Routine Care (routine + care)

Distribution by Scientific Domains
Distribution within Medical Sciences

Selected Abstracts

Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis

ADDICTION, Issue 1 2009
Jannette M. Parr
ABSTRACT Aims To assess the effectiveness of current treatment approaches to assist benzodiazepine discontinuation. Methods A systematic review of approaches to benzodiazepine discontinuation in general practice and out-patient settings was undertaken. Routine care was compared with three treatment approaches: brief interventions, gradual dose reduction (GDR) and psychological interventions. GDR was compared with GDR plus psychological interventions or substitutive pharmacotherapies. Results Inclusion criteria were met by 24 studies, and a further eight were identified by future search. GDR [odds ratio (OR) = 5.96, confidence interval (CI) = 2.08,17.11] and brief interventions (OR = 4.37, CI = 2.28,8.40) provided superior cessation rates at post-treatment to routine care. Psychological treatment plus GDR were superior to both routine care (OR = 3.38, CI = 1.86,6.12) and GDR alone (OR = 1.82, CI = 1.25,2.67). However, substitutive pharmacotherapies did not add to the impact of GDR (OR = 1.30, CI = 0.97,1.73), and abrupt substitution of benzodiazepines by other pharmacotherapy was less effective than GDR alone (OR = 0.30, CI = 0.14,0.64). Few studies on any technique had significantly greater benzodiazepine discontinuation than controls at follow-up. Conclusions Providing an intervention is more effective than routine care. Psychological interventions may improve discontinuation above GDR alone. While some substitutive pharmacotherapies may have promise, current evidence is insufficient to support their use. [source]

Effect of insulin infusion on electrocardiographic findings following acute myocardial infarction: importance of glycaemic control

R. M. Gan
Abstract Aims, To determine the effects of insulin infusion and blood glucose levels during acute myocardial infarction (AMI) on electrocardiographic (ECG) features of myocardial electrical activity. Methods, ECGs at admission and 24 h were examined in a randomized study of insulin infusion vs. routine care for AMI patients with diabetes or hyperglycaemia. Results were analysed according to treatment allocation and also according to average blood glucose level. Results, ECG characteristics were similar at admission in both groups. Patients allocated to conventional treatment had prolongation of the QT interval (QTc) after 24 h but those receiving infused insulin did not. In patients with a mean blood glucose in the first 24 h > 8.0 mmol/l, new ECG conduction abnormalities were significantly more common than in patients with mean blood glucose , 8.0 mmol/l (15.0% vs. 6.0%, P < 0.05). Conclusions, Prevention of QTc prolongation by administration of insulin may reflect a protective effect on metabolic and electrical activity in threatened myocardial tissue. Abnormalities of cardiac electrical conduction may also be influenced by blood glucose. [source]

Nephropathy, but not retinopathy, is associated with the development of heart disease in Type 1 diabetes: a 12-year observation study of 462 patients

O. Torffvit
Abstract Aims To study the occurrence of heart disease and death in Type 1 diabetic patients and evaluate whether presence of microangiopathy, i.e. nephropathy and retinopathy, was associated with the outcome. Methods A 12-year observation study of 462 Type 1 diabetic patients without a previous history of heart disease at baseline who were treated under routine care in a hospital out-patient clinic. Results A total of 85 patients developed signs of heart disease, i.e. myocardial infarction (n = 41), angina (n = 23), and heart failure (n = 17) and 56 patients died. The mortality for patients without signs of heart disease during the observation period was 7.6% compared with 51% in patients with myocardial infarction (P < 0.001), 26% in patients with angina (P < 0.01) and 65% in patients with heart failure (P < 0.001). The relative risk for death was 9.0 (P < 0.001) and 2.5 (P < 0.05) times higher in patients with macroalbuminuria and microalbuminuria, respectively. The risk for cardiovascular death was 18.3 times (P < 0.001) higher in patients with macroalbuminuria compared with patients with normoalbuminuria. In patients with sight-threatening retinopathy, the relative risk for death was 7.0 times higher (P < 0.01) and the risk for coronary heart disease events 4.4 times higher (P < 0.05) compared with patients with no retinopathy. However, when retinopathy was adjusted for presence of macroalbuminuria, this association disappeared. Conclusion This study shows a high incidence of heart disease in patients with Type 1 diabetes. The worse prognosis was seen in patients with sight-threatening retinopathy and macroalbuminuria and microalbuminuria at baseline. Macroalbuminuria and microalbuminuria were independently associated with a high risk for heart disease and death while the association with sight-threatening retinopathy only occurred in the presence of nephropathy. [source]

