Xiao Procedure for Neurogenic Bladder in Spinal Cord Injury and Spina Bifida

The Xiao procedure, which reroutes nerves surgically to establish a somatic–autonomic reflex arc for restoring voluntary bladder and bowel control in patients with spinal cord injury or spina bifida, is reviewed in this article on its history, current status, and how to optimize its efficiency.     

Transition to Adult Care for Youth with Type 1 Diabetes

Emerging adults with type 1 diabetes are at risk for poor glycemic control, gaps in medical care, and adverse health outcomes. With the increasing incidence in type 1 diabetes in the pediatric population, there will be an increase in the numbers of teens and young adults transferring their care from pediatric providers to adult diabetes services in the future. In recent years, the topic of transitioning pediatric patients with type 1 diabetes to adult diabetes care has been discussed at length in the literature and there have been many observational studies. However, there are few interventional studies and, to date, no randomized clinical trials. This paper discusses the rationale for studying this important area. We review both observational and interventional literature over the past several years, with a focus on new research. In addition, important areas for future research are outlined.     

Comparison of the Effects by Obybutynin and Tolterodine on Spina Bifida Patients: A Pilot Crossover Study

Objectives: To compare the effects of obybutynin and tolterodine in neurogenic bladder patients with spina bifida in a crossover study. Methods: Seven myelomeningocele and one spinal lipoma cases, maintained with obybutynin and clean intermittent catheterization for more than 60 months, were enrolled. Age ranged from 8 to 23 years (mean 12.0, male/ female = 2/6). After 2 weeks of washout period, obybutynin (0.3 mg/kg, maximum 12 mg) or tolterodine (0.12 mg/kg, maximum 4 mg) was administered for 4 weeks, and then switched to the other drug for 4 weeks. At the end of the three periods, the patients and/or parents documented urinary storage status and adverse effects, and urodynamic study was performed. Results: In seven cases undergoing sequential urodynamic study, the baseline compliance of the patients (6.81 ± 1.83) increased to 9.98 ± 4.97 by obybutynin and 10.16 ± 2.53 by tolterodine (P < 0.05 for each). Better compliance was noted in two cases with tolterodine and in two cases with obybutynin. Stronger adverse effects were reported in three out of eight patients (37.5%) by obybutynin and three out of eight patients (37.5%) by tolterodine. Although storage effect and side effects were equivalent for total patients, markedly diverse response was noted for each patient, with five choosing tolterodine and three choosing obybutynin. Conclusions: Individualized evaluation is required for optimal choice of anticholinergics.     

Patient Satisfaction with Primary Care Office-Based Buprenorphine/Naloxone Treatment

Background Factors associated with satisfaction among patients receiving primary care–based buprenorphine/naloxone are unknown. Objective To identify factors related to patient satisfaction in patients receiving primary care–based buprenorphine/naloxone that varied in counseling intensity (20 vs 45 minutes) and office visit frequency (weekly vs thrice weekly). Design and Participants One hundred and forty-two opioid-dependent subjects. Measurements Demographics, drug treatment history, and substance use status at baseline and during treatment were collected. The primary outcome was patient satisfaction at 12 weeks. Results Patients’ mean overall satisfaction score was 4.4 (out of 5). Patients were most satisfied with the medication and ancillary services and indicated strong willingness to refer a substance-abusing friend for the same treatment. Patients were least satisfied with their interactions with other opioid-dependent patients, referrals to Narcotics Anonymous, and the inconvenience of the treatment location. Female gender (β = .17, P = .04) and non-White ethnicity/race (β = .17, P = .04) independently predicted patient satisfaction. Patients who received briefer counseling and buprenorphine/naloxone dispensed weekly had greater satisfaction than those whose medication was dispensed thrice weekly (mean difference 4.9, 95% confidence interval 0.08 to 9.80, P = .03). Conclusions Patients are satisfied with primary care office-based buprenorphine/naloxone. Providers should consider the identified barriers to patient satisfaction. The findings of this study were presented in part at the 67th annual scientific meeting of the College on Problems of Drug Dependence, Orlando, FL, 22 June 2005.     

Primary Care of the Transplant Patient

A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.     

Patient Factors Associated with Guideline-concordant Treatment of Anxiety and Depression in Primary Care

Objective  

To identify associations of patient characteristics (predisposing, enabling and need factors) with guideline-concordant care for anxiety and depression in primary care.