Does patient education in chronic disease have therapeutic value?

A pool of 320 articles on patient education were screened to select controlled experiments in chronic disease where the dependent variables included (a) compliance with a therapeutic regimen, (b) physiological progress of patients or (c) long-range health outcome. Thirty such articles were found; and the magnitude of experimental effects of patient education were calculated using an empirical form of integrating research findings known as meta-analysis. Summary of all experimental effects showed patient education most successful in altering compliance (average improvement = 0.67σ over control, p < 0.05). However, average improvements in physiological progress (0.49σ) and health outcome (0.20σ) were also statistically significant (p < 0.01 and p < 0.05, respectively). Efforts to improve health by increasing patient knowledge alone were rarely successful. Behaviorally-oriented programs, often with special attention to changing the environment in which patients care for themselves, were consistently more successful at improving the clinical course of chronic disease.     

Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy

OBJECTIVES: Few studies have evaluated the ability of the endoscopist to predict the presence of Barrett's esophagus (BE) at index endoscopy. The goals of this study were to determine the operating characteristics of endoscopy in diagnosing BE, and to determine the clinical and endoscopic predictors of BE in suspected BE patients at the index endoscopy. METHODS: From September 1993 to October 1997, endoscopic reports were examined to identify patients with suspected BE. All esophageal pathology reports during the same period were evaluated for the presence of specialized intestinal metaplasia. RESULTS: During the study period, 4053 endoscopies were performed on 2393 patients. Eight percent of all procedures were performed for suspected or confirmed BE. Fifty-three patients were known to have BE and thus their reports were excluded from this analysis. Five hundred seventy of the remaining patients had esophageal biopsies performed, and were included in this analysis. Among these 570 patients, 146 were suspected to have BE on endoscopy, while 424 were not suspected to have BE at the time of endoscopy. There were no differences among the two groups in terms of gender, race, and dyspepsia as an indication for the endoscopy. However, suspected BE patients were slightly younger and were more likely to have heartburn, but were less likely to have dysphagia as an indication for the endoscopy. The sensitivity and specificity of the endoscopists' assessments were 82% (95% confidence interval [CI], 72-92) and 81% (95% CI, 78-84), respectively. The positive predictive value and the negative predictive value were 34% and 97%, respectively. The positive likelihood ratio was 4.32 (95% CI, 3.49-5.31) and the negative likelihood ratio was 0.22 (95% CI, 0.13-0.38). Univariate analysis showed that endoscopists diagnosed BE in those with long-segment BE (LSBE) more accurately than in those with short-segment BE (SSBE) (55% vs 25% p = 0.001; odds ratio [OR] = 3.63, 95% CI, 1.71-7.70). Barrett's esophagus was correctly diagnosed in 38.5% of white patients but in only 14.7% of black patients (p = 0.01; OR = 3.63, 95% CI, 1.31-10.13). Multivariable logistic regression identified only the length of the columnar-appearing segment (p = 0.002; OR = 3.33, 95% CI, 1.54-7.17) and race (p = 0.08; OR = 2.31, 95% CI, 0.88-6.03) to be associated with the presence of BE on biopsy. CONCLUSIONS: Barrett's esophagus is frequently suspected at endoscopy; SSBE was more frequently suspected than LSBE, but was correctly diagnosed only 25% of the time, versus 55% for LSBE. Endoscopists diagnosed BE with a sensitivity of 82% and a specificity of 81%. However, the positive predictive value was only 34%, whereas the negative predictive value was 97%. The length of the columnar-appearing segment is the strongest predictor of BE at endoscopy. Alternative methods are needed to better identify BE patients endoscopically, especially those with SSBE.     

Sentinel lymph node navigation surgery for gastric cancer: Does it really benefit the patient?

