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PubMed1999

Systematic review of surgery in malignant bowel obstruction in advanced gynecological and gastrointestinal cancer. The Systematic Review Steering Committee.

OBJECTIVE: The objective was to locate, appraise, and summarize evidence from scientific studies on intestinal obstruction due to advanced gynecological and gastrointestinal cancer in order to assess the efficacy of surgery. MATERIALS AND METHODS DATA SOURCES: A comprehensive list of studies was provided by an extensive search of electronic databases, relevant journals, bibliographic databases, conference proceedings, reference lists, the gray literature, personal contact, and the worldwide web. DATA SYNTHESIS: Two researchers extracted the data independently. Due to the methodological quality of the studies, only a qualitative assessment was possible. RESULTS: The role of surgery in malignant bowel obstruction remains controversial, and no firm conclusions from the many retrospective case series can be made. Control of symptoms varies from 42% to over 80%, although it is often unclear how symptoms were measured and whether the symptom scores used are validated. There is a large range in the rates of reobstruction, from 10 to 50%, although time to reobstruction was often not included. There is a wide range of postoperative morbidity and mortality, although again the definition of both of these surgical outcomes varied among many of the papers. CONCLUSION: The role of surgery in malignant bowel obstruction needs careful evaluation, using validated outcome measures on symptom control and quality of life scores. Further information would include reobstruction rates together with the morbidity associated with the various surgical procedures. Currently, bowel obstruction is managed empirically, and there are marked variations in clinical practice by different units. There needs to be a greater standardization of management so that comparisons between different series can be made.

Female↗
PubMed1999

Discrimination of the native from misfolded protein models with an energy function including implicit solvation.

An essential requirement for theoretical protein structure prediction is an energy function that can discriminate the native from non-native protein conformations. To date most of the energy functions used for this purpose have been extracted from a statistical analysis of the protein structure database, without explicit reference to the physical interactions responsible for protein stability. The use of the statistical functions has been supported by the widespread belief that they are superior for such discrimination to physics-based energy functions. An effective energy function which combined the CHARMM vacuum potential with a Gaussian model for the solvation free energy is tested for its ability to discriminate the native structure of a protein from misfolded conformations; the results are compared with those obtained with the vacuum CHARMM potential. The test is performed on several sets of misfolded structures prepared by others, including sets of about 650 good decoys for six proteins, as well as on misfolded structures of chymotrypsin inhibitor 2. The vacuum CHARMM potential is successful in most cases when energy minimized conformations are considered, but fails when applied to structures relaxed by molecular dynamics. With the effective energy function the native state is always more stable than grossly misfolded conformations both in energy minimized and molecular dynamics-relaxed structures. The present results suggest that molecular mechanics (physics-based) energy functions, complemented by a simple model for the solvation free energy, should be tested for use in the inverse folding problem, and supports their use in studies of the effective energy surface of proteins in solution. Moreover, the study suggests that the belief in the superiority of statistical functions for these purposes may be ill founded.

Models, Molecular↗
PubMed1999

The significance of excursions above the ADI: duration in relation to pivotal studies.

