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PubMed1992

The practical management of haemophilia.

Haemophilia is a rare and complex disorder and its successful management will depend upon the establishment of a network of 'comprehensive care' including the services of haematologists, orthopaedic surgeons, rheumatologists, dental surgeons, physiotherapists, specialised nurses and counsellors. One of the major lessons to be learned from the HIV epidemic in haemophilia is that it is critical to strive to obtain the safest and purest forms of blood products for these patients. The advent of clinically available recombinant factor VIII is expected soon; in the meantime there is a move towards treating all patients with high purity products.

Cerebral Hemorrhage↗
PubMed1990

Effect of nematode infections and management practices on growth performance of calves on commercial dairy farms.

Liveweight of calves on 86 dairy farms was measured at the end of the grazing season and related per herd to the level of exposure to nematode infection estimated in October and December. There were significant between-herd variations in all the serological infection parameters measured. On average 20.5 larvae per gram faeces (geometric mean) were found in October. Faecal samples of 20.5% of the herds contained lungworm larvae. Liveweight of calves deviated per herd from -59.8 kg to +52.2 kg from an age-adjusted population mean after their first grazing season. Growth performance was significantly related negatively to several serological and parasitological parameters. Data were fitted by means of both linear and segmented curvilinear regression. By combining infection parameters 19% of the variation in growth performance among herds could be explained. Infection parameters involved were antibody titre against Cooperia spp., egg output and lungworm larval count. It was found that antibody titres were significantly correlated positively to herd age, while pepsinogen values and egg output were negatively correlated to age. Combining supplementary feeding and anthelmintic treatment during the grazing season with the infection parameters into one model explained approximately 30% of the observed variation in growth performance among herds. It was shown that these findings were consistent with those of a similar study conducted on the same farms a year earlier, although there were clear differences between the years. Finally, significant positive relations were found between the levels of exposure to nematode parasites within farms between two consecutive years.

Age Factors↗
PubMed2006

Excess body weight, clinical profile, management practices, and hospital prognosis in men and women after acute myocardial infarction.

BACKGROUND: Excess body weight is increasingly being recognized as a major health problem in American men and women. It is unclear, however, whether body weight is associated with the demographic and clinical profile, treatment of, and hospital prognosis after acute myocardial infarction (AMI). METHODS: Nonconcurrent prospective epidemiologic investigation of Worcester (Massachusetts) metropolitan residents hospitalized at all 11 greater Worcester medical centers with validated AMI in 1997, 1999, 2001, and 2003. RESULTS: A total of 2008 men and 1505 women were hospitalized with confirmed AMI during the 4 study periods. Approximately 41% of men and 29% of women were classified as being overweight (body mass index [BMI] of 25-29.9), whereas 27% of men and 26% of women hospitalized with AMI were considered to be obese (BMI > or = 30). Obese men and women were significantly younger than individuals of normal weight. Effective cardiac treatment regimens were less often used in men and women of normal body weight, compared with patients who were overweight or obese. After controlling for several potentially confounding prognostic factors, there were no significant differences in the risk of dying during hospitalization for either overweight or obese men and women, compared with patients of normal body weight. Obese men and women were, however, at greater risk for developing heart failure during the acute hospitalization than men and women of normal weight. CONCLUSIONS: The results of this community study suggest an association between BMI and use of different treatment approaches in patients with AMI. Further examination of the impact of excess body weight on hospital outcomes associated with AMI remains warranted.

Aged↗
PubMed2004

Recent trends in hospital management practices and prognosis after acute myocardial infarction in patients with kidney disease.

Patients who have kidney disease receive aspirin, beta blockers, lipid-lowering therapy, thrombolytic agents, and coronary interventions less often than patients who have normal kidney function. The odds of dying during hospitalization for acute myocardial infarction were significantly higher among patients who had kidney disease than among those who did not have kidney disease after adjusting for several demographic and clinical confounders and year of hospitalization.

Aged↗
PubMed2006

Epidemiology of work-related upper extremity disorders: understanding prevalence and outcomes to impact provider performances using a practice management reporting tool.

