Clinical experience with the Stretta procedure

The benchmarks in GERD therapy comprise the commonly prescribed anti-secretory drugs (H2RAs and PPIs) and anti-reflux surgery. Although drugs are typically safe, cost and patient compliance are challenges to long-term management. Furthermore, while heartburn may be controlled with aggressive medical therapy, other symptoms such as regurgitation may persist, reducing patient satisfaction and adversely affecting quality of life. Surgical anti-reflux procedures, most commonly laparoscopic Nissen fundoplication, improve GERD symptoms and normalize esophageal acid exposure in most patients. Patient perception of the potential risk of abdominal surgery and general anesthesia may limit willingness to undergo surgery resulting in only a small portion of GERD sufferers that actually undergo anti-reflux surgery each year. Overall, the Stretta procedure is well tolerated, with an acceptably low incidence of complications and obviates the need for anti-secretory drug therapy for most patients at the 6- and 12-month follow-up. GERD symptom scores, heartburn, satisfaction, and SF-36 scores significantly improve over the baseline and this effect lasts at least 12 months. The symptomatic improvement after Stretta at 12 months in one trial (GERD score, 27 to 9) is similar to that reported by Velanovich after fundoplication (GERD score, 27 to 3). Furthermore, the significant reduction in median esophageal acid exposure time (distal 10.6% to 6.2%, proximal 1.9% to 0.9%), provides objective evidence of an anti-reflux effect. Although the reported studies have been non-randomized, the objective improvement observed in esophageal acid exposure and the persistence of GERD symptom score improvement with repeated measure analysis over a course of 12 months make a significant placebo effect unlikely. Stretta is a promising new technology for the treatment of GERD that should be considered for patients who wish to discontinue a lifelong anti-secretory medication regimen or who have incomplete GERD symptom control on drugs, but are not yet accepting anti-reflux surgery.     

Clinical databases in physical therapy

Clinical databases in physical therapy provide increasing opportunities for research into physical therapy theory and practice. At present, information on the characteristics of existing databases is lacking. The purpose of this study was to identify clinical databases in which physical therapists record data on their patients and treatments and to investigate the basic aspects, data sets, output, management, and data quality of the databases. Identification of the databases was performed by contacting members of the World Confederation for Physical Therapy, searching Pubmed, searching the Internet, and snowball sampling. A structured questionnaire was used to study the characteristics of the databases. The search was restricted to North America, Australia, Israel, and Western Europe. Seven clinical databases on physical therapy were identified. Four databases collected data on specific patient categories, whereas the others collected data on all patients. All databases collected data on patient characteristics, referrals, diagnoses, treatments, and closure, whereas some databases also collected functional status information. The purposes of the databases were diverse, but they can be summarized as quality improvement, research, and performance management. Although clinical databases are new to the field, they offer great potential for physical therapy research. Potential can be increased by further cooperation among databases allowing international comparative studies.     

The experience of providing physical therapy in a changing health care environment

BACKGROUND AND PURPOSE: The changes in the health care environment during the last decade have had an impact on the roles and responsibilities of all health care professionals. The purpose of this phenomenological study was to describe the experience of staff physical therapists during a time of systemic change within a large urban academic medical center. SUBJECTS AND METHODS: Participants were 5 physical therapists working in various clinical settings within the medical center. The participants were interviewed and asked the question "Over the past 4 years, there have been major changes in your work environment. What has it been like for you working as a clinician during this time of change?" Interviews were recorded, transcribed, and analyzed to find thematic patterns of responses. RESULTS: Four common themes emerged in which participants described experiencing loss of control, stress, discontent, and disheartenment. A fifth theme showed that despite these negative feelings, participants were able to "find the silver lining" in their daily work lives (ie, they were able to find positive aspects of their professional lives despite the perceived unpleasant changes with which they had to cope). DISCUSSION AND CONCLUSION: This study provides insight into the experiences of a group of staff physical therapists during a time of systemic change in their work environment. Although the themes reflect largely unsettling and negative experiences, there seems to be an underlying ability to find affirmative aspects of work.     

