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PubMed2001

The multidisciplinary approach to prevention and treatment of cardiovascular disease: creation of a vascular care network.

Vascular care, diagnosis, and intervention can be very complex. Multiple specialists commonly are involved in dealing with patients with systemic atherosclerotic disease. Although each specialist may provide state-of-the-art care with good result, it would be advantageous to minimize duplication of effort and thereby improve cost efficiency. Patients still could reap the benefit of all these disciplines if evaluated for their vascular complaint in a coordinated system. In doing so, atherosclerosis prevention with risk factor modification, as well as diagnosis and therapy for the presenting problem all can be simultaneously managed. This is the concept that has motivated groups such as our own to form a comprehensive vascular center. We describe our experience with establishing a vascular center and outline its benefits and limitations.

Cardiovascular Diseases↗
PubMed2005

A health care program for homeless children using Healthy People 2010 objectives.

A health care program based on Healthy People 2010 objectives provides screening and treatment to homeless children residing in a homeless shelter through a nursing center located on site. In addition to treatment for minor acute illnesses, children receive physical assessment and screening for health problems for which they are at increased risk. Interventions address these problems within the context of the complex psychosocial issues they face. Outcomes of interventions are monitored to support the value of case management and health education with these families.

Adolescent↗
PubMed2006

Initial highly-active antiretroviral therapy with a protease inhibitor versus a non-nucleoside reverse transcriptase inhibitor: discrepancies between direct and indirect meta-analyses.

BACKGROUND: The optimum treatment choice between initial highly-active antiretroviral therapy (HAART) with a protease inhibitor (PI) versus a non-nucleoside reverse transcriptase inhibitor (NNRTI) is uncertain. An indirect analysis reported that PI-based HAART was better than NNRTI-based HAART. However, direct evidence for competing interventions is deemed more reliable than indirect evidence for making treatment decisions. We did a meta-analysis of head-to-head trials and compared the results with those of indirect analyses. METHODS: 12 trials of at least 24 weeks' duration directly compared NNRTI-based versus PI-based HAART in HIV-infected patients with limited or no previous exposure to antiretrovirals. We also identified six trials of NNRTI-based HAART and eight trials of PI-based HAART, each versus two NRTI regimens. We analysed the outcomes of virological suppression, death or disease progression, and withdrawals due to adverse events. FINDINGS: In the direct meta-analysis, NNRTI-based regimens were better than PI-based regimens for virological suppression (OR 1.60, 95% CI 1.31-1.96). The difference was reduced in higher-quality trials, but still favoured NNRTI-based HAART. There were no differences in death or disease progression (0.87, 0.56-1.35) or withdrawal because of adverse events (0.68, 0.43-1.08). By contrast, in indirect analyses NNRTI-based HAART was worse than PI-based HAART for virological suppression (0.26, 0.07-0.91). There were no significant differences for death or disease progression (1.28, 0.56-2.94) and withdrawals because of adverse events (1.46, 0.66-3.24). When trials of delavirdine were excluded, similar results were produced. INTERPRETATION: Results from direct analyses suggested that NNRTI-based HAART was more effective than PI-based HAART for virological suppression and was similar to PI-based HAART for clinical outcomes. Indirect comparisons could be unreliable for complex and rapidly evolving interventions such as HAART.

Adult↗
PubMed2002

Platelet inhibition with tirofiban early during percutaneous coronary intervention: dosing revisited.

