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PubMed1991

Tumors of the central nervous system. Improvement in outcome through a multimodality approach.

More children with CNS tumors will continue to be cured of their neoplasms as a result of improved surgical, radiotherapeutic, and chemotherapeutic intervention. The complex problems seen in these patients mandate their treatment at academic centers actively involved in therapeutic investigations and capable of providing comprehensive multidisciplinary care.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1999

Cardiac mechano-electric feedback in man: clinical relevance.

Clinical conditions associated with sudden cardiac death due to arrhythmia are frequently accompanied by abnormalities of mechanical loading and wall stretch. These arrhythmias may result from several mechanisms including secondary depolarisations during or following the action potential or from a combination of conduction slowing and action potential shortening. Mechanical perturbations have been shown to reproduce these electrophysiological effects experimentally. However the effect of mechanical intervention is complex depending on the timing and intensity of the stimulus and the interplay between effects mediated via stretch activated channels and calcium cycling. Studies in patients during cardiac catheterisation or cardiac surgery using monophasic action potentials have shown alteration in the time course and shape of action potential repolarisation in response to changes in ventricular loading. Although stretch in experimental preparations has been shown to be arrhythmogenic, particularly in pathological conditions, the role of mechanically induced electrophysiological changes in important clinical ventricular arrhythmias remains to be established.

Animals↗

PubMed1995

A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting.

STUDY OBJECTIVE: To compare the efficacy and base hospital physician use of adenosine with that of verapamil in the prehospital treatment of supraventricular tachycardia (SVT). DESIGN: A 12-month prospective chart review of adenosine administration and a 12-month retrospective chart review of verapamil administration. SETTING: A single-tier advanced life support emergency medical service system. PARTICIPANTS: Prehospital adult patients presenting with narrow-complex SVT. INTERVENTIONS: Field paramedics identified SVT. They then administered verapamil or adenosine under on-line physician medical control. Paramedics administered up to two i.v. doses of verapamil, 2.5 mg and 5 mg, or up to two i.v. doses of adenosine, 6 mg and 12 mg. They recorded ECG readings; blood pressure; pulse; respirations; and symptoms before, during, and after drug administration. RESULTS: During the verapamil period, paramedics identified 102 cases of SVT and administered verapamil to 17 patients. Review by a cardiologist revealed 6 of the 17 patients to have been in atrial fibrillation, atrial tachycardia, or sinus tachycardia. Of the remaining 11 patients, 7 (64%) converted from SVT to sinus rhythm. During the adenosine period, paramedics identified 89 cases of SVT, and they administered adenosine to 64 patients. Eight patients had no review because prehospital rhythm strips were lost. Of the remaining 56 patients, 24 were later determined to have been in atrial fibrillation, atrial tachycardia, sinus tachycardia, atrial flutter, or ventricular tachycardia. Of the remaining 32 patients who were in SVT, adenosine converted 25 (78%) to sinus rhythm. An important incidental finding was the misinterpretation of tachydysrhythmias in 30 of 73 patients by paramedics and base hospital physicians. CONCLUSION: Our study showed no difference in conversion rates between verapamil and adenosine. Base hospital physicians were more likely to order adenosine than verapamil. Paramedics and base hospital physicians often misinterpret tachydysrhythmias.

Adenosine↗

PubMed2000

[Menopause and hormone replacement].

INTRODUCTION: Considered until recently as a biological fate, menopause has evolved within a decade into a major public health issue at stake. Such an evolution results from various factors that deserve an exhaustive critical approach because the situation is much more complex than it appears to be at first analysis. CURRENT KNOWLEDGE AND KEY POINTS: 1) Ninety-five percent of the available epidemiological information relies on observation or cohort studies, such as case-control studies that do not allow any certitude in regard to therapy. 2) Chronic estrogen deficiency probably plays a pathogenic role in various symptoms or pathological conditions that are associated to menopause. 3) However, behind the paradigm of menopause, there is a whole psychosocial construct that classifies what remains a physiological condition within major risk factors, just as for the most serious chronic diseases. 4) Indeed, menopause cannot be considered as a well-characterized disease, and hormone replacement therapy is undeniably a complex therapeutic intervention that requires proper prescription and careful evaluation of the benefit:risk ratio. 5) While such a treatment is now considered as the gold standard for the prevention of post-menopausal osteoporosis, this does not hold true regarding cardiovascular diseases. 6) Although hormone replacement therapy may lead to the relief of various symptoms associated with menopause, it may also result in side-effects that extreme medication cannot prevent, especially since some of them are not fully known, particularly in the case of either long-term or very long-term treatments. FUTURE PROSPECTS AND PROJECTS: A more rigorous evaluation of side-effects of hormone replacement therapy in the framework of long-term controlled trials is therefore clearly required. The indications of such a treatment should only rely on objective data and not on questionable studies or impressions at clinical examination.