Clinical research agenda for physical therapy

The American Physical Therapy Association (APTA) has developed a clinical research agenda that is designed to support, explain, and enhance physical therapy clinical practice by facilitating research that is useful primarily to clinicians. The Clinical Research Agenda was developed through a series of conferences and extensive editorial and review processes and represents input from a large number of physical therapists. The Clinical Research Agenda represents questions that are believed to be important to clinical practice, the profession, and APTA. The themes of the Clinical Research Agenda were developed in an attempt to span the breadth of patient/client management beyond the particulars of any single question and to signal the full emergence of the physical therapist clinician as a scientific practitioner. Furthermore, the Clinical Research Agenda is intended to serve as a benchmark of the systematic progression of the scientific basis of the profession as a whole. As approved by APTA's Board of Directors, the Clinical Research Agenda will serve as the focal point for the research programs of the Foundation for Physical Therapy, as directed by the Foundation's trustees, and will be shared with other funding agencies and researchers outside of physical therapy as well.     

Clinical reasoning strategies in physical therapy

BACKGROUND AND PURPOSE: Clinical reasoning remains a relatively under-researched subject in physical therapy. The purpose of this qualitative study was to examine the clinical reasoning of expert physical therapists in 3 different fields of physical therapy: orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (home health) physical therapy. SUBJECTS: The subjects were 6 peer-designated expert physical therapists (2 from each field) nominated by leaders within the Australian Physiotherapy Association and 6 other interviewed experts representing each of the same 3 fields. METHODS: Guided by a grounded theory method, a multiple case study approach was used to study the clinical practice of the 6 physical therapists in the 3 fields. RESULTS: A model of clinical reasoning in physical therapy characterized by the notion of "clinical reasoning strategies" is proposed by the authors. Within these clinical reasoning strategies, the application of different paradigms of knowledge and their interplay within reasoning is termed "dialectical reasoning." DISCUSSION AND CONCLUSION: The findings of this study provide a potential clinical reasoning framework for the adoption of emerging models of impairment and disability in physical therapy.     

自体肺动脉瓣移植术在治疗主动脉瓣病变中的应用

目的:总结我院自体肺动脉瓣移植术的临床经验。方法:1994年10月-2005年1月,共完成自体肺动脉瓣移植术42例;术前诊断:先心病、主动脉瓣病变39例,亚急性细菌性心内膜炎合并主动脉瓣关闭不全1例,主动脉瓣人工机械瓣置换术后心内膜炎合并瓣周漏1例,老年退行性病变1例,为重度主动脉瓣狭窄。全组患者术前UCG示主动脉瓣病变,狭窄和/或关闭不全(中重度),主动脉瓣环径(2.45±0.31)cm;肺动脉瓣发育正常,功能良好,肺动脉瓣环径(2.34±0.21)cm;术前心功能2.12级。所有病例均在全麻中度低温体外循环下进行,手术分三步进行:(1)采取自体肺动脉瓣;(2)切除病变的主动脉瓣并移植自体肺动脉瓣于主动脉位,采用主动脉根部移植法;(3)利用同种动脉瓣重建右室流出道。结果:全组患者无手术死亡;术后主动脉平均跨瓣压差在正常范围(6.11±0.12)mmHg,左室舒张末径明显缩小(P<0.01),LVEF0.49±0.23,心功能I~II级。38例患者接受随访,随访1个月~10年,心功能I级,主动脉瓣、肺动脉瓣均功能良好,末见瓣膜狭窄或关闭不全。1例早期手术患者术后6个月出现同种瓣心内膜炎再次手术死亡,另1例患者术后不明原因突发心脏骤停,复苏后应用体外人工膜肺支持一周后心脏功能明显好转,后因经费问题家属要求自动出院。结论:自体肺动脉瓣移植术是一种临床疗效好的治疗主动脉瓣病变的手术方法。     

Outpatient physical therapy cardiovascular assessment: Physical therapist perspective and experience

