Treatment of urinary incontinence in women in general practice: observational study

OBJECTIVE: To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN: Observational study with 12 months' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING: General practice in the rural district of Rissa, Norway. SUBJECTS: 105 women aged 20 or more with urinary incontinence. INTERVENTIONS: Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES: Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS: After 12 months' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS: Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.     

Why use clinical pathways rather than practice guidelines?

Chronic suppurative otitis media (CSOM) without cholesteatoma, the surgical treatment of which is still controversial, is a common diagnosis in otologic practice. A retrospective analysis of 323 patients who underwent surgery for noncholesteatomatous chronic otitis media in the Gruppo Otologica, Piacenza, Italy, between April 1983 and December 1993 is presented. Cases were separated into three groups according to different surgical treatment modalities and conditions of the ears at the time of operation. Group I (n = 53) consisted of cases of CSOM treated by tympanoplasty without mastoidectomy (TLWOM). Group II (n = 28) included cases of CSOM treated by tympanoplasty with mastoidectomy (TLWM). Intact canal wall technique was used in these cases. The ears in both these groups were discharging severely at the time of surgery. Group III (n = 242) included patients whose ears were dry at the time of surgery but who had had previous recurrent episodes of suppuration and who were treated by TLWOM. At the last follow-up, graft success rates for groups I, II, and III were 90.5%, 85.7%, and 89.2%, respectively, and mean residual gaps were 17.2 dB, 20.1 dB, and 19.4 dB, respectively. There was no statistically significant difference between the three groups either on graft success rates (p > 0.05) or on final functional hearing outcome (p > 0.05). TLWM is the preferable treatment modality for most surgeons in noncholesteatomatous CSOM. Nevertheless, in our experience TLWOM yields comparable results for this group of patients. In addition, we could not find any significant difference in results of graft success and final functional hearing rates between dry and discharging ears (p > 0.05).     

Enhancing clinical practice: The role of practice guidelines.

Health service researchers believe that significant practice variations occur, in part, because there is no strong consensus on best practices for managing a specific condition. The Agency for Health Care Policy and Research supports the development of science-based clinical guidelines, performance measures, and standards of quality. Since 1992, it has published 6 clinical guidelines and is supporting development of more than 20 others. Each has a consumer version, in English and Spanish, to educate patients and describe care options. Widespread use of these guidelines will improve the quality of health care by assisting providers in making more informed decisions, thereby reducing unnecessary health care practices; will reduce some costs; and will provide feedback on knowledge gaps that merit the attention and support of researchers and policymakers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Compliance with gloving in anesthesia: an observational study of gloving practice at induction of general anesthesia

STUDY OBJECTIVE: To gather direct observational data on anesthesiologists' compliance with universal precautions' gloving standards during induction of general anesthesia. DESIGN: Prospective, observational study. SETTING: Operating theaters of an Israeli government teaching hospital. SUBJECTS: Over a four-month period, all "first case of the day" general anesthetics were observed to determine if the anesthesiologist directly administering patient care wore gloves during the period of anesthetic induction. All anesthesia department members were observed and none was aware of the ongoing study. MEASUREMENTS AND MAIN RESULTS: Resident anesthesiologists were found to be more compliant with gloving policy than their attendings (61.8% vs. 33.7%, p < 0.0001). However, the lower compliance among the attendings was entirely attributable to the most senior staff members (over age 55 years) whose compliance rate was 11.5% versus 55.6% for attending staff below age 55 years (p < 0.0001). Departmental compliance as a whole was 49.6%. Compliance in pediatric cases averaged 10% and was equally poor among all department staff. CONCLUSIONS: Although glove use remains inconsistent, in less than one and one half years since institution of a departmental gloving policy, a substantial degree of compliance was achieved. Nevertheless, further efforts are still needed to improve compliance with universal precautions. In this study, glove use was particularly deficient in pediatric cases and among senior staff aged 55 years and older. Pinpointing specific areas of greatest deficiency may prove useful in guiding additional efforts to improve compliance with universal precautions.     

