Perspectives of patients with cystic fibrosis on preventive counseling and transition to adult care

The purpose of this study was to investigate how adolescents and adults with cystic fibrosis (CF) view preventive counseling and their transition to adult-centered care within a children's hospital. Thirty-two patients >/=16 years old diagnosed with CF were recruited from a pediatric tertiary care setting. During face-to-face interviews, patients were asked 27 structured questions and completed a 30-item self-administered questionnaire on preventive counseling by healthcare providers and on transition issues. The median age of patients was 25.5 years (range, 16-43 years); 69% of patients identified a pulmonologist as their "main doctor," even though 78% had a primary care provider. Participants felt that 13-16 years of age was the best time for them to begin spending time alone with their main doctor. Less than half of the participants recalled receiving preventive counseling during the previous 12 months, and more patients wanted to discuss issues than actually did. Qualitative data emphasized the importance of independence in making decisions in healthcare and establishing relationships with providers, and many patients did not desire to transfer care to an adult hospital. Participants identified adult-focused services such as inpatient rooms, discussion groups, work options, and social service support that would enhance care. In conclusion, the majority of adolescent/young adult patients with CF receiving care in a pediatric institution reported satisfaction with their healthcare. However, patients identified preventive issues that they desired to be more regularly addressed, starting in early adolescence, and changes in the delivery of services to enhance transition to adult-oriented care. This study underscored the understanding of the integration of transition planning into the facilitation of healthcare decision-making by the adolescent in issues of self-care, sexuality, education, and finances. Future initiatives to enhance the care of patients with CF should provide training of pulmonologists in preventive care and increased attention to helping patients utilize appropriate primary-care services during the adult years. In addition, prospective studies are needed to compare outcomes of CF patients who have transitioned and transferred to adult hospitals and those transitioning to adult-oriented services in a pediatric institution.     

Understanding statistics. Putting p-values into perspective

Understanding statistics can be one of the more difficult and daunting tasks facing the clinician attempting to understand and use the research literature. While the fundamental aim of including statistics in literature is to justify the conclusions and to enhance the information presented, all too often, statistics serve only to intimidate and alienate clinicians. There are two sources for this barrier to understanding: poor comprehension of statistics by clinicians, and inappropriate presentation of statistics by researchers. In the third of our papers on evidence-based practice and the clinician, some basic principles of statistics are introduced. Aspects such as the concepts of clinical and statistical significance are discussed, and an outline of the appropriate use of specific statistics is provided. The hope is that this will enable the clinician to better judge the applicability of statistical techniques as applied in the published literature. Some of the newer, more 'clinician friendly' statistical approaches are also presented. Finally some of the cheats and shortcuts commonly encountered in the presentation of research are discussed, and the methods for dealing with them are outlined.     

Serum-derived IgG1-mediated immune exclusion as a mechanism of protection against H. pylori infection

The induction of protective immunity against Helicobacter challenge in a murine model was found to correlate with the magnitude of IgG (serum and gastric lavage) responsiveness to intra-nasal (i.n.) immunisation. IgG1-secreting hybridoma backpacks in Helicobacter pylori (H. pylori)-infected mice revealed serum transudation into the stomach. A Lpp20-specific monoclonal antibody was associated with significantly reduced H. pylori colonisation. Histology revealed aggregates of the remaining H. pylori in these mice, suggesting a role for IgG1-mediated immune exclusion of the bacteria. In vitro immunogold electron microscopy supported this hypothesis, but also suggested that a threshold of H. pylori-specific antibody needs to be maintained if immune exclusion by the host is to overcome immune evasion by the bacteria.     

Results of simultaneous bilateral total knee replacement: a study of 1208 knees in 604 patients

Bilateral symptomatic knee arthritis is a common clinical problem. There are conflicting opinions as to the advisability of simultaneous sequential bilateral total knee replacement. Complication rates of primary unilateral knee replacement are well documented and there are several small series that compare the two techniques. The objective of this study was to identify the complication rate of simultaneous sequential bilateral total knee replacement in a large patient population. Over a 13-year period, 604 primary bilateral sequential simultaneous total knee replacements (1208 knees) were performed. Office notes and hospital charts were retrospectively reviewed to obtain age, sex, diagnosis, knee alignment, associated comorbidities, operative protocol, transfusions, and complications. The study results showed 5.1% local and 15.3% systemic complications and 0.7% mortality rate (none in the past 9 years). With appropriate patient selection and operative technique, patients who present with bilateral symptomatic knee arthritis can enjoy the benefits of simultaneous sequential bilateral total knee replacement without increasing their risks of complications.     

An evaluation of two foot-specific,health-related quality-of-life measuring instruments

In the past decade, health-related quality-of-life (HRQoL) assessment has become an important tool to measure change as a result of treatment in clinical trials. The aim of this project was to compare and contrast two foot-specific HRQoL questionnaires: the Foot Function Index (FFI) and the Foot Health Status Questionnaire (FHSQ). To assist in this process, a quasi-experimental trial was performed to evaluate the effectiveness of foot orthoses in improving HRQoL in people suffering from plantar fasciitis. The results from this study found that the FFI is generally less responsive to change, particularly in the domain of Activity Limitation. Nevertheless, significant improvements were found for two out of the three domains (Pain and Disability, but not Activity Limitation) for the FFI, as well as the overall score of FFI. In contrast, all four domains (Pain, Function, Footwear and General Foot Health) of the FHSQ showed significant improvement. Our experience with the questionnaires also revealed that certain questions in the Activity Limitation domain of the FFI can lead to inconsistent scoring, thus casting doubts over the suitability of this domain for use with patients with plantar fasciitis. Therefore, the FHSQ has several advantages when evaluating HRQoL in patients being treated with foot orthoses for plantar fasciitis, and should be viewed as the preferred questionnaire.     

Minimally invasive surgical staging for esophageal cancer

Background: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. Methods: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. Results: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n= 1), I (n= 1), II (n= 23), III (n= 20), IV (n= 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. Conclusions: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer. Received: 5 April 1999/Accepted: 15 March 2000/Online publication: 12 July 2000     

International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines

The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) formulated new evidenced-based recommendations for neonatal resuscitation. These guidelines comprehensively update the last recommendations, published in 1992 after the Fifth National Conference on CPR and ECC. As a result of the evidence evaluation process, significant changes occurred in the recommended management routines for: * Meconium-stained amniotic fluid: If the newly born infant has absent or depressed respirations, heart rate <100 beats per minute (bpm), or poor muscle tone, direct tracheal suctioning should be performed to remove meconium from the airway. * Preventing heat loss: Hyperthermia should be avoided. * Oxygenation and ventilation: 100% oxygen is recommended for assisted ventilation; however, if supplemental oxygen is unavailable, positive-pressure ventilation should be initiated with room air. The laryngeal mask airway may serve as an effective alternative for establishing an airway if bag-mask ventilation is ineffective or attempts at intubation have failed. Exhaled CO(2) detection can be useful in the secondary confirmation of endotracheal intubation. * Chest compressions: Compressions should be administered if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds. The 2-thumb, encircling-hands method of chest compression is preferred, with a depth of compression one third the anterior-posterior diameter of the chest and sufficient to generate a palpable pulse. * Medications, volume expansion, and vascular access: Epinephrine in a dose of 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) should be administered if the heart rate remains <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions. Emergency volume expansion may be accomplished with an isotonic crystalloid solution or O-negative red blood cells; albumin-containing solutions are no longer the fluid of choice for initial volume expansion. Intraosseous access can serve as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available. * Noninitiation and discontinuation of resuscitation: There are circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate.