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Many Clinicians (many + clinician)
Selected AbstractsNaltrexone: report of lack of hepatotoxicity in acute viral hepatitis, with a review of the literatureADDICTION BIOLOGY, Issue 1 2004Colin Brewer Many clinicians appear to be concerned about the potential hepatotoxicity of the opiate antagonist naltrexone (NTX) and this may be one reason why it is not used more widely in treating both heroin and alcohol abusers. Some much-quoted early studies noted abnormalities in liver function tests (LFTs) in very obese patients taking high doses, although there was no evidence of clinically significant liver dysfunction. These concerns may be reinforced by advice in the UK product information sheet to perform LFTs before and during treatment, by high infection rates with hepatitis C virus (HCV) among injecting heroin addicts and by the frequency of abnormal LFTs in alcohol abusers. We describe a heroin abuser in whom clinical and laboratory manifestations of acute hepatitis B and C appeared a few days after the insertion of a subcutaneous naltrexone implant. A decision was made not to remove the implant but the hepatitis resolved completely and uneventfully well within the normal time-scale. A review of the literature indicates that even when given at much higher doses than are needed for treating heroin or alcohol abusers, there is no evidence that NTX causes clinically significant liver disease or exacerbates, even at high doses, serious pre-existing liver disease. During the past decade, NTX has been shown to be safe and effective in the treatment of pruritus associated with severe jaundice caused by severe and sometimes life-threatening cirrhosis and other liver diseases. Its safety, even in these extreme conditions, is particularly reassuring. We suggest that it may be more appropriate and economical to advise patients to report promptly any suspected side effects than to perform regular LFTs, which may be misleading. [source] Beyond ethnic match: Effects of client,therapist cognitive match in problem perception, coping orientation, and therapy goals on treatment outcomesJOURNAL OF COMMUNITY PSYCHOLOGY, Issue 5 2005Nolan Zane This study examined the outcome effects of cognitive match between Asian and White outpatient clients and their therapists. Many clinicians believe that one hindrance to the treatment of ethnic minority clients is that therapists and clients may not share common assumptions and attitudes about therapy and about the problems that are presented in treatment. The study investigated client,therapist similarity in their perceptions of the presenting problem, coping orientation, and expectations about treatment goals. This study constituted a more rigorous test of the cognitive match hypotheses in that it was prospective in nature, used separate and independent sources for the cognitive predictors, employed multiple outcome measures, and focused on specific attitudes and perceptions that are quite salient and relevant to treatment. Cognitive match on treatment goals was predictive of session impact. Moreover, cognitive matches in avoidant coping orientation and in perceived distress associated with interpersonal problems were predictive of certain treatment outcomes. The findings may help explain why clients matched on ethnicity with their therapists tend to stay longer in treatment and do better in psychotherapy. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 569,585, 2005. [source] How to get the most from the medical literature: Keeping up to date in nephrologyNEPHROLOGY, Issue 3 2010JEREMY CULLIS ABSTRACT Best clinical practice means being up to date with the latest research, trials, guidelines and patient perspectives. Recent developments in the Internet, specifically Web 2.0 and its tools offer numerous opportunities for the doctor to keep up to date with all types of information, from professional news to the latest clinical research. Many clinicians are time-poor, and may not have had the opportunity to learn about newer technological innovations, or to understand how they can be used to save clinician's time and energy, while making information management more efficient. In this paper we will examine Web 2.0, including the use of RSS, and suggest a number of different websites that offer free access to nephrology news. [source] Clinician safety: Assessing and managing the violent patientNEW DIRECTIONS FOR YOUTH DEVELOPMENT, Issue 86 2000Arthur Z. Berg Many clinicians deny the possibility of violence occurring in their practices, and this denial has its roots in fear of violence or overconfidence in safety. To appropriately address the issue of violence, clinicians must engage in proactive behaviors and attitudes that will ensure their safety. [source] An infantile-onset, severe, yet sporadic seizure pattern is common in Sturge-Weber syndromeEPILEPSIA, Issue 9 2009Eric H. Kossoff Summary The young age of onset and frequently intractable nature of seizures associated with Sturge-Weber syndrome (SWS) have been well-reported in large studies. However, many clinicians also anecdotally describe prolonged but sporadic seizure clusters. Over a 5-year period, 77 children and adults with SWS and at least one reported seizure were referred to and evaluated at the Hunter Nelson Sturge-Weber Center at the Kennedy Krieger Institute. The median age of seizure onset was 6 months with 43 (56%) presenting <1 year of age. Age