The use of empiric clinical data in the evaluation of practice guidelines for unstable angina

OBJECTIVE: To determine the applicability to emergency department (ED) clinical practice of a nationally disseminated practice guideline on the disposition of patients with a diagnosis of unstable angina, and to determine the potential impact of the guideline on hospital admissions and demand for intensive care beds. DESIGN: Application of guideline criteria for ED disposition decisions to a validation sample derived from a prospective clinical trial. SETTING: Five hospitals, including 2 urban general teaching hospitals, 2 urban tertiary care university hospitals, and 1 suburban university-affiliated community hospital. PATIENTS: A consecutive sample of 457 patients who presented with symptoms suggestive of acute cardiac ischemia and who had "unstable angina" or "rule out unstable angina" diagnosed by ED physicians. Greater than 90% of eligible patients were enrolled in the clinical trial; follow-up data sufficient for assignment of a definitive diagnosis were obtained for 99% of subjects. MAIN OUTCOME MEASURES: Acute myocardial infarction and unstable angina, based on blind review of initial and follow-up clinical data, including cardiac enzyme levels and electrocardiograms. After completion of the trial, without knowledge of final diagnosis or outcome, the investigators classified patients into risk groups specified by the unstable angina guideline. RESULTS: Of subjects with an ED diagnosis of unstable angina, only 6% (n=28) met the guideline's criteria corresponding to low risk for adverse events and were therefore suitable for discharge directly to home. Fifty-four percent (n=247) met the intermediate-risk criteria; 40% (n=182) met the high-risk criteria and were identified as requiring admission to an intensive care unit. Actual ED disposition differed from guideline recommendations in 2 major areas: only 4% (1/28) of low-risk patients were discharged to home with outpatient follow-up, and only 40% (72/182) of high-risk patients were admitted to an intensive care unit. CONCLUSIONS: Although the guideline was intended to reduce hospitalization by identifying a low-risk group, the small size of this group among ED patients suggests that little reduction in hospitalization can be expected. Indeed, the guideline may increase demand for the limited number of intensive care beds to accommodate patients with unstable angina considered high-risk but currently placed elsewhere. These results emphasize the need to use empiric data from target clinical settings to assess the likely actual impact of guidelines on clinical care prior to national dissemination.     

Questionnaire study and audit of use of angiotensin converting enzyme inhibitor and monitoring in general practice: the need for guidelines to prevent renal failure

OBJECTIVES: To determine the current pattern of use of angiotensin converting enzyme inhibitor and monitoring of renal function in general practice and to audit all admissions to a regional renal unit for uraemia related to use of these drugs. DESIGN: Postal questionnaire sent to 400 general practitioners; audit of clinical notes of all patients receiving these drugs in one large general practice; audit of all cases of uraemia (creatinine concentration >500 micromol/l) related to treatment presenting to hospital renal services over 12 months. SETTING: General practices in the North Wales health authority and one in central Manchester. Regional renal unit in Salford. MAIN OUTCOME MEASURES: Proportion of general practitioners who regularly monitored renal function before and after initiation of angiotensin converting enzyme inhibitors. Indications for treatment and details of monitoring of renal function in patients receiving these drugs. Incidence of related uraemia and evidence of comorbid disease, other aetiological factors, delayed detection, and patient outcome. RESULTS: 277 (69%) general practitioners replied; 235 (85%) checked renal function before but only 93 (34%) after the start of treatment, and 42 (15%) never checked renal function. Angiotensin converting enzyme inhibitors were prescribed for 162 patients from a total of 3625 aged >35 years (mean age 66.4 (SD 15.9) years). Monitoring of renal function occurred before treatment in 55 (45%) and after start of treatment in 35 (29%) of the 122 patients treated in general practice. Angiotensin converting enzyme inhibitors could be causally implicated in 9 (7%) of 135 admissions for uraemia (mean age 74.2 (7. 2) v 62.1 (2.1) years; P<0.01). 3 patients had renovascular disease and 6 had congestive cardiac failure with another intercurrent illness. Renal function had not been checked in any patient after the start of treatment; mean duration of illness before admission was 10.5 (3.2) days. Mean length of hospital stay was 20.9 (10.4) days; there were 8 survivors. CONCLUSION: Cases of uraemia related to treatment with angiotensin converting enzyme inhibitors are still encountered and are often detected late because of lack of judicious monitoring of renal function in vulnerable, often elderly, patients, especially at times of intercurrent illness. Guidelines for appropriate monitoring of renal function may help to minimise the problem.     

