New strategies for prophylactic platelet transfusion in patients with hematologic diseases. (73/1023)

There is an increasing demand for platelet transfusions due to intensive chemotherapy and blood stem cell or bone marrow transplantation for the treatment of hematologic and oncologic diseases. There has been a long-lasting debate over whether the traditional threshold for prophylactic platelet transfusion of 20,000/microl is really necessary to prevent hemorrhagic complications. During the last 10 years several studies with more than 1,000 patients together have proven the safety of a platelet transfusion trigger of 10,000/microl or even lower when patients are clinically stable without active bleeding. This experience has been mostly gathered in patients with acute leukemia. But this stringent platelet transfusion policy can be used also after blood stem cell and bone marrow transplantation. In stable patients with aplastic anemia and myelodysplasia, prophylactic transfusions should be replaced in most patients by a therapeutic transfusion strategy. Such restrictive platelet transfusion strategies decrease the risk of infectious disease transmission, immunization, and febrile transfusion reactions. Besides reduced hospital visits and a shorter hospital stay for the patients, the costs for platelet transfusions are lowered by 20%-30% compared with traditional transfusion strategies. The decision to administer platelet transfusions should incorporate individual clinical characteristics of the patients and not simply be a reflexive reaction to the platelet count. Further clinical studies are needed to answer the still open question of whether patients with acute leukemia should also be transfused therapeutically rather than prophylactically when they are in stable condition without signs of active bleeding.  (+info)

The dream: a psychodynamically informative instrument. (74/1023)

The dream is a unique psychodynamically informative instrument for evaluating the subjective correlates of brain activity during REM sleep. These include feelings, percepts, memories, wishes, fantasies, impulses, conflicts, and defenses, as well as images of self and others. Dream analysis can be used in a variety of clinical settings to assist in diagnostic assessment, psychodynamic formulation, evaluation of clinical change, and the management of medically ill patients. Dreams may serve as the initial indicators of transference, resistance, impending crisis, acting-out, conflict resolution, and decision-making. A clinically functional categorization of dreams can facilitate an understanding of psychopathology, psychodynamics, personality structure, and various components of the psychotherapeutic process. Examples of different types of dreams are provided to illustrate their relevance and use in various clinical situations.  (+info)

The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. (75/1023)

OBJECTIVES: To test the hypotheses that: (1) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes, including pain, disability, health status, sickness absence, reassurance, and patient satisfaction or belief in the value of radiography. (2) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management, including medication use, and the use of primary and secondary care services, physical therapies and complementary therapies. (3) Participants choosing their treatment group (i.e. radiography or no radiography) do not have better outcomes than those randomised to a treatment group. (4) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography. DESIGN: A randomised unblinded controlled trial. SETTING: Seventy-three general practices in Nottingham, North Nottinghamshire, Southern Derbyshire, North Lincolnshire and North Leicestershire. Fifty-two practices recruited participants to the trial. SUBJECTS: Randomised arm: 421 participants with low back pain, with median duration of 10 weeks. Patient preference arm: 55 participants with low back pain, with median duration of 11 weeks. INTERVENTION: Lumbar spine radiography and usual care versus usual care without radiography. MAIN OUTCOME MEASURES: Roland adaptation of the Sickness Impact Profile, visual analogue pain scale, health status scale, EuroQol, use of primary and secondary care services, and physical and complementary therapies, sickness absence, medication use, patient satisfaction, reassurance and belief in value of radiography at 3 and 9 months post-randomisation. RESULTS: Participants randomised to receive an X-ray were more likely to report low back pain at 3 months (odds ratio (OR) = 1.56; 95% confidence interval (CI), 1.02 to 2.40) and had a lower overall health status score (p = 0.02). There were no differences in health or functional status at 9 months. A higher proportion of participants consulted the general practitioner (GP) in the 3 months following an X-ray (OR = 2.72; 95% CI, 1.80 to 4.10). There were no differences in use of any other services, medication use or sickness absence at 3 or 9 months. No serious spinal pathology was identified in either group. The commonest X-ray reports were of discovertebral degeneration and normal findings. Many patients did not perceive their information needs were met within the consultation. Satisfaction with care was greater in the group receiving radiography at 9 months. Participants randomised to receive an X-ray were not less worried, or more reassured about serious disease causing their low back pain. Satisfaction was associated with meeting participants' information needs and reduced belief in the necessity for investigations for low back pain, including X-rays and blood tests. In both groups, at 3 and 9 months 80% of participants would choose to have an X-ray if the choice was available. Participants in the patient preference group achieved marginally better outcomes than those randomised to a treatment group, but the clinical significance of these differences is unclear. Lumbar spine radiography was associated with a net economic loss at 3 and 9 months. CONCLUSIONS: Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.  (+info)

