NICE guidelines and the treatment of Alzheimer's disease: evidence-based medicine may be discriminatory.
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Alzheimer Disease↗
Biomedical subjects
R Stewart
Publications and source records attributed to R Stewart.
Motives for seeking a second opinion in orthopaedic surgery.
OBJECTIVES: The number of second opinions in orthopaedic surgery is increasing rapidly, yet the grounds on which patients and their doctors decide to seek a second opinion have been little studied. The goal of the study was to identify patient and consultant factors that appeared to contribute to a second opinion being sought. METHODS: Two thousand and seventy-nine consecutive new patients visiting an orthopaedic surgical outpatient clinic in 1996-1997 participated in the study. Patients were self-defined as seeking a second opinion if they had visited at least one other consultant for the same condition within the previous two years. Each of these patients completed a questionnaire before seeing the orthopaedic surgeon; this included details about the physician-patient relationship, reasons for seeking a second opinion and perceived health status. The first-opinion consultants were contacted by mail; their practice characteristics and the motives for seeking a second opinion were also obtained. RESULTS: Thirty per cent of the study population (n = 625) had sought a second opinion. Patients sought a second opinion because of disappointment concerning their original treatment, or because they wanted more information about their condition and/or its treatment. First-opinion consultants were usually unaware of these communication issues. Patients' inclination to initiate a second opinion was best predicted by their evaluation of their relationship with their first-opinion consultant. The propensity to initiate referrals for a second opinion varied widely among the first-opinion consultants (10-70%) and was inversely proportional to the size of the group they worked in and their distance from the referral centre. CONCLUSIONS: Patients did not seek a second opinion because they had doubts about the competence of their treating consultant, but because they were dissatisfied about the level of communication or about the results of their treatment. Medical educators should continue to increase their efforts to improve specialists' communication and relationship skills since these seem to generate referrals for second opinions, which occupy clinic space that could be used by other patients.
Humans↗
Pregnancy and primary pulmonary hypertension : successful outcome with epoprostenol therapy.
Primary pulmonary hypertension (PPH) associated with pregnancy carries a high maternal mortality rate. Short-term epoprostenol infusion has been demonstrated to improve the hemodynamic profile in patients with PPH. We report a successful maternal-fetal outcome with epoprostenol therapy during pregnancy, cesarean section, and postpartum in a patient with PPH. Epoprostenol therapy did not produce any physical or developmental abnormalities in the fetus. A favorable maternal-fetal outcome may occur with a multidisciplinary approach.
Adult↗
Depression, APOE genotype and subjective memory impairment: a cross-sectional study in an African-Caribbean population.
BACKGROUND: Subjective memory impairment (SMI) is common in older populations but its aetiology and clinical significance is uncertain. Depression has been reported to be strongly associated with SMI. Associations with objective cognitive impairment are less clear cut. Other factors suggested to be associated with SMI include poor physical health and the apolipoprotein E (APOE) epsilon4 allele. Studies of SMI have been predominantly confined to white Caucasian populations. METHOD: A community study was carried out in a UK African-Caribbean population aged 55-75, sampled from primary care lists. Twenty-three per cent were classified with SMI. Depression was defined using the 10-item Geriatric Depression Scale. Other aetiological factors investigated were education, objective cognitive function, APOE genotype, disablement and vascular disease/risk. The principal analysis was restricted to 243 participants scoring > 20 on the Mini-Mental State Examination (85%). A second analysis included all 290 participants. RESULTS: Depression, self-reported physical impairment and APOE epsilon4 were associated with SMI. The association between SMI and physical impairment was not explained by depression, vascular disease/risk, or disability/handicap. The association between epsilon4 and SMI increased as MMSE scores decreased and was particularly strong in those with depression. The epsilon4 allele was present in 69% (95% CI 41-89%) of those with depression and SMI compared with 28% (20-36%) of those with neither. CONCLUSIONS: Depression may not be a sufficient explanation for subjective memory complaints. Memory complaints in the presence of depression are associated with high prevalence of epsilon4 and therefore, presumably, a raised risk of subsequent dementia.
Aged↗
Continuous pulse oximetry in acute hemiparetic stroke.