The significance of excursions of intake above the ADI, TDI, or PTWI can only be assessed by reference to the database which led to the derivation of these, most particularly the duration of the pivotal study (chronic, subchronic, acute), the pharmacokinetic parameters, and the nature of toxicity and mechanism of action. Although this implies a case by case assessment, a number of typical situations may be recognized: (1) The substance (usually a contaminant, not an additive) has a very long half-life leading to accumulation in target organs/tissues, e.g., Cd or dioxin. The chronic toxicity is manifested when critical concentrations are achieved in these tissues and there is a large difference between the acutely toxic dose and the chronic NOAEL. In such a case, the effect of excursions above the PTWI on tissue levels is readily calculated; peak excursions of several times the PTWI for short periods (days, weeks, or even months) or lower peak intakes for even longer periods (months to years) may be inconsequential provided that the integrated exposure over longer periods does not lead to critical steady-state tissue concentrations being achieved. (In such cases, it is clearly inappropriate to divide the PTWI by 7 and treat this as an ADI.) (2) A more common situation for food additives is where the ADI is based on a chronic study, but the t1/2 is short, i.e., the situation is one of chronic stress rather than cumulative toxicity. In such cases, e.g., BHA or BHT, the effects on the target organ (hyperplasia, foci of altered cells, etc.) can usually be identified in subchronic studies, although progressive changes may occur in chronic studies. Two subsituations then arise. First, when the effects seen at the LOAEL in subacute/subchronic studies are truly reversible (e.g., methemoglobinemia), short-term studies with a reversibility component may become pivotal in assessing the consequences of short-term excursions above the ADI. Second, when the short-term effects are not fully reversible, or are even progressive, the consequences of short-term peaks of intake above the ADI would require careful evaluation against the NOAEL or LOAEL in subacute or subchronic studies. (3) A rare situation might arise where the ADI is based on a chronic toxicity study but the margins between the chronic NOAEL and some aspects of acute toxicity may be small. For example, for a compound which behaved like retinol, the ADI might be based on chronic effects on the liver but at maternally nontoxic doses the substance may be teratogenic following acute exposure during early pregnancy. Clearly in such a situation, the acute NOAEL for teratogenicity would be used appropriately to evaluate the risks associated with short-term peaks of exposure, i.e., a different study may be pivotal in determining the effects of large excursions above the ADI than that which was used to calculate it. Clearly, these cases are not comprehensive but do provide a framework against which to discuss the potential effects of excursions above the ADI and to reach rational conclusions which are not based on the misapprehension that the ADI (or worse, the PTWI x 7) is a lower bound of toxicity.

Abnormalities, Drug-Induced↗
PubMed1995

Medical knowledge systems: applications to telemedicine.

The application and form of electronically stored medical knowledge has a direct impact on the design of any healthcare delivery system. For those who plan for remote medical care or who work at the disaster relief level, there are specific requirements which will dictate the type of knowledge required and the vehicle best suited to deliver that information. The PC based multimedia biomedical library developed for NASA was originally intended for long-term space missions where complete isolation from each support was a distinct possibility. The library is a combination of traditional references and secondary databases structured within a primary care physician's workstation. The integration of the library and a point-of-care system allows optimal use of both resources and provides a basic building block for telemedicine networking.

Artificial Intelligence↗
PubMed1982

Training in medical informatics. The use of computers for diagnostic purposes.

Part of a blockcourse on medical informatics is presented; this course is intended for medical students. It is shown how medical students are introduced to the study of the role of computers for diagnostic purposes. The course consists of an oral presentation which introduces the student to the subject, and of practical work on systems in order to more fully comprehend the topics explained in the oral part of the blockcourse. In the oral presentation the student is introduced to various concepts that are used in computer-aided diagnosis. A critical review of the possibilities of computer use for diagnostic purposes is given. A system is presented, with which the student can work interactively. It consists of a database of patients, referred to the hospital because of suspected congenital heart disorder. Bayes' rule and diagnostic tree decision schemes are available to the student to acquaint himself with the subject. The ways he can work with this system are explained. The course is given regularly (every 4 months) to medical students and is well appreciated.

Computers↗
PubMed1994

The effectiveness of nicotine replacement therapies in smoking cessation.

