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Routine Clinical Practice (routine + clinical_practice)
Selected AbstractsComparison of High Resolution Magnifying Endoscopy and Standard Videoendoscopy for the Diagnosis of Helicobacter pylori Gastritis in Routine Clinical Practice: A Prospective StudyHELICOBACTER, Issue 1 2009Can Gonen Abstract Background:, It has been shown that standard endoscopic features often labeled as gastritis has a poor correlation with histopathology. Recently, high resolution magnifying endoscopy has been reported to be an effective method to diagnose gastritis. The aim of the present study was to compare standard endoscopy with magnifying endoscopy for the diagnosis of Helicobacter pylori gastritis, and to determine whether gastritis can be diagnosed based on findings at magnification endoscopy. Materials and Methods:, A total of 129 patients were enrolled into the study. Erythema, erosions, prominent area gastrica, nodularity, and regular arrangement of collecting venules (RAC) were investigated by standard endoscopy. Standard endoscopy was followed by magnifying endoscopy in all patients, and repeated in 55 patients after indigo carmine spraying. Results:, None of the standard endoscopic features showed a sensitivity of more than 70% for H. pylori gastritis, except RAC pattern analysis. Absence of a corporal RAC pattern had 85.7% sensitivity and 82.8% specificity for predicting H. pylori infection. Under magnification, the sensitivity and specificity of regular corporal pattern (regular collecting and capillary vascular structures with gastric pits resembling pinholes) for predicting normal histology were 90.3% and 93.9%, respectively. Loss of collecting venules, or both collecting and capillary structures was correlated with chronic inflammation and activity. With the progression of mucosal atrophy, irregular collecting venules became visible. The values for irregularly arranged antral ridge pattern for the prediction of antral gastritis were 89.3% and 65.2%, respectively. Indigo carmine staining increased sensitivity and specificity up to 97.6% and 100% for corporal gastritis, and up to 88.4% and 75.0% for antral gastritis, respectively. Indigo carmine staining significantly increases the detection of intestinal metaplasia. Conclusions:, High resolution magnifying is superior to standard endoscopy for the diagnosis of H. pylori gastritis, and identification of specific histopathologic features such as atrophy and intestinal metaplasia seems possible. [source] Ultrasound as an outcome measure to assess disease activity in disorders of skin thickening: an example of the use of radiologic techniques to assess skin diseaseDERMATOLOGIC THERAPY, Issue 2 2007Sandra E. Bendeck ABSTRACT:, Good outcome measures are required to determine whether a therapy is effective, both in routine clinical practice and in experimental clinical trials. In disorders of skin thickening such as morphea and scleroderma, more commonly used outcome measures that use a subjective score based on palpated skin thickening are fraught with error. By contrast, measurements made by ultrasound have great promise as outcome measures that are quantitative, valid, reproducible, and responsive. Further studies should establish its role in the field. In this paper, the present authors used ultrasound to illustrate the criteria that are required to establish a technology-based outcome measure. [source] The Canadian National Outcomes Measurement Study in Schizophrenia: overview of the patient sample and methodologyACTA PSYCHIATRICA SCANDINAVICA, Issue 2006G. Smith Objective:, The Canadian National Outcomes Measurement Study in Schizophrenia (CNOMSS) is a prospective survey of routine clinical practice. Method:, Patients with schizophrenia or a related disorder were consecutively enrolled from all regions of Canada. Both academic and community psychiatric clinics were included and patients were followed up for 2 years. Clinical and functional status, quality of life, medication and economic costs were assessed at enrollment and monitored throughout the follow-up period. Results:, Patients attending an academic clinic tended to be younger and more severely ill than those from community clinics. Both types of sites prescribed atypical neuroleptics to more than three-quarters of the patients. The majority of those enrolled were unemployed and living in poverty. Poor clinical status was associated with poverty. Conclusion:, The CNOMSS provides demographic, clinical and treatment-related information about a large Canada-wide sample of psychiatric patients. The following three articles in this issue of Acta Psychiatrica Scandinavica explore issues related to medication, quality of life and resource utilization. [source] Assessing prolonged recovery in first-episode psychosisACTA PSYCHIATRICA SCANDINAVICA, Issue 2002L. Wong The Early Psychosis Prevention and Intervention Centre (EPPIC) is a comprehensive, specialized treatment service for individuals residing in the western metropolitan region of Melbourne who are experiencing their first psychotic episode. A subprogramme of EPPIC, the Treatment Resistance Early Assessment Team (TREAT), has been developing a framework for the management of individuals experiencing ,prolonged recovery' in early psychosis. TREAT is a consultation team that provides technical assistance to clinicians within EPPIC, comprising senior clinicians with expertise in the biopsychosocial treatment of early psychosis and persisting positive and negative symptoms. A system has recently been set up within the TREAT framework to routinely assess clinical and functional outcomes of these clients using standardized instruments. Case managers are trained to conduct