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At least 757 records · Page 42Linked to original sources
PubMed1984

Emergency medicine redux: the rise and fall of a community medical specialty.

The specialty of Emergency Medicine has evolved circuitously . The poor relation of medicine, previously the domain of moonlighting dermatologists and semi-retired physicians, we considered it a diamond in the rough, a wealth of opportunity hidden by the prejudice of established specialties . We tailored the discipline to meet our needs and desires. As we created form from void, we generated an interest in a practical area of medicine previously indulged only theoretically. Now we are enlarging geometrically as a specialty and have discovered that our actual role as practicing physicians in the community hospital setting has turned out differently than we had conceived in training. As we overpower the available market by expanding our numbers, we are learning about some practical realities that are only now becoming apparent.

Cost-Benefit Analysis↗
PubMed2004

Spinal manipulative therapy for low back pain.

BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Humans↗
PubMed2006

Error classification in community optometric practice - a pilot project.

OBJECTIVE: A pilot study was conducted to undertake a baseline assessment of errors reported in community optometric practice. The feasibility and acceptability of a method for recording staff-reported errors in optometric community practice was investigated. DESIGN: An anonymous self-reporting system was introduced in order to collect information regarding errors/untoward events in community optometric practice. SETTING: UK community optometric practice. MAIN OUTCOME MEASURES: Classification of errors according to a previously published study pertaining to general medical practice in the same geographical area. RESULTS: Thirty-six notebooks were distributed to 10 participating community optometric practices. At the end of the 1 month study period the note books were returned and the 439 entries made were classified into seven categories: optical prescriptions (18.2%), communication (35.5%), administrative (15%), appointments (2.3%), equipment (11.9%), clinical (10.3%) and other (6.9%). CONCLUSION: A previously developed classification of errors in general medical practice was found to be equally applicable to community optometric practice. This study forms the basis of providing an acceptable and practical methodology, which can be applied by Primary Care Trusts (PCTs) when developing their risk management strategy to include optometry.

Appointments and Schedules↗
PubMed2003

How will practices cope with information for the new GMS contract? Coronary heart disease data recording in five Scottish practices.

OBJECTIVES: To investigate whether practices will be ready for the data reporting requirements for the new General Medical Services (GMS) contract, using coronary heart disease (CHD) as an example. DESIGN: Cross-sectional survey. DATA SOURCES: Electronic general practitioner (GP) records of all CHD patients in five Scottish practices, validated by manual searches in 50 randomly selected patients in each practice. MAIN OUTCOME MEASURES: Recording of family history, smoking status, blood pressure (BP), diabetes testing, aspirin therapy and cholesterol measurement. RESULTS: It is extremely easy for practices with completely electronic patient records to extract a disease register (mean 10 min, range 38 sec to 3 hr 6 min). Extraction of a complete dataset takes several days if it involves checking through paper records, whereas setting up and running a search from electronic records is possible in less than two hours. If practices use the same clinical system and identical data entry templates, the data can be directly compared. Some items that are easily recorded as part of routine clinical practice, such as prescribing of aspirin, are well recorded, but others, such as BP recording, are more of a problem. One hundred percent of the CHD patients sampled had a BP recording within the previous year, but some practices had these data in the paper records where they were not readily accessible. CONCLUSIONS: We have shown that in Scotland there is a high level of testing and recording of all the important information regarding patients with recorded CHD, irrespective of whether practices have fully electronic records, paper-based records, or a mixture of the two. If practices have fully electronic patient records, the information can be extracted easily, but unless there is a standard template, the information can only be viewed in isolation and is of little value for comparative purposes.

Coronary Disease↗
PubMed1992

High dose rate intracavitary brachytherapy for carcinoma of the cervix: the Madison system: I. Clinical and radiobiological considerations.

The decision to use five high dose rate intracavitary (HDR-ICR) insertions at weekly intervals for invasive carcinoma of the cervix treated at the University of Wisconsin Comprehensive Cancer Center (UWCCC) was made clinically. It was based on practical considerations and on previous clinical experience worldwide which showed that between 2 and 16 insertions have been used with apparently acceptable results. Although radiobiological considerations favor a large number of small doses, such a large number of HDR-ICR insertions is not clinically practical. Our strategy was to keep the biological effects of external beam and intracavitary insertions in the same ratio as used on a large series of patients treated here with low dose rate (LDR) therapy. This means keeping the same external beam treatment scheme and finding high dose rate (HDR) doses that are biologically equivalent to the previous LDR therapy, as far as possible. External beam and HDR intracavitary dose schedules for the Madison System of treating cervical carcinoma are described in detail. Because there is more repairable damage in late-reacting normal tissues, there is a bigger loss of sparing in these tissues than in tumors when changing from LDR to HDR, so total doses should be reduced more for equal late complications than for equal tumor control. The clinical decision was made to aim at equal tumor control. The possible increase in late complications has to be avoided by reducing the doses to critical normal tissues using extremely careful anatomic positioning of the HDR sources. Critical normal tissues must be kept further away from the radiation sources so that their doses are about 20% lower than with LDR geometry. This requires an extra separation of some millimeters depending on the anatomy and geometry of the individual insertion. The strategy is that the unfavourable radiobiological effects of a few large fractions must be counteracted by better physical dose distributions with HDR-ICR than with the previous LDR insertions. These good distributions are obtainable with the short exposures at HDR.