Platelet inhibition is central to the efficacy of the intravenous glycoprotein IIb/IIIa receptor inhibitors. Differences in the degree of platelet inhibition achieved with these agents may account for the disparity in clinical efficacy noted in recently completed clinical trials. The purpose of this study was to evaluate ex vivo platelet inhibition with tirofiban in patients admitted with acute coronary syndrome and who were referred for percutaneous coronary interventions. Twenty-five patients were studied. Ten patients received tirofiban 10 microg/kg bolus and 0.15 microg/kg infusion for 16 hr. Platelet inhibition was determined at 5, 15, 30, 45, 60, and 120 min after tirofiban, by light transmission aggregometry (LTA), rapid platelet function assay (RPFA), and platelet works (PW). The average platelet inhibition using RPFA with PPACK, was 87% at 5 min, then decreased to a nadir of 72% at 30 min and recovered back to > 80% at 60 min and onward. Similar trends were noted with RPFA-citrate, PW, and LTA. Ca-chelating anticoagulants (EDTA and citrate) overestimated platelet inhibition at all time points. Dose adjustment was done by increasing the bolus (15 microg/kg) in five patients, increasing the maintenance dose (0.2 microg/kg/min) in five patients, and increasing both the bolus and the maintenance dose in another five patients. Platelet inhibition tested by all the above methods was consistently over 90% when both the bolus and maintenance doses were increased. No increased incidence of major bleeding was noted at this adjusted dose. The current dosing of tirofiban may be inadequate to achieve appropriate platelet inhibition during PCI in patients admitted with acute coronary syndrome and receiving tirofiban immediately before the procedure in the cardiac catheterization laboratory. Dose adjustment may be needed to maximize platelet inhibition early during PCI.

Cardiac Catheterization↗
PubMed2000

A multivariate model of determinants of motor change for children with cerebral palsy.

The purpose of this article is to describe the development of a theory- and data-based model of determinants of motor change for children with cerebral palsy. The dimensions of human functioning proposed by the World Health Organization, general systems theory, theories of human ecology, and a philosophical approach incorporating family-centered care provide the conceptual framework for the model. The model focuses on relationships among child characteristics (eg, primary and secondary impairments, personality), family ecology (eg, dynamics of family function), and health care services (eg, availability, access, intervention options). Clarification of the complex multivariate and interactive relationships among the multiple child and family determinants, using statistical methods such as structural equation modeling, is necessary before determining how physical therapy intervention can optimize motor outcomes of children with cerebral palsy. We propose that the development and testing of multivariate models is also useful in physical therapy research and in the management of complex chronic conditions other than cerebral palsy. Testing of similar models could provide physical therapists with support for: (1) prognostic discussions with clients and their families, (2) establishment of realistic and attainable goals, and (3) interventions to enhance outcomes for individual clients with a variety of prognostic attributes.

Activities of Daily Living↗
PubMed2006

Laparoscopic management of rectal endometriosis.

PURPOSE: Surgical treatment of females with rectal endometriosis is challenging. The aim of this study was to review the results of laparoscopic intervention in the management of females with this complex disorder. METHOD: All cases of complex tertiary referral pelvic endometriosis requiring laparoscopic surgical intervention of the rectum were identified and reviewed from a prospective database. RESULTS: Between April 1996 and August 2004, 95 patients with pelvic endometriosis involving the rectum had laparoscopic surgical procedures performed by one gynecologist and one colorectal surgeon. Eighty percent of rectal procedures were completed laparoscopically. Forty-three (45 percent) were treated with diathermy excision, 18 (19 percent) had shave partial-thickness disc excision, 20 (21 percent) had full-thickness disc excision (including 14 endoanally using a circular stapler), while 14 (15 percent) were managed with laparoscopic-assisted segmental low anterior resection. A history of rectal pain during defecation present only during menstruation (adjusted odds ratio=8.6, 95 percent confidence interval (CI)=1.8-41.2) and previous laparoscopy (adjusted odds ratio=3.2, 95 percent CI=1.2-8.3) independently predicted a need for more extensive surgery than diathermy excision. There were no rectal anastomotic leaks, with 8 percent overall morbidity. The only significant predictor of ongoing postoperative symptoms was a history of dyspareunia (P=0.03). CONCLUSIONS: Patients with complex endometriosis of the rectum can be safely managed laparoscopically using a multidisciplinary approach. This case series suggests that a history of rectal pain during defecation that occurs only during menstruation is predictive of females with more extensive rectal disease.

Adult↗
PubMed2002

Evaluation of quality improvement programmes.