OBJECTIVE: To determine the effectiveness of nicotine replacement therapies (NRTs) (including gum, transdermal patch, intranasal spray, and inhaled preparations) in facilitating smoking cessation, and to determine whether the effect was influenced by the clinical setting in which the smoker was recruited and treated, the level of nicotine dependency, the dosage of NRT used, or the intensity of additional advice and support offered to the smoker. DATA SOURCES: Published trials of NRT were identified by a systematic search of 7 electronic databases, published reviews, reference lists from clinical trials, conference abstracts, smoking and health bulletins, and a bibliography on smoking and health. Unpublished trials were identified by approaching manufacturers of NRT. STUDY SELECTION: A total of 53 trials (42 gum, 9 patch, 1 intranasal spray, and 1 inhaler), with data from 17,703 patients, were included in the analyses. Only trials that assessed abstinence at least 6 months after the commencement of therapy were included. DATA EXTRACTION: Data were extracted from the trial reports by 2 authors independently. Where the methodology was unclear or the results were not expressed in a form which allowed extraction of key data we wrote to the investigators for the required information. DATA SYNTHESIS: Use of NRT increased the odds ratio (OR) of abstinence to 1.71 (95% confidence interval [CI], 1.56 to 1.87) compared with those who had been allocated to the control interventions. The OR for the different forms of NRT were 1.61 for nicotine gum (95% CI, 1.46 to 1.78), 2.07 (95% CI, 1.62 to 2.62) for transdermal patch, 2.92 (95% CI, 1.49 to 5.74) for nasal spray, and 3.05 for inhaled nicotine (95% CI, 1.42 to 6.57). These odds were not significantly higher in patients with higher levels of nicotine dependence (Fagerstrom score > or = 7; P = 0.06), but they were largely independent of the intensity of additional support provided or the setting in which the NRT was offered. CONCLUSION: We conclude that the currently available forms of NRT are effective therapies to aid smoking cessation.

Administration, Cutaneous↗
PubMed1996

Lithium compared to valproic acid and carbamazepine in the treatment of mania: a statistical meta-analysis.

The hypothesis that lithium is the most appropriate and efficacious pharmacological treatment in the therapy of manic-depressive illness was examined in a meta-analysis. The efficacy of lithium was compared with that of the antiepileptics, carbamazepine and valproic acid. Data sources include the Medline database and relevant references from articles. Only randomised controlled clinical trials with a double-blind assessment of outcomes were included. Lithium levels were required to be within the therapeutic range of 0.4-1.5 mmol/l. The effect sizes were measured by the odds ratio using the Mantel-Haenszel method. No significant difference was observed between the treatment effect of the 3 drugs compared. While the efficacy of the 3 treatments was identical, there is a general tendency in favour of the antiepileptics in the treatment of manic depression with regard to adverse events and treatment tolerance. The impact and importance of this study seriously question the relevance of today's practice of prescribing lithium in the acute management of manic-depressive illness.

Bipolar Disorder↗
PubMed1996

Efficacy of serial electrical cardioversion therapy in patients with chronic atrial fibrillation after valve replacement and implications for surgery to cure atrial fibrillation.

Chronic atrial fibrillation (AF) occurs often in the setting of mitral and aortic valve disease. Eventually, these patients undergo valve replacement which improves cardiac function but does not prevent AF. This study investigates which patient may benefit from additional surgery for the cure of AF performed in combination with valve surgery. Seventy-four patients were retrospectively included from our prospective database of patients referred for serial cardioversion therapy between 1986 and 1993. All these patients had chronic AF after valve replacement. After the first electrical cardioversion, patients did not receive antiarrhythmic drugs. Relapses were managed by repeated cardioversions, and then antiarrhythmic drugs were instituted. After a median follow-up of 7 years (range 1.3 to 23), 39 patients had intractable AF. Multivariate analysis revealed that patients with a history of chronic AF before surgery (risk ratio 5.4, confidence intervals 2.5 to 11.3, p = 0.0001) had a poor arrhythmia outcome. In addition, Kaplan-Meier survival analysis demonstrated a lower success rate (p = 0.0017) in patients with mitral valve disease than in those with aortic valve disease. Congestive heart failure (41% vs 6%, p = 0.0007) and cardiovascular mortality (23% vs 9%, p = 0.09) were seen most often in patients with an unsuccessful cardioversion strategy. Thus, patients scheduled for mitral valve surgery with a history of chronic AF should be considered candidates for additional surgery for AF concomitantly performed during valve surgery.

Adult↗
PubMed1999

Drug interactions and anti-infective therapies.

Drug interactions are an important and often underappreciated cause of adverse clinical outcomes. This review considers the mechanisms for several clinically important drug interactions that involve the major classes of anti-infective agents. This approach is intended to complement the use of text-based references and computer databases so that physicians and pharmacists can avoid prescribing and dispensing drugs that have adverse interactions.

