Sexually transmitted diseases and communications with general practitioners. (57/3199)

OBJECTIVES: To devise a method of communicating with the general practitioners (GPs), overcoming the constraints imposed by patient confidentiality and the low levels of staffing in genitourinary medicine (GUM) clinics. To assess the GPs' responses to this method of communication. SETTING: GUM clinics at two centres in Kent-Maidstone and Tunbridge Wells. METHODS: Patients were recruited if they attended the clinic of their own accord without a letter of referral from their GPs; a definitive or provisional diagnosis was made and the patient was managed in the clinic; the patient's GP had received a conventional reply from the GUM clinic for other patients referred in the past. Separate GP letters were developed for male and female patients. These handwritten study letters were read by the patients who took the responsibility to deliver them to their GPs. This was followed by a questionnaire to the GPs. RESULTS: 75 patients were eligible. Seven patients refused to participate. All questionnaires were returned by the GPs for the 68 participating patients (100%). Seven GPs failed to receive the study letter. For these unreferred patients, this was an improvement in communication level from 0% to 80%. 79% (95% confidence interval: 67%-87%) preferred the study letter, 97% (89%-99%) would like to receive a similar letter for future patients. All GPs thought that the study letter was at least as good as the standard letter 52% (40%-64%) thought it was better. For 82% (70%-90%) it was the preferred format for future communication. CONCLUSION: The study has shown a way of establishing communication with GPs for patients who do not object to this. The results also suggest that in the study districts neither the GPs nor the majority of study patients had any objection to the sharing of information between the GUM clinics and GPs.  (+info)

Acupuncture in alcoholism treatment: a randomized out-patient study. (58/3199)

Seventy-two alcoholics were treated with acupuncture to the ear in a randomized single-blind controlled design over 10 weeks. Orthodox points and incorrect points 3-5 mm from orthodox points were used. No initial differences were found regarding social characteristics, the responses to the Swedish version of the Alcohol Use Inventory and the Three-dimensional Personality Questionnaire, indicating a successful randomization. There were non-significant tendencies towards gender differential response after acupuncture treatment (P = 0.07). There was no difference in the number of drinking days or level of craving between treatment and control patients. Among females, those in the treatment group reported reduction of anxiety after 1 month, more often than those in the control group (P < 0.05). Response to acupuncture was not related to personality or drinking pattern. Patients' experience of needle placement was similar in the study and control groups. The effects of acupuncture were less pronounced than those previously reported.  (+info)

Implementing guidelines for cancer pain management: results of a randomized controlled clinical trial. (59/3199)

PURPOSE: Pain and symptom management is an integral part of the clinical practice of oncology. A number of guidelines have been developed to assist the clinician in optimizing comfort care. We implemented clinical guidelines for cancer pain management in the community setting and evaluated whether these guidelines improved care. PATIENTS AND METHODS: Eighty-one cancer patients, aged 37 to 76 years, were enrolled onto a prospective, longitudinal, randomized controlled study from the outpatient clinic settings of 26 western Washington-area medical oncologists. A multilevel treatment algorithm based on the Agency for Health Care Policy and Research Guidelines for Cancer Pain Management was compared with standard-practice (control) pain and symptom management therapies used by community oncologists. The primary outcome of interest was pain (Brief Pain Inventory); secondary outcomes of interest were all other symptoms (Memorial Symptom Assessment Scale) and quality of life (Functional Assessment of Cancer Therapy Scale). RESULTS: Patients randomized to the pain algorithm group achieved a statistically significant reduction in usual pain intensity, measured as slope scores, when compared with standard community practice (P < .02). Concurrent chemotherapy and patient adherence to treatment were significant mediators of worst pain. There were no significant differences in other symptoms or quality of life between the two treatment groups. CONCLUSION: This guideline implementation study supports the use of algorithmic decision making in the management of cancer pain. These findings suggest that comprehensive pain assessment and evidence-based analgesic decision-making processes do enhance usual pain outcomes.  (+info)

Clinical value and cost of a respiratory sleep-related breathing disorders screening service for snorers referred to a District General Hospital ENT department. (60/3199)

Sleep-related breathing disorders and snoring often co-exist in the community. We hypothesized that a significant proportion of patients referred from primary care to ENT surgeons for management of snoring might have significant sleep-related breathing disorders requiring medical management. The Respiratory Medicine Department at Whipps Cross Hospital, London, U.K. screened all such referrals using sleep questionnaires, overnight oximetry and diagnostic sleep studies where necessary as recommended by the Royal College of Physicians of London. Over 38 months, 115 patients were screened, of whom 43 (38%) had clinically significant sleep-disordered breathing. One-third were established on nasal continuous positive airway pressure ventilation and the remainder were mainly offered conservative treatment. The cost of the screening service is estimated at 14,000 Pounds for the initial year. The savings to the ENT service and the possible long-term benefits to the patients identified as having sleep-disordered breathing balance this. We conclude that screening all referred snorers for sleep-disordered breathing using a simple protocol identifies a significant number requiring medical management at a relatively low cost to the service provider.  (+info)

Performance of a short lung-specific health status measure in outpatients with chronic obstructive pulmonary disease. (61/3199)

