techniques. Two hundred ninety-five patients were randomized into two treatment groups: enhanced care alone and enhanced care with manual therapy. Main outcome measures included the Roland-Morris functional disability scale measured over time and patient-reported time to functional recovery, time to complete recovery, and satisfaction with care. RESULTS: No differences were found in Roland-Morris scores over time, mean functional days to recovery, days absent from work, or patient satisfaction. More patients receiving manual therapy (21; 14%) had completely recovered after the first visit compared with the control group (8; 6%; P = 0.01). Patients who received more intense manual therapy (four or more maneuvers) had a more rapid return to functional recovery (7.8 days) compared with those who received less intense manual therapy (11.1 days; P = 0.02). CONCLUSION: Limited training in manual therapy techniques offers very modest benefit compared with high-quality (enhanced) care for acute low back pain. Outcomes may have been modified by failure of some participant physicians to undertake the required sequence of maneuvers. Intensity of manual therapy may be a factor in improving patient outcomes and needs further study.
PURPOSE: To describe the organization, models of training, and institutional impact of National Research Service Award fellowship programs in primary care research. METHOD: Survey of 25 directors of currently-funded and former training sites. RESULTS: Twenty-four program directors (96%) completed the survey. Programs allocated 39% of fellows' time to course work leading to an advanced degree or other didactic instruction, and 40% of time to the conduct of research. Collaborations with other training programs within the institution occurred at 83% of sites. Programs commonly (54%) or exclusively (42%) relied on a research model of "early research independence" in which the fellow defined an area of research interest, rather than an "apprenticeship" model in which the fellow worked in a senior investigator's research area. These programs enriched the local academic environment, but required extensive financial subsidies. The high costs of training often had adverse impacts on recruitment and other components of the training process. CONCLUSION: Research training programs in primary care often substitute acquisition of advanced degrees for early immersion in research. The "early independence" model of research differs from fellowships in the medical specialties, and requires further study to assess its effectiveness. The need to subsidize training costs poses substantial problems for the institutions that host these fellowship programs.
BACKGROUND: Few useful interventions exist for patients with persistent low back pain. We suggest that a fibro-fatty nodule ("back mouse") may be an identifiable and treatable cause of this and other types of pain. METHODS: We describe 2 patients with painful nodules in the lower back and lateral iliac crest areas. In both cases, the signs and symptoms were unusual and presented at locations distant from the nodule. One patient complained of severe acute lower abdominal pain, and the other had been treated for chronic recurrent trochanteric bursitis for several years. RESULTS: In both patients, symptoms appeared to be relieved by multiple injection of the nodule. DISCUSSION: There is agreement that back mice exist. Referred pain from the nodules might explain the distant symptoms and signs in these cases. Multiple puncture may be an effective treatment because it lessens the tension of a fibro-fatty nodule. CONCLUSIONS: Randomized trials on this subject are needed. In the meantime, physicians should keep back mice in mind when presented with atypical and unaccountable symptoms in the lower abdomen, inguinal region, or legs.
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BACKGROUND: We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques. METHODS: From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson's chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time. RESULTS: Characteristics of the 13 physicians' patients in the cohort group and the manual therapy trial showed some differences in income, workers' compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities. CONCLUSIONS: A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.
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BACKGROUND: Controversy continues regarding the relation between the quality of Papanicolaou (Pap) smears, especially the presence of endocervical cells (ECC), with the finding of cytologic abnormalities. METHODS: As part of a study regarding performance feedback on the quality of Pap smears, data from 56,475 Pap smears obtained by 176 participating clinicians over a 20-month period were analyzed to assess the relation between the presence of ECC, the categorization of global specimen adequacy as "satisfactory" or "satisfactory with limitations," and the prevalence of atypia and squamous intraepithelial lesions (SILs). RESULTS: Atypia was less likely to be found in "satisfactory" Pap smears than in "satisfactory with limitations" quality Pap smears (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.5-0.6; P < 0.001), even though the latter could contain ECC. No association was found between satisfactory Pap smears and cytologic abnormalities. Compared with specimens with no ECC, an ECC count of > or = 50 on a slide was associated positively with the detection of atypia (OR, 2.1; 95% CI, 1.8-2.4; P < 0.001) or SILs (OR, 1.7; 95% CI, 1.3-2.2; P < 0.001). A similar relation existed between ECC counts of 25-50 (OR, 1.9; 95% CI, 1.1-2.2; P = 0.01) and the detection of SILs. No relation was found between specimens with < 25 ECC and the presence of atypia or abnormalities. CONCLUSIONS: The global adequacy criterion of "satisfactory" assigned to a Pap smear does not indicate that there is a greater likelihood of detecting cytologic abnormalities compared with lower quality Pap smears. To the authors' knowledge, previous studies regarding the link between ECC in the Pap smear and cytologic abnormalities have not addressed the relevance of how many ECC are needed to maximize the identification of abnormalities. The data from the current study support the value of obtaining at least 25 ECC as a quality indicator of sampling.
