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PubMed1984

Limitations of qualitative angiographic grading in aortic or mitral regurgitation.

This study was performed to assess the accuracy of qualitative angiographic grading in persons with aortic regurgitation (AR) or mitral regurgitation (MR) and to determine the factors that may influence the reliability of such grading. In 230 patients (152 men, 78 women, aged 52 +/- 14 years) with AR or MR, forward cardiac index was measured by the Fick and indicator dilution techniques and left ventricular (LV) angiographic index by the area-length method, from which the regurgitant volume index was calculated. In 124 other patients (89 men, 35 women, aged 52 +/- 11 years) without regurgitation, there was good agreement between forward and angiographic cardiac indexes (r = 0.87, p less than 0.001). In the 83 patients with AR, the regurgitant volume indexes in those with 1+ (0.87 +/- 0.57 liters/min/m2) and 2+ (1.72 +/- 1.19 liters/min/m2) angiographic regurgitation were not significantly different from one another, but were significantly different from those with 3+ (3.0 +/- 1.42 liters/min/m2) and 4+ (4.80 +/- 2.25 liters/min/m2) regurgitation; at the same time, the regurgitant volume indexes of patients with 3+ and 4+ AR were not significantly different from one another. In the 147 patients with MR, the regurgitant volume indexes in patients with 1+ regurgitation (0.61 +/- 0.64 liters/min/m2) were significantly lower than other grades, but the regurgitant volume indexes of 2+ (1.14 +/- 0.85 liters/min/m2) vs 3+ (2.14 +/- 1.37 liters/min/m2) and of 3+ vs 4+ (4.60 +/- 2.31 liters/min/m2) were not significantly different. With AR and MR, regurgitant flow within each angiographic grade varied widely, especially in grades 3+ and 4+, and there was considerable overlap of regurgitant volume indexes between grades.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

The dilemma of osteoporosis in men.

Hip fractures in men account for one third of all hip fractures and have a higher mortality than in women. The age-specific incidence of hip fractures is increasing so that the public health burden will increase out of proportion to the burden imposed by the increase in the numbers of elderly men in the community. Vertebral fractures are a public health problem of lesser magnitude in terms of morbidity, mortality, and cost, but they are debilitating and are seen commonly in clinical practice. (Forearm fractures should probably not be regarded as a public health problem.) The pattern of earlier gain/later loss of bone during ageing in healthy men is well documented. Peak bone mass is higher in men than women because men have bigger bones. Peak bone density is the same. The absolute amount of trabecular bone lost at the spine and iliac crest during ageing is similar in men and women. Cortical bone loss is less in men. It is less because endocortical resorption is less, and periosteal formation is greater, in men. Bone loss may accelerate in elderly men and women (rather than decelerate), perhaps because endocortical resorption and increasing cortical porosity increase the effective surface available for resorption in cortical bone. Thus, bone fragility is less in men because (a) the cross-sectional surface of the vertebral body is larger; (b) trabecular bone loss is less as a percentage of the higher peak bone mass; (c) trabecular bone loss occurs by thinning rather than perforation; and (d) periosteal appositional growth compensates for endocortical resorption by maintaining the bending strength of bone. Reduced bone density in men with fractures may be due to reduced peak bone density and bone loss. As found in women with spine fractures, men with fractures have smaller bone size. Bone loss occurs by reduced bone formation and increased bone resorption. Loss of connectivity appears to predominate in men with vertebral fractures; trabecular thinning appears to predominate in men with hip fractures. Whether men with fractures have increased bone fragility due to reduced periosteal appositional growth during ageing is unknown. The age-related decline in testosterone, adrenal androgens, growth hormone, and insulin-like growth factor 1 may be concomitants of ageing or may contribute to reduced bone-formation and bone loss. Men with vertebral fractures may be more deficient in growth hormone and insulin-like growth factor 1. Thy often have illness, hypogonadism, or illnesses associated with hypogonadism that should be sought with a high index of suspicion.(ABSTRACT TRUNCATED AT 400 WORDS)

Age Factors↗
PubMed1996

The reliability of the functional independence measure: a quantitative review.