The objective of this study was to assess the performance of a lung-specific health status measure in patients with chronic obstructive pulmonary disease (COPD). We used the Respiratory Quality of Life Questionnaire (RQLQ), a modification of an Australian questionnaire intended for asthma patients and adapted in this study to fit patients with COPD also. For comparison we chose the general health profile measure Short Form 36 (SF-36). We assessed the five RQLQ scales and eight SF-36 scales for reliability, validity and responsiveness in 59 outpatients attending a Norwegian hospital for COPD. Statistical analysis included internal consistency, test-retest reliability and convergent validity between the two questionnaires. Responsiveness was assessed in patients reporting global change in health status over 1 year. All scales of the RQLQ showed good internal consistency (Cronbach's a = 0.85-0.94) and test-retest reliability (intraclass correlation coefficient = 0.86-0.94), as did the SF-36 scales (a = 0.66-0.90) and intraclass correlation coefficient = 0.60-0.86). Pearson correlations between scales with similar items ranged from 0.54 to 0.76, supporting the construct validity of both questionnaires. The RQLQ had responsive scales, showing significant changes in the expected direction over 1 year. We conclude that the RQLQ showed an acceptable reliability, construct validity and responsiveness in COPD patients, encouraging further use of this questionnaire.  (+info)

Out-patient management of acute myeloid leukemia after consolidation chemotherapy. Role of a hematologic emergency unit. (62/3199)

BACKGROUND AND OBJECTIVE: Increasing attention to quality of life and to health care costs has recently induced several cancer centers to change in-patient management into an out-patient setting even during high risk phases of disease. The aim of this prospective study was to evaluate feasibility and safety, as well as clinical characteristics, of out-hospital management of AML patients during their post-consolidation phase. DESIGN AND METHODS: All patients who were treated over a three year period by the three following protocols were included in the study: AML10 EORTC/GIMEMA for patients with AML, except for APL, aged 60 years; AIDA GIMEMA for APL patients. All patients submitted to the AML10 and AML13 protocols and those patients submitted to the AIDA protocol with difficult peripheral vein access had a central venous catheter (CVC) sited. Patients treated as in-patients were discharged at the end of consolidation chemotherapy provided they were in a good clinical condition. They were routinely evaluated on an out-patient basis twice weekly. In the event of any complication they were referred to the Emergency Unit of our Department dedicated to out-patients with hematologic diseases. RESULTS: One hundred and eleven patients with AML were eligible for intensive chemotherapy. After achievement of complete remission they received a total of 133 consolidation courses and in 127 instances they were followed on an out-patient basis during the aplastic phase. There were 69 cases (54%) of rehospitalization, 68 because of fever and only one because of severe anemia. Rehospitalization occurred in 90%,70% and 38% of courses in AML10, AML13 and AIDA protocols, respectively. Only one patient died: the cause of death was a brain hemorrhage. Coagulase negative staphylococci and viridans streptococci were the organisms most frequently isolated from blood. Most coagulase negative staphylococci were isolated in patients submitted to AML10 and AML13 protocols, who had an indwelling CVC. Empiric once-a-day antibacterial therapy with ceftriaxone and amikacin was effective in 75% of the cases and made early discharge possible in 28% of the cases with antibiotic therapy continued in an out-patient setting. Overall, patients were managed out of the hospital for 66% of the period of post-consolidation neutropenia (77%, 48% and 50% of the post-consolidation neutropenia period in patients treated with AIDA, AML10 and AML13 protocols, respectively). INTERPRETATION AND CONCLUSIONS: Thanks to the availability of an emergency unit specifically dedicated to out-patients with hematologic diseases, selected out-hospital management of AML patients during post-consolidation cytopenia is a feasible, well accepted and cost-saving option, and can contribute to lower the risk of developing severe nosocomial infections. The empiric therapy with once-a-day ceftriaxone plus amikacin was effective, with the exception of staphylococcal infections, and made it possible to discharge patients early to continue treatment in an out-patient setting.  (+info)

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. (63/3199)

OBJECTIVE: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. METHODS: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. RESULTS: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711. CONCLUSION: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.  (+info)

Safety and efficacy of a continuous infusion, patient controlled anti-emetic pump to facilitate outpatient administration of high-dose chemotherapy. (64/3199)

We evaluated the combination of diphenhydramine, lorazepam, and dexamethasone delivered as a continuous i.v. infusion via an ambulatory infusion pump with patient-activated intermittent dosing (BAD pump) for prevention of acute and delayed nausea/vomiting in patients receiving high-dose chemotherapy (HDC) for peripheral blood progenitor cell (PBPC) mobilization (MOB) or prior to autologous PBPC rescue. The BAD pump was titrated to patient response and tolerance, and continued until the patient could tolerate oral anti-emetics. Forty-four patients utilized the BAD pump during 66 chemotherapy courses, 34 (52%) for MOB and 32 (48%) for HDC with autologous PBPC rescue. The median number of days on the BAD pump during MOB and HDC was 3 (1-6) and 9 (2-19) days, respectively. Complete overall or complete emesis control occurred on 94% of MOB and 89% of HDC treatment days during chemotherapy administration and 72% and 43%, respectively, following chemotherapy administration. Eighty-three percent of MOB and 55% of HDC treatment days were associated with no nausea. While on the BAD pump, no patient experienced severe toxicity or required hospitalization for management of nausea/vomiting. The BAD pump was safe and effective in minimizing nausea and vomiting associated with HDC, and thus, eliminated the need for hospitalization for management of chemotherapy-induced nausea and vomiting.  (+info)