Pediatricians' awareness of and attitudes about four clinical practice guidelines

BACKGROUND: The increasing complexity of medical care and a desire to increase quality and control costs have led to growing use of clinical practice guidelines (CPGs). It is unclear how helpful these guidelines are to the practitioners expected to use them. We surveyed pediatricians about their knowledge and impressions of four well-publicized CPGs: the American Academy of Pediatrics' "Practice Parameter for Hyperbilirubinemia in Newborns" (hyperbilirubinemia), "A Guideline for the Management of Febrile Infants" (fever), the Agency for Health Care Policy and Research's "Guideline for Otitis Media With Effusion" (otitis), and the US Preventive Services Task Force Guide to Clinical Preventive Services (preventive care). OBJECTIVES: 1) What percentage of practicing pediatricians are aware of these guidelines? 2) How helpful do they find them? 3) What are practitioners' perceived limitations of these guidelines? 4) Have these guidelines affected provider behavior? 5) Are there features of a provider's training or practice that are associated with changing practice as a result of guidelines? DESIGN: A national survey of 600 pediatricians selected at random from the American Medical Association master file. RESULTS: A total of 300 of 555 eligible participants (54%) returned surveys. Of the respondents, 66% were aware of the hyperbilirubinemia guideline, 64% of the fever guideline, 50% of the otitis guideline, but only 16% knew of the preventive care guidelines. Mean helpfulness scores (1 to 10 scale, where 1 = "not at all helpful" and 10 = "extremely helpful") ranged from 3.67 to 6.67 for the different guidelines. In terms of limitations, 15% to 33% of respondents reported that CPGs were "too cookbook," 6% to 19% reported that they were "too time-consuming," and 4% to 16% reported that they were "too cumbersome." Additional reported limitations were believing that a guideline left no room for personal experience and judgment, concern of increased liability risk, and poor parental acceptance of CPG recommendations. The proportions reporting change in management as a result of a CPG were 28% for the hyperbilirubinemia guideline, 36% for the fever guideline, 19% for the preventive care guidelines, and 28% for the otitis guideline. Mean helpfulness scores reported by nonuniversity-affiliated physicians were significantly higher than those reported by university-affiliated physicians. In a regression model of respondents aware of a particular guideline, more recent graduation from medical school and increased helpfulness scores were associated with guideline-related behavior change. CONCLUSION: In their present form, CPGs are not perceived as very helpful by most practitioners. More recent medical school graduates and nonuniversity-affiliated physicians are more likely to find them helpful and more likely to change their behavior because of them.     

Cross-sectional analysis of the implant-abutment interface

The purpose of this study was to develop a technique to evaluate the implant-abutment gap of an external hexagon implant system as a function of radius. Six implants of 3.75 mm in diameter (Conexao Sistema de Protese Ltda, Sao Paulo, Brazil) and their respective abutments were screw connected and torqued to 20 N cm(-1). The implants were mounted in epoxy assuring an implant long-axis position perpendicular to the vertical axis. Each implant was grounded through its thickness parallel to implant long-axis at six different distance interval. Implant-abutment gap distances were recorded along the implant-abutment region for each section. Individual measurements were related to their radial position through trigonometric inferences. A sixth degree polynomial line fit approach determined radial adaptation patterns for each implant. Micrographs along implant sections showed a approximately 300 mum length implant-abutment engagement region. All implants presented communication between external and internal regions through connection gaps and inaccurate implant-abutment alignment. Average gap distances were not significantly different between implants (P > 0.086). Polynomial lines showed implant-abutment gap values below 10 mum from 0 mum to approximately 250 mum of the implant-abutment engagement region. Gap distances significantly increased from approximately 250 mum to the outer radius of the implant-abutment engagement region. The technique described provided a broader scenario of the implant-abutment gap adaptation compared with previous work concerning implant-abutment gap determination, and should be considered for better understanding mechanical aspects or biological effects of implant-abutment adaptation on peri-implant tissues.     

Tear of the distal biceps branchii tendon: A new method of ultrasound evaluation

Tear of the distal biceps brachii tendon is an uncommon injury. Ultrasound evaluation of the distal tendon using an anterior approach is often difficult because of technical factors. We describe a new method of ultrasound evaluation of the distal biceps tendon insertion. This involves a posterior approach with the forearm pronated. With pronation of the forearm, the radial tuberosity faces posteriorly, bringing the distal biceps tendon insertion into view. A surgically proven case of distal biceps tendon tear is presented to illustrate our technique.     