Brachytherapy↗
PubMed2000

A maternal vegetarian diet in pregnancy is associated with hypospadias. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood.

OBJECTIVE: To investigate the possible role of the maternal diet, particularly vegetarianism and consumption of phytoestrogens, in the origin of hypospadias, which is reported to be increasing in prevalence. SUBJECTS AND METHODS: Detailed information was obtained prospectively from mothers, including previous obstetric history, lifestyle and dietary practices, using structured self-completed questionnaires during pregnancy. Previously recognized associations with environmental and parental factors were examined, focusing particularly on the hypothesized hormonal link. Multivariate logistic regression was used to identify independent associations. RESULTS: Of 7928 boys born to mothers taking part in the Avon Longitudinal Study of Pregnancy and Childhood, 51 hypospadias cases were identified. There were no significant differences in the proportion of hypospadias cases among mothers who smoked, consumed alcohol or for any aspect of their previous reproductive history (including the number of previous pregnancies, number of miscarriages, use of the contraceptive pill, time to conception and age at menarche). Significant differences were detected for some aspects of the maternal diet, i.e. vegetarianism and iron supplementation in the first half of pregnancy. Mothers who were vegetarian in pregnancy had an adjusted odds ratio (OR) of 4.99 (95% confidence interval, CI, 2.10-11.88) of giving birth to a boy with hypospadias, compared with omnivores who did not supplement their diet with iron. Omnivores who supplemented their diet with iron had an adjusted OR of 2.07 (95% CI, 1.00-4.32). The only other statistically significant association for hypospadias was with influenza in the first 3 months of pregnancy (adjusted OR 3.19, 95% CI 1.50-6.78). CONCLUSION: As vegetarians have a greater exposure to phytoestrogens than do omnivores, these results support the possibility that phytoestrogens have a deleterious effect on the developing male reproductive system.

Diet, Vegetarian↗
PubMed2006

Prognostic factors, disability, and functional status among patients in a headache specialty practice.

The objective of this study was to identify prognostic factors and assess functional status over time among patients in a headache specialty practice. Study questionnaires were mailed to 599 patients who previously presented to a headache specialty practice. Outcome measures included headache frequency, the Headache Impact Test (HIT) and the SF-36 Health Survey. Completed surveys were received from 333 respondents (56%). Thirty-five respondents (11%) had HIT scores in the 'little or no impact' range at follow-up and 191 (57%) had HIT scores in the 'severe impact' range. A diagnosis of migraine at baseline was an independent predictor of elevated HIT scores at follow-up, but gender, age, age at headache onset, daily headache at baseline, and time to follow-up did not predict poor prognosis. A subset of headache patients continue to experience marked disability and impaired functional status, months to years after presenting for headache specialty care. A diagnosis of migraine at the time of presentation may predict prognosis, but additional cohort studies with careful attention to baseline variables are needed to help identify other prognostic factors.

Activities of Daily Living↗
PubMed2005

Adalimumab in clinical practice. Outcome in 70 rheumatoid arthritis patients, including comparison of patients with and without previous anti-TNF exposure.

