Home About us Contact
|
Home About us Contact | ||
|
|
||
Patient History (patient + history)
Selected AbstractsContemporary Results of Total Aortic Arch ReplacementJOURNAL OF CARDIAC SURGERY, Issue 3 2004Thoralf M. Sundt M.D. The results of surgical intervention reported from large centers are improving; however, the degree to which these results are reproducible by other surgeons is less clear. We therefore reviewed our recent experience with total aortic arch replacement. Methods: Between July 1, 1997 and July 1, 2001 19 patients underwent complete aortic arch replacement, with or without concomitant procedures. We retrospectively reviewed perioperative results retrieved from the computerized database and clinical records. Results: The mean age of the study population was 68 ± 8.3 years (range 52 to 82), with women predominating (11 women, 8 men). All patients had hypertension. Patient history indicated active or past tobacco abuse in 16 patients (80%); cerebrovascular disease in 3, and peripheral vascular disease in 7 patients. Associated procedures included an elephant trunk in 12 (63%), replacement of the upper descending thoracic aorta in 5 (26%), concomitant coronary artery bypass in 5 (26%), and aortic root replacement in 3 (16%). One patient underwent replacement of the entire aorta from sinotubular ridge to iliac bifurcation in a single procedure. Brachiocephalic reconstruction with a "Y-graft" permitting early antegrade cerebral perfusion was performed in 12 patients. Retrograde cerebral perfusion was performed in ten patients (53%). Perioperatively, death occurred in two patients (11%) and stroke in two (11%). Conclusions: With cautious application, techniques developed in high-volume centers can also achieve satisfactory results when used at centers with a more modest case volume. (J Card Surg 2004;19:235-239) [source] Patient history must be incorporated into any guidelinesBIPOLAR DISORDERS, Issue 7 2009Robert H. Belmaker M.D. No abstract is available for this article. [source] Aniridia among children and teenagers in Sweden and NorwayACTA OPHTHALMOLOGICA, Issue 2 2009Ulla Edén In the November 2008 issue (AOS 86:7), the article by Ulla Edén et al. was not published correctly in the printed issue. Unfortunately, part of the section ,Visual acuity' in the Results was repeated on page 732, and the start of the Discussion was omitted on page 732. The full and correct version of this article is printed hereunder. The Publisher apologises for this error. Reference EdénU, BeijarC, RiiseR & TornqvistK (2008): Aniridia among children and teenagers in Sweden and Norway. Acta Ophthalmol86: 730,734. Abstract. Purpose:, To investigate patients under the age of 20 with aniridia in Sweden and Norway in order to estimate the prevalence of aniridia, to describe clinical signs and identify complications in the young, which will help improve diagnostic tools and treatment. Methods:, A thorough search for patients with aniridia (of all ages) was performed. Sixty-two of the 181 patients were under the age of 20. Fifty-two of them were examined and they constituted the study population. Patient history was obtained and all participants underwent clinical ophthalmologic examination, including photography. Blood samples were taken for mutation analysis. Results:, Epidemiological data are only based on the results in Sweden. The age-specific prevalence in Sweden was 1:47 000, male/female ratio was 0.57, mean age 12 years and median age 14 years. The proportion of sporadic cases including WAGR (Wilms tumour, Aniridia, Genitourinary abnormalities, Mental Retardation) and Gillespie syndrome (aniridia, cerebellar ataxia and mental retardation) was 48%. In the entire study population (Sweden and Norway), the mean visual acuity (VA) was 0.2 (range 0.04,0.9). We found VA < 0.3 in 80% and <0.1 in 18% of the patients. Twenty-two patients (42%) had one or more of the sight threatening complications such as cataract/lens luxation, corneal clouding or glaucoma. Conclusion:, Descriptions of aniridia in the younger are rare. This study shows that aniridia seems to be more common than previously estimated and that some complications appear early in life. Watchfulness as regards these complications and regular examinations are essential even in the youngest. [source] Change in Mammographic Breast Density Associated with the Use of Depo-ProveraTHE BREAST JOURNAL, Issue 4 2003Charlotte L. Dillis MD Abstract: We report two cases in which routine mammograms showed a significant increase in breast density compared to previous studies. Review of patient histories revealed that both women had been receiving contraceptive injections of Depo-Provera at the time of their earlier mammograms. Breast density increased after Depo-Provera was discontinued. We postulate that Depo-Provera has a suppressive effect on breast density. Alterations in breast density may have implications regarding breast cancer risk. Etiologies of generalized change in breast density are reviewed. [source] Prevalence and clinical relevance of corrected QT interval prolongation during methadone and buprenorphine treatment: a mortality assessment studyADDICTION, Issue 6 2009Katinka Anchersen ABSTRACT Aims To determine the prevalence of corrected QT interval (QTc) prolongation among patients in opioid maintenance treatment (OMT) and to investigate mortality potentially attributable to QTc prolongation in the Norwegian OMT programme. Participants and setting Two hundred OMT patients in Oslo were recruited to the QTc assessment study between October 2006 and August 2007. The Norwegian register of all patients receiving OMT in Norway (January 1997,December 2003) and the national death certificate register were used to assess mortality. Mortality records were examined for the 90 deaths that had occurred among 2382 patients with 6450 total years in OMT. Design and measures The QTc interval was assessed by electrocardiography (ECG). All ECGs were examined by the same cardiologist, who was blind to patient history and