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PubMed1979

Improving exposure component and generalization potential of stress inoculation for pain.

Stress inoculation for pain involves education about the psychological dimensions of pain, training in a number of coping skills, and practice in applying these skills during exposure to the noxious stimulus. In a previous study the exposure component (which involved six practice sessions) proved ineffective; moreover the efficacy of the other components was not repeated on the generalization measures. The present study compared three variations in the exposure component and found that training with a single practice session on the cold pressor task proved more helpful than training with no practice at all, which in turn was no worse than training with six practice sessions. Moreover, therapeutic attention to generalization resulted in increased pain tolerance on the pressure algometer task.

Behavior Therapy↗

PubMed1994

Screening for alcohol use disorder in a general practice.

AIM: To report the results of screening for alcohol use disorder in 611 general practice patients aged 30-69 years over a three year period. METHOD: Patients attending a health screening appointment completed a self-administered questionnaire assessing alcohol consumption and concern about drinking, and liver function tests were arranged. Positive results were assessed and patients classified according to DSM IIIR criteria for alcohol use disorder into an alcohol abuse or dependence group. Those screening positive but not meeting criteria for alcohol use disorder were classified as at-risk drinkers. RESULTS: A positive alcohol screen was confirmed in 133 patients (22%), of whom 39 met the criteria for an alcohol use disorder, the remaining 94 classified at-risk. Weekly alcohol consumption above 20 drinks for men and 15 drinks for women identified 79% of those with an alcohol use disorder increasing to 83% by the addition of information about episodic heavy drinking. The inclusion of laboratory results improved the sensitivity of the overall alcohol screen to 93%, mostly by improving detection of alcohol abuse among men. The prevalence of alcohol use disorder among the 801 patients in this practice age group over three years was 13% for men and 2.5% for women. Half of these patients were identified only as a result of the screening programme. CONCLUSION: Screening for alcohol use disorder with items included in a health check proved very effective in this practice, identifying a significant number of previously undetected patients with alcohol abuse and dependence.

Adult↗

PubMed2002

Reasons for current practices in managing Barrett's esophagus.

We evaluated the reasons for current practices in managing Barrett's esophagus. Using a questionnaire, we assessed the practices and beliefs of 162 Californian gastroenterologists in managing Barrett's esophagus, using descriptive statistics as well as multivariate logistic regression. Out of the 103 respondents, 87% screened for Barrett's esophagus in patients with > 12 months of reflux symptoms, but only 72% believed that screening would improve survival, and 48% believed it to be cost-effective. In total, 98% surveyed patients with long-segment Barrett's esophagus at least biennially (76% thought this would improve survival and 49% believed it to be cost-effective) and 82% surveyed short-segment Barrett's esophagus at least biennially (57% thought this would improve survival and 30% believed it to be cost-effective). Finally, 44% surveyed microscopic intestinal metaplasia at least biennially (26% thought this would improve survival and 11% believed it to be cost-effective). In total, 18% performed endoscopic ablation, whereas 3% referred patients with low-grade dysplasia and 85% referred patients with high-grade dysplasia for esophagectomy. Finally, 81% treated asymptomatic Barrett's esophagus patients with proton pump inhibitors, but only 56% believed that this would reduce the risk of cancer. Logistic regression showed that the only independent factor predictive of surveillance practices was belief in efficacy. Practice patterns tend to be more aggressive than those recommended by recent guidelines and those reported by previous surveys. Medico-legal considerations affect practice substantially.

Attitude of Health Personnel↗

PubMed1998

Using videotaped benchmarks to improve the self-assessment ability of family practice residents.