Administration, Oral↗
PubMed1999

Hydramnios prediction of adverse perinatal outcome.

OBJECTIVE: To determine whether hydramnios is associated with an increased risk of adverse perinatal outcomes. METHODS: Computerized records of all ultrasound examinations done at the University of Alabama at Birmingham from 1986 to 1996 (n = 40,065) were reviewed to identify 370 women with singleton pregnancies beyond 20 weeks' gestation and hydramnios diagnosed sonographically by amniotic fluid index of 25 cm or more, largest vertical pocket of 8 cm or more, or subjective impression. Controls were all women with singleton gestations with normal amniotic fluid volumes (n = 36,426). Obstetric outcomes were determined by cross-reference to our database. Cases with hydramnios were compared with controls for perinatal death, anomaly rate, fetal growth restriction (FGR), cesarean delivery, fetal aneuploidy, and maternal diabetes. Cases were sorted according to diabetes status, after which perinatal death, anomaly rate, FGR, cesarean delivery, and fetal aneuploidy were compared again. RESULTS: The incidence of hydramnios was 1%. The perinatal mortality rate in all women with hydramnios was 49 per 1000 births, compared with 14 per 1000 births in the control group (P < .001). Women with hydramnios had 25 times more anomalies than controls (8.4% versus 0.3%; P < .001), although the prevalence of fetal aneuploidy was not significantly different (one in 370 versus one in 3643; P = .10). The cesarean rate was three times higher in women with hydramnios compared with controls (47.0% versus 16.4%; P < .001). When hydramnios cases were divided according to diabetes status, all of the increased risk was in nondiabetic women: Perinatal mortality was 60 per 1000 in nondiabetic women versus 0 per 1000 in diabetic women (P = .03); the anomaly rate was 10.4% versus 0%, respectively (P = .005). CONCLUSION: Hydramnios indicated an increased risk of adverse perinatal outcomes, especially if not associated with diabetes. A comprehensive fetal evaluation, a workup to rule out maternal factors, and fetal surveillance are warranted; amniocentesis for fetal karyotype analysis might not be necessary.

Adult↗
PubMed2000

Preventing perineal trauma during childbirth: a systematic review.

OBJECTIVE: To review systematically techniques proposed to prevent perineal trauma during childbirth and meta-analyze the evidence of their efficacy from randomized controlled trials. DATA SOURCES: MEDLINE (1966-1999), the Cochrane Library (1999 Issue 1), and the Cochrane Collaboration: Pregnancy and Childbirth Database (1995); and reference lists from articles identified. Search terms included childbirth or pregnancy or delivery, and perineum, episiotomy, perineal massage, obstetric forceps, vacuum extraction, labor stage-second. No language or study-type constraints were imposed. STUDY SELECTION: Randomized controlled trials (RCTs) of interventions affecting perineal trauma were reviewed. If no RCTs were available, nonrandomized research designs such as cohort studies were included. Studies were selected by examination of titles and abstracts of more than 1,500 articles, followed by analysis of the methods sections of studies that appeared to be RCTs. INTEGRATION AND RESULTS: Eligible studies used random or quasirandom allocation of an intervention of interest and reported perineal outcomes. Further exclusions were based on failure to report results by intention to treat, or incomplete or internally inconsistent reporting of perineal outcomes. Final selection of studies and data extraction was by consensus of the first two authors. Data from trials that evaluated similar interventions were combined using a random effects model to determine weighted estimate of risk difference and number needed to treat. Effects of sensitivity analysis and quality scoring were examined. Results indicated good evidence that avoiding episiotomy decreased perineal trauma (absolute risk difference -0.23, 95% confidence interval [CI] -0.35, -0.11). In nulliparas, perineal massage during the weeks before giving birth also protected against perineal trauma (risk difference -0.08, CI -0.12, -0.04). Vacuum extraction (risk difference -0.06, CI -0.10, -0.02) and spontaneous birth (-0.11, 95% CI -0.18, -0.04) caused less anal sphincter trauma than forceps delivery. The mother's position during the second stage has little influence on perineal trauma (supported upright versus recumbent: risk difference 0.02, 95% CI -0.05, 0.09). CONCLUSION: Factors shown to increase perineal integrity include avoiding episiotomy, spontaneous or vacuum-assisted rather than forceps birth, and in nulliparas, perineal massage during the weeks before childbirth. Second-stage position has little effect. Further information on techniques to protect the perineum during spontaneous delivery is sorely needed.