The Audit Commission review of diabetes services in England and Wales, 1998,2001

B. Fitzsimons
Abstract Aims of the Audit Commission The Audit Commission has a statutory duty to promote the best use of public money. It does this through value for money studies, such as that reported in Testing Times[1]. This work has been followed with a review of innovative practice in commissioning. These initiatives aim to support the implementation of the diabetes national service framework. The Audit Commission also appoints external auditors to NHS organizations who assess probity and value for money in the NHS; the latter by applying national studies locally and by carrying out local studies. Methods Research for Testing Times consisted of structured visits to nine acute trusts, a telephone survey of 26 health authorities and a postal survey of 1400 people with diabetes and 250 general practitioners. Local audits used a subset of the original research tools. Case studies were identified through a cascade approach to contacts established during Testing Times and through self-nomination. Results Rising numbers of people with diabetes are placing increasing pressure on hospital services. Some health authorities and primary care organizations have reviewed patterns of service provision in the light of the increasing demands. These reviews show wide variations in patterns of routine care. In addition, there is a widespread lack of data on the delivery of structured care to people with diabetes. People with diabetes report delays in gaining access to services, and insufficient time with staff. There are insufficient arrangements in place for providing information and learning opportunities to support self-management. Conclusion As the number of people with diabetes continues to rise, the potential for providing more care in a primary care setting needs to be explored. This will enable specialist services to focus more effectively on those with the most complex needs. [source]

A System for Grouping Presenting Complaints: The Pediatric Emergency Reason for Visit Clusters

MSCE, Marc H. Gorelick MD
Abstract Objectives: To develop a set of chief complaint groupings for pediatric emergency department (ED) visits that is comprehensive, parsimonious, clinically sensible, and evidence-based. Methods: Investigators derived candidate chief complaint clusters and ranked them a priori into three perceived severity categories. Pediatric visits were extracted from the National Hospital Ambulatory Medical Care Survey (NHAMCS); data for years 1998 and 2000 (n= 13,186) were used for derivation and data for year 1999 (n= 5,365) were used for validation. Visits were assigned to clusters based on the recorded complaints; clusters were combined to ensure adequate numbers for analysis (minimum n= 20), and the clusters were reviewed for clinical sensibility. Resource utilization was categorized in three levels: routine (examination only), ED treatment (tests or therapy in the ED but not admitted), and admission. Area under the receiver-operating characteristic (ROC) curve (AUC) was used to demonstrate the discriminative ability of the clusters in predicting resource use. Results: There were 463 unique complaints in the derivation database; 95 (20%) had a single associated visit. Fifty-two clusters were generated; only 2.4% of complaints were classified as other. The eight most common clusters encompassed 52% of the visits. The top five were fever (11%), extremity pain/injury, vomiting, cough, and trauma (unspecified). Complaint clusters were associated with actual resource utilization: for routine care, the AUC was 0.73 (0.74 in the validation set), and for admission, the AUC was 0.77 (0.74 in the validation set). Both resource utilization and triage classification increased with increased expert severity ranking (test for trend, p < 0.001). Conclusions: The proposed Pediatric Emergency Reason for Visit Cluster (PERC) system is a comprehensive yet parsimonious, clinically sensible means of categorizing pediatric ED complaints. The PERC system's association with measures of acuity and resource utilization makes it a potentially useful tool in epidemiologic and health services research. [source]

Commentary on Larney (2010): A call to action,opioid substitution therapy as a conduit to routine care and primary prevention of HIV transmission among opioid-dependent prisoners

ADDICTION, Issue 2 2010
No abstract is available for this article. [source]

Effectiveness of current treatment approaches for benzodiazepine discontinuation: a meta-analysis

ADDICTION, Issue 1 2009
Jannette M. Parr
ABSTRACT Aims To assess the effectiveness of current treatment approaches to assist benzodiazepine discontinuation. Methods A systematic review of approaches to benzodiazepine discontinuation in general practice and out-patient settings was undertaken. Routine care was compared with three treatment approaches: brief interventions, gradual dose reduction (GDR) and psychological interventions. GDR was compared with GDR plus psychological interventions or substitutive pharmacotherapies. Results Inclusion criteria were met by 24 studies, and a further eight were identified by future search. GDR [odds ratio (OR) = 5.96, confidence interval (CI) = 2.08,17.11] and brief interventions (OR = 4.37, CI = 2.28,8.40) provided superior cessation rates at post-treatment to routine care. Psychological treatment plus GDR were superior to both routine care (OR = 3.38, CI = 1.86,6.12) and GDR alone (OR = 1.82, CI = 1.25,2.67). However, substitutive pharmacotherapies did not add to the impact of GDR (OR = 1.30, CI = 0.97,1.73), and abrupt substitution of benzodiazepines by other pharmacotherapy was less effective than GDR alone (OR = 0.30, CI = 0.14,0.64). Few studies on any technique had significantly greater benzodiazepine discontinuation than controls at follow-up. Conclusions Providing an intervention is more effective than routine care. Psychological interventions may improve discontinuation above GDR alone. While some substitutive pharmacotherapies may have promise, current evidence is insufficient to support their use. [source]

Dementia and the Over-75 Check: the role of the primary care nurse

Heather Trickey BSc MSc (Med)
Abstract Primary care nurses are very likely to provide a substantial part of the routine care for patients with dementia. In order to examine the knowledge and attitudes of the primary care nurses who undertake the Over-75 Check, towards assessing and managing patients with symptoms of dementia, and to assess their level of support for a clinical practice guideline, a postal questionnaire survey was undertaken of primary care nurses responsible for the Over-75 Check in 209 general practices in Gloucester, Avon and Somerset. The questionnaire ascertained some demographic information about the nurses, their training and the practice routine for the Over-75 Check. It also included a case vignette describing a typical presentation of dementia at an Over-75 Check. A 65% response rate was achieved. Only one-fifth of respondents ever used formal validated cognitive tests as part of the Over-75 Check. In response to the vignette, nearly 10% took no action at all and a further 25% simply referred the patient on. Amongst the remainder there was considerable variation regarding the tasks considered to be within their remit. The respondents strongly supported the introduction of guidelines. Given the variation in professional responsibilities between practices, it is proposed that a clinical practice guideline covering diagnosis, assessment and management of dementia should address the practice as a whole rather than be targeted to specific professionals. The guideline should prompt professionals carrying out an Over-75 Check to recognize symptoms of dementia and raise awareness of the range of tasks which need to be undertaken in confirming diagnosis, assessing needs and managing patients. Results from this study suggest that improved training and increased autonomy for primary care nurses would improve access to services for these patients and their carers. [source]