PURPOSE: To address methodologic and statistical problems of previous studies of self-assessment by exposing participants to relevant standards, anchoring rating scales, and providing practice in the use of the assessment tool. METHOD: Fifty first- and second-year family practice residents performed a ten-minute patient interview with a difficult communication problem. Following each interview, the resident and two experts independently evaluated the resident's communication skills. The resident was then shown a videotape of four performances (ranging in quality from poor to good) of the same scenario. The resident evaluated the communication skills displayed in each performance and then reevaluated his or her own performance. RESULTS: The correlation between experts' evaluations and residents' self-evaluations was moderate immediately after the interview (r = 0.38) but increased significantly after the residents viewed the videotape (r = 0.52). This effect was more pronounced for first-year residents (0.22 to 0.45) than for second-year residents (0.53 to 0.65), although the difference was not significant. Post-hoc analysis revealed that neither initial nor post-benchmark self-assessment ability was related to the ability to accurately evaluate the benchmarks in a manner consistent with the experts. CONCLUSIONS: The ability to self-assess does not seem strongly tied to the ability to assess the performances of others on the same task. Nonetheless, providing a set of benchmarks against which trainees can compare their own performances improves their ability to self-evaluate even if the qualities of the benchmarks are not explicitly identified.

Adult↗

PubMed2000

Duties of a doctor: UK doctors and good medical practice.

OBJECTIVE: To assess the responses of UK doctors to the General Medical Council's (GMC) Good Medical Practice and the Duties of a Doctor, and to the GMC's performance procedures for which they provide the professional underpinning. DESIGN: Questionnaire study of a representative sample of UK doctors. SUBJECTS: 794 UK doctors, stratified by year of qualification, sex, place of qualification (UK v non-UK), and type of practice (hospital v general practice) of whom 591/759 (78%) replied to the questionnaire (35 undelivered). MAIN OUTCOME MEASURES: A specially written questionnaire asking about awareness of Good Medical Practice, agreement with Duties of a Doctor, amount heard about the performance procedures, changes in own practice, awareness of cases perhaps requiring performance procedures, and attitudes to the performance procedures. Background measures of stress (General Health Questionnaire, GHQ-12), burnout, responses to uncertainty, and social desirability. RESULTS: Most doctors were aware of Good Medical Practice, had heard the performance procedures being discussed or had received information about them, and agreed with the stated duties of a doctor, although some items to do with doctor-patient communication and attitudes were more controversial. Nearly half of the doctors had made or were contemplating some change in their practice because of the performance procedures; a third of doctors had come across a case in the previous two years in their own professional practice that they thought might merit the performance procedures. Attitudes towards the performance procedures were variable. On the positive side, 60% or more of doctors saw them as reassuring the general public, making it necessary for doctors to report deficient performance in their colleagues, did not think they would impair morale, were not principally window dressing, and were not only appropriate for problems of technical competence. On the negative side, 60% or more of doctors thought the performance procedures were not well understood by most doctors, were a reason for more defensive practice, and could not be used for problems of attitude. Few differences were found among older and younger doctors, hospital doctors, or general practitioners, or UK and non-UK graduates, although some differences were present. CONCLUSIONS: Most doctors working in the UK are aware of Good Medical Practice and the performance procedures, and are in broad sympathy with Duties of a Doctor. Many attitudes expressed by doctors are not positive, however, and provide areas where the GMC in particular may wish to encourage further discussion and awareness. The present results provide a good baseline for assessing changes as the performance procedures become active and cases come before the GMC over the next few years.

Attitude of Health Personnel↗

PubMed1996

The frequency and nature of skin conditions seen in a private dermatology practice in central Victoria, 1991-95.

A dermatology diagnostic database was established in order to determine the frequency and nature of skin conditions in a private dermatological practice in Central Victoria, Australia. Between August 1991 and June 1995, a total of 3346 dermatological diagnoses were recorded for 3000 new patient presentations. More women (58.9%) were seen than men (41.1%). Dermatitis and tumours of the skin accounted for 50% of new consultation(s), the highest attendance being for solar keratoses (11.9%). The frequency of patients seen was comparable to the previous 1970s survey of private dermatological practice in Australia, with the exception of melanocytic naevi, which was seen with twice the frequency compared to previously. The proportion of patients presenting with dermatitis was higher in the colder seasons of the year (winter and spring compared with summer and autumn). The proportion of people seen with melanocytic naevi was higher in summer and autumn compared with winter and spring. These results illustrate the usefulness of recording clinical patient data in practice as a way of recording patterns of referral as well as having a role in determining causation of disease.

