NSAIDs and the gastrointestinal mucosa

In the United States, these double-edged drugs cause as many as 20,000 deaths a year. To blunt their harmful effects, two promising strategies are being pursued: concurrent administration of prostaglandin analogues to support gastric homeostasis, and the development, or identification among existing NSAIDs, of an agent that targets inflammatory prostaglandins while sparing the homeostatic ones.     

The risks and costs of upper gastrointestinal disease attributable to NSAIDs

NSAIDs, including both aspirin and nonaspirin NSAIDs, are among the most frequently used drugs, and their use may result in serious adverse gastrointestinal outcomes and significant medical costs. The increased risks for adverse upper GI hemorrhage and peptic ulcer disease associated with NSAID use have been demonstrated in observational studies and clinical trials; an overview of these results is presented in this article. The magnitude of these risks should play an important role in clinical decision making and should influence decisions regarding the use of this class of drugs.     

Historical development of whiteners: clinical safety and efficacy

Trimming composite restorations includes gross removal of excess material, contouring, and finishing. Many surfaces such as the lingual surface of anterior teeth or the occlusal surfaces of posterior teeth require the use of rigid rotating instruments. The purpose of our study was to assess the suitability of eight finishing diamonds, five tungsten carbide finishing burs, and one ceramically coated finishing instrument for trimming a small-particle hybrid composite material. A total of 70 specimens of Herculite XRV were treated with the different finishing instruments under simulated practice conditions, and surface roughness was recorded quantitatively using an optical laser pick-up. The resulting surfaces were examined qualitatively with the help of scanning electron microscopy (SEM). Cutting efficiency of the diamonds and burs was evaluated at a constant pressure of 2.5 N using 42 additional specimens of Herculite XRV. Significant differences were calculated using one-way ANOVA and pairwise contrasts by Tukey's multiple range test. The results showed that finishing diamonds were characterized by high cutting efficiency and relatively rough corresponding composite surfaces, whereas tungsten carbide finishing burs led to smooth composite surfaces but had little cutting efficiency. For gross removal and contouring of composite restorations, a 15-40 microns finishing diamond is recommended followed by a tungsten carbide bur for finishing the restoration.     

Improving the relationship between the randomized clinical trial and real-world clinical practice.

I comment on the article by Krause (see record 2011-19228-002), which discusses a number of ways for clinical psychotherapy outcome researchers to make the results of randomized controlled trials (RCT) more useful to practicing psychotherapists primarily by making the distributions of raw data from those studies available to the public. In this way, it would be possible for psychotherapists to determine which treatment of an RCT (experimental or control) would be best for a specific patient. Problems with this proposal are discussed and an alternative model that integrates psychotherapy outcome data from group means and clinical case studies is offered. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Improving outcomes using dental implants: integrating improvements in clinical practice

Modern restorative dentistry is confronted with many challenges related to implant use in the craniofacial region, such as attempting to place implants in esthetically critical sites or anatomically limiting regions of the jaw. To assure a successful implant placement that is satisfactory to both the patient and the dentist, four key areas need to be improved: diagnostic procedures, surgical procedures and outcomes, esthetic results, and prosthetic complications. This article discusses how an integrated approach to these areas can improve clinical practice.     

An unusual clinical course of a hormone-secreting gastrointestinal tumor: a case presentation from clinical practice

The gastrinoma was first described in 1955 by the surgeons Zollinger and Ellison. The basic characteristic of this disease is an endocrine tumor of the gastrointestinal tract, which secretes gastrin. There is a hypersecretion of gastric juice and recurrent gastric, duodenal and jejunal ulcers. Herein, the case of a 49 year-old female is presented. In 1982, two liver tumors, sized 10 and 6 cm, were discovered in the right and left lobes of the liver, respectively. A duodenal ulcer was also found. During explorative laparotomy, a liver biopsy specimen was obtained and defined pathohistologically as a metastatic, small cell epithelial tumor with an organoid endocrine pattern, morphologically corresponding to tumors of the APUD (Amine Precursor Uptake and Decarboxylation) series. The gastrinoma was verified by immunohistochemical staining. Serum gastrin values exceeded normal values by 10 times. The patient refused further treatment at that time. In the following years, she was treated conservatively several times for sequelae of ulcer disease. For the past three years, she has been treated as an outpatient, mostly for chronic diarrhea.     

