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PubMedDate not supplied

Dysmorphology and the orbital region: a practical clinical approach.

Dysmorphology is the field of medicine focusing on congenital developmental abnormalities due to exogenous teratogens, chromosomal anomalies, or to a defect in a single gene. Numerous syndromes have been reported and a growing number of genes or chromosomal anomalies are identified. The clinical observation of the face remains an essential part of the clinical evaluation of the patients. The orbital region, as other regions of the face, should be systematically evaluated. Orbital malformations can be isolated or part of a syndrome. In the diagnostic process, the orbital anomaly can be classified as a major feature (essential for the diagnosis), a moderate feature (important but not essential for the diagnosis), or a minor feature (contributing weakly to the diagnosis). The diagnoses of the main orbital anomalies in dysmorphology are reviewed and illustrated with relevant examples of syndromes that are presented as well as the usual landmarks used in clinical practice. Abnormal position of the eyes in syndromes such as hypertelorism, hypotelorism, primary or secondary telecanthus, asymmetry, and proptosis are discussed. Eyelid anomalies, such as cryptophthalmos, ablepharon, blepharophimosis, euryblepharon, or anomalies at the level of the eyelashes and eyebrows are described.

Craniofacial Abnormalities↗
PubMed1986

Hepatitis in clinical practice. 1. Hepatitis A and B.

As is evident from the foregoing discussion, hepatitis A and hepatitis B are not static, passé disease. Knowledge concerning these illnesses continues to expand at a fantastic rate--all of it of extreme practical clinical significance. Most interesting is the elucidation of the etiology of the acquired immune deficiency syndrome (AIDS) and the increase this knowledge is hoped to produce on the utilization of hepatitis B vaccine. Also extremely important is the development of recombinant DNA vaccine, which will permit total circumvention of the question of AIDS and safety of the hepatitis B vaccine.

Acquired Immunodeficiency Syndrome↗
PubMed1984

Urinary chemiluminescence--an evaluation of its use in clinical practice.

It has been proposed that a substance, as yet unidentified, is excreted in the urine and acts as a chemical carcinogen. This substance during oxidative reactions will exhibit urinary chemiluminescence (UCL) and it is this release of energy in the form of light which activates the intracellular changes responsible for carcinogenesis. One hundred and seventy-seven people, 110 patients being followed up endoscopically for transitional cell carcinoma of the bladder (TCCB) and 67 controls, had their UCL measured. The UCL estimations confirmed previously reported trends where those with active disease had the highest UCL (84) and the controls had the lowest (55). These results did not reach statistical significance and the wide variations of the results do not allow UCL, as yet, to be of practical clinical use.

Adolescent↗
PubMed1989

[Intracranial pressure monitoring in clinical practice. Report of 180 cases].

180 severe neurosurgical cases were monitored by intraventricular, epidural and subdural measurements. Intracranial infection rate was 1.1% and the intracranial hypertension rate was 83.3%. Increased intracranial pressure was most often seen in group of head injury. The outcome was poor in cases of uncontrol intracranial hypertension. It was found that intracranial pressure monitoring is useful for diagnosis, treatment and estimation of prognosis and has practical clinical value. This method and indications should be used appropriately according to the different situations. The patients with acute intracranial hypertension should be monitored intensively.

Adolescent↗
PubMed2001

Evaluating and applying clinical practice guidelines.

Clinical practice guidelines (CPG) hold great potential for providing a summary of large volumes of clinical evidence and a related set of practical recommendations. Nurse practitioners should become aware of the range of available CPGs and methods by which they can be evaluated for use. Appropriate evaluation of CPGs should include their overall reliability and validity, as well as their applicability in specific situations. This article provides an overview of an appropriate evaluation method and serves as an introduction to future columns presenting individual CPGs.

Evidence-Based Medicine↗
PubMed2006

Making clinical decisions using a clinical practice guideline.

Clinical practice guidelines are statements developed from best evidence about clinically relevant appropriate care. A simulated patient case is presented to demonstrate how to use a CPG in decision-making in determining a clinical decision. Conceptualized knowledge management software templates are provided to explain a process by which best evidence is retrieved from a primary, centralized network database. Templates describe the process of converting a clinical question into a research question, retrieving best evidence, and performing data analysis for the outcome of individualizing and optimizing a clinical decision. Templates also describe the reciprocation of information to update CPGs by translational researchers who manage and build the primary, centralized network database.