Aged↗

PubMed2002

Managed care members talk about trust.

Informed choice of health insurance could morally justify later, potentially harmful rationing decisions the way informed consent justifies potentially harmful medical interventions. In complex and technical areas, however, individuals may base decisions more on trust than informed choice. We interviewed enrollees in managed care plans in Southeast Michigan, United States, to explore in detail their expectations and experiences in choosing and using their health plan. Diverse subjects participated in semi-structured interviews about health insurance choices, experiences, and expectations. Results are presented for the theme of trust (and distrust), which emerged spontaneously in discussions about health care and health insurance. Forty subjects diverse in age, ethnicity, and income took part in 31 interviews. Interviewees mentioned many of the elements of interpersonal trust in specific physicians, often in the context of discussions about care experiences, doctor payment, and conflict of interest. Elements included physical and emotional vulnerability, expectations of goodwill, advocacy and competence. and belief in professional ethics. Trust in the medical profession had more hesitancy, and often included mention of honesty or ethics. Elements of trust in hospitals included vulnerability to financial loss, and expectations of competence (quality). Elements of trust in health insurance plans often emerged in discussions about catastrophic illness coverage denials, and profit, and were more often negative. Vulnerability, worry, fear and security were prominent. Fiscal rather than clinical competence was emphasized, while expectations of goodwill remained. Enrollees in managed care plans spontaneously discussed trust and distrust in individuals and institutions during conversations about their insurance expectations and experiences. Similarities and differences in the elements and the context of these discussions illuminate distinctions between these healthcare relationships of trust.

Anecdotes as Topic↗

PubMed2004

[Gadolinium-medium filter-protected percutaneous stended carotid angioplasty].

We report on a patient who underwent a percutaneous carotid angioplasty with stenting. The procedure was protected by a filter and used gadolinium instead of iodine. No neurological or renal complication occurred. This observation represents one of the first publications describing the use of this contrast medium in a complex neuroradiological intervention.

Adult↗

PubMed2000

Family functioning of recovered alcohol-addicted patients: a comparative study.

Regaining the communication, concentration on role conflicts and strengthening of emotional ties are the central issues of socio-therapeutic approach to alcoholism. The aim of the present cross-sectional study was to compare family functioning between two groups of recovered alcohol-addicted patients. They were all participants of treatment program where complex therapeutic interventions were used, and were abstaining for at least 1 year. A total of 30 patients with a spouse or partner participating in the treatment were compared to 20 patients without spouse or partner participation. In order to show a different perspective on family strengths and weaknesses, we used a multidimensional questionnaire of family functioning, Family Assessment Measure (FAM). A significant difference in family functioning between both groups was found. Family functioning difficulties in two dimensions: control and affective involvement, were found in families without spouse or partner participation in the treatment. Even after years of abstinence, family functioning was not satisfactory in these families.

Adult↗

PubMed2002

Integrating qualitative research into evidence based practice.

This article attempts to provide an overview of qualitative tools and methods using mainly examples from diabetes research. The other articles in this issue of the Endocrinology and Metabolism Clinics of North America have demonstrated the enormous contribution made in the past 15 years or so by rigorous quantitative studies of prevalence, diagnosis, prognosis, and therapy to clinical decision-making in endocrinology. In the early 21st century, the state of qualitative research into such topics as the illness experience of diabetes; the barriers to effective self care and positive health choices; the design of complex educational interventions; the design of appropriate, acceptable and responsive health services; and the decision-making behavior of health professionals, is such that there remain many more questions than answers. But qualitative research is increasingly recognized as an important, legitimate and expanding dimension of evidence-based health care (18;19). It is highly likely that the major landmark studies in diabetes care over the next decade will build on an exploratory qualitative study or incorporate an explanatory or evaluative dimension based on qualitative methods.

Endocrinology↗

PubMed2001

Pre-registration student nurses' perceptions of the day surgery unit.

An increasing number of complex surgical interventions are now taking place on a day case basis with some surgical specialities able to perform 80% of their elective surgery as day surgery. It is important that student nurses are exposed to clinical practice within the day surgery unit. Some students, for a variety of reasons, exhibit a reluctance to experience a day-surgery placement. The writer describes a programme of study which takes place before the students take up their placements to demonstrate that day surgery offers many opportunities for the delivery of highly skilled, specialised nursing care. Day Surgery Nursing is emerging as a speciality in its own right. The clinical skills of the nurse are required alongside the interpersonal, informational and psychological care-giving skills to ensure safety and comfort for the patient whilst in the unit and transfer home where responsibility for care, normally performed by nurses, now lies with the patients and their carers.

