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PubMed1991

Cost savings in a hospital clinical laboratory with a pay-for-performance incentive program for supervisors.

A pay-for-performance incentive program for clinical laboratory supervisors was developed and implemented at Brigham and Women's Hospital (Boston, Mass). It provides monetary rewards to personnel who directly produce cost savings in their area of responsibility. This reward system is new to the hospital laboratory but is commonly used in industry. Substantial true cost savings over and above previously established stringent budgets were achieved, 11% of which was returned to first-line supervisors in the form of a bonus. The program expanded the scope of professionalism for supervisors to include fiscal management.

Cost Control↗

PubMed1991

Redesigning management roles. The executive challenge.

The revolutionary changes that have occurred in healthcare during the past decade challenge nurse executives to analyze and redesign managerial roles. To confront future change and developments in nursing and management practice, the role of the first-line nurse manager must take on new dimensions to facilitate quality outcomes in patient care and empowerment of nurses at all levels of practice. The author presents a model of job redesign for nurse managers with emphasis on the motivational approach. Role outcomes for nurse managers are also detailed.

Feedback↗

PubMed1991

The role of calcium channel blockers in the treatment of essential hypertension.

Calcium channel blockers, originally developed for the treatment of angina and supraventricular arrhythmias, have been shown to lower elevated blood pressure effectively in hypertensive patients. Verapamil, nifedipine, and diltiazem represent prototype compounds for unique chemical classes with differing pharmacologic properties. These drugs lower elevated blood pressure with efficacy comparable with other commonly used antihypertensives. Combination therapy with other agents usually results in an additive response. Side effects are usually mild and reversible and usually are an extension of the drug's pharmacologic effects. Moreover, adverse metabolic effects on lipid, glucose, or potassium levels are not common. Because of the excellent antihypertensive effects of calcium channel blockers and their potential importance in a variety of other disease states, these agents should be routinely considered for use as a first-line antihypertensive agent in appropriately selected patients with hypertension of any severity as part of a comprehensive plan to minimize cardiovascular risk.

Animals↗

PubMed1991

Intraperitoneal cisplatin-based chemotherapy for ovarian carcinoma.

Ovarian carcinoma demonstrates a steep dose-response curve for cisplatin, but even very small levels of acquired resistance at the cellular level are sufficient to block the efficacy of intravenous (IV) cisplatin. The intraperitoneal (IP) route of administration produces a 12-fold to 15-fold greater exposure for the peritoneal cavity, and concurrent use of IV thiosulfate permits the safe IP injection of 200 mg/m2 cisplatin. In this study, two phase II trials of an IP regimen containing cisplatin 200 mg/m2 and etoposide 350 mg/m2 with IV thiosulfate were conducted; the first trial enrolled patients with residual disease less than 2 cm who had failed primary cisplatin-based IV chemotherapy and the second trial newly diagnosed ovarian carcinoma patients irrespective of the size of residual disease after primary surgery. As salvage therapy, the IP cisplatin/etoposide regimen produced a median survival of 26 months from the start of IP therapy and 51 months from diagnosis. As first-line therapy, the median survival has not yet been reached; projected survival is 68% at 27 months. In both studies the major toxicity was myelosuppression; the use of concurrent thiosulfate almost completely eliminated serious nephrotoxicity and neurotoxicity. The size of the largest tumor mass was an important determinant of efficacy in both settings. The results of these trials are consistent with the hypothesis that increased drug delivery will result in higher response rates and improved survival. Data are sufficiently encouraging to mandate phase III randomized trials of this program.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1991

[Main indications for upper digestive endoscopy].

Upper gastrointestinal endoscopy (UGI) is now widely accepted as the first-line examination of the digestive tract. UGI provides the diagnosis of most oesophageal and gastroduodenal diseases such as ulcer, cancer or oesophagitis. It is also valuable in the diagnosis of chronic diarrhoea, immunodeficiencies (immunoglobulin deficiency) and in AIDS patients. Improvements in disinfection and anesthesia make UGI a safe and well-tolerated procedure. Finally, it is, of course, the gold standard for the diagnosis of upper gastrointestinal haemorrhages and in many cases requiring endoscopic therapy.

Digestive System Diseases↗

PubMed1991

Acyclovir in herpetic anterior uveitis.

The optimal management of herpes simplex stromal keratitis and uveitis is controversial. Thirty-two patients with presumptive herpetic anterior uveitis without active corneal inflammation received 3% acyclovir ophthalmic ointment five times daily and acyclovir 200mg orally five times a day. Eight of 18 patients (44.4%) who had received corticosteroids deteriorated over the first five days of therapy; one of 14 patients (7.1%) without previous corticosteroid use worsened during this time (P less than .05). The mean healing time was similar in these two groups. These results suggest that antiviral therapy may be first-line treatment in patients with herpetic keratouveitis who have not received corticosteroids.

