Effective headache management. Strategies to help patients gain control over pain

A general guideline to successful treatment of headache focuses on a diagnosis that satisfies both physician and patient. Thorough history taking, patient and family education, aggressive approaches, and careful follow-up help patients reach therapeutic goals. Successful long-term therapy for headache enables patients to gain control over their symptoms with a combination of carefully selected medications and nonpharmacologic approaches.     

Family pharmacy and family medicine: a viable private practice alliance

The association of the new roles of the family physician and the family pharmacist in a model private practice is described. The pharmacist works closely with the family physician to offer personalized patient education and follow-up for therapeutic effectiveness. He also serves as a consultant to the physician for up-to-date drug information and assists in solving difficult therapeutic problems. Reimbursement for pharmacy services occurs for consultative time as well as by traditional methods. Initial response by the professionals themselves as well as the patients and staff has been very positive. An appropriate physical plant and ongoing communication between physician and pharmacist are mandatory for the success of this model. Some specifics of this practice at its present stage of development are included.     

Causes and treatment of bone pain of malignant origin

Pain relief has been one of the oldest and most important duties of the physician. There has been little change with regard to this obligation of all caregivers. One-third of patients with advanced cancer will develop clinically relevant skeletal metastases and chronic pain during the course of their disease. All physicians involved in the treatment of cancer patients should know the basic principles of pain treatment. These are described in the following article with special regard to bone pain of malignant origin. Correct assessment of pain intensity and frequency, as well as of the probable causes of pain, and the administration of adequate analgesic treatment should achieve satisfactory results in the vast majority of patients. Every physician should obtain detailed knowledge of the indications and adequate administration of pain-killing therapy as well as possible adverse effects and their successful treatment. It is important in particular to concentrate on a few nonsteroidal anti-inflammatory drugs (NSAIDs) as well as opiates. Knowledge of adequate doses, maximal recommended daily doses, pharmacological properties, important adverse effects and interactions is essential for success in the daily routine. Only by selecting 2 or 3 drugs from each step in the analgesic ladder (WHO) will the nonspecialised physician obtain sufficient experience for optimal analgesia. Physicians should also not hesitate to contact other specialists (medical oncologists, radiotherapists, neurosurgeons, anaesthesiologists and others) in order to maximise benefit for an individual patient.     

Treatment of progressive metastatic prostate cancer

The optimal therapy for metastatic prostate cancer that has failed initial hormonal therapy poses a significant dilemma for the attending physician. No salvage therapy has proven to be clearly superior. Currently accepted treatment options range from supportive care alone to highly investigational regimens. Recent encouraging results have been reported with investigational agents such as suramin and R. 75251 (Liarozole), and with novel combinations such as estramustine (Emcyt) plus vinblastine. However, there is still no proof that salvage therapy prolongs survival. In a patient population that is older and frequently debilitated, with an expected median survival of 6 months, determinants of therapy should include drug toxicity profiles, frequency of treatment and follow-up studies, and necessity for hospitalization. For patients with good performance status and organ function, participation in clinical trials should be advocated. Quality-of-life issues should be integrated into all clinical trials involving hormone-refractory metastatic prostate cancer.     

Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia

The failure of patients to adhere adequately to prescribed medication and behavioral regimens is an important medical problem. Poor adherence is most common when the treatment regimen is preventive rather than curative, when patients are asymptomatic, and when the duration of treatment is long. For these reasons, adherence with dietary therapy for hypercholesterolemia is well recognized to be a significant clinical and research challenge. Medication adherence has been acknowledged to be a problem for those treatments with significant side effects, such as flushing and pruritus or the low palatability of bile acid sequestering agents. The availability of drugs that lack these effects has long been viewed as an important contribution to improving overall patient compliance. However, the literature on patient adherence with life-long treatment regimens that are simple and palatable (e.g., antihypertensives) suggests that while these improved treatments can enhance adherence, the overall rates of patient compliance still average only 50%. The fact that patients with heterozygous familial hypercholesterolemia are at high risk for early coronary artery disease and death if they fail to adhere to therapy is not sufficient to assure high rates of appropriate therapy over long periods of time, as demonstrated by the poor or erratic adherence commonly reported to treatments for other life-threatening diseases, such as advanced renal disease, hemophilia, and type I diabetes. The measurement of patient adherence to hypercholesterolemia therapy is often neglected in clinical practice and inadequate in hypercholesterolemia research.(ABSTRACT TRUNCATED AT 250 WORDS)     

