Assessment‐Guided Therapy of Urinary Incontinence After Stroke

Urinary incontinence (UI) frequently occurs after stroke and often remains an extensive problem for these patients and their relatives even after discharge from the hospital. Therapeutic interventions, such as behavioral training, can help manage UI. Recently, a multimodal application of nursing interventions was recommended ( Wilbert‐Herr, Hürlimann, Imhof & Wilbert, 2006 ). The primary goals of the study discussed in this article were to introduce therapeutic interventions of UI management into clinical rehabilitation practice based on a structured process of interdisciplinary caregiving and test the treatment effect. Forty‐four patients who had suffered a cerebrovascular accident (CVA) were included in the study. Nursing interventions included distinction of stress or urge UI and the assessment of different forms of UI The latter intervention was based on the functional independence measure (FIM Item G—bladder management), the protocol of micturition, urine dipstick, and ultrasound measurement of post‐void residual urine (PVR). Interventions were applied according to the recommendations of the 3rd International Consultation on Incontinence. An algorithm of the interdisciplinary process was implemented, and the nursing staff received specific education regarding the interventions. Twenty‐one (47%) of the patients in the study were diagnosed with UI; 67% of these patients achieved the targeted level of continence by individually tailored interventions, which consisted of a systematic nursing assessment and standards for prompted voiding, timed voiding, and habit training. Planned processes, including screening procedures, assessment, profile of continence, intervention, and education and evaluation, increase the likelihood of positive results of rehabilitation of patients after CVA. Additional intervention studies are suggested to investigate the effectiveness of the algorithm used in this study.     

Acute gout management during hospitalization: a need for a protocol

Aim: To review systematically the management of acute gout during hospitalization. Methods: Case‐file review of all episodes of acute gout occurring in a large tertiary hospital over a 20‐month period. Results: Of 134 acute gout episodes identified, the large majority (118) occurred in patients not admitted under the rheumatology unit. Baseline anti‐gout medications were frequently ceased on admission and in 9% of episodes, no pharmacotherapy was prescribed. Delays in initiation of treatment occurred in up to 29% of patients. Acute management included anti‐inflammatory monotherapy, or combinations of colchicine, non‐steroidal anti‐inflammatory drugs (NSAIDs) and corticosteroids. Of patients prescribed colchicine, 26% received >1.5 mg/day and a strong correlation was found between colchicine dose and the occurrence of diarrhoea. NSAIDs were prescribed in 29% of patients with pre‐existing renal impairment. Overall, 25% of patients received inappropriate pharmacological management. In patients not under the direct care of the rheumatology unit, in‐hospital rheumatology consultation was sought by the treating unit in 34% of episodes. Consultation was sought more frequently in patients with multiple joint involvement, but there were no other obvious differences in baseline clinical characteristics between cases with or without rheumatology involvement. In cases with rheumatology involvement, patients were investigated more frequently, they received more pharmacotherapeutic intervention, in particular combination anti‐inflammatory therapy, and they achieved better symptomatic relief and long‐term follow up. Conclusion: Acute gout episodes in hospital are variably investigated and treated with frequent suboptimal management. We recommend establishment of a hospital‐wide protocol to support decision‐making regarding investigations, treatment and follow up.     

诊治指南为基础的教学方法在泌尿外科研究生临床实习教学中的应用

目的以诊治指南为基础,提高临床实习教学效果。方法将本科实习的泌尿外科研究生分为2组,实验组采用以诊治指南为基础进行教学,对照组采用传统方法带教,一定时间后,采用试卷加问卷的形式进行考核,比较两组之间的区别。结果实验组基础理论考试成绩优于对照组,临床病例分析优于对照组。临床技能考试两组无明显区别。问卷结果表明,学生更乐意接受以诊治指南为基础的教学方法。结论 以诊治指南为基础的临床实习带教可以提高泌尿外科临床实习效果,增强学生的学习兴趣。     

Increasing Adherence to Cervical Cancer Screening Guidelines

The dramatic changes in the 2009 American College of Obstetrician and Gynecologists’ (ACOG) cervical cancer screening guidelines created challenges in clinical implementation. When audited in October 2010, adherence to the new guidelines by clinicians in a university health center was 73.95%. After implementation of a multifaceted quality-improvement project, adherence significantly improved to 90.20%. This article discusses the components of a quality-improvement project focused on increasing providers’ adherence to guideline-consistent practice.     

In‐hospital rehabilitation after multiple joint procedures of the lower extremities in haemophilia patients: clinical guidelines for physical therapists

Summary. This project aimed to develop guidelines for use during in‐hospital rehabilitation after combinations of multiple joint procedures (MJP) of the lower extremities in persons with haemophilia (PWH). MJP are defined as surgical procedures on the ankles, knees and hips, performed in any combination, staged, or during a single session. MJP that we studied included total knee arthroplasty, total hip arthroplasty and ankle arthrodesis. Literature on rheumatoid arthritis demonstrated promising functional results, fewer hospitalization days and days lost from work. However, the complication rate is higher and rehabilitation needs optimal conditions. Since 1995, at the Van Creveldkliniek, 54 PWH have undergone MJP. During the rehabilitation in our hospital performed by experienced physical therapists, regular guidelines seemed useless. Guidelines will guarantee an optimal physical recovery and maximum benefit from this enormous investment. This will lead to an optimal functional capability and optimal quality of life for this elderly group of PWH. There are no existing guidelines for MJP, in haemophilia, revealed through a review of the literature. Therefore, a working group was formed to develop and implement such guidelines and the procedure is explained. The total group of PWH who underwent MJP is described, subdivided into combinations of joints. For these subgroups, the number of days in hospital, complications and profile at discharge, as well as a guideline on the clinical rehabilitation, are given. It contains a general part and a part for each specific subgroup.     

Does the current stepwise approach to asthma pharmacotherapy encourage over‐treatment?

For the past 20 years, asthma pharmacotherapy has been described in clinical practice guidelines in terms of a stepwise approach, with medications and/or doses increased if asthma is not well‐controlled, and reduced once good control is achieved and maintained. Although many patients with asthma are untreated, there are also significant problems with over‐treatment once regular controller therapy is commenced. This increases the cost of treatment and exposes patients to unnecessary risks of side‐effects. The present pro‐con debate addresses the question of whether the stepwise approach itself leads to over‐treatment. Two asthma experts discuss factors for and against this proposition, identify issues on which more research is needed, and suggest areas in which guidelines can be changed in order to facilitate more appropriate prescribing of asthma medications. These strategies include better validation of the concepts underlying asthma treatment recommendations, stronger recommendations that every treatment change should be followed up with a scheduled review using evidence‐based assessment tools and incorporation of phenotype‐specific considerations into treatment recommendations. In addition, the process for development and dissemination of clinical practice guidelines should ensure that recommendations are easily understood, feasible to implement, and relevant to everyday asthma care and the needs and concerns of patients and clinicians.