Prevention of gastrointestinal cancer--the potential role of NSAIDs in colorectal cancer

Gastrointestinal cancers are among the leading sites of cancer and leading causes of cancer-related deaths. Gastrointestinal cancers are often at an advanced stage at the time of diagnosis, and are highly resistant to non-surgical therapy. Thus early diagnosis and prevention are approaches that are under active investigation. Screening and surveillance are considered secondary prevention. Primary prevention is the use of dietary or environmental modification or chemopreventive agents. This written review will emphasize the potential role of acetylsalicylic acid and other non-steroidal anti-inflammatory drugs (NSAIDs) in the prevention of gastrointestinal cancer, and specifically colorectal cancer. Cell culture and animal studies have shown that NSAIDs possess anti-proliferative and anti-neoplastic effects. Recent epidemiologic surveys also suggest that individuals who regularly take NSAIDs, particularly acetylsalicylic acid, have about a 50% decrease in colorectal cancer incidence and mortality. However, in the only interventional trial of aspirin (and beta-carotene), a retrospective analysis had inadequate statistical power to demonstrate any protective effect against colorectal cancer. About a dozen small prospective intervention studies have been done in a total of about a hundred patients with familial adenomatous polyposis to test the efficacy of NSAIDs, particularly sulindac. All human trials have shown substantial partial and some complete regression of colorectal and perhaps also duodenal adenomatous polyps. But virtually all patients had regrowth of adenomatous polyps after sulindac was stopped. In addition, sulindac and other NSAIDs result in occasional adverse events such as gastrointestinal bleeding. Thus sulindac cannot be recommended for routine use outside of a study setting. One valid current approach to the prevention of gastrointestinal cancer, and colorectal cancer in particular, is the adoption of a healthy lifestyle and appropriate screening and surveillance. Screening and surveillance guidelines have been developed by several public agencies and their recommendations should be adopted. In addition, we should adopt a healthy lifestyle and diet, which consists of low fat ( < 30% to total calories), and high fiber (> 3 daily servings of fruits/vegetables), with the avoidance of red meats ( < 3 weekly servings) and alcohol ( < 2 drinks daily), and the absolute avoidance of tobacco smoking.     

The development of leadership skills in clinical practice

Leadership is often seen as the province of the manager. However, as the NHS changes and responsibility is increasingly devolved, practitioners at all levels are expected to lead change and innovation. In this paper the author describes how attending the Leadership in Nursing for the Community (LINC) programme has influenced her practice. As a result of the programme she has an increased awareness of her own leadership role and of the political and professional climate in which she works.     

Improving the clinical practice of violence risk assessment: Technology, guidelines, and training.

Despite a long history of interest in, and criticism of, the ability of mental health professionals to assess and predict violence, there have been few efforts to develop or evaluate interventions to improve decision making in this area. This article provides a brief overview of recent research developments on violence risk. Drawing on these advances, 3 recommendations are outlined for improving the clinical practice of risk assessment: (a) to improve assessment technology, (b) to develop clinical practice guidelines, and (c) to develop training programs and curricula. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review article: olestra and its gastrointestinal safety

Olestra is a fat substitute made from sucrose and vegetable oil. Olestra is neither digested nor absorbed, and therefore adds no calories or fat to the diet. Because the gut is the only organ that is exposed to olestra, the potential for olestra to affect gastrointestinal structure and function, and the absorption of nutrients from the gut, has been investigated. Histological evaluations performed after long-term feeding studies have shown no indications that olestra causes injury to the gastrointestinal mucosa. Olestra is not metabolized by the colonic microflora, and has no meaningful effects on the metabolic function of these organisms. Studies of gastrointestinal transit have shown that the consumption of olestra with food does not affect gastric emptying, or small or large bowel transit times. Olestra does not affect the absorption of macronutrients, water-soluble vitamins or minerals. It causes a dose-responsive decrease in the availability of the fat-soluble vitamins A, D, E and K; however, this potentially adverse effect is offset by the addition of vitamins to olestra-containing foods. Olestra has no consistent effect on the amount of total bile acids excreted in the faeces, and therefore probably has no significant effect on bile acid absorption. The occurrence of gastrointestinal symptoms, including diarrhoea, loose stools, gas and abdominal cramping, after consumption of olestra under ordinary snacking conditions is comparable to that following consumption of triglyceride-containing snacks.     

Relationship of counselor conceptual level to clinical hypothesis formation.