Delivery, Obstetric↗
PubMed1999

Normal global motion of the cervical spine: an electrogoniometric study.

OBJECTIVE: Establishment of a normal database and clinical reference of active global cervical spine motion ranges and patterns using a commercial electrogoniometer. DESIGN: Three-dimensional cervical motion ranges and patterns were analyzed in 250 asymptomatic volunteers. BACKGROUND: In vivo out-of-plane motion patterns of the cervical spine have not yet been reported in large populations, but could be of clinical interest. METHODS: In 250 subjects (aged 14-70 yr), motion range and patterns between the first thoracic vertebra and the head were analyzed for flexion-extension, lateral bending, rotation in neutral sagittal plane position and in full flexion using the CA 6000 Spine Motion Analyzer. RESULTS AND CONCLUSIONS: Average motion range in the sagittal plane was 122 degrees (SD: 18 degrees ). Flexion was slightly more important than extension. Out-of-plane components were negligible. Global bending range averaged 88 degrees (SD: 16 degrees ), left and right bending being comparable. Homolateral rotation was associated to lateral bending. Its extent was approximately 40% of the bending range. Global rotation range in neutral sagittal plane position was 144 degrees (SD: 20 degrees ), without significant difference between right and left rotations. Associated motion components were small. During rotation in flexed head position, global range (134 degrees, SD: 24 degrees ) was comparable to the one in neutral flexion. But heterolateral bending, averaging 60% of the primary motion, was associated to flexed rotation. Significant reduction of all primary (but not conjunct) motions with age were obtained. Sex had no influence on cervical motion range. RELEVANCE: Our results agreed with previous observations, validating the methodology used. They thus constitute reference data of cervical out-of-plane motion for clinical applications.

Adolescent↗
PubMed2000

Secondary intracranial meningiomas after high-dose cranial irradiation: report of five cases and review of the literature.

PURPOSE: To review cases of secondary intracranial meningiomas following high-dose cranial irradiation (>/= 10 Gy) identified in Slovenia between 1968 and 1998, to determine their histological profile and to review the literature on this topic. METHODS AND MATERIALS: Personal files of patients treated for secondary intracranial meningioma during a 31-year period were reviewed. In cases which met the criteria for radiation-induced tumors, steroid hormone receptor and Ki-67 status were analyzed. For the literature review, computerized database systems and reference lists from respective publications were used. RESULTS: Five patients (2 females, 3 males), 3-11 years old at the time of cranial irradiation, developed secondary meningioma after a latency period of 9.5-31.5 years. Three patients had multiple tumors and 2 developed recurrent disease. Of 9 histologically examined tumors, 5 were graded as benign and 4 as atypical meningiomas, with Ki-67 proliferative index 3.2 +/- 3.6 and 10 +/- 6, respectively. The ratio between positive and negative meningiomas regarding immunostaining for progesterone and estrogen receptors was eight-to-one and six-to-three, respectively. Cumulative actuarial risk of secondary meningioma in a cohort of 445 children 16 years or younger treated with high-dose cranial irradiation between 1968 and 1990 in Slovenia at 10, 20, and 25 years was 0.53%, 1.2%, and 8.18%, respectively. Out of 126 cases of radiation-induced meningiomas reported, 57% were females and 43% were males, with mean age at presentation 33 +/- 17.3 years. The majority (68%) of patients was irradiated during childhood. The latency period was significantly shorter in those who aged 5 years or less at the time of cranial irradiation (p = 0.04), and in those with atypical/anaplastic tumor (p = 0.01). Correlation between radiation dose and latency period could not be found. CONCLUSION: Secondary meningiomas following high-dose cranial irradiation are characterized by younger age at presentation, by higher male-to-female ratio and by biologically more aggressive variants compared to primary spontaneous meningiomas. Latency period correlated with the age at the time of cranial irradiation and with tumor grade but not with irradiation dose. Ki-67 immunoreactivity correlated with histological grade. The progesterone and estrogen receptor immunoreactivity was high. The risk for development of secondary meningioma after high-dose cranial irradiation was increasing with the time of follow-up.

