Preparation of patients for anaesthesia - achieving quality care.
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Implementation of anaesthesia begins with a preoperative assessment of the surgical patient and development of an anaesthetic plan. Preparation of the patient includes the preoperative assessment, review of preoperative tests, optimisation of medical conditions, adequate preoperative fasting, appropriate premedication, and the explanation of anaesthetic risk to patients. The goals of preoperative preparation are to reduce the morbidity of surgery, to increase the quality while decreasing the cost of perioperative care, and to return the patient to desirable functioning as quickly as possible. A knowledgeable anaesthesiologist is the 'final clinical gatekeeper', who coordinates perioperative management and ensures that the patient is in the optimal state for anaesthesia and surgery. (+info)
Use of health care services in seasonal affective disorder.
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BACKGROUND: Little is known about the presentation and management of seasonal affective disorder (SAD) in primary care. AIMS: To determine the use of health care services by people suffering from SAD. METHOD: Following a screening of patients consulting in primary care, 123 were identified as suffering from SAD. Each was age- and gender-matched with two primary care consulters with minimal seasonal morbidity, yielding 246 non-seasonal controls. From primary care records, health care usage over a 5-year period was established. RESULTS: Patients with SAD consulted in primary care significantly more often than controls and presented with a wider variety of symptoms. They received more prescriptions, underwent more investigations and had more referrals to secondary care. CONCLUSIONS: Patients with SAD are heavy users of health care services. This may reflect the condition itself, its comorbidity or factors related to the personality or help-seeking behaviour of sufferers. (+info)
Evaluation of dysuria in adults.
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Dysuria, defined as pain, burning, or discomfort on urination, is more common in women than in men. Although urinary tract infection is the most frequent cause of dysuria, empiric treatment with antibiotics is not always appropriate. Dysuria occurs more often in younger women, probably because of their greater frequency of sexual activity. Older men are more likely to have dysuria because of an increased incidence of prostatic hyperplasia with accompanying inflammation and infection. A comprehensive history and physical examination can often reveal the cause of dysuria. Urinalysis may not be needed in healthier patients who have uncomplicated medical histories and symptoms. In most patients, however, urinalysis can help to determine the presence of infection and confirm a suspected diagnosis. Urine cultures and both urethral and vaginal smears and cultures can help to identify sites of infection and causative agents. Coliform organisms, notably Escherichia coli, are the most common pathogens in urinary tract infection. Dysuria can also be caused by noninfectious inflammation or trauma, neoplasm, calculi, hypoestrogenism, interstitial cystitis, or psychogenic disorders. Although radiography and other forms of imaging are rarely needed, these studies may identify abnormalities in the upper urinary tract when symptoms are more complex. (+info)
Routine daily chest radiography in patients with pulmonary artery catheters.
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BACKGROUND: Pulmonary artery catheters are widely used invasive monitoring devices in critically ill patients. Clinicians disagree about whether daily chest radiographs are needed or clinical parameters alone are sufficient to verify catheter placement. OBJECTIVES: To determine whether daily chest radiographs are needed to assess migration of pulmonary artery catheters. METHODS: One hundred consecutive patients with pulmonary artery catheters were prospectively evaluated. Clinical criteria for optimal position of the pulmonary artery catheters and findings on chest radiographs were compared. Optimal clinical criteria were (1) amount of air required to measure pulmonary capillary wedge pressure: 1.25 to 1.5 mL and (2) pulmonary artery catheter migrated 1 cm or less from initial position. RESULTS: Three hundred ninety comparisons of clinical criteria and radiographic findings were done. Chest radiographs indicated the catheter required repositioning in 15 (4%) of 390 instances but in only 4 (1%) of 310 instances in which bedside clinical findings indicated adequate catheter position. In 69 (18%) of the 390 cases, the clinical criteria for adequate catheter position were not met, but radiographs showed the catheter in an appropriate position. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of abnormal clinical criteria were 73%, 82%, 81%, 14%, and 99%, respectively. CONCLUSIONS: Chest radiographs indicated that about 4% of catheters required repositioning. Catheter malposition can be reliably excluded (negative predictive value, 99%) by close observation of specific clinical criteria, so routine daily chest radiographs do not seem justified. (+info)
Objective comparison of quantitative imaging modalities without the use of a gold standard.