Consumer attitudes towards the use of routine outcome measures in a public mental health service: A consumer-driven study

David Guthrie
ABSTRACT:, In this study conducted by consumer consultants, 50 consumers who have a Barwon Health case manager (the majority of whom were nurses) were interviewed using a structured questionnaire to ascertain their attitudes towards the routine use of outcome measures. Forty participants (80% of those interviewed) reported they had been offered the Behaviour and Symptom Identification Scale (BASIS-32) to complete in routine care by their case managers and of those, 95% (n = 38) completed it. On those who completed the BASIS-32, 42% said their case manager had explained what the BASIS-32 would be used for, 45% said that the case manager had discussed their responses with them, 76% stated that completing the BASIS-32 had helped the case manager to understand them better and 66% believed that completing the BASIS-32 had led to them receiving better care. Only 30% of the group interviewed were aware that their case manager regularly completed a Health of the Nation Outcome Scales and Life Skills Profile. Feedback about the process of completing the BASIS-32 was obtained as well as suggestions on how the process may be improved. The results indicate that consumers see the benefit of routine outcome measurement and believe it leads to improved care. More information about outcome measures, including the clinician-rated outcome measures, needs to be provided to consumers if they are to be engaged constructively in this exercise. [source]

Buprenorphine and methadone in the treatment of opioid dependence: methods and design of the COBRA study

Prof Dr Hans-Ulrich Wittchen
Abstract Buprenorphine and methadone are the two established substitution drugs licensed in many countries for the treatment of opioid dependence. Little is known, however, about how these two drugs are applied and how they work in clinical practice. In this paper we present the aims, methods, design and sampling issues of a collaborative multi-stage epidemiological study (COBRA) to address these issues. Based on a nationally representative sample of substitution physicians, the study is designed as an observational, naturalistic study, consisting of three major parts. The first part was a national survey of substitution doctors (prestudy, n = 379 doctors). The second part was a cross-sectional study (n = 223 doctors), which consisted of a target-week assessment of 2,694 consecutive patients to determine (a) the severity and problem profiles and treatment targets; (b) the choice and dosage scheme of the substitution drug; (c) past and current interventions, including treatment of comorbid hepatitis C; and (d) cross-sectional differences between the two drugs with regard to comorbidity, clinical course, acceptance/compliance and social integration. The third part consists of a prospective-longitudinal cohort study of 48 methadone-treated and 48 buprenorphine-treated patients. The cohort is followed up over a period of 12 months to investigate whether course and outcome of the patients differ by type or treatment received in terms of clinical, psychosocial, pharmaco-economic and other related measures. The response rate among substitution doctors was 57.1%; that among eligible patients was 71.7%. Comparisons with the federal registers reveal that the final samples of doctors and patients may be considered nationally representative with regard to regional distribution, training, type of setting as well as the frequency of patients treated with buprenorphine or methadone. The COBRA study provides a unique comprehensive database, informing about the natural allocation and intervention processes in routine care and about the course and outcome of patients treated with buprenorphine or methadone. Copyright 2005 Whurr Publishers Ltd. [source]

A decision theory perspective on why women do or do not decide to have cancer screening: systematic review

Kelly Ackerson
Abstract Title.,A decision theory perspective on why women do or do not decide to have cancer screening: systematic review. Aim., This paper is a report of a review in which decision theory from economics and psychology was applied to understand why some women with access to care do not seek cancer screening. Background., Mammography and cervical smear testing are effective modes of cancer screening, yet many women choose not to be screened. Nurses need to understand the reasons behind women's choices to improve adherence. Data sources., Research papers published between January 1994 and November 2008 were identified using the Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PsycINFO data bases. The search was performed using the following terms: cervical cancer screening, breast cancer screening, decision, choice, adherence and framing. Forty-seven papers were identified and reviewed for relevance to the search criteria. Methods., Nineteen papers met the search criteria. For each paper, reasons for obtaining or not obtaining cancer screening were recorded, and organized into four relevant decision theory principles: emotions, Prospect Theory, optimism bias and framing. Findings., All women have fears and uncertainty, but the sources of their fears differ, producing two main decision scenarios. Non-adherence results when women fear medical examinations, providers, tests and procedures, do not have/seek knowledge about risk and frame their current health as the status quo. Adherence is achieved when women fear cancer, but trust care providers, seek knowledge, understand risk and frame routine care as the status quo. Conclusion., Nurses need to address proactively women's perceptions and knowledge about screening by openly and uniformly discussing the importance and benefits. [source]