Sentinel lymph node(SLN) navigation surgery is accepted as a standard treatment procedure for malignant melanoma and breast cancer. However, the benefit of reduced lymphadenectomy based on SLN examination remains unclear in cases of gastric cancer. Here, we review previous studies to determine whether SLN navigation surgery is beneficial for gastric cancer patients. Recently, a large-scale prospective study from the Japanese Society of Sentinel Node Navigation Surgery reported that the endoscopic dual tracer method, using a dye and radioisotope for SLN biopsy, was safe and effective when applied to cases of superficial and relatively small gastric cancers. SLN mapping with SLN basin dissection was preferred for early gastric cancer since it is minimally invasive. However, previous studies reported that limited gastrectomy and lymphadenectomy may not improve the patient's postoperative quality of life(QOL). As a result, the benefit of SLN navigation surgery for gastric cancer patients, in terms of their QOL, is limited. Thus, endoscopic and laparoscopic limited gastrectomy combined with SLN navigation surgery has the potential to become the standard minimally invasive surgery in early gastric cancer.     

Does good clinical practice at the primary care improve the outcome care for diabetic patients? Gender differences

BackgroundThe Middle East region is predicted to have one of the highest prevalence of diabetes mellitus (DM) in the world. This is the first study in the region to assess treatment outcome of DM according to gender.ObjectiveTo assess the quality and effectiveness of diabetes care provided to patients attending primary care settings according to gender in the State of Qatar.DesignIt is an observational cohort study.SettingThe survey was carried out in primary health care (PHC) centers in the State of Qatar.Subjects and methodsThe study was conducted from January 2010 to August 2010 among diabetic patients attending (PHC) centers. Of the 2334 registered with diagnosed diabetes, 1705 agreed and gave their consent to take part in this study, thus giving a response rate of 73.1%. Face to face interviews were conducted using a structured questionnaire including socio-demographic, clinical and satisfaction score of the patients.ResultsMajority of subjects were diagnosed with type 2 DM (84.9%). A significantly larger proportion of females with DM were divorced or widowed (9.1%) in comparison to males with DM (3.4%; p < 0.001). A significantly larger proportion of females were overweight (46.5%; p = 0.009) and obese (29.5%; p = 0.003) in comparison to males. Males reported significantly greater improvements in mean values of blood glucose (mmol/l) (?2.11 vs. ?0.66; p = 0.007), HbA1c (%) (?1.44 vs. ?0.25; p = 0.006), cholesterol (mmol/l) (?0.16 vs. 0.12; p = 0.053) and systolic blood pressure (mmHg) (?9.04 vs. ?6.62; p < 0.001) in comparison to females. While there was a remarkable increase in male patients with normal range of fasting blood glucose (FBG; 51.6%) as compared to the FBG measurement 1 year before (28.5%: p < 0.001) there was only a slight increase in females normal range FBG during this period from 28.0% to 30.4% (p = 0.357).ConclusionThe present study revealed that the current form of PHC centers afforded to diabetic patients provided significantly improved outcomes for males, but only minor improved outcomes for females. This study reinforces calls for a gender-specific approach to diabetes care.     

Does my patient have a pulmonary embolism? The Wells vs. PISA 2 rule in orthopedic patients

The diagnosis of venous thromboembolism is difficult in the postoperative setting because signs such as hypoxemia, leg pain, and swelling are so common. CTPA can also detect subsegmental PE (SSPE), of which the clinical significance has been widely debated. Clinical decision rules (CDR), such as the Wells and PISA 2, have been developed to identify symptomatic patients at low risk for PE who could forgo imaging. We performed this study in order to (1) compare the performance of the Wells and PISA 2 CDR in orthopedic patients; (2) compare CDR scores in patients with subsegmental PE (SSPE) versus larger clots; and (3) identify variables that improve performance of the Wells in orthopedic patients. This retrospective cohort study included all orthopedic surgery patients that underwent computerized tomographic pulmonary angiography at a single institution from 1/1/13 to 12/31/14 and had data to calculate both Wells and PISA 2 scores. CDR sensitivity, specificity and c-statistics were calculated. Multivariable logistic regression was used to identify variables that improved CDR performance. 402 patients were included in the study. The Wells rule (cutoff?>?4) had sensitivity 74% and specificity 45%. PISA 2 (cutoff 0.6) had sensitivity 90% and specificity 11%. The Wells performed better than PISA 2: c-statistic 0.60 vs. 0.50; p?=?0.007. The mean Wells score was 5.20?±?1.68 for patients with SSPE and 5.41?±?1.86 for patients with larger clots. Adding the variables prior smoking and varicose veins improved the performance of the Wells rule (c-statistic 0.66 vs. 0.60, p?=?0.008). The Wells rule (cutoff?>?4) performs better than PISA 2 in orthopedic patients. Neither can distinguish patients with SSPE from those with larger clots. Although adding past smoking and varicose veins to the Wells improves its performance, this requires validation in other populations.     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.     

