Training in back care to improve outcome and patient satisfaction. Teaching old docs new tricks

BACKGROUND

We examined clinical outcomes and patient perceptions of back care given by physicians before and after an intensive course of training in back care and limited manual therapy techniques.

METHODS

From a prospective observational cohort study of low back pain involving 208 physicians (115 primary care) and their patients and a subsequent clinical trial of treatment of low back pain given by 31 physicians specially trained in manual therapy and enhanced back care, outcome data from the patients of 13 physicians participating in both studies were compared. In the observational study, the 13 physicians cared for 120 patients. In the manual therapy trial (191 patients) a control group of 94 patients received enhanced back care and an intervention group of 97 patients received enhanced back care plus manual therapy. Pearson's chi-square comparisons and linear and Cox proportional hazard modeling were used to examine effects of variables and recovery time.

RESULTS

Characteristics of the 13 physicians' patients in the cohort group and the manual therapy trial showed some differences in income, workers' compensation, previous employment, and baseline dysfunction. Both control and intervention patients in the manual therapy trial showed more rapid improvement in functional status over time and greater satisfaction with their care than those in the previous cohort study. However, there was no difference between the studies in patient-reported time to return to performing usual daily activities.

CONCLUSIONS

A structured clinical approach to low back care may bring modestly improved clinical outcomes and patient satisfaction.

Strength in numbers: the ARISE method for mobilizing family and network to engage substance abusers in treatment. A Relational Intervention Sequence for Engagement

The model described in this paper takes into consideration two key findings: (a) In a given year, the vast majority (90-95%) of active substance abusers do not enter treatment or self-help groups, and (b) substance abusers have frequent contact with their families (60-80% either live with a parent or are in daily contact). This paper presents a method for mobilizing and collaborating with families and extended the support system toward working with resistance and getting the substance abuser into treatment. Principles and techniques are provided for convening and structuring intervention network meetings toward that end. This intervention network approach can be used either alone or as part of an overall model, ARISE (A Relational Intervention Sequence for Engagement). The ARISE model addresses both clinical and programmatic issues in treatment engagement for substance abusers.

Allergic bronchopulmonary aspergillosis in the asthma clinic. A prospective evaluation of CT in the diagnostic algorithm

OBJECTIVE

Allergic bronchopulmonary aspergillosis (ABPA) occurs in cases of atopic asthma and may result in important lung disease. Early diagnosis is essential as this disease is responsive to steroids. However, while asthma is common, ABPA is infrequently diagnosed. CT allows precision in the diagnosis of central bronchiectasis (which is virtually pathognomonic of ABPA) and may enable earlier diagnosis.

DESIGN

A prospective evaluation of 255 patients with asthma for ABPA, using skin prick testing (SPT) for Aspergillus fumigatus (AF) as a screening tool and incorporating CT into the diagnostic algorithm.

SETTING

Asthma clinic, Green Lane Hospital, Auckland, New Zealand.

PARTICIPANTS

Patients with asthma.

INTERVENTIONS

ABPA was diagnosed using "essential" criteria (ie, asthma, SPT positivity to AF, elevated serum total IgE, elevated serum AF-specific IgE, and pulmonary infiltrates seen on chest radiography or central bronchiectasis seen on CT scan) and "minimal essential" criteria (ie, asthma, SPT positivity, and central bronchiectasis).

MEASUREMENTS AND RESULTS

Two hundred fifty-five consecutive patients with asthma who consented to SPT were studied: 218 of 255 patients (86.8%) were atopic; and 47 of 255 patients (21.6%) were AF-positive, of whom 35 accepted further evaluation including CT scanning. A secure diagnosis of ABPA, satisfying all essential criteria, was evident in 9 of 35 patients (25.7%), a proportion that increased to 13 of 35 patients (37.1%) by using the minimal essential diagnostic criteria.

CONCLUSIONS

SPT positivity to AF was present in approximately 20% of patients in the asthma clinic. A diagnosis of ABPA is disclosed by CT in 25 to 40% of SPT-positive patients, depending on the selection of diagnostic criteria. These findings support the use of SPT as a screening tool in the asthma clinic and indicate that a routine CT scan is warranted in SPT-positive patients.