OBJECTIVE: To assess the efficacy and safety of the fully human recombinant monoclonal anti-TNF antibody adalimumab in routine clinical practice, including comparison of patients with and without previous anti-TNF exposure. METHODS: We prospectively studied the outcome of 70 rheumatoid arthritis patients treated with adalimumab in normal clinical practice. The primary outcome measures were Disease Activity Score 28 (DAS28), EULAR (European League Against Rheumatism) response and Health Assessment Questionaire (HAQ). RESULTS: Seventy-seven per cent achieved a EULAR response (26% good, 51% moderate) and 19% were in remission. The mean decrease in DAS28 was 2.1 (6.3-4.2; P<0.001). The mean decrease in HAQ score was 0.34 (2.07-1.73; P<0.001), 66% achieving a clinically significant decrease of greater than 0.22. Twenty-three per cent stopped treatment because of side-effects (7%) or failure to respond (16%). Of the 26 patients who had previously tried 29 biologicals, 65% responded to adalimumab. There was no significant difference in the change in mean DAS (P = 0.69) or HAQ (P = 0.88) between groups with and without previous anti-TNF exposure. Of the 13 patients with previous secondary failure to infliximab, 77% responded to adalimumab. Patients with previous secondary failure had significantly better improvement in DAS (P = 0.023) than patients with previous primary failure. CONCLUSION: Our clinical experience confirms that adalimumab is effective and safe in the treatment of RA. It also shows adalimumab is effective in patients with previous biological failures, particularly patients with secondary failure to infliximab.

Adalimumab↗
PubMed2006

[Allergy in general practice in Arhus County. Quality assessment of diagnosis, treatment and instructions to patients. III. Allergy testing].

INTRODUCTION: The aim of this study was to compare the allergy test with the skin prick test and the specific IgE by Phadiatop test to a purely clinical allergy diagnosis by an allergy specialist in adult patients previously tested in general practice. MATERIALS AND METHODS: A total of 103 patients suspected of having asthma and/or rhinitis were re-evaluated with a clinical diagnosis and the two allergy tests. Both the patient and the individual general practitioner were asked about existing allergy diagnosis. RESULTS: The two test systems showed large differences in a semiquantitative linear system with an explained variation (r2) of only 8%. In comparison to a purely clinical diagnosis, they were diagnostically equal with both tests, with an additional 15% positive reactions of which 25% were judged clinically active. Both tests resulted in about 33% false-positive tests classified as clinically inactive. In the case of a positive Phadiatop test and clinically active allergy, both the patient and the general practitioner reported identical specialist diagnoses in about 75% of cases, while in 20-50% of the cases an identical diagnosis was reported when the clinical diagnosis was qualitatively different from the result of Phadiatop. CONCLUSION: The results of the two test systems often differ, and they both detect extra positive tests, in which case they should be used in a serial manner. Both tests often result in a false-positive diagnosis, and identification of clinically relevant positive tests often requires an experienced medical evaluation.

Adult↗
PubMed1989

Predictive validity of certification by the American Board of Internal Medicine.

STUDY OBJECTIVE: To determine the predictive validity of the American Board of Internal Medicine (ABIM) certification process. DESIGN: Prospective measurement of the knowledge, skills, and attitudes of 185 ABIM-certified and 74 noncertified internists by a written examination; evaluation by professional associates; a patient questionnaire assessing satisfaction with care, physician's counseling role, and preventive care; and review of records of patients with common illnesses. SUBJECTS: Practicing internists who completed training or received ABIM certification 5 to 10 years previously. SETTING: Office-based practices in six western states. RESULTS OF DATA ANALYSIS: Physicians certified by the ABIM had significantly higher scores on the written examination than the noncertified physicians, and scores on our examination correlated highly with the ABIM certification examination (r = 0.73). Ratings of clinical skills by professional associates were significantly higher for certified internists and also correlated highly with ABIM examination scores (r = 0.53 to 0.59). Regression analysis showed that ABIM certification status was the major variable affecting performance on these measures of clinical competence. Results from other measures did not show many differences between certified and noncertified physicians in the care of patients with common illnesses, but modest differences in preventive care and a few differences in outcome favored the certified physicians. CONCLUSIONS: Comparison of findings from the written examination and the professional associate ratings with certification status and original ABIM certification examination scores shows predictive validity of ABIM certification. Further studies are needed to determine if certification status predicts important differences in the care of patients with complex illnesses.

Certification↗
PubMed1995

Opening Pandora's box: patients' attitudes towards trainees. Dublin General Practice Vocational Training Scheme Third Year Group 1991-1992.

This study set out to establish patients' attitudes towards GP trainees and to determine if patient age, sex, a history of having previously attended a GP trainee and practice location affected these attitudes. Two hundred questionnaires were distributed to each of the 10 training practices of the 1991-1992 Dublin GP Vocational Training Scheme. The questionnaires, which were completed anonymously, consisted of six statements regarding trainees which were answered on a five point Likert scale. A further question enquired about patient preference regarding type of doctor for six clinical scenarios. A total of 1510 completed questionnaires were returned (75%). More than three-quarters of patients expect the usual standard of care when seeing a trainee and 91% consider it advantageous for a practice to have a trainee. A third consider home visits by trainees to be less satisfactory than those performed by the usual doctor. A third would not feel as comfortable with the trainee as with their usual doctor and 41% would prefer to see their usual doctor after seeing the trainees. Few expressed a preference to see the trainee for five out of the six clinical scenarios. The exception was consultations regarding gynaecological problems. Negative attitudes towards trainees were sigificantly increased amongst urban practices, patients over 40 and those who had not previously attended a trainee. Patients have definite attitudes towards trainees. These attitudes are negatively affected by patient age greater than 40, a history of not previously attending a trainee and an urban practice location. These results have implications for the training of future general practitioners. How they can be best addressed merits further discussion.