BACKGROUND AND PURPOSE: Hypoxemia can adversely affect ischemic brain tissue in laboratory animals. The aim of this study was to assess the value of early continuous monitoring with pulse oximetry in detecting arterial oxygen desaturations in patients with acute hemiparetic stroke, and the effects of oxygen administration. METHODS: Over a period of 6 months 49 consecutive patients with acute hemiparetic stroke of </=12 h duration were monitored for the first 48 h with pulse oximetry. Patients in whom arterial oxygen saturation (SaO(2)) fell beneath 96% for a period longer than 5 min were treated with oxygen administered via nasal prongs or oxygen mask. RESULTS: Thirty-one patients (63.3%) developed arterial oxygen desaturations. Of these patients 28 could effectively be treated with oxygen up to a flow-rate of 5 l/min. Only 3 patients required higher oxygen concentrations from 6 to 10 l/min. No acute adverse effects of oxygen treatment were observed. All patients with a history of cardiac and pulmonary disease developed drops in SaO(2). The occurrence of arterial oxygen desaturations was related to stroke severity (P=0.024), the presence of dysphagia (P=0.047), and older age (P=0.037). CONCLUSION: Patients with acute hemiparetic stroke frequently develop arterial oxygen desaturations. Continuous monitoring with pulse oximetry in this group of patients is a simple and useful method to detect drops in SaO(2) and to titrate oxygen administration.
Acute Disease↗
Neurotrophins enhance electric field-directed growth cone guidance and directed nerve branching.
Neurotrophins play major roles in the developing nervous system in controlling neuronal differentiation, neurite outgrowth, guidance and branching, synapse formation and maturation, and neuronal survival or death. There is increasing evidence that nervous system construction takes place in the presence of dc electric fields, which fluctuate dynamically in space and time during embryonic development. These have their origins in the neural tube itself, as well as in surrounding skin and gut. Early disruption of these endogenous electric fields causes failure of the nervous system to form, or else it forms aberrantly. Nerve growth, guidance, and branching are controlled tightly during pathway construction and in vitro dc electric fields have profound effects on each of these behaviours. We have used cultured neurones to ask whether neurotrophins and dc electric fields might interact in shaping neuronal growth, given their coexistence in vivo. Electric field-directed nerve growth generally was enhanced by the simultaneous presentation of several neurotrophins to the growth cone. Under certain circumstances, more nerves turned cathodally, they turned faster, further, and in lower field strengths. Intriguingly, other combinations of dc electric field and neurotrophins (low field strength and neurotrophin 3 (NT-3) switched the direction of growth cone turning. Additionally, cathodally directed nerve growth was faster and directed branching was much more common when electric fields and neurotrophins interacted with neuronal growth cones. Given such profound changes in growth cone behaviour in vitro, neurotrophins and endogenous electric fields are likely to interact in vivo.
Animals↗
Xenopus NK cells identified by novel monoclonal antibodies.
Early-thymectomized (Tx) Xenopus frogs, which are permanently deficient in T cells, are used as a model sytem for the characterization of novel monoclonal antibodies (mAb) which identify candidate NK cells at the amphibian level of evolution. Hybridomas, generated from mice immunized with splenocytes from Tx Xenopus following B cell and thrombocyte depletion, were screened by flow cytometry. Three mAb (1F8, 4D4 and 1G5) were identified that stained increased proportions of splenocytes from Tx compared with control frogs. These mAb identified lymphoid populations from Xenopus spleen, liver and gut which, after 48 h culture in growth factor-rich medium, exhibited spontanous killing of MHC-deficient allotumor targets. mAb-defined splenocytes also rapidly induced apoptosis of such tumor targets. Dual color analysis confirmed that NK cells are neither T nor B cells. Cytospins of splenocytes isolated with anti-NK mAb revealed large lymphoid cells with distinct pseudopodia. Immunohistology indicated each anti-NK mAb routinely labeled cells within the gut epithelium but NK cells were difficult to visualize in spleen sections. Western blotting of spleen, liver and intestinal lysates subjected to sodium dodecyl sulfate polyacrylamide gel electrophoresis showed that 1G5 reacted strongly with protein bands of approximately 70 - 85 kDa, whereas mAb 1F8 and 4D4 stained less intensely, but identified similar protein bands.
Animals↗
Smallest detectable difference of maximal mouth opening in patients with painfully restricted temporomandibular joint function.
Changes in maximal mouth opening reflect the impact of temporomandibular disorders and the effect of a therapeutic intervention. No information about the amount of change in maximal mouth opening with regard to reasoned decision-making is available. The smallest detectable difference, as a measure of reliability assessment, provides this information and is expressed in the unit of the measurement instrument. Twenty-five consecutive patients (5 males, 20 females) with a painfully restricted temporomandibular joint participated in this study. Measurements of maximal mouth opening were performed by two well-trained observers on two separate measurement days, one week apart. The maximal mouth opening measurements were repeated three times. Inter-observer, intra-observer, and test-retest reliability varied between 0.90 and 0.96. Inconsistency in measurement results analyzed in terms of absolute error variance, i.e. the measurement facets plus all the interactions, represented 11% of total variance. The smallest detectable difference of maximal mouth opening varied from 9 to 6 mm. For being successful in painfully restricted temporomandibular joint patients, statistically as well as clinically, the clinician has to measure at least 9 mm of improvement in maximal mouth opening. To reduce the smallest detectable difference from 9 to 6 mm, repeated measurement is necessary.
