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Background and Objectives: Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity.Methods: PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy.Results: Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management.Conclusions: Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking. [ABSTRACT FROM AUTHOR]

Aim: Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered.Methods: Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012.Results: 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety.Discussion and Conclusions: Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators. [ABSTRACT FROM AUTHOR]

Artificial neural network (ANN) is increasingly applied in clinical medicine. We therefore constructed an ANN to predict intracellular water (ICW) volume in 44 healthy Taiwaners. Demographic and anthropometric data were recorded as predictors, and ICW volume measured by bioelectrical impedance analysis (ICW-BIA) was the reference. ICW volume predicted by ANN (ICW-ANN) was compared with ICW-BIA. ICW-BIA (21.26 ± 0.58 l) and ICW-ANN (21.25 ± 0.57 l) was insignificantly different (p = 0.76). ICW-BIA and ICW-ANN were strongly correlated (r = 0.94, p < 0.0001) with a significant agreement (mean difference, 0.01; lower and upper limits of agreement, −2.31 and 2.33) in Bland–Altman plot. Passing–Bablok regression was described as ICW-BIA = 1.04 × ICW-ANN − 0.49, with 95% confidence interval for slope 0.94–1.14 and for intercept −2.76–1.49, indicating that both methods were interchangeable. ANN provided an excellent alternative of BIA to predict ICW volume in healthy subjects. [ABSTRACT FROM AUTHOR]

The quantity of referrals to secondary care is increasing. That the quality of medical referrals is decreasing is a common allegation yet has rarely been assessed. We report a time-limited, cross-sectional survey evaluating cardiological referral information quality. Referral letters ( n = 218, excluding direct access pro formas) from GPs to the Cardiology Department at City Hospital, Birmingham, were collated and analysed over 2 months. A subset ( n = 49) of these patients completed questionnaires assessing their knowledge and patient communication of the referral. Information quality was poor (length, diagnosis, expectation, prior treatment and investigation) with almost half of all letters containing only outline symptomatic complaints without diagnosis. The majority of patients referred had not been investigated or treated in any way before referral. Despite lack of understanding of the reason for referral, typically the majority of patients expressed themselves as satisfied with the process. Given most referrals are seen as appropriate, information exchange between secondary and primary care is crucial. By contrast, the standard of even basic clinical assessment communicated between primary care and secondary care was severely limited. The reason(s) why medical assessment is lacking are unclear but must be explored to give more support to primary care to complete basic medical task particularly if investment is to flow into this source. [ABSTRACT FROM AUTHOR]

We conducted a retrospective cohort study of thromboprophylaxis rates and the quality of anticoagulation control among patients with atrial fibrillation (AF) using a large, geographically diverse database of electronic medical records. The study population consisted of 13,709 AF patients treated in US outpatient physician practices. Approximately two-thirds were prescribed warfarin alone or in combination with another drug. Older patients, males, and those with congestive heart failure (CHF) or prior stroke were more likely to receive antithrombotic therapy. Among 6454 patients treated with warfarin who had at least two valid prothrombin time/international normalised ratio test results, approximately half of study days were spent in target range. Female sex, CHF and residence in the Northeast were associated with more time out of range. Our study confirms that, in routine medical practice, warfarin is not prescribed for substantial numbers of eligible patients, and anticoagulation control with warfarin is suboptimal for many of those at risk for thromboembolism. [ABSTRACT FROM AUTHOR]

The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting β2-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly. [ABSTRACT FROM AUTHOR]

Acute bacterial rhinosinusitis (ABRS), which manifests as an inflammation of at least one of the paranasal sinuses, is a major public health issue in developed countries. Diagnosis and treatment of ABRS can pose significant challenges in clinical practice, including difficulty in differentiation between viral and bacterial infection and a lack of simple, reliable and convenient methods for definitive diagnosis. Treatment choice is also a challenge because a decision is typically made empirically; therefore, the selection of therapy should be based on knowledge of local patterns of antimicrobial resistance, spectrum of activity against the most common ABRS pathogens (including those that are resistant to penicillins and macrolides) and pharmacodynamic potency. Current guidelines for diagnosis and treatment of ABRS in various countries share some similarities but also have important differences. Criteria for making the clinical diagnosis of sinusitis vary only slightly from country to country, while recommendations of therapy reflect the local impact of bacterial resistance. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine whether patients ( n = 40) with chronic obstructive pulmonary disease (COPD) currently receiving short-burst oxygen therapy meet existing criteria for ambulatory oxygen. A prospective randomised balanced double-blind crossover design was used. Criterion (i) for ambulatory oxygen (desaturation by 4% to below 90% on the practice walk) was met in 21 patients; 15 of these 21 patients also met criterion (ii) (10% improvement in distance and/or breathlessness score with oxygen). Despite no evidence of desaturation in 19/40 patients, 9/19 improved their distance and/or breathlessness score with oxygen. This study has shown that many patients on short-burst oxygen meet existing criteria for ambulatory oxygen and may have been receiving suboptimal therapy. It supports recent proposals for the development of comprehensive assessment services which incorporate assessment for all categories of oxygen. [ABSTRACT FROM AUTHOR]