at seizure onset ,6 months was associated with increased hemiparesis, but not seizures. A characteristic pattern of clustering, intense seizures followed by prolonged seizure-free periods was reported in 30 (39%), but was not associated with worse prognosis. This seizure pattern appears to be common with SWS and leads to difficult treatment decisions, especially in regard to the timing of potential surgical resection. [source] Levetiracetam in the Treatment of Idiopathic Generalized EpilepsiesEPILEPSIA, Issue 2005Richard Grünewald Summary:, Since its introduction into clinical practice in 1999, levetiracetam, the S enantiomer of piracetam, has rapidly found a secure place, initially in the therapy of partial onset seizures and subsequently in the treatment of idiopathic generalized epilepsies (IGE). It has many of the properties of an "ideal" antiepileptic drug, including rapid absorption, linear pharmokinetics, and sparse drug interactions. Tolerabiliy is generally excellent in both adults and children, although tiredness is a common dose-limiting adverse effect. Occasionally the drug can precipitate behavioral abnormalities, especially in patients with learning disability. There is a wide safety margin in overdose. In common with most antiepileptic drugs its mode of action remains uncertain. Levetiracetam binds to a specific site in the brain, influences intracellular calcium currents and reverses negative allosteric modulators of GABA- and glycine-gated currents in vitro. Its effectiveness has been demonstrated in animal models of epilepsy and in clinical trials of partial onset and IGE. Treatment of IGEs may be straightforward, with many patients demonstrating an excellent and robust response to valproate monotherapy. However, there remains a significant minority of patients for whom valproate is unsuitable, including those who experience unacceptable adverse effects (e.g., weight gain or hair loss) and women of childbearing age in whom the teratogenic potential of valproate is unacceptable. Therapeutic response to lamotrigine in this group is often disappointing, and many clinicians now are turning to the choice of levetiracetam. Efficacy in generalized tonic,clonic seizures and myoclonus is usually apparent and some patients experience improvement in typical absences. Experience of combinations of levetiracetam with other antiepileptic drugs is limited in IGE and the responses are largely anecdotal. In our hands, patients with refractory IGEs may respond to combinations of levetiracetam with valproate, lamotrigine, and phenobarbital, and adverse effects when they occur are usually limited to tiredness. Levetiracetam does not interact with the oral contraceptive pill, simplifying treatment in women of childbearing age. Although animal data look encouraging, questions over levetiracetam's teratogenic potential and overall safety in pregnancy will remain for many years to come. [source] Pharmaceutical industry-sponsored meetings: good value or just a free meal?INTERNAL MEDICINE JOURNAL, Issue 8 2001S. L. Carney Abstract Although the role of the pharmaceutical industry in continuing medical education (CME) has been debated for many years, industry CME funding continues to increase. Because of concern about the educational quality of industry CME, the Hunter Postgraduate Medical Institute (HPMI), an independent Newcastle and Hunter Valley CME provider, evaluated the use and quality of industry CME as reported by rural and urban general practitioners, physicians and psychiatrists. Furthermore, clinicians were asked if they supported increased industry-funded independent CME. Sixty-two per cent of general practitioners and 71% of psychiatrists attended at least three industry-organized meetings each year, compared with 24% of physicians. Twenty-five per cent of general practitioners attended five or more such meetings. Industry meetings were judged to be of good to excellent quality by 81% of generalists, 79% of physicians and 87% of psychiatrists. All clinical groups ranked the topic and then speaker as the most important reason for attending, with CME points, venue and the sponsor ranked lowest. Eighty to 90% of doctors supported a greater role of industry-funded independent CME. Despite the absence of current data on the use and perceived benefits of industry CME, these preliminary results suggest that industry CME is playing an increasingly important role in clinician education. However, many clinicians and industry representatives support a greater role by independent postgraduate organizations in industry-sponsored CME. (Intern Med J 2001; 31: 488,491) [source] Understanding heterogeneity in meta-analysis: the role of meta-regressionINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 10 2009W. L. Baker Summary Background:, Meta-regression has grown in popularity in recent years, paralleling the increasing numbers of systematic reviews and meta-analysis published in the biomedical literature. However, many clinicians and decision-makers may be unfamiliar with the underlying principles and assumptions made within meta-regression leading to incorrect interpretation of their results. Aims:, This paper reviews the appropriate use and interpretation of meta-regression in the medical literature, including cautions and caveats to its use. Materials & Methods:, A literature search of MEDLINE (OVID) from 1966-February 2009 was conducted to identify literature relevant to the topic