Brain Neoplasms↗
PubMed1999

Drug-induced heart failure.

Heart failure is a clinical syndrome that is predominantly caused by cardiovascular disorders such as coronary heart disease and hypertension. However, several classes of drugs may induce heart failure in patients without concurrent cardiovascular disease or may precipitate the occurrence of heart failure in patients with preexisting left ventricular impairment. We reviewed the literature on drug-induced heart failure, using the MEDLINE database and lateral references. Successively, we discuss the potential role in the occurrence of heart failure of cytostatics, immunomodulating drugs, antidepressants, calcium channel blocking agents, nonsteroidal anti-inflammatory drugs, antiarrhythmics, beta-adrenoceptor blocking agents, anesthetics and some miscellaneous agents. Drug-induced heart failure may play a role in only a minority of the patients presenting with heart failure. Nevertheless, drug-induced heart failure should be regarded as a potentially preventable cause of heart failure, although sometimes other priorities do not offer therapeutic alternatives (e.g., anthracycline-induced cardiomyopathy). The awareness of clinicians of potential adverse effects on cardiac performance by several classes of drugs, particularly in patients with preexisting ventricular dysfunction, may contribute to timely diagnosis and prevention of drug-induced heart failure.

Adjuvants, Immunologic↗
PubMed1999

The specific deterrence of administrative per se laws in reducing drunk driving recidivism.

OBJECTIVE: To determine if administrative per se laws are more effective than other forms of sanction against drunk drivers. SEARCH STRATEGIES: The overall goal of the search strategy was to identify all relevant research concerning the specific effects of administrative per se laws in reducing drunk driving recidivism, traffic crashes, and other alcohol-related driving offenses by those drivers with suspended licenses. Known review articles and MEDLINE reviews formed the reference bibliography; numerous databases were searched from 1966 to the present, using such terms as alcohol, driver's license, recidivism, deterrence, and legislation. SELECTION CRITERIA: To be selected the study had to be designed to test the presence of an administrative per se license revocation or restriction in a defined cohort, have a suitable comparison cohort whose sanctions for drunk driving were not administrative per se, and provide relevant data that lead to an objective assessment of recidivism. Types of studies included were randomized controlled trials, nonrandomized controlled trials, other specialized cohort studies, and case-control studies. Three studies were identified; all met inclusion criteria. DATA COLLECTION AND ANALYSIS: One of the studies provided Kaplan-Meier survival curves for failure times defined as days to new conviction following the initial arrest. Odds ratios and 99% confidence intervals were extracted from two of the studies and additional information was supplied by the author of one of the studies. MAIN RESULTS: One study found that one state in the United States experienced a reduction of about one third in repeat arrests for drunk driving over a 3-year period among those who were arrested under administrative per se, relative to recidivism seen in a comparison cohort of drivers prior to administrative per se. Two other states did not experience any change in recidivism. The second study found that drivers whose licenses were suspended under administrative per se were 39% less likely during the first year following suspension to be rearrested on the charge of driving while intoxicated compared with a comparison cohort. This differential persisted into the second year of follow-up, but disappeared by the third year. The third study found both first offenders and repeat offenders arrested under administrative per se were 34% less likely to be involved during the year following their arrest in a subsequent motor vehicle crash compared with those in the comparison cohort. Drivers with administrative per se suspensions were 21% less likely to be involved in additional drunk driving offenses, and 27% less likely to be involved in reckless driving offenses related to alcohol. CONCLUSIONS: Administrative per se laws governing license restriction for drivers have been shown to be effective in some states but not others in decreasing the rates at which these same drivers are subsequently involved in a motor vehicle crash or in another alcohol-related offense, compared with drivers who were sanctioned through other conventional judicial processes. Replications are needed in other states or large driver populations using improved methodology.