A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China

Xiaolian Jiang MSc
Aim., The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu, China. Background., Epidemiological studies indicate a dose-, level- and duration-dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality. Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes. Design methods., A randomized controlled trial was conducted. Coronary heart disease patients (n = 167) who met the sampling criteria in two tertiary medical centres in Chengdu, south-west China, were randomly assigned to either an intervention group (the cardiac rehabilitation programme) or control group (the routine care). The change of health behaviours (walking performance, step II diet adherence, medication adherence, smoking cessation) and physiological risk parameters (serum lipids, blood pressure, body weight) were assessed to evaluate the programme effect. Results., Patients in the intervention group demonstrated a significantly better performance in walking, step II diet adherence, medication adherence; a significantly greater reduction in serum lipids including triglyceride, total cholesterol, low-density lipoprotein; and significantly better control of systolic and diastolic blood pressure at three months. The majority of these positive impacts were maintained at six months. The effect of the programme on smoking cessation, body weight, serum high-density lipoprotein, was not confirmed. Conclusions., A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients. Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease. Relevance to clinical practice., This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients. Furthermore, the hospital,home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care. [source]

Pharmacoepidemiologic investigation of a clonazepam-valproic acid interaction by mixed effect modeling using routine clinical pharmacokinetic data in Japanese patients

E. Yukawa
Summary Non-linear Mixed Effects Modeling (NONMEM) was used to estimate the effects of clonazepam,valproic acid interaction on clearance values using 576 serum levels collected from 317 pediatric and adult epileptic patients (age range, 03,326 years) during their clinical routine care. Patients received the administration of clonazepam and/or valproic acid. The final model describing clonazepam clearance was CL = 1440 TBW,0172 114VPA, where CL is total body clearance (mL/kg/h); TBW is total body weight (kg); VPA = 1 for concomitant administration of valproic acid and VPA = zero otherwise. The final model describing valproic acid clearance was CL (mL/kg/h) = 172 TBW,0264 DOSE0159 0821CZP 0896GEN, where DOSE is the daily dose of valproic acid (mg/kg/day); CZP = 1 for concomitant administration of clonazepam and CZP = zero otherwise; GEN = 1 for female and GEN = zero otherwise. Concomitant administration of clonazepam and valproic acid resulted in a 14% increase in clonazepam clearance, and a 179% decrease in valproic acid clearance. [source]

A Quasi-Experimental Trial on Individualized, Developmentally Supportive Family-Centered Care

Jacqueline F. Byers
Objective:, To evaluate the impact of individualized, developmentally supportive family-centered care on infant physiological variables, growth, behavioral stress cues, return to sleep state, medical and developmental progress, complications, resource utilization, parental perception of the neonatal intensive-care unit experience, and overall parental satisfaction. Design:, Quasi-experimental, repeated measures design. Setting:, Developmental and a control nursery in a 78-bed, level II/III neonatal intensive-care unit. Participants:, A convenience sample of 114 premature infants and their parents. Interventions:, Control group infants received the routine neonatal intensive-care unit standard of care. Experimental infants received routine care plus the addition of individualized, developmentally supportive family-centered interventions. Main Outcome measures:, Between groups, there were no statistically significant differences in demographic factors, days to medical or developmental milestones, length of stay, or direct cost/case. Repeated measures analysis of variance determined that at every point of data collection, the average number of baseline, activity, and postactivity stress cues were lower in the developmentally supportive group. Infants in the developmental group had 8% less sedatives/narcotics and 15% less vasopressors costs than the control group. There were no differences in complication rates, parental perceptions of the neonatal intensive-care unit experience, or parental satisfaction between groups. Conclusions:, Preterm infants who received developmentally supportive family-centered care demonstrated fewer behavioral stress cues and comparable short-term outcomes and resource utilization than infants who received routine care. JOGNN, 35, 105-115; 2006. DOI: 10.1111/J.1552-6909.2006.00002.x [source]

Safety and effectiveness of topical dry mouth products containing olive oil, betaine, and xylitol in reducing xerostomia for polypharmacy-induced dry mouth

summary, Polypharmacy is a common cause of salivary hypofunction, producing symptoms of dry mouth or xerostomia, especially among older populations. As the number of older people continues to increase, polypharmacy-induced salivary hypofunction is becoming an increasing problem. Many over-the-counter products are available for relieving symptoms of dry mouth, but few have been tested in controlled clinical investigations. The purpose of this investigation was to evaluate the safety and efficacy of a group of topical dry mouth products (toothpaste, mouth rinse, mouth spray and gel) containing olive oil, betaine and xylitol. Forty adults were entered into this single-blinded, open-label, cross-over clinical study and 39 completed all the visits. Subjects were randomly assigned at baseline to using the novel topical dry mouth products daily for 1 week, or to maintain their normal dry mouth routine care. After 1 week, they were crossed over to the other dry mouth regimen. The results demonstrated that the use of the novel topical dry mouth products increased significantly unstimulated whole salivary flow rates, reduced complaints of xerostomia and improved xerostomia-associated quality of life. No clinically significant adverse events were observed. These data suggest that the daily use of topical dry mouth products containing olive oil, betaine and xylitol is safe and effective in relieving symptoms of dry mouth in a population with polypharmacy-induced xerostomia. [source]

