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PubMed2004

Recommended guidelines for the treatment of cancer treatment-induced diarrhea.

PURPOSE: To update and expand on previously published clinical practice guidelines for the treatment of cancer treatment-induced diarrhea. METHODS: An expert multidisciplinary panel was convened to review the recent literature and discuss recommendations for updating the practice guidelines previously published by this group in the Journal of Clinical Oncology in 1998. MEDLINE searches were performed and the relevant literature published since 1998 was reviewed by all panel members. The treatment recommendations and algorithm were revised by panel consensus. RESULTS: A recent review of early toxic deaths occurring in two National Cancer Institute-sponsored cooperative group trials of irinotecan plus high-dose fluorouracil and leucovorin for advanced colorectal cancer has led to the recognition of a life-threatening gastrointestinal syndrome and highlighted the need for vigilant monitoring and aggressive therapy for this serious complication. Loperamide remains the standard therapy for uncomplicated cases. However, the revised guidelines reflect the need for recognition of the early warning signs of complicated cases of diarrhea and the need for early and aggressive management, including the addition of antibiotics. Management of radiation-induced diarrhea is similar but may not require hospitalization, and chronic low- to intermediate-grade symptoms can be managed with continued loperamide. CONCLUSION: With vigilant monitoring and aggressive therapy for cancer treatment-induced diarrhea, particularly in patients with early warning signs of severe complications, morbidity and mortality may be reduced.

Algorithms↗
PubMed1996

Normal mammograms and the practice of obtaining previous mammograms: usefulness and costs.

PURPOSE: To determine the usefulness and cost of acquiring and comparing mammograms previously obtained at a different facility with normal mammograms. MATERIALS AND METHODS: Comparison mammographic reports obtained within 52 months in 1,297 consecutive women (aged 33-82 years; mean age, 53 years) were retrospectively reviewed. Mammograms in which a normal interpretation was altered after comparison were reviewed. The clinical importance and the cost of obtaining previous mammograms were determined. RESULTS: Initially, interpretation was normal in 756 (58%) comparison mammograms and abnormal in 541 (42%). Of the 756 normal mammograms, 197 (26%) were not compared with previous mammograms. Of the remaining 559, 551 (98%) had no change. In eight of the 559 (1%), the original interpretation was altered. Seven of these eight mammograms were available for review: In one, a developing density was detected; in three, differences were attributable to technique; and in three, radiologists had different interpretations. No malignancies were detected. The average labor and postage cost was $21.49. CONCLUSION: Considering the cost and low diagnostic yield, obtaining previous mammograms is of limited usefulness.

Adult↗
PubMed1980

Oral rehydration of infants with acute diarrhoeal dehydration: a practical method.

Previous studies demonstrated the efficacy of oral glucose/electrolytes solution (GES) in rehydration of moderately dehydrated infants; the importance of providing one volume (200 ml) of solute-free water for every two volumes (400 ml) of GES ingested was also stressed. In this study we investigated a variation of our previous method intended to make it simpler and more practical. The entire calculated volume of GES was administered as rapidly as possible followed by a volume of free water equal to one-half the volume of GES ingested. In total 50 children (25 girls), aged 10 days to 24 months, with diarrhoeal dehydration were studied; the mean degree of dehydration was 7.2% of body weight. Hypernatraemia present on admission was corrected within a few hours, as was severe metabolic acidosis. Vomiting rapidly diminished or disappeared following onset of therapy and the mean rate of ingestion of fluids was high, 28 ml/kg/h, allowing for rapid rehydration; the mean time required for rehydration was 7.9 h (range 2.3-17). The described method offers simplicity and practicality, while still providing free water to correct or prevent hypernatraemia.

Acute Disease↗
PubMed1992

A sensorimotor basis for motor learning: evidence indicating specificity of practice.

Our previous work (Proteau, Marteniuk, Girouard, & Dugas, 1987) was concerned with determining whether with relatively extensive practice on a movement aiming task, as the skill theoretically starts becoming open-loop, there would be evidence for a decreasing emphasis on visual feedback for motor control. We eliminated vision of the moving limb after moderate and extensive practice and found that the movement became more dependent on this feedback with greater amounts of practice. In the present study, we wished to test the hypothesis, developed from our previous work, that at the base of movement learning is a sensorimotor representation that consists of integrated information from central processes and sensory feedback derived from previous experiences on the movement task. A strong test of this hypothesis would be the prediction that for an aiming task, the addition of vision, after moderate and relatively extensive practice without vision, would lead to an increasingly large movement decrement, relative to appropriate controls. We found good support for this prediction. From these and our previous results, and the idea of the sensorimotor representation underlying learning, we develop the idea that learning is specific to the conditions that prevail during skill acquisition. This has implications for the ideas of the generalized motor program and schema theory.