The hospital treatment of alcoholism and drug addiction

Inpatient treatment of alcoholism is an option indicated by certain clinical criteria. The American Society of Addiction Medicine suggests four levels of care, and six assessment dimensions determine which level of care is indicated. An addiction medicine physician can consult with the primary care physician to recommend appropriate placement in difficult cases. Abstinence is a primary goal of treatment; for without abstinence, no other recovery will be possible. The remaining goals of recovery are detoxification, medical evaluation, stabilization of life-threatening emotional issues, education, identification of barriers to recovery, readjustment of behavior toward recovery, and orientation and membership in a self-help group. Successful family contributions can make the difference between success or failure of treatment goals; the role the family plays in recovery is discussed. Treatment for family members is important; the physical, emotional, and spiritual effects on family members can be just as profound on them as they are on the alcoholic. Continuing care maintains the link between the patient and the professional recovery community after discharge and is appropriate for all patients. Extended care allows for structured support of sobriety and often further progress through psychosocial issues identified during the initial treatment phase (i.e., abuse, molestation, unresolved grief). Extended care is indicated for patients requiring further structured assistance in early recovery. A large variety of treatment options are available once the decision has been made to hospitalize the patient.     

Prostaglandin E2 induction of labor for fetal demise

Intrauterine fetal demise is a source of anxiety to both patient and physician. Heretofore, the standard treatment was either careful observation until the patient went into labor or attempt at induction of labor with oxytocin. Unfortunately, oxytocin stimulation has not proven to be uniformly successful for this problem. Prostaglandin E2 suppositories have been shown to be effective in inducing uterine evacuation after intrauterine fetal demise. In the opinion of the authors, this approach will in the future replace the sometimes dangerous and emotionally laden convention of watchful delayed therapy.     

Prostate cancer: 6. Surgical treatment of localized disease

A 65-year-old man undergoes a routine checkup before retiring. His wife has urged him to have his prostate examined, because she has read about testing for prostate cancer and a friend has just died of this disease. During the rectal examination, the man's physician discovers some firmness in the right lobe of the prostate gland. The patient has had no urinary symptoms and is in excellent general health. Sexual function is normal. There is no history of prostate cancer; his father died of a stroke at age 86 years. Testing shows that the patient's prostate-specific antigen level is 9.3 ng/mL, and he is referred to a urologist. Transrectal ultrasound-guided needle biopsy reveals adenocarcinoma with a Gleason score of 7 (intermediate grade). At a follow-up meeting with his physician, the patient says, "I have been doing some research, and it appears that I should have treatment. However, what is less clear to me is what form of therapy is best--surgery or radiation treatment. Please tell me what you can about the state of the art with respect to surgery."     

Michael Balint and his conceptions of medical education of physicians for effectiveness in working with patients

The paper presents conception of the education of students and physicians in the Balint's group. The most important is the Balint's idea is to present fundamental relations between the physician and the patient. A therapeutic effect is the result of the very good understanding, confidence, tolerance, positive emotions between physician and patient. The Balint's group changes the physician's attitude, the relation to the patient is more intensive, there less fear is more intensive, there less fear and frustration. In the Balint's idea very important is an intensity and quality of the therapy. In the group with the leader, students and physicians learn to understand themselves in the emotional and intellectual areas.     

Effect of physician-recommended treatment on mental health practitioners' attributions for chronic fatigue syndrome.

Objective: To evaluate whether differing treatment recommendations for chronic fatigue syndrome (CFS) by physicians influence attributions about CFS among mental health practitioners. Participants and Study Design: 93 mental health practitioners were randomly assigned to 1 of 3 conditions. All groups read the same case study of a person diagnosed with CFS, with the only difference between groups being the type of treatment recommended by a physician. The treatment conditions included a drug trial (Ampligen) or 1 of 2 differing psychotherapy approaches, cognitive–behavior therapy with graded activity or cognitive coping skills therapy. Results: Ss in the 3 groups did not differ with respect to their prior familiarity with CFS. Ss who read the case study proposing treatment with Ampligen were more likely to report that the patient was correctly diagnosed and more likely to perceive the patient as disabled than those whose case study described cognitive–behavioral therapy with graded activity as the treatment. Conclusion: Results of this investigation support the hypothesis that physician recommendations for CFS treatment can influence subsequent attributions about a patient's illness among mental health practitioners. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Features, prevention and management of acute overdose due to antidiabetic drugs