medication. Mortality was calculated by cross-matching the OMT register and the national death certificate register: deaths that were possibly attributable to QTc prolongation were divided by the number of patient-years in OMT. Findings In the QTc assessment sample (n = 200), 173 patients (86.5%) received methadone and 27 (13.5%) received buprenorphine. In the methadone group, 4.6% (n = 8) had a QTc above 500 milliseconds; 15% (n = 26) had a QTc interval above 470 milliseconds; and 28.9% (n = 50) had a QTc above 450 milliseconds. All patients receiving buprenorphine (n = 27) had QTc results <450 milliseconds. A positive dose-dependent association was identified between QTc length and dose of methadone, and all patients with a QTc above 500 milliseconds were taking methadone doses of 120 mg or more. OMT patient mortality, where QTc prolongation could not be excluded as the cause of death, was 0.06/100 patient-years. Only one death among 3850 OMT initiations occurred within the first month of treatment. Conclusion Of the methadone patients, 4.6% had QTc intervals above 500 milliseconds. The maximum mortality attributable to QTc prolongation was low: 0.06 per 100 patient-years. [source] Clinical Presentations and Phenomenology of MyoclonusEPILEPSIA, Issue 2003Edward Faught Summary: The term "myoclonus" has been used to describe heterogeneous phenomena involving sudden movements, but there is no generally accepted, precise definition of myoclonus. Myoclonus can often be classified based on electroencephalographic (EEG) and/or electromyographic (EMG) data. Some myoclonic epilepsy syndromes, including juvenile myoclonic epilepsy, may frequently be misdiagnosed because of failure to obtain a complete patient history and/or failure to appreciate characteristic EEG changes. A good understanding of the features associated with myoclonic disorders (particularly the myoclonic epilepsies) and of features associated with other neurologic disorders that are often confused with myoclonic disorders is an invaluable aid in obtaining an accurate diagnosis and will ultimately help in determining the best course of treatment for patients. [source] Zonisamide Prophylaxis in Refractory Pediatric HeadacheHEADACHE, Issue 5 2006Ann Pakalnis MD Introduction.,Currently, no medications are approved for pediatric headache prophylaxis in the United States. Zonisamide is an antiepileptic drug with preliminary studies suggesting some efficacy in the adult headache population. Methods.,A retrospective chart review was conducted on refractory headache patients in our multidisciplinary Headache Clinic who were treated with zonisamide, an antiepileptic drug, for headache prophylaxis. Records were reviewed for pertinent data including patient history, diagnosis, prior treatment regimens, and zonisamide response, along with headache frequency. Results.,Twelve patients were identified (8 girls); mean age was 13.5 years. Eight of the 12 patients had a positive response to zonisamide with greater than 50% reduction in headaches from pretreatment values. Conclusion.,Zonisamide had some efficacy in headache reduction. It was well tolerated with only minor side effects. Further prospective studies with zonisamide are warranted in refractory pediatric headache patients. [source] Atypical pityriasis rosea or psoriasis guttata?INTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 11 2002Early examination is the key to a correct diagnosis Pityriasis rosea is a self-limited, mild, inflammatory skin disease characterized by scaly lesions, possibly due to an unidentified infectious agent. It may occur at any age, but is seen most frequently in young adults. This paper reports a patient who presented with a skin condition which was initially diagnosed as pityriasis rosea; however, due to the persistence and change in appearance of the lesions, the diagnosis was later altered to psoriasis guttata. Changes in pityriasis rosea lesions over the course of the disease may make a correct diagnosis difficult, unless the patient is seen during the early stages of lesion formation. The final diagnosis in this case was of the rare variant known as pityriasis rosea irritata. This case highlights the importance of an excellent patient history in order to correctly diagnose the disease. [source] A Computerized Nursing Process Support System in BrazilINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Maria da Graça Oliveira Crossetti BACKGROUND Hospital de Clinicas de Porto Alegre introduced the nursing process model as the basis for nursing practice at the hospital more than 20 years ago. A computerized nursing order system based on nursing diagnoses was introduced. The strategies used in the development of the system included establishment of Nursing Diagnosis Work Groups in 1998; systematic analysis of nursing processes based on the work of existing studies, the NANDA taxonomy in 1999; development and implementation of a data collection instrument to analyze the nursing diagnosis process; training of all nursing staff during 1999,2000; meetings between analysts and nursing staff to articulate the nursing process needs the system would be required to support; pilot implementation of the computerized nursing process system in the ICU in February 2000; and hospital-wide implementation in December 2000. The system supports nursing diagnoses and orders. It was developed in-house by the information systems group at the hospital and is implemented as an Oracle database accessed in client server mode over a Windows NT-based Ethernet network. The system is part of the hospital's larger clinical information management system. MAIN CONTENT POINTS The patient care module includes medical orders and nursing orders. On entering the nursing orders module, the user selects a patient and the system presents a list all current orders completed and pending. These orders can be examined, updated, and reprinted, and new daily nursing orders can also be input at this time. The "new order" screen provides the user with any previous orders