of heterogeneity and/or meta-regression in systematic reviews and meta-analysis. Results:, Meta-analysis, a statistical method of pooling data from studies included in a systematic review, is often compromised by heterogeneity of its results. This could include clinical, methodological or statistical heterogeneity. Meta-regression, said to be a merging of meta-analytic and linear regression principles, is a more sophisticated tool for exploring heterogeneity. It aims to discern whether a linear relationship exists between an outcome measure and on or more covariates. The associations found in a meta-regression should be considered hypothesis generating and not regarded as proof of causality. Conclusions:, The current review will enable clinicians and healthcare decision-makers to appropriately interpret the results of meta-regression when used within the constructs of a systematic review, and be able to extend it to their clinical practice. [source] The diagnostic value of barium swallow in globus syndromeINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 1 2004Daniel Hajioff Summary Serious lesions presenting as globus syndrome appear to be extremely rare, but many clinicians routinely request barium swallow to exclude these. No data yet exist on the diagnostic yield of contrast radiography. We reviewed 2854 barium swallows from one department over 7 years. The false-positive rate (37%) depended on presenting symptoms and differed between radiology departments, suggesting substantial subjectivity. No serious radiological abnormalities occurred in the estimated 2011 patients with globus syndrome. The 95% confidence interval for the likelihood of finding a significant abnormality on routine barium swallow in a patient with globus symptoms is 0,0.00145. The 2854 barium swallows cost an estimated £685,000 and 0.22,0.48 deaths. As the risk of missing a serious lesion in a patient with globus is very unlikely to exceed one in 700, we support the opinion that barium swallow should be reserved for those with risk factors or atypical features. [source] UVB phototherapy and skin cancer risk: a review of the literatureINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 5 2005Ernest Lee MD Background, UVB phototherapy is a common treatment modality for psoriasis and other skin diseases. Although UVB has been in use for many decades, many clinicians are hesitant to use this type of phototherapy because of concern over increasing the skin cancer risk. Over the past 20 years, numerous studies have been published examining this issue, but a consensus or analysis of the skin cancer risk is required for the dermatologist to make an educated risk,benefit analysis. Objective, To assess the risk of skin cancer associated with UVB phototherapy. Methods, All prospective or retrospective studies were identified in MEDLINE from 1966 to June 2002. Bibliographies were searched to identify any additional studies examining this issue. All studies that attempted to quantify or qualify any additional skin cancer risk from UVB phototherapy were included. Study selection was performed by two independent reviewers. Results, Eleven studies (10 of which concerned psoriasis patients), involving approximately 3400 participants, were included. Of note, three of the studies involved the same cohort: members of the 16-center US Psoralen plus UVA (PUVA) Follow-up Study. Other than the most recent Finnish study, all studies eventually showed no increased skin cancer risk with UVB phototherapy. One of the PUVA cohort studies examined genital skin cancers, and found an increased rate of genital tumors associated with UVB phototherapy, although this study has not been duplicated. Conclusion, The evidence suggests that UVB phototherapy remains a very safe treatment modality. [source] An investigation of language used by children to describe discomfort expected and experienced during dental treatmentINTERNATIONAL JOURNAL OF PAEDIATRIC DENTISTRY, Issue 5 2005K. HARMAN Summary., Objectives. A study of dental pulp testing has shown that children's linguistic comprehension and chronological age independently influence their descriptions of pain. The present study sought first to demonstrate this for expectations and experience of routine dental treatment, and secondly, to determine whether the effect of age was the result of previous dental and medical experience. Sample. Forty-six children between 6 and 17 years of age attending two paediatric dental clinics for routine invasive procedures comprised the study sample. Methods. To describe their expectations of forthcoming treatment, each child selected words from a published list, and gave ratings on scales describing the degree of severity as ,sore' or ,tingly'. They also completed the Child Dental Anxiety Scale and the Spielberger State-Trait Anxiety Scale for Children. After treatment, they described the treatment with the same list and scales, then completed the British Picture Vocabulary Scale and a dental,medical history questionnaire. Results. The children, especially the most anxious ones, chose more words from the list for their expectations than for their experience of treatment, suggesting, as in previous studies, that they expected more discomfort than they experienced. Ratings of ,sore' and ,tingly' did not show this discrepancy. For both expectations and experience of treatment, the children with the largest vocabularies chose the fewest words, thus being