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PubMed2006

Cluster randomized trial of a multifaceted primary care decision-support intervention for inherited breast cancer risk.

BACKGROUND: GPs are increasingly expected to meet the needs of patients concerned about their risk of inherited breast cancer, but may lack skills or confidence to use complex management guidelines. We developed an evidence-based, multifaceted intervention intended to promote confidence and skills in this area. OBJECTIVE: To evaluate the effectiveness of the intervention in improving GP confidence in managing patients concerned about genetic risk of breast cancer. METHODS DESIGN: Cluster randomized controlled trial. SETTING: General practices in the Grampian region of Scotland. SUBJECTS: GPs and the patients they referred for genetic counselling for risk of breast cancer. MAIN OUTCOME MEASURES: GPs' self-reported confidence in four activities related to genetics; rates of referral of patients at elevated genetic risk; and referred patients' understanding of cancer risk factors. RESULTS: No statistically significant differences were observed between intervention and control arms in the primary or secondary outcomes. A possible effect of the intervention on the proportion of referred patients who were at elevated risk could not be discounted. Only a small proportion of intervention GPs attended the educational session, were aware or the software, or made use of it in practice. CONCLUSIONS: No convincing evidence of the effectiveness of the intervention was found, probably reflecting barriers to its use in routine practice.

Breast Neoplasms↗

PubMed2005

Impact of educational intervention on confidence and competence in the performance of a simple surgical task.

BACKGROUND: Many complex new procedures involve a learning curve, and patients treated by individuals who are new to a procedure may have more complications than those treated by a practitioner who has performed the intervention more frequently. Still, at some point on the learning curve, each individual must decide that he or she is qualified to perform a procedure, presumably on the basis of his or her level of confidence, background, education, and skill. To evaluate the interrelationship of these factors, we designed a study in which we assessed the performance of a simulated knee joint injection. METHODS: Ninety-three practitioners attending a continuing medical education session on knee injection were randomized to receive skills instruction through the use of a printed manual, a video, or hands-on instruction; each performed one injection before and after instruction. The participants completed pre-instruction and post-instruction questionnaires gauging confidence and also provided self-assessments of their performances of injections before and after instruction. Self-assessments were compared with objective performance standards measured by custom-designed knee models with electronic sensors that detected correct needle placement. RESULTS: Before instruction, the participants' confidence was significantly but inversely related to competent performance (r = -0.253, p = 0.02); that is, greater confidence correlated with poorer performance. Both men and physician-practitioners displayed higher pre-instruction confidence (p < 0.01), which was not correlated with better performance. After instruction, performance improved significantly in all three training groups (p < 0.001), with no significant differences in efficacy detected among the three groups (p = 0.99). After instruction, confidence correlated with objective competence in all groups (r = 0.24, p = 0.04); however, this correlation was weaker than the correlation between the participants' confidence and their self-assessment of performance (r = 0.72, p = 0.001). CONCLUSIONS: Even low-intensity forms of instruction improve individuals' confidence, competence, and self-assessment of their skill in performing the fairly straightforward psychomotor task of simulated knee injection. However, men and physicians disproportionately overestimated their skills both before and after training, a finding that worsened as confidence increased. The inverse relationship between confidence and competence that we observed before the educational intervention as well as the demographic differences that we noted should raise questions about how complex new procedures should be introduced and when self-trained practitioners should begin to perform them.

Clinical Competence↗

PubMed1998

Efficacy of a dry fibrin sealant dressing for hemorrhage control after ballistic injury.