Alcohol Drinking↗
PubMed1995

A study of five variable number tandem repeat (VNTR) loci in the Greek population.

The use of hypervariable tandem repeat loci for population genetic studies, genetic analysis of inherited disease and individual identification purposes requires establishment of a genetic database for each reference population. In the present study we have analysed variability at five tandem repeat loci (D1S80, D17S5, 3'-hvr/apoB, F8vWF and D6S89)in a representative sample (88 to 156 individuals of greek ancestry), using polymerase chain reaction amplification. Between nine and 19 alleles were resolved throughout the five polymorphic loci. Heterozygosity indices for these loci in the greek population ranged from 0.68 to 0.85. Allele frequencies follow a bimodal discrimination (pd) and allelic diversity (h) values ranged from 0.84 to 0.94 and 0.85 to 0.91, respectively, and indicated that these loci are highly informative and can be used for population studies, forensic purposes and parentage and family testing. Comparison of observed and expected genotype frequencies by the conventional chi-square test indicated conformity to Hardy-Weinberg predictions.

Alleles↗
PubMed1999

Tools, methods, and strategies. Do innovative models of health care delivery improve quality of care for selected vulnerable populations? A systematic review.

BACKGROUND: A criticism of conventional office or clinic-based models of care is that they focus on patients' urgent problems and do not provide the comprehensive assessments, education, and psychosocial support that vulnerable patients also need. Innovative models have emerged to address these needs. A systematic review of prospective studies involving searches of computerized databases, reviews of reference lists, and contacts with authors, was conducted to determine whether multidisciplinary teams, outreach or home care, and case management improve the quality of the care in two vulnerable populations-the terminally ill and the mentally ill. RESULTS: Literature searches identified 730 citations. 52 original articles met screening standards, and 24 studies fulfilled all criteria. Patient and caregiver satisfaction was consistently higher with innovative models. In no study was satisfaction lower. Functional, clinical, or psychological improvements were not consistently demonstrated. For mentally ill patients, multidisciplinary outreach strategies were effective in reducing inpatient hospitalizations. Costs were inadequately assessed in the studies to draw a summary conclusion. DISCUSSION: Like other interventions, health care delivery models can be assessed from an evidence-based perspective. More needs to be learned about the costs and health improvements of innovative models before we can determine whether the increased patient and caregiver satisfaction found justifies widespread use of these models. Development of a uniform set of quality outcome measures and encouragement to evaluate efforts and disseminate results will help accomplish this goal.

Humans↗
PubMed1999

Heart failure disease management: a critical review.

BACKGROUND: Despite major advances in the pharmacotherapy of heart failure, hospitalization rates remain high, owing in large part to a multitude of psychosocial, behavioral, and financial factors that serve as barriers to effective compliance with prescribed treatment. To deal with these issues, many centers have adopted a multidisciplinary approach to heart failure disease management. METHODS AND RESULTS: A systematic review of the literature was conducted using the Medline database supplemented by reference lists from published articles. From 1983 to 1998, 16 studies describing multidisciplinary heart failure disease management programs were published in the English language literature. Of these, 10 were nonrandomized, observational studies and 6 were randomized clinical trials. All studies reported significant benefits in terms of reducing hospital utilization, and several studies reported improved quality of life, functional capacity, patient satisfaction, and compliance with diet and medications. In all studies in which a cost analysis was performed, heart failure disease management programs were found to be cost-effective. The limitations of the current data include concerns about the generalizability of published findings to the large and heterogenous population of patients with heart failure in the community, the feasibility of translating specific disease management programs into diverse practice environments, uncertainty about how to design and implement a maximally cost-effective heart failure disease management strategy, and how to best tailor the treatment program to the needs of each individual patient. The impact of heart failure disease management programs on survival is also unknown. CONCLUSION: Based on currently available data, heart failure disease management programs appear to be a cost-effective approach to reducing morbidity and enhancing quality of life in selected patients with heart failure. However, additional study is needed involving larger and more diverse populations to define the optimal approach to heart failure disease management.

Cost-Benefit Analysis↗