This study was conducted to investigate the relationship between unplanned readmission and breast cancer operation cases, with the assumption that the rate of unplanned readmission within 30 days of surgery was solely due to postsurgical complications. We divided hospitals into three categories based on breast cancer operation cases: low-volume hospitals (≤50 annual procedures), medium-volume hospitals (51–99 annual procedures) and high-volume hospitals (≥100 annual procedures). The medical records of 1351 subjects in 24 hospitals were investigated. We found unplanned readmission rates were significantly higher in hospitals with a lower surgical volume. From these three groups, a sample consisting of 1351 patients was created and 17 unplanned readmission cases (1.2%) were reported. Of these 17 cases, 12 (70.59%) cases were from low-volume hospitals. The present results indicate that unplanned readmission within 30 days following discharge is an important adverse outcome in breast cancer surgery. [ABSTRACT FROM AUTHOR]

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder. Characterised by abdominal pain or discomfort, bloating and altered bowel habit, IBS is a chronic recurring condition, typically affecting up to 15% of the Western population, IBS can be subclassified into IBS with constipation (IBS-C), IBS with diarrhoea (IBS-D), or IBS with alternating constipation or diarrhoea symptoms (IBS-A). Conventional clinical diagnosis focuses on excluding all potential organic causes of patient symptoms. However, a positive diagnosis of IBS may be estiblished using published criteria such as the Manning and/or Rome criteria. While these methods are useful to identify patients with IBS who are suitable for enrolment into clinical trials, the criteria are relatively complex and not readily applicable to general practice. In this review we present an ‘identify, eliminate, probe’ algorithm that may be appropriate to establish a positive diagnosis of patients with IBS-C, as symptoms characteristic of patients in this IBS subgroup are least likely to be confused with symptoms reflecting serious organic disease. [ABSTRACT FROM AUTHOR]

The efficacy of thyroxine (T4) for solitary non-toxic thyroid nodule remains uncertain. In this study, 60 patients with solitary non-toxic thyroid nodule were divided randomly into two groups. Group I ( n = 30) received thyroxine 100 µg/day for 6 months and group II ( n = 30) received placebo. The volume of the thyroid nodules in 11 patients decreased more than 50% after thyroxine therapy (36.7%, responders). In these 11 patients, the mean serum thyroglobulin level decreased significantly (340 ± 115 to 162 ± 86 µg/l, p < 0.01). Compared with the non-responders ( n = 19, 63.3%), the serum thyroglobulin level before treatment was significantly higher (340 ± 115 vs. 220 ± 102 µg/l, p < 0.05). Thyroxine-suppressive therapy is proved as a useful tool in reducing nodule size in some patients with solitary thyroid nodules. The patients with a higher serum thyroglobulin level generally respond better to thyroxine-suppressive therapy. [ABSTRACT FROM AUTHOR]

The objectives are to evaluate and compare the response and toxicity of a 3-weekly and a 2-weekly regimen of gemcitabine (Gem) and paclitaxel (Pac) second-line treatment in patients with transitional cell carcinoma (TCC). Between June 2000 and July 2001, 30 patients with progressive disease (PD) during first-line chemotherapy ( n = 11) or relapse after adjuvant cisplatin-based chemotherapy of a metastatic or locally advanced TCC ( n = 18) have been randomised to receive either six cycles (schedule A) of 3-weekly Gem (1000 mg/qm, days 1 and 8) and Pac (175 mg/qm, day 1) or 2-weekly treatment until disease progression (schedule B) with Gem (1250 mg/qm, day 1) and Pac (120 mg/qm, day 2). Restaging was performed after every 6 weeks by clinical imaging. Of 30 patients, one patient in schedule A and two patients in schedule B were not evaluable for response due to serious adverse events (SAEs) during the first cycle. The overall objective response (OR) was 44% (12 of 27) with eight complete remissions (CRs) and four partial remissions. Median time to progression (TTP) was 11 (3–41) months in schedule A and 6 (1–15+) months in schedule B. Median survival was 13 (5–46) months in schedule A and 9 (0–16) months in schedule B. Schedule A showed a significantly higher rate of CRs (7 vs. 1, p < 0.05). With a median number of six (1–6) cycles (A) and nine (1–23) cycles (B), TTP and survival were not significantly different. In schedule B, one patient had WHO grade IV anaemia and leucopenia. WHO grade III toxicities were seen in schedule A/B as follows: anaemia 3 (23%)/2 (16%) patients, leucopenia 5 (38%)/2 (16%), thrombocytopenia 0/2 (16%) and alopecia 10 (76%)/4 (32%). The combination of Gem and Pac is an effective second-line regimen in patients with mainly poor prognosis due to PD after cisplatin-based chemotherapy. Except for three SAEs (uncertainly therapy related), both regimens were tolerated well. The 3-weekly schedule with a nonsplit Pac dose showed a significantly higher complete response rate in our small study population and, thus, might be superior to the 2-weekly schedule. [ABSTRACT FROM AUTHOR]

