Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children.
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AIMS: The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia. METHODS: Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers' (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching. RESULTS: Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists' recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child's activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child's activities. CONCLUSION: The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of 'self-efficacy' and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching. (+info)
Advances in the clinical care of burned patients.
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Very few areas of medical science have experienced more rapid development of new and beneficial treatment approaches during the past two decades than the disciplines required for total care of patients with major thermal injury. The introduction of a multidisciplinary scientific approach to the diagnosis and treatment of very complex postburn complications has been primarily responsible for the major advances in clinical care. This report highlights those areas of advancement which have been most significant in upgrading current inpatient therapy. (+info)
A reduction in serum cytokine levels parallels healing of venous ulcers in patients undergoing compression therapy.
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INTRODUCTION: vascular endothelial growth factor (VEGF) and tumour necrosis factor alpha (TNF(alpha)) have been specifically implicated in the tissue damage associated with chronic venous disease (CVD). Furthermore, production of both factors is known to be upregulated in vessel wall cells subject to hypertension. The aim of this study was to determine the local venous levels of VEGF and TNF(alpha) in limbs with venous ulcers before and after treatment with graduated compression. PATIENTS AND METHODS: eight patients with venous ulcers and 8 patients with varicose veins only were included in the study. For ulcer patients, serum samples were taken from the superficial veins in lower limbs and repeated after 4 weeks of treatment with 4-layered graduated compression. Serum from the arms of the same patients served as controls. Determination of the concentrations of VEGF and TNF(alpha) proteins were performed with sandwich enzyme-linked immunosorbent assays. RESULTS: both groups of patients had elevated levels of VEGF and TNF(alpha). In patients with venous ulcers there was a reduction in the levels of both cytokines to below control values with treatment. These changes correlated with healing of the ulcers as determined by reduction in ulcer size. CONCLUSION: these data, for the first time, suggest a central role for both TNF(alpha) and VEGF in the pathogenesis of venous ulceration which may constitute a causative link between venous hypertension and tissue pathology. (+info)
Why insurers should reimburse for compression stockings in patients with chronic venous stasis.
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BACKGROUND: Chronic venous stasis ulcers produce substantial morbidity rates and result in a significant expense to society. Fortunately, compression stockings (CS) have been found to reduce the rate of recurrence in patients with previous ulceration. Surprisingly, Medicare and other insurers do not reimburse the expense associated with CS or with patient education (Ed), which is essential to ensure compliance. METHODS: A Markov decision analysis model was used for analysis of the cost-effectiveness of a strategy of reimbursement for CS and Ed (prophylaxis) versus one that does not supply these resources in a 55-year-old patient with prior venous stasis ulceration. The mean time to ulcer recurrence (53 months with CS+Ed; 18.7 months without prophylaxis), the mean time for ulcer healing (4.6 months), the probabilities of hospitalization (12%) and amputation (0.4%) after the development of an ulcer, and quality-adjustment factors (0.80 during ulcer treatment) were derived from the literature. The cost of CS ($300/year) and Ed ($93 for initial evaluation; $58/year; $40/recurrence) and the medical cost of ulcer treatment (average cost, $1621/recurrence) were calculated from our hospital cost accounting system. RESULTS: A strategy of CS and Ed was cost saving, with 0.37 quality-adjusted life years and $5904 saved, compared with a strategy that does not provide these resources. The inclusion of loss of revenue related to absence from work in the analysis increased cost savings to $17,080 during the patient's lifetime. With sensitivity analysis, CS and Ed remained cost-effective (lifetime cost per quality-adjusted life year saved, <$60,000) if amputations and the cost of ulcer treatment were eliminated or if the cost of prophylaxis was increased to 600% of the base-case. The mean time to recurrence in patients with CS and Ed needed to be reduced from 53 months to 21.1 months before this strategy was no longer cost-effective. CONCLUSION: Prophylactic CS and Ed in patients with prior venous stasis ulceration are cost saving, even with the most conservative of assumptions. Insurers should routinely reimburse for these interventions. (+info)
Amblyopia treatment outcomes after screening before or at age 3 years: follow up from randomised trial.
