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Feasibility of bimanual microincision phacoemulsification in hard cataracts.

PURPOSE: The purpose of this work was to assess the feasibility of bimanual phacoemulsification in hard cataracts of N3+ using WhiteStar technology of Soveriegn (Advanced Medical Optics, Santa Ana, CA, USA). SETTING: Ain-Shams University Hospitals, Ophthalmology Department, Cairo, Egypt. DESIGN: A randomized prospective noncomparative study. METHODS: A randomized prospective study of 33 consecutive cases (N3+ or more) was conducted, phacoemulsification using a bimanual microincision technique using the Sovereign with WhiteStar technology phacoemulsification machine. One phaco mode was used in all eyes. The ultrasound power was set at 30-25% according to the hardness of the nuclei, duty cycle of 33%, flow rate of 20-28 cm3/min, and vacuum of 240 mmHg. Occlusion mode was on. Nine eyes received rollable intraocular lenses (IOL) of ThinOptx, whereas 24 eyes had been implanted with hydrophobic acrylic foldable IOL (Sensar OptiEdge SA40e of AMO) through a third incision. Study parameters were effective phacotime (EPT), presence of wound burn, degree of immediate postoperative iritis, amount of infusion solution used, and total operating time. RESULTS: The mean EPT was 4.3 s with an average ultrasound used of 5.7%. The mean operating time was 11 min and 20 s. Although the nuclear hardness was of grade 3 or above (in a scale of 5), there were no cases of thermal burn; P=0.005. Only three eyes suffered postoperative iritis 2+, which resolved within 1 week on topical steroids, statistically nonsignificant, P=0.2. The amount of infusion solution was less than that used in conventional coaxial phaco. This technique induced considerably less corneal astigmatism than surgery using conventional corneal incisions. CONCLUSIONS: Hard cataracts of N3 or more could be safely removed through an incision of 1.4 mm incision using bimanual micro-phaco.

Aged↗

VIEWPOINT.

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Biometry↗

Attrition among adolescents and infants involved in a parenting intervention.

Attrition was assessed in a randomized trial of a parenting intervention programme for adolescent mothers and their infants. Infants who were admitted to the neonatal intensive care unit, mothers who had partner difficulties, and mothers and infants who were visited for less than 60 min a week on average (typically in the control group) were more likely to miss one of the two follow-up visits.

Adolescent↗

Does a trial on the effects of ventilation tubes influence clinical practice?

A survey was performed to study the implementation of the results of a clinical trial on the effect of ventilation tubes on daily clinical practice. Two random samples of 75 Dutch otorhinolaryngologists each were drawn: one before the conduction of the trial and another after the results were disseminated. In both surveys participants were asked to give their personal estimate of the probability of complete recovery without treatment and after the insertion of ventilation tubes in an infant with bilateral otitis media with effusion. The trial showed no long lasting effects of ventilation tubes on hearing, language development and quality of life, yet, the overall expectation with respect to the effect of ventilation tubes remained high. The study suggests that the adoption of research results require more than simple dissemination of the results. (Inter)national debate is recommended to value the results of clinical trials for daily practice.

Attitude of Health Personnel↗

Impact of patient information booklet on treatment decision--a randomized trial among women with heavy menstruation.

OBJECTIVE: Does a patient information booklet influence treatment for menorrhagia? DESIGN: Randomized trial and a pre-trial prospective cohort study. SETTING: Gynaecology outpatient clinics in 14 Finnish hospitals. PARTICIPANTS: A total of 363 (randomized trial) plus 206 (cohort study) patients with menorrhagia. INTERVENTION: An information booklet about menorrhagia and treatment options, mailed before the first visit to the outpatient clinic. MAIN OUTCOME MEASURES: Distribution of treatment modalities, knowledge about treatment options, satisfaction with communication with personnel and anxiety. RESULTS: Treatment decision within 3 months was made more often in the intervention group than in the control group (96% and 89% respectively, P = 0.02). Oral medication was more frequently chosen, and newly introduced treatments (minor surgery, hormonal intrauterine system) were less frequently used in the intervention group (at 3-month follow-up 21% and 29%, respectively). The differences persisted at the 12-month follow-up. In the pre-trial group, new treatment methods were less frequently chosen and used than in the control group. Additional information did not increase the number of surgical procedures used, improve knowledge, or influence satisfaction or anxiety. CONCLUSIONS: Additional information led to an increase in specific treatment decisions and changed the distribution of used treatments without increasing the number of surgical procedures. The study suggests that well-informed women adopting an active role may counteract physicians' emphasis on newly introduced treatments.

Adult↗

Threshold measurements: ten rules for good measuring practice.

The following rules for professionally measuring thresholds are derived and discussed: RULE 1: Thresholds should be expressed as voltage averaged over pulse duration to get reproducible and comparable results! RULE 2: Pacing threshold measurements with exponentially decaying pulses should not be extended beyond 1.4 ms as that portion of the pulse below rheobase does not contribute to the stimulation effect! RULE 3: Threshold measurements are best carried out with fixed pulse duration and variable voltage! RULE 4: If threshold measurements are carried out in discrete steps, the steps should be chosen such that the relative step size is as equal as possible! RULE 5: Accuracy of threshold measurements is highly increased if the arithmetically averaged value of the last effective and the first ineffective pulse is defined as threshold! RULE 6: To determine strength-duration-curves, a linear regression of the quantity versus pulse duration should be calculated which yields simply the numerical values of the chronaxie and rheobase! RULE 7: To reach representative strength-duration-curves, measurements with at least four pairs of values must be carried out! RULE 8: Measuring defibrillation thresholds, the relative voltage step size should be chosen equally to have equal accuracy for all steps. RULE 9: If the result of a defibrillation threshold investigation does not reach significance, a too large voltage step size could be an explanation! RULE 10: Comparing intraindividually the threshold of two different defibrillation systems or parameter settings, the threshold ratios should be formed and averaged! Obeying these rules guaranties professional threshold measurements expressed as "rheobase" and "chronaxie" even with devices with discrete steps in parameter programming.