to ensure consistency in nursing care. New nursing orders are prepared based on the patient history, physical exam, and daily evaluations. Required interventions are identified based on changes in the patient's "basic human needs." This process can be realized through two distinct paths through the nursing care module: one associated with diagnoses and the other with signs and symptoms. A nurse with more clinical experience and knowledge of diagnostic reasoning will opt to develop orders based on diagnoses. After the diagnosis and associated etiology is input, the system generates a list of possible interventions for selection. The duration and frequency of the intervention can then be specified and the order individualized to a patient's particular needs. Less experienced nurses and students will develop nursing orders based on a patient's signs and symptoms. The system generates a list of diagnoses, etiology, and associated basic human needs in response to the signs and symptoms input. The nurse selects the appropriate diagnoses and etiology and the system generates the list of nursing intervention options. Nurses following either path are required to confirm their orders. They then have the option of developing other orders for the same patient until all that patient's basic human needs have been addressed. The orders can be printed but also remain in the system for nursing staff to implement. CONCLUSIONS The application of systematic, evidence-based methods in nursing care results in improved quality of service that conforms to individual patients' basic human needs. [source] Nurses' decision-making in collecting information for the assessment of patients' nursing problemsJOURNAL OF CLINICAL NURSING, Issue 2 2002TARJA JUNNOLA MNSc ,,The paper addresses two questions: Firstly, what kind of information do nurses acquire from cancer patients for purposes of judging their patients' problems and preparing a care plan? Secondly, how systematically do nurses proceed in the decision-making process from the formulation of initial assumptions about the patient's situation to the final definition of problems? ,,The instrument used for data collection was a computer-simulated case description compiled by a team of four nursing researchers and one medical researcher. The case description was based on a real patient history. ,,The sample consisted of 107 Registered Nurses on four oncology, two internal medicine and five surgical wards of two central university hospitals in Finland. Data were collected in autumn 1998 and spring 1999 using a laptop computer and a tape recorder. ,,The four most important problems identified by nurses at baseline were pain (85%), pain medication (59%), family situation (66%) and spread of cancer (49%). Presented with a list of 23 options, they obtained additional information on average on 13 areas. Almost one-third collected information from 16 to 22 areas. On average nurses identified 12 of the 28 nursing problems specified. A statistically significant association was observed between information acquisition and problem definition in seven different variables. These had to do with pain, general condition and prognosis. ,,Nurses adequately prioritized their patients' problems and systematically collected data on those problems. On the other hand they also identified a number of problems that were not relevant to the situation. [source] Laparoscopic scar: A mimicker of Sister Mary Joseph's nodule on positron emission tomography/CTJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 5 2006B Setty Summary Positron emission tomography/CT is an established imaging method in the diagnosis and staging of cancers. 18F-fluoro-2-deoxy- d -glucose (FDG) is the most commonly used radiotracer in positron emission tomography/CT. It is a tumour viability agent and usually its uptake within a lesion reflects the presence of a viable tumour tissue. However, false-positive FDG uptake is known to occur in benign processes of either inflammatory or infectious aetiology. We describe FDG uptake at the site of laparoscopic scar that mimicked Sister Mary Joseph's nodule in a patient with gastric adenocarcinoma. Here, the knowledge of the patient's history and subtle imaging findings helped in accurate staging of the patient. In this case report, we emphasize the value of the knowledge of the patient history and awareness of different pitfalls of FDG to achieve a correct diagnosis on positron emission tomography/CT. [source] Fibromyalgia,Management of a misunderstood disorderJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 7 2007Education & Training Flight Commander), Erin L. Peterson RN, FNP (Major; Family Nurse Practitioner Abstract Purpose: The purpose of this article is to review (a) what is currently known about the pathophysiology of fibromyalgia (FM), (b) how to identify patients who are susceptible to this disorder, and (c) the recommended pharmacological and nonpharmacological treatment options. Data sources: Data sources include reviews and original research from scholarly journals and Internet sites. Conclusions: There are approximately 6 million individuals in the United States diagnosed with FM, making it the third most prevalent rheumatologic disorder in this country. Failure to identify a specific causal mechanism for FM has resulted in a shift in the focus of research from etiology to treatment (Baumstark & Buckelew, 2002). Based on the literature, the most successful interventions for reduction of chronic symptoms in the FM patient is a combination of education, psychological assistance, and exercise, along with medications. It is essential that nurse practitioners (NPs) understand the issues and concerns of patients afflicted with this complex disorder. Although the organic etiology of FM syndrome remains unclear, the goals of treatment are to control pain and improve adjustment, well-being, and daily functioning of these patients to the maximum extent possible. Implications for practice: NPs are in a unique position to help