Haemolytic-uraemic syndrome in a renal transplant recipient treated by conversion to mycophenolate mofetil

OBJECTIVE: The authors' goal was to study the recommended dose schedule for risperidone. METHOD: They obtained computerized pharmacy data on 1,283 inpatients with the diagnoses of schizophrenia or schizoaffective disorder who were treated with risperidone. Continuance on risperidone was defined as remaining on the drug for 16 days or until discharge. RESULTS: The majority of the patients (84%) continued on resperidone. Use of the recommended dose schedule decreased greatly over time. Patients were more likely to continue on risperidone if they had a higher maximum dose (5.7 mg/day versus 4.7 mg/day), a longer number of days to maximum dose (5.7 days versus 3.9 days), and a maximum rise in dose of 0.5-2 mg/day. CONCLUSIONS: These findings suggest that the recommended dose schedule should be altered to one that recommends a less rapid titration (over 6 days to a week) and that the dose increments consist of 0.5-2 mg/day.     

Noonan syndrome in clinical practice

The author presents the basic criteria for clinical recognition of Noonan syndrome. The hypothetical pathogenesis, differential diagnosis and risk of recurrence of this syndrome are also discussed.     

Pain syndrome in gastroenterological practice: potentialities of evaluation

Qualitative and quantitative characteristics of chronic pain syndrome and their possible use in assessing analgetic effects of treatment were studied in 16, 49, 26 and 17 patients with gastric ulcer, duodenal ulcer, chronic pancreatitis, chronic colitis, respectively. Pain was measured with the use of McHill's questionnaire modification and visual-verbal-analog scale. In addition to routine analysis of the data from the respondents, graphic mean profiles of pain for each group have been devised. There were differences in quantitative parameters of pain syndrome depending on nosological unity and profiles of patients. The questionnaire proved rather informative in evaluation and gradation of analgetic effects of therapeutic factors in ulcer patients.     

Prevalence of fatigue and chronic fatigue syndrome in a primary care practice

BACKGROUND: Our goals were to determine the prevalence of unusual, debilitating fatigue and the frequency with which it was associated with the chronic fatigue syndrome (CFS) or other physical or psychological illness in an outpatient clinic population. METHODS: We prospectively evaluated a cohort of 1000 consecutive patients in a primary care clinic in an urban, hospital-based general medicine practice. The study protocol included a detailed history, physical examination, and laboratory and psychiatric testing. RESULTS: Five patients who came because of CFS studies were excluded. Of the remaining 995, 323 reported fatigue, and 271 (27%) complained of at least 6 months of unusual fatigue that interfered with their daily lives. Of the 271, self-report or record review revealed a medical or psychiatric condition that could have explained the fatigue in 186 (69%). Thus, 85 (8.5%) of 995 patients had a debilitating fatigue of at least 6 months' duration, without apparent cause. Of these patients, 48 refused further evaluation, and 11 were unavailable for follow-up; 26 completed the protocol. Three of the 26 were hypothyroid, and one had a major psychiatric disorder. Of the remaining 22 patients, three met Centers for Disease Control and Prevention criteria for CFS, four met British criteria, and 10 met the Australian case definition. The point prevalences of CFS were thus 0.3% (95% confidence interval [CI], 0% to 0.6%), 0.4% (95% CI, 0% to 0.8%), and 1.0% (95% CI, 0.4% to 1.6%) using the Centers for Disease Control and Prevention, British, and Australian case definitions, respectively. These estimates were conservative, because they assumed that none of the patients who refused evaluation or were unavailable for follow-up would meet criteria for CFS. CONCLUSIONS: While chronic, debilitating fatigue is common in medical outpatients, CFS is relatively uncommon. Prevalence depends substantially on the case definition used.     

Piriformis syndrome: assessment of current practice and literature review

Although piriformis syndrome was initially described in 1928, it has remained a nebulous and controversial diagnosis. A literature review reveals that there is no consensus on the diagnosis or treatment of piriformis syndrome. In addition, a survey of 75 physiatrists revealed that whether the diagnosis of piriformis syndrome even exists is controversial. This survey and literature review examines the diagnosis and treatment of piriformis syndrome. The fact that it remains controversial is likely due to a lack of objective clinical trials.     

False memory syndrome: A false dichotomy between science and practice.