Cardiac Pacing, Artificial↗

Practical methods to increase use of advance medical directives.

OBJECTIVE: To compare the effectiveness of two means for increasing the use of advance medical directives: written materials only versus written materials and an educational videotape. DESIGN: Population-based, randomized controlled trial with 3-month follow up. SETTING: Kaiser Permanente Colorado Region, a not-for-profit group-model health maintenance organization. PARTICIPANTS: A population-based sample of all 1,302 members aged 75 years and older who used the Franklin Medical Office, excluding 55 persons who died or disenrolled during the study period or were identified by their physicians as blind or cognitively impaired. INTERVENTIONS: All subjects were mailed a 10-page cartoon-illustrated educational pamphlet on patient choices, a selection of Colorado advance medical directive forms, and a guide to their completion; 619 subjects also were mailed a 20-minute videotape on advance directives. Both groups had access to a study nurse for assistance in completing and placing advance medical directives. MEASUREMENTS AND MAIN RESULTS: The main outcome measure is the proportion of subjects who placed a directive in their medical record for the first time. Placement rates increased almost identically, from 21.2% to 35.0% in the written materials-only group and from 18.9% to 32.6% in the group receiving the videotape (95% confidence interval for difference -0.04, 0.04, p =.952). CONCLUSIONS: In an elderly population with a substantial baseline placement rate, mailing of written materials substantially increased placement of an advance directive in the medical record, but the addition of a videotape did not. Mailing the video did increase the use of treatment trials and made patients more aware of reasons not to use advance directives.

Advance Directives↗

Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia.

OBJECTIVES: To compare two strategies for implementing guidelines for nursing home-acquired pneumonia (NHAP) and to measure outcomes associated with treatment in accordance with the guidelines. DESIGN: Randomized controlled trial. SETTING: Ten skilled nursing facilities (SNFs) from a single metropolitan area. PARTICIPANTS: Patients with an episode of pneumonia acquired more than 3 days after admission to SNF (N = 350): 226 preintervention episodes of pneumonia and 116 postintervention episodes. INTERVENTIONS: Multi-faceted education intervention including small-group consensus process limited to physicians and a similar intervention that included physicians and nurses within randomly selected SNFs. MEASUREMENTS: Antibiotic use at diagnosis compared with the guidelines, hospital admission, severity of pneumonia, and 30-day mortality. RESULTS: Data were complete for 344 episodes of NHAP. For the preintervention group (n = 226), 62.2% (79/127) of the episodes were treated with parenteral antibiotics (PA) when PA were recommended by the guidelines and 57.6% (57/99) of episodes were treated with oral antibiotics (OA) when OA were indicated by the guidelines. Postintervention, treatment with PA and OA according to the guidelines was not significantly different between the two groups of randomized SNFs. A multivariate analysis comparing PA use pre- and postintervention for all SNFs, adjusted for variation in the frequency and severity of pneumonia, found significantly more of the postintervention episodes were treated with PA in accordance with the guidelines (P < .02). A preintervention significant difference in 30-day mortality observed between episodes with indications for PA (37.8% (48/127)) and episodes with indications for OA (6.1% (6/99)) (P < .001) was not present postintervention (11.5% (6/52); (23.8% (15/64); P = .06). There was no significant difference in 30-day mortality preintervention and postintervention for episodes with guideline indications for OA (P = .35) or for PA (P = .05) (P = .16 for multivariate analysis). The difference in PA use was not associated with significant differences in hospital admissions for episodes on NHAP. CONCLUSION: The increase in the use of PA provides evidence that care within SNFs can be significantly changed using standard quality improvement techniques. Use of the guidelines did not significantly affect mortality. The addition of a practical severity of NHAP model or a change in reimbursement structure may enhance the guidelines' impact on hospitalization for NHAP. The financial benefits available with use of the guidelines will be limited unless the guidelines contribute to a reduction in rates of hospitalization.

Administration, Oral↗

[Meta-analysis].

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Clinical Trials as Topic↗

Time lapse between hypothesis and publication in the medical sciences.

We studied a number of factors involved in the publication of 103 papers by Mayo Clinic authors. Basic-science and clinical-research articles averaged about four years from initiating the research idea until publishing; case reports averaged about two years, and literature reviews three years. Of this time, 75 per cent was spent contemplating the basic idea, performing the research, and writing the paper. The rest was required for processing, from institutional editing through publication. Most clinical workers wrote at home, and most basic researchers at the office. In a suprising 23 per cent of papers, about three fourths of the manuscript was written by someone other than the first author. Of references cited, between 10 per cent and 20 per cent were to the authors' own work or to that of co-workers. Half the papers were revised or rejected at least once, prolonging the journal handling time only in papers rejected or requiring more than one revision.

Authorship↗