Extreme College Drinking and Alcohol-Related Injury Risk

ALCOHOLISM, Issue 9 2009
Marlon P. Mundt
Background:, Despite the enormous burden of alcohol-related injuries, the direct connection between college drinking and physical injury has not been well understood. The goal of this study was to assess the connection between alcohol consumption levels and college alcohol-related injury risk. Methods:, A total of 12,900 college students seeking routine care in 5 college health clinics completed a general Health Screening Survey. Of these, 2,090 students exceeded at-risk alcohol use levels and participated in a face-to-face interview to determine eligibility for a brief alcohol intervention trial. The eligibility interview assessed past 28-day alcohol use and alcohol-related injuries in the past 6 months. Risk of alcohol-related injury was compared across daily drinking quantities and frequencies. Logistic regression analysis and the Bayesian Information Criterion were applied to compute the odds of alcohol-related injury based on daily drinking totals after adjusting for age, race, site, body weight, and sensation seeking. Results:, Male college students in the study were 19% more likely (95% CI: 1.12,1.26) to suffer an alcohol-related injury with each additional day of consuming 8 or more drinks. Injury risks among males increased marginally with each day of consuming 5 to 7 drinks (odds ratio = 1.03, 95% CI: 0.94,1.13). Female participants were 10% more likely (95% CI: 1.04,1.16) to suffer an alcohol-related injury with each additional day of drinking 5 or more drinks. Males (OR = 1.69, 95% CI: 1.14,2.50) and females (OR = 1.81, 95% CI: 1.27,2.57) with higher sensation-seeking scores were more likely to suffer alcohol-related injuries. Conclusions:, College health clinics may want to focus limited alcohol injury prevention resources on students who frequently engage in extreme drinking, defined in this study as 8+M/5+F drinks per day, and score high on sensation-seeking disposition. [source]

Using the chronic care model to tackle depression among older adults who have long-term physical conditions

P. MCEVOY phd bsc
Effective psychological and pharmacological treatments are available, but for depressed older adults with long-term physical conditions, the outcome of routine care is generally poor. This paper introduces the chronic care model, a systemic approach to quality improvement and service redesign, which was developed by Ed Wagner and colleagues. The model highlights six key areas that need to be addressed, if depression is to be tackled more effectively in this neglected patient group: delivery system design, patient,provider relationships, decision support, clinical information systems, community resources and healthcare organization. Three influential programmes, the Improving Mood Promoting Access to Collaborative Treatment programme, the Prevention of Suicide in Primary Care Elderly Collaborative Trial, and the Program to Encourage Active, and Rewarding Lives for Seniors, have shown that when the model is adopted, significant improvements in outcomes can be achieved. The paper concludes with a case study, which illustrates the difference that adopting the chronic care model can make. Radical changes in working practices may be required, to implement the model in practice. However, Greg Simon, a leading researcher in the field of depression care, has suggested that there is already sufficient evidence to justify a shift in emphasis from research towards dissemination and implementation. [source]

Prevalence of cardiovascular disease and risk factors in a type 2 diabetic population of the North Catalonia diabetes study

DNS (Diabetes Nurse Specialist & Clinical Researcher), Jeronimo Jurado RN
Abstract Purpose: The purpose of the study was to evaluate the prevalence of cardiovascular disease (CVD), cardiovascular risk factors (CVRFs), and their control in patients with type 2 diabetes mellitus (T2DM) at primary care settings from the North Catalonia Diabetes Study (NCDS). Data sources: In this multicentre cross-sectional descriptive study, data were collected from a random sample of 307 patients with T2DM. The prevalence of CVD, CVRF, metabolic syndrome (MS), coronary heart disease (CHD) risk at 10 years (Framingham Point Scores), and CVRF control was evaluated. MS and lipid profiles were established according to Adult Treatment Panel III criteria. Conclusions: CVD prevalence was 22.0% (CHD: 18.9% and peripheral ischemia: 4.5%) and more frequent in men. The prevalence of selected CVRF was: hypertension: 74.5%; dyslipidemia: 77.7%; smoking: 14.9%; obesity 44.9%, and familial CVD: 38.4%. Three or more CVRFs, including T2DM, were observed in 91.3%. MS prevalence was 68.7%. Framingham score was 10.0%, higher in men than in women. CVD prevalence was related to: age, number of CVRFs, duration of diabetes, familial history of CVD, waist circumference, hypertension, lipid profile, kidney disease, and Framingham score, but not to MS by itself. Correct lipid profiles and blood pressure were only observed in 18.9% and 24.0%, respectively, whereas platelet aggregation inhibitors were only recorded in 16.1% of the patient cohort. MS presence was not an independent risk factor of CVD in our study. Implications for practice: The high prevalence of CVD and an inadequate control of CVRF, which were apparent in the NCDS population, would suggest that advanced practice nurses should consider incorporating specific cardiovascular assessment in their routine care of persons with T2DM. [source]

Health-related quality of life in patients with gastro-oesophageal reflux disease under routine care: 5-year follow-up results of the ProGERD study

Summary Background, Gastro-oesophageal reflux disease (GERD) is a common disorder associated with substantial reductions in health-related quality of life (HRQL). Aim, To describe patterns of change in HRQL during 5 years of follow-up in a large population of GERD patients. Methods, In 2000, a total of 6215 GERD patients were enrolled in the Progression of GERD (ProGERD) study. During follow-up, patients received any medication considered necessary. HRQL was assessed yearly with the Short-Form 36 and the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. Associations between patient characteristics and changes in HRQL were analysed using multiple logistic regression models. Results, After 5 years, data on HRQL were available for 4597 (74%) patients. Both generic and disease-specific HRQL improved after baseline and remained well above baseline levels in the following years. A clinically relevant decrease in QOLRAD scores was reported by 3,5% of patients. According to our multivariate analysis, a decrease in HRQL was associated with a higher reflux symptom load and the presence of night-time heartburn. Conclusions, Only a small minority of the ProGERD population reported a clinically relevant decrease in HRQL, which was associated most strongly with nocturnal heartburn. [source]

Long-term treatment of patients with gastro-oesophageal reflux disease in routine care , results from the ProGERD study

Summary Background Gastro-oesophageal reflux disease (GERD) is a common condition frequently requiring long-term pharmacological treatment. Aim To describe the long-term pattern of GERD medication use in GERD patients receiving routine care. Methods Patients were recruited as part of the ongoing ProGERD study, a 10-year-cohort study including 6215 patients at baseline. GERD medication and symptoms were assessed with patient questionnaires. During follow-up, medical treatment was prescribed by participating primary care physicians. Associations between patient characteristics and medication were analysed by logistic regression. Results The percentage of patients who reported using any GERD medication remained constant from year 1 to year 4 (74%, 74%, 73% and 71%). Of patients who reported using GERD medication, the majority were taking proton pump inhibitors (PPI) (79%, 84%, 85%, and 87%). Continuous PPI intake was the predominant prescription pattern (53%, 49%, 56% and 56%), followed by on-demand treatment (26%, 35%, 29% and 29%). Continuous PPI intake was strongly associated with the presence of erosive GERD. Conclusion Three-quarters of the GERD population in our study reported long-term treatment with a PPI. Continuous PPI intake was the predominant treatment pattern, and the proportion of patients taking a PPI on a continuous basis remained constant over time. [source]

Motivational interviewing for adherence problems in cystic fibrosis

Alistair J.A. Duff
Abstract This review focuses on adherence in cystic fibrosis (CF), and the factors known to influence it. In particular, it discusses the importance of effective communication in clinical settings and considers the evidence for the effectiveness of motivational interviewing (MI), to increase adaptation and adherence in physical health and CF. The review also contains an overview of the key concepts of MI, its' practice in medical settings and recommendations on how to adopt MI techniques in the routine care of people with CF. Pediatr Pulmonol. 2010; 45:211,220. 2010 Wiley-Liss, Inc. [source]

Validation of a new measure of protective footcare behaviour: the Nottingham Assessment of Functional Footcare (NAFF)

NB Lincoln PhD
Abstract There are no measures available to document footcare practice among people with diabetes and yet such measures are needed as a surrogate marker in studies designed to determine the effectiveness of footcare education. We have therefore developed such a measure, the Nottingham Assessment of Functional Footcare (NAFF), and have assessed its reliability and validity. A pilot questionnaire was distributed to people with diabetes and healthy controls, before being revised and shortened. The revised version was assessed for internal consistency and reliability. The pilot 51-item questionnaire was determined in 100 out-patients with diabetes and 61 healthy controls. The internal consistency was 0.46 in people with diabetes and 0.39 in healthy volunteers. Twenty-eight items showed significant differences between those with and without diabetes. The internal consistency and test,retest reliability of a revised version were determined in people with diabetes. The measure was further refined to a 29-item version, which had an internal consistency of 0.53. There was a significant correlation (rs 0.83; p<0.001) and no significant difference (p = 0.85) between scores in the test,retest study. Respondents with neuropathy scored significantly higher than those without (p<0.01). We conclude that the NAFF could act as an outcome measure in the prospective trials which are needed to establish the place of education programmes in clinical practice. The measure could also be used in routine care to identify those whose usual foot care might put their feet at risk of future ulceration. Copyright 2007 John Wiley & Sons. [source]

Interest in services among prostate cancer patients receiving androgen deprivation therapy

Pamela J. Shapiro
Treatment side effects and decreased quality of life associated with androgen deprivation therapy (ADT) suggest the need for supportive services for prostate cancer (PC) patients receiving ADT. Nonetheless, uptake of services is low, suggesting that PC patients' preferences are not being addressed. We examined interest in supportive services and predictors of interest among 118 PC patients receiving ADT. Overall interest in services was associated with lower quality of life (p=0.01). The majority of participants expressed interest in informational services (70%), with a minority (22%) expressing interest in psychosocial services. Interest in psychosocial services was associated with younger age (p=0.02), and shorter duration of ADT (p<0.04), but was unrelated to psychological distress or social support. Although most men (68%) reported that they would prefer not to take medication for depression, 75% would do so if advised by their physician. Overall, results suggest that PC patients on ADT prefer individualized informational support. Substantial interest (61%) in Oncolink, an internet-based informational resource, suggests the Internet may provide an acceptable mode of service delivery. Health care providers should consider integrating increased informational support into routine care and, more generally, consider patient preferences in prioritizing and designing support services. Copyright 2003 John Wiley & Sons, Ltd. [source]