Adult↗
The effects of a postgraduate course on opioid-prescribing patterns of general practitioners.
BACKGROUND: The objective of this study is to evaluate whether a single palliative cancer care workshop, which included information about drug prescribing, had an effect on the opioid-prescription patterns of general practitioners in daily practice. METHOD: The opioid-prescription figures of 68 general practitioners who had participated in the workshop were aggregated from the computer system of the Regional Sick Fund. The prescription figures of a year before and a year after the workshop were compared and a control group of non-participants was included. RESULTS: This study showed a limited efficacy of a palliative cancer care workshop on the morphine-prescription figures of the general practitioners in daily practice. This limited effect did not accord with the results of a pre- and post-workshop questionnaire evaluating the attitudes of the same practitioners. CONCLUSION: A single workshop can not effectuate substantial changes in prescription behaviors. Possibilities for more reinforcements are discussed.
Drug Utilization↗
Adherence to the guidelines of a regional formulary.
BACKGROUND: Pharmacotherapeutical guidelines, called formularies, have been developed to facilitate effective, efficient and cost-conscious prescribing. Monitoring adherence to such guidelines may be a reasonable way of assessing prescribing practices. OBJECTIVE: The aim of this study was to assess how strictly the GPs participating in our department's registration network adhere to the guidelines of the regional formulary, and which indications and drugs the GPs used. METHODS: This is a descriptive study, concerning 1000 consecutive prescriptions from each of the 17 participating GPs. The third edition of the Groningen formulary (GFIII), published in 1995, was used. If the drug prescribed was advised in the formulary, we considered it to be global adherence. If the indication was mentioned in the formulary, and the drug prescribed was advised for that indication in the formulary, it was considered to be specific adherence. Both the medications prescribed and the health problems registered by the GPs, but not mentioned in the GFIII, were analysed. RESULTS: The 17 000 prescriptions chosen for analysis formed approximately 25% of all prescriptions written by the GPs in 1 year. The indications for only 24 prescriptions (0. 14%) were missing. Among the 17 GPs, the number of different drugs prescribed varied between 167 and 219 per 1000 prescriptions. The global adherence varied from 76 to 89% among the GPs, and the specific adherence varied from 55 to 71%. Of the 17 000 prescriptions, 11 457 (67%) concerned indications mentioned in the GFIII. Prescriptions for indications not mentioned in the GFIII contained 4353 (78.5%) drugs advised in the formulary. Of the 251 medications mentioned in the GFIII, only 15 (6%) were not prescribed. DISCUSSION: The GPs in our study were neither representative, nor were they chosen at random. Their patient population was comparable in age, sex and insurance status. These findings are an example of what level of adherence is obtainable. The formulary covered approximately two-thirds of the indications registered by GPs, and did not contain many unnecessary medications (6%).
Adult↗
The development of polypharmacy. A longitudinal study.
BACKGROUND: To date, only a few studies have been carried out on the development and progress of polypharmacy in relation to morbidity in general practices in The Netherlands. OBJECTIVE: The aim of this study was to investigate the relationship between an increase in long-term drug use and the incidence and severity of some chronic diseases, particularly in the elderly. METHODS: Data on medication and morbidity of 1544 elderly people were collected for the period 1994-1997 from three family practices in the medication and morbidity Registration Network of Groningen (RNG) in the northern part of The Netherlands. Polypharmacy is defined as the long-term simultaneous use of two or more drugs; long-term is defined as >240 days in a year. We looked for differences in incidences of some chronic diseases in those subgroups of the elderly in whom multiple long-term drug use respectively increased, stayed constant or did not exist. Polypharmacy at the end of the period was predicted using regression analysis. RESULTS: Polypharmacy occurred in 42% of the elderly at the end of 1997, with major polypharmacy (>5 drugs) in only 4%. The average number of drugs used long-term increased from 1.3 to 1.8 in 4 years. Predictors for the increase of polypharmacy were the number of drugs at the start, age, diabetes, coronary ischaemic diseases and use of medication without a clear indication (P < 0.005). The average number of diseases also increased, especially in the elderly who showed the greatest increase in long-term drug use; however, there was no significant difference from the groups with a slow or no increase in drug use. DISCUSSION: Polypharmacy showed a slow increase over 4 years: almost 20% of the elderly developed polypharmacy, i.e. going from no drugs or one drug to two or more drugs. Polypharmacy develops mainly in elderly patients who already use several drugs, who are known to suffer from cardiovascular diseases, diabetes or stomach symptoms, those who often take drugs (especially sedatives/hypnotics) without clear indication and those who develop hypertension or atrial fibrillation over time.
