From
Southern California:
Sacral
neuromodulation as an effective treatment for refractory pelvic floor
dysfunction
Aboseif
S, Tamaddon K, Chalfin S, Freedman S, Kaptein J. Urology 2002 Jul;60(1):52-6
objectives:
To determine the long-term efficacy and complications of sacral nerve
stimulation as an alternative therapy for pelvic floor dysfunction.
Pelvic floor dysfunction is a complex problem that can be refractory
to current treatment modalities. Conservative therapy rarely results
in a durable cure of patients, and various surgical procedures have
significant side effects and less than optimal results.
methods:
Sixty-four patients, 54 women and 10 men, with various forms of voiding
dysfunction for whom other forms of therapy had failed underwent placement
of the Medtronic Implantable Pulse Generator sacral nerve implant. The
mean age was 47 years. The presenting complaint was frequency, urgency,
and urge incontinence in 44 patients and chronic nonobstructive urinary
retention requiring self-catheterization in 20 patients. Forty-one patients
also had chronic pelvic and perineal pain associated with their voiding
symptoms. The mean duration of symptoms was 69 months. All patients
underwent percutaneous nerve evaluation before the permanent implant
and demonstrated more than 50% improvement in their symptoms. All patients
were evaluated at 1, 3, 6, 12, and 24 months, and yearly thereafter.
The assessment of the voiding symptoms was done both subjectively by
patient symptoms and objectively using voiding diaries recorded for
three days. A validated verbal rating pain scale was used to evaluate
pain levels.
results:
Eighty percent of the patients had 50% or greater improvement in their
presenting symptoms and quality of life after the procedure, with a
mean follow-up of 24 months. Patients with frequency-urgency showed
a reduction in the number of voids per day with a significant increase
in voided volumes. Patients with urge incontinence showed a reduction
in leaking episodes from 6.4 to 2.0/24 hr, with a decrease in the number
of pads used from 3.5 to 1.2/day. Sixteen of 20 patients with urinary
retention were able to void with a residual volume of less than 100
mL. Patients with chronic pelvic pain showed a decrease in the severity
of pain from a score of 5.8 to 3.7. Complications were minimal and encountered
in 18.7% of the patients.
conclusions:
Sacral nerve stimulation is an effective and durable new approach to
pelvic floor dysfunction with minimal complications. Test stimulation
provides a valuable tool for patient selection.
Reprinted
from Urology, Vol 60, Aboseif S, Tamaddon K, Chalfin S, Freedman S,
Kaptein J, Sacral neuromodulation as an effective treatment for refractory
pelvic floor dysfunction, 52-6, Copyright 2002, with permission from
Elsevier Science.
clinical
implication: This article presents a new modality for the treatment
of patients with severe voiding dysfunction, including severe frequency,
urgency, and urge incontinence as well as inadequate bladder emptying.
This procedure should be used after failure of all conservative measures
as pharmacologic therapy and pelvic floor exercises. It is a relatively
simple procedure compared to other invasive surgical procedures as
augmentation cystoplasty. --SA
From
Northern California:
Discontinuation of use and switching
of antidepressants: influence of patient-physician communication
Bull SA, Hu XH, Hunkeler EM, et al. JAMA 2002 Sep 18;288(11):1403-9
context:
Although current depression treatment guidelines recommend continuing
antidepressant therapy for at least four to nine months, many patients
discontinue treatment prematurely, within three months.
objectives: To investigate the relationship between patient-physician
communication and the continuation of treatment with antidepressants
and to explore the demographics, adverse effects, therapeutic response,
and frequency of follow-up visits.
design, setting, and patients: A total of 401 telephone interviews
of depressed patients being treated with selective serotonin reuptake
inhibitor (SSRI) therapy between December 15, 1999, and May 31, 2000,
were conducted and 137 prescribing physicians completed written surveys
from Northern California Kaiser Permanente health maintenance organization
outpatient clinics.
main outcome measures: Patient-physician communication about therapy
duration and about adverse effects; therapy discontinuation or medication
switching within three months after start of SSRI therapy.
results: Ninety-nine physicians (72%) reported that they usually
ask patients to continue using antidepressants for at least six months,
but 137 patients (34%) reported that their physicians asked them to
continue using antidepressants for this duration and 228 (56%) reported
receiving no instructions. Patients who said they were told to take
their medication for less than six months were three times more likely
to discontinue therapy (odds ratio [OR], 3.12; 95% confidence interval
[CI], 1.21-8.07) compared with patients who said they were told to continue
therapy longer. Patients who discussed adverse effects with their physicians
were less likely to discontinue therapy than patients who did not discuss
them (OR, 0.49; 95% CI, 0.25-0.95). Patients who reported discussing
adverse effects with their physicians were more likely to switch medications
(OR, 5.60; 95% CI, 2.31-13.60). Fewer than three follow-up visits for
depression, adverse effects, and lack of therapeutic response to medication
were also associated with patients' discontinuing therapy.
conclusions: Discrepancies exist between instructions that physicians
report they communicate to patients and what patients remember being
told. Explicit instructions about expected duration of therapy and discussions
about medication adverse effects throughout treatment may reduce discontinuation
of SSRI use. Our finding that patients with three or more follow-up
visits were more likely to continue using the initially prescribed antidepressant
medication suggests that frequent patient-physician contact may increase
the probability that patients will continue therapy. Copyright
2002, American Medical Association
From
Southern California:
Surgical treatment for stress urinary
incontinence with urethral hypermobility: what is the best approach?