identify patients who may be suffering from FM or those diagnosed with FM reporting inadequate relief of symptoms. The incomplete understanding of the biological underpinnings, as well as the multiple symptoms that characterize FM syndrome, make it a challenging disorder to diagnose and treat. It takes time and patience to care for FM patients, and there are no "quick fixes." Diagnosis is made by a combination of patient history, physical examination, laboratory evaluations, and exclusion of other causes of symptoms confused with FM. Understanding the symptomology and recommended treatments will allow NPs to give appropriate care that may include making referrals for multidisciplinary treatment of these complex patients. [source] Recognizing And Treating Non-Infectious RhinitisJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 9 2003Terrye Mastin APRN Purpose To increase clinicians' familiarity with nonallergic and mixed rhinitis and to differentiate these from allergic rhinitis, thus providing for an accurate diagnosis and facilitating a successful initial treatment program. Data Sources A Medline search of published journal articles was supplemented with known books and proceedings pertaining to rhinitis. Conclusions Although there is significant overlap of symptoms among the three types of rhinitis (i.e., allergic, nonallergic, and mixed), the patient history often contains clues that can aid in establishing a correct diagnosis. The new Patient Rhinitis Screen, a questionnaire developed for use in the primary care arena, facilitates the diagnostic process. Implications for Practice As the most common condition in the outpatient practice of medicine, rhinitis is frequently treated by primary care practitioners. Recent guidelines for the diagnosis and management of rhinitis suggest that a specific diagnosis of allergic, nonallergic, or mixed rhinitis leads to more effective treatment strategies. The result is successful and efficient care utilizing, as appropriate, broad-based and symptom-specific therapies. [source] GA2LEN skin test study II: clinical relevance of inhalant allergen sensitizations in EuropeALLERGY, Issue 10 2009G. J. Burbach Background:, Skin prick testing is the standard for diagnosing IgE-mediated allergies. A positive skin prick reaction, however, does not always correlate with clinical symptoms. A large database from a Global Asthma and Allergy European Network (GA2LEN) study with data on clinical relevance was used to determine the clinical relevance of sensitizations against the 18 most frequent inhalant allergens in Europe. The study population consisted of patients referred to one of the 17 allergy centres in 14 European countries (n = 3034, median age = 33 years). The aim of the study was to assess the clinical relevance of positive skin prick test reactions against inhalant allergens considering the predominating type of symptoms in a pan-European population of patients presenting with suspected allergic disease. Methods:, Clinical relevance of skin prick tests was recorded with regard to patient history and optional additional tests. A putative correlation between sensitization and allergic disease was assessed using logistic regression analysis. Results:, While an overall rate of ,60% clinically relevant sensitizations was observed in all countries, a differential distribution of clinically relevant sensitizations was demonstrated depending on type of allergen and country where the prick test was performed. Furthermore, a significant correlation between the presence of allergic disease and the number of sensitizations was demonstrated. Conclusion:, This study strongly emphasizes the importance of evaluating the clinical relevance of positive skin prick tests and calls for further studies, which may, ultimately, help increase the positive predictive value of allergy testing. [source] Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular OutcomesACADEMIC EMERGENCY MEDICINE, Issue 8 2009Abhinav Chandra MD Abstract Objectives:, The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event. Methods:, This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina. Results:, Of 15,608 unique patients in the registry, 10,145 met inclusion/exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). Conclusions:, In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes. [source] POST CAESAREAN VESICOUTERINE FISTULAE , YOUSSEF SYNDROME: OUR EXPERIENCE AND REVIEW OF PUBLISHED WORKANZ JOURNAL OF SURGERY, Issue 4 2006M. Prasad Rao Objective: To analyse the incidence, symptomatology, diagnosis and therapeutic aspects of Youssef syndrome (post caesarean vesicouterine fistula), and to review relevant published work. Methods: A retrospective study from the urosurgical unit of a tertiary care referral hospital was carried out. In a retrospective analysis of urogenital fistulae over 10 years, we identified 14 patients with uterovesical fistulae, resulting from caesarean section. All the patients were evaluated by history, physical examination, radiological tests and cystoscopy. All patients underwent transperitoneal repair of these fistulae with omental interposition. Results of surgery were evaluated by absence of cyclic haematuria, stoppage of urinary incontinence, and achievement of fertility. Results: A total of 12 patients who had minimum follow up was included in the present study. The results showed that 50% of the fistulae resulted from emergency caesarean operation with 58% of patients presenting after their second caesarean section. The mean age of the patients was 19 years (range 15,29) and mean duration of symptoms was 7 months (range 3,16). Menouria and amenorrhoea were predominant presenting symptoms. The results of surgical treatment were excellent with good continence and resolution of the cyclic haematuria. Three pregnancies (37.5%) which resulted in elective caesarean section were recorded. Conclusion: Vesicouterine fistulae, despite being infrequent, are no longer a rare diagnosis and are most commonly secondary to lower