Data Collection↗

PubMed2000

The early detection of glaucoma in general practice.

BACKGROUND: Glaucoma is one of the most common preventable causes of visual loss. Because it is an asymptomatic condition until late in the process only 50% of the population with glaucoma are aware they have it. Primary care physicians rarely test their patients for glaucoma, primarily because of the lack of specificity or sensitivity of any one particular test. OBJECTIVE: To determine if it was possible to identify patients with early signs of glaucoma from within my own practice, in patients who had not previously been tested for glaucoma or had not been tested for at least two years. DISCUSSION: This study has shown that glaucoma case-finding is feasible in general practice. Direct ophthalmoscopy proved to be the most valuable single test in diagnosing glaucoma and the combination of measurement of intraocular pressure and direct ophthalmoscopy was shown to be the most likely method of diagnosing glaucoma or identifying glaucoma suspects.

Aged↗

PubMed2006

Pneumatic dilatation and surgical myotomy for achalasia.

CONTEXT: Pneumatic dilatation and surgical (Heller) myotomy are the 2 principal methods for treatment of achalasia. There are no population-based studies comparing outcomes of these 2 treatments in typical practice settings. OBJECTIVE: To compare the outcomes of pneumatic dilatation and surgical myotomy for achalasia. DESIGN, SETTING, AND PARTICIPANTS: Retrospective longitudinal study using linked administrative health data in Ontario. A total of 1461 persons aged 18 years or older received treatment for achalasia between July 1991 and December 2002, 1181 (80.8%) of whom had pneumatic dilatation and 280 (19.2%) of whom had surgical myotomy as the first procedure. MAIN OUTCOME MEASURES: Use of subsequent interventions for achalasia (pneumatic dilatation, surgical myotomy, or esophagectomy) following the first treatment during the study period, subsequent physician visits, and use of gastrointestinal medications among persons aged 65 years or older. We adjusted for confounding variables using regression models. RESULTS: The cumulative risk of any subsequent intervention for achalasia after 1, 5, and 10 years, respectively, was 36.8%, 56.2%, and 63.5% for persons treated initially with pneumatic dilatation and was 16.4%, 30.3%, and 37.5% for persons treated initially with surgical myotomy (adjusted hazard ratio [HR], 2.37; 95% confidence interval [CI], 1.86-3.02; P<.001). Differences in risk were observed only when subsequent pneumatic dilatation was included as an adverse outcome; there was no statistical difference between the 2 groups with respect to the risk of subsequent surgical myotomy or esophagectomy. Compared with persons treated initially with surgical myotomy, those treated with pneumatic dilatation were not statistically different with respect to subsequent physician visits (adjusted rate ratio, 1.01; 95% CI, 1.00-1.03), or time to use of histamine-2 receptor blockers (adjusted HR, 1.19; 95% CI, 0.79-1.80), proton pump inhibitors (HR, 1.02; 95% CI, 0.70-1.49), and prokinetic medications (HR, 0.92; 95% CI, 0.60-1.41). CONCLUSIONS: Subsequent intervention after the initial treatment of achalasia is common. Although the risk of subsequent interventions among persons treated with surgical myotomy in typical practice settings is higher than previously thought, the risk of subsequent intervention is greater among persons treated with pneumatic dilatation than with surgical myotomy. This difference is attributable to the use of subsequent pneumatic dilatation rather than surgical procedures.

Adult↗

PubMed1975

Current status of estrogen receptors in human breast cancer.