OBJECTIVE: To determine if a dry fibrin sealant dressing (DFSD) will provide superior hemostasis when compared with regular gauze in a ballistic injury animal model. DESIGN: A nonsurvival randomized goat study. SETTING: A federal biomedical research institute. SUBJECTS: Eighteen anesthetized Angora goats. INTERVENTIONS: Uncontrolled hemorrhage was induced by a complex ballistic extremity injury. Control of hemorrhage was achieved by applying and holding pressure with the DFSD or regular gauze for 2 minutes. The dressings were left in place for 1 hour. MAIN OUTCOME MEASURES: Total blood loss, mean arterial pressure, ballistic injury, and mortality were recorded after 1 hour. RESULTS: The injuries were equivalent for the 2 groups. No animal mortality was seen. After 1 hour, the mean (+/-SEM) blood loss was 124+/-64 mL in the DFSD-treated group and 377+/-64 mL in the gauze dressings-treated group (P=.01). Twenty minutes after injury, the mean arterial pressure was 95.0 mm Hg (+/-SEM, +/-4.7 mm Hg) in the DFSD-treated group and 70.0+/-5.0 mm Hg in the gauze dressings-treated group. The difference persisted for the remainder of the study (P=.01). CONCLUSION: The DFSD was superior to gauze in decreasing blood loss and maintaining blood pressure while retaining the simplicity of standard dressing application.

Animals↗

PubMed2003

Subpopulations of proliferating cells of the adult hippocampus respond differently to physiologic neurogenic stimuli.

To study how adult hippocampal neurogenesis might originate from the proliferation of stem or progenitor cells in vivo, we have used transgenic mice expressing green fluorescent protein (GFP) under the nestin promoter to identify these cells. Having described an astrocyte-like type 1 cell with low proliferative activity, a characteristic morphology, vascular end feet, and passive electrophysiological properties, we focused here on the large population of nestin-GFP-expressing type 2 cells, which lack all these features. Type 2 cells were highly proliferative and showed signs suggestive of their involvement in the neuronal lineage. They could be subclassified by the absence (type 2a) or presence (type 2b) of a coexpression of the early neuronal marker doublecortin. A third type of proliferating cells was doublecortin positive but nestin-GFP negative (type 3). We believe that type 2a, 2b, and 3 cells mirror a marker progression during earliest neuronal development. This view is supported by the increasing coexpression of the early granule cell-specific marker Prox-1. The low proliferative activity of type 1 cells showed little change over time or under "neurogenic interventions," such as a challenge by environmental complexity (ENR) or voluntary physical activity (RUN). However, RUN led to a significant increase of type 2 cells labeled with the proliferation marker bromodeoxyuridine (BrdU). ENR did not cause increased cell proliferation or an increased number of BrdU-labeled type 2 cells, but both ENR and RUN resulted in more newly generated cells lacking nestin-GFP immunoreactivity and expressing Prox-1. These findings allow us to break down what was broadly perceived as "proliferation" in earlier experiments into the relative contribution of several cell types, representing the earliest steps of neuronal development.

Animals↗

PubMed2007

Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review.

BACKGROUND: Wandering occurs in 15-60% of people with dementia. Psychosocial interventions rather than pharmacological methods are recommended, but evidence for their effectiveness is limited and there are ethical concerns associated with some non-pharmacological approaches, such as electronic tracking devices. OBJECTIVE: To determine the clinical and cost effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia. DESIGN: A systematic review to evaluate effectiveness of the interventions and to assess acceptability and ethical issues associated with their use. The search and review strategy, data extraction and analysis followed recommended guidance. Papers of relevance to effectiveness, acceptability and ethical issues were sought. RESULTS: (i) Clinical effectiveness. Eleven studies, including eight randomised controlled trials, of a variety of interventions, met the inclusion criteria. There was no robust evidence to recommend any intervention, although there was some weak evidence for exercise. No relevant studies to determine cost effectiveness met the inclusion criteria. (ii) Acceptability/ethical issues. None of the acceptability papers reported directly the views of people with dementia. Exercise and music therapy were the most acceptable interventions and raised no ethical concerns. Tracking and tagging devices were acceptable to carers but generated considerable ethical debate. Physical restraints were considered unacceptable. CONCLUSIONS: In order to reduce unsafe wandering high quality research is needed to determine the effectiveness of non-pharmacological interventions that are practically and ethically acceptable to users. It is important to establish the views of people with dementia on the acceptability of such interventions prior to evaluating their effectiveness through complex randomised controlled trials.