Intrahepatic cysts are generally classified as congenital, traumatic, infectious or neoplastic. Non-parasitic hepatic cysts (NPHCs) include simple cysts and adult polycystic liver disease in which the liver is diffusely occupied by cysts. NPHCs usually reach a large size before causing symptoms, unless a complication such as rupture, bleeding, infection, obstructive jaundice or neoplastic transformation occurs. We report the case of a 67-year-old man with spontaneous rupture of simple liver cyst. The clinical pictures and the unusual ultrasound features of this rare condition are discussed. [ABSTRACT FROM AUTHOR]

Patients with congestive heart failure (CHF) are at increased risk of thromboembolic events. However, there is much debate and uncertainty over the use of antithrombotic therapy in these patients. The evidence for oral anticoagulation is limited, although large randomised trial data are forthcoming. Aspirin may be detrimental for heart failure due to a possible interaction with angiotensin-converting enzyme inhibitors, leading to increased hospitalisations from decompensated heart failure. The objective of this review article is to summarise the available evidence regarding the risk of stroke and thromboembolic events in CHF patients, as well as the effectiveness and risks of antithrombotic therapy in these patients. [ABSTRACT FROM AUTHOR]

This is the last of the three review articles dealing with thyroid cancer. Over 90% of thyroid cancer is of the differentiated type associated with a very good 10-year disease-free survival rate. In contrast, the rare forms of thyroid cancer which comprise medullary thyroid cancer arising from parafollicluar C cells, Hurthle cell carcinoma, anaplastic carcinoma, thyroid lymphoma and squamous cell carcinoma are typically associated with a poorer survival rate. Management is based upon small retrospective cohort studies. [ABSTRACT FROM AUTHOR]

The aim of this article was to describe (i) the epidemiology and outcomes of stroke relating to diabetes; (ii) the pathophysiology of diabetes as a risk factor for stroke; (iii) the management of acute stroke in patients with diabetes; (iv) the evidence of primary and secondary prevention of stroke in patients with diabetes; and (v) the risk of new-onset diabetes using older antihypertensive agents. The combination of diabetes and stroke disease is a major cause of morbidity and mortality worldwide. Evidence from large clinical trials performed in patients with diabetes supports the need for aggressive and early intervention to target patients' cardiovascular (CV) risks in order to prevent the onset, recurrence and progression of acute stroke. Identification of at-risk patients with diabetes and metabolic syndrome has also allowed the delivery of early and effective intervention to reduce stroke risks, while active treatment during the acute phase of stroke will reduce long-term neurological and functional deficits. While the ongoing debate on the risk benefits of different antihypertensive, lipid-lowering and antiplatelet agents should not detract clinicians from pursuing aggressive CV risk reduction, the application of evidence-based medicine specifically in patients with diabetes will facilitate the use of appropriate agents to improve clinical outcomes. The overall management of patients with diabetes and acute stroke or at risk of secondary stroke should also include multifactorial intervention that not only targets patient's CV risk but also includes behavioural, lifestyle and, where appropriate, surgical intervention. [ABSTRACT FROM AUTHOR]

Hepatic actinomycotic abscesses are rare and secondary to other intra-abdominal infections. History of intra-abdominal surgery is a principal contributing factor for the abscess formation. Patients with hepatic actinomycotic abscess may suffer from fever, malaise, abdominal pain and bodyweight loss. The clinical progress of actinomycotic abscess is more indolent than the usual course of other pyogenic abscess. It is sometimes diagnosed as malignancy. This report consists of two cases of hepatic actinomycotic abscess mimicking tumours. Laboratory data revealed elevated alkaline phosphatase and leucocytosis. The abdominal computed tomography scan showed multiloculated lesions with peripheral contrast enhancement appearance. Diagnosis confirmation was based on the typical histologic feature of sulfur granules with inflammatory process by echo-guided fine needle biopsy or surgical specimen. These two cases were resolved with extended courses of intravenous and oral penicillin treatment. [ABSTRACT FROM AUTHOR]

The following article reviews treatment for acne vulgaris. Selection of therapy should be based on clinical appearance taking into account lesion type and severity, as well as identification of acne scarring and the psychosocial disability caused by the disease. [ABSTRACT FROM AUTHOR]