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Imaging is often used for the purpose of estimating the value of some parameter of interest. For example, a cardiologist may measure the ejection fraction (EF) of the heart in order to know how much blood is being pumped out of the heart on each stroke. In clinical practice, however, it is difficult to evaluate an estimation method because the gold standard is not known, e.g., a cardiologist does not know the true EF of a patient. Thus, researchers have often evaluated an estimation method by plotting its results against the results of another (more accepted) estimation method, which amounts to using one set of estimates as the pseudogold standard. In this paper, we present a maximum-likelihood approach for evaluating and comparing different estimation methods without the use of a gold standard with specific emphasis on the problem of evaluating EF estimation methods. Results of numerous simulation studies will be presented and indicate that the method can precisely and accurately estimate the parameters of a regression line without a gold standard, i.e., without the x axis. (+info)
Offering routine antenatal testing for HIV and hepatitis B in the rural setting of Cornwall.
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Before Department of Health directives to offer HIV and hepatitis B (HBV) testing to all pregnant women, there was little such screening in Cornwall. Through a multiagency collaborative approach a new antenatal screening programme for HIV/HBV has been introduced with high uptake in the first year (HIV 92% and HBV 93%). We also report the findings of a questionnaire survey of community midwives who alone offer antenatal HIV/HBV testing in Cornwall. (+info)
Mammography screening and differences in stage of disease by race/ethnicity.
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OBJECTIVES: We examined the effect of routine screening on breast cancer staging by race/ethnicity. METHODS: We used a 1990 to 1998 mammography database (N = 5182) of metropolitan Denver, Colo, women to examine each racial/ethnic cohort's incident cancer cases (n = 1902) and tumor stage distribution given similar patterns of routine screening use. RESULTS: Regardless of race/ethnicity, women participating in routine screenings had earlier-stage disease by 5 to 13 percentage points. After control for possible confounding factors, White women were more likely to have early-stage disease compared with Black and Hispanic women. CONCLUSIONS: Lack of screening coverage in certain racial/ethnic populations has often been cited as a reason for tumor stage differences at detection. In this study, correcting for screening did not completely reduce stage differentials among Black and Hispanic women. (+info)
How underlying patient beliefs can affect physician-patient communication about prostate-specific antigen testing.
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CONTEXT: Routine cancer screening with prostate-specific antigen (PSA) is controversial, and practice guidelines recommend that men be counseled about its risks and benefits. OBJECTIVE: To evaluate the process of decision making as men react to and use information after PSA counseling. DESIGN: Written surveys and semistructured qualitative interviews before and after a neutral PSA counseling intervention. PARTICIPANTS: Men 40 to 65 years of age in southeastern Michigan were recruited until thematic saturation--that is, the point at which no new themes emerged in interviews (n = 40). RESULTS: In a paper survey, 37 of 40 participants (93%) said that they interpreted the counseled information as unfavorable toward PSA. However, 30 participants (75%) said after the intervention that they intended to be tested in the future, including 29 of 30 men (97%) with prior PSA testing. In the interview, many participants cited underlying beliefs as a reason to dismiss the counseled information. Qualitative analysis found the seven most common beliefs cited were fear of cancer, relevance of salient anecdotes and analogies, distrust of statistics, enthusiasm for "prevention," protection from "bad luck," faith in science, and valuing PSA as knowledge for its own sake. Although some beliefs could be interpreted as judgment errors, most were credible on a personal level. CONCLUSIONS: Most men who underwent PSA counseling cited underlying beliefs rather than the content of counseled information as the basis for their decisions regarding future PSA screening. If widespread, such beliefs may render clinician counseling and decision support methods less effective. Eliciting patient beliefs prior to counseling may improve the shared decision-making process. (+info)