A phase II study of two cycles of high-dose chemotherapy with autologous stem cell support in patients with metastatic breast cancer who meet eligibility criteria for a single cycle

Multi-cycle high-dose chemotherapy with autologous stem cell support (HDC-ASCS) may improve the results obtained with single-cycle HDC-ASCS in metastatic breast cancer (MBC). However, the tolerability and efficacy of additional cycles of HDC-ASCS in patients selected using standard eligibility criteria for single cycle HDC-ASCS is uncertain. Twenty-nine patients with MBC and a CR or PR to induction chemotherapy were selected by standard institutional eligibility criteria for single-cycle HDC-ASCS. Cycle 1 HDC-ASCS (cyclophosphamide 6 g/m2; mitoxantrone 70 mg/m2; carboplatin 800 mg/m2) was followed by a planned second cycle (etoposide 1.6 g/m2; thiotepa 800 mg/m2; carboplatin 800 mg/m2 modulated by tamoxifen 120 mg/m2/day x 5 days) with a median interval of 3.2 months. CR rate was 20% after induction chemotherapy and 33% and 54% after HDC cycles I and II, respectively. Sixteen patients (55%) failed to complete HDC cycle II within 200 days because of disease progression, toxicity, inadequate stem cell collection, insurance denials or patient choice. Median progression-free survival (PFS) for all 29 patients entered is 301 days from date of HDC cycle I and actuarial PFS at 2 years is 35%. For the 13 patients who received the two cycles of HDC-ASCS, actuarial PFS at 2 years was 54% (P = NS compared to those receiving only one cycle). These data show that a second cycle of full-dose intensity HDC-ASCS may increase the proportion of patients with MBC that achieve CR and may increase PFS. However, a large proportion of patients that complete HDC-ASCS cycle I may fail to proceed to cycle II in a timely fashion. Bone Marrow Transplantation (2000) 25, 519-524.

Estimation of fetal weight: mean value from multiple formulas

Mean fetal weight value from multiple formulas was compared to fetal weight from single formulas. Data were collected on 975 fetuses who had estimation of fetal weight by ultrasonography within 1 week before birth. Improvement in estimation of fetal weight occurred using either the mean value of multiple formulas or the Hadlock BPD/FL/AC, in comparison to fetal volume, BPD/AC, or FL/AC. BPD/FL/AC appeared to provide the best estimate of true weight in terms of overall accuracy and in terms of not showing a trend in either overestimating or underestimating true weight.

Anticonvulsant and sodium channel-blocking properties of novel 10,11-dihydro-5H-dibenz[b,f]azepine-5-carboxamide derivatives

A series of esters of the major metabolite of oxcarbazepine (2), 10, 11-dihydro-10-hydroxy-5H-dibenz[b,f]azepine-5-carboxamide, were synthesized and evaluated for their anticonvulsant and brain sodium channel-blocking properties. The compounds were assayed intraperitoneally and per os in rats against seizures induced by maximal electroshock (MES). Neurologic deficit was evaluated by the rotarod test. The enantiomeric acetates (R)-11 and (S)-12 were the most active of the series against MES-induced seizures with oral ED(50) values at t(max) of 10.9 +/- 2.3 and 4.7 +/- 0.9 mg/kg, respectively. After intraperitoneal administration, carbamazepine (1) behaved more potently than 2 and all other new dibenz[b, f]azepine-5-carboxamide derivatives in the MES test; compounds 2 and 12 were equally potent. In the rotarod test, low doses of 1 produced considerable motor impairment, which did not occur with 2, enantiomeric alcohols (S)-6, (R)-7, and racemic alcohol 8, or racemic acetate 10 or (R)-11. The potencies of the racemic and enantiomerically pure alcohols 8, (S)-6, and (R)-7 derived from 2 in the MES and rotarod test were found to be similar between them, and consequently they exhibit similar protective index values. All three forms of the alcohol and their corresponding acetates (pairs 8 & 10, 6 & 12, and 7 & 11) were found to differ in the MES or rotarod tests; the ED(50) value for (S)-6 against MES-induced seizures was nearly 3-fold that for (S)-12. The protective index also differed markedly between all stereoisomers of the alcohol and their corresponding acetates, most pronouncedly for compound (S)-12 which attained the highest value (12.5) among all compounds tested. Blockade of voltage-sensitive sodium channels was studied by investigating [(3)H]batrachotoxinin A 20-alpha-benzoate ([(3)H]BTX) binding. Acetates (R)-11 and (S)-12 were more potent than the standards 1 and 2 at inhibiting the binding of [(3)H]BTX to sodium channels and the influx of (22)Na(+) into rat brain synaptosomes. It is concluded that acetates (R)-11 and (S)-12 are not simple metabolic precursors of alcohols (R)-7 and (S)-6 in rodents but that they possess anticonvulsant and sodium channel-blocking properties in their own right.