Acyclovir↗

PubMed1991

[Truth at the bedside--also with cancer patients?].

The emotional discussion on a frank information strategy towards cancer patients 10 to 15 years ago has fortunately become more objective today, not the 'if', but the 'how' is now important; however, psychologic problems in the confrontation with the terminally ill are still recognized, mainly in groups of physicians lacking personal contact with dying and death during postgraduate training and later practise. Improvement of primary information and of further adapted communication with cancer patients cannot be solved alone by a larger number of experienced oncologists, since these represent in most instances only the second or third medical authority approaching the patient with neoplastic disease. Therefore, more supporting and less prejudiced patient contacts should be provided by first-line medical care, i.e. the family physician or surgeon. However, a truthful information strategy is a personal challenge for the physician. It demands an individual preoccupation of the therapist with the basic questions regarding his own life and its impermanence. Critical peer-reviewed training (i.e. in discussion and Balint groups) can teach a balanced dimension for a difficult patient interview (information, emotional involvement, patient-oriented behaviour). Deviations from adapted behaviour such as over-identification can thus be recognized and prevented. Since coping with disease does not develop in a linear fashion from initial resistance and negation of disease to mature acceptance in many patients, experienced therapists may always encounter sudden new problems regarding communication and information; therefore, the requirements for a therapist regarding tact, sensitivity and readiness to learn are high. This overview is written in this intent from an oncologists point of view in order to provide practical hints for daily encounters with cancer patients.

Adaptation, Psychological↗

PubMed1991

[Erysipelas: epidemiological, clinical and therapeutic data (111 cases)].

A retrospective study of 111 patients admitted to the Dermatology department of the Bichat hospital, Paris, between 1981 and 1988 for treatment of erysipelas revealed the following data: 1. Erysipelas was located on the lower limbs in 88.3 p. 100 of the cases and on the face in only 9.8 p. 100. 2. Facilitating and/or aggravating factors were: portal of entry in 75 p. 100 of the cases; impairment of venous and lymphatic circulations (41 p. 100); diabetes mellitus (13.5 p. 100); alcoholism and its socio-economic consequences (29 p. 100); unnecessary prescription of anti-inflammatory agents (11 p. 100). 3. Insufficient consideration was given to the clinical diagnosis: in 7.2 p. 100 of the patients erysipelas was diagnosed either after failure of heparin therapy or because phlebography was normal; some clinical features, notably bullae (30 p. 100) or purpura on the lower limbs (13 p. 100), confused the physicians. Delayed treatment was the main cause of local complications, such as abscess (4 cases) or focal cutaneous necrosis (4 cases). Erysipelas was recurrent in 23.5 p. 100 of the patients. 4. Bacteriological data in this series were insufficient to establish percentages of responsible organisms. However, penicillin G in mean doses of 12 million units per day administered intravenously for 5.5 days, then intramuscularly for 10 days was effective as first-line treatment in 80 p. 100 of the cases. Penicillin therapy may fail in patients with insulin-dependent diabetes or belated treatment with complications. No thromboembolic complication was observed (89 p. 100 of patients with lower limb erysipelas had received anticoagulants). There was only one death due to a severe underlying condition.

Administration, Oral↗

PubMed1991

Malignant neck lumps: a measured approach.

The options currently available for establishing the histological diagnosis of a neck mass are open biopsy or a measured approach involving head and neck examination, fine-needle aspiration biopsy (FNAB) and panendoscopy. We present the results of 10 patients initially managed by open biopsy and 22 who were subject to the alternative approach. All had a histological diagnosis of squamous carcinoma. Seven of the open biopsy patients developed problems related to the biopsy that later adversely affected their management. There were no such problems in the other group. Patients undergoing open biopsy required a mean of one further general anaesthetic and a mean inpatient stay of 7 days longer than the patients in the second group. FNAB in our hospital was shown to be reliable (91% accurate, 93% sensitive, 97% specific), especially for squamous malignancy (100% specific). The relative merits of the two methods are discussed. It is our belief that open biopsy should not be used as a first-line investigation of a neck mass.

Adult↗

PubMed1991

Intensive sequential chemotherapy with mitoxantrone and continuous infusion etoposide and cytarabine for previously treated acute myelogenous leukemia.