segment caesarean section. With patient history and selected investigations diagnosis is relatively easy. The surgical repair of these fistulae is standard treatment, especially with delayed fistulae with achievement of total continence, and complete resolution of cyclic haematuria. Meticulous practice of obstetric and surgical principles during caesarean section can prevent the formation of these fistulae. [source] Guardian Availability in Children Evaluated in the Emergency Department for Blunt Head TraumaACADEMIC EMERGENCY MEDICINE, Issue 1 2009James F. Holmes MD Abstract Background:, Enrolling children in research studies in the emergency department (ED) is typically dependent on the presence of a guardian to provide written informed consent. Objectives:, The objectives were to determine the rate of guardian availability during the initial ED evaluation of children with nontrivial blunt head trauma, to identify the reasons why a guardian is unavailable, and to compare clinical factors in patients with and without a guardian present during initial ED evaluation. Methods:, This was a prospective study of children (<18 years of age) presenting to a single Level 1 trauma center after nontrivial blunt head trauma over a 10-month period. Physicians documented patient history and physical examination findings onto a structured data form after initial evaluation. The data form contained data points regarding the presence or absence of the patient's guardian during the initial ED evaluation. For those children for whom the guardian was not available during the initial ED evaluation, the physicians completing the data forms documented the reasons for the absence. Results:, The authors enrolled 602 patients, of whom 271 (45%, 95% confidence interval [CI] = 41% to 49%) did not have a guardian available during the initial ED evaluation. In these 271 patients, 261 had reasons documented for lack of guardian availability, 43 of whom had multiple reasons. The most common of these was that the guardian did not ride in the ambulance (51%). Those patients without a guardian available were more likely to be older (mean age, 11.4 years vs. 7.6 years; p < 0.001), be victims of a motor vehicle collision (MVC; 130/268 [49%] vs. 35/328 [11%]; p < 0.001), have a Glasgow Coma Scale (GCS) score <14 (21/269 [7.8%] vs. 11/331 [3.3%]; p = 0.02), and undergo cranial computed tomography (CT) scanning (224/271 [83%] vs. 213/331 [64%]; p < 0.001). Multivariate analysis identified similar independent risk factors for lack of guardian presence. Conclusions:, Nearly one-half of children with nontrivial blunt head trauma evaluated in the ED may not have a guardian available during their initial ED evaluation. Patients whose guardians are not available at the time of initial ED evaluation are older and have more severe mechanisms of injury and more serious head trauma. ED research studies of pediatric trauma patients that require written informed consent from a guardian at the time of initial ED evaluation and treatment may have difficulty enrolling targeted sample size numbers and will likely be limited by enrollment bias. [source] Prediction of findings at defecography in patients with genital prolapseBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 11 2005Jan-Paul W.R. Roovers Objective Defecography may be useful in pre-operative assessment of patients with genital prolapse. Defecography is an invasive and embarrassing procedure for patients and little effort has been made to optimalise selection criteria for defecography. This study investigated whether discrimination of high and low probability of abnormal defecography is possible based on the quantified findings from patient history, pelvic examination and a validated questionnaire. Design Prospective observational study. Setting Three teaching hospitals in The Netherlands. Population Eighty-two patients undergoing surgical correction of uterine prolapse Stages 2,4. Methods A history and pelvic examination were obtained from all patients. A validated questionnaire was used to assess the presence of defecation and micturition symptoms. Using multivariate logistic regression analyses with receiver operating characteristic curves, a diagnostic model to predict the presence of an abnormal defecography was systematically constructed and validated. Main outcome measure Presence of abnormal finding at defecography. Results The most important predictors for abnormal defecography were prolapse of the posterior vaginal wall, history of abdominal or pelvic surgery and the presence of constipation. With these variables, a prediction rule could be constructed which predicted the prevalence of an abnormal defecography (area under curve = 0.73; 95% CI 0.61,0.83). Conclusions This study shows that a diagnostic model based on findings obtained from a non-invasive workup can accurately predict the presence of an abnormal defecography. Such a model provides the possibility to tailor the request for defecography to the individual patient. [source] Preterm premature rupture of membranes: diagnosis, evaluation and management strategiesBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 2005Hyagriv N. Simhan Preterm premature rupture of the membranes (PPROM) is responsible for one-third of all preterm births and affects 120,000 pregnancies in the United States each year. Effective treatment relies on accurate diagnosis and is gestational age dependent. The diagnosis of PPROM is made by a combination of clinical suspicion, patient history and some simple tests. PPROM is associated with significant maternal and neonatal morbidity and mortality from infection, umbilical cord compression, placental abruption and preterm birth. Subclinical intrauterine infection has been implicated as a major aetiological factor in the pathogenesis and subsequent maternal and neonatal morbidity associated with PPROM. The frequency of positive cultures obtained by transabdominal amniocentesis at the time of presentation with PPROM in the absence of labour is 25,40%. The