Methylprednisolone aceponate (MPA) has been shown to provide rapid, reliable and highly effective treatment of eczematous disorders, with an efficacy comparable to that of most reference topical corticosteroids. It also has excellent local and systemic tolerability. MPA is effective in the treatment of facial and scalp eczema and sunburn and has shown promising results in the treatment of psoriasis. Its rapid efficacy and lack of undesirable local and/or systemic side effects make MPA particularly suitable for use in children and infants. The wide range of formulations (0.1%) of MPA, including cream, ointment, fatty ointment, milk and solution, enable treatment to be tailored to the individual patient. In addition, MPA has the advantage of once-daily application compared with twice-daily treatment for other topical corticosteroids, thereby improving patient safety and promoting patient compliance but without compromising efficacy. [ABSTRACT FROM AUTHOR]

Almotriptan is a 5-HT1B/1D receptor agonist, or triptan, indicated for the acute treatment of migraine. It has been shown to be effective and well tolerated for the treatment of acute migraine in approximately 5000 patients enrolled in short-term placebo- and active-controlled trials and long-term open-label trials. A recent meta-analysis reported that almotriptan has the highest sustained pain-free (SPF) rate and lowest adverse-event (AE) rate of all oral triptans. Sustained pain free is a composite endpoint of pain freedom at 2 h, no recurrence of moderate-to-severe headache and no use of rescue medication from 2 to 24 h after dosing. Patient surveys have indicated that migraine sufferers consider complete pain relief, no recurrence, rapid onset and no side-effects to be the most important attributes of their acute treatment. Composite endpoints such as SPF and SPF with no AEs (SNAE) contain the attributes that migraine sufferers express as being the most important elements of an acute migraine therapy, and their use in future clinical trials should aid in the selection of agents that can offer patients the highest likelihood of consistent treatment success. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the proportion of therapeutic interventions that is supported by scientific evidence between hospital-based and community-based primary care clinics. The study setting is a primary care clinic in university-affiliated tertiary hospital and community-based primary care clinic in a region in Seoul. A retrospective review of patients' medical records was done according to the primary diagnosis and treatment for 890 patients in community-based clinic and 307 in hospital-based clinic. The evidence for the intervention was searched for in Medline (1966–2001) and other evidence-based databases. The evidence was then classified as one of the three categories (i) evidence from randomised controlled trials (RCTs); (ii) convincing non-experimental evidence; and (iii) interventions without substantial evidence. In the hospital-based clinics, out of 356 primary diagnosis and treatment pairs, 59.6% were supported by evidence from at least one RCTs, and 19.4% were supported by convincing non-experimental evidence. In the community-based clinics, 47.1% out of 893 pairs and 10.5% fell into each category. As a result, the proportion of interventions in community settings that were based on evidence meeting our criteria was significantly lower than that of the hospital-based settings. To facilitate evidence-based practice, supportive activity should be focused on the primary care settings based on community where medical practices are less evidence-based. [ABSTRACT FROM AUTHOR]

Hypertension is probably the most important public health problem in developed countries. Over the last 40 years, an increasing number of hypertensive patients have been treated with various antihypertensive drugs. If the blood pressure (BP) is controlled, the discontinuation of the antihypertensive drug may result either in a relapse of the disease or in the maintenance of normal BP for a long time. In this study, we discuss the available data regarding the consequences of antihypertensive drug withdrawal in successfully treated patients and we suggest guidelines for the application in clinical practice. [ABSTRACT FROM AUTHOR]

Hereditary angioedema (HAE) is caused by a deficiency in C1 esterase-inhibitor (C1-INH) and is characterised by skin swelling, abdominal pain and episodes of upper respiratory tract obstruction. Oedema of the larynx can result in rapid asphyxiation and requires emergency treatment. Three treatment options for emergency treatment of HAE are reviewed: fresh frozen plasma, solvent/detergent-treated plasma and C1-INH concentrate. It is concluded that while all three treatment options are theoretically effective in the emergency treatment of HAE, C1-INH is the treatment of choice. [ABSTRACT FROM AUTHOR]

The article informs that case reports can trigger the discovery of new diseases and unexpected adverse events. One can learn from case reports about disease mechanisms and educate oneself not only about recognition and treatment but also about how to avoid diagnostic and management traps. Case reports can also be the stimulus to research ideas, a good example being sildenafil for pulmonary hypertension. An ideal case report will therefore add to the collective knowledge while educating and entertaining its readers. The journal publishes case reports that are clearly focused, clearly written, and that present practical clinical messages.

Focuses on the implications of the new General Medical Services contract for disease management. Provision for quality of care of the quality and outcome framework; Measurement of the outcome of treatment by diabetes-related clinical endpoints, diabetes-related death and all-cause mortality; Set of standards for glycemic control in patients with diabetes.