Journal Article↗

PubMed2001

Percutaneous closure of a subclavian artery injury after inadvertent catheterization.

Life-threatening complications of subclavian central venous access are rare. Herein a case of inadvertent subclavian artery catheterization and subsequent percutaneous arterial repair with use of the Prostar XL suture-mediated closure device and temporary balloon tamponade is reported. This approach obviated a complex surgical intervention that would have required medial clavicle resection.

Aged↗

PubMed1996

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Academic Medical Centers↗

PubMed2006

Clomiphene citrate challenge test predicts outcome of intrauterine insemination in women aged under 37 years.

The clomiphene citrate challenge test is a tool to predict ovarian reserve and fertility. It has mainly been used as a predictor of success of IVF/intracytoplasmic sperm injection (ICSI) cycles. Infertile young women with diminished ovarian reserve have a worse prognosis than women with adequate ovarian reserve attempting IVF/ICSI cycles. Nothing is known regarding the outcome of young women with diminished ovarian reserve undergoing low-complexity assisted reproductive treatment such as ovulation induction plus intrauterine insemination (IUI). This study included all women under 37 years who consulted in the authors' centre between May 2004 and August 2005 who underwent ovulation induction and IUI. Ninety-six women younger than 37 years with adequate ovarian reserve, and 50 women with diminished ovarian reserve were found. The pregnancy rate and pregnancy rate per cycle in the adequate ovarian reserve group were significantly higher than those of the diminished ovarian reserve group (46.7% versus 25%, P < 0.02 ; 15.9% versus 7.6%, P < 0.02 respectively). It is concluded that the clomiphene citrate challenge test is a good predictor of low-complexity infertility intervention outcome, and represents an effective tool to establish a prognosis. Therefore, it is very useful in planning therapy, and advising the infertile couple.

Adult↗

PubMed2006

A prospective study of dysfunctional thinking and the regulation of negative intrusive memories in bipolar 1 disorder: implications for affect regulation theory.

BACKGROUND: Cognitive behavioural therapy (CBT) has been implemented in bipolar (BP) disorder with varying degrees of success. The link between CBT for BP disorder and underlying theory is not clear. There have been attempts to identify a unique style of dysfunctional thinking in BP disorder analogous to that in unipolar (UP) disorder but this has suffered from a dearth of prospective studies controlling for mood and phase of illness. In this prospective study, we have examined whether dysfunctional thinking and the (dys)regulation of traumatic memories are trait vulnerability factors in BP versus UP mood disorders. METHOD: BP-1 and UP groups were followed-up from acute episode to recovery, and compared with a healthy control group. Measures of dysfunctional thinking and linked personality dimensions were taken, together with measures assessing autobiographical memory retrieval (AMT). The presence and control of intrusive memories of traumatic events in BP and UP disorder were assessed. RESULTS: Controlling for mood symptoms and phase of illness, the BP (but not the UP) group was largely indistinguishable from controls on dysfunctional thinking. Intrusive memories of traumatic events were present in 45% of the BP and 48% of the UP groups; and those without intrusions were more overgeneral on the AMT in all phases of illness. CONCLUSION: These findings are in line with the 'affect regulation' hypothesis for UP disorder and deliberate self-harm. This may help in understanding the mode of action of CBT in BP disorder and to further improve the therapy, primarily through the promotion of affective regulation, which is one component of the complex CBT intervention for BP disorder.

Adolescent↗

PubMed2002

Predicting workplace outcomes from the ability to eavesdrop on feelings.

Emotion recognition, the most reliably validated component within the construct of emotional intelligence, is a complicated skill. Although emotion recognition skill is generally valued in the workplace, "eavesdropping," or relatively better recognition ability with emotions expressed through the less controllable "leaky" nonverbal channels, can have detrimental social and workplace consequences. In light of theory regarding positive emotion in organizations, as well as research on the consequences of perceiving negative information, the authors hypothesized and found an interaction between nonverbal channel and emotional valence in predicting workplace ratings from colleagues and supervisors. Ratings were higher for eavesdropping ability with positive emotion and lower for eavesdropping ability with negative emotion. The authors discuss implications for the complexity of interventions associated with emotional intelligence in workplace settings.

Adolescent↗

PubMed2003

Towards valid measures of self-directed clinical learning.