assessments at multiple timepoints over the duration of their clients' treatment at EPPIC. A summary will be presented on the current sample (n=15) and examples of clinician and client feedback reports will be illustrated. Discussion is also provided on the development of training, procedures and materials to enhance integration of clinician and client outcome measures into routine clinical practice. [source] Role of fine-needle aspirate immunophenotyping by flow cytometry in rapid diagnosis of lymphoproliferative disordersDIAGNOSTIC CYTOPATHOLOGY, Issue 7 2007Ritu Gupta M.D. Abstract Immunophenotyping is an essential component in the diagnostic work-up of lymphoproliferative disorders (LPD). As compared to immunohistochemistry, flow cytometric immunophenotyping (FCMI) is rapid, quantitative and a more objective technique. This study was designed to evaluate the utility of FCMI on fine needle aspirates (FNA) in rapid diagnosis of LPD in routine clinical practice. FNA from 31 consecutive cases clinically suggestive of LPD were subjected to FCMI. Representative material for FCMI was obtained in 28 (90%) cases and a definite diagnosis established in 27 cases. Histopathogical correlation was available in 22 cases and concordance with FCMI results was observed in 19 (86.4%) cases. FCMI analysis was inconclusive in 4 cases. The results of FCMI were available the same day and were crucial for therapeutic purpose in 3 patients with superior vena cava syndrome. FCMI combined with cytological examination of aspirate smears permits rapid diagnosis with high level of accuracy resulting in efficient treatment planning for critically ill patients and those from far-off rural areas. Diagn. Cytopathol. 2007;35:381,385. © 2007 Wiley-Liss, Inc. [source] Opioid agonist pharmacotherapy in New South Wales from 1985 to 2006: patient characteristics and patterns and predictors of treatment retentionADDICTION, Issue 8 2009Lucy Burns ABSTRACT Aims The aims of this study were to: examine the number and characteristics of patients entering and re-entering opioid replacement treatment between 1985 and 2006, to examine select demographic and treatment correlates of leaving treatment between 1985 and 2000, and to compare retention rates in methadone and buprenorphine maintenance treatment from 2001 to 2006. Design A retrospective cohort study using register data from the Pharmaceutical Drugs of Addiction System. Setting Opioid substitution treatment in New South Wales (NSW), Australia. Participants A total of n = 42 690 individuals prescribed opioid replacement treatment between 1985 and 2006 in NSW. Measurements Client characteristics over time, retention in days in first treatment episode, number of episodes of treatment and proportion switching medication. Findings Overall, younger individuals were significantly more likely to leave their first treatment episode than older individuals. In 2001,06, after controlling for age, sex and first administration point, the hazard of leaving treatment was 1.9 times for those on buprenorphine relative to those on methadone. Retention in treatment varied somewhat across historical time, with those entering during 1995,2000 more likely to leave at an earlier stage than those who entered before that time. Conclusions Retention in treatment appears to fluctuate in inverse proportion to the availability of heroin. Individuals in contemporary treatment are older users with a lengthy treatment history. This study has provided population-level evidence to suggest that retention in methadone and buprenorphine differ in routine clinical practice. Future work might investigate ways in which patient adherence and retention may be improved. [source] Alcohol screening and brief intervention: dissemination strategies for medical practice and public healthADDICTION, Issue 5 2000Thomas F. Babor This paper introduces the concept of risky drinking and considers the potential of alcohol screening and brief intervention (SBI) to reduce alcohol-related problems in medical practice and in organized systems of health care. The research evidence behind this approach is reviewed. Potential strategies for the dissemination of SBI to systems of health care are then discussed within the context of a public health model of clinical preventive services. There is an emerging consensus that SBI should be promoted in general healthcare settings, but further research is needed to determine the best ways to achieve widespread dissemination. In an attempt to provide an integrative model that is relevant to SBI, dissemination strategies are discussed for three target groups: (1) individual patients and practitioners; (2) health care settings and health systems; and (3) the communities and the general population. Dissemination strategies are considered from the fields of social change, social science, commercial marketing and education in terms of their potential for translating SBI innovations into routine clinical practice. One overarching strategy implicit in the approaches reviewed in this article is to embed alcohol SBI in the more general context of preventive health services, the utility of which is becoming increasingly recognized as a critical supplement to more traditional clinical medicine. [source] Decision aids in routine practice: lessons from the breast cancer initiativeHEALTH EXPECTATIONS, Issue 3 2006Kerry A. Silvia BA Abstract Background, Many decision aids have been developed to help patients make treatment and screening decisions; however, little is known about implementing them into routine clinical practice. Objective, To assess the feasibility of implementing a patient decision aid (PtDA) for the early stage breast cancer surgical decision into routine clinical