Feedback↗
PubMed2003

[Self-reported level of skills in practical procedures following internship in general practice].

BACKGROUND: Previous reports have demonstrated variable and partly insufficient skills in standard practical procedures among young doctors who have served their internship. The present study examines the development of interns' self-reported level of skills in practical procedures during internship in general practice in relation to quantity and quality of supervision, gender and the size of the community they served in. MATERIAL AND METHODS: Between 1996 and 1999, all doctors going through internships in Norway were asked to indicate their level of skills in 88 practical clinical procedures before and after internship in general practice. Of 575 interns asked, 439 replied (76 %). RESULTS: All interns reported a significant overall improvement in self-reported practical skills during internship in general practice. Supervision and feedback was also significantly better in general practice than in internships in hospital. INTERPRETATION: The quality of the general practice internship in Norway is superior to the quality of hospital training. Supervision and feedback is a standard part of the education of general practitioners and represents a valuable tradition. A combination of internship in hospitals and in general practice is necessary for acquiring adequate skills in practical procedures.

Adult↗
PubMed2005

The treatment of common mental health problems in general practice.

BACKGROUND: Previous studies report GPs under-treat mental health disorders, particularly depression, and treatments are non-specific and lack an evidence base. They conclude further training and education of GP's is required. OBJECTIVE: To describe the treatment of common mental health disorders in relation to the level and severity of psychological problems as defined by the GP and external assessment. METHODS: Cross sectional survey of General Practice attenders in New Zealand. Fifty consecutive adult patients were recruited from each practice of 70 randomly selected GP's. The psychological status of 773 respondents selected via the General Health Questionnaire (GHQ) was assessed, and details of management provided. Management options were compared with the level of psychological problem identified by the GP. RESULTS: Treatment varied depending on the level of problem identification, and frequency of consultation, from 93% given treatment when an explicit diagnosis was made to 22.3% in patients with subclinical symptoms. The most commonly given treatment with an explicit diagnosis was psychotropic medication [73% (95% CI 63.6-82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1-24.2)]. Only 1.7% (0.3-3.0) of patients with subclinical symptoms received psychotropics. CONCLUSION: There is a clear association between the level of psychological problem identified and treatment. In contrast to previous views that treatment often appears to be given regardless of diagnosis, these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than previously described.

Adult↗
PubMed2004

A model for increasing senior dental student production using private practice principles.

Previous dental graduates have reported a lack of confidence in their ability to implement business practices upon graduation. The purpose of the new model was to enable senior students to gain experience using sound business principles in their senior year. This model involves setting and meeting production goals, teamwork, personnel evaluation, and performance incentives. This article reports the findings after implementing this model in the academic year 2003-04. Each student averaged 226 more charged visits than in 2002-03. Total dollars produced increased $7,526 per student, which represented a 63 percent increase in production over the previous year. Total dollars produced by the senior class increased from $713,740 to $1,066,139 over the previous year. A survey of the students' attitudes toward the model showed an increase in acceptance from the beginning of the senior year to the end of the year. The model was successful in achieving most of the desired outcomes but failed to increase seniors' chairtime utilization.

Attitude of Health Personnel↗
PubMed2003

Sustained increases in productivity with maintenance of quality in an academic anesthesia practice.

UNLABELLED: Previously, the authors reported trends in anesthesia quality and productivity in a university-based anesthesia practice as it responded to increasing service demands with shortages of qualified staff and decreasing reimbursement. From 1992 to 1997, productivity increased, with a significant decrease in patient injury. In this study, we analyzed whether previous productivity and quality gains were sustained from 1998 to 2000 despite continued staff shortages. Productivity, caseload, and outcome data were abstracted from departmental administrative and quality-improvement reports. Retrospective cohort analysis compared trends during 3 yr of moderate productivity (1994-1996) with those during 3 yr of high productivity (1998-2000). The mean monthly productivity in 1998-2000 (15 +/- 0.6 billed hours per attending per clinical day) was larger than levels from 1994 to 1996 (mean, 14 +/- 0.7 h; P < 0.01). The overall continuous quality improvement report rate was slower at larger productivity levels, as were rates of patient injuries. When adjusted for declining report rates, patient injury rates showed no change between smaller- and larger-productivity years. Adjusted rates of operational inefficiencies and human errors were more frequent at larger productivity levels. Although the pressures of increased demands, shrinking resources, and shortages of qualified academic anesthesiologists have not abated, productivity and quality have been sustained. Future management must be directed toward reductions in operational inefficiencies and human error. IMPLICATIONS: Our academic anesthesia service sustained increases in productivity with maintenance of quality. During a 3-yr period of high productivity, patient injury rates did not increase compared with prior years with lower productivity.