Good occlusal practice in advanced restorative dentistry. (76/1023)

In most patients the existing occlusal scheme will be functional, comfortable and cosmetic; and so if a tooth or teeth need to be restored, the most appropriate way to provide the restoration(s) would be to adopt a 'conformative' approach: that is to provide treatment within the existing envelope of static and dynamic occlusal relationships. There will, however, be situations where the conformative approach cannot be adopted, and this section aims to describe what is 'Good Occlusal Practice' in these circumstances.  (+info)

Quality evaluation of clinical records of a group of general dental practitioners entering a quality assurance programme. (77/1023)

This paper discusses the importance of maintaining high quality clinical records. Evidence from studies carried out in the USA, Australia and Scandinavia shows that record keeping often falls well below accepted standards. Evidence of current standards in the UK, however, has tended to be anecdotal or circumstantial. An assessment was carried out on 47 general practitioners entering the quality assurance programme of a private capitation scheme. A sample of clinical records from each practitioner was analysed, and the presence or absence of key diagnostic and treatment planning entries were recorded. Overall, the quality of record keeping was poor, and in line with the findings of the other worldwide studies. Fundamental clinical entries that could impact on basic dental care provision were missing from many records. The frequency of recording for patients whose treatment was funded under NHS regulations was significantly worse than for patients whose treatment was privately funded.  (+info)

Better care and better teaching. New model of postpartum care for early discharge programs. (78/1023)

PROBLEM BEING ADDRESSED: Rapid postpartum discharge has reduced opportunities to detect early newborn or parenting problems and to teach neonatal assessment and maternal postpartum care to medical trainees. OBJECTIVE OF PROGRAM: Development of a program to not only ensure adequate care of mothers and newborns after early hospital discharge, but also to teach outpatient assessment skills to family medicine residents. MAIN COMPONENTS OF PROGRAM: In an urban, secondary care, university-affiliated teaching hospital predominantly training family medicine residents, an interdisciplinary committee created and supervised a neonatal and maternal postpartum assessment program. Newborn infants and their mothers are seen by a family physician, a family medicine resident, and a nurse within 48 hours of discharge, after which care is assumed in the community by the child's primary care physician. An assessment protocol developed by the interdisciplinary group promotes standardized mother and child care and a structured learning experience for trainees. CONCLUSION: Rapid follow up of early discharged infants and their mothers can be facilitated by a program of standardized assessment by a roster of pooled, interacting family physicians and nurses. When this assessment occurs in a teaching milieu, a comprehensive learning experience can be combined with defined objectives that emphasize and encourage newborn and maternal assessment for ambulatory patients.  (+info)

Good occlusal practice in removable prosthodontics. (79/1023)

The loss of teeth may result in patients experiencing problems of a functional, aesthetic and psychological nature. This section addresses the very important subject of occlusal considerations for partial and complete dentures. The occlusion is particularly important given the bearing that occlusal factors have, especially on edentulous patients.  (+info)

Usefulness of volume-rendered three-dimensional computed tomographic angiography for surgical planning in treating unruptured paraclinoid internal carotid artery aneurysms. (80/1023)

Paraclinoid internal carotid artery aneurysms are difficult to treat and difficult to visualize by using DSA, MRA, or surface-rendered 3D-CTA. Because those aneurysms are surrounded by bone, the dural ring (proximal and distal), the optic nerve, the oculomotor nerve, and the cavernous sinus. This report represents the first attempt to assess the verification of volume-rendered 3D-CTA for surgical planning in treating paraclinoid internal carotid artery aneurysms. From January, 1996 to October, 2001, we treated 15 cases of unruptured paraclinoid internal carotid artery aneurysms at Kobe University Hospital. Twelve of the patients were women and three were men, ranging age from 33 to 70 (55.7 /10.3). We studied used volume-rendered 3D-CTA to examine five patients and surface-rendered 3D-CTA for ten. Volume-rendered 3D-CTA allowed observation of the aneurysms and their necks and the surrounding structures in all cases (P<0.001), while surface-rendered 3D-CTA allowed partial observation of the aneurysms in 5 cases (50%). Volume-rendered 3D-CTA enabled virtual removal of bones by using the clip-plane editing and allowed the aneurysms to be viewed from various angles. When the pterional approach is used and the neck of the aneurysm is found to be remote from the anterior clinoid process, the anterior clinoid process need not be removed. In conclusion, for paraclinoid internal carotid artery aneurysms, volume-rendered 3D-CTA is superior to surface-rendered 3D-CTA, MRA and digital subtraction angiography in terms of visualization of the aneurysm and surrounding bones. It was great help for surgical planning in treating paraclinoid internal carotid artery aneurysms.  (+info)