Biomedical subjects
Publications and source records attributed to W Moore.
The UK has a poor record on retraining underperforming doctors and rehabilitating sick ones. But that is set to change. Wendy Moore examines new attitudes and plans of action aimed at meeting the demands of the clinical governance revolution.
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The aim of this study was to determine the effect of primary closure versus patch angioplasty on the incidence of early recurrent stenosis after carotid endarterectomy in the hands of a single surgeon, and to analyze the risk factors associated with early recurrent stenosis after carotid endarterectomy. A retrospective review was performed of 178 consecutive patients who underwent 200 carotid endarterectomies-100 done consecutively with primary closure and 100 done consecutively with patch angioplasty. Of these patients, 126 qualified for analysis by having had at least 18 months of follow-up by serial duplex scanning. Of this group, the first 65 patients underwent 75 routine primary closures, while the last 61 underwent 67 routine patch angioplasties. All patients underwent a completion angiogram at the end of the case. Recurrent stenosis was defined as luminal diameter narrowing >60% on duplex scan. A multifactorial analysis was performed to analyze the effect of age, sex, tobacco use, diabetes, hypertension, peripheral vascular disease, coronary artery disease, and contralateral stenosis on recurrent stenosis. The results of this study showed that in a single surgeon's experience with carotid endarterectomy, varying only the method of closure between primary closure versus patch angioplasty, there is no statistically significant difference in the rate of early restenosis. No difference was noted in the perioperative morbidity and mortality between groups.
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OBJECTIVE: To examine baseline renal screening practices and the effect of nurse case management of patients with diabetes in a group model health maintenance organization (HMO). RESEARCH DESIGN AND METHODS: We performed both 1-year retrospective and 1-year prospective studies of renal assessment practices and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a randomized controlled trial of a diabetes nurse case management program in a group model HMO. In accordance with American Diabetes Association recommendations, urine dipstick and quantitative protein and microalbuminuria testing rates were calculated. RESULTS: At baseline, 77% of patients were screened for proteinuria with dipsticks or had quantitative urine testing. Of patients with negative dipstick findings, 30% had appropriate quantitative protein or microalbumin follow-up at baseline. Baseline ACE inhibitor usage was associated with decreased follow-up testing (relative risk = 0.47). Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing (relative risk = 1.65 and 1.60, respectively). CONCLUSIONS: We found a higher degree of adherence to recommendations for renal testing than has been reported previously. Nurse case management intervention further increased renal screening rates. The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways.
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BACKGROUND: Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control. OBJECTIVE: To compare diabetes control in patients receiving nurse case management and patients receiving usual care. DESIGN: Randomized, controlled trial. SETTING: Primary care clinics in a group-model health maintenance organization (HMO). PATIENTS: 17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus. INTERVENTION: The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians. MEASUREMENTS: The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed. RESULTS: 72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events. CONCLUSIONS: A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.
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Doctors' failure to communicate with patients is at the root of many complaints. But an increasing number of medical schools are now teaching their students how to talk to patients. Wendy Moore reports.
While there is clear-cut epidemiologic, morphologic, and functional evidence to suggest that cigarette smoking is deleterious to the cardiovascular system and endothelium, previous experiments with regard to the effect of cigarette smoking on endothelial-derived vasorelaxation are not conclusive. This study examines the effect of cigarette smoking on endothelium-derived vasorelaxation and its relationship to serum nitric oxide concentrations. Fourteen Sprague-Dawley rats (350-500 g) were divided into two groups (N = 7). The experimental group was exposed to six cigarettes (Kentucky 1R4F) per day for 50 days using a Griffith snout exposure method. The two groups were sacrificed and the carotid arteries were mounted on isometric force transducers in a physiologic bath. The arteries were constricted with norepinephrine (1 x 10(-4) M). Vasorelaxation to acetylcholine (Ach) was measured in a dose response manner. Vasorelaxation to nitroglycerin was measured at 10(-4) M. After the rats were sacrificed, blood samples from each rat were examined for total nitrate/nitrite concentration with serum chemiluminescence on a vanadium column. The results were analyzed with ANOVA and the Student's t test. Vasorelaxation to nitroglycerin was 17.42% +/- 0. 44 versus 16.25% +/- 0.42 in the control and smoke exposure groups, respectively (P = 0.19). This experiment counterintuitively demonstrates that cigarette smoking augments endothelial-derived vasorelaxation. No effect was noted in the endothelium-independent vasorelaxation to nitroglycerin. Alternative mechanisms including the presence of hypoxia and exogenous nitric oxide, which lead to endothelial-dependent and -independent vasorelaxation secondary to cigarette smoking, may serve to explain the apparent augmentation of endothelial-derived vasorelaxation. Further experiments with isolated components of smoke will need to be done to resolve the debate.
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OBJECTIVES: 1) To describe elements of adult nontraumatic cardiac arrest protocols in those U.S. cities in which resuscitative efforts are being terminated in the out-of-hospital setting. 2) To determine the prevalence and methods of on-scene family grief counseling delivered in this setting. METHODS: Emergency medical services (EMS) systems in each of the 200 largest cities in the United States were surveyed by telephone regarding the content of their adult cardiac arrest protocols. Type of arrest (medical vs trauma), final dysrhythmia, termination policies, and presence or absence of a grief counseling protocol were recorded. RESULTS: All of the target population responded to the telephone survey. Most (135; 68%) EMS systems currently have written protocols that allow in-field termination of resuscitative efforts for adult nontraumatic cardiac arrest patients who remain asystolic. Only 47 (24%) EMS systems allow cessation of efforts for patients without return of spontaneous circulation regardless of the dysrhythmia. Base station contact is required for authorization to end resuscitative efforts in 120/135 (89%) EMS systems. Only 26/135 (19%) EMS systems that cease efforts in the field have written policies concerning on-scene family grief counseling. This counseling is most likely to be conducted by the out-of-hospital providers themselves. CONCLUSION: Many U.S. urban EMS systems are terminating efforts for selected adult nontraumatic cardiac arrest patients, although few have written policies to address grief intervention for family members at the scene.
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