OBJECTIVE: The reliability of the Functional Independence Measure (FIMSM) for adults was examined using procedures of meta-analysis. DATA SOURCES: Eleven published studies reporting estimates of reliability for the FIM were located using computer searches of Index Medicus, Psychological Abstracts, the Functional Assessment Information Service, and citation tracking. STUDY SELECTION: Studies were identified and coded based on type of reliability (interrater, test-retest, or equivalence), method of data analysis, size of sample, and training or experience of raters. DATA EXTRACTION: Information from the articles was coded by two independent raters. Interrater reliability for coding all elements included in the analysis ranged from .89 to 1.00. DATA SYNTHESIS: The 11 investigations included a total of 1,568 patients and produced 221 reliability coefficients. The majority of the reliability values (81%) were from interrater reliability studies, and the intraclass correlation coefficient (ICC) was the most commonly used statistical procedure to compute reliability. The reported reliability values were converted to a common correlation metric and aggregated across the 11 studies. The results revealed a median interrater reliability for the total FIM of .95 and median test-retest and equivalence reliability values of .95 and .92, respectively. The median reliability values for the six FIM subscales ranged from .95 for Self-Care to .78 for Social Cognition. For the individual FIM items, median reliability values varied from .90 for Toilet Transfer to .61 for Comprehension. Median and mean reliability coefficients for FIM motor items were generally higher than for items in the cognitive or communication subscales. CONCLUSIONS: Based on the 11 studies examined in this review the FIM demonstrated acceptable reliability across a wide variety of settings, raters, and patients.

Activities of Daily Living↗
PubMed1999

Evidence-based practice in pediatric surgery.

BACKGROUND/PURPOSE: The current medical environment demands the provision of quality healthcare at an affordable cost. Both payors and regulators are committed to lowering cost through initiation of best practice strategies that include practice guidelines, clinical pathways, and standards of care. The only practical way to join this debate is through the use of objective, unbiased clinical data. This study was undertaken to review the current state of the pediatric surgery literature and its value in determining best clinical practice. METHODS: The National Library of Medicine Medline database was accessed using the Ovid Internet client software. All references, abstracts, and keyword indexes from the core pediatric surgery literature, the Journal of Pediatric Surgery, the European Journal of Pediatric Surgery, Pediatric Surgery International, Zeitschrift fur Kinderchirurgie, and Seminars in Pediatric Surgery were downloaded and reviewed. Search criteria were defined to identify prospective, randomized, controlled studies. References were then categorized as case reports; retrospective case series; prospective case series; randomized, controlled studies; laboratory studies; review articles; or miscellaneous studies. RESULTS: As of March 1, 1998, there are 9,373 references, excluding citations of letters or comments, contained in the core pediatric surgery literature, as provided through Medline. Of these, 485 were identified as studies for review, possible prospective case series or prospective, randomized, controlled studies. After review, 34 studies (0.3%) were classified as prospective, randomized, controlled studies, whereas 139 (1.48%) were classified as prospective studies. There were 3,241 (34.6%) case reports, 5,619 (59.9%) retrospective case series, 1,109 (11.8%) laboratory studies, 195 (2.1%) review articles, and 36 (0.3%) miscellaneous studies that did not fit into other categories. When analyzed by decade of publication, prospective studies and prospective, randomized, controlled studies (n = 173) numbered 103 in the 1990s, 63 in the 1980s, and seven in the 1970s. CONCLUSIONS: There is a paucity of scientifically rigorous data on which to base clinical practice in pediatric surgery. The increasing numbers of prospective, case-controlled studies or the more sound prospective, randomized, controlled trials in the 1990s suggests that pediatric surgeons are aware of the need to generate unbiased data to support current clinical practice and the development of practice guidelines. Limitations exist in conducting prospective, randomized, controlled trials because of the rare nature of many pediatric surgical conditions and the lack of clinical "equipoise" over available treatment options. The authors encourage the use of multiinstitutional trials and the prospective, randomized, controlled study methodology to develop data that can be used to guide clinical practice in our evolving healthcare environment.

Evidence-Based Medicine↗
PubMed1995

Self-management teaching programs and morbidity of pediatric asthma: a meta-analysis.

BACKGROUND: Self-management teaching programs are becoming an important asset in the management of pediatric asthma. OBJECTIVE: The study was designed to evaluate the impact of self-management teaching programs on the morbidity of pediatric asthma. METHODS: The meta-analysis included randomized clinical trials, published between 1970 and 1991, addressing the outcome of morbidity. Studies were retrieved from searches of MEDLINE, American Journal of Nursing International Index, and Dissertation Abstracts Online Database. The quality of studies was assessed with the scale of Chalmers. The pooled effect size was calculated by the method of Hedges. RESULTS: The literature search retrieved 23 randomized clinical trials, but 12 studies had to be excluded. Global score of quality of studies (Chalmers' scale) was fair, 51.6% +/- 9.9%. As indicated by the effect size (ES) of the pooled studies, self-management teaching did not reduce school absenteeism (ES: 0.04 +/- 0.08), asthma attacks (ES: 0.09 +/- 0.14), hospitalizations (ES: 0.06 +/- 0.08), hospital days (ES: -0.11 +/- 0.08), or emergency visits (0.14 +/- 0.09). CONCLUSION: Self-management teaching programs do not seem to reduce morbidity, and future programs should focus more on intermediate outcomes such as behavior.