Aged↗
Low blood pressure and depression in the elderly.
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Aged↗
20 of the most influential people in EMS. Part 1.
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Career Choice↗
Primary care groups. Chemistry lessons.
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Administrative Personnel↗
Comparison of the effects of oral or subcutaneous carprofen or ketoprofen in rats undergoing laparotomy.
Rats undergoing laparotomy received either carprofen (5 mg/kg) or ketoprofen (5 mg/kg) administered orally in flavoured gelatin, or by subcutaneous injection. A control group that received no analgesic showed a significant (3 per cent) fall in bodyweight (P = 0.009) after laparotomy. This decrease was greater than that seen in the groups receiving carprofen (P = 0.006) or ketoprofen (P = 0.012) administered subcutaneously, which continued to gain weight following surgery. All animals showed a significant fall in food consumption but this decrease was greater in the jelly alone group (47 per cent) than in the group receiving carprofen (17 per cent) (P = 0.015) administered subcutaneously. A significant fall in water consumption occurred in the control group (40 per cent) and in animals that received oral carprofen (13 per cent) or Ketoprofen (22 per cent). No significant decrease was seen in groups receiving either carprofen or ketoprofen administered subcutaneously (P > 0.1). This study shows that a relatively simple surgical procedure results in a major reduction in food and water consumption in rats. This reduction can be minimised by the administration of ketoprofen or carprofen (5 mg/kg subcutaneously), but higher dose rates are required if these drugs are to be administered by the oral route.
Administration, Oral↗
[Chronic polypharmacy in one-third of the elderly in family practice].
OBJECTIVE: Description of the extent and nature of polypharmacy in the elderly in general practice. DESIGN: Retrospective cross-sectional study. METHOD: Medication and morbidity data were collected over July-December 1994 on all 2197 patients > or = 65 years registered in 3 family practices connected with the Medication and Morbidity Registration Network Groningen, the Netherlands. Special attention was paid to the simultaneous use of > or = 2 drugs during > or = 120 days in the study period ('chronic use'). Three categories of polypharmacy were distinguished: mild (2-3 drugs), moderate (4-5) and extensive (> 5). RESULTS: Forty per cent of the study group were males; 54% were 65-74 years, 34% were 75-84 years and 12% were > or = 85 years. The mean number of drugs used was 3.9 per person (SD: 3.6), of which 1.4 (SD: 1.8) chronically. Polypharmacy occurred in 35%: mild in 23%, moderate in 8% and extensive in 4%. All occurred mostly in the group between 75 and 84 years old. Cardiovascular drugs, in particular diuretics, and psycholeptics were mostly prescribed concomitantly with each other and with other drugs. The prevalence of concomitant use of drugs with potential interactions was low (< 3%). The indications for psycholeptic drugs were quite often not clear. Congestive heart failure, chronic obstructive pulmonary disease (COPD)/asthma and diabetes mellitus were mainly responsible for extensive polypharmacy.
Aged↗
Effective cancer therapy with a single injection of interleukin-2 at the site of the tumour.
Mice with a severe metastasized tumour burden can be cured with a single local injection of interleukin-2. Such a treatment can also be effective against ocular squamous cell carcinoma in cows and transmissible venereal tumours in dogs. We did not notice any toxic effects of this treatment.
Animals↗
Long distance telementoring. A novel tool for laparoscopy aboard the USS Abraham Lincoln.
BACKGROUND: As general surgeons perform a growing number of laparoscopic operations in increasingly specialized environments, the ability to obtain expert advice during procedures becomes more important. Technological advances in video and computer communications are enabling surgeons to procure expertise quickly and efficiently. In this article, we present laparoscopic procedures completed through an intercontinental telementoring system and the first telementored laparoscopic procedures performed aboard a naval vessel. METHODS: Video, voice, and data streams were linked between the USS Abraham Lincoln Aircraft Carrier Battlegroup cruising the Pacific Ocean and locations in Maryland and California, creating the Battlegroup Telemedicine (BGTM) system. Three modes of BGTM communication were used: intraship, ship to ship, and ship to shore. RESULTS: Five laparoscopic inguinal hernia repairs were completed aboard the Lincoln under telementoring guidance from land-based surgeons thousands of miles away. In addition, the BGTM system proved invaluable in obtaining timely expertise on a wide variety of surgical and medical problems that would otherwise have required a shore visit. CONCLUSIONS: Successful intercontinental laparoscopic telementoring aboard a naval vessel was accomplished using "off-the-shelf" components. In many instances, the high risk and cost of transporting patients to land-based facilities was averted because of the BGTM system. Also, the relationship between the on-site and telementoring surgeon was critical to the success of this experiment. Long-distance telementoring is an invaluable tool in providing instantly available expertise during laparoscopic procedures.
Adult↗