Hypoglycaemic medication forms a disparate group of therapeutic compounds including insulin, the sulphonylureas and biguanides. They are all designed to prevent hyperglycaemia and in general are well tolerated. Careful prescribing practice and patient education by the physician can do much to reduce the risk of adverse effects from diabetic therapy. However, the presentation of adverse effects, together with accidental and non-accidental overdose, is a frequent clinical problem. Furthermore, the possible impairment of hypoglycaemic awareness in patients prescribed human insulin has added complexity to diabetic management. The cardinal features of insulin overdose are hypoglycaemia and hypokalaemia. The sulphonylureas predominantly cause hypoglycaemia, while the biguanides may precipitate lactataemia and acidosis. Recognition of hypoglycaemia is therefore crucial in avoidance of toxicity. Intravenous dextrose is the mainstay of therapy following gut decontamination (for the oral agents). The efficacy of glucagon is dependent on hepatic glycogen stores and should therefore be used with caution. Diazoxide is not recommended. More recently, octreotide has been shown to be effective in sulphonylurea overdose. Patients should be admitted and monitored with serial blood sugar measurements for a minimum of 1 to 2 days as clinically warranted.     

Preliminary examinations on the effects of the breed characteristic feature "feather crest" on skull and brain anatomy of domestic ducks (Anas platyrhynchos f. dom.)]

Physical therapy assessment involves confirmation of a medical diagnosis. To help discuss this process, this case report is presented regarding a ballet dancer who experienced 6 years of chronic hip pain and dysfunction. Many diagnostic tests and surgical procedures were performed by various physicians in search of a diagnosis. Physical therapy assessments did not support the working diagnoses, and treatment given according to evaluation findings was not effective. Initial hip radiographs revealed a bony ossicle at the lesser trochanter, which was overlooked. Hip radiographs taken 5 years later revealed the same bony ossicle. Ultimately, surgical removal of the ossicle eliminated the hip pain, and the patient returned to full activity and dance again. With the attempt to confirm the patient's diagnosis, the physical therapy approach to problem solving is discussed. This case gives an example where it is important to question the physician's diagnosis when the physical therapy assessment and treatment response do not support it. it is also evident that an in-depth physical therapy assessment may be self-limiting if pathology has not been ruled out properly by the physician.     

Insulin therapy in type II diabetes

The results of conventional intensified insulin therapy (4 injections per day) in type II diabetics correspond more to those of conventional therapy (2 injections per day). Compared to a conventionally treated collective with strict dietetic regimen the intensified treated type II diabetics did not lead to an improved metabolic control. The frequency of hypoglycemic episodes did not differ in both collectives. Intensified insulin therapy is associated with subjectively increased comfort and increased life quality despite the seldom use of the advantages of the therapy. The management of the intensified therapy probably has to be learned in an earlier stage of life and requires repeated and more intensified education in elderly patients. The regression of typical late complications of diabetes mellitus as seen in the DCCT may possibly be achieved by a greater effort in therapy and empowerment of the patient.     

Characterization of axenic Pseudomonas fragi and Escherichia coli biofilms that inhibit corrosion of SAE 1018 steel

The purpose of this study was to evaluate the effect of redesigning the education program from individual instructional sessions to a format where the majority of instruction was provided through small group classes. Patient outcomes of lifestyle changes as evidenced by weight loss, improved glycemic control, adoption of a consistent pattern of blood glucose monitoring, and increased physical activity were evaluated using a physician satisfaction survey and a patient satisfaction and lifestyle change survey. The findings indicate that the changes in the education program accommodated a variety of needs; facilitated cost-effectiveness; were convenient for the patients, educators, and physicians; and still promoted adaptive lifestyle changes in behavior leading to improved glycemic control, increased levels of physical activity, and weight loss in persons with type 2 diabetes.     