majority of amniotic fluid infection in the setting of PPROM does not produce the signs and symptoms traditionally used as diagnostic criteria for clinical chorioamnionitis. Any evidence of infection by amniocentesis should be considered carefully as an indication for delivery. Documentation of amniotic fluid infection in women who present with PPROM enables us to triage our therapeutic decision making rationally. In PPROM, the optimal interval for delivery occurs when the risks of immaturity are outweighed by the risks of pregnancy prolongation (infection, abruption and cord accident). Lung maturity assessment may be a useful guide when planning delivery in the 32- to 34-week interval. A gestational age approach to therapy is important and should be adjusted for each hospital's neonatal intensive care unit. Antenatal antibiotics and corticosteroid therapies have clear benefits and should be offered to all women without contraindications. During conservative management, women should be monitored closely for placental abruption, infection, labour and a non-reassuring fetal status. Women with PPROM after 32 weeks of gestation should be considered for delivery, and after 34 weeks the benefits of delivery clearly outweigh the risks. [source] Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapseBJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 4 2000Mario Colombo Senior Registrar Objective To compare the Burch colposuspension and the anterior colporrhaphy in women with both stress urinary incontinence and advanced anterior vaginal wall prolapse (cystocele). Design Prospective randomised study. Setting Secondary referral centre, Urogynaecology Unit, San Gerardo Hospital, Monza, Italy. Sample Seventy-one women undergoing surgery for primary genuine stress incontinence and concurrent grade 2 or 3 cystocele (descending at or outside the vaginal introitus). Methods Full urodynamic investigation performed pre-operatively and repeated six months after surgery. Clinical follow up continued for 8 to 17 years. Main outcome measures Subjective (patient history) and objective (negative stress test result) cure of stress incontinence. Assessment of cystocele recurrence. Results Thirty (86%) of the 35 evaluable women who had the Burch colposuspension and 17 (52%) of the 33 evaluable women who had the anterior colporrhaphy were subjectively cured (OR 5.6, 95% CI 1.6 to 21.6; P= 0.005). Objective cure rates were 74% (26 of 35) and 42% (14 of 33), respectively (OR 3.9, 95% CI 1.3 to 12.5; P= 0.02). A recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites was recorded in 34% (12 of 35) and 3% (1 of 33) of women, respectively (OR 16.7, 95% CI 2.0 to 368.1; P= 0.003). Conclusions The Burch colposuspension was better in controlling stress incontinence but it lead to an unacceptable high rate of prolapse recurrence. The anterior colporrhaphy was more effective in restoring vaginal anatomy but it was accompanied by an unacceptable low cure rate of stress incontinence. Neither of the two operations is recommended for women who are suffering from a combination of stress incontinence and advanced cystocele. [source] A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?BJU INTERNATIONAL, Issue 9 2003J. Irani The Clinical Practice Guidelines on BPH/LUTS are examined by authors from London and Poitiers. They found in their review of the literature that the overall and methodological quality of such guidelines varies widely. They acknowledge the difficulties in developing careful guidelines, but suggest a formal appraisal of quality and methods, as these are the ones more likely to help urologists in decision-making. There are three papers on the prevalence of symptoms relating to lower tract conditions. The first examines male urinary incontinence in four European centres, the second nocturia and its effect on quality of life and sleep in a US community sample, and a further paper describes the prevalence diagnosis and treatment of prostatitis in Italy. A study from Sydney describes the authors use of the Inflow intra-urethral device for managing acontractile bladders in female patients. They found that the device provides an effective method of bladder drainage, with an acceptable side-effect profile and a significant improvement in quality of life. OBJECTIVE To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence. METHODS An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application. RESULTS Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year. CONCLUSION The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients. [source] Accidental mydriasis from exposure to Angel's trumpet (Datura suaveolens)ACTA OPHTHALMOLOGICA, Issue 3 2002Ulf Havelius ABSTRACT. Purpose:, To report clinical findings after accidental instillation into the eye of sap from Angel's trumpet (Datura suaveolens). Methods:, We report findings on seven patients who developed sudden onset of unilateral mydriasis. At least three of them also had ipsilateral cycloplegia and one developed transient tachycardia. Results:, The symptoms evolved after ocular exposure to sap from Angel's trumpet, a plant containing natural alkaloids with parasympatholytic properties. Six patients were initially unaware of the cause of their symptoms. In these cases, patient history revealed recent contact with Angel's trumpet. Conclusion:, Accidental ocular instillation of sap from Angel's trumpet should be noted as a cause of sudden onset of mydriasis in otherwise unaffected patients and also of general symptoms like tachycardia. [source] Antiplatelet Therapy in Cerebrovascular Disease: Implications of MATCH and CHARISMA Results for CardiologistsCLINICAL CARDIOLOGY, Issue 12 2007Dan James Fintel M.D. Abstract Cardiovascular disease is prevalent among patients with stroke; thus, cardiologists frequently treat patients at high risk for stroke. Results from recent clinical trials of antiplatelet medications, given alone or in combination, may be of special interest to cardiologists. The MATCH study demonstrated