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Patients in acute care hospitals face an increasingly complex environment for care delivery. Because of the need for 24-hour care that is often provided by multiple disciplines and services, communication [...], One unit's staff developed and evaluated an intervention to relocate shift-to-shift nursing report to the patient's bedside. Despite challenges related to privacy, distractions, and integration of nursing technicians to the change, bedside shift report reduced shift report times and improved nursing satisfaction.

Background: Researchers of sickle cell disease have traditionally used health care utilization as a proxy for pain and underlying vaso-occlusion. However, utilization may not completely reflect the amount of self-reported pain or acute, painful episodes (crises). Objective: To examine the prevalence of self-reported pain and the relationship among pain, crises, and utilization in adults with sickle cell disease. Design: Prospective cohort study. Setting: Academic and community practices in Virginia. Patients: 232 patients age 16 years or older with sickle cell disease. Measurements: Patients completed a daily diary for up to 6 months, recording their maximum pain (on a scale of 0 to 9); whether they were in a crisis (crisis day); and whether they used hospital, emergency, or unscheduled ambulatory care for pain on the previous day (utilization day). Summary measures included both simple proportions and adjusted probabilities (for repeated measures within patients) of pain days, crisis days, and utilization days, as well as mean pain intensity. Results: Pain (with or without crisis or utilization of care) was reported on 54.5% of 31 017 analyzed patient-days (adjusted probability, 56%). Crises without utilization were reported on 12.7% of days and utilization on only 3.5% (unadjusted). In total, 29.3% of patients reported pain in greater than 95% of diary days, whereas only 14.2% reported pain in 5% or fewer diary days (adjusted). The frequency of home opiate use varied and independently predicted pain, crises, and utilization. Mean pain intensity on crisis days, noncrisis pain days, and total pain days increased as the percentage of pain days increased (P < 0.001). Intensity was significantly higher on utilization days (P < 0.001). However, utilization was not an independent predictor of crisis, after controlling for pain intensity. Limitations: The study was done in a single state. Patients did not always send in their diaries. Conclusion: Pain in adults with sickle cell disease is the rule rather than the exception and is far more prevalent and severe than previous large-scale studies have portrayed. It is mostly managed at home; therefore, its prevalence is probably underestimated by health care providers, resulting in misclassification, distorted communication, and undertreatment.

Combination therapy was found most effective immediately after treatment for urinary incontinence in women in a study comparing bladder training, pelvic muscle exercise with biofeedback, and therapy involving a combination of both methods. Three months after treatment, however, similar results were obtained from the three treatment conditions. A randomized clinical trial was conducted with 204 women.

Byline: Jean F. Wyman, J.Andrew Fantl, Donna K. McClish, Richard C. Bump Keywords: Behavioral therapy; biofeedback; urinary incontinence; female Abstract: Objective: We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes. Study Design: A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and I.sup.2 tests. Results: The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site. Conclusions: Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact. (Am J Obstet Gynecol 1998;179:999-1007.) Author Affiliation: Richmond, Virginia, and Durham, North Carolina Article History: Received 9 July 1997; Revised 6 March 1998; Accepted 31 March 1998 Article Note: (footnote) [star] From the Departments of Adult Health Nursing,a Obstetrics and Gynecology,b and Biostatistics,c Virginia Commonwealth University/Medical College of Virginia, the Department of Obstetrics and Gynecology, Duke University Medical Center,d and The Continence Program for Women Research Group.e A complete list of group members and their affiliations appears at the end of the article., [star][star] Supported by the National Institute of Aging/National Institutes of Health, Bethesda, Maryland, grant No. UO1 AG05170., a Reprint requests: Jean F. Wyman, PhD, RN, School of Nursing, University of Minnesota, 6-101 Weaver-Densford Hall, 308 Harvard St SE, Minneapolis, MN 55455., aa 0002-9378/98 $5.00 + 0 6/1/90643

Background: Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. Objective: To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival. Methods: This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients, vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases. Results: By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.6 [SE=0.020] for 90 days; 0.63 [SE=0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%. Conclusions: Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Byline: Richard C. Bump, W.Glenn Hurt, James P. Theofrastous, W.Allen Addison, J.Andrew Fantl, Jean F. Wyman, Donna K. McClish Keywords: Potential stress incontinence; prolapse surgery; needle bladder neck suspension; sacrospinous ligament vaginal suspension; recurrent prolapse Abstract: OBJECTIVE: Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not. STUDY DESIGN: This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years. RESULTS: Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support. CONCLUSIONS: Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension. (Am J Obstet Gynecol 1996;175:326-35.) Author Affiliation: Richmond, Virginia, and Durham, North Carolina Article Note: (footnote) [star] From the Departments of Obstetrics and Gynecologya and Biostatistics b and the School of Nursing, c Virginia Commonwealth University/Medical College of Virginia, and the Department of Obstetrics and Gynecology, Duke University Medical Center. d , [star][star] Supported by National Institute on Aging grant No. UO1-AG-05170., a Reprint requests: Richard C. Bump, MD, Duke University Medical Center, Box 3609, Durham, NC 27710., aa 0002-9378/96 $5.00 + 0 6/6/74481