It has been generally accepted that the clinical onset of familial Mediterranean fever (FMF) begins before 20 years of age in most patients. In this study, we aimed to investigate the demographic and clinical characteristics of our FMF patients with an age of onset≥20.Records of 401 patients (female/male: 204/197) that followed up between 1990 and 1999 were reviewed according to a pre-defined protocol. All patients fulfilled the diagnostic criteria of Livneh et al. The demographic and clinical features of adult-onset FMF patients were compared to those of patients with a disease onset before 20 years of age.There were 57 patients (14%) who experienced symptoms of FMF at≥20 years of age; 34 of them (8.5%) reported their first attack between 20 and 29 years of age; 18 of them (4.5%) between 30 and 39 years of age and five patients (1.25%) had their first attack after 40 years of age. Arthritis (42 vs. 65%, p = 0.001) and erysipelas-like erythema (7 vs. 17%, p = 0.047) were significantly less frequent in patients with adult-onset FMF compared to patients with disease onset before 20 years of age.Arthritis and erysipelas-like erythema were less frequent in adult-onset patients compared to those with an earlier disease onset. Adult-onset FMF may be a form of disease with distinct clinical, demographic and molecular characteristics. Prospective clinical studies and investigation of genotypic features are needed to identify the characteristics of this phenotypic variant. [ABSTRACT FROM AUTHOR]

Striant™ SR (marketed as Striant® in the US) is a novel sustained-release mucoadhesive buccal testosterone tablet for the treatment of male hypogonadism. Striant™ SR restores serum testosterone concentrations to the physiological range within 4 h of application, and steady-state concentrations are achieved within 24 h of twice-daily dosing. In phase III clinical trials, 87–97% of patients using Striant™ SR achieved 24-h-averaged serum testosterone concentrations within the normal range. In a comparative study, Striant™ SR was more likely to restore testosterone concentrations to the physiological range than Andropatch®. In a small study, Striant™ SR produced steady-state testosterone concentrations comparable with those achieved with a testosterone gel (50 mg testosterone). Striant™ SR was well tolerated, with a low incidence of adverse events and a low discontinuation rate (3.5%) due to adverse events in phase III studies. Striant™ SR is an effective, well-tolerated, convenient and discreet treatment for male hypogonadism. [ABSTRACT FROM AUTHOR]

Treatments for mild viral infections are usually directed at providing symptomatic relief. The effectiveness of the homoeopathic remedy Gripp-Heel® was compared with that of conventional treatments in a prospective, observational cohort study in 485 patients with mild viral infections and symptoms such as fever, headache, muscle pain, cough or sore throat. Practitioners specialised in homoeopathy or conventional treatment, or practised both to similar extents. As evaluated by the practitioners, the homoeopathic therapy was effective to similar or greater degree than the conventional therapies: 67.9% of patients were considered asymptomatic at the end of Gripp-Heel® therapy vs. 47.9% of patients in the control group. Practitioners judged homoeopathic treatments as‘successful’ in 78.1% of cases vs. 52.2% for conventional therapies. Tolerability and compliance were good in both treatment groups, with the verdict‘very good’ given for 88.9% of patients in the homoeopathic group vs. 38.8% in the conventional treatment group. [ABSTRACT FROM AUTHOR]

Oral anti-diabetic combinations that address insulin resistance andβ-cell dysfunction (e.g. metformin and glibenclamide) represent a rational therapeutic option for patients uncontrolled on monotherapy. A 52-week, open-label extension to a double-blind study evaluated metformin-glibenclamide combination tablets (Glucovance®) in 477 patients with hyperglycaemia despite sulphonylurea therapy. Reductions in HbA1C were maintained, with a mean reduction of−1.7% after 52 weeks, compared with the baseline value for the double-blind trial. Eighty-five patients receiving 4 × 500 mg/2.5 mg tablets daily displayed a marked improvement in HbA1C following up-titration to a regimen of 2 × 500 mg/2.5 mg + 3 × 500 mg/5 mg tablets. Lipid profiles improved significantly. The combination tablets were well tolerated: 11.1% of patients reported hypoglycaemic symptoms (all either mild or moderate severity). No patient withdrew or required pharmacologic intervention for hypoglycaemia. Metformin-glibenclamide combination tablets are an effective and well-tolerated therapeutic option for intensifying oral anti-diabetic therapy. [ABSTRACT FROM AUTHOR]

Cardiovascular mortality and morbidity are increased in patients with type 2 diabetes. However, there are few data from clinical trials comparing cardiovascular effects of alternative oral anti-diabetic agents. Major cardiovascular outcomes during four one-year, double-blind trials in over 3700 patients with type 2 diabetes randomised to either a thiazolidinedione, pioglitazone, metformin or a sulphonylurea, gliclazide treatment have been combined. Mean blood pressure was slightly reduced by all treatments, with pioglitazone treatment resulting in the largest falls (approximately 1.5 mmHg). Hospitalisations for cardiac or cerebrovascular events were similar with the different treatments. Overall mortality was seven of 1857 for pioglitazone and 10 of 1856 for non-pioglitazone treatments, of which three and six were cardiac deaths, respectively. The incidence of congestive cardiac failure was similar with pioglitazone (12/1857) and non-pioglitazone (10/1856) treatments. The results show similar cardiovascular outcome for the three different treatments over a one-year period, but demonstrate interesting differences, which will require longer-term formal outcome studies to determine their significance. [ABSTRACT FROM AUTHOR]