Aged↗

PubMed2000

Provider issues in HIV care.

This chapter examines the impact of HIV infection and its associated biopsychosocial complications on provider-patient relationships and addresses the implications for health care teams and organizations. Several interventions are suggested that can relieve the complex stresses that health care providers are currently experiencing as they care for HIV and AIDS patients.

Acquired Immunodeficiency Syndrome↗

PubMed1991

Let's hang up and try again: lessons learned from a social support intervention.

A support intervention by Heller et al. (1991) sought to improve the well-being of elderly women by providing friendly telephone contact with staff or peers. The failure of this thoughtful and carefully implemented intervention serves to highlight the difficulty of designing support interventions. Several lessons are discussed regarding the complexity of the support process, the utility of different research strategies, the importance of specifying the targeted focal point in the support process, the need to state models explicitly, the choice of measures, and the implications of select participant samples.

Aged↗

PubMedDate not supplied

Duodenal atresia and stenosis: reassessment of treatment and outcome based on antenatal diagnosis, pathologic variance, and long-term follow-up.

Duodenal atresia and stenosis was observed in 103 infants and children from 1972 to 1991. There were 59 girls and 44 boys. Atresia was noted in 79 instances and stenosis in 24. Maternal hydramnios was detected in 33 cases, 46 babies were premature, and 31 had Down's syndrome. Fifty-four infants had significant associated anomalies including 35 with cardiac defects. Diagnosis was achieved by prenatal ultrasound examination in 14 cases, observation of a double-bubble sign on abdominal radiograph in 73, and contrast studies in 30 infants including 24 with stenosis. At operation annular pancreas was noted in 37 cases, malrotation in 37 cases, anterior portal vein in 4, and a second web in 3. Surgical treatment included duodenoduodenostomy in 85, duodenotomy and web excision in 8, and duodenojejunostomy in 10. Operative survival was 95%. Deaths were related to complex cardiac defects. Despite antenatal diagnosis, prompt intervention, and apparent early surgical success (95% survival), late deaths (5%) and late complications including motility disorders, megaduodenum, gastroesophageal reflux, duodenal-gastric reflux, gastritis, peptic ulcer disease, blind loop syndrome, and biliary-pancreatic conditions may be observed months to years after management during the neonatal period. Modifications in surgical technique including early tapering duodenoplasty may be useful, and close long-term follow-up is an essential component of patient care.

Anastomosis, Surgical↗

PubMed1996

An algorithm for the management of urinary stress incontinence.

An algorithm for the management of urinary incontinence in the female is presented. The performance of history, physical examination, and simple office bladder testing are reviewed. Patients are categorized into a complex group which require multi-channel urodynamic testing or a non-complex group which may proceed to surgical intervention without such testing. Indications for collagen injection and pubo-vaginal sling procedure are discussed.

Algorithms↗

PubMed1997

[The perioperative phase as a part of anesthesia. Tasks of the recovery room].