Surgery to support the bladder neck appears to be an important part of reconstructive pelvic prolapse surgery. Urinary continence tests performed before reconstructive pelvic prolapse surgery do not seem to accurately predict continence problems after surgery or the need for later surgery to correct incontinence. Thirty-two women had either two stitches to support the vagina or three to five stitches to support the bladder neck as part of reconstructive prolapse surgery. All patients had urinary continence tests before surgery. The women who had the vaginal stitches had more post-surgical complications.

The technique of measuring Valsalva leak point pressures needs to be standardized before it is used as a means of evaluating stress incontinence in women. This test measures pressure within the bladder at the point at which bearing down or coughing produces leakage at the urethral opening. Sixty women with known stress incontinence underwent Valsalva leak point pressure evaluations with two different sized catheters to measure pressure. All but one woman leaked urine with at least one of the four measurements. However, the pressure at which leakage occurred varied between catheter sizes, and while larger catheters usually increased the pressure at which leakage occurred, this was not always true. Higher pressures were also required for coughing than steadily bearing down, probably because there is a protective reflex with a cough.

The severity of urinary stress incontinence may potentially be evaluated by Valsalva leak point pressure determinations. Stress incontinence occurs when abdominal pressure on the bladder exceeds the ability of the urethral sphincter to remain closed. Seventy-five women with stress incontinence had a Valsalva maneuver test and passive and dynamic urethral pressure profiles. In the Valsalva leak point pressure test, women hold their breath and bear down. The urethral pressure at which leakage occurs is determined. Incontinence severity was evaluated by the number of incontinence episodes and pads used weekly, measurements of the amount of fluid lost, and scores on a quality-of-life evaluation. The Valsalva leak point pressure was correlated with severity of incontinence as was the passive urethral pressure profile. No significant correlations were found with dynamic urethral pressure profiles. Only the Valsalva maneuver test correlated with amount of fluid lost. The Valsalva leak point pressure test requires less equipment so is potentially cheaper to perform.

BACKGROUND: Postoperative radiation is considered to be 'standard of care' therapy for advanced, resectable squamous cell carcinoma of the head and neck. This approach has been supported by retrospective data but has not been validated in randomized clinical trials. PATIENTS AND METHODS: The present analysis examined the clinical course of 110 patients with squamous cell cancer of the hypopharynx treated with surgery alone (n = 65) and postoperative radiotherapy alone (n = 45) between 1966 and 1990. Staging of patients was performed using the 1988 American Joint Committee on Cancer criteria. Cox regression analyses identified clinical and pathologic factors that were significant for disease-free and overall survival. Crude and adjusted cancer-specific survival rates were calculated. RESULTS: The postoperative radiotherapy group presented with more advanced disease than the surgery alone group (stage Ill and IV combined, 96% versus 77%, P = 0.015). Crude 5-year cancer-specific survival probabilities were 43% for the postoperative therapy group and 27% for the surgery alone group (P = NS). Adjusted 5-year survival rates, correcting for differences in significant prognostic variables between groups, were 18% and 48%, respectively, for the surgery and postoperative radiotherapy groups (P = 0.029). CONCLUSIONS: The addition of postoperative radiotherapy was associated with improved disease-free and adjusted overall cancer-specific survival in patients with advanced hypopharyngeal squamous cancer. The potential survival benefit of postoperative radiotherapy should be addressed in a randomized clinical trial.

Women who smoke seem to be at an increased risk of developing urinary stress incontinence despite the fact that they often have stronger urethral sphincters. Urinary stress incontinence is the leaking of urine during physical exertion. The urethra is the tube that drains urine from the bladder. The urethral sphincter is the muscle that keeps the urethra closed. Evaluations of their urinary tracts were performed on 71 smokers with stress incontinence and 118 non-smokers with stress incontinence. Incontinent smokers tended to be younger than incontinent non-smokers. Smokers had stronger urethral sphincters and stronger urethral closure pressure than non-smokers. It appears that smokers are more likely to develop stress incontinence because they cough more frequently. Coughing may lead to pressure transmission defects that override the benefits of stronger urethral sphincters.

Background: The validity of outcome report cards may depend on the ways in which they are adjusted for risk. Objectives: To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method. Design: Analysis of data from a prospective cohort study. Setting: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital. Patients: Sequential patients presenting in the emergency department with acute congestive heart failure. Measurements: Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Charlson comorbidity index). Results: The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve [is less than] 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment. Conclusions: Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.