Background: Physical therapists are recognized healthcare providers who play an important role in cardiovascular disease prevention. Heart rate (HR) and blood pressure (BP) are important parameters in cardiovascular risk assessment; however, physical therapists do not usually integrate them into clinical practice. Therefore, this study aimed to examine the current practice and opinion of outpatient physical therapists toward HR and BP measurements in clinics. Methods: A 12-item survey questionnaire was distributed to outpatient physical therapists. Five senior staff from different specialties, including orthopedic, neurology, pediatric, cardiopulmonary, and sport specialties, participated in a focus group interview to gather their opinions. Results: In total, 285 (56%: male) physical therapists participated. Only 68 (24%) measured HR and BP; of these, 27 (41%) used manual sphygmomanometers. Nearly one-fifth reported that cardiovascular adverse events, such as syncope and chest pain, occurred during therapeutic exercise of their patients and were the highest among the sport and orthopedic physical therapists. Most physical therapists felt that measuring cardiovascular indices is not their job and does not add value to their treatment plan. Conclusion: Majority of the physical therapists were not measuring HR and BP during clinical assessment, although some reported cardiovascular adverse events occurring in their patients.     

Clinical cognition and embodiment

I first identify two different distinctions: between Cartesian cognition and embodied cognition, and between calculative rationality and intuitive know-how. I then suggest that, in the nursing literature, these two distinctions are run together, to create an opposition between 'Cartesian rationality' and 'embodied know-how'. However, it is vital to keep the two distinctions apart, because 'embodied knowing' is very frequently rational. In separating the idea of embodied cognition from non-rational intuition, I show how 'embodiment' leads to the concepts of distributed cognition and distributed expertise. This has extensive and important implications for how we understand clinical cognition in nursing.     

脑磁生理治疗对失眠症的治疗效果

目的观察使用脑磁生理仪治疗失眠症的的临床效果。方法将70失眠症患者随机分为脑生理治疗组（观察组）35例和安定治疗组（对照组）35例。共治疗7 d,停止治疗后观察3 d。观察两组患者用药期间的睡眠状况和停止治疗后3 d的睡眠状况。结果观察组失眠症缓解有效率为91%,对照组失眠症有效率为94%,结果差异无统计学意义（P < 0.05）。而停止治疗后观察组失眠症缓解有效率为91%对照组为11%,结果差异有统计学意义（P>0.05）.结论脑磁生理治疗失眠症安全有效,可作为失眠症的非药物代替疗法。     

Clinical experience with adenovirus in cancer therapy

Gene therapy is emerging as a novel treatment for cancer. Preclinical data utilizing adenovirus vectors have been promising and several clinical trials employing this employing this vector are underway. Data from many phase I trials have established the safety of adenovirus vectors, but have not as yet demonstrated significant therapeutic benefit. In order to refine this approach, continuing efforts are being made to improve antitumor potency, efficiency of gene delivery and accuracy of vector targeting. It is anticipated that adenovirus-mediated gene therapy will be integrated with existing treatment modalities, including surgery, chemotherapy and radiotherapy, to facilitate improvement in cancer treatments in the future.     

辨证施护在外感发热物理降温中的实施体会

目的：探讨中医辨证施护在外感发热物理降温中的应用方法和效果。方法：对22例因外感发热需行物理降温的患者用辨证施护的原理进行护理实践,综合评价降温效果及患者的舒适度。结果：2～4h内19例患者体温降至正常,有效率为86.36%;77.27%的患者认为整个降温过程是舒适可以接受的。结论：中医辨证施护应用于外感发热物理降温中,可有效提高降温效果及患者的舒适度,充分体现了以人为本的护理程序,对保证护理质量和提高整体护理水平有着极其重要的意义。     

Clinical teaching in physical therapy: student and teacher perceptions

Many practicing physical therapists participate in the most crucial phase of a student's education by serving as Clinical Instructors. The purposes of this study were to identify the clinical teaching behaviors perceived as most effective and most hindering by students and CIs and to compare the response rates of students in bachelor's and master's degree programs. A published 58-item questionnaire was completed by 172 participants from eight physical therapy education programs. The results were analyzed by multivariate analysis of variance. The perceived most helpful teaching behaviors pertained to providing information through feedback. The perceived most hindering behaviors were intimidating questioning and correcting student errors in the presence of patients. The different student and CI ratings for the item "leaves student alone until asked to supervise" has important ethical and educational implications. Master's and bachelor's degree students' ratings differed significantly on four teaching behaviors. Different instructional methods might be necessary for educating these students.