Evaluation of clinical outcomes in anterior cruciate ligament surgery

Clinical outcomes data can be used to facilitate patient management decisions, assess clinician and organizational performance, and to provide evidence for the effectiveness of surgery and rehabilitation. The validity of the inferences made from outcomes data are dependent on the validity of the outcomes measures themselves and the circumstances under which the data were collected, analyzed, and interpreted. Clinical outcomes may include measures of impairment of body structure and function, activity limitation, and participation restriction. However, because the relationship between impairment and the resulting activity limitation and participation restriction is not direct, and because activity limitations and participation restrictions are of the utmost concern to the athlete, the primary clinical outcome should be measures of activity limitation and participation restriction. Activity limitation and participation restriction may be measured either through direct observation of performance or by general or specific measures of health related quality of life. Clinical outcomes data must be collected systematically to ensure valid inferences from the data.     

Vascular Endothelial Growth Factor Expression and Cyclosporine Toxicity in Renal Allograft Rejection

The aim of this study was to evaluate the influence of vascular endothelial growth factor (VEGF) on renal function and on development of interstitial fibrosis (IF) in renal allografts. Tubular and interstitial expressions of VEGF and TNF-α, and density of macrophages in the interstitium were examined in 92 patients with nonrejected kidneys, acute rejection (AR), chronic allograft nephropathy (CAN), borderline changes (BC) and acute cyclosporin A (CsA) toxicity. Follow-up biopsy specimens from patients with AR and BC were evaluated for development of IF. A significant difference in tubular and interstitial VEGF expressions was found between patients with AR, BC, CAN and CsA toxicity (p < 0.001). Macrophage infiltration was positively correlated with VEGF and TNF-α expressions (p < 0.001). VEGF expression increased with increasing expression of TNF-α (p < 0.001). Renal function in first 6 months after initial biopsy was better in patients with marked tubular VEGF expression (p < 0.01); however, in follow-up, development of IF and graft loss was found earlier in these patients (p < 0.01 and p < 0.05, respectively). Increased renal VEGF expression has protective properties immediately following renal allograft but allows for increased risk of early IF, and therefore poor graft outcome in the long term.     

Overview: Beyond guidelines and guidance—psychosocial perspectives on treatment interventions for young people with substance problems in the United Kingdom

Over the last two decades there has been accumulating evidence that both psychosocial and pharmacological treatment interventions can effect change in substance-misusing adults. Thus, treatment interventions implemented for young people with substance problems largely draw on the adult addiction experience and that of child and adolescent psychiatry and psychology. As young people with problematic drug use have different treatment needs, and require different interventions and services to those of adults, results of adult studies cannot necessarily be directly extrapolated to young people.

Over the last five years evidence has been rapidly mounting that treatment may potentially work in young people, but as yet it is not as extensive as that for adults. The interventions that appear most fruitful are those based on learning theory, e.g. cognitive behavioural therapy and family therapy. Outcome studies in young people demonstrate substantial variability in substance use and misuse following treatment. From the UK perspective, the evidence is almost entirely USA based, and these evaluations of non-UK treatment programmes for young people cannot be simply transferred or transported to UK healthcare settings. This has significant implications for practice and policy.

At this stage, 'guidelines' or 'guidance' that is available is either not directed at young people and/or is largely gleaned from the USA literature. In addition, it does not adequately capture the complexity of cases at front-line specialist settings. The management of young substance misusers in the UK is, in the main, 'beyond guidelines and guidance'.

The restricted treatment service network for young people in the UK makes the potential for undertaking studies on treatment effectiveness extremely limited, but because there is evidence of a growing number of young people requiring treatment, such specialist drug services require evaluation. Serious consideration of the establishment and funding of evaluation of treatment interventions to be delivered to young substance misusers in the UK is urgently needed.     

The carotid endarterectomy: Experience with 260 cases and discussion of the indications

Summary During 1978 to 1989, 235 patients were operated upon with 260 procedures for cervical carotid endarterectomy. The patients were classified according to the presence or absence of ischaemic symptomatology, and for symptomatic patients, according to the reversibility or persistance of ischaemic symptoms. So the selection of patients was: reversible ischaemia 46%, stroke 29%, asymptomatic patients 25%. In the stroke group, no patient was operated on as an emergency, the endarterectomy was only performed after stabilization of the clinical state. Three subgroups were included in patients operated on for asymptomatic carotid stenosis: casual discovery 40%, treatment of the second carotid artery (previous endarterectomy for symptomatic contralateral stenosis) 34%, and treatment of the second carotid artery (previous ECIC by-pass for contralateral carotid occlusion) 26%. All patients were operated upon after angiographic exploration (femoral catheterisation in most cases), and after cerebral CT scan. The surgical technique included general anaesthesia, systematic shunting, endarterectomy after longitudinal arteriotomy, closure without patch. The operating microscope has been used since 1985.The surgical results were studied in terms of uneventful postoperative course (87%), reversible complications (8%) and long lasting complications (5%). The long lasting complications were of local origin (1%), of neurological origin (2%), of general origin (1%). Overall the operative outcome at 6 months was: return to previous clinical state 95%, neurological sequelae 2%, death 3%. In the patients operated on for asymptomatic carotid stenosis the overall outcome was: previous clinical state 97%, death 3%. The legitimacy of carotid endarterectomy procedure is discussed in relation to some recent pertinent literature.     

Factors leading to long-term hospitalization after laparoscopic appendectomy.