In estrogen target tissues and hormone-dependent tumors, the steroid enters the cells and binds to a cytoplasmic protein called the estrogen receptor (ER). The steroid-receptor complex then migrates to the nuclei, where it initiates the biochemicial events characteristic of estrogen stimulation. Since ER is absent in tissues not responsive to estrogen, recent studies have asked whether ER assays in human breast cancer tissue might be used to identify those patients likely to respond to endocrine therapy. Data on 436 clinical trials contributed from a dozen centers around the world now clearly indicate that if a patient's tumor does not contain ER, there is virtually no chance of tumor regression following endocrine therapy. A large number of patients can be thus spared unrewarding major endocrine ablative therapy if ER assays are performed routinely. Of tumors with positiev ER, 55-60% respond to endocrine therapy. This single piece of data, when coupled with available clinical prognostic factors such as menopausal status, disease free interval, site of the dominant lesion, and especially response to previous hormonal therapies, should be practicing oncologist to select or reject endocrine therapy with considerable confidence.

Adrenalectomy↗

PubMed2005

Physician exposure to and attitudes toward advertisements for genetic tests for inherited cancer susceptibility.

Commercial marketing materials may serve as a source of information for physicians about genetic testing for inherited cancer susceptibility (GTICS) in addition to medical guidelines, continuing education, and journal articles. The primary purposes of this study were to: (1) determine the percentage of physicians who received advertisements for GTICS early in the diffusion of commercial GTICS (1999-2000); (2) assess associated characteristics; and (3) measure the perceived importance of commercial advertisements and promotions in physicians' decisions to recommend testing to patients. A nationally representative, stratified random sample of 1,251 physicians from the American Medical Association (AMA) Physician Masterfile completed a 15-20 min mixed mode questionnaire that assessed specialty, previous use of genetic tests, practice characteristics, age, and receipt of advertising materials (response rate = 71%). Overall, 27.4% (n = 426) had received advertisements. In multivariate analysis, factors associated with receipt of advertisements included: specialties in obstetrics/gynecology, oncology, or gastroenterology; past GTICS use, and age 50+. One of four felt that advertisements would be important in their decision to recommend GTICS. Study results indicate that physicians, particularly in oncology, obstetrics/gynecology, and gastroenterology, began receiving GTICS advertisements commensurate with the early diffusion of commercially available tests into clinical practice. At that time, one-quarter of the physicians considered advertisements to play an important role in their clinical decision making, suggesting attention to other sources of information and additional factors.

Advertising↗

PubMed1988

Migration models of prehistoric postmarital residence.

It has previously been suggested that residential practices can be inferred from within- or between-group analysis of male and female skeletal morphology. Arguments have proceeded from intuitively derived hypotheses about the genetic consequences of drift and migration. In this paper, a formal basis is presented for these hypotheses using modified versions of Wright's island model and the migration matrix method. It is shown that the usual measures of standardized genetic variance or genetic kinship can be decomposed into male, female, and male/female components. The male and female components can in turn be used separately to assess the effect of different residential practices on the population genetic structure of the two sexes. Following upon these models, nonmetric cranial trait data from prehistoric sites in west-central Illinois are used to delineate the probable residential practices for this region.

Female↗

PubMed2004

Fetal brain activity and hemodynamic response to a vibroacoustic stimulus.

Previous studies have demonstrated the practicality of using functional magnetic resonance imaging (fMRI) techniques to assess fetal brain activity. The purpose of this study was to compare the fetal hemodynamic response to that of the adult. Seventeen pregnant subjects, all of whom were at more than 36 weeks gestation were scanned while the fetus was exposed to a vibroacoustic stimulus. Thirteen adult subjects were scanned with an equivalent acoustic stimulus. Of the fetal subjects, two could not be analyzed due to technical problems, eight did not show significant activation, and seven showed significant activation. In all cases, activation was localized within the temporal region. Measures of fetal hemodynamic responses revealed an average time to peak (ttp) of 7.36 +/- 0.94 sec and an average percentage change of 2.67 +/- 0.93%. In contrast, activation was detected in 5 of 13 adults with an average ttp of 6.54 +/- 0.54 sec and an average percentage change of 1.02 +/- 0.40%. The measurement of changes in the fetal hemodynamic response may be important in assessing compromised pregnancies.