Intensive sequential chemotherapy with mitoxantrone, 12 mg/m2/d on days 1 through 3, etoposide, 200 mg/m2/d as a continuous infusion on days 8 through 10, and cytarabine, 500 mg/m2/d as a continuous infusion on days 1 through 3 and 8 through 10 was administered to 72 patients aged less than 60 years with previously treated acute myelogenous leukemia (AML). Forty patients had refractory AML (nonresponse to prior therapy, early first relapse, or multiple relapse) and 32 had late first relapse. Sixty-one percent of patients, with a 95% confidence interval (CI) ranging from 49% to 72%, achieved complete remission (CR), including 45% (CI: 30% to 62%) of refractory patients and 81% (CI: 64% to 93%) of late first relapse patients. Twenty-nine percent of patients (CI: 19% to 41%) did not respond to therapy and 10% (CI: 4% to 19%) died from therapy-related toxicity. Median duration of aplasia was 30 days. Nonhematologic WHO grade 3 or more toxicity included sepsis (57% of patients), vomiting (10%), mucositis (35%), diarrhea (7%), skin rash (6%), and hyperbilirubinemia (11%). Postinduction therapy was attempted in 36 of 44 CR patients: 16 of them received a second course of the same regimen, 7 received maintenance chemotherapy, 4 underwent autologous bone marrow transplantation (BMT), and 9 allogeneic BMT. At a median follow-up of 20 months, 23 of the 44 complete remitters have relapsed, 1 to 14 months after achievement of CR, including 19 of 31 patients not undergoing BMT. Median survival is 7 months with 16% (CI: 4% to 28%) projected survival at 47 months. Median disease-free survival is 6 months with 21% (CI: 3% to 39%) of CR patients projected to remain disease-free at 46 months. Twenty-six percent (CI: 13% to 43%) of the evaluable patients who did not receive transplantation had inversion of CR duration. Among patients younger than 50 years, there was no significant difference in disease-free survival between patients receiving postinduction chemotherapy and those receiving BMT. We conclude that this chemotherapy regimen is highly efficient and could be used as first-line therapy in young patients with AML.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1977

Drug prescribing in rheumatoid arthritis in Otago.

The drug therapy prescribed for a group of 50 patients with rheumatoid arthritis in Otago prior to specialist referral was examined. Thirty-two patients were receiving some first-line anti-inflammatory drugs and six were receiving no therapy at the time of their first hospital clinic visit. Salicylates had been prescribed first in only 16 of the 50 patients while this drug had been withdrawn because of side effects in about one-third of the patients who had been treated with it prior to specialist referral. Seven patients had received phenylbutazone and six corticosteroids as the first treatment for their rheumatoid arthritis. About one-third of the patients were receiving more than one anti-inflammatory drug at the time of their initial clinic visit.

Adult↗

PubMed1979

Bretylium tosylate: a review.

The chemistry, pharmacology, pharmacokinetics, clinical uses, adverse effects, drug interactions and dosage of bretylium tosylate, a recently approved antiarrhythmic agent, are reviewed. Bretylium tosylate is used to treat life-threatening ventricular arrhythmias, principally ventricular fibrillation and ventricular tachycardia, that have not responded to treatment with first-line antiarrhythmic agents. The drug has a direct positive inotropic effect on the myocardium and blocking effect on postganglionic sympathetic nerve transmission. The drug is poorly absorbed orally, requiring either i.m. or i.v. administration. Drug excretion occurs primarily through the kidney, necessitating dosage modification in renal disease. Hypotension is the most commonly observed adverse reaction to bretylium tosylate. Rapid i.v. administration may cause severe nausea and vomiting, and i.m. injection at the same site may cause atrophy and necrosis of muscle tissue. Quinidine and procainamide may potentiate the hypotensive effects of bretylium. Bretylium will aggravate digitalis-induced arrhythmias. Bretylium's use in resistant ventricular tachyarrhythmias requires close clinical monitoring.

Arrhythmias, Cardiac↗

PubMed1979

[Current chemotherapy of pulmonary tuberculosis].

Tuberculosis has today lost much of its dread for mankind: in 1976, 1823 persons contracted tuberculosis and 182 died of pulmonary tuberculosis in Switzerland. In contrast, 1375 died of pneumonia, 1309 of non-specific airway disease and 2202 of bronchial cancer in the same year. The present data on morbidity and mortality in Switzerland resemble those of the other industrial European countries or the USA. The decrease in morbidity and mortality of pulmonary tuberculosis was caused-among other factors-by chemotherapy. Chemotherapy not only profoundly changed the infectivity of tuberculous patients and made ambulatory, domiciliary treatment possible, but cured pulmonary tuberculosis. The introduction of the bactericidal rifampicin led to the latest major landmark in the chemotherapy of tuberculosis in the past 20 years: namely, short-course chemotherapy. Together with the other first-line drugs (isoniazid, streptomycin, ethambutol), rifampicin shortened the duration of chemotherapy from 18--24 to 9--12 months. Short-course chemotherapy is today the therapy of choice for most patients with pulmonary tuberculosis.