Effects of music therapy on women's physiologic measures, anxiety, and satisfaction during cesarean delivery

Shu-Chen Chang
Abstract The purpose of the study was to investigate the effects of music therapy on women's physiologic measures, level of anxiety, and satisfaction during cesarean delivery. Sixty-four women who were planning to have a cesarean delivery were randomly divided into an experimental and a control group. The experimental group received routine care and music therapy, whereas the control group received routine care only. Our results indicated that compared to the control group the experimental group had significantly lower anxiety and a higher level of satisfaction regarding the cesarean experience. No significant differences were found between the two groups in any of the physiological indexes. This controlled study provides evidence that music therapy can reduce anxiety and create a more satisfying experience for women undergoing cesarean delivery. 2005 Wiley Periodicals, Inc. Res Nurs Health 28:453,461, 2005 [source]

Care of the Chronically Ill at Home: An Unresolved Dilemma in Health Policy for the United States

The problems of caring for patients with disabling illnesses who neither get well nor die are not new. Such patients have always required assistance at home from family, benevolent volunteers, or paid caregivers. Despite two centuries of experimentation, however, no agreement exists concerning the balance between the public and private resources to be allocated through state funding, private insurance, and family contributions for the daily and routine care at home for chronically ill persons of all ages. This article examines these issues and the unavoidable tensions between fiscal reality and legitimate need. It also uses historical and policy analyses to explain why home care has never become the cornerstone for caring for the chronically ill. [source]

Direct comparison of treatment responses, remission rates, and drug adherence in patients with rheumatoid arthritis treated with adalimumab, etanercept, or infliximab: Results from eight years of surveillance of clinical practice in the nationwide Danish DANBIO registry

Merete Lund Hetland
Objective To compare tumor necrosis factor , inhibitors directly regarding the rates of treatment response, remission, and the drug survival rate in patients with rheumatoid arthritis (RA), and to identify clinical prognostic factors for response. Methods The nationwide DANBIO registry collects data on rheumatology patients receiving routine care. For the present study, we included patients from DANBIO who had RA (n = 2,326) in whom the first biologic treatment was initiated (29% received adalimumab, 22% received etanercept, and 49% received infliximab). Baseline predictors of treatment response were identified. The odds ratios (ORs) for clinical responses and remission and hazard ratios (HRs) for drug withdrawal were calculated, corrected for age, disease duration, the Disease Activity Score in 28 joints (DAS28), seropositivity, concomitant methotrexate and prednisolone, number of previous disease-modifying drugs, center, and functional status (Health Assessment Questionnaire score). Results Seventy percent improvement according to the American College of Rheumatology criteria (an ACR70 response) was achieved in 19% of patients after 6 months. Older age, concomitant prednisolone treatment, and low functional status at baseline were negative predictors. The ORs (95% confidence intervals [95% CIs]) for an ACR70 response were 2.05 (95% CI 1.52,2.76) for adalimumab versus infliximab, 1.78 (95% CI 1.28,2.50) for etanercept versus infliximab, and 1.15 (95% CI 0.82,1.60) for adalimumab versus etanercept. Similar predictors and ORs were observed for a good response according to the European League Against Rheumatism criteria, DAS28 remission, and Clinical Disease Activity Index remission. At 48 months, the HRs for drug withdrawal were 1.98 for infliximab versus etanercept (95% 1.63,2.40), 1.35 for infliximab versus adalimumab (95% CI 1.15,1.58), and 1.47 for adalimumab versus etanercept (95% CI 1.20,1.80). Conclusion Older age, low functional status, and concomitant prednisolone treatment were negative predictors of a clinical response and remission. Infliximab had the lowest rates of treatment response, disease remission, and drug adherence, adalimumab had the highest rates of treatment response and disease remission, and etanercept had the longest drug survival rates. These findings were consistent after correction for confounders and sensitivity analyses and across outcome measures and followup times. [source]

Cancer risk in patients with rheumatoid arthritis treated with anti,tumor necrosis factor , therapies: Does the risk change with the time since start of treatment?

Johan Askling
Objective To determine the short-term and medium-term risks of cancer in patients receiving anti,tumor necrosis factor , (anti-TNF,) therapies that have proven effective in the treatment of chronic inflammatory conditions. Methods By linking together data from the Swedish Biologics Register, Swedish registers of RA, and the Swedish Cancer Register, we identified and analyzed for cancer occurrence a national cohort of 6,366 patients with RA who first started anti-TNF therapy between January 1999 and July 2006. As comparators, we used a national biologics-naive RA cohort (n = 61,160), a cohort of RA patients newly starting methotrexate (n = 5,989), a cohort of RA patients newly starting disease-modifying antirheumatic drug combination therapy (n = 1,838), and the general population of Sweden. Relative risks (RRs) were estimated using Cox regression analyses, examining overall RR as well as RR by time since the first start of anti-TNF therapy, by the duration of active anti-TNF therapy, and by the anti-TNF agent received. Results During 25,693 person-years of followup in 6,366 patients newly starting anti-TNF, 240 first cancers occurred, yielding an RR of 1.00 (95% confidence interval 0.86,1.15) versus the biologics-naive RA cohort, and similar RRs versus the other 2 RA comparators. RRs did not increase with increasing time since the start of anti-TNF therapy, nor with the cumulative duration of active anti-TNF therapy. During the first year following the first treatment start, but not thereafter, dissimilar cancer risks for adalimumab, etanercept, and infliximab were observed. Conclusion During the first 6 years after the start of anti-TNF therapy in routine care, no overall elevation of cancer risk and no increase with followup time were observed. [source]