Chien
GW, Tawadroas M, Kaptein JS, et al. World J Urol 2002 Sep;20(4):234-9
A comparative
study evaluating the results of three surgical procedures for stress
urinary incontinence (SUI) with urethral hypermobility. This is a retrospective
study of 189 patients, evaluating the outcomes of the percutaneous needle
suspension using bone anchors (PNS), abdominal suspension (AS), and
pubovaginal sling (PVS). The mean follow-up was 30.5 months. In our
results, the patients were divided into three groups: PNS (49), AS (34),
and PVS (106). No differences were found preoperatively. Intraoperatively,
PNS had the shortest operative time and lowest estimated blood loss,
and it is the only outpatient procedure. However, it had the highest
complication rate. PNS had the lowest satisfactory rate (16.7%). This
was followed by AS (78%), PVS with cadaveric fascia (90%), and PVS with
autologous fascia (94%). In conclusion, PNS is a simple outpatient procedure,
but the long-term results are disappointing. Both AS and PVS gave good
results. PVS was superior to AS in shorter hospitalization, early recovery
and overall patient satisfaction. http://link.springer.de/
clinical
implication: Many procedures have been described for stress urinary
incontinence. Most studies have reported separate series of pubovaginal
sling (PVS) and abdominal suspension (AS) with good results. In our
study we were able to compare three commonly used procedures: the
needle suspension, AS, and PVS. We found that PVS has the best result
and patient satisfaction. On the contrary, needle suspension has the
worst result and patient satisfaction. We learned from our study that
the most minimally invasive procedure may not be effective for stress
urinary incontinence. PVS appears to be most efficacious due to its
ability to create fibrosis from the sling on the posterior bladder
neck and urethra. --GC
From
the Northwest:
Adapting
to psychiatric disability and needs for home- and community-based care
Green CA, Vuckovic NH, Firemark AJ. Ment Health Serv Res 2002 Mar;4(1):29-41
The objective
of the study was to describe adaptation strategies and use of formal
and informal support by individuals with psychiatric disabilities, to
delineate remaining needs, and to determine how home- and community-based
services might address those needs. Using in-depth interviews and structured
questionnaires, we examined functional status, adaptation, and needs
for home- and community-based care among 33 severely mentally ill members
of a large health maintenance organization. Despite success in community
living, participants had significant functional deficits (physical and
emotional), relied heavily on only one or two key informal caregivers,
and often needed significant support from mental health professionals.
Limited numbers of caregivers and social isolation placed participants
at risk of negative outcomes if informal support resources were to be
lost. Home- and community-based care interventions that attempt to increase
informal support networks and provide instrumental help (cooking, cleaning,
transport) on short notice during flare-ups could augment existing (but
limited) informal caregiving, help severely mentally ill individuals
remain independent, and reduce the likelihood that loss of an informal
caregiver would result in unwanted outcomes. www.wkap.nl/prod/j/1522-3434
clinical
implication: Primary care providers should be alert to special
needs and risks for loss of functioning among patients with serious
mental health problems. These patients may need additional support
during flare-ups, are likely to have important medical comorbidities,
and may be at increased risk for poor health and social outcomes if
the support of informal caregivers is lost. Working with patients
and caregivers to enhance informal and formal sources of community-based
care could reduce risk for loss of independence and improve outcomes.
-- CG
From
the Northwest:
Steps to Soulful Living (Steps):
a weight loss program for African-American women
Karanja N, Stevens VJ, Hollis JF, Kumanyika SK. Ethn Dis 2002 Summer;12(3):363-71
background:
The disproportionate disease burden experienced by African-American
women can be explained partially by the higher rates of obesity in this
population. African-American women who can benefit from weight loss
may be less likely to attempt it and may have relatively less success
in using traditional weight loss programs compared to white women. Steps
to Soulful Living (Steps) was a pilot study to test the effects of a
culturally adapted weight loss program on weight loss in African-American
women.
methods:
Sixty-six African-American women participated in a six-month weight
loss program that included weekly group meetings and supervised exercise
sessions. Mean baseline body mass index was 39 kg/m2, and mean baseline
weight was 107 kg. Cultural adaptations, defined as program adjustments,
made in response to women's preferences as expressed in focus group
interviews included changes in intervention format, the content of the
group meetings, and the location and format of the exercise sessions.