Insulin resistance is a major endocrinopathy underlying the development of hyperglycaemia and cardiovascular disease in type 2 diabetes. Metformin (a biguanide) and rosiglitazone (a thiazolidinedione) counter insulin resistance, acting by different cellular mechanisms. The two agents can be used in combination to achieve additive glucose-lowering efficacy in the treatment of type 2 diabetes, without stimulating insulin secretion and without causing hypoglycaemia. Both agents also reduce a range of atherothrombotic factors and markers, indicating a lower cardiovascular risk. Early intervention with metformin is already known to reduce myocardial infarction and increase survival in overweight type 2 patients. Recently, a single-tablet combination of metformin and rosiglitazone, Avandamet, has become available. Avandamet is suitable for type 2 diabetic patients who are inadequately controlled by monotherapy with metformin or rosiglitazone. Patients already receiving separate tablets of metformin and rosiglitazone may switch to the single-tablet combination for convenience. Also, early introduction of the combination before maximal titration of one agent can reduce side effects. Use of Avandamet requires attention to the precautions for both metformin and rosiglitazone, especially renal, cardiac and hepatic competence. In summary, Avandamet is a single-tablet metformin–rosiglitazone combination that doubly targets insulin resistance as therapy for hyperglycaemia and vascular risk in type 2 diabetes. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases are the principal causes of mortality in middle-aged people and in older people. Coronary heart disease (CHD) is the most common of the cardiovascular diseases; high serum levels of cholesterol are associated with atherosclerosis and an increased risk of CHD. Cholesterol homeostasis is achieved by means of a fine balance between cholesterol intake, absorption/excretion and synthesis. All of these processes are tightly linked and a change in one of them can significantly influence the others. Results from both experimental studies and clinical trials have shown that inhibition of cholesterol synthesis with a statin increases absorption and that conversely, inhibition of cholesterol absorption increases synthesis. The tight linkage of cholesterol absorption and synthesis in maintaining cholesterol homeostasis suggests that treatment with an agent that influences only one of these two processes is likely to have distinct limits with respect to its effects on cholesterol levels. Better understanding of cholesterol homeostasis, particularly the close interrelationship between cholesterol synthesis and absorption, may result in the design of rational integrated treatment regimens that employ multiple agents with complementary actions that attack multiple mechanisms to lower cholesterol. [ABSTRACT FROM AUTHOR]

This study was conducted to find out the group B streptococcus colonisation of pregnant women in Kocaeli, Turkey. A culture plus individualised high-risk-based antibiotic prophylaxis was compared with high-risk-based approach alone. The screening of women was performed via vaginal and anal cultures for group B streptococcus (GBS). The maternal GBS colonisation rate was found to be 6.5%. All colonised women or preterm labours with unavailable culture results until delivery received prophylactic antibiotics. Neonatal colonisation rate and early-onset neonatal sepsis due to GBS was 1/200. The unscreened 900 women received prophylactic antibiotics due to a risk factor-based approach. The neonatal colonisation rate was 17/900 (p = 0.1), and the rate of early-onset neonatal sepsis was 3/900 (p = 0.6). A culture plus individualised high-risk-based antibiotic prophylaxis provided an insignificant change in neonatal colonisation and early-onset neonatal sepsis with GBS when compared with high-risk-based approach alone. [ABSTRACT FROM AUTHOR]

To identify clinicians working within the field of sexual and psychosexual medicine and to identify and quantify the diversity of problems seen by specialist physicians, nurses and therapists working in the UK and compare these with French clinicians, a prospective 89 item questionnaire was sent to 2352 practitioners in the UK. Eight hundred and fourteen completed questionnaires were returned detailing clinician practice and training and the presenting problems of patients in their clinical practice. The commonest presenting problem amongst men was erectile dysfunction (562/814) followed by emotional and relational problems. The commonest problem for women was loss or absence of sexual desire and was of a similar magnitude to that of erectile dysfunction in men. The substantial majority of clinicians working with patients and clients with sexual problems are non-physicians from a diverse professional training background which contrasts with a high number of physicians in France. The high incidence of emotional and relational problems in both men and women would suggest that clinical services require considerable psychotherapeutic consultation space within the service provision. [ABSTRACT FROM AUTHOR]