no significant difference between clopidogrel alone and clopidogrel plus aspirin in reducing risk of vascular events after stroke or transient ischemic attack. A 1.3% increased risk of major bleeding was associated with clopidogrel plus aspirin. In CHARISMA, clopidogrel plus aspirin did not reach statistical significance vs. placebo plus aspirin in reducing incidence of myocardial infarction (MI), stroke, or death from cardiovascular causes in patients with stable atherothrombotic disease; clopidogrel was associated with an increase in moderate bleeding. These results suggest that clopidogrel plus aspirin may be inappropriate as first-line therapy for secondary stroke prevention. In patients with established cardiovascular disease at risk for MI or other vascular events, physicians must weigh the benefits and risks before choosing this therapy. Selection of an antiplatelet agent must be based on patient history, including previous MI and stroke, susceptibility to bleeding, and other high-risk factors (e.g. advanced age and diabetes). Aspirin plus extended-release dipyridamole may be more effective than clopidogrel for preventing stroke in high-risk patients. This article strives to put MATCH and CHARISMA results into context by providing an overview of antiplatelet therapy, including relevant clinical trial results, a review of current practice guidelines, and a summary of an ongoing study that will improve clinical decision making. Copyright © 2007 Wiley Periodicals, Inc. [source] The role of ENT surgeons in snoring assessment: some prospective preliminary evidenceCLINICAL OTOLARYNGOLOGY, Issue 5 2008S. Robertson Objectives:, To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers. Design:, Prospective analytical cohort study. Setting:, Snoring clinic in Secondary Care Otolaryngology centre. Participants:, Ninety-three patients referred with disruptive snoring. Main outcome measures:, A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected. Results:, The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology. Conclusion:, The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment. [source] Targets and elective colorectal cancer: outcome and symptom delay at surgical resectionCOLORECTAL DISEASE, Issue 2 2005S. Bharucha Abstract Objective To determine, for elective patients with colorectal cancer, if associations exist between the length of symptom history at surgical resection and Dukes stage, completeness of the surgical procedure and patient survival. Patients and methods A prospective cohort study was undertaken. Five hundred and eighty-two patients with colorectal cancer, admitted for surgical resection after outpatient consultation, divided into four equal quartiles according to length of symptom history (short: n = 131, 0,103 days; medium: n = 136, 104,177 days; long: n = 136, 178,318 days; very long: n = 137, 319,1997 days). The main outcome measures used were the Extent of tumour (Dukes stage) at resection, completeness of resectional surgery (curative vs palliative), patient survival after resection. Results For patients undergoing elective surgical resection of colorectal cancer we did not find an association between Dukes stage and duration of patient history (Dukes stage C tumours were seen in 37% (CI: 26.2%-48.0%) of patients with a short symptomatic history as opposed to 34% (CI: 32%-62%) with a very long symptomatic history). Elective curative resection was not associated with a significantly different symptom duration than elective palliative resection (Palliative resections were performed in 24% (CI: 11.7%-36.4%) of patients with a short symptomatic history as opposed to 16% (CI: 2.4%-29.9%) with a very long symptomatic history). The median survival time for the four elective colorectal patient groups defined by length of symptomatic history was not significantly different , (short: n = 131, 4.3 years; medium: n = 136, 5.9 years; long: n = 136, 7.1 years; very long: n = 137, 5.0 years). Conclusion Tumour extent, completeness of resection and patient outcome after elective colorectal cancer resection was not found to have an association with length of patient history at the time of surgery. [source] The symptomatic treatment of multiple system atrophyEUROPEAN JOURNAL OF NEUROLOGY, Issue 3 2002C. Colosimo Multiple system atrophy (MSA) is a neurodegenerative disease of undetermined aetiology that occurs sporadically and manifests itself as a combination of parkinsonian, autonomic, cerebellar and pyramidal signs. Despite the lack of any effective therapy to reverse this condition, some of the symptoms may be, at least temporarily, improved with adequate symptomatic therapies. Medical treatment is largely aimed at mitigating the parkinsonian and autonomic features. The therapeutic results of levodopa therapy in cases of MSA are difficult to interpret because of their variability. Nevertheless, the statement that patients with MSA are non or poorly levodopa-responsive is misleading. Clinical and pathologically proven series document about 40,60% levodopa efficacy in patients with MSA presenting with predominant parkinsonian features. Unfortunately, other antiparkinsonian compounds (dopamine agonists, amantadine) are not more effective than levodopa. Orthostatic hypotension (OH) can be suspected from the patient's history and subsequently documented in the clinic by measuring lying and standing blood pressure. The diagnosis ideally should be confirmed in the laboratory with additional tests to determine the cause and evaluate the functional deficit, so as to aid treatment. A variety of pharmacological agents with different mechanisms of action have been used in MSA to reduce OH when this is symptomatic. OH can also be alleviated by avoiding aggravating factors, such as the effects of food, micturition, exposure to a warm environment and physiological diurnal changes and by using other non-pharmacological strategies. The treatment of the very common genito-urinary symptoms (incontinence, retention, impotence) should also be