more discriminating in their choices. However, vocabulary had no effect on ratings of ,sore' and ,tingly'. There were no significant relationships among age, estimates of discomfort and medical,dental histories. Conclusions. The results suggest that a list of adjectives provides the most discriminating measure of discomfort. They also show that it is necessary to take into account children's linguistic development to evaluate their estimates of pain so as not to entertain the belief of many clinicians that children exaggerate such reports. [source] Diagnosis and Management of Maxillary Incisors Affected by Incisal Wear: An Interdisciplinary Case ReportJOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY, Issue 6 2002JUSSARA KARINA BERNARDON ABSTRACT In the attempt to restore anterior teeth affected by erosion and bruxism, many clinicians have been frustrated with the constant restorative failures. Frequently, these failures are attributed to the restorative materials employed, especially in cases in which composite resins are used. However, some flaws of the restorations are related to the oversight of occlusal principles. The purpose of this article is to discuss the etiology, signs, and symptoms of incisal wear, with special attention to that caused by bruxism and chemical erosion. Relatively simple management techniques (e.g., occlusal adjustment, adhesive restorations) are proposed, and the diagnosis and management of a representative clinical case is presented. [source] Synergistic enhancement of collagenous protein synthesis by human gingival fibroblasts exposed to nifedipine and interleukin-1-beta in vitroJOURNAL OF ORAL PATHOLOGY & MEDICINE, Issue 1 2000R. B. Johnson Abstract: Gingival overgrowth commonly occurs coincident to therapy with calcium channel blockers. The biologic mechanism for this condition is unknown; however, many clinicians suggest that poor oral hygiene may contribute to development of the overgrowth. This study tests the hypothesis that collagenous protein synthesis by gingival fibroblasts is synergistically enhanced when they are exposed to both nifedipine (N) and the pro-inflammatory cytokine, interleukin-1-beta, a cytokine expressed in inflamed gingiva. Human gingival fibroblasts were isolated from biopsies of normal gingiva and cells separated into two groups. Group 1 was exposed to media containing 0, 5, 50, or 500 pg/ml IL-1-beta, or 10,7 M N for 7 days; Group 2 was exposed to those concentrations of IL-1-beta +10,7 M N. [3H]-proline was added to the medium for the final 24 h. Cells and matrix were harvested and radioactivity determined by liquid scintillation analysis. Means (d.p.m./103 cells) were compared by factorial ANOVA and Scheffè comparisons. Collagenous protein synthesis was significantly reduced by 5 pg/ml IL-1-beta +10,7 M N and enhanced by 500 pg/ml IL-1-beta +10,7 M N as compared to N or IL-1-beta alone. Thus, patients may be more susceptible to gingival overgrowth coincident to nifedipine therapy as a result of the synergistic enhancement of connective tissue synthesis by these agents. [source] Shrinking Lung Syndrome in a 14-Year-Old Boy with Systemic Lupus ErythematosusPEDIATRIC PULMONOLOGY, Issue 2 2006Polly J. Ferguson MD Abstract Pulmonary complications occur frequently in people with systemic lupus erythematosus. We report on an adolescent with an acute onset of dyspnea and pleuritic chest pain with severe restrictive lung physiology on pulmonary function testing (forced vital capacity, 20% of predicted) who had no evidence of parenchymal lung or pleural disease. He was found to have restricted diaphragmatic movement as assessed by fluoroscopy, without evidence of generalized respiratory muscle weakness. His clinical presentation and results of diagnostic tests were typical for shrinking lung syndrome. Given the rarity of shrinking lung syndrome in the pediatric age range, many clinicians are not aware of it as a clinical entity. Shrinking lung syndrome should be included in the differential diagnosis of dyspnea in both children and adults with systemic lupus erythematosus. Pediatr Pulmonol. © 2005 Wiley-Liss, Inc. [source] Visualisation of needle position using ultrasonographyANAESTHESIA, Issue 2 2006G. A. Chapman Summary Anaesthetists and intensivists spend a considerable proportion of their working time inserting needles and catheters into patients. In order to access deeper structures like central veins and nerves, they have traditionally relied on surface markings to guide the needle into the correct position. However, patients may present challenges due to anatomical abnormalities and size. Irrespective of the skill of the operator, there is the ever-present risk of needle misplacement with the potential of damage to structures like arteries, nerve bundles and pleura. Repeated attempts, even if ultimately successful, cause patient suffering and probably increase the risk of infection and other long term complications. Portable and affordable, high-resolution ultrasound scanners, has accelerated the interest in the use of ultrasound guidance for interventional procedures. Ultrasound guidance offers several advantages including a greater likelihood of success, fewer complications and less time spent on the procedure. Even if the target structure is identified correctly there is still the challenge to place the needle or other devices in the optimum site. The smaller and deeper the target, the greater the challenge and