Comments on K. S. Pope's (see record 83-37387) article on the validity of false memory syndrome. The author agrees with Pope that proponents of the validity of false memory syndrome have failed to generate data which would permit empirical evaluation of their claims. The author also offers his perception that clinicians are moving away from an emphasis on memory retrieval in their practices, in favor of the goal of improving functioning, decreasing distress, and augmenting safety and coping skills in patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Defining the practice population in fee-for-service practice

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.     

The scope of professional practice in specialist practice

The Scope of Professional Practice (UKCC, 1994a) now offers nurses, midwives and health visitors new opportunities to develop their clinical role. Role expansion is at the centre of debate in the health service. In the spirit of Scope, trusts and regional health authorities have been experimenting with new roles that combine medical and nursing practice in order to promote a holistic approach to health care. Education, experience and the appropriate clinical competency are the foundations for role expansion and the development of professional practice. However, some of the new roles and innovative practices have also been targeted at reducing junior doctors' hours (Read and Graves, 1994). New roles must be evaluated before they are allowed to develop and there is an urgent need for national evaluation of the initiatives underpinning Scope. This article examines the changing role of practitioners in specialist practice. The ethical, professional and legal issues surrounding these changes will also be considered.     

Negotiating the role of the practice nurse in general practice

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care. Two related issues emerge as significant: the role of the practice nurse in providing primary health care; and the effective use of the practice nurse resource in the 'new' National Health Service. This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this. The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely. The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds. Practice nurses' accounts of the future, for example, focused on professional issues. General practitioners stressed the importance of role development which met their General Medical Service responsibilities. Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service. The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated.     

中国31省市ST段抬高急性冠状动脉综合征住院患者治疗现状分析

目的:了解我国目前ST段抬高急性冠状动脉综合征(acute coronary syndrome,ACS)住院患者接受经循证医学证实有效的临床治疗的应用现状.方法:在中国31个省市自治区选择32家三级医院和32家二级医院注册研究,每家医院选择患者50例,共3 223例,对其中ST段抬高ACS的1307例患者的临床特点、接受再灌注现状、应用阿司匹林、血管紧张素转换酶抑制剂(angiotensin-converting enzyme inhibitors,ACEI)或血管紧张素受体阻滞剂(angiotensin receptor blockers,ARB)、β-受体阻滞剂、低分子量肝素、氯吡格雷和他汀类调脂药物的临床情况及预后进行评价.结果:(1)在不同地区、不同级别医院接受再灌注治疗率为30.9%～69.4%;单纯溶栓治疗率为1.9%～45.8%、经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗患者的治疗率为1.3%～62.7%;其中急诊PCI、补救PCI、择期PCI的治疗率分别为0～28.8%,0～9.1%,0～36.6%;溶栓治疗率二级医院显著高于三级医院(36.8%vs.14.6%,P＜0.01),接受PCI的治疗率三级医院显著高于二级医院(48.2%vs.6.46%,P＜0.01),总灌注率为53.8%;而有46.2%的患者未接受任何形式的再灌注治疗.(2)药物使用率分别为:阿司匹林88.0%～98.6%、ACEI或ARB 60.5%～84.4%、β-受体阻滞剂55.8%～84.4%、低分子量肝素54.2%～94.2%、氯吡格雷14.3%～88.6%、调脂药51.9%～90.9%;在不同地区、不同级别医院低分子量肝素、氯吡格雷和他汀类调脂药应用差异有统计学意义(P＜0.01).(3)住院期间主要事件的发生率以及死亡或再发心肌梗死联合事件发生率,二级医院高于三级医院(P＜0.05),接受再灌注与非再灌注治疗患者有显著差异(P＜0.01).(4)多因素分析结果表明,年龄、高血压、糖尿病、再灌注治疗、使用阿司匹林、ACEI或ARB、β-受体阻滞剂与住院期间死亡率有独立的联系.结论:目前我国ST段抬高ACS的临床治疗在三级医院与二级医院之间、各地区之间存在很大的差异,仍有较大的提升空间,应加大力度推动指南在心血管临床实践中的实施.     

Colposcopy in private practice

The clinical results of 162 operations performed with combined-acupuncture-analgesia are reported. The experiences so collected are satisfying. This method seems suitable for anaesthetic practice. Total absence of toxity good analgesia and the negligible circulatory reactions give this method advantages in the anesthetic treatment of old and poor risk patients. A heavy disadvantage is that the method in time consuming is expensive in personnel.