BCG Vaccine↗

PubMed2026

[Tics and Tourette Syndrome].

Tics disorders and Tourette syndrome (TS) are neurodevelopmental conditions characterized by motor and/or vocal tics with onset in childhood. Their clinical presentation is heterogeneous and fluctuating over time, with exacerbations related to emotional, environmental, and medical factors. Diagnosis is clinical and based on medical history and neurological examination, following DSM-5-TR criteria, with ancillary testing rarely required. The prevalence of TS is estimated at 0.7%, while transient tic disorders affect up to 10% of children. The natural history is generally favorable, with symptom improvement during adolescence, although a subset of patients continues to experience tics into adulthood. Most individuals with TS present psychiatric comorbidities, particularly attention-deficit/hyperactivity disorder and obsessive-compulsive disorder, which significantly impact quality of life and should be prioritized in management decisions. Treatment is recommended only when tics cause functional impairment and follows a stepwise approach including psychoeducation, behavioral interventions, and individualized pharmacological therapy. Comprehensive behavioral intervention for tics is considered first-line treatment when available. Alpha-2 adrenergic agonists and dopamine antagonists are the most commonly used pharmacological options. Neuromodulation therapies are reserved for severe, refractory cases. These recommendations from the Ibero-American Academy of Pediatric Neurology summarize current evidence and provide a practical, updated framework for the diagnosis and management of tic disorders and Tourette syndrome in pediatric patients.

Humans↗

PubMed1978

Rheumatoid arthritis.

Management should help relieve symptoms, increase or maintain function, produce few side effects and keep the cost to a minimum. Aspirin remains the first-line drug; other nonsteroidal anti-inflammatory drugs may be useful when aspirin cannot be tolerated. Symptoms and signs of rheumatoid disease may be suppressed by corticosteroids, but only gold compounds, penicillamine and cytotoxic therapy have been shown to decrease disease activity and lessen permanent joint damage.

Adrenal Cortex Hormones↗

PubMed1976

Role of DTIC (NSC-45388) in the chemotherapy of sarcomas.

DTIC was one of the first of several new agents evaluated by the Southwest Oncology Group (SWOG) and the M.D. Anderson Hospital and Tumor Institute (MDAH) in the therapy of adult patients with metastatic sarcomas. It yielded an overall response rate of 17%. This is similar to that seen in a review of 138 patients who represent the total number reported in either published or unpublished data. The subsequent addition of DTIC to adriamycin in several studies carried out at the MDAH and in the SWOG has increased the complete and partial remission rate over that seen with adriamycin alone, and more importantly has increased remission duration and survival. DTIC is currently used in combination with adriamycin in the first-line therapy of patients with metastatic sarcomas and should be considered for patients who have relapsed on primary therapy not including DTIC.

Clinical Trials as Topic↗

PubMed1976

Present state of cardiovascular community control programme in the Czech Socialist Republic.

The high incidence, great import, and long duration of cardiovascular diseases are reflected in high demands placed on the health services. Experience shows that utilization of the results of research in general practice is lagging behind. The application of any improvement in the diagnosis, therapy, and prevention in health care waits several years for its accomplishment. In order to improve this situation, the Ministry of Health of the CSR constituted, in line with WHO recommendations, a Department for Cardiovascular Diseases Control. The Department has worked out a programme of prevention and control of the major cardiovascular diseases, in particular, ischaemic heart disease, systemic hypertension and its complications, rheumatic heart disease, congenital cardiac and vascular defects, and cor pulmonale. New diagnostic, therapeutic, and preventive procedures are first tried out in so-called model areas and are only after this introduced into the national health care of people suffering from or endangered by cardiovascular diseases. In parallel, organizational measures necessary for comprehensive care are implemented. The authors report on the experience gained so far with the realization of the programme of care of people suffering from IHD and acute myocardial infarction. They emphasize the importance of continual schooling of medical personnel and of health education of the entire population. They describe the implementation on a national scale of postgraduate cardiological courses intended especially for first-line doctors.

Cardiovascular Diseases↗

PubMed1976

Buccal administration of fenoterol aerosol in young children with asthma.

A new technique for the administration of a bronchodilator aerosol, fenoterol, in young children with asthma is described. Rapid and effective bronchodilatation can be obtained in many patients simply by directing the jet of the bronchodilator aerosol onto the buccal mucosa. This method will frequently obviate the need for painful or potentially dangerous injections of adrenaline or aminophylline as a first-line treatment in children with acute attacks of asthma.

Aerosols↗