Historically, recovery rooms were established in order to reduce complications in the period immediately following surgery and anaesthesia, utilising staffing and equipment resources economically. To minimise the incidence of postoperative complications remains the main task of post anaesthesia care units (PACU). However, especially in hospitals with a high degree of surgical emergencies, the scope of tasks and procedures within the PACU has expanded. Facing restricted capacities in intensive therapy (ITU) and high dependency units (HDU) the PACU serves as a buffer; intensive care functions can be covered here until the patient can be admitted to an intensive care unit. In this context, the PACU also has a switch function; postoperatively, the patient is evaluated here and the level for further treatment determined: ITU, HDU, or normal ward. The PACU period can be utilised to improve the patient's condition (upgrade function) enabling continuation of treatment on a lower level (HDU instead of ITU, normal ward instead of HDU). This combination of buffer, switch and upgrade function is of special importance when ITU and HDU resources are limited. A new task for the PACU arises from efforts to optimise acute pain therapy; initial adjustment of continuous infusion systems according to the patients' needs can be performed here without additional staffing requirements. Finally, the PACU can be used preoperatively for "tune up" procedures in high risk patients. The basis for co-operation between anaesthetist and surgeon is the separation of responsibilities in combination with mutual trust. Accordingly, the anaesthetist is responsible for monitoring and maintenance of vital functions. Consequently, the anesthetist has a professional and organisational responsibility in the PACU. The surgeon can and must rely on notification whenever surgical complications may require his intervention. With increasing comorbidity of patients and complexity of surgical procedures the anaesthetist's responsibility in the immediate perioperative period gains a new quality. The number of surgical procedures requiring intraoperative intensive therapy from the anaesthetist is increasing; the delivery of anaesthesia becomes a background task during these operations. Thus, the anaesthetist becomes responsible for perioperative patient treatment in the operating room area which divides into three phases: preoperative "tune up" in the PACU (e.g.) haemodynamic optimisation, starting continuous regional anaesthesia techniques), anaesthesia and support of vital functions in the OR, and immediately postoperative treatment in the PACU.

Anesthesia↗

PubMed1998

Practical approach to quality of life in Parkinson's disease: the nurse's role.

In recent years it has become apparent that nurses have several key roles in the treatment of Parkinson's disease. These include the practice of skilled clinical care, the provision of advice and education, communicating with patients and carers, and also between health and social care agencies. Their goals are to facilitate good clinical care, to reduce morbidity (both physical and psychological) and to achieve better informed patients by the reduction of misinformation, fear and distress caused by the diagnosis and consequences of this disease. The overall goal is to improve the prognosis and to reduce the impact of this disease on patients and their care givers. To achieve these goals the specialist nurse needs skills in assessment, reassessment and counselling in addition to knowledge of the disease and its management. The training needs have been established for the nursing profession to address these issues, and courses have been established and approved. A scale comprising four clinical management stages has been proposed: initially around the time of diagnosis; stable maintenance therapy; a more complex management stage, and palliative care. Nursing interventions and priorities differ in these arbitrary stages. Several models of nursing provision have been piloted in the United Kingdom, and results of evaluations are keenly awaited. Meanwhile, specialist nurses are proving to be popular with patients and carers, medical specialists, and the Parkinson's Disease Society which aims to see their provision in each Health District throughout the United Kingdom. In summary, the nursing role is complementary to those of the other members of the multi-disciplinary health team that aims to improve the quality of life of PD patients and their carers.

Disease Management↗

PubMed2001

Dural Fistulas.

The treatment of dural fistulas is varied and complex. Treatment decisions require consideration of the nature of the symptoms, the location of the lesion, the complexity of the angioarchitecture, and the risk of progression. Standard treatment modalities include compression therapy, endovascular embolization, neurosurgery, and radiosurgery. Complex lesions will often require multiple different interventions. Because dural fistulas may present with a variety of neurologic and ophthalmologic problems, a team of neurologists, neuro-ophthalmologists, neuroradiologists, and neurosurgeons should develop a comprehensive treatment plan.

Journal Article↗

PubMed2006

Provisional glycoprotein IIb/IIIa blockade in a randomized investigation of bivalirudin versus heparin plus planned glycoprotein IIb/IIIa inhibition during percutaneous coronary intervention: predictors and outcome in the Randomized Evaluation in Percutaneous coronary intervention Linking Angiomax to Reduced Clinical Events (REPLACE)-2 trial.

BACKGROUND: The REPLACE-2 trial demonstrated the noninferiority of bivalirudin with provisional glycoprotein IIb/IIIa (GPIIb/IIIa) blockade as compared with heparin plus planned GPIIb/IIIa blockade among patients undergoing percutaneous coronary revascularization. Provisional drug was used in 374 (6%) of the 6010 patients. We sought to analyze the predictors for provisional drug use and to assess the outcomes in this cohort. METHODS: Outcome among the 5.2% of patients in the heparin plus GPIIb/IIIa blockade group and the 7.2% of patients in the bivalirudin group who received provisional placebo or GPIIb/IIIa inhibitor, respectively, was compared against patients without provisional drug use and between randomized arms. Multivariate models identified predictors of provisional drug use and outcome at 30 days, 6 months, and 1 year. RESULTS: Myocardial infarction, repeat revascularization, and bleeding events occurred more frequently among patients who required provisional drug than those who did not, but there were no differences in 1-year mortality. Ischemic and hemorrhagic end points occurred at similar rates among patients receiving provisional drug in either the heparin plus GPIIb/IIIa group compared with the bivalirudin group. Independent predictors of provisional drug use were randomization to bivalirudin, recent infarction, multilesion intervention, impaired pretreatment coronary flow, and lesion complexity. Provisional drug use, but not randomization to bivalirudin, independently predicted 30-day and 6-month ischemic events. CONCLUSIONS: Provisional administration of a GPIIb/IIIa inhibitor is associated with more frequent ischemic and bleeding events, reflecting the procedural complications that led to the use of provisional drug. The proportion of bivalirudin-treated patients who will require provisional GPIIb/IIIa blockade, however, is not large enough to have a significant deleterious impact on the overall incidence of ischemic end points or to invalidate the strategy of bivalirudin plus provisional GPIIb/IIIa blockade.

Aged↗

PubMed2006

Rapid detection of Norovirus based on an automated extraction protocol and a real-time multiplexed single-step RT-PCR.

BACKGROUND: Molecular diagnosis of Norovirus infection can be a complex multistep process, which requires significant user intervention and expertise, and is not amenable to automation without extensive validation and optimization. OBJECTIVES: To develop a real-time multiplexed RT-PCR assay with automated sample preparation that requires only a single-step and a single-tube for reverse transcription, amplification, and detection while exceeding the sensitivity of conventional PCR for broad-spectrum Norovirus detection. STUDY DESIGN: Limit of detection was assessed against dilutions of clinical specimens. Fifty archived extractions were used to compare TaqMan sensitivity with either a separate RT using random primers or a single-step RT-PCR. The sensitivity of the novel assay was compared with conventional RT-PCR using 100 specimens from gastroenteritis cases. RESULTS: Automated extraction reduced RNA recovery by 0.5 logs compared to manual extraction but was more effective at removing PCR inhibitors from stool specimens. The optimized single-step real-time RT-PCR demonstrated no reduction in sensitivity. Together, the sensitivity of the novel assay was 19% higher than manual extraction with conventional RT-PCR. CONCLUSIONS: A semi-automated and simplified molecular diagnostic protocol for the rapid detection of Norovirus has been achieved. PCR inhibitors are present in human fecal specimens and cause a significant problem for Norovirus detection by RT-PCR.

Caliciviridae Infections↗

PubMed2006

The corticostriatal pathway in Huntington's disease.

The corticostriatal pathway provides most of the excitatory glutamatergic input into the striatum and it plays an important role in the development of the phenotype of Huntington's disease (HD). This review summarizes results obtained from genetic HD mouse models concerning various alterations in this pathway. Evidence indicates that dysfunctions of striatal circuits and cortical neurons that make up the corticostriatal pathway occur during the development of the HD phenotype, well before there is significant neuronal cell loss. Morphological changes in the striatum are probably primed initially by alterations in the intrinsic functional properties of striatal medium-sized spiny neurons. Some of these alterations, including increased sensitivity of N-methyl-D-aspartate receptors in subpopulations of neurons, might be constitutively present but ultimately require abnormalities in the corticostriatal inputs for the phenotype to be expressed. Dysfunctions of the corticostriatal pathway are complex and there are multiple changes as demonstrated by significant age-related transient and more chronic interactions with the disease state. There also is growing evidence for changes in cortical microcircuits that interact to induce dysfunctions of the corticostriatal pathway. The conclusions of this review emphasize, first, the general role of neuronal circuits in the expression of the HD phenotype and, second, that both cortical and striatal circuits must be included in attempts to establish a framework for more rational therapeutic strategies in HD. Finally, as changes in cortical and striatal circuitry are complex and in some cases biphasic, therapeutic interventions should be regionally specific and take into account the temporal progression of the phenotype.