The efficacy and tolerability of the 5-HT1B/1D-receptor agonist zolmitriptan was evaluated in an open post-marketing surveillance study in 12,919 patients, treating 36,510 migraine attacks. Mean visual analogue scale scores for pain decreased (6.9–2.2; 68% improvement) and scores for impairment of normal activities decreased (6.6–2.2; 67% improvement) at 2 h after dose. Non-headache symptoms of migraine resolved in 73–86% of attacks. Improvement was achieved within 2 h in>80% of attacks and within 1 h in 37% of attacks. This high level of efficacy was achieved with a single 2.5 mg dose in 95% of attacks. Compared with previous migraine treatments, 85% of patients preferred zolmitriptan for efficacy and 56% for better tolerability. Corresponding preference rates were 87 and 63% when compared with ergot alkaloids. Adverse events occurred in 2% of patients and were either typical class effects or known symptoms and complications of migraine. These results provide evidence for the high efficacy and good tolerability of the 2.5 mg dose of zolmitriptan in clinical practice in migraine. Zolmitriptan was very well tolerated, with patients expressing a distinct preference for zolmitriptan over previous treatments. [ABSTRACT FROM AUTHOR]

Atherosclerotic diseases are responsible for the majority of deaths in the elderly, and they can also increase the risk of disability. Statins are first-line therapies for lowering lipid levels and have been shown to reduce the risk of cardiovascular events in large-scale clinical trials. There is a growing body of evidence that statins are as efficacious at lowering lipid levels and reducing the risk of coronary heart disease (CHD) in elderly patients as in younger individuals. Furthermore, as this population is at a greater absolute risk of CHD, they may receive greater absolute benefits from treatment. However, despite these benefits, many elderly individuals at risk of CHD and stroke are not receiving adequate lipid-lowering therapy, which could help them to maintain their health and independence. Further, prospective randomised trials are required to guide physicians in the treatment of elderly patients at risk of atherosclerotic disease, thereby resolving the current undertreatment. [ABSTRACT FROM AUTHOR]

This prospective study was undertaken in the day surgery unit of Monklands Hospital, Airdrie. The consultant hand surgeon screened all general practitioner referrals between September 1998 and July 2002, and suitable patients referred for minor hand procedures were listed directly on to the day-case waiting list without an initial review in outpatient department. The main end points in this study were accuracy of diagnosis, the appropriateness of surgical treatment plan, patient acceptability and the impact of direct listing on waiting times and attendance. There was agreement in clinical diagnosis in 92%, and the choice of treatment plan was judged to be appropriate in 96% cases. The overall patient acceptability was 90%. This one-visit system not only cuts down on the patients waiting time from initial referral up to surgery but also reduces the number of hospital visits for the patients. [ABSTRACT FROM AUTHOR]

Robot-assisted renal surgery is usually performed transperitoneally due to more available space for excursion of the robotic arms. To our knowledge, we report the first experience with robotic retroperitoneoscopic nephroureterectomy using the Da Vinci™ Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and a hybrid port technique. Robotic retroperitoneal nephroureterectomy was performed on two male patients. One 37-year-old patient had a painful non-functioning hydronephrotic left kidney and megaureter; the other aged 76 had a muscle invasive lower left ureteric tumour. Both the procedures were successfully completed with the robot without conversion. Mean operative time was 182.5 min and estimated blood loss 75 ml. Histological examination confirmed the preoperative diagnoses; margins were clear in the patient with tumour. Postoperative recovery was uneventful. We report the technical feasibility of robotic retroperitoneoscopic nephroureterectomy. However, as with all new technology, the benefits need to be further evaluated and proven before this technique can be widely accepted. [ABSTRACT FROM AUTHOR]

Patients with recurrent ureteropelvic junction obstruction (UPJO) present a treatment dilemma to urologists. Second-line therapies have previously been shown to fail at a higher rate than the initial therapeutic procedure. We report our experience with robotic-assisted, dismembered pyeloplasty in patients with secondary UPJO. Since November 2002, 44 robotic-assisted laparoscopic pyeloplasties (RALPs) have been performed at our institution. Of these, seven patients had undergone previous definitive treatment for UPJO. Anderson–Hynes-dismembered pyeloplasty was the preferred reconstructive technique in all patients. The patients were divided into two groups: primary pyeloplasty patients (group 1) and secondary pyeloplasty patients (group 2). Variables examined include operative time, estimated blood loss (EBL), length of hospital stay (LOS) and success rates. All operations were completed laparoscopically, and there were no conversions to open surgery in either group. Mean operative time was 60 min longer in the secondary pyeloplasty group compared with primary cases, but the EBL, LOS and success rates were similar. A patent UPJ was confirmed in both groups by renal scan and/or excretory urography (intravenous pyelogram) examinations. RALP is a viable option in select patients with recurrent UPJO after previous endoscopic or open surgical repair. As expected, operative times were longer in these patients due to a more challenging dissection (p < 0.05). However, the magnification afforded by the robot allows for a precise dissection, and subsequently, there was no significant increase in blood loss, hospital stay or perioperative morbidity in our series (p > 0.05). [ABSTRACT FROM AUTHOR]