potential usefulness of ultrasound guidance. As a result of limited training in the use of ultrasound we believe that many clinicians fail to use it to its full potential. A lack of understanding, with regard to imaging the location of the needle tip remains a major obstacle. Needle visualisation and related topics form the basis for this review. [source] THE CONUNDRUM OF CLAUDICATIONANZ JOURNAL OF SURGERY, Issue 10 2006Ramon L. Varcoe Stable claudication has traditionally been treated conservatively by many clinicians as operative therapies involve considerable risk for a condition that is often slowly progressive and non-fatal. The relative safety of less invasive endovascular techniques brings potential survival benefits from the increased exercise tolerance that result. We aimed to revisit and clarify the aetiologies of intermittent claudication in a review of the rarer causes that can mimic atherosclerotic occlusive disease. An extensive search of Medline, Embase and the Cochrane databases was carried out to compile published work addressing the aetiology of claudication and specific non-atherosclerotic causes. The reference lists of these manuscripts were also searched for relevant articles. There are several vasculogenic and neurogenic causes for intermittent claudication, many of which are unrelated to atherosclerosis. Recognition of these rarer syndromes is essential when planning endovascular or operative management strategies. Consideration of non-atherosclerotic differential diagnoses is recommended when assessing the patient with intermittent claudication. This is particularly critical in the young patient whose pattern of symptoms and risk factors may not fit precisely with atherosclerosis. [source] Prospective study of skin surgery in smokers vs. nonsmokersBRITISH JOURNAL OF DERMATOLOGY, Issue 2 2009A.J. Dixon Summary Background, Smoking may increase complications following minor surgery leading many clinicians to urge patients to refrain from smoking before and after surgery. Objective, To study the association between smoking and complications following skin surgery. Methods, In a 5-year prospective observational study 7224 lesions were excised on 4197 patients. Patients were not instructed regarding smoking. All complications were recorded. Results, A total of 439 smokers (10·5%) underwent 646 procedures (9%), 3758 nonsmokers (89·5%) underwent 6578 procedures (91%). Smokers were younger (55 ± 16 years) than nonsmokers (66 ± 17 years) (P < 0·001). Infection incidence was not significantly different, 1·9% (12/646) in smokers compared with 2·2% (146/6578) in nonsmokers (P = 0·55). There were two bleeds with smokers (0·3%) vs. 50 in nonsmokers (0·8%) (P = 0·2). The incidence of wound dehiscence in nonsmokers (three) was not different from nonsmokers (21) (P = 0·54). However, the incidence of scar contour distortion in smokers (three) was greater than in nonsmokers (two) (odds ratio 15·3; 95% confidence interval 2·5,92). Total complication incidence was similar, 3·6% in smokers vs. 4·0% in nonsmokers (P = 0·58). Out of 2371 flaps there were 14 (0·6%) cases of end-flap necrosis but smokers were not at increased risk. The case,control analysis compared each smoker with two nonsmokers matched for age, sex, postal code and outdoor occupational exposure. This again demonstrated no difference in infection, scar complication, bleed, dehiscence, end-flap necrosis or total complication incidence. Conclusions, Smokers and nonsmokers suffer skin surgery complications similarly. The increased risk of contour distortion identified was difficult to interpret. Advice to cease smoking in the short term to improve outcomes with skin cancer surgery is not supported by these data. [source] Structural parameters of the vastus medialis muscle and its relationship to patellofemoral joint deteriorationCLINICAL ANATOMY, Issue 3 2007J. Peeler Abstract Vastus medialis (VM) muscle dysfunction and abnormal limb alignment are commonly observed in patients who experience changes in patellofemoral joint (PFJ) function, leading many clinicians to assume that there is a direct relationship between VM structural parameters, leg alignment, and PFJ dysfunction. This study tested the hypothesis that there is a relationship between structural parameters of the VM muscle, limb alignment, and the location and severity of patellofemoral joint deterioration (PFJD). The dissection study used 32 limbs from 24 intact cadavers. Data were collected on limb alignment, angle of VM muscle fibers below the superior aspect of the patella, length of VM inserting on the medial aspect of the patella, and severity and location of PFJD. Parametric and nonparametric statistical analyses illustrated that PFJD was most commonly located on the middle third of the medial half of the patellar articular surface. The severity of PFJD did not vary with location. There was no significant correlation between any of VM insertion length, VM fiber angle, limb alignment, and PFJD location and severity lpar;r2 < 0.34). The results of this study did not support the hypothesis of a relationship between structural parameters of the VM muscle, limb alignment, and the location and severity of PFJD in this subject group. Future research should examine the relationship between functional parameters of the entire quadriceps muscle group and PFJ dysfunction. Clin. Anat. 20:307,314, 2007. © 2006 Wiley-Liss, Inc. [source] | ||||||||||||||||||||||||||||