BACKGROUND: Randomized studies demonstrate that laparoscopic appendectomy yields better results compared with open techniques. We sought to identify factors that determine an extended hospital stay among patients undergoing laparoscopic appendectomy. METHODS: This was a prospective study including 669 patients undergoing laparoscopic appendectomy. We analyzed variables that can predict the length of hospital stay. RESULTS: Of 669 patients undergoing laparoscopic appendectomy, 141 stayed in the hospital for > or = 5 days (Group 1), and 97 stayed in the hospital for < or = 1 day after surgery (Group 2). The univariate analysis demonstrated that fever (P<0.0001), nausea and vomiting (P=0.060), leukocytosis (P<0.0001), gangrened or perforated intraoperative appearance of the appendix (P<0.0001), and appendix position behind the ileocecal junction (P<0.001) were related to a longer hospital stay. The multivariate analysis through logistical regression showed that the factors independently and significantly associated with an extended hospital stay were presurgical fever, appendix position behind the ileocecal junction, and intraoperative gangrened or perforated appearance of the appendix. CONCLUSION: Fever, appearance, and position of the appendix are factors related to an extended hospital stay.     

Minor Psychiatric Morbidity, Its Prevalence and Outcome in a Cohort of Civil Servants A Seven-year Follow-up Study

During the years 1979–1986, a cohort of direct entrantexecutive officers in the Civil Service were followed up toexamine the prevalence and outcome of minor psychiatric morbidityin an occupational setting. All studies using epidemiologicalstandardized research methods agree, that prevalence rates arehigh in occupational settings. As in primary care settings,half of the illness episodes followed a chronic course, whichemphasizes the need for early detection and prompt managementof these conditions, and for evaluative studies of interventionstrategies.     

综合疗法治疗儿童弱视的疗效分析

目的 :评价综合疗法治疗儿童弱视的远期疗效。方法 :追踪观察治疗 3年以上的弱视患者 2 30例、36 5眼 ,在治疗过程中根据患者弱视程度、年龄及注视性质采用传统遮盖疗法 ,光学及药物压抑疗法 ,后像疗法及脉冲红光闪烁疗法等综合治疗。结果 :总治愈率为 71.78% ,其中轻度弱视治愈率为 93.85 %、中度为 82 .6 7%、重度为 34.6 9%。屈光不正性弱视 81.95 %、屈光参差性弱视 6 4.13%、斜视性弱视 4 9.4 7%。中心注视与旁中心注视之间差异有显著性 (P <0 .0 5 )。表明弱视程度越轻 ,治疗效果越好。各种类型弱视中 ,以屈光不正性弱视疗效最好。中心注视者疗效明显好于旁中心注视者。结论 :采用综合疗法治疗弱视 ,疗效显著 ,能明显缩短疗程 ,是目前治疗弱视最有效的方法。     

Tubal patency and fertility outcome after expectant management of ectopic pregnancy

Objective: To study tubal patency and fertility outcome of patients with expectantly managed ectopic pregnancy (EP).

Design: A prospective study.

Setting: Department of Obstetrics and Gynecology, Turku University Central Hospital, Turku, Finland.

Patient(s): Thirty patients who wanted to become pregnant again were treated successfully by expectant management of EP.

Intervention(s): Patients were examined with posttreatment hysterosalpingography, and they filled out a questionnaire about their subsequent pregnancies.

Main Outcome Measure(s): Free passage through open lumen showing tubal patency; number of full-term pregnancies and EPs revealing relative rate of subsequent fertility.

Result(s): A free passage through the diseased tube was seen in 93% of the cases (28 of 30). Two of the 24 patients (8.4%) who wanted to become pregnant had an obstruction in the diseased tube. One (4.2%) of them had a normal opposite tube and later had a normal pregnancy. The other (4.2%) had an obstruction in both tubes and subsequently had a repeat EP. One of the 6 patients had an EP (this patient did not want to become pregnant and did not use contraception). However, her posttreatment hysterosalpingography was normal. In total, the subsequent pregnancy rate was 88% (21 of 24), and the rate of repeat EP was 4.2% (1 of 24).

Conclusion(s): Patients who are treated with expectant management have a good long-term fertility outcome. Spontaneous regression of EP does not lead to increased harm or damage to the tube, i.e., the risk for repeat EP is low.     

FEASIBILITY OF CONDUCTING CARDIOVASCULAR OUTCOME RESEARCH IN AUSTRALIAN GENERAL PRACTICE: RESULTS FROM THE ANBP2 PILOT STUDY

1. The present study aimed to determine the feasibility of conducting a 5 year cardiovascular outcome trial of the treatment of 6000 elderly hypertensive patients in Australian general practices. 2. General practitioners (GPs) were invited to participate by mail and personal follow-up. Patient records were reviewed to identify subjects for a blood pressure (BP) screening programme. Blood pressure was measured on three occasions and eligible subjects were included if the average BP was 160 mmHg systolic or 90 mmHg diastolic if systolic BP was 140 mmHg. 3. Seven hundred and forty-one GPs were approached and 89 were enrolled in the study (12% of mail invites and 75% of those receiving a personal contact). In 16 practices where screening was completed, 82 000 records were reviewed to identify 4% patients eligible for screening. Twenty-two per cent of eligible subjects attended screening. Of 1938 subjects screened, 180 (9%) had BP 5=160/90 mmHg. Forty-seven percent of subjects (n = 916) were receiving antihypertensive therapy and 184 (20%) were withdrawn from therapy. One hundred and sixteen (63%) of these subjects had BP return to study entry levels within 6 weeks. Fifty-seven newly diagnosed and 81 previously treated subjects were randomized (7% of the screened population). 4. Based on the high participation rate of GPs, the response rate of patients to attend a BP screening programme and the 7% randomization to screening ratio for entry into the study, the ANBP2 pilot study has demonstrated that it is feasible to recruit subjects from Australian general practices to a cardiovascular outcome trial.