considered in order to improve the quality of life of these patients. [source] Defining the patient at high risk for melanomaINTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 4 2010Estee L. Psaty BA In this practical review, we aim to help clinicians identify patients who are at significant risk of developing malignant melanoma. Universal screening is challenging, thus it is important to effectively single out patients who have a high risk of developing the disease. We provide a summary of pertinent questions to review when taking the patient's history, point out the phenotypic features to note during skin examination, and suggest risk stratification as a means to plan initial and long-term surveillance strategy. We mention personal and family history of melanoma as prime risk factors for melanoma, yet the review also focuses on the patient who has no history of melanoma, either in himself or his family, and the proper ways to evaluate his likelihood of developing the disease. [source] Haemoglobinometry in general practiceINTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY, Issue 6 2003S. M. Lewis Summary Haemoglobinometry as a primary point-of-care test is well established. This study was undertaken to assess whether haemoglobinometry by itself provides an adequate haematological screening procedure in general practice. In a series of 500 sequential blood counts received by the central hospital laboratory from local doctors, 405 (81%) had a normal haemoglobin. Full blood counts on these samples showed 15% with one or more blood count parameters outside 2SD of normal reference values, including increased MCV, low MCV with low MCH and MCHC, leucocytosis with neutrophilia, a few cases with neutropenia, lymphopenia, monocytosis or eosinophilia. When the limits were set at 3SD, these abnormalities were found in only 7.6% of the cases. Calculation of test utility gave a positive predictive value of 0.83, a negative predictive value of 0.85, with a likelihood ratio of 14.3 and an overall diagnostic reliability of 84%. It was concluded that haemoglobin alone is a valuable primary screening test and a full blood count is required only when anaemia is present or when the patient's history and clinical signs indicate the need for such further investigation. Using this protocol it is unlikely that any serious error will be made in diagnosing a clinically significant condition; the main limitation is failure to diagnose pre-anaemic iron deficiency. [source] Primary health care nursing staff in Crete: an emerging profileINTERNATIONAL NURSING REVIEW, Issue 1 2006A. Markaki rn Background:, In 2001, the newly established Regional Health and Welfare System of Crete commissioned the first needs' assessment study of nursing personnel employed in the public sector of primary health care (PHC). Aim:, To capture the profile and professional needs of nursing staff working in Health Centers throughout the island of Crete and explore variations in nursing practice by educational preparation. Methods:, A newly developed, psychometrically tested questionnaire, was administered to all nursing staff in 14 rural Health Centers. Findings:, Vacancy rates are high, indicating a serious staffing deficit. The type of degree earned (2-year vs. 3 or 4-year program) does not differentiate nursing practice, with only two exceptions (obtaining a patient's history and counselling patients). The majority of respondents assess their existing knowledge and skills as ,adequate' while indicating a strong desire for continuing education. Job satisfaction is high in terms of interactions with clients and community recognition, while it is rated ,low' in terms of daily interactions with colleagues and support from work environment. Conclusion:, Cretan nursing staff in PHC operate within a restricted and task-orientated framework. Their educational preparation has little effect in practice role variations and professional needs. The Regional Health and Welfare System of Crete should address daily supervision and support issues, on-the-job training, continuing education needs, while taking immediate action to avoid potential turnover of existing staff and to aggressively recruit young, qualified nursing staff who will choose a career in PHC nursing. [source] A11. UV-related skin hazards: allergic photodermatitisJOURNAL OF COSMETIC DERMATOLOGY, Issue 2 2002Paolo Pigatto Cases of dermatitis induced by exposure to ultra-violet radiation are increasingly encountered in clinical practice, with contact allergic photodermatitis accounting for about 10% of cases. Its frequency seems to be increasing, not only as a result of the increased use of cosmetic products and contact with some of the materials of working processes, but above all because of the greater exposure to both natural and artificial sources of UV radiation. Many substances have been defined ,photo-allergising' but their exact prevalence has varied over the years with the introduction and use of new substances in cosmetics and pharmaceutical products. For these, and other reasons, there are few studies concerning the prevalence and incidence of contact allergic photodermatitis in Italy. A total of 2160 patients with clinical histories suggestive of photoallergic contact dermatitis were seen. All patients underwent photopatch tests with haptens proposed by the Gruppo Italiano Ricerca Dermatiti da Contatto plus other substances suggested by each patient's history. 518 patients (24%) were positive to at least one test substance of the standard series or to added substances. Typical photoallergic reactions were seen in 423 subjects, representing 19.5% of the total population. Topical drugs are the substances most frequently involved in photodermatitis. The incidence in our population was about equal for antimicrobial agents, additives to fragrances, and fragrances themselves. Other allergens frequently found were sun screening agents which were the second group of haptens with clear-cut relevance. [source] | |||||||||||||||||||||||||||||||