care. Design, Structured individual interviews. Setting and participants, A convenience sample of providers from nine sites, including two community resource centres, a community hospital and six academic centres. Main outcome measures, Usage data, barriers to and resources for implementing the PtDAs. Results, Six of the nine sites were using the PtDAs with patients. Two sites were primarily using a scheduling system and four sites relied on a lending system. For the academic centres, the keys to successful implementation included integrating the PtDA into the flow of patients through the centre and having physicians who recommended it to patients. At the community centres, the keys to successful implementation included an informed staff and the flexibility to get the PtDAs to patients in different ways. Barriers that limited or prevented sites from using the PtDA included a lack of clinical support, a lack of system support, competing priorities and scheduling problems. Conclusions, It is feasible to implement a breast cancer PtDA into routine clinical care at academic centres and community resource centres. Future research should assess the effectiveness of PtDAs in routine clinical care as well as resources and barriers to their implementation in community hospitals. [source] Helicobacter pylori Culture from a Positive, Liquid-Based Urease Test for Routine Clinical Use: A Cost-Effective ApproachHELICOBACTER, Issue 1 2000Bernhard H. Jaup Background. The aim of our study was to test the feasibility of culturing Helicobacter pylori directly from biopsies aimed for rapid urease test in routine clinical practice. Materials and Methods. In 260 consecutive patients referred for gastroscopy because of dyspepsia one antral biopsy was routinely used for our "in house" rapid urease test (RUT). Positive biopsies were placed in a transport medium and sent to the laboratory. The biopsies were cultured and incubated at 37°C for 5,7 days. H. pylori was identified and routinely tested for antimicrobial resistance by using the E -test. Results. In 118 out of 260 patients (45%) the urease test turned positive and the growth of H. pylori was sufficient to allow testing of antimicrobial resistance. Conclusion.H. pylori could be cultured from almost all positive RUT specimens. A liquid RUT is thus more suitable for culture, saving additional biopsies. [source] Atazanavir and lopinavir with ritonavir alone or in combination: analysis of pharmacokinetic interaction and predictors of drug exposureHIV MEDICINE, Issue 4 2008S Di Giambenedetto Objectives Studies on the pharmacokinetic interaction between atazanavir and lopinavir with ritonavir (lopinavir/ritonavir) report contradictory results. We aimed to establish the in vivo interaction between these two protease inhibitors as well as the variables influencing drug exposure. Methods Pharmacokinetic parameters were investigated in HIV-infected patients treated with atazanavir 300 mg with ritonavir 100 mg q24h (group A) or lopinavir/ritonavir 400/100 mg q12h (group B) or atazanavir 300 mg q24h with lopinavir/ritonavir 400/100 mg q12h (group C). Patients receiving other concomitant protease inhibitors or non-nucleoside reverse transcriptase inhibitors were excluded. Results In group A (n=10), mean ± standard deviation atazanavir Cmin was 390 ± 460 ng/mL, Cmax 3051 ± 1996 ng/mL and AUC24 29 913 ± 17 686 ng/mL/h. In group B (n=9), lopinavir Cmin was 7562 ± 4292 ng/mL, Cmax 12 944 ± 4838 ng/mL and AUC0,12 122 313 ± 38 225 ng/mL/h. In group C (n=7), atazanavir Cmin was 876 ± 460 ng/mL (P=0.039 vs. group A), Cmax 3421 ± 3399 ng/mL and AUC0,24 65 055 ± 49 843 ng/mL/h (two-sided P>0.05 for each comparison with group A), lopinavir Cmin was 7471 ± 3745 ng/mL, Cmax 10 143 ± 5217 ng/mL and AUC0,12 104 501 ± 43 565 ng/mL/h (P>0.05 for each comparison with group B). When analysing all the groups, including controls from routine clinical practice, higher body mass index was associated with lower atazanavir Cmin and with lower lopinavir Cmax. Atazanavir Cmin showed a correlation with total bilirubin levels. Conclusions Combination with lopinavir/ritonavir provides higher atazanavir Cmin than combination with ritonavir alone, possibly because of an effect of the additional ritonavir dose. Low BMI may be associated with higher drug exposure. [source] CD4 cell count and initiation of antiretroviral therapy: trends in seven UK centres, 1997,2003HIV MEDICINE, Issue 3 2007W Stöhr Objectives We examined whether the timing of initiation of antiretroviral therapy (ART) in routine clinical practice reflected treatment guidelines, which have evolved towards recommending starting therapy at lower CD4 cell counts. Methods We analysed longitudinal data on 10 820 patients enrolled in the UK Collaborative HIV Cohort (UK CHIC) Study, which includes seven large clinical centres in south-east England. CD4 cell and viral load measurements performed in the period between 1 January 1997 and 31 December 2003 were classified according to whether ART was subsequently initiated or deferred, to estimate the probability of ART initiation by CD4 count and viral load over time. The effect of nonclinical factors (age, sex, ethnicity, and exposure category) was analysed by logistic regression. Kaplan,Meier analysis was used to estimate the proportion of patients who had initiated ART by a particular CD4 count among ,early' presenters (initial CD4 cell count >500 cells/,L). Results There was a tendency to initiate ART at lower CD4 cell counts over time in the years 1997,2000, especially in the range 200,500 cells/,L, with little change thereafter. An estimated 34% of HIV-infected individuals having presented early initiated ART at a CD4 count <200 cells/,L. We also found an independent influence