Community physicians who provide terminal care

BACKGROUND

Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians.

OBJECTIVE

To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices.

METHODS

Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings.

RESULTS

Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making.

CONCLUSIONS

Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.

The "concerned other" call: using family links and networks to overcome resistance to addiction treatment

Untreated chemical dependency costs the United States over $165 billion annually. Meanwhile, treatment offsets these costs by a ratio of $7 saved for every $1 spent. But the vast majority of chemically dependent people (CDPs) remain uninvolved in either treatment or self-help groups. It is therefore imperative that more effective ways be developed for therapeutically engaging them. One avenue is to maximize the opportunity presented when a "concerned other" (CO) person-such as a family member, friend, coworker, or clergy member-contacts a treatment agency to get help for a CDP. This paper provides a method for handling such calls. Specific guidelines are presented as to (a) the kind of information to b e gathered, (b) procedures to be followed, and (c) options to be offered toward mobilizing the CO and other family/social network members in successfully effecting CDP treatment engagement.

Prosocial coping and substance use during pregnancy

In structured interviews of pregnant inner-city residents, 38 substance users reported more current liking of drugs and polysubstance use, disengagement coping, depressive symptoms, negative affect, and antisocial behavior than did 45 nonusers. During videotaped interviews, trained observers coded less warmth and less prosocial information exchange (e.g., self-disclosure, question asking) among users. Factor analysis of measures of coping and its concomitants yielded a three-factor (prosocial, antisocial, asocial) solution, with asocial and antisocial coping predominating among substance users. These results suggest that coping has emotional, social, and cognitive elements. This study is the first to demonstrate an association between a substance-using lifestyle and limited prosocial information exchange.

Patterns and determinants of multiple provider use in patients with acute low back pain

OBJECTIVE

To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost.

METHODS

The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up.

MAIN RESULTS

Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p < .05) associated with seeking care from multiple provider types. Age, race, gender, and education were not significant. The adjusted proportions of multiple provider type use were 14% (95% confidence interval [CI] 11%, 17%) for the private primary care provider stratum; 19% (95% CI 16%, 23%) for the chiropractic stratum; 30% (95% CI 23%, 37%) for the orthopedic stratum; and 9% (95% CI 5%, 14%) for the HMO primary care physician stratum. Cost of seeing only the index provider was $439 (95% CI $404, $475), and cost of seeing multiple provider types was $1,137 (95% CI $1,064, $1,211) based on the adjusted model.

CONCLUSIONS

Use of multiple provider types, is associated with several factors, one of which is the initial provider type. The cost of such use is significant.

Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid

OBJECTIVE

To investigate the efficacy of an increased dose of inhaled steroid used within the context of an asthma self management plan for treating exacerbations of asthma.

DESIGN

Randomised, double blind, placebo controlled, crossover trial.

METHODS

Twenty eight children aged 6-14 years with asthma of mild to moderate severity were studied for six months. Eighteen pairs of exacerbations were available for analysis, during which subjects took an increased dose of inhaled steroids or continued on the same dose.

RESULTS

There was no significant difference between increasing inhaled steroids or placebo on morning or evening peak expiratory flow rates (PEFRs), diurnal peak flow variability, or symptom scores in the two weeks following an asthma exacerbation. Difference (95% confidence intervals) in baseline PEFR on days 1-3 were 3.4% (-3.5% to 10.4%) and -0.9% (-4.7% to 2.9%) for inhaled steroid and placebo, respectively. Spirometric function and the parents' opinion of the effectiveness of asthma medications at each exacerbation were also not significantly different between inhaled steroid or placebo.

CONCLUSION

This study suggests that increasing the dose of inhaled steroids at the onset of an exacerbation of asthma is ineffective and should not be included in asthma self management plans.

The ARISE Intervention. Using family and network links to engage addicted persons in treatment

An alternative method to the Johnson Institute's "Intervention" is presented which, while incorporating many of Johnson's innovations, is, additionally: (a) less confrontative, thereby avoiding the reactivity in clients and family members that such confrontational approaches have tended to evoke; (b) takes into account both the needs of the chemically dependent person as well as the needs of the larger family and network system; and (c) aimed toward enrolling substance abusers in outpatient (as well as inpatient) treatment, thus placing it more in line with managed care priorities. Principles for treatment engagement are presented, accompanied by case examples. The approach is part of a more comprehensive model designed to maximize successful engagement with a minimum amount of professional time and effort.