Acoustic Stimulation↗

PubMed1979

Psychological development of the child with leukemia: a review.

With improvements in prognosis for children with leukemia, there has been a corresponding increase in degree of adverse psychological effects on the patient and his family. This review considers (1) the methods of coping adopted by parents, siblings, and the patient and (2) the possibility of damage to normal intellectual growth following the type of medical treatment involved. Implications of previous research in terms of practical help for the families and theoretical issues regarding normal brain development are discussed.

Adaptation, Psychological↗

PubMed1997

Chemotherapeutic treatments: a study of the interplay among drug resistance, toxicity and recuperation from side effects.

A system of differential equations for the control of tumor growth cells in a cycle nonspecific chemotherapy is analyzed. Spontaneously acquired drug resistance is taken into account, and a criterion for the selection of chemotherapeutic treatment is used. This criterion purports to describe the possibility of improvement of the patient's health when treatment is discontinued. Contrary to our early results which also take drug resistance into account, in this context strategies of continuous chemotherapy in which rest periods take part may be better than maximum drug concentration throughout the treatment (which appears to be in accordance with clinical practice). This bears out our previous conjecture that when drug resistance is accounted for, the imperfections in the usual modelling of treatment criteria, which in general do not allow for patient recuperation, ruled out the possibility of rest periods in optimal continuous chemotherapy.

Antineoplastic Agents↗

PubMed2002

Treatment of complete rupture of the lateral ligaments of the ankle: a randomized clinical trial comparing cast immobilization with functional treatment.

This study compared the therapeutic efficacy between cast immobilization and functional treatment of grade III ruptures of the lateral ankle ligaments. Subjects ( n=121) had closed physeal cartilage, age under 35 years, grade III rupture without previous or associated injuries, and practiced regular sports. Patients were randomized into an immobilization group (21 days plaster cast) or a functional one (15 days strapping plus early controlled mobilization). Symptoms (pain, swelling, stiffness, subjective instability), joint laxity, return to preinjury activity (time and level) and rate of reinjury were assessed 3, 6, and 12 months after sprain. Objective joint laxity was related to constitutional laxity, creating a new variable [talar tilt at injury - talar tilt at control]/contralateral talar tilt. The functional group showed significantly earlier and better return to physical activity, fewer symptoms at 3 and 6 months but no intergroup difference at 12 months. Functional treatment also showed better decrease in joint laxity. No intergroup differences were found in the reinjury rate. We conclude that functional treatment is safe, associated with a more rapid recovery, and particularly suitable in athletic populations.

Adolescent↗

PubMed1999

The diagnostic value of colour duplex ultrasound for symptomatic carotid stenosis in clinical practice.

We assessed the accuracy of colour duplex ultrasound for the detection of severe (70-99%) symptomatic carotid stenosis in a clinical setting, in order to assess whether it could make carotid angiography unnecessary. In 152 patients with a transient ischaemic attack or nondisabling ischaemic stroke in the carotid distribution, we compared the degree of colour duplex ultrasound stenosis with angiographic stenosis by receiver-operating-characteristic analysis. The angiograms were evaluated by blinded observers, and compared with routine reports of the colour duplex examination. We computed the sensitivity and specificity of colour duplex, and the number of angiograms and sonographic studies needed to prevent one stroke within 3 years, taking into account the risks of angiography, and the risks and efficacy of endarterectomy. The estimates were adjusted for nonverification bias. We found 34 patients (22%) with a severe (70-99%) symptomatic carotid stenosis. In 16 patients (11%) the symptomatic artery was occluded. The sensitivity and specificity of duplex ultrasound were 76% and 85%, respectively. The number of patients needed to undergo angiography to prevent one stroke was reduced from almost 200 to 33, when colour duplex was used as a preoperative examination. After adjustment for the effects of nonverification, the sensitivity dropped to 58% and the number of duplex studies needed to prevent one stroke would double. The number of angiograms needed after positive duplex sonography would be virtually unaffected. Were colour duplex sonography to have been the sole preoperative investigation, the number needed to diagnose to prevent one stroke within 3 years would be approximately 350, more than twice as many as with the combined diagnostic strategy. The diagnostic accuracy of colour duplex sonography in clinical practice seems less impressive than previous studies have suggested, but it remains an effective way to select patients for angiography. Its use as a single preoperative assessment cannot be recommended.

Adult↗

PubMed1996

[Differentiation of pain-related and morphine related impairment of cognitive performance and mood in bone marrow transplantation patients].

AIMS: Severe pain of mucositis induced by cytostatic conditioning therapy in bone marrow transplantation (BMT) patients generally requires continuous parenteral opioid treatment. Cognitive and psychological disturbances are frequent complications subsequent to BMT and may result from cerebral opioid side effects. The aim of the study was to evaluate the efficiency of continuous morphine in mucositis pain and the side-effects in BMT patients. Particular emphasis was placed on the question of whether reaction times, which are usually measured to estimate opioid effects upon vigilance, are influenced by pain-induced cognitive impairments in pain patients. METHODS: While in hospital, 10 BMT patients were examined daily with the aid of a mucositis scale, subjective visual analog scales (VAS) for pain and mood parameters, a German version of the McGill pain questionnaire (MPQ), and a mental performance task battery, and the morphine given was documented. Mental performance tests were simple auditory reaction time and choice reaction time. Seven patients also performed a Sternberg memory search test in which they had to use 'yes' and 'no' response keys to match visually presented test letters to a previously memorized set of letters. Practice and baseline data were collected within the first week before BMT. RESULTS: The intensity and duration of mucositis differed from patient to patient, resulting in different pain intensities and MPQ scores. Prolongation of the choice reaction time averaged over the period of mucositis treatment correlated significantly with residual pain intensity (Spearman r(s) = 0.88, p < 0.01) but not with morphine dose (r(s) = 0.35, p = 0.33). For the Sternberg memory search test greater correlation coefficients resulted between reaction time and morphine dose (r(s) = 0.86, p = 0.014) than between reaction time and residual pain intensity (r(s) = 0.61, p = 0.15). In turn, pain intensity, unlike morphine dose, was significantly correlated with high scores in the mood parameters for depression, passivity, and tiredness. CONCLUSIONS: It is concluded that both pain and morphine can impair cognitive performance, but that these mental stressors seem to differ according to qualitative criteria. Whereas pain might slow reaction time by distracting a patient's attention, particularly in low mental demand tasks, morphine could interfere with more specific cognitive processes, such as short-term memory operations, that are required in more complex tasks.

English Abstract↗

PubMed2006

River habitat monitoring and assessment in Germany.

Whereas assessing the biological and chemical quality of water is a standard environmental procedure in many countries, the use of habitat survey methods that assess the ecomorphological quality of rivers is relatively new. In Europe, the EC Water Framework Directive requires such assessment from all EU Member States. In Germany, the first river habitat assessments were introduced in the late 1990 s. Each federal state develops its own river habitat map using the 'On-site Survey' and/or the 'Overview Survey'. The assessment describes the difference of the actual condition from a previously defined reference condition. In practice, a defined 'potential for restoration', a more realistic condition, makes restoration activities much easier and more successful. In Germany, the first River Habitat Map 2001 was published in 2002. The survey covered 33,000 km of river length, which equates to 10% of all rivers. A wide range from 'Undisturbed' (class 1) to 'Totally Disturbed' (class 7) river units exists; 77% of them are 'Clearly Disturbed' (class 4) or in worse condition. These result reflects extensive anthropogenic impact on the environment in general, but also past intense technical river 'improvements' that focused on the protection of settlements and traffic routes from flooding, better shipping conditions, the use of water power, and drainage of floodplains for agriculture and urban development. For comparability of survey results between EU Member States, a harmonization of national survey methods is in progress. A crucial point here is the definition of the reference condition for each river (near-natural conditions), since it influences the survey results.

Ecosystem↗