The legal implications of clinical practice guidelines

In the past several years, considerable attention has been focused on clinical practice guidelines. They are developed to foster improved clinical care and to increase clinical efficiency. The legal implications of developing and following guidelines are not yet clear. The author argues that properly formulated guidelines could reduce the burdens of preventing and resolving malpractice claims.     

The use of clinical practice guidelines (CPGs) to evaluate practice and control costs in ventriculoperitoneal shunt management

Radical resection of ductal adenocarcinoma of the pancreas affords the only realistic chance of cure. Despite some reports, in particular from Japan, suggesting an improvement in the long-term prognosis, this is true only in subgroups of selected patients. In actual fact, the overall long-term survival of resected patients is still below 10%. How meaningful is a more extended resection? The lack of randomized prospective trials involving a sufficient number of cases does not enable us to make any final conclusions. The only controlled data, recently reported by an Italian multicenter study, suggested that extended lymphadenectomy improved prognosis not in the whole population of resected patients, but only in a subgroup of patients with lymph node involvement. No definitive judgments can be made without further prospective controlled clinical trials involving a greater number of patients. The suspicion arises that surgery alone, even when extensive, may not be the best treatment for pancreatic ductal cancer.     

Implementing guidelines and innovations in general practice: which interventions are effective?

BACKGROUND: It is crucial that research findings are implemented in general practice if high-quality care is to be achieved. Multifaceted interventions are usually assumed to be more effective than single interventions, but this hypothesis has yet to be tested for general practice care. This review evaluates the effectiveness of interventions in influencing the implementation of guidelines and adoption of innovations in general practice. A systematic literature study was carried out using MEDLINE searches for the period from January 1980 until June 1994, and 21 medical journals were searched manually. Randomized controlled trials and controlled before and after studies (with pre- and post-intervention measurements in all groups) were selected for the analysis. Clinical area, interventions used, methodological characteristics and effects on clinical behaviour were noted independently by two researchers using a standardized scoring form. Of 143 studies found, 61 were selected for the analysis, covering 86 intervention groups that could be compared with a control group without the intervention. Information transfer alone was effective in two out of 18 groups, whereas combinations of information transfer and learning through social influence or management support were effective in four out of eight and three out of seven groups respectively. Information linked to performance was effective in 10 out of 15 groups, but the combination of information transfer and information linked to performance was effective in only three out of 20 groups. Some, but not all, multifaceted interventions are effective in inducing change in general practice. Social influence and management support can improve the effectiveness of information transfer, but information linked to performance does not necessarily do so. The variation in the effectiveness of interventions needs further analysis.     

Clinical judgement and antibiotic use in general practice

Illustrated booklets that contained standard physical but variable social and psychological information relating to 16 patients with sore throats were posted to 1000 general practitioners. The doctors were asked whether they would prescribed antibiotics in each of the cases presented. Replies were received from 634 doctors and it was found that the variations in social and psychological history provided had significantly affected the doctor's responses.     

The use of touch in psychotherapy: Ethical and clinical guidelines.

With the emergence of humanistically oriented therapies, and given recent developments, a different view of the therapist–client relationship has evolved. Although touch has long been associated with healing in most cultures, Freud and other psychoanalysts established a no-touch rule in the therapist–client relationship. Critics of the touch taboo argue that the blank screen stance of therapists recreates the cold and distance environment that contributed to the client's dysfunction, and it ignores the value of touch as a powerful therapeutic ingredient, one which emphasized a more open and intimate relationship between client and therapist. Today there is a lack of consensus about the use of touch and the complex ethical and clinical issues surrounding its use. This article review the clinical and research literature and explores views for and against using touch in therapy. Given the powerful effect of touch and the legal climate in our society, ethical and clinical guidelines are presented to assist the therapist in using touch appropriately, with sensitivity and skill. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Intervention in alcohol use disorder in a general practice