Rapid onset asthma: a severe but uncommon manifestation

BACKGROUND

Studies of asthma death and severe life threatening asthma (SLTA) include reports of patients who had rapid onset asthma. A study was undertaken to determine the relative frequency of rapid (< 6 hours duration) and slow (> or = 6 hours) onset attacks in patients admitted to hospital with acute severe asthma, and to establish whether those with rapid onset asthma differ in terms of risk factors for asthma morbidity and mortality such as indices of asthma severity/control, socioeconomic factors, health care, and psychological factors.

METHODS

A cross sectional study was performed on 316 patients aged 15-49 years admitted with acute severe asthma and interviewed within 24-48 hours of admission.

RESULTS

Patients underestimated the duration of the index attack. Only 27 (8.5%) were classified as rapid onset. There were more men in the rapid onset group than in the slow onset group (52% versus 26%), and there was evidence of socioeconomic advantage in the patients with rapid onset attacks. The rapid onset group had more previous episodes of SLTA and were more likely to present with SLTA, but there was no difference in length of stay in hospital. The rapid onset group were less likely to have presented to a GP during the index attack and were more likely to have used ambulance services. There was no difference between the groups in any psychological or health care measure.

CONCLUSIONS

Rapid onset attacks are an important but uncommon manifestation of asthma that are more likely to present with SLTA in patients who are more likely to have had previous SLTA. Male subjects are at increased risk of rapid onset attacks, and socioeconomic disadvantage, deficiencies in health care (ongoing and acute), and psychological factors are no more common in these patients than in those with attacks of slow onset. These data are consistent with the hypothesis that there is a small proportion of patients with rapid onset severe asthma who do not have the usual risk factors associated with asthma morbidity or mortality, and thus require different management strategies.

What is wrong with end-of-life care? Opinions of bereaved family members

OBJECTIVE

To describe family perceptions of care at the end of life.

METHODS

In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care.

RESULTS

Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%).

CONCLUSION

Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.

Application of asthma action plans to childhood asthma: a national survey

AIM

To determine the frequency of asthma action plan use by doctors in the management of childhood asthma in New Zealand, and their recommendations about the application of an increased dose of inhaled steroids in those plans.

METHODS

A postal survey was sent to all 236 paediatricians and paediatric registrars and to a random sample of 500 general practitioners (GPs) in New Zealand. Questions related to asthma action plan use, the inclusion of an increased dose of inhaled steroid in those plans and details of the way the inhaled steroid dose is adjusted.

RESULTS

Valid responses were received from 168 (71%) paediatricians and paediatric registrars and 340 (68%) GPs. The majority (92.6%) of GPs and paediatricians and paediatric registrars used action plans and 83.6% included a step involving an increased dose of inhaled steroids. Compared with paediatricians and paediatric registrars, GPs gave action plans to a smaller proportion of asthmatic children in their care and included an increased dose of inhaled steroid more often (GPs = 94.5%, paediatricians and paediatric registrars = 57%).

CONCLUSION

In New Zealand the use of asthma action plans is inconsistent with the recommendations contained in published consensus documents in that not all asthmatic children are advised about an action plan. Specific issues relating to this and to the use of an increased dose of inhaled steroids in action plans require clarification and further research.

ARISE: a method for engaging reluctant alcohol- and drug-dependent individuals in treatment. Albany-Rochester Interventional Sequence for Engagement

A method, the Albany-Rochester Interventional Sequence for Engagement (ARISE), is described for engaging highly ambivalent alcohol- and/or drug-dependent individuals in treatment. A three stage interventional sequence is presented, which begins when a family member or concerned other contacts a treatment program regarding a substance abuser who needs help. At that point a process is set in motion for collaboration with significant others toward client enrollment. Staff move to the next stage in a graduated operating procedure if initial, less demanding efforts do not succeed. The final stage, if needed, is a modified Johnson Institute Intervention. The overall procedure is designed to maximize the probability of patient recruitment, while minimizing the amount of time and energy required of staff. The method compares favorably with results obtained with other approaches, such as coercion (legal, employer) and client self-referral.

A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: the Southeast Cholesterol Project

OBJECTIVE

To assess the effectiveness of a cholesterol-lowering intervention designed to facilitate the management of hypercholesterolemia by primary care clinicians.