Renal insufficiency because of obstruction may not always be represented by dilated pelvicalyceal system. This may make diagnosis and thence the management very difficult with the present available investigative armamentarium. Experience and clinical acumen may help with a decision of empirical treatment in the form of stenting or nephrostomy in these cases. This may be diagnostic as well as curative of the renal failure. We present herewith three such challenging cases managed by us. We also have reviewed the literature as to the diagnosis and management of such cases. [ABSTRACT FROM AUTHOR]

Paraphimosis is a frequently presented complaint in the emergency department. This review outlines the treatment options available for resolving this condition: manual reduction methods, osmotic methods, puncture and aspiration methods and treatments using sharp incision. The technique of penile block local anaesthesia is described. A technique sequence for treatment is suggested. [ABSTRACT FROM AUTHOR]

The treatment of condyloma acuminatum may be problematic in clinical practice. We present a 27-year-old man with condyloma acuminatum who was treated successfully with a combination therapy of isotretinoin and interferon-alfa-2a. In the previous reports of combination therapy, isotretinoin has been given in a dosage of 1 mg/kg/day. However, we achieved the same success at a dosage of 0.5 mg/kg/day of isotretinoin. [ABSTRACT FROM AUTHOR]

The article discusses the findings of a study report on the medical students' anxiety levels and its consequences on pre-clinical curriculum. The findings show that there were differences in the level of anxiety in medical students over getting up early for ward rounds. The study also suggests that communication skills should be made a significant part of the medical teaching and assessment.

The role of viral infections in the aetiopathogenesis of polymyositis remains speculative ( 1 ). We report a case of profound subacute polymyositis with incipient ventilatory failure following serologically confirmed infection by respiratory syncytial virus (RSV), with a dramatic and sustained response to pulse corticosteroid therapy. We suggest a possible autoimmune mechanism to account for this sequence of events. [ABSTRACT FROM AUTHOR]

In the evaluation of ptosis, the ice pack test is a simple, quick, bedside method to ascertain whether it is of myasthenic origin, which requires no specialised medication or equipment and is free of reported adverse effects. Pooling of published studies suggests very high sensitivity, specificity and likelihood ratios, but standardisation and operationalisation of the test are important. False-negative tests may occasionally occur. [ABSTRACT FROM AUTHOR]

We present a case of post-operative wound infection withClostridium novyiin a non-intravenous drug user. Clinical features included progressive cellulitis despite being on antibiotics, accompanied by hypotension, marked leucocytosis and oedema but minimal fever. While established infection with this organism is associated with high mortality, our patient survived. The administration of clindamycin and intravenous immunoglobulin in addition to early surgical assessment and aggressive debridement of affected tissue may have contributed to this successful outcome. To our knowledge, this is the only reported post-operative wound infection due to this pathogen. [ABSTRACT FROM AUTHOR]

The lifespan of medical equipment must be maximised to ensure cost-effectiveness. Flexible ureterorenoscopes have become widely used in the diagnosis and treatment of urolithiasis. They are relatively expensive and current literature shows that they require frequent repair and replacement. We have analysed our data for the number of procedures and repairs required for each new instrument we have used. So far we have used four new flexible ureteroscopes, which have been used for a total of 375 procedures, an average of 94 procedures each. On average each required repair twice. We believe that a few simple precautions taken during use and storage help to maximise the lifespan of the flexible ureterorenoscope and our results would appear to support this. [ABSTRACT FROM AUTHOR]

Inflammatory pseudotumour (IP) of the heart is an extremely uncommon and potentially fatal lesion which presents a challenging diagnosis even for the experienced pathologist, cardiologist and cardiac surgeon. This spindle cell tumour is known to be present in virtually every anatomical region but, in adults, has only previously been found in the heart at postmortem. We report the case of a 27-year-old man who presented with ventricular tachyarrhythmias and a right ventricular mass which was subsequently shown to be an IP. [ABSTRACT FROM AUTHOR]

Most cases of urolithiasis in pregnancy are managed conservatively either with ureteric stents or percutaneous nephrostomy tubes, which need to be changed at regular intervals. Definitive management of the stone is usually delayed till after delivery. We describe a patient who presented with pyonephrosis in the fifth week of gestation, due to a stone obstructing the right ureteropelvic junction. This was managed by insertion of a nephrostomy tube. She declined nephrostomy tube/stent changes during the rest of her pregnancy and requested termination as an alternative. She successfully underwent percutaneous nephrolithotomy in the 14th week of pregnancy, with radiation exposure strictly localised to the kidney for 6 s. A healthy male baby was delivered at term. [ABSTRACT FROM AUTHOR]