Cardiac involvement in systemic sclerosis assessed by tissue-doppler echocardiography during routine care: A controlled study of 100 consecutive patients

Christophe Meune
Objective To assess the prevalence of primary cardiac complications in a large population of patients with systemic sclerosis (SSc), using recently developed echocardiographic techniques. Methods We prospectively studied 100 consecutive patients (mean SD age 54 14 years; 86 women) presenting with SSc without pulmonary arterial hypertension or clinical manifestations of heart failure. All patients underwent standard echocardiography, along with measurements of longitudinal velocities by tissue Doppler imaging (TDI) to assess left ventricular (LV) and right ventricular (RV) contractility and LV diastolic function. Results were compared with those in 26 age- and sex-matched healthy controls. Results Patients with SSc had a wider mean left atrial diameter and impaired relaxation compared with the controls. A trend was observed toward a smaller LV ejection fraction (EF) in the patients (mean SD 64.9 0.6%) than in the controls (67.2 0.7%), as well as higher pulmonary artery pressure (mean SD 33.3 0.6 mm Hg versus 30.8 1.0 mm Hg). LVEF was <55% in 7 patients versus none of the controls. Peak systolic mitral annular velocity as measured by TDI was <7.5 cm/second in 14 patients versus none of the controls (P = 0.040). Mitral annulus early diastolic velocity was <10 cm/second in 30 patients versus 2 of the controls (P = 0.022). Fifteen patients and none of the controls had reduced peak systolic tricuspid annular velocity (P = 0.039). The TDI results correlated with each other, but not with lung abnormalities or other disease characteristics. Conclusion Depression of LV and RV systolic and LV diastolic function is common in patients with SSc and is due to primary myocardial involvement. Considering the major contributions of TDI, the addition of this simple technique to standard measurements may improve the detection of heart involvement in patients with SSc. [source]

Acupuncture in patients with osteoarthritis of the knee or hip: A randomized, controlled trial with an additional nonrandomized arm

Claudia M. Witt
Objective To investigate the effectiveness of acupuncture in addition to routine care, compared with routine care alone, in the treatment of patients with chronic pain due to osteoarthritis (OA) of the knee or hip. Methods In a randomized, controlled trial, patients with chronic pain due to OA of the knee or hip were randomly allocated to undergo up to 15 sessions of acupuncture in a 3-month period or to a control group receiving no acupuncture. Another group of patients who did not consent to randomization underwent acupuncture treatment. All patients were allowed to receive usual medical care in addition to the study treatment. Clinical OA severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and health-related quality of life (Short Form 36) were assessed at baseline and after 3 months and 6 months. Results Of 3,633 patients (mean SD age 61.8 10.8 years; 61% female), 357 were randomized to the acupuncture group and 355 to the control group, and 2,921 were included in the nonrandomized acupuncture group. At 3 months, the WOMAC had improved by a mean SEM of 17.6 1.0 in the acupuncture group and 0.9 1.0 in the control group (3-month scores 30.5 1.0 and 47.3 1.0, respectively [difference in improvement 16.7 1.4; P < 0.001]). Similarly, quality of life improvements were more pronounced in the acupuncture group versus the control group (P < 0.001). Treatment success was maintained through 6 months. The changes in outcome in nonrandomized patients were comparable with those in randomized patients who received acupuncture. Conclusion These results indicate that acupuncture plus routine care is associated with marked clinical improvement in patients with chronic OA,associated pain of the knee or hip. [source]

Detection and management of decreased fetal movements in Australia and New Zealand: A survey of obstetric practice

Background:, Decreased fetal movement (DFM) is associated with increased risk of adverse pregnancy outcome. However, there is limited research to inform practice in the detection and management of DFM. Aims:, To identify current practices and views of obstetricians in Australia and New Zealand regarding DFM. Methods:, A postal survey of Fellows and Members, and obstetric trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Results:, Of the 1700 surveys distributed, 1066 (63%) were returned, of these, 805 (76% of responders) were currently practising and included in the analysis. The majority considered that asking women about fetal movement should be a part of routine care. Sixty per cent reported maternal perception of DFM for 12 h was sufficient evidence of DFM and 77% DFM for 24 h. KICK charts were used routinely by 39%, increasing to 66% following an episode of DFM. Alarm limits varied, the most commonly reported was < 10 movements in 12 h (74%). Only 6% agreed with the internationally recommended definition of < 10 movements in two hours. Interventions for DFM varied, while 81% would routinely undertake a cardiotocograph, 20% would routinely perform ultrasound and 20% more frequent antenatal visits. Conclusions:, While monitoring fetal movement is an important part of antenatal care in Australia and New Zealand, variation in obstetric practice for DFM is evident. Large-scale randomised controlled trials are required to identify optimal screening and management options. In the interim, high quality clinical practice guidelines using the best available advice are needed to enhance consistency in practice including advice provided to women. [source]