of viral load, which was particularly pronounced for CD4 <350 cells/,L. Use of injection drugs was the only nonclinical factor associated with initiation of ART at lower CD4 cell counts. Conclusions The initiation of ART in the clinics included in this analysis reflected evolving treatment guidelines. However, an unexpectedly high proportion of patients started ART at lower CD4 counts than recommended, which is only partly explained by late presentation. [source] Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinomaHPB, Issue 1 2004R Andersson Background Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non-operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice. Discussion In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient-related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour-related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital-related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra-operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down-staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear-cut evidence of irresectability. [source] Frequently discordant results from therapeutic drug monitoring for digoxin: clinical confusion for the prescriberINTERNAL MEDICINE JOURNAL, Issue 1 2010N. M. Rogers Abstract Background: Digoxin remains a commonly prescribed medication for the treatment of congestive cardiac failure or atrial tachyarrhythmias. Its utility is offset by its narrow therapeutic index requiring regular blood concentration monitoring. Recent evidence suggests that a lower therapeutic range (0.5,0.8 µg/L, or 0.6,1.0 nmol/L) is associated with reduced mortality in patients with congestive cardiac failure. Therapeutic drug monitoring for digoxin is carried out by immunoassays that are well established in routine clinical practice. Laboratories using different immunoassays may be involved in monitoring individual patients throughout the protracted course of therapy. These results should be concordant to ensure consistent dose individualization and optimum clinical management. We have investigated the discordance in digoxin measurements involving five different laboratories across the Adelaide metropolitan area. Methods: Aliquots from routine digoxin samples (n= 261) were analysed by accredited laboratories using commercially available immunoassays. Results: The results showed that 119 (46%) of 261 samples were so varied that a different clinical outcome was indicated when reviewed by the treating physician. The differences between the highest and lowest readings from any one sample were also substantial, with 45% of the measurements exceeding 0.3 µg/L. Conclusions: Our study shows the considerable variation in the routine monitoring of digoxin. This makes therapeutic drug monitoring difficult to interpret and complicates clinical management when treating physicians are endeavouring to avoid toxicity and optimize dosing. These results raise a significant concern for the quality of therapeutic drug monitoring of digoxin and have direct repercussions on patient care. [source] Impact of COPD severity on physical disability and daily living activities: EDIP-EPOC I and EDIP-EPOC II studiesINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 5 2009J. M. Rodriguez Gonzalez-Moro Summary Aims:, The severity of chronic obstructive pulmonary disease (COPD) is associated to patients' health-related quality of life (HRQL). Physical impairment increasingly affects daily activities creating economic, social and personal burden for patients and their families. This burden should be considered in the management of COPD patients; therefore, we intended to assess the impact of the disease severity on physical disability and daily activities. Methods:, Two epidemiological observational cross-sectional descriptive studies were carried out in 1596 patients with moderate COPD and 2012 patients with severe or very severe COPD in the routine clinical practice. Demographic and basic clinical-epidemiological data were collected and patients completed questionnaires to assess their physical disability because of COPD [Medical Research Council (MRC)], COPD repercussion on daily activities [London Chest Activity of Daily Living (LCADL)], job, economy and family habits and their health status [EQ-5D visual analogue scale (VAS)]. Results:, In all, 37% of severe/very severe COPD patients and 10% of moderate (p < 0.0001) had MRC grades 4 and 5. Mean global LCADL was significantly higher in severe/very severe than in moderate patients [29.6 (CI 95%: 28.91,30.25) vs. 21.4 (CI 95%: 20.8,21.9); p < 0.0001]. COPD job impact and economic and family habits repercussions were significantly higher and health status significantly worse in severe/very severe cases than in patients with moderate COPD. Conclusions:, COPD severity is highly associated with physical disability by MRC grading, with functionality on daily activities and with impairment of other social and clinical activities. Moderate COPD patients show already a significant degree of impairment in all these parameters. [source] Clinical predictors of response to acetyl cholinesterase inhibitors: experience from routine clinical use in NewcastleINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 10 2003S. Pakrasi Abstract Background Acetyl Cholinesterase Inhibitors (AChEIs) have been in clinical use for the past five years in the UK for the symptomatic treatment of Alzheimer's disease (AD). There are few data on the patterns and predictors of response to AChEI therapy in routine clinical practice. We therefore investigated clinical variables that may distinguish between AChEI responders and non-responders. Methods A retrospective sample of 160 consecutive patients with dementia who were treated on clinical grounds with an AChEI was studied. Treatment response was defined in two ways: (a) A clinical response was achieved when there was no deterioration or there was an improvement on a global clinical assessment (CGI) and (b) a Mini-Mental-State-Examination (MMSE) response when there was an improvement of 2 or more MMSE points. Results A total of 62 (45%) patients achieved an MMSE response. A diagnosis of dementia with Lewy Bodies (DLB) and Parkinson's disease+Dementia (PDD) was associated with a MMSE response, as were hallucinations, and lower MMSE scores at baseline. 