AIM: To compare the validity of different measures of self-directed clinical learning. METHODS: We used a quasi-experimental study design. The measures were: (1) a 23-item quantitative instrument measuring satisfaction with the learning process and environment; (2) free text responses to 2 open questions about the quality of students' learning experiences; (3) a quantitative, self-report measure of real patient learning, and (4) objective structured clinical examination (OSCE) and progress test results. Thirty-three students attached to a single firm during 1 curriculum year in Phase 2 of a problem-based medical curriculum formed an experimental group. Thirty-one students attached to the same firm in the previous year served as historical controls and 33 students attached to other firms within the same module served as contemporary controls. After the historical control period, experimental group students were exposed to a complex curriculum intervention that set out to maximise appropriate real patient learning through increased use of the outpatient setting, briefing and supported, reflective debriefing. RESULTS: The quantitative satisfaction instrument was insensitive to the intervention. In contrast, the qualitative measure recorded a significantly increased number of positive statements about the appropriateness of real patient learning. Moreover, the quantitative self-report measure of real patient learning found high levels of appropriate learning activity. Regarding outpatient learning, the qualitative and quantitative real patient learning instruments were again concordant and changed in the expected direction, whereas the satisfaction measure did not. An incidental finding was that, despite all attempts to achieve horizontal integration through simultaneously providing community attachments and opening up the hospital for self-directed clinical learning, real patient learning was strongly bounded by the specialty interest of the hospital firm to which students were attached. Assessment results did not correlate with real patient learning. CONCLUSIONS: Both free text responses and students' quantitative self-reports of real patient learning were more valid than a satisfaction instrument. One explanation is that students had no benchmark against which to rate their satisfaction and curriculum change altered their tacit benchmarks. Perhaps the stronger emphasis on self-directed learning demanded more of students and dissatisfied those who were less self-directed. Results of objective, standardised assessments were not sensitive to the level of self-directed, real patient learning. Despite an integrated curriculum design that set out to override disciplinary boundaries, students' learning remained strongly influenced by the specialty of their hospital firm.

Clinical Competence↗

PubMed2003

Advances in the management of the craniosynostoses.

The spectacular beginning of craniofacial surgery in the modern era involved a case of craniosynostosis. Progress from that time to the present in the development of our understanding of this disease process and its management reflects the wider progress in the development and institutionalization of the discipline of craniofacial surgery. Complex surgical interventions have led the way to multidisciplinary units that have developed a greater understanding of the pathology and natural history of the craniosynostoses. New technologies have been developed to further advance the surgical techniques and these can now be evaluated by the institutions that have spawned them. This paper deals with the development of the discipline, the current status of the management of craniosynostosis, both syndromal and non-syndromal, and discusses the technological advances including imaging, distraction osteogenesis and the current status of genetic investigations.

Adolescent↗

PubMed2001

Erectile dysfunction in uremic dialysis patients: diagnostic evaluation in the sildenafil era.

The two words that mean sexual dysfunction, impotence and erectile dysfunction (ED), express two different concepts. Impotence is a general male sexual dysfunction that includes libidinal, orgasmic, and ejaculatory dysfunction. ED is the inability to achieve or maintain an erection sufficient to allow satisfactory sexual intercourse and is part of the general male sexual dysfunction termed impotence that includes libidinal, orgasmic, and ejaculatory dysfunction. Uremic men of different ages report a variety of sexual problems, including sexual hormonal pattern alterations, reduction in or loss of libido, infertility, and impotence, conditioning their well-being status. In evaluating and treating sexual dysfunction, a nephrologist must consider factors involved in its pathogenesis, such as hypothalamic-pituitary-gonadal axis alterations, psychological problems related to chronic disease, secondary hyperparathyroidism, anemia, autonomic neuropathy, derangements in arterial supply or venous outflow, and the normal structure of cavernous body smooth muscle cells. The introduction of sildenafil to treat impotent patients has completely changed the approach to evaluating these subjects because this drug is considered an effective well-tolerated treatment for men with ED. In the past, we proposed an algorithm that gave the opportunity to explore the previously mentioned factors using such instrumental interventions as the nocturnal penile tumescence test, penile echo color Doppler, nervous conduction velocity, and cavernous body biopsy, addressed to prescribe needed surgical or medical interventions. The complexity of the proposed algorithm requires many diagnostic procedures and much time and economic resources to localize the pathological lesions responsible for ED. Because of the new oral drug sildenafil, we propose a new algorithm to test the possibility of obtaining an erection and classify patients as responders or nonresponders to the sildenafil test.

Bromocriptine↗

PubMed2004

Pediatric cardiac transplantation.

Pediatric cardiac transplant patients present many challenges to the medical community. These include such things as complex evaluations, preoperative heart failure support, complex operative interventions, and postoperative challenges in management. In spite of these challenges, survival outcomes for children undergoing a heart transplant have improved dramatically over the last two decades.

Child↗