results: Seventy-six percent of the participants attended at
least 50% of the 26 weekly sessions, and 56% attended at least 75% of
the sessions. Average hours of exercise per week approximately doubled
during the program in comparison to baseline levels. Mean weight loss
at 26 weeks was 3.7 kg, categorizing those who were lost to follow-up
as having zero weight loss. Participants who attended at least 75% of
the group meetings lost a mean of 6.2 kg at six months. Those who attended
fewer meetings lost a mean of 0.9 kg.
conclusions:
This six-month program was associated with relatively larger weight
losses, particularly among participants with high attendance, than have
usually been observed in culturally adapted programs for African-American
women.
From
Colorado:
Meningococcal vaccine use in college
students
Kelleher JA, Raebel MA. Ann Pharmacother 2002 Nov;36(11):1776-84
objective:
To discuss the role of meningococcal vaccine in prevention of meningococcal
disease.
data sources: A MEDLINE search (1966-June 2001) was performed to
identify key literature. Search terms included, but were not limited
to, meningococcal vaccines, meningococcal meningitis, meningococcal
infection, and meningococcus. The search was limited to English-language
literature and references dealing with humans. The MEDLINE search was
supplemented by a hand search of various bibliographies.
data synthesis: The impact of meningococcal disease has caused national
and regional organizations to develop recommendations for use of meningococcal
vaccine. Even though the meningococcal vaccine can provide benefit,
limitations exist. The available vaccine does not cover all meningococcal
strains and is not useful in all age groups. The appropriate target
groups for prevention of disease through vaccination have been difficult
to determine; vaccine use in college students is especially controversial.
conclusions: Although a meningococcal vaccine is available, meningococcus
causes significant morbidity and mortality. Controversy exists over
the meningococcal vaccine and its use. Students entering college who
will be living in dormitories should be informed of the increased risk
of meningococcal disease and be offered vaccination.
clinical
implication: Even though meningococcal disease carries a significant
risk for morbidity and mortality, not everyone is an appropriate vaccination
candidate. An understanding of the vaccine and who is at an increased
risk for disease is important in determining who should be vaccinated.
In particular, college students living in dormitories are at an increased
risk of disease, and therefore, need to be informed of their risk
for meningococcal disease, as well as the benefits and limitations
of the vaccine. This knowledge can help health care providers, parents,
and potential vaccine candidates make more informed decisions about
receiving the vaccine. --JK
From
Southern California:
Health resource utilization of the
emergency department headache "repeater"
Maizels
M. Headache 2002 Sep;42(8):747-53
objective:
To document the health resource utilization of patients who repeatedly
use emergency department services for headache care.
background: Patients with headache who frequently use emergency
department services may differ from patients with more typical, episodic
migraine. Previous studies of health resource utilization have often
failed to distinguish the high utilizer as a specific subset of the
migraine population.
design:
Retrospective review of urgent care/emergency department charts, clinic
charts, and pharmacy rosters.
patients
and methods: Patients who made three or more visits for headache
to an urgent care/emergency department (UC/ED) facility for headache
over a six-month study period were identified and designated as "repeaters"
for this study. Pharmacy profiles and appointment histories of 52 of
the 54 repeaters whose records were available were reviewed for the
12 months prior to the study period.
results:
Over the six-month study period, 518 patients visited the UC/ED 1004
times for primary headache complaints. Fifty-four (10%) repeaters made
502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months
prior to the study period, 52 of these repeaters made 1832 visits to
the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache
related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated
12-month cost for all visits was $183,760. Pharmacy rosters showed use
of narcotics in 41 of the 52 patients (annual mean ± SD, 613 ±
670 tablets), benzodiazepines in 30 patients (500 ± 486 tablets),
and butalbital products in 27 patients (395 ± 590 tablets). Mean
daily use of all symptomatic medications combined was 3.9 ± 3.2
doses/day.
conclusion:
Health resource utilization of emergency department headache repeaters
is predominantly headache-related acute care. Associated medication
overuse is frequently present. Efforts to improve care for patients
with headache will benefit from distinguishing the high utilizer as
a subset of the migraine population.
clinical
implication: A bias which prevents the appropriate care of headache
patients who present to an Emergency Department is that they are thought
of as drug seekers. Over a six-month study period, 518 patients visited
the UC/ED 1004 times for primary headache complaints. Fifty-four (10%)
of the patients made 502 (50%) of these visits. Thus, although the
"repeaters" represent only 10% of the headache patients,
every other headache visit in the ED is by a "repeater."
An estimate of health-related cost for 52 of these patients in the
previous 12 months was $183,760. The ED headache "repeater"
is a minority of headache patients, but uses health resources disproportionately,
and may benefit from a multidisciplinary approach. --MM
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