125 (78%) patients achieved a CGI response for which there were no clinical predictors. Conclusions Severity of illness, a diagnosis of DLB and PDD, and presence of hallucinations at baseline were predictive of a MMSE response. Non-AD dementia and severe dementia responded equally well to AChEI treatment and results of further randomised, placebo-controlled studies are needed to clarify the role of AChEI in the treatment of these disorders. Copyright © 2003 John Wiley & Sons, Ltd. [source] Acetylcholinesterase treatment,modelling potential demand and auditing practiceINTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 12 2001Simon Lovestone Abstract Background Acetylcholinesterase inhibitors represent an entirely novel treatment option for patients with Alzheimer's disease (AD). As such they represent a significant change in practice and a significant cost pressure on funding bodies. Objectives To assess the impact of cholinesterase inhibitors on routine clinical practice. Methods We estimated potential demand for the compounds taking into account eligibility criteria and prescribing practice agreed between clinicians and funders. We then audited actual prescribing practice assessing whether the estimated demand matched actual demand and whether practice and prescribing criteria were adhered to. Results Over a two-year period we estimated the demand for treatment at a total of 89 patient years for the population of the audit unit. In practice only 24.5 patient years of therapy were received, the short fall apparently being due to low referral rates for treatment. Prescribing by clinicians matched practice guidelines and a high proportion of three monthly assessments using scales for cognition, function and global state were performed. Using these assessment procedures treatment successes could be differentiated from primary and secondary treatment failures and, where apparently appropriate, treatment could be stopped. Conclusion In the real world of clinical practice demand for treatment in AD is modest but likely to grow and assessment with an aim to identifying those receiving benefit from treatment can be achieved. Copyright © 2001 John Wiley & Sons, Ltd. [source] The erythrocyte adhesiveness/aggregation test for the detection of an acute phase response and for the assessment of its intensityINTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY, Issue 4 2002N. Maharshak Summary We have developed a simple slide test and image analysis to reveal the state of erythrocyte adhesiveness/aggregation in the peripheral blood of patients with various degrees of the humoral acute phase response. The significant correlation between the results of the erythrocyte adhesiveness/aggregation test (EAAT), the erythrocyte sedimentation rate and fibrinogen concentration support the notion that it is possible to use the EAAT as a marker for the intensity of the acute phase response. Within a group of 860 individuals, we were able to differentiate effectively between groups of patients with a different intensity of humoral acute phase response. The present study confirms previous observations that support the applicability of the EAAT to routine clinical practice. [source] A standardized and reliable method to apply the Global Assessment of Functioning (GAF) scale to psychiatric case recordsINTERNATIONAL JOURNAL OF METHODS IN PSYCHIATRIC RESEARCH, Issue 2 2000Dr M. Mirandola Abstract The Global Assessment of Functioning (GAF) scale is widely used both in routine clinical practice and in research. However, its reliability has never been assessed when used to rate information in clinical records. The present study focuses on the development of a standardized method (an ongoing modelling process between raters) for establishing desired levels of inter-rater reliability (IRR) in the application of the GAF to psychiatric case records. Fifty-one patients at first-ever contact with mental health services were included in the study. They were selected from a total sample of 662 first-ever patients by using a systematic sampling. Three raters (resident psychiatrists at their third year of training) took part in a 12-hour training programme, during which they were asked to assess the global psychological functioning of patients, taking into account information recorded in case records. The extent of agreement between raters was estimated by applying the ,limits of agreement' method and the ,concordance correlation coefficient'. The training programme proved to be feasible, easy to administer and acceptable to psychiatrists in training with limited previous experience of using rating scales. Very high levels of concordance (all greater than 0.95) emerged between the three raters. The GAF, completed using information from case records included in the initial assessment form, appeared to be a reliable instrument, even when used by clinical psychiatrists in training. Copyright © 2000 Whurr Publishers Ltd. [source] Genetic and epigenetic aspects of bladder cancerJOURNAL OF CELLULAR BIOCHEMISTRY, Issue 1 2005Wun-Jae Kim Abstract Transitional cell carcinoma of the urinary bladder has a diverse collection of biologic and functional characteristics. This is reflected in differing clinical courses. The diagnosis of bladder cancer is based on the information provided by cystoscopy, the gold standard in combination with urinary cytology findings. Many tumor markers have been evaluated for detecting and monitoring the disease in serum, bladder washes, and urinary specimens. However, none of these biomarkers reported to date has shown sufficient sensitivity and specificity for the detection of the whole spectrum of bladder cancer diseases in routine clinical practice. The limited value of established prognostic markers requires the analysis of new molecular parameters of interest in predicting the prognosis of bladder cancer patients; in particular, the high-risk patient groups at risk of progression and recurrence. Over the past decade, there has been major progress elucidating of the molecular genetic and epigenetic changes leading to the development of transitional cell carcinoma. This review focuses on the recent advances of genetic and epigenetic aspects in bladder cancer, and emphasizes how molecular biology would be likely to affect the future therapies. © 2005 Wiley-Liss, Inc. [source] Ambulatory or Home Measurement of Blood Pressure?JOURNAL OF CLINICAL HYPERTENSION, Issue 4 2009Philippe Gosse MD Ambulatory blood pressure monitoring (ABPM) and home blood pressure (HBPM) monitoring have been shown to be superior to conventional measurement of blood pressure in terms of reproducibility, relationship to the impact of high blood pressure on target organs, and the prediction of cardiovascular events. Nevertheless, these 2 techniques have yet to find their place in the diagnosis of hypertension and during evaluation of the efficacy of antihypertensive treatment. Although these 2 methods do not give identical results in approximately 20% of cases, their diagnostic performance and prognostic value are quite comparable. Although ABPM remains a valuable tool in clinical research, its utilization in routine clinical practice is limited by cost and availability. HBPM is increasingly employed for informed and well-managed patients, and it can help to improve control of the patient's blood pressure. Physicians involved in the management of hypertensive patients should be aware of its value in order to assist patients in their care. [source] Aldosterone receptor antagonism and heart failure: insights from an outpatient clinicJOURNAL OF CLINICAL PHARMACY & THERAPEUTICS, Issue 4 2008R. Mariotti Summary Objective:, In randomized clinical trials, aldosterone antagonists have been shown to reduce mortality and morbidity in heart failure (HF). The aim of the present study was to examine the risk-benefit profile of aldosterone antagonists in routine clinical practice. Methods:, A retrospective analysis, extending over a 1-year period, of the clinical, instrumental and laboratory data of 264 HF outpatients was performed. All patients were on a ,-blocker and an ACE-inhibitor (or angiotensin-II receptor-blocker) and 151 were taking an aldosterone antagonist. Results:, At baseline, subjects treated with aldosterone antagonists had a higher NYHA class, a larger left-ventricular end-diastolic volume, a worse ejection fraction and a higher systolic pulmonary arterial pressure (sPAP). During follow-up, a greater reduction in sPAP and a tendency towards improved systolic and diastolic function were observed in subjects treated with aldosterone antagonists. Moreover, clinical and laboratory parameters did not deteriorate in patients taking aldosterone antagonists. Mortality rates were similar in the two groups (8·6% vs. 8·8%, P = NS). Conclusions:, The use of aldosterone antagonists in HF is associated with an improvement in cardiac function and is well tolerated. In the present study, patients administered these agents had a comparable clinical outcome to that of the control group, despite important differences in baseline risk. [source] Using patient-focused research in evaluating treatment outcome in private practiceJOURNAL OF CLINICAL PSYCHOLOGY, Issue 10 2002Ted P. Asay The increasing emphasis on therapist accountability and empirical demonstration of psychotherapeutic treatment effectiveness points to the need for practicing therapists to integrate treatment evaluation methods into routine clinical practice. Unfortunately, most private practitioners have little involvement in carrying out evaluation procedures. In this study we demonstrate how patient-focused research was used to track the progress and outcome of patients seen by a clinical psychologist in private practice. Twenty-nine adults and 40 children/adolescents were evaluated on a weekly basis to assess the number of sessions required to reach improvement (reliable change) and recovery (clinically significant change). Dose-response survival analysis results indicated that 50% of adults reached clinically significant change in 54 sessions, and 50% of youth met the same standard in 14 sessions. These results were compared with outcome in large-scale studies. Implications of this study for integrating treatment evaluation methods into clinical practice are discussed. © 2002 Wiley Periodicals, Inc. J Clin Psychol 58: 1213,1225, 2002. [source] Assessing quality of life in paediatric clinical practiceJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 6 2010Angela M Morrow The rising prevalence of children with chronic conditions has made quality of life an increasingly important outcome measure in paediatric practice. The discrepancy between doctors' and patients' perceptions of quality of life makes formal assessment necessary. In this paper we use a case scenario to answer commonly asked questions. What is quality of life and who