Anesthesiology↗
PubMed2000

Immunization levels and risk factors for low immunization coverage among private practices.

OBJECTIVES: Previous studies have indicated that provider characteristics are an important determinant of immunization coverage. The objectives of this study were to: 1) assess immunization coverage levels among 2-year-old children receiving care in private practices in 3 California counties; and 2) evaluate practice and patient risk factors for low immunization coverage. STUDY DESIGN: Cross-sectional chart review of immunization histories and provider survey of immunization policies. SETTING: Forty-five randomly selected, private medical practices in 3 counties in California. PATIENTS: Children 12 to 35 months old, followed by the participating practices. METHODS: Providers underwent a detailed assessment of their immunization coverage and completed a questionnaire describing their immunization policies and procedures. Immunization data were abstracted from randomly selected medical charts of children 12 to 35 months old. Only patients who met the criteria for active status (>/=2 visits and >/=1 visit during the preceding 18 months) were included in analyses. Immunization coverage levels were calculated and logistic regression was used to estimate the risk of underimmunization associated with different practice and child characteristics. RESULTS: Of the 72 eligible practices that were contacted, 45 participated in the study, yielding a participation rate of 62%. The median immunization coverage of participating offices was 54% (range: 0%-91%). Multivariate analysis revealed 5 independent risk factors for underimmunization. The strongest predictors were having fewer than 50% active children in the practice and children having fewer than 8 visits to the provider. Other significant predictors were the percentage of patients in the practice on Medicaid, administering diphtheria-tetanus-pertussis 4 at a separate visit from the Haemophilus influenzae type b booster, and practice location. CONCLUSIONS: These data provide new insights into immunization practices in an important clinical setting that has been poorly characterized previously. Immunization coverage levels were found to be low and significant risk factors for underimmunization were identified. Recommendations are made for immunization policy changes and targeting of immunization improvement interventions at practices that may be at risk for low immunization coverage. immunization, vaccination, immunization programs, primary prevention, private practice, child, preschool, pediatrics, family practice.

California↗
PubMedDate not supplied

Maintaining food sufficiency: Coping strategies identified by limited-resource individuals versus nutrition educators.

OBJECTIVE: This study's purposes were to identify food acquisition and management coping strategies used by limited-resource individuals to maintain food sufficiency, compare strategies named by the target audience to those previously identified by nutrition educators, and examine these strategies to advance grounded theory. DESIGN: Eleven focus groups, conducted with 62 limited-resource individuals, elucidated coping strategies that they or others they knew used to acquire or manage food to maintain food sufficiency. The results were compared with practices as previously identified by nutrition educators who regularly worked with this audience. SUBJECTS/SETTINGS: Subjects aged 19 to 67 from throughout New Jersey were recruited by Food Stamp agencies, low-income outreach programs, soup kitchens, welfare offices, Head Start centers, shelters, and food pantries. RESULTS: Of the 95 coping strategies identified, 83% were known from nutrition educators previously. Ten new practices (eg, selling blood) had not previously been identified by educators. Four of 10 practices were not found in the literature (eg, repeated participation in research studies). Six practices previously reported by nutrition educators were not mentioned by the study population. IMPLICATIONS: Educators who work with limited-resource individuals are a good resource for research with this audience. Study findings may be important considerations for nutrition program planning and policy making.

Adaptation, Psychological↗
PubMedDate not supplied

Instructing adolescents with learning disabilities: converting a meta-analysis to practice.

A previous meta-analysis indicated that eight instructional factors--Questioning, Sequencing and Segmentation, Skill Modeling, Organization and Explicit Practice, Small-Group Setting, Indirect Teacher Activities (e.g., homework), Technology, and Scaffolding-captured the majority of successful intervention programs for adolescents with learning disabilities (LD). Most important was the Organization/Explicit factor, which contributed significant variance (16%) to effect size. This factor included two important instructional components: advance organization and explicit practice. In this article, we convert these findings into practical guidelines to direct instructional practice.

Adolescent↗
PubMed2001

Funding new cancer drugs in Ontario: closing the loop in the practice guidelines development cycle.

PURPOSE: The previously described practice guidelines development cycle follows an iterative model in which recommendations are reached by a process that incorporates practitioners at all phases. A key feature is the separation of the evidence-based systematic review and the generation of recommendations from policy decisions surrounding implementation. This article describes how this implementation phase has evolved in Ontario and how implementation has affected the guidelines process. METHODS: The development of the New Drug Funding Program in Ontario and the appointment of a policy advisory committee (PAC) to make funding recommendations were reviewed. The decision-making framework of the PAC is described in this article. RESULTS: The PAC has had to address a number of issues in making funding recommendations. These issues have included dealing with evidence arising solely from phase II versus phase III trials, using economic information, and involving community representatives in its deliberations. Its activities have had a substantial impact on the practice guidelines initiative. CONCLUSION: It is possible to integrate an evidence-based, practitioner-driven approach to clinical guideline development with a funding program that takes policy considerations into account. However, even though these two roles are conceptually separate, the needs of the funding program have inevitably had an impact on the guidelines process.