In response to increasing concerns about quality, many countries are carrying out large scale programmes which include national quality strategies, hospital programmes, and quality accreditation, assessment and review processes. Increasing amounts of resources are being devoted to these interventions, but do they ensure or improve quality of care? There is little research evidence as to their effectiveness or the conditions for maximum effectiveness. Reasons for the lack of evaluation research include the methodological challenges of measuring outcomes and attributing causality to these complex, changing, long term social interventions to organisations or health systems, which themselves are complex and changing. However, methods are available which can be used to evaluate these programmes and which can provide decision makers with research based guidance on how to plan and implement them. This paper describes the research challenges, the methods which can be used, and gives examples and guidance for future research. It emphasises the important contribution which such research can make to improving the effectiveness of these programmes and to developing the science of quality improvement.

Evidence-Based Medicine↗
PubMed2003

Organisational infrastructures to promote evidence based nursing practice.

BACKGROUND: The purpose of this systematic review is to determine to what extent organisational infrastructures are effective in promoting the implementation of high quality research evidence on the effectiveness of nursing interventions. OBJECTIVES: To identify and summarize rigorous evaluations of organisational infrastructure developments aimed at promoting evidence based nursing practice. SEARCH STRATEGY: We searched: The Cochrane Library, MEDLINE, EMBASE, CINAHL, SIGLE, HEALTHLINE, National Research Register, Nuffield Database of Health Outcomes, NIH Databases up to August 2002. We hand searched the Journal of Advanced Nursing, Applied Nursing Research and Journal of Nursing Administration (to 1999), and checked the reference lists of articles obtained. We contacted experts in the field and relevant Internet groups. SELECTION CRITERIA: Randomized controlled trials, controlled clinical trials and interrupted times series studies of an entire or identified component of an organisational infrastructure development aimed at promoting effective nursing interventions. The participants were health care organisations comprising nurses, midwives and health visitors in hospital and community settings. DATA COLLECTION AND ANALYSIS: All identified papers were screened independently for relevance, design and outcome by two reviewers. MAIN RESULTS: No studies were sufficiently rigorous to be included in this systematic review. Seven case study evaluations were identified but excluded from the review because of poor design and lack of controls. REVIEWER'S CONCLUSIONS: 1. There are no clear implications for practice.2. Several conceptual models on organisational processes to promote evidence based practice have been described in published papers, and a number of organisational infrastructural interventions have been described in published papers. None have been evaluated properly. The next step in this field should be to conduct well planned evaluations of well planned interventions. 3. Interrupted and Complex Interrupted Times Series (ITS and CITS) designs should be adopted as a useful alternative to randomized controlled trials where such trials would be impractical. The health service cost of any infrastructure developments should be assessed in any evaluation. If possible, patient outcomes should be measured directly.

Efficiency, Organizational↗
PubMed2001

A natural history of cleidocranial dysplasia.

Cleidocranial dysplasia (CCD) is an autosomal dominant skeletal dysplasia associated with clavicle hypoplasia and dental abnormalities. The condition is caused by mutations in the CBFA1 gene, a transcription factor that activates osteoblast differentiation. Clinical characteristics associated with CCD have previously been described in case reports and small case series. This study was undertaken to gain a more complete delineation of clinical complications associated with CCD. The study population was composed of 90 CCD individuals and 56 relative controls ascertained from genetic and dental practices in the United States, Canada, Europe, and Australia. A number of previously unrecognized complications were significantly increased including: genua valga, scoliosis, pes planus, sinus infections, upper respiratory complications, recurrent otitis media, and hearing loss. Primary Cesarean section rate was significantly increased compared to relative controls and the general population rate. Finally, dental abnormalities, including supernumerary teeth, failure of exfoliation of the primary dentition, and malocclusion, are serious and complex problems that require intervention. Clinical recommendations based on the results of this study are included.

Adolescent↗
PubMedDate not supplied

Sterilization of women: benefits vs risks.

Voluntary sterilization is the birth control method most widely practiced throughout the world. The last ten years have witnessed great improvements in techniques and perfection of innovations, explaining the important role that it now plays in the regulation of fertility. Different methods are examined and it is concluded that hysterectomy is the best, if medically indicated; conventional laparotomy is not justified unless required by concomitant intraabdominal pathology; minilaparotomy is mostly suitable postpartum; colpotomy is better left to specialists; laparoscopy is ideal for nonpregnant patients; culdoscopy is a relic of the past; and hysteroscopy, although still experimental, may be the way of the future. The advantages of voluntary sterilization lie in its remarkable and immediate efficiency, freedom from ongoing motivation, the convenience of a one-time operation, the absence of side effects and the reduction of total costs. Its disadvantages are the complexity of any surgical intervention for a woman, its indisputable finality, its uncertain legality and the risks inherent in any operation. Hysterectomy and tubal ligation are practically never fatal, so this argument does not influence the choice of either method. However, incidence of morbidity is higher following hysterectomies, which must therefore be justified. The balance is clearly in favor of voluntary sterilization for the woman who is convinced that the size of her family is complete.