37 counseling students completed the Paragraph Completion Method, a measure of conceptual level (CL). All Ss then viewed a videotape of a client in a counseling session and completed the Clinical Assessment Questionnaire, which is designed to assess counselors' hypotheses about a client's problem. Questionnaire responses were scored on 7 categories relevant to clinical judgment and information processing. Two factors were considered in a multiple regression analysis—CL and clinical experience. Results indicate that experience level was not significantly related to the characteristics of the students' clinical hypothesis formation. CL was significantly related to the overall quality and clarity of expression in clinical hypotheses and the number of divergent questions asked about the client's problems. Methodological and counselor-training implications are discussed. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On the relation of clinical research to clinical practice: Current issues, new directions.

Recent trends in clinical psychology training have institutionalized the scientist–practitioner split after observations that clinicians are unlikely to engage in research of any kind. But a more serious development is the realization that many clinicians are not even influenced by clinical research findings, resorting instead to a trial-and-error eclecticism in their clinical practice. This is due more to limitations in traditional research strategies than to inadequate training. Practical and philosophical differences between traditional research and clinical practice make it impossible for clinicians to do research and make research findings of limited relevance to clinicians. L. J. Cronbach's (1975) method of intensive local observation provides a meaningful and necessary role in the research process for practicing clinicians. It provides answers to questions that have not been forthcoming from clinical research, specifically, the effectiveness of treatments with individual clients and its generality. This would not require radical changes in clinical practice but would increase accountability and ensure the influence of research findings on practice. (54 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Improving nursing practice with staff education: the challenges of dysphagia

The 15 million Americans who experience some degree of dysphagia risk choking, airway obstruction, aspiration-related pulmonary disease, and/or death. These complications increase mortality, morbidity, length of hospitalization, and healthcare costs, but may be preventable through nursing intervention. Fifty-four nursing care workers (NCWs) from medical/surgical units in two acute care hospitals were assigned by convenience to two experimental groups and a control group. Experimental groups A and B participated in an educational program on dysphagia designed to increase their knowledge of dysphagia, knowledge attention, and the number of dysphagic patients identified and referred. Group B received deliberate reinforcement of program content over a 1-month period. The educational intervention had a significant effect on knowledge level and knowledge retention, immediately and at 1-month posttest in both experimental groups. NCWs applied what they learned to clinical practice as evidenced by an increase in the number of patients identified as being at risk for or experiencing dysphagia. Reinforcement of program content did not affect the outcomes. The study has implications for staff educators and nursing personnel who care for persons at risk for dysphagia.     

Beyond clinical trials: Generalizing from research to practice.

Suggests that clinical trials, or evaluations of psychotherapy techniques in clinical settings with patient populations, play a pivotal role in treatment research. Well-controlled psychotherapy trials provide a test of what treatment can do under conditions in which procedures such as therapist training and monitoring and the integrity of treatment are optimal. Methods designed to reduce the hiatus in how treatments are implemented, monitored, and evaluated in clinical research and practice include developing standardized assessment and treatment packages that can be implemented by practitioners, altering the manner in which clinical training is implemented and evaluated, training clinicians in strategies to evaluate their own clinical work, and conducting clinical replication case studies as a way to evaluate treatment applications in clinical practice. These alternatives combine standardization, training, evaluation, and clinical practice to help increase the generality of research findings to clinical work and to help merge research and clinical priorities. (46 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ovarian follicular dynamics: from basic science to clinical practice

The management of low responders (LR) to ovarian stimulation in cycles of assisted reproduction (AR) is a difficult challenge. Aging of the ovary and LR are coincidental in many situations, but LR is also present in young patients undergoing AR. In fact, today it is a recognized cause of infertility. When the aged ovary is considered, there is evidence that the functioning of the granulosa cells as well as the quality of the oocytes and resulting embryos are affected. Similarly, in young LR, the production of inhibin is affected. However, there is no evidence that the quality of the oocyte and/or the resulting embryo is affected. In this study, we have retrospectively analyzed our files and observed that the quality of the oocytes and embryos was similar between younger and older LR and normal responders (NR). Studies using color Doppler vaginal ultrasound have shown that the pulsatility index (PI) and the resistance index (RI) were increased in LR as compared with NR, suggesting that there was some degree of vascular resistance to flow. Treatment of LR is also a difficult challenge. Ovum donation is a successful treatment for LR, since cumulative birth rates are > 85% with four attempts of embryo transfer. The future may be promising for LR once new technologies are introduced into clinical practice. The use of recombinant gonadotropins and genetically engineered human gonadotropin derivatives may be of considerable help for LR. Similarly, non-gonadotropin hormones, such as cytokines or growth factors, may be shown to play a role in the stimulation of the ovary in the near future, and may therefore open new frontiers for treatment of LR.