A total of 427 cancer patients receiving cyclophosphamide chemotherapy participated in this multicenter, double-masked, double-dummy, parallel-group, randomized study comparing the antiemetic efficacy and safety of an 8-mg conventional ondansetron tablet (OT, n = 212) taken twice daily with an 8-mg orally disintegrating ondansetron tablet (ODT, n = 215) taken twice daily for 3 days. In the primary efficacy analysis, complete or major control of emesis (0 to 2 emetic episodes) between days 1 and 3 was seen in 80% of OT and 78% of ODT patients. The 90% confidence interval for the differences between treatments was -8.6% to 4.4% (defined interval of equivalence, +/-15%), showing that the formulations were equivalent. In the secondary efficacy analysis, no significant differences were observed in the rates of complete control of emesis (no episodes of emesis) over 3 days (63% and 64% of the respective groups) and on day 1 (84% and 81%, respectively) and in the complete control of nausea over 3 days (37% and 43%, respectively) and on day 1 (59% and 61% of patients, respectively). The taste of ODT was acceptable to the majority of patients (89%) who received it. OT and ODT were both well tolerated. Thus 8 mg ODT twice daily represents a palatable, well-tolerated, and effective antiemetic treatment for the control of cyclophosphamide-induced emesis and nausea and provides equivalent treatment to OT 8 mg twice daily.
Nausea and vomiting are common side effects of opioids administered for pain control. This double-blind, randomized, parallel-group study evaluated the anti-emetic efficacy and tolerability of single intravenous (i.v.) doses of ondansetron 8 mg, ondansetron 16 mg and metoclopramide 10 mg in the treatment of opioid-induced emesis. Adult patients undergoing low emetogenic surgical procedures, using a standardized anaesthesia regimen were assessed for 24 h following administration of study anti-emetic to treat established post-surgical opioid-induced emesis. A total of 4511 patients were enrolled of whom 1366 experienced opioid-induced emesis and received randomized study medication. Ondansetron 8 mg and 16 mg were significantly better than metoclopramide 10 mg (P < 0.05) for both complete control of emesis, complete control of nausea and other efficacy measures. There were no significant differences between the two ondansetron groups. All three treatments were well tolerated. In conclusion, this large, multicentre study demonstrates that ondansetron is more effective than metoclopramide in the treatment of opioid-induced emesis following administration of post-surgical opioids to control pain.
BACKGROUND: Breast stimulation to augment labor has been used for centuries in tribal societies and by midwives. In recent years it has been shown to be effective in ripening the cervix, inducing labor, and as an alternative to oxytocin for the contraction stress test. This study compared the effectiveness of breast stimulation with oxytocin infusion in augmenting labor. METHODS: Women admitted to the labor ward were eligible for the study if they had inadequate labor with premature rupture of the membranes and met inclusion criteria. They were assigned to oxytocin augmentation or breast stimulation (manual or pump), and were switched to oxytocin in the event of method failure. Outcomes included time to delivery, intervention to delivery, proportion of spontaneous deliveries, and Apgar scores. One hundred participants were needed in each arm of the study to demonstrate a 2- to 3-hour difference in delivery time, with a power of 80 percent. RESULTS: Analysis was performed on 79 women, of whom 49 were in the breast stimulation group and 30 in the oxytocin group. Sixty-five percent of the participants failed breast stimulation and were switched to oxytocin infusion. Although augmentation start to delivery was shorter for the oxytocin group (p < 0.001), no differences in total labor time occurred between the groups. Nulliparas receiving breast stimulation had more spontaneous (relative risk 1.7, p = 0.04), and fewer instrumental deliveries than those receiving oxytocin (relative risk 0.2, p = 0.02). No significant differences in adverse fetal outcomes occurred between the study groups. CONCLUSIONS: The small number of participants and a variety of problems with the conduct of the study prevented the formulation of reliable conclusions from the results. However, the study provided important insights into the feasibility and problems of developing a high-quality randomized trial of augmentation by breast stimulation.
This paper describes the development of a researchable project, arising from the clinical observation of a physiologic phenomenon during labor. Augmentation of labor by breast stimulation has been used in a variety of cultures for centuries. The process of developing a clinical study of augmentation in the modern obstetric environment is discussed, with reference to cultural attitudes of patients and health care workers.
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