Adult↗
PubMed2004

[Shock trauma room management of pelvic injuries. A systematic review of the literature].

OBJECTIVE: Injuries to the pelvis may occur as a life threatening situation which then requires immediate surgical treatment. A review of the literature represents the range of current recommendations. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) reviewed and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: According to the literature there is a consent that immediate resuscitation and surgical intervention is essential in complex pelvic fractures. In contrast the way of emergency stabilization of the pelvis (fixateur externe or c-clamp) is still under discussion as well as the radiological diagnostic (x-ray or CT) and the way of bleeding control (tamponade or embolization). CONCLUSION: Emergency management of pelvic fractures means treatment of a life threatening injury in first place. Although there are different methods that can be used, they all follow the same principle of resuscitation and mechanical stabilization of the pelvis in parallel.

Clinical Trials as Topic↗
PubMed1993

Biology and treatment of multiple myeloma.

The uniformly fatal plasma cell malignancy, multiple myeloma (MM), currently represents 10-15% of hematologic neoplasms in the USA and has been steadily increasing in incidence for several decades. Therapeutic alternatives have lagged significantly behind insights into the biology and pathogenesis of this entity. Traditionally felt to be a neoplasm of fully differentiated plasma cells, evidence has been mounting that the self renewing population consist of cells derived from a much earlier compartment; perhaps prior to B-cell lineage commitment or even at the level of an earlier 'stem cell'. Bcl-2 protein overexpression has been almost uniformly seen in both clinical myeloma specimens as well as in myeloma cell lines. The failure to consistently identify the t(14;18) translocation, normally found in follicular lymphomas and characteristically associated with overexpression of bcl-2, implies a unique mechanism in MM. A number of cytokines, including TNF alpha, IL-1 and IL-6 have been found to play a central role not only in the biology of the malignant clone but also in the bony and other systemic manifestations of this disease. Since both IL-6 and bcl-2 protein have been shown to prevent programmed cell death, this may be the unifying event in MM. Standard therapy for MM has been an alkylating agent and corticosteroid. Combination chemotherapy provides more prompt palliation but no clear survival advantage. In advanced stages, adriamycin may offer some survival advantage. High dose chemotherapy with or without stem cell support offers a potentially curative therapeutic approach. New interventions directed at the complex cytokine networks pertinent to the pathogenesis of MM are an exciting new area of investigation. Identification of new prognostic parameters as well as new active agents remains the central theme in clinical myeloma research.

Adult↗
PubMed2006

Constrained liners in revision: total hip arthroplasty an overuse syndrome: in opposition.

Use of constrained liners in revision total hip arthroplasty is frequently a necessary evil. Concomitant with the increasing complexity of the operative intervention is the deterioration of periarticular soft-tissue envelope integrity, causing increased risk of dislocation. Risk factors can be categorized as impingement independent or impingement related. Impingement-independent risk factors include those related to compromised soft-tissue tension, patient-specific issues, and surgical approach. Impingement-related risk factors include head-to-neck size and geometry, acetabular liner geometry, and surgical technique. Indications for constraint include recurrent hip instability after arthroplasty, intraoperative multidirectional hip instability, neuromuscular diseases that impair hip dynamics, neurologic diseases that impair the patient's ability to restrict activities, and proximal muscle weakness with or without deficiency of the protective muscular. Newer designs featuring large heads, improved range of motion, and reduced impingement hold the promise of improved results.

Acetabulum↗
PubMed2004

Plastic surgery in the undergraduate curriculum: the importance of considering students' perceptions.