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OBJECTIVE: To assess the effectiveness of early treatment for amblyopia in children. DESIGN: Follow up of outcomes of treatment for amblyopia in a randomised controlled trial comparing intensive orthoptic screening at 8, 12, 18, 25, 31, and 37 months (intensive group) with orthoptic screening at 37 months only (control group). SETTING: Avon, southwest England. PARTICIPANTS: 3490 children who were part of a birth cohort study. MAIN OUTCOME MEASURES: Prevalence of amblyopia and visual acuity of the worse seeing eye at 7.5 years of age. RESULTS: Amblyopia at 7.5 years was less prevalent in the intensive group than in the control group (0.6% v 1.8%; P=0.02). Mean visual acuities in the worse seeing eye were better for children who had been treated for amblyopia in the intensive group than for similar children in the control group (0.15 v 0.26 LogMAR units; P<0.001). A higher proportion of the children who were treated for amblyopia had been seen in a hospital eye clinic before 3 years of age in the intensive group than in the control group (48% v 13%; P=0.0002). CONCLUSIONS: The intensive screening protocol was associated with better acuity in the amblyopic eye and a lower prevalence of amblyopia at 7.5 years of age, in comparison with screening at 37 months only. These data support the hypothesis that early treatment for amblyopia leads to a better outcome than later treatment and may act as a stimulus for research into feasible screening programmes. (+info)
Closure of traumatic wounds without cleaning and suturing.
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BACKGROUND: In less than ideal situations wounds have to be closed without extensive cleaning using sterile adhesive strips (Steristrips). This prospective analyses the efficiency of this technique and compares it to the more conventional approach. METHODS: Altogether 147 lacerations were closed with sterile strips with no wound cleaning. Patients were subsequently followed up for a minimum of three months. RESULTS: The sepsis rate in compliant patients was 1.4% with a total complication rate of 2.7%. CONCLUSION: This technique, while contradicting the "sacred tenets" of wound closure, is a cheap, quick, and effective alternative to routine closure of traumatic wounds in a casualty department. (+info)
Less frequent catheter dressing changes decrease local cutaneous toxicity of high-dose chemotherapy in children, without increasing the rate of catheter-related infections: results of a randomised trial.
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Cutaneous lesions caused by catheter dressing changes can be serious and generate local pain in children undergoing high-dose chemotherapy followed by bone marrow transplantation. One hundred and thirteen children entered a randomised trial to compare two catheter dressing change frequencies (15 days vs 4 days). Skin toxicity was classified according to the following scale: grade 0: healthy skin, to grade 4: severe skin toxicity. A qualitative culture of the skin at the catheter entry site was taken whenever the dressing was changed. Of the 112 evaluable children (56 in each group) 32 developed grade > or = 2 local skin toxicity (eight in the 15-day group and 24 in the 4-day group; P = 0.001). Although higher in the 4-day group, the proportions of children experiencing pain during and between dressing changes were not statistically different between the two groups. The proportion of patients with one or more positive skin culture(s) at the catheter entry site during hospitalisation were similar in the two groups (27% in the 15-day group and 23% in the 4-day group) as were the proportions of documented nosocomial bloodstream infections (11% and 13%; NS). Whereas the planned frequency was maintained in the 4-day group (mean = 4 days, s.d. = 1), it was usually shortened in the 15-day group (mean = 8 days, s.d. = 4), mainly because dressings had loosened. Decreasing the catheter dressing change frequency proved efficient in reducing cutaneous toxicity without increasing the risk of local and systemic infection. In our unit, catheter dressings are changed every 8 days since this analysis. (+info)
Low agreement for assessing the risk of postoperative deep venous thrombosis when deciding prophylaxis strategies: a study using clinical vignettes.
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BACKGROUND: Several clinical practice guidelines (CPG) on antithrombotic prophylaxis in surgical patients help to decide about the prophylaxis strategy based on the patient risk of deep venous thrombosis (DVT). However, the physician risk estimates of DVT could have little inter-observer reproducibility, which could lead to different individual prophylaxis practices. METHODS: Physicians were asked to evaluate DVT risk in eight clinical vignettes, describing actual patients cared for in our hospital. The vignettes included all possible levels of DVT risk. RESULTS: The degree of prophylaxis strategies accuracy was 63% (95% CI 523-75%). Overall agreement was 0.32 (z = 7.61, p < 0.001) and for each level of risk kappa was 0.38 (z = 6.50, p < 0.001); 0.1 (z = 1.65, p < 0.049) and 0.5 (z = 8.45, p < 0.001) for small, moderate and high risk group respectively CONCLUSIONS: Our results showed that there is poor agreement when physicians have to evaluate the risk for postoperative DVT, and in the cases of low and moderate risks of DVT there is the smallest agreement. In addition, the data also showed that the overall accuracy of DVT prophylaxis strategy was only moderate and the risk evaluation did not correlate to the selection of the strategy. The issue of inter-observers variability should be taken into account when CPG performance are analysed, especially when considering the risk-evaluation to choose the appropriate actions. (+info)