Aged, 80 and over↗
PubMed1990

Good clinical practice.

Good Clinical Practice (GCP) is a quality assurance system dealing with all stages of clinical trials which is progressively being adopted by European countries. European GCP guidelines are in preparation and will be issued soon. However, implementation of the guidelines poses major and costly problems. The training of investigators, the proper functioning of research ethics committees, the practice of obtaining written informed consent, source data verification, and quality control with internal audit and official inspections are among the most difficult issues. The obvious benefits of GCP are the improved quality of clinical trials and of data generated by such trials, as well as mutual recognition of studies conducted abroad.

Anti-Infective Agents↗
PubMedDate not supplied

[The difficulties of translating into daily clinical practice the favorable results of clinical trials in chronic heart failure].

Congestive heart failure is a growing public health problem and continues to be characterized by a poor prognosis. Its prevalence may be estimated at 0.4-2% of the general population with an incidence varying from 1-10% in elderly patients. This may be in part explained by the progressive aging of the population and the more effective therapeutic strategies for coronary heart disease and hypertension: since they increase the life-expectancy of patients, they favor the onset of this clinical syndrome at a more advanced age. The number of hospital admissions has also increased; mortality is 50% within 4 years of diagnosis, although patients with very severe cardiac decompensation die within 1 year. Despite the fact that with the use of the most advanced molecules created by pharmacological research (ACE inhibitors, beta-blockers, angiotensin-II-receptor antagonists) a significant reduction in morbidity and mortality as well as clear improvement of symptoms and quality of life have been obtained in diverse clinical trials, there is still no certain evidence that in the general population, mortality due to chronic heart disease has been reduced. In our opinion, several factors explain the gap between the favorable results of clinical trials and the lack of significant reduction in morbidity and mortality in clinical practice: A) the selection criteria utilized in clinical studies exclude, for the most part, patients present in general population; B) the average age of the patients included (60 years) is not representative of the overall population; C) patients with associated co-morbidity are generally excluded; D) the number of women enrolled in the trials is quite low; E) compliance is certainly better in the trials than in clinical practice; F) higher drug dosages are used in the trials than in clinical practice. To intervene in these areas and thus make the positive results obtained in the trials available to the general population is, in our opinion, the principal challenge of the future. For this task, the close collaboration and commitment of the internist, the geriatrist, the cardiologist and the family doctors is necessary so that the results reported in clinical trials may be translated into general medical practice.

Aged↗
PubMed1998

The changing use of esophageal manometry in clinical practice.

OBJECTIVE: Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987-1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes. METHODS: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study. RESULTS: Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44; p < 0.0001), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3; p < 0.05; odds ratio, 13.7; p < 0.0001, respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63; p = 0.0001), whereas hypomotility disorders increased (odds ratio, 1.6; p < 0.01). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58; p < 0.0001); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable. CONCLUSIONS: These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.

Adult↗
PubMed1993

Empathy: an essential skill for understanding the physician-patient relationship in clinical practice.

In clinical practice, empathy is the skill used by physicians to decipher and respond to thoughts and feelings in the physician-patient relationship. Empathetic understanding and empathetic response occur in three phases of every office visit: the negotiation phase, the clinical reasoning phase, and the establishment of therapeutic alliance. Masters of empathetic skills is difficult, and before teaching empathy to residents and students, teachers must first develop their own empathetic skills. Development of empathetic skills can occur in Balint training programs, through the use of audio- or videotaped patient encounters, or through one-on-one training with an experienced preceptor.

Adolescent↗
PubMed1998

Use of medical informatics to implement and develop clinical practice guidelines.

Clinical practice guidelines have enormous potential to improve the quality of and accountability in health care. Making the most of this potential should become easier as guideline developers integrate guidelines within information systems and electronic medical records. A major barrier to such integration is the lack of computing infrastructure in many clinical settings. To successfully implement guidelines in information systems, developers must create more specific recommendations than those that have been required for traditional guidelines. Using reusable software components to create guidelines can make the development of protocols faster and less expensive. In addition, using decision models to produce guidelines enables developers to structure guideline problems systematically, to prioritize information acquisition, to develop site-specific guidelines, and to evaluate the cost-effectiveness of the explicit incorporation of patient preferences into guideline recommendations. Ongoing research provides a foundation for the use of guideline development tools that can help developers tailor guidelines appropriately to their practice settings. This article explores how medical informatics can help clinicians find, use, and create practice guidelines.