In 2001, the number of repeated trauma cases accounted for 4% of total workplace injuries and 65% of all occupational illnesses, with work-related upper extremity disorders accounting for most cases. Because chronic disability leads to the highest cost, systematic evaluation of this growing occupational condition is needed. This article sheds light on work-related upper extremity disorders by understanding the prevalence and pattern for these diagnoses, their impact on outcomes influenced by age, gender and geography on metrics such as utilization, duration, disability status, and costs. To assess these types of outcomes measurements, a good reporting and management system must be in place to allow for ongoing evaluation and analysis of data and in the construction of intervention programs to improve provider performances and, ultimately, patient outcomes.

Adult↗
PubMed2005

Comparing steroid estrogen, and nonylphenol content across a range of European sewage plants with different treatment and management practices.

The effluent of 17 sewage treatment works (STW) across Norway, Sweden, Finland, The Netherlands, Belgium, Germany, France and Switzerland was studied for the presence of estradiol (E2), estrone (E1), ethinylestradiol (EE2) and nonylphenol (NP). Treatment processes included primary and chemical treatment only, submerged aerated filter, oxidation ditch, activated sludge (AS) and combined trickling filter with activated sludge. The effluent strength ranged between 87 and 846 L/PE (population equivalent), the total hydraulic retention time (HRT) ranged between 4 and 120 h, sludge retention time (SRT) between 3 and 30 d, and water temperature ranged from 12 to 21 degrees C. The highest estrogen values were detected in the effluent of the STW which only used primary treatment (13 ng/L E2 and 35 ng/L E1) and on one occasion in one of the STW using the AS system (6.5 ng/L E2, 50.5 ng/L E1, but on three other occasions the concentrations in this STW were at least a factor of 6 lower). For the 16 STW employing secondary treatment E2 was only detected in the effluent of six works during the study period (average 0.7-5.7 ng/L). E1 was detected in the effluent of 13 of the same STW. The median value for E1 for the 16 STW with secondary treatment was 3.0 ng/L. EE2 was only detected in two STW (1.1, <0.8-2.8 ng/L). NP could be detected in the effluent of all 14 STW where this measurement was attempted, with a median of 0.31 microg/L and values ranging from 0.05 to 1.31 microg/L. A comparison of removal performance for E1 was carried out following prediction of the probable influent concentration. A weak but significant (alpha<5%) correlation between E1 removal and HRT or SRT was observed.

Environmental Monitoring↗
PubMed1998

The obstetrician-gynecologist's role in the practical management of polycystic ovary syndrome.

Women with polycystic ovary syndrome come to the gynecologist with a variety of symptoms, including menstrual irregularities, hirsutism, acne, weight gain, obesity, and infertility. An accurate diagnosis requires both confirmation of signs and symptoms of polycystic ovary syndrome and exclusion of other disorders. Once the diagnosis of polycystic ovary syndrome has been established, the presence of concomitant conditions, such as hypertension, dyslipidemia, and diabetes, must be assessed. Because the cause of polycystic ovary syndrome is not clear, treatment options have focused on symptom management. Such treatment options include oral contraceptives, gonadotropin-releasing hormone analogs with "add-back" hormone regimens, antiandrogens, ovulation-inducing agents, electrolysis, nutritional and weight loss counseling, exercise, laparoscopic ovarian drilling, and glucocorticoids. Pathogenic considerations, risk factor assessments, and treatment objectives combine to determine the choice of therapies. It is not clear whether insulin resistance is clinically important or causal in polycystic ovary syndrome symptom complex in all affected women. Polycystic ovary syndrome may be the final common expression of a variety of metabolic or neuroendocrine perturbations. If insulin resistance is a universal feature, it would make sense to treat with an insulin-sensitizing agent in the expectation that symptoms would resolve or improve. If insulin resistance is not the main etiologic factor, however, then insulin-sensitizing agents would be useful as adjunctive agents only for women with clinically important insulin resistance (eg, patients with polycystic ovary syndrome in whom insulin resistance causes hyperglycemia). In such cases an insulin-sensitizing agent could be instituted along with a program of weight loss and exercise.

Algorithms↗
PubMed1999

Esophageal fistula sealing: choice of stent, practical management, and cost.

BACKGROUND: Three models of covered metal stents are available to seal esophageal fistulas. METHODS: Stainless steel covered stents were inserted in 5 patients (group I); nitinol covered stents were inserted in 12 patients (group II) with malignant (n = 14) or benign (n = 3) esophageal fistulas. RESULTS: Stent positioning was satisfactory in all cases. Fistula sealing was complete in 1 of 5 (20%) and 12 of 12 (100%) patients of groups I and II, respectively (p < 0.005). Continued esophageal leakage was initially related to the passage of fluids alongside the stent covering (n = 3) and to early stent migration (n = 1). Complications related to stent placement were observed in 2 of 17 (12%) patients and were fatal. During follow-up (mean 153 +/- 143 days), esophageal fistulas relapsed after initial sealing in 5 of 13 (38%) patients. Further treatment (glue or fibrin sealant injection, additional stent insertion) was attempted in 7 cases of persistent or relapsing esophageal fistula, with sealing obtained in 5 of them. The costs per patient and per day free from symptoms due to the esophageal fistula were $106 and $57 in groups I and II, respectively. CONCLUSION: Nitinol covered stents more frequently provided complete esophageal fistula sealing, as compared with stainless steel covered stents. Further treatments tailored to the mechanisms of fistula persistence or relapse often provided sealing.

Adolescent↗
PubMed1991

Practical management of epistaxis.

Epistaxis is a very common presenting symptom of patients seen in the emergency room or the physician's office. An understanding of the nasal anatomy and physiology is important for proper treatment of these patients. New methods of treatment are discussed briefly.

Catheterization↗
PubMed1989

Practical management of urinary incontinence.

A comprehensive evaluation of incontinence using office-based techniques may discover reversible problems such as delirium, urinary infections, vaginitis, depression, drug effects, endocrinologic causes, immobility, or impaction. Treatment of these causes may alleviate incontinence. Bedside urodynamics are a sensitive, specific, and useful office-based technique that can identify detrusor instability, overflow incontinence, or stress incontinence. Low urinary flow rate, difficulty with catheterization, slow bladder filling or severe urgency, bladder capacity over 600 ml, and post-void residual over 150 ml need referral. Patients with hematuria, recurrent infections, recent surgery or pelvic irradiation, and pelvic or prostatic masses also need further evaluation. A number of medical and behavioral therapies are available for stress incontinence and detrusor instability that can substantially reduce incontinence, but most patients with overflow have more complicated problems requiring further evaluation, surgery, or long-term bladder drainage.

Aged↗
PubMed1997

Practical management of venous thromboembolism following pelvic fractures.

The management of thromboembolic complications remains one of the most controversial issues in the care of patients with pelvic and acetabular fractures. Recent studies have indicated that the incidence of proximal deep vein thrombosis is much higher than was previously believed. These patients should be managed with a formal institutional protocol that includes universal prophylaxis, supplemented in some cases by screening for deep vein thrombosis.

Algorithms↗
PubMed1999

A prospective study of ED pain management practices and the patient's perspective.

OBJECTIVE: This study was conducted to describe the prevalence of pain in the emergency department and to identify factors that may contribute to its treatment. METHODS: Interviews were conducted with 203 patients who entered the emergency department during the study period. Patients were interviewed regarding various aspects of their pain. Medical records were reviewed to determine what treatments were provided. RESULTS: One hundred sixty of the 203 patients came to the emergency department with a chief complaint related to pain, indicating a prevalence rate of 78%. Approximately 58% of all patients received either medication or an intervention. An average of 74 minutes elapsed from the time of arrival in the emergency department to the time of treatment with pharmacologic agents. Various independent variables were examined to determine their ability to predict the treatment of pain. Chest pain was most often treated with medication, and abdominal pain was least often treated with medication. Despite high pain ratings, only 15% of the sample received an opioid. DISCUSSION: This study revealed a very high prevalence of pain among patients in the emergency department and showed that, overall, pain was poorly treated. The findings suggest that chest pain is the only type of pain routinely relieved in the emergency department. An anecdotal finding was that 31 patients said they would refuse pain medications if such medications were offered. Twenty-five patients reported fear of addiction as their reason for this refusal.

Adult↗