Who will become my co-residents? The role of attractiveness of institutional care in the changing demand for long-term care institutions

BackgroundIn several OECD countries the percentage of people over 80 in LTC institutions has been declining for more than a decade, despite population ageing. The standard model to explain healthcare utilization, the Andersen model, cannot explain this trend. We extend the Andersen model by including proxies for the relative attractiveness of community living compared to institutional care. Using longitudinal data on long-term care use in the Netherlands from 1996 to 2012, we examine to what extent a decline in institutional care is associated with changes in perceived attractiveness of institutional LTC care compared to community living.MethodsWith a Blinder–Oaxaca decomposition regression, we decomposed the difference in admission to LTC institutions between the period 1996–1999 and 2009–2012 into a part that accounts for differences in predictors of the Andersen model and an “unexplained” part, and investigate whether the perceived attractiveness of institutional care reduces the size of the unexplained part.ResultsWe find that factors related to the perceived attractiveness of institutional care compared to community living explains 12.8% of the unexplained negative time trend in admission rates over the total period (1996–2012), and 19.1–19.2% over shorter time frames.DiscussionOur results show that changes in the perceived attractiveness of institutional LTC may explain part of the decline in demand for institutional care. Our findings imply that policies to encourage community living may have a self-reinforcing effect.     

Current role for resection of thoracic metastases in children and young adults--do we need different strategies for this population?

A retrospective review of surgical interventions for pulmonary metastases found 44 surgical metastasectomies in patients 20 years old or younger. OBJECTIVE: Indications for pulmonary metastasectomy are well established in adults, but are not so clear when we are dealing with a younger population. PATIENTS AND METHODS: A retrospective review of surgical interventions for pulmonary metastases (from December 1996 to October 2001) found 44 surgical metastasectomies in patients considered pediatric or young adults (20 years old or younger). Initial primary tumor, disease-free interval (DFI), previous thoracotomies, tumor histology, number of metastases, surgery performed, postoperative complications, other treatments received, and outcomes were recorded. RESULTS: Median age was 16.3 years (range 5 to 20 years) with 27 male and 17 female patients. Primary tumors were sarcoma (n = 31), Ewing's tumor (n = 8), Wilms' tumor (n = 3), and testicular carcinoma (n = 2). 27 patients had undergone previous resection of pulmonary metastases. Approaches were posterolateral thoracotomy (n = 18), clamshell incision (n = 8), VATS (n = 7), axillary thoracotomy (n = 9), and others (n = 2). Wedge resections were the procedure of choice (n = 35). In very select cases 1 pneumonectomy, 3 lobectomies, 2 chest wall resections, and 1 spinal surgery (vertebrectomy) were performed. Intra-operative radiotherapy (IORT) was employed in 2 patients. Cardiopulmonary bypass was necessary in 1 patient in order to resect an intra-atrial tumor thrombus. There was no operative mortality. Morbidity was related to prolonged air leaks (3 patients), hemothorax (2 patients), cerebrospinal fluid leak (1 patient), atelectasia (1 patient), peritoneal pain (1 patient), and postoperative fever syndrome (1 patient). Patterns of failure were thoracic (lung-pleura-chest wall) (n = 20), distant (n = 3) and thoracic + distant (n = 6). CONCLUSION: A close collaboration between oncologists, radiotherapists, and surgeons is mandatory in order to obtain good results. IORT is an interesting option. Better results are obtained if there is a long DFI and probably justifies a more aggressive approach in these specific cases.