As the undergraduate medical curriculum becomes increasingly crowded the competition for time inevitably increases and surgical specialties have decreasing representation. Plastic surgery is regarded with some confusion in terms of its relevance to the generic doctor. Plastic surgeons have no doubt about the relevance of the specialty to undergraduates. Others see this as a very technical specialty dealing with complex reconstructions and surgical interventions or, as a rather indulgent specialty focusing mainly on glamour and cosmesis. This study focuses on students' perceptions of an undergraduate teaching program in plastic surgery. The reality is that highly pressured undergraduates do not have the luxury of time to consider the finer details of the specialties to which they are exposed. Their priority is to pass their examinations and, having addressed that concern, further information becomes an acceptable bonus. The conclusion is that if plastic surgeons are going to gain greater involvement in the undergraduate curriculum they must start with involvement in examinations and assessments. The students will then ensure that adequate and appropriate teaching time is allocated.

Attitude of Health Personnel↗
PubMed2006

Imaging the neonatal heart--essentials for the radiologist.

Modern radiological imaging provides precise diagnosis in congenital heart disease (CHD). The most important and readily available radiological examination is still chest radiography. The diagnostically most important imaging method is echocardiography. Magnetic resonance imaging and computed tomography have gained much ground over the more invasive cardiac catheter angiography, which is still needed in more complex conditions and for interventional procedures, which are performed more frequently. This article is focused on imaging of the neonatal heart. Basically, characteristics of the chest radiograph in CHD are illustrated. To establish an understanding of CHD haemodynamics are reviewed. It is not the role of the radiologist to make a detailed anatomic or physiologic diagnosis on the basis of a plain film, but the radiologist should be aware of changes in a neonatal chest X-ray that CHD can cause and should point out that the child might have CHD thus initiating further work-up.

Cyanosis↗
PubMed2005

Blastocyst formation in in vitro fertilization versus intracytoplasmic sperm injection cycles: influence of the fertilization procedure.

OBJECTIVE: To compare the quality of early cleaving embryos and blastocysts obtained by IVF or intracytoplasmic sperm injection (ICSI). DESIGN: Retrospective study. SETTING: Tertiary infertility center. PATIENT(S): Sibling oocytes of 104 patients in 104 IVF vs. ICSI cycles. INTERVENTION(S): Cumulus oocyte complexes (n = 1,358) were randomly subjected to ICSI or IVF. MAIN OUTCOME MEASURE(S): Embryo development and blastocyst formation rate. The blastocyst quality and cycle efficiency were also evaluated. RESULT(S): Early embryo cleavage was higher after ICSI (37.1%) compared to IVF (14.1%). The percentage of > or =4-cell embryos on day 2 and > or =8-cell embryos on day 3 was similar for both procedures. The overall blastocyst formation was not different between ICSI (50.2%) and IVF (54.8%), neither was the percentage of good-quality blastocysts (31.3% for ICSI and 36.0% for IVF). The total cycle efficiency (percentage of embryos transferred and frozen per two pronuclei [2PN]) was comparable for the two techniques (51.7% for ICSI and 57.4% for IVF). CONCLUSION(S): No differences were found on sibling oocytes in the embryo development and blastocyst formation, irrespective of the fertilization procedure. Earlier suggestions that the ICSI technique may result in impaired blastocyst development were not confirmed in this study.

Adult↗
PubMed2004

The placebo-controlled trial as a test of complementary and alternative medicine: observations from research experience of individualised homeopathic treatment.

The authors' experience of conducting clinical trials in homeopathy and analysing data from these has drawn attention to a fundamental problem with the interpretation of results from placebo controlled trials in homeopathy: It is not reasonable to assume that the specific effects of homeopathic medicine and the non-specific effects of consultations are independent of each other-specific effects of the medicine (as manifested by patients' reactions) may influence the nature of subsequent consultations and the non-specific effects of the consultation may enhance or diminish the effects of the medicine. For clinical trials of homeopathy to be accurate representations of practice, we need modified designs that take into account the complexity of the homeopathic intervention. Only with such trials will the results be generalisable to homeopathic practice in the real world. The authors propose that comparative trials are a meaningful way of evaluating the effectiveness of homeopathic treatment.

Adult↗