Decision Trees↗
PubMed2003

Quality of life and HIV: current assessment tools and future directions for clinical practice.

Routine clinical assessment of health-related quality of life in persons with HIV infection has the potential to improve care by assessing and monitoring treatment effects, enhancing communication between patient and provider, and tracking changes in functional status over time. Currently available research-based assessment tools may be inadequate for routine clinical use because of the lack of inclusion of HIV-relevant aspects of quality of life and the impracticality of the use of such tools in the clinical setting. There may be a need for a new, clinically relevant, HIV-specific assessment tool that would be easy to incorporate into clinical practice to briefly, yet comprehensively, assess characteristics frequently found in HIV-infected persons, such as fatigue, pain, nausea and vomiting, sleep disturbances, sexual dysfunction, and body image issues. Until such a tool is developed, the Linear Analogue Self-Assessment questionnaire and the Medical Outcomes Study Short Form-12 (MOS SF-12) are short enough for routine use in a clinical setting. Slightly longer measures, such as the MOS-HIV Health Survey (MOS-HIV), can provide information in a greater number of domains.

Activities of Daily Living↗
PubMed2005

Curvature affects Doppler investigation of vessels: implications for clinical practice.

In clinical practice, blood velocity estimations from Doppler examination of curved vascular segments are normally different from those of nearby straight segments. The observed "accelerations," sometimes considered as a sort of stochastic disturbances, can actually be related to very specific physical effects due to vessel curvature (i.e., the development of nonaxial velocity [NAV] components) and the spreading of the axial velocity direction in the Doppler sample volume with respect to the insonation axis. The relevant phenomena and their dependence on the radius of curvature of the vessels and on the insonation angle are investigated with a beam-vessel geometry as close as possible to clinical setting, with the simplifying assumptions of steady flow, mild vessel curvature, uniform ultrasonic beam and complete vessel insonation. The insonation angles that minimize the errors are provided on the basis of the study results.

Algorithms↗
PubMed2002

Appropriate analysis and presentation of data is a must for good clinical practice.

Good Clinical Practice (GCP) is defined as an international ethical and scientific quality standard for designing, conducting, monitoring, auditing, analyzing and reporting trials that involve the participation of human subjects. This paper focuses mainly on the issues that need attention at the time of statistical analysis and reporting of results. Findings from a review of published articles in Turkey are also presented. The types of variables, the distributions of variables, the number of groups compared, the dependency structure among these groups and the primary goal of the analysis determine the appropriate method to be selected for the statistical analysis. The review of a stratified sample of research articles from 60 journals published in 1992 in Turkey revealed that in 56% of the cases the statistical methods were improper or inadequate. In 15% of the articles the authors failed to select an appropriate design for the proposed aim mentioned in the manuscript. Despite the recent improvements, the necessity and the value of performing and presenting research according to the international standards remains to be assimilated better by Turkish investigators.

Clinical Trials as Topic↗
PubMed1997

Clinical practice guidelines.

Clinical practice guidelines are becoming an important determinant of how we practice medicine and surgery. They are the strategy of our federal agencies to reduce variability in care, improve quality, measure outcomes, and reduce costs. The payors and entrepreneurs of medicine have endorsed the use of practice guidelines as the most efficacious way to manage costs, and variability. This economic force alone will perpetuate their development in the foreseeable future. It could be tempting to recoil from these pressures that may seem outside the realm of the individual surgeon trying to do the best for the individual patient. However, when viewed as a way to work with our colleagues and use scientific evidence and expert opinion to achieve consensus about best practice, this effort is very much in line with the way we practice surgery. The surgical community should not be concerned with participating but, in fact, should lead. The surgical tradition with outcomes assessment-the Morbidity and Mortality Conference-is a fundamental principle used to improve care. The process of practice guideline development is designed to do the same to continuously improve care.

General Surgery↗
PubMed2000

Consensual validation of clinical practice model practice guidelines.

Clinical Practice Model (CPM) Practice Guidelines facilitate the delivery of consistent, high-quality patient care by clarifying nursing services and supporting the practice and documentation of each step of the nursing process. CPM Practice Guidelines are unique because they are part of an integrated interactive systems thinking framework to support professional practice; they are reviewed and improved routinely using multiple sources of data and are used by hundreds of nurses daily throughout the United States and Canada. Guidelines are developed using a rigorous standardized format and process. Consensual validation is an important part of establishing and maintaining the credibility of these Guidelines.

Humans↗