AIM: To report the outcome of intervention in 70 patients with alcohol use disorder in a general practice. METHOD: Of the 84 patients age 18-69 years identified clinically or by a screening programme with alcohol use disorder, 70 who were available for at least 2 year follow up after diagnosis were included in the study group. The clinical notes of these patients were reviewed to determine evidence of sustained achievement of abstinence or controlled drinking and factors contributing to successful change in alcohol use. RESULTS: Sustained abstinence or controlled drinking was verified for 31 patients (44%) with a further 26 patients (37%) reporting reduction in alcohol use without evidence of sustained improvement. The mean interval from diagnosis to sustained improvement was 4 years. Only five patients accepted referral to specialist alcohol units. Successful change in the 31 patients achieving their drinking goal was directly related to intervention at the surgery for 9 patients. CONCLUSION: A motivational approach with focus on the patient's perception of the issues proved relatively successful in this practice. A prolonged period of change was required to achieve drinking goals. Other factors contributing to improvement are discussed.     

Frequent attenders in general practice: a study from Slovenia

This study describes the entrapment of squid-type diisopropylphosphorofluoridate-hydrolyzing enzyme (DFPase) within mouse red blood cells. These erythrocytes thereby gain the ability to rapidly hydrolyze alkylphosphate cholinesterase (ChE) inhibitors such as diisopropyl fluorophosphate (DFP). DFPase rapidly hydrolyzes DFP to diisopropyl phosphate. Resealed erythrocytes provide a stable carrier system that can preserve the activity of encapsulated enzymes against otherwise rapid in vivo degradation; thus, ChE inhibitors can be degraded to relatively nontoxic metabolites by these erythrocyte carriers. Squid DFPase was purified from the hepatopancreas of Atlantic squid and DFPase activity was determined by measuring changes in fluoride ion concentration using a fluoride ion selective electrode. Mouse erythrocytes in suspension with excess squid DFPase were dialyzed against hypotonic buffer to allow the encapsulation of the enzyme to occur. Cells were then resealed by returning the suspension to isosmotic with saline. Rate of DFP hydrolysis observed with these cells was much greater than the rate of nonenzymatic hydrolysis and was directly proportional to the amount of the erythrocyte suspension added to the assay solution. The rate of hydrolysis was first order in substrate. Erythrocyte controls showed no endogenous DFPase activity. These results suggest that enzyme entrapment may be developed as a method to prevent and antagonize organophosphate poisoning.     

Twelve years of injectable contraceptive use in a general practice

OBJECTIVE: To present our experience with the use of ultrasonography in the evaluation of hysterectomized patients. METHODS: The study group was comprised of 100 consecutive women referred to our ambulatory unit for pelvic sonographic evaluation between April 1, 1996 and March 31, 1997. Inclusion criteria were previous hysterectomy for a benign condition with or without concomitant bilateral salpingo-oophorectomy and available medical and gynecological histories. RESULTS: No significant difference was observed in the rate of abnormal ultrasonographic findings among the patients who had had bilateral salpingo-oophorectomy 5/50 and those who had not (8/50). There was also no significant difference in pelvic mass rate between the patients who were receiving hormone replacement therapy and those who were not. The sensitivity of sonography in our study was 100% and the positive predictive value, 84.5%. CONCLUSIONS: Sonography is a useful diagnostic tool in the follow-up and management of post-hysterectomy patients.     

Structure and process: the relationship between practice management and actual clinical performance in general practice

The transposable element impala is a member of the widespread superfamily of Tc1-mariner transposons, identified in the genome of the plant pathogenic fungus Fusarium oxysporum. This element is present in a low copy number and is actively transposed in the F. oxysporum strain F24 that is pathogenic for melons. The structure of the impala family was investigated by cloning and sequencing all the genomic copies. The analysis revealed that this family is composed of full-length and truncated copies. Four copies contained a long open reading frame that could potentially encode a transposase of 340 amino acids. The presence of conserved functional domains (a nuclear localisation signal, a catalytic DDE domain and a DNA-binding domain) suggests that these four copies may be autonomous elements. Sequence comparisons and phylogenetic analysis of the impala copies defined three subfamilies, which differ by a high level of nucleotide polymorphism (around 20%). The coexistence of these divergent subfamilies in the same genome may indicate that the impala family is of ancient origin and/or that it arose by successive horizontal transmission events.