DESIGN

Randomized controlled trial, with randomization of clinician-patient groups.

SETTING

Twenty-one community and rural health centers in North Carolina and Virginia.

PARTICIPANTS

Primary care clinicians (n = 42, 71% physicians) and the patients they enrolled with high cholesterol (n = 372). Twenty-two clinicians were randomized to give the special intervention (184 patients) and 20 to give usual care (188 patients). Two thirds of participating patients were women, 40% were African American, and 11% were Native American.

INTERVENTION

A 90-minute tutorial to train clinicians how to use a structured assessment and treatment program (Food for Heart Program) consisting of a brief dietary assessment and three 5- to 10-minute dietary counseling sessions given by the primary care clinician, referral to a local dietitian if the low-density lipoprotein cholesterol (LDL-C) remained elevated at 4-month follow-up, and a prompt for the clinician to consider lipid-lowering medication based on the LDL-C at 7-month follow-up.

MAIN OUTCOME MEASURES

Changes in total and LDL cholesterol at 4-month follow-up and averaged over a 1-year follow-up period (4-, 7-, and 12-month follow-up).

RESULTS

At 4-month follow-up, total cholesterol decreased 0.33 mmol/L (12.6 mg/dL) in the intervention group and 0.21 mmol/L (8.3 mg/dL) in the control group: the difference was 0.11 mmol/L (4.2 mg/dL) (90% confidence interval [CI], -0.02 to 0.24 mmol/L [-0.7 to 9.1 mg/dL]). The average reduction during the 1-year follow-up period was 0.09 mmol/L (3.6 mg/dL) greater in the intervention group (90% CI, -0.01 to 0.19 mmol/L [-0.3 to 7.5 mg/dL]). Eight percent of intervention patients were taking lipid-lowering medication at follow-up visits compared with 15% of control patients. In a subgroup analysis restricted to the 89% of returnees who were not taking lipid-lowering medication, the reduction in total cholesterol at 4-month follow-up was 0.14 mmol/L (5.5 mg/dL) greater in the intervention group (95% CI, 0.01 to 0.28 mmol/L [0.3 to 10.7 mg/dL]); averaged over 1 year, it was 0.14 mmol/L (5.3 mg/dL) greater (95% CI, 0.03 to 0.24 mmol/L [1.2 to 9.4 mg/dL]). Changes in LDL-C were similar.

CONCLUSIONS

Total cholesterol and LDL-C decreased more in the intervention group than in the control group. Overall, the difference in lipid reduction between groups was modest and of borderline statistical significance; among participants who did not take lipid-lowering medication during follow-up, the difference in lipid reduction between groups was larger. We conclude that primary care clinicians can be trained to give a cholesterol-lowering intervention to low-income patients that results in modest, short-term reductions in total cholesterol and LDL-C.

Mft52, an acid-bristle protein in the cytosol that delivers precursor proteins to yeast mitochondria

We have identified a novel protein, Mft52, in the cytosol of yeast cells. Mft52 has a two-domain structure that includes a receptor-like carboxyl-terminal "acid-bristle" domain, which binds basic, amphipathic mitochondrial targeting sequences. Native Mft52, purified from the cytosol of yeast cells, is found as a large particle eluting in the void volume of a Superose 6 gel filtration column. Fusion proteins, consisting of mitochondrial targeting sequences fused to nonmitochondrial passenger proteins, are targeted to mitochondria in wild-type yeast cells, but defects in the gene encoding Mft52 drastically reduce the delivery of these proteins to the mitochondria. We propose that Mft52 is a subunit of a particle that is part of a system of targeting factors and molecular chaperones mediating the earliest stages of protein targeting to the mitochondria.

Engaging and retaining women in outpatient alcohol and other drug treatment: the effect of referral intensity

Women with alcohol or other drug (AOD) problems experience a range of barriers to inpatient treatment. Although research in the general population shows that high-intensity referrals are more effective than low-intensity referrals at engaging and retaining individuals in outpatient AOD treatment, the impact of referral intensity has not been assessed for women only. To examine this issue, a secondary analysis was conducted using an existing data set that included a sample of 109 women. Although intensity of referral was not related to entry into or relapse during treatment, high-intensity referral was associated with completion of treatment. In addition, women who relapsed during treatment were less likely to complete it, underscoring the need for relapse prevention training.