can assess it? Why assess quality of life in the clinical setting? Is it feasible to measure in routine clinical practice? How is quality of life formally assessed? We provide a basic outline of the language and methods of quality of life assessment and use the case scenario to discuss the process of choosing an appropriate instrument. We conclude that quality of life assessment in clinical practice is feasible and provides benefits for both patients and doctors. The benefits include better informed doctors, improved patient doctor communication and a means to effectively monitor quality of life as a treatment outcome. [source] Fostering a culture of engagement: an evaluation of a 2-day training in solution-focused brief therapy for mental health workersJOURNAL OF PSYCHIATRIC & MENTAL HEALTH NURSING, Issue 4 2009H. FERRAZ msc pg dip ed rmn The focus of mental health care has changed considerably in recent years, from an almost exclusive inpatient system of care to one where the majority of care is being delivered within the community. Arguably this has contributed to a reduction in the length of inpatient admissions. Therefore, there is a need to understand the ramifications that shorter admissions have on inpatient care and nursing practice. This paper reports on a study designed to test the knowledge and skill acquisition and self-reported application of solution-focused brief therapy by staff following a 2-day training. The study adopted a repeated measures design where participants' baseline knowledge was measured prior to the 2-day training and then at 3 and 6 months post-training. This study has demonstrated that the 2-day training was effective in increasing participants' reported knowledge and understanding of solution-focused brief therapy and their self-reported use of the techniques in routine clinical practice. In conclusion, this study has established that staff from a variety of professional and non-professional backgrounds can make good skill acquisition from a fairly modest training. Additionally, the current study has also highlighted the need for well-conducted large-scale trials of this potentially important technology. [source] Experience of implementing an adult educational approach to treating anxiety disordersJOURNAL OF PSYCHIATRIC & MENTAL HEALTH NURSING, Issue 1 2005S. D. WOOD rmn rgn dms bsc pgce Lecturer Practitioner This paper describes the background to the development and delivery of a self-help package for anxiety disorders. Evidence of effectiveness is summarized. The paper outlines the intervention and describes the experience of two mental health nurses, who set out to assess its acceptability, evaluate its outcomes in routine clinical practice and assess the feasibility of its delivery by mental health nurses. Acceptability of the intervention was high, judged by retention and attendance rates. The pilot study produced promising clinical outcomes, especially for people with depression secondary to anxiety. Clinical measures showed significant improvements from pre-course to 6-month follow-up in anxiety, psychological well-being and depression. The outcomes suggest that appropriately trained mental health nurses could deliver the intervention as a routine treatment. The paper concludes by discussing future plans, including a randomized controlled trial and implementation in primary care. [source] Incorporating psycho-educational family and carers work into routine clinical practiceJOURNAL OF PSYCHIATRIC & MENTAL HEALTH NURSING, Issue 6 2003J. SIN msc bsc (hons)- thorn bn bgs rmn There is growing evidence of the benefits of family and carers interventions using a psycho-educational model for carers of people with psychosis. In order to get this work into clinical practice, a network of interrelated services for carers and families of people with psychoses has been established in Reading, Berkshire. This paper reports the experience of the authors in establishing these services using a series of practice development initiatives including training for staff, education programmes, integration projects and collaboration across organizations. This work illustrates change processes through which evidence-based practice has been incorporated into routine clinical care and in which research-based assessment and evaluation tools have being used in routine clinical practice to measure outcomes. [source] Detection of Recent Ethanol Intake With New Markers: Comparison of Fatty Acid Ethyl Esters in Serum and of Ethyl Glucuronide and the Ratio of 5-Hydroxytryptophol to 5-Hydroxyindole Acetic Acid in UrineALCOHOLISM, Issue 5 2005K Borucki Background: At present, recent ethanol consumption can be routinely detected with certainty only by direct measurement of ethanol concentration in blood or urine. Because ethanol is rapidly eliminated from the circulation, however, the time span for this detection is in the range of hours. Several new markers have been proposed to extend the detection interval, but their characteristics have not yet justified their use in routine clinical practice. We therefore investigated three new markers and compared their kinetics and sensitivities: (1) fatty acid ethyl esters (FAEEs) in serum, (2) ethyl glucuronide (EtG) in urine, and (3) the ratio of 5-hydroxytryptophol to 5-hydroxyindole acetic acid (5-HTOL/5-HIAA) in urine. Methods: Seventeen healthy men participated in a drinking experiment. Blood and urine samples were collected twice daily on three consecutive days and once daily on days 4 and 5. Ethanol concentration was determined by gas chromatography, FAEE levels, by gas chromatography with mass spectrometry, EtG concentration, by liquid chromatography-tandem mass spectrometry, and 5-HTOL/5-HIAA ratio, by high-performance liquid chromatography. Results: The peak serum ethanol concentrations of the subjects ranged from 5.4 to 44.7 mmol/liter (mean ± SD, 30.1 ± 9.1 mmol/liter). In the case of the serum ethanol determination, 100% sensitivity was reached only immediately after the end of the drinking experiment, and in the case of FAEE levels and 5-HTOL/5-HIAA ratio, it tested for 6.7 hr after the end of the ethanol intake. Thereafter, these latter parameters declined until 15.3 hr (FAEEs) and 29.4 hr (5-HTOL/5-HIAA), subsequently remaining in a stable range until 78.5 hr without further decrease. In contrast, EtG concentration showed 100% sensitivity until 39.3 hr and thereafter decreased, falling to below the limit of quantification of 0.1 mg/liter at 102.5 hr. Conclusion: After moderate drinking, EtG in the urine proved to be a superior marker of recent ethanol consumption in healthy subjects. This is because EtG is a direct ethanol metabolite, it occurs in the urine only when ethanol has been consumed, and its sensitivity remains at the level of 100% for 39.3 hr. [source] A review of photodynamic therapy in cutaneous leishmaniasisJOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 8 2008EM Van Der Snoek Summary We present a review of six clinical studies investigating the use of photodynamic therapy (PDT) using porphyrin precursors for the treatment of Old World cutaneous leishmaniasis (CL). Thirty-nine patients with a total of 77 lesions received PDT using a range of treatment schedules following topical application of aminolevulinic acid (ALA) or methyl-aminolevulinate (MAL). The tissue response to PDT is accompanied by a mild burning sensation, erythema and reversible hypo- and hyperpigmentation. Few mechanistic studies have addressed the principles underlying the use of PDT for CL. All six reviewed papers suggest that PDT with porphyrin precursors is relatively effective in treating CL. Data are still limited, and PDT cannot at this point be recommended in routine clinical practice. The mechanism of action of this promising therapeutic modality needs to investigated further and additional controlled trials need to be performed. [source] Efficacy and tolerability of peginterferon alfa-2a or alfa-2b plus ribavirin in the daily routine treatment of patients with chronic hepatitis C in Germany: The PRACTICE StudyJOURNAL OF VIRAL HEPATITIS, Issue 7 2010T. Witthoeft Summary., In randomized clinical trials, treatment with peginterferon plus ribavirin (RBV) results in a sustained virological response (SVR) in around half of hepatitis C virus genotype 1-infected and 80% of genotype 2/3-infected individuals. This study aimed to evaluate efficacy and tolerability of peginterferon alfa-2a plus RBV compared with peginterferon alfa-2b plus RBV for the treatment of chronic hepatitis C in routine clinical practice. The intent-to-treat cohort consisted of 3414 patients treated with either peginterferon alfa-2a plus RBV (Group A) or peginterferon alfa-2b plus RBV (Group B) in 23 centres participating in the large, multicentre, observational PRACTICE study. Collected data included baseline characteristics, treatment regimen, RBV dose and outcome. Rates of early virological response, end of treatment response and SVR were 76.6%, 75.7% and 52.9% in Group A, and 70.2%, 65.6% and 50.5% in Group B, respectively. In patients matched by baseline parameters, 59.9% of patients in Group A and 55.9% in Group B achieved an SVR (P , 0.051). In genotype 1-infected patients matched by baseline parameters and cumulative RBV dose, SVR rates were 49.6% and 43.7% for Group A and Group B, respectively (P , 0.047); when matched by baseline parameters and RBV starting dose, SVR rates were 49.9% and 44.6%, respectively (P = 0.068). Overall, 21.8% of group A and 29.6% of group B patients discontinued treatment (P , 0.0001). The efficacy and tolerability of peginterferon plus RBV in this large cohort of patients treated in routine daily practice was similar to that in randomized clinical trials. In matched pairs analyses, more patients achieved an SVR with peginterferon alfa-2a compared with peginterferon alfa-2b. [source] Role of dopamine transporter imaging in routine clinical practiceMOVEMENT DISORDERS, Issue 12 2003Vicky Marshall MRCP Abstract Functional imaging of the dopamine transporter (DAT) defines integrity of the dopaminergic system and has its main clinical application in patients with mild, incomplete, or uncertain parkinsonism. Imaging with specific single positron emission computerised tomography ligands for DAT (FP-CIT, ,-CIT, IPT, TRODAT) provides a marker for presynaptic neuronal degeneration. Striatal uptake correlates with disease severity, in particular bradykinesia and rigidity, and monitoring of progression assists in clinical trials of potential neuroprotective drugs. DAT imaging is abnormal in idiopathic Parkinson's disease, multiple system atrophy and progressive supranuclear palsy and does not distinguish between these disorders. Dopamine loss is seen even in the earliest clinical presentations of true parkinsonism; a normal scan suggests an alternative diagnosis such as essential tremor, vascular parkinsonism (unless there is focal basal ganglia infarction), drug-induced parkinsonism, or psychogenic parkinsonism. Congruence between working clinical diagnosis and DAT imaging increases over time in favour of baseline DAT imaging results. Additional applications are characterising dementia with parkinsonian features (abnormal results in dementia with Lewy bodies, normal in Alzheimer's disease); and differentiating juvenile-onset Parkinson's disease (abnormal DAT) from dopa-responsive dystonia (normal DAT). © 2003 Movement Disorder Society [source] | |||||||||||||||||||||||||||||||||||||