Adult↗
PubMed2003

Future demand for general practice services: effects of population change and trends in service use.

This study investigated three key determinants of demand for general practice services: population growth, population ageing and trends in service use. Projection of future service use on the basis of the two demographic factors yielded a projected growth in number of general practice services of 5.9% by 2006, with a further 6.5% growth by 2011. When trends in service use were taken into account as well as demographics, a lower rate of growth in services was projected, but an increasing proportion of long consultations and an increasing proportion of services for older adult patients. It is concluded that population ageing and population growth will continue to be major drivers of demand for general practice services in the next decade. Patterns of service use will also be a key contributor, with increased use of long consultations suggesting a greater requirement for the general practice workforce than has previously been proposed.

Adolescent↗
PubMed1996

Is HIV screening being requested appropriately? The experience of a Victorian public health laboratory.

From the start of clinical testing for human immunodeficiency virus (HIV) antibody in 1985 until the end of June 1994, the Microbiological Diagnostic Unit tested 134 346 serum samples from 109 391 individuals, identifying 672 as infected. A suitable database, using coded identities, was established from the beginning. Because the sera came from a variety of clinical settings, it was possible to extract information about patterns of requests for tests and about the yield of seropositive cases. The data were able to highlight factors associated with high rates of positive tests that can be lost in amalgamated statewide data. The discovery of HIV-positive females was sporadic and there was a much lower detection rate than from testing males. While males were most commonly diagnosed through specialist venereology services, 61 per cent of diagnoses in females were through nonspecialised practices, often those without previous experience in diagnosis and management of HIV infection. Despite some individual exceptions, the requesting of HIV tests appears generally to have been justifiable (particularly in view of the direction of official preventive campaigns) and not profligate. Overall, where practice was unsatisfactory, this lay less in thoughtless ordering of tests than in failing to include with the specimen the elementary, but vital, epidemiological information requested.

Adolescent↗
PubMed1992

How effective is systematic care of diabetic patients? A study in one general practice.

A method of systematic diabetic care compatible with personal lists, the 'diabetic day', was introduced into a seven partner inner city general practice. The effect on glycosylated haemoglobin levels and the recording of six process measures (fundoscopy, visual acuity, weight, blood glucose levels, glycosylated haemoglobin levels and blood pressure) was assessed. Of the 111 known registered diabetic patients, 64 entered the diabetic day and fulfilled the eligibility criteria. General practice records were analysed retrospectively over a period of four years--the two years before entry into the diabetic day were compared with the subsequent two years. Mean glycosylated haemoglobin levels fell from 10.52% in the year before entry to the diabetic day to 9.71% in the second year after entry (P < 0.01, 95% confidence intervals 0.19 to 1.39). There was a significant increase in all process measures recorded in the general practice notes after entry into the diabetic day. The introduction of systematic care for diabetic patients led to an improvement in recorded process measures and a reduction in patients' glycosylated haemoglobin levels in a general practice which had made previous efforts to improve diabetic care and was already well staffed, organized and motivated.

Adolescent↗
PubMed1998

Can medical audit change electromyographic practice?

Considerable variation in EMG practice has been described previously. Since 1992, 7 clinical neurophysiologists from 6 European countries prospectively collected electromyographic (EMG) examinations. The aim of this study was to examine whether several years of mutual influence among physicians using medical audit resulted in a more uniform EMG practice. We studied whether there was a change in the number of examinations per patient and the techniques used from the first 12 to the last 12 EMG examinations on patients with polyneuropathy. For F-wave studies and motor nerve studies, there was a clear change towards a more uniform practice. For sensory nerve conduction studies and muscle studies, there were only minor changes. With regard to examination techniques, there was a reduction in the use of more time-consuming examination techniques (near-nerve sensory studies and quantitative muscle studies). It seems possible to change the EMG practice of individual physicians by international collaboration and medical audit. However, until now most changes have been minor and large differences in European EMG practices persist. The diversity of practices suggests a need for studies on the optimal application of existing examination techniques.

Electromyography↗