Absenteeism↗
PubMed2004

Adverse events after immunisation with aluminium-containing DTP vaccines: systematic review of the evidence.

We have reviewed evidence of adverse events after exposure to aluminium-containing vaccines against diphtheria, tetanus, and pertussis (DTP), alone or in combination, compared with identical vaccines, either without aluminium or containing aluminium in different concentrations. The study is a systematic review with meta-analysis. We searched the Cochrane Vaccines Field Register, the Cochrane Library, Medline, Embase, Biological Abstracts, Science Citation Index, and the Vaccine Adverse Event Reporting System website for relevant studies. Reference lists of retrieved articles were scanned for further studies. We included randomised and semi-randomised trials and comparative cohort studies if the report gave sufficient information for us to extract aluminium concentration, vaccine composition, and safety outcomes. Two reviewers extracted data in a standard way from all included studies and assessed the methodological quality of the studies. We identified 35 reports of studies and included three randomised trials, four semi-randomised trials, and one cohort study. We did a meta-analysis of data from five studies around two main comparisons (vaccines containing aluminium hydroxide vs no adjuvant in children aged up to 18 months and vaccines containing different types of aluminium vs no adjuvants in children aged 10-16 years). In young children, vaccines with aluminium hydroxide caused significantly more erythema and induration than plain vaccines (odds ratio 1.87 [95% CI 1.57-2.24]) and significantly fewer reactions of all types (0.21 [0.15-0.28]). The frequencies of local reactions of all types, collapse or convulsions, and persistent crying or screaming did not differ between the two cohorts of the trials. In older children, there was no association between exposure to aluminium-containing vaccines and onset of (local) induration, swelling, or a raised temperature, but there was an association with local pain lasting up to 14 days (2.05 [1.25-3.38]). We found no evidence that aluminium salts in vaccines cause any serious or long-lasting adverse events. Despite a lack of good-quality evidence we do not recommend that any further research on this topic is undertaken.

Adjuvants, Immunologic↗
PubMed2001

Do community-based support services benefit bereaved children? A review of empirical evidence.

AIMS: To consider the evidence of effect from English language, empirically based quantitative evaluations of community-based interventions for bereaved children; community-based interventions being understood as those taking place outside a clinical setting. METHODS: MedLine, PsychInfo, Applied Social Sciences Index and Sociological Abstracts were searched for documents containing the words 'child', 'bereavement' and 'program', 'group', 'intervention', 'support' or 'evaluation'. The criterion for inclusion was that studies use a control group or pre- and post-test measurements using a standardized instrument. RESULTS: Nine relevant studies were identified. However, empirical evidence of positive outcomes for children was limited and compromised by methodological weaknesses in the design of the studies. Small sample sizes, irregular attendance, high levels of attrition, short time scales between pre- and post-testing and difficulty in developing appropriate instrumentation, including assessment of adherence to the agreed intervention programme, all created problems. CONCLUSIONS: The case for universal inclusion of this group of children in such support programmes remains unproven, and further exploration of the outcomes of a range of different community interventions is required, with a specific focus on long-term and/or unwanted effects and evaluation of the basis for referral.

Bereavement↗
PubMed2000

Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit.

STUDY OBJECTIVE: A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population. METHODS: Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days. RESULTS: Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older). CONCLUSION: The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.

Aged↗
PubMed2000

Down will come baby, cradle and all: diagnostic and therapeutic implications of chronic trauma on child development.

OBJECTIVE: This review examines the clinical outcomes associated with exposure to chronic intrafamilial trauma and explores the treatment of the psychological, biological and cognitive sequelae. METHOD: The existing research literature on the subject was collected, using Index Medicus/MEDLINE, Psychological Abstracts and the PILOTS database. The research findings were supplemented with clinical observations by the authors and other clinical writings on this topic. RESULTS: Children with histories of exposure to multiple traumatic experiences within their families or in medical settings usually meet criteria for numerous clinical diagnoses, none of which capture the complexity of their biological, emotional and cognitive problems. These are expressed in a multitude of psychological, cognitive, somatic and behavioural problems, ranging from learning disabilities to aggression against self and others. CONCLUSIONS: Exposure to intrafamilial violence and other chronic trauma results in pervasive psychological and biological deficits. Treatment needs to address issues of safety, stabilise impulsive aggression against self and others, promote mastery experiences, compensate for specific developmental deficits, and judiciously process both the traumatic memories and trauma-related expectations.