Antineoplastic Agents↗
PubMed1996

A field trial of the NASA Telemedicine Instrument Pack in a family practice.

BACKGROUND: Previous studies of telemedicine applications have demonstrated that the technology is effective but inefficient. Little attention has been directed to the primary care portion of the connection, especially the use of the medical peripheral devices. This study used a telemedicine testbed that simulates a rural practice environment to describe the effectiveness and efficiency of the NASA Telemedicine Instrument Pack, a small self-contained system of medical peripheral devices. METHOD: This study was an 8-week field trial of a suitcase-sized pack containing a fundus camera, flexible nasopharyngoscope, dermatology macrolens, light source, and video monitor. The pack was first studied in specialty clinics and then was used in a family practice office connected to the consultant node by digital lines. Evaluations were obtained from technicians, patients, and consultants. RESULTS: During 20 video clinic sessions, 59 patients with 38 different diagnoses were examined. The ear, nose, and throat portion of the exam was effective, with some decrement in color and clarity with compression of the signal. The eye portion was marginally effective, limited by a field of view that was too narrow and also by rigorous technician requirements. The skin exam was largely unacceptable primarily because the macrolens did not meet the requirements for color or clarity prior to compression of the signal. CONCLUSIONS: Subsequent design efforts for medical peripheral devices for telemedicine use will require significant modifications to "off the shelf" equipment to be effective and efficient. A family practice telemedicine testbed provides the appropriate environment for such field trials.

Attitude of Health Personnel↗
PubMed1994

Case mix and content of trainee consultations: findings from the north of England study of standards and performance in general practice.

BACKGROUND: Previous studies have examined the differences in the work of trainees and trainers. However, they have not investigated how many of these differences are due to differences in the case mix seen by trainees. AIM: A study was undertaken to investigate the effect of case mix on the content of consultations with trainee general practitioners. METHOD: Details of surgery consultations with 207 trainee general practitioners and 255 principals in 62 training practices in the north of England were prospectively recorded during one week in each of four consecutive years. RESULTS: Trainee general practitioners saw a higher proportion of younger patients and those categorized as suffering from an acute minor condition compared with principals. They saw a lower proportion of patients categorized as suffering from chronic intermediate, chronic major and female conditions. The reported content of trainee and principal consultations differed over all four years in that trainees examined more patients, issued more new prescriptions, issued fewer repeat prescriptions, arranged fewer return appointments and referred fewer patients. However, adjusting for case mix reduced the number of significant differences between trainees and principals to two: trainees issued fewer repeat prescriptions and had more consultations lasting longer than nine minutes. CONCLUSION: The case mix and content of consultations differ between trainees and principals and some of the differences in content are due to the differences in case mix; trainees generally behave more like principals than has been previously suggested. Thus, case mix is an important factor in understanding the content of trainee consultations.

Diagnosis-Related Groups↗
PubMed1994

Comparison of an ephedrine/caffeine combination and dexfenfluramine in the treatment of obesity. A double-blind multi-centre trial in general practice.

In previous separate studies, dexfenfluramine (DF) and ephedrine/caffeine (EC) have been shown to promote weight loss in obese patients as compared with placebo. In order to compare the efficacy and safety of these two anorectic drugs, 103 patients with 20-80% overweight were included in a 15-week double-blind study in general practice. Patients were randomized to either 15 mg DF twice daily (n = 53), or 20 mg/200 mg ephedrine/caffeine three times a day (n = 50), supplementary to a 5 MJ/day diet. Forty-three patients from the DF group and 38 from the EC group completed the study. After 15 weeks of treatment, the DF group (n = 43) had lost 6.9 +/- 4.3 kg and the EC group (n = 38) had lost 8.3 +/- 5.2 kg (mean +/- s.d., P = 0.12). In the subgroup of patients with BMI > or = 30 kg/m2 (n = 59), the mean weight loss was 7.0 +/- 4.2 kg in the DF group (n = 29) and 9.0 +/- 5.3 kg in the EC group (n = 30), P < 0.05. Both systolic and diastolic blood pressures were reduced similarly during both treatments. Twenty-three patients in the DF group (43%) and 27 in the EC group (54%) complained of side-effects. Central nervous system side-effects, especially agitation, were more pronounced in the EC group (P < 0.05), whereas gastro-intestinal symptoms were more frequent in the DF group (P < 0.05). The side-effects declined markedly during the first month of treatment in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