Cerebral Embolism Due to a Retained Pacemaker Lead: A Case Report

There are only a few reported cases of a pacemaker lead migrating inadvertently into the left atrium or ventricle. An unusual complication of unremoved, unwanted pacemaker lead is presented. The free tip of the lead caused cerebral embolism after perforating the interatrial septum.     

The effect of antibody against TNF alpha on cytokine response in Jarisch-Herxheimer reactions of louse-borne relapsing fever

Severe Jarisch Herxheimer reaction (J-HR) precipitated by antibiotic treatment of louse-borne relapsing fever (LBRF) is associated with a transient, marked rise in circulating tumour necrosis factor alpha (TNF alpha), interleukin 6 (IL-6) and interleukin 8 (IL-8). Ovine polyclonal anti-TNF alpha antibody fragments (Fab) were used in a randomized double blind placebo controlled trial in an attempt to prevent this reaction. Within 4 h after penicillin, in controls (n = 29), a several- fold rise in cytokines occurred, concomitant with a fall in spirochaetes and maximal clinical manifestations of the J-HR. An intravenous infusion of anti-TNF alpha Fab, 30 min before penicillin in 20 patients reduced peak plasma levels of IL-6 and IL-8 (but not IL-1 beta) compared with controls (p = 0.01 and < 0.001, respectively) and the incidence of the J-HR, indicating some neutralization of TNF alpha. An apparent fall in TNF alpha reflected interference of anti-TNF alpha in the immunoassay.      

不断提高异基因造血细胞移植的疗效

1957年美国著名血液学家Thomas教授首先成功地应用异基因骨髓移植（allogeneic bone marrow transplantation，allo-BMT）治疗恶性血液病，并以此获得诺贝尔医学奖。此后allo-BMT技术不断改进，并在世界范围内迅速开展，目前已成为治愈恶性血液病的重要方法。亚洲的骨髓移植首先于20世纪60年代初在北京获得成功，为应用同基因骨髓移植治愈1例重型再生障碍性贫血患者。经历了十年动乱暂时无奈中断研究后，80年代初作者等又成功地将allo-BMT应用于恶性血液病的治疗，之后该项技术在全国不断开展，逐渐成熟，并已形成规模，且在许多方面已达到或超过国际水平。     

The Treatment of Septicemia in Pacemaker Patients

The authors analyzed the data of seven patients who had undergone open heart surgery because of pacemaker endocarditis in the past 4 years. Repeated surgical interventions on the pacemaker system were found to be the most common predisposing factors. Staphylococcus aureus and Staphylococcus epidermidis were the most common causative organisms. Two-dimensional echocardiography was important in the diagnosis of cases with atypical clinical picture and negative blood cultures. We concluded that: (1) any pacemaker patient with fever should be considered to have a pacemaker endocarditis; (2) all of these patients should be examined by two-dimenensional echocardiography; and (3) the total removal of the infected hardware seems to be the only way to achieve complete recovery.     

Management Strategies for Pain in Breast Carcinoma Patients: Current Opinions and Future Perspectives

Breast cancer is the most frequently encountered carcinoma in women worldwide. Pain is the most distressing symptom in patients with breast carcinoma and can occur at all stages of the disease due to the cancer per se as well as due to various diagnostic and treatment modalities. A proper pain assessment helps in identification of pain syndromes and guides in formulating analgesic strategies. Primary therapies of breast carcinoma like surgery, chemotherapy, and radiotherapy for bony metastases can cause substantial pain relief. However, multimodal analgesic approaches incorporating pharmacological, interventional as well as non-conventional techniques should be employed prior to, in conjunction with, and after primary therapies of breast cancer. The prevalence of chronic neuropathic pain following breast cancer surgery may exceed 50% by current estimates, and with the increase in life expectancy of these patients, providing adequate pain relief is of paramount importance to improve their quality of life. In this review, we discuss prevailing methods of evaluation and management of pain in patients of breast carcinoma and the new techniques that may become the mainstay of pain management protocols in future.     

Relationship between estimated aerobic fitness and injury rates among active duty at an Air Force base based upon two separate measures of estimated cardiovascular fitness

With the increased focus on physical fitness and increased fitness regimens, overuse injuries in United States Air Force (USAF) personnel are increasing. We evaluated injuries and level of fitness among a large population-based sample of USAF men and women aged 18 to 60 years from 2003 to 2005. Aerobic capacity was estimated by submaximal cycle ergometry fitness test and the 1.5-mile run. There was an increase of 6.04 mL kg(-1) min(-1) in approximate maximal oxygen uptake (VO2 max) for men and 3.25 mL kg(-1) min(-1)for women with the run test results versus the cycle ergometry test. The results showed increased injuries and higher VO2 max scores during the implementation of a new "Fit to Fight" fitness program.