Efficacy of the conventional diagnostic approach to pulmonary tuberculosis

Oncological pathology represents a topic of particular interest and importance owing to both its rising frequency (151,690 deaths in Italy in 1992) and the continuous progress made in the diagnostic and therapeutic field. The steady growth of this pathology has led to the need to identify a new professional figure: the cancer physician capable of bringing together all the skills required to optimise the diagnosis and treatment of oncological patients. As it is now universally accepted in theory, but not always put into practice, the treatment of oncological pathologies calls for a multidisciplinary approach. The optimal treatment is based on the integration of the roles of all the various specialists: oncologist, surgeon, radiotherapist and expert in pain therapy. In this therapeutic strategy, the cancer physician should manage the starting phase of the disease and subsequently should manage its course together with the surgeon and radiotherapist, returning in the terminal phase to sole management of the cancer patient with the help of other qualified professional figures. In short, the authors feel that it is not exaggerated to state that the cancer physician plays a central role in resolving the needs posed by the problem of cancer, needs which may take the form of diagnosis, therapy and care.     

Physician-patient relations--participation of patients with ureteral calculi in clinical decision making and level of anxiety

In a study examining the relationship between patient participation in clinical decision making and levels of anxiety, patients were offered a choice of treatment for ureteral calculus. 42 received information about 2 treatment options, ultrasound fragmentation of the stone through a ureteroscope and extracorporeal shock wave lithotripsy (ESWL), and were asked to choose the method that they preferred. 54 received treatment decided on by the physician without their participation in the decision making process. Anxiety was measured before meeting with the physician, immediately after the meeting and on hospitalization for treatment. The contribution of the patient's perception of participation in the decision-making process and level of education was also examined. There was a decrease in level of anxiety after meeting with the physician only among those who did not actually participate in the decision-making process (p < 0.05). There was no change in the level of anxiety among those offered choice of treatment. However, a decrease in anxiety was evident among patients who perceived that they had received information about their illness and its treatment (p < 0.01). This was not the case for patients who perceived themselves as participants in decision making unless they had a relatively high-level of education (p = 0.05).     

Arterial hypertension: lessons from patient education

The face of hypertension has been changing rapidly over the last few decades, from a serious disease to a cardiovascular risk factor. Patient education has been instrumental in bringing about tremendous improvements in hypertension-related mortality, morbidity, life expectancy, and life quality. Patient education has evolved from an adjunct to medical therapy to an intervention in its own right. In this process patient education tasks and techniques themselves have undergone remarkable developments, driven by evolving patient needs due to medical progress. The same is true for the roles of patients and health care providers. Dealing with hypertension is a behavior change process which demands serious learning efforts from all parties involved, patients, health practitioners and health care administrators alike. This paper focuses therefore on patient education for preventive behavior change and risk factor management. Special emphasis will be placed on processes and tools for effective patient education.     

The Hawkins sign

A 77-year-old man with type II diabetes taking a stable dose of subcutaneous, twice daily human insulin developed symmetrical, inflammatory, rheumatoid factor positive polyarthritis. Within 2 weeks of starting therapy with prednisone 5 mg daily and hydroxychloroquine 400 mg daily he had 2 episodes of severe hypoglycemic coma requiring emergency care. His blood glucose became controlled again when his insulin was decreased by 37%. There are no reported cases of hypoglycemia in diabetic or nondiabetic patients treated with hydroxychloroquine. Hydroxychloroquine has been reported to reduce insulin requirements in refractory type II diabetes by an average of 30%. When hydroxychloroquine is initiated for the treatment of polyarthritis in a type II diabetic requiring insulin or sulfonylurea treatment, blood glucose levels should be monitored closely and the insulin dose may need to be reduced.     

Obsessive-compulsive disorder: diagnosis and treatment in the primary care setting

BACKGROUND: Obsessive-compulsive disorder is a common anxiety disorder found in 1 to 2 percent of the population. Obsessions are recurrent and persistent thoughts that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts done to prevent or reduce anxiety. Patients might underreport symptoms or complain of coexisting depression or anxiety instead. The primary care physician is often the first to encounter this disorder in patients. METHODS: The authors cared for and observed a patient with obsessive-compulsive disorder at a family practice office and used her case to illustrate a literature review gathered by means of a MEDLINE search. RESULTS AND CONCLUSIONS: A combination of patient education, selective serotonin reuptake inhibitors, and behavioral techniques allow the family physician to maximize patient recovery and play a major role in the diagnosis and treatment of obsessive-compulsive disorder.