Adolescent↗
PubMed2000

A meta-analysis of cerebrovascular disease and hyperhomocysteinaemia.

Hyperhomocysteinaemia has been identified as a risk factor for stroke and cerebrovascular disease in several studies. To evaluate the evidence we performed a meta-analysis. We found 21 studies searching Medline from 1966-July 1999 using the key words homocysteine, homocystine and cerebrovascular disease or stroke combined with a search of Embase, Science Citation Index and Biological Abstract. In 17 of these studies the populations were comparable. The studies were divided into two groups, cross-sectional studies and longitudinal studies where a pre-insult plasma or serum total homocysteine was used. The reports on 8 cross-sectional and 4 longitudinal studies gave data on the mean and standard deviations of plasma or serum homocysteine for both cases and controls, and these studies were included in the meta-analysis. The results of the 5 excluded studies all pointed to a positive relationship between hyperhomocysteinaemia and cerebrovascular disease. For each study, the expected fractions of the cases with total homocysteine higher than the 95-percentile for the controls were calculated, using the means and standard deviations, assuming a log-normal distribution, and the odds-ratios for disease with total homocysteine above the 95-percentile were computed. The overall weighted odds-ratio for disease with a concentration of homocysteine in plasma or serum above the 95-percentile (95% confidence interval) for the cross-sectional studies was 4.12 (2.94-5.77), for the longitudinal studies 3.74 (2.53-5.54), and for all 12 studies 3.97 (3.07-5.12). In conclusion, the results support the case for a strong relation between hyperhomocysteinaemia and cerebrovascular disease.

Cerebrovascular Disorders↗
PubMed2005

Minority ethnic elders in care homes: a review of the literature.

BACKGROUND: Health and social care services are required to provide quality service provision to meet all older people's needs, including any needs specific to minority ethnic groups. The heterogeneity of the population, however, highlights the need to offer a range of services that reflect people's language, cultural and religious differences. OBJECTIVES: This paper reviews the literature concerned with minority ethnic elders in care homes. METHODS: Systematic searches were conducted using the following online databases: Web of Science, Pub Med, Sociological Abstracts, Social Sciences Index, AMED, British Nursing Index, Medline, PsycInfo and CINAHL. Independent reviewers undertook a structured assessment of each piece of literature. Data extraction and analysis were in accordance with established methods. FINDINGS: The literature has been classified into two key areas. First, issues arising from international literature, including factors relating to access, equality and workforce issues, care satisfaction and placement decision-making. The second area focuses on the issues emerging from the UK literature. Issues of particular concern include barriers to care provision for minority ethnic older people, loss of independence and the recognition of cultural needs. CONCLUSION: The review indicates how problems remain in ensuring the delivery of best-quality long-term care to ethnic elders in care homes. The review also highlights the absence of studies focusing on the perception of care from residents' perspectives and their involvement in making placement and care decisions.

Aged↗
PubMed2000

Return to the emergency department among elders: patterns and predictors.

OBJECTIVES: 1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits. METHODS: Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database. RESULTS: Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use. CONCLUSIONS: In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.

Aged↗
PubMed1995

Systematic review of clinical efficacy of topical treatments for head lice.

OBJECTIVES: To collect and evaluate all trials on clinical efficacy of topical treatments for head lice. DESIGN: Systematic review of randomised trials identified from following data sources: Medline, International Pharmaceutical Abstracts, Science Citation Index, letters to key authors and companies, and hand search of journals. SETTING: Trials in schools or communities. SUBJECTS: Patients infested with lice. MAIN OUTCOME MEASURE: Cure rate (absence of live lice and viable nits) on day 14 after treatment. RESULTS: Total of 28 trials were identified and evaluated according to eight general and 18 lice specific criteria. Of the 14 trials rated as having low to moderate risk of bias, seven were selected as they used the main outcome measure. These seven trials described 21 evaluations of eight different compounds and placebo (all but two evaluations were of single applications). Only permethrin 1% creme rinse showed efficacy in more than two studies with the lower 95% confidence limit of cure rate above 90%. CONCLUSIONS: Only for permethrin has sufficient evidence been published to show efficacy. Less expensive treatments such as malathion and carbaryl need more evidence of efficacy. Lindane and the natural pyrethrines are not sufficiently effective to justify their use.

Administration, Topical↗
PubMed2002

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors.

OBJECTIVE: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting. DESIGN: Systematic review of randomised controlled trials and prospective observational studies. DATA SOURCES: Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies. INCLUDED STUDIES: Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care. RESULTS: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations. CONCLUSION: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.

Clinical Competence↗