Animals↗

PubMed2006

Indications for tracheostomy in children.

Vaccination programs, improvements in material engineering and anaesthetic skills have dramatically reduced the number of emergency tracheostomies performed for acute upper airway obstruction. Today, the indication to tracheotomise a child is generally ruled by the anticipation of long-term (cardio)respiratory compromise due to chronic ventilatory or, more rarely, cardiac insufficiency, or by the presence of a fixed upper airway obstruction that is unlikely to resolve for a significant period of time. As many of the younger candidates for tracheostomy have complex medical conditions, the indication for this intervention is often complicated by ethical, funding and socio-economic concerns that necessitate a multidisciplinary approach. Unfortunately, these considerations are frequently not made until the first catastrophe has occurred, even in those patients in whom imminent cardiorespiratory failure has been foreseeable. Non-invasive ventilation via a face mask and newer developments such as the in-exsufflator device have gained importance as an alternative to tracheostomy in selected patients.

Airway Obstruction↗

PubMed1999

Effect of institutional volume and academic status on outcomes of coronary interventions: the IMPACT-II experience.

BACKGROUND: Rates of morbidity and mortality after interventional procedures are reported to be inversely associated with institutional volume. METHODS: This study assessed both procedural volume and academic status at the 82 US centers that participated in the IMPACT-II trial. Interventional volumes at the sites ranged from 90 to 3300 cases per year. Patients were randomly assigned to a platelet glycoprotein IIb/IIIa inhibitor (eptifibatide) or placebo during procedures done by experienced operators. The primary end point was the composite of death, myocardial infarction, nonelective repeat coronary intervention, or nonelective coronary artery bypass surgery at 30 days, or placement of an intracoronary stent for abrupt closure during the initial procedure. RESULTS: Baseline patient characteristics and median length of stay were similar between the academic and nonacademic centers. In univariable analysis, volume as a continuous variable had a nonlinear relation with the incidence of the composite end point, with better outcomes noted at the highest volume institutions. Academic status did not predict outcome. When added to a predictive model that contained the variables unstable angina, weight, prior coronary artery bypass grafting, heart rate, and platelet count, procedural volume continued to be associated with the composite outcome (P =.04). CONCLUSIONS: We conclude that among hospitals participating in this trial, there is a nonlinear relation between annual interventional volume and outcomes. This relation is complex, involving variations in periprocedural infarction rates and additional, undefined institutional differences (other than academic status) that result in differences in procedural outcome.

Academic Medical Centers↗

PubMedDate not supplied

Coping styles and psychosocial-related variables in HIV-infected patients.

The study examined the relationship between coping and psychosocial variables (psychological stress symptoms, locus of control, emotional repression, and social support) among 108 human immunodeficiency virus (HIV)-infected patients. The authors administered several tests, including one that measures fighting spirit and degree of hopelessness, to assess each patient's individual coping style. The patients who were adjusting well to their HIV-positive status tended to have a higher level of fighting spirit and lower degree of hopelessness than those patients who were not adjusting well to their HIV-positive status. A coping style based on incapacity to face and confront HIV infection was associated with symptoms of psychological stress, repression of anger, external locus of control, and low social support in the latter group. These patients showed symptoms indicating maladjustment to HIV infection (43% of the sample) and differed from the "noncases" (the well-adjusted patients) in that the former group reported inadequate coping responses (lower fighting spirit and higher hopelessness, fatalistic attitude, and anxious preoccupation) and poorer social support, and had a greater tendency to repress anger and express sadness. The data support the hypothesis that coping with HIV infection is a complex phenomenon involving multiple and interacting variables. Interventions aimed at improving the coping style for many HIV patients are needed.

Adaptation, Psychological↗