What a difference a day makes

With the availability of group A beta-hemolytic streptococcal (GABHS) antigen detection tests, the management of adult pharyngitis is being reassessed. A decision analytic model was developed which considered four strategies: immediate treatment, no treatment, performing a rapid antigen test, or obtaining a bacterial culture. Patient outcomes were expressed in “well” days, which were reduced by the “sick” days associated with adverse reactions to treatment or complications of GABHS infection. When immediate test results are available, testing is the optimal strategy for probabilities of GABHS between 1 and 49 per cent. This range includes almost all patients, using probability estimates based on clinical criteria. The absolute benefit of testing was 0.1 days. The major advantage of a rapid test is the avoidance of penicillin reactions. Variations in the symptomatic benefits of treatment had minimal effects on the analysis. The analysis supports the use of an antigen test for adult patients with pharyngitis. Received from the Division of General Medicine and Primary Care. Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond. Virginia. A preliminary version of this work was presented at the seventh annual meeting of the Society for Medical Decision Making, October 21, 1985.     

What a difference a year makes: Reflections on the ACR recommendations for the medical management of osteoarthritis

Since the publication in 2000 of the updated American College of Rheumatology (ACR) recommendations for the medical management of patients with lower limb osteoarthritis (OA), additional recommendations, newer epidemiologic studies, systematic reviews, and clinical trials have been published. The results of these reviews, studies, and trials, which highlight the greater efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) for controlling pain and the potential serious upper gastrointestinal toxicity of acetaminophen, require us to reassess the use of acetaminophen as the first-line pharmacologic agent for all patients with knee OA. Furthermore, the documented efficacy of glucosamine for pain relief and function improvement in patients with knee OA, with an effect size that is comparable with that of NSAIDs, requires us to reassess the use of glucosamine as a potential first-line agent at least for patients with knee OA who have mild-to-moderate pain. The availability of the cyclo-oxygenase 2 (COX-2)-specific inhibitors and their documented greater safety relative to traditional dual-inhibitor NSAIDs with regard to serious upper gastrointestinal toxicity lead us to reassess the use of traditional NSAIDs in patients with OA, especially in those at increased risk for such adverse events. The COX-2-specific inhibitors cost less than the combination of a generic NSAID plus a proton-pump inhibitor. The results of ongoing and future studies, especially of structure-modifying antiosteoarthritis drugs, will lead to further reassessment and updating of recommendations for the medical management of patients with knee OA. Hopefully, the use of such recommendations will improve the outcomes for patients with this debilitating chronic condition.     

Aging and attractiveness: marriage makes a difference

In order to explore women's agreement with the double standard of aging, thirty-two women ranging in age from twenty-eight to sixty-three were asked to share their definitions of attractiveness, femininity, and sexual appeal. They were then asked if they had changed these definitions over time and if they perceived themselves as growing more or less attractive, feminine, and sexually appealing as they grew older. The findings showed that attractiveness was defined primarily by appearance, femininity by behavior and inferred traits, and sexual appeal by both. More single than married women had changed definitions of these terms, and more single women perceived themselves as having grown more attractive, feminine, and sexually appealing as they grew older. Age differences in these evaluations were found among the group of married women, but few age differences were found among single women. The findings suggest there may be qualitatively differing experiences between single and married women that are reflected in their evaluations of attractiveness and sexual appeal.     

The perfect pelvic pouch--what makes the difference?

The aim of this study was to determine what factors are important for the achievement of perfect anal continence after restorative proctocolectomy. One hundred patients underwent paired studies of anorectal physiology before and one year after restorative proctocolectomy with pelvic ileal reservoir (11 S, 25 J, 64 W) with stapled ileoanal anastomosis, without mucosectomy. Fifty seven patients attained perfect anal continence and were able to discriminate flatus from faeces with such confidence that they were able to release flatus safely without fear of faecal soiling. The remaining 43 patients experienced minor problems in this regard. Four factors were found to correlate significantly with a perfect functional result (median, perfect v imperfect): maximum resting anal pressure (72 v 57 cm H2O, p < 0.02), the sensory threshold in the upper and mid-anal canal (7.3 v 8.6 and 5.3 v 7.0 mA, p < 0.05 and p < 0.02), compliance of the ileal reservoir (12.4 v 7.6 ml/cm H2O, p < 0.01), and the presence of a pouch-anal inhibitory reflex (56 of 57 patients v 29 of 43 patients, p < 0.01). The quality of anal continence depends on several factors: a complaint ileal reservoir, a strong sensitive anal sphincter, and normal reflex coordination of the activities of the reservoir and the sphincter. Excellent pouch-anal coordination is obtainable irrespective of the design of the reservoir, provided that these criteria are satisfied.     

Diagnosis makes a difference: Perceptions of older persons with dementia symptoms

Background/Study Context: Employing the stereotype content model and terror management theory, we examined whether stereotypes and feelings about persons with dementia vary depending on the type of dementia diagnosis and purported causes of the dementia.

Methods: Participants were randomly assigned to read one of four vignettes that depicted a man who consulted his doctor because of memory problems. All vignettes described the same symptoms and diagnostic tests, but each of four groups read a different result: all tests normal (Normal); Alzheimer’s disease (AD); Wernicke–Korsakoff Syndrome (WKS) associated with alcohol abuse; and chronic traumatic encephalopathy (CTE) associated with head injuries from playing football in high school and college. Measures included a word fragment completion task, a stereotype content scale, and an emotions scale.

Results: Results showed no differences in the number of death-related words generated in the word fragment completion task and no differences in assessment of competence across the four groups. Those in the Normal, AD, and CTE groups evaluated the man as warmer than those in the WKS group. Participants in the AD condition showed more empathy than those in the WKS group. There were no differences in pity or fear but the CTE condition produced more envy and admiration and the WKS condition produced more contempt.

Conclusion: These results suggest that different forms of dementia elicit varying emotional and cognitive responses.     

Structured patient education: the diabetes X-PERT Programme makes a difference.

AIMS: To develop a patient-centred, group-based self-management programme (X-PERT), based on theories of empowerment and discovery learning, and to assess the effectiveness of the programme on clinical, lifestyle and psychosocial outcomes. METHODS: Adults with Type 2 diabetes (n = 314), living in Burnley, Pendle or Rossendale, Lancashire, UK were randomized to either individual appointments (control group) (n = 157) or the X-PERT Programme (n = 157). X-PERT patients were invited to attend six 2-h group sessions of self-management education. Outcomes were assessed at baseline, 4 and 14 months. RESULTS: One hundred and forty-nine participants (95%) attended the X-PERT Programme, with 128 (82%) attending four or more sessions. By 14 months the X-PERT group compared with the control group showed significant improvements in the mean HbA1c (- 0.6% vs. + 0.1%, repeated measures anova, P < 0.001). The number needed to treat (NNT) for preventing diabetes medication increase was 4 [95% confidence interval (CI) 3, 7] and NNT for reducing diabetes medication was 7 (95% CI 5, 11). Statistically significant improvements were also shown in the X-PERT patients compared with the control patients for body weight, body mass index (BMI), waist circumference, total cholesterol, self-empowerment, diabetes knowledge, physical activity levels, foot care, fruit and vegetable intake, enjoyment of food and treatment satisfaction. CONCLUSIONS: Participation in the X-PERT Programme by adults with Type 2 diabetes was shown at 14 months to have led to improved glycaemic control, reduced total cholesterol level, body weight, BMI and waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction.