Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain.

OBJECTIVE--To evaluate a progressive fitness programme for patients with chronic low back pain. DESIGN--Single blind randomised controlled trial. Assessments were carried out before and after treatment by an observer blinded to the study and included a battery of validated measures. All patients were followed up by postal questionnaire six months after treatment. SETTING--Physiotherapy department of orthopaedic hospital. SUBJECTS--81 patients with chronic low back pain referred from orthopaedic consultants for physiotherapy. The patients were randomly allocated to a fitness programme or control group. INTERVENTION--Both groups were taught specific exercises to carry out at home and referred to a back-school for education in back care. Patients allocated to the fitness class attended eight exercise classes over four weeks in addition to the home programme and backschool. RESULTS--Significant differences between the groups were shown in the changes before and after treatment in scores on the Oswestry low back pain disability index (P < 0.005), pain reports (sensory P < 0.05 and affective P < 0.005), self efficacy reports (P < 0.05), and walking distance (P < 0.005). No significant differences between the groups were found by the general health questionnaire or questionnaire on pain locus of control. A benefit of about 6 percentage points on the disability index was maintained by patients in the fitness group at six months. CONCLUSION--There is a role for supervised fitness programmes in the management of moderately disabled patients with chronic low back pain. Further clinical trials, however, need to be established in other centres to confirm these findings.     

Native Healing in Alaska—Report From Serpentine Hot Springs

Traditional Alaskan Native healing practices, specifically sweat bathing and hot springs bathing, have medical connotations in that they involve sociocultural factors important to practicing medicine among Alaskan Native people. At Serpentine Hot Springs in northwest Alaska, relief for arthritis, back pain, hip pain, headaches, skin rashes and other disorders was sought. The “treatment setting” was an informal bathhouse and bunkhouse and Eskimo tribal doctors and patients were assigned tasks related to healing. Continuity with traditional cultural patterns was achieved in several ways: meals tended to be traditional Eskimo fare, the predominant language spoken was Inupiaq and styles of interaction were Inupiat in character. All patients showed improvement. The experience reported herein is instructive for those seeking innovative approaches treating Native American groups.     

Methoxyflurane and Nitrous Oxide as Obstetric Analgesics. I.—A Comparison by Continuous Administration

Methoxyflurane and nitrous oxide have been compared as obstetric analgesics. The inhaled concentrations of these agents, given continuously, were adjusted by an anaesthetist to maintain each patient at the optimum state between reaction to pain and consciousness. Assessments were made continuously.Though the anaesthetist''s assessment showed no difference between the mean results, a greater proportion of the methoxyflurane patients were “satisfactory” for 90–100% of the time than of the nitrous oxide patients, particularly in regard to objective pain relief. The midwives'' opinion of those who had “complete” pain relief supported this. Nausea was significantly less among methoxyflurane patients, and vomiting during labour occurred only in patients who had nitrous oxide. It is concluded that nitrous oxide and methoxyflurane given in a continuously adjusted concentration are almost equally effective as obstetric analgesics, though there are certain features which favour methoxyflurane.     

Percutaneous Radiofrequency Trigeminal Gangliolysis in the Treatment of Tic Douloureux

The treatment of tic douloureux was dramatically altered in 1962 with the demonstration that carbamazepine (Tegretol®) alone or in combination with diphenylhydantoin sodium (Dilantin®) was effective in controlling the painful paroxysms. However, 30 percent of the patients so treated have not been successfully managed and some type of surgical therapy is required to control their pain. A wide variety of surgical alternatives are available but they all trade a sensory deficit for pain relief and have a significant risk of morbidity and mortality.Experience with percutaneous radiofrequency trigeminal gangliolysis has indicated that this new technique is capable of producing lasting relief of tic douloureux in as many as 95 percent of the patients. To date there have been no deaths from this procedure and a very low incidence of minor complications. It achieves this high success rate at the expense of only partial sensory deficits restricted to a circumscribed area of the face. No other surgical alternative carries such a high long-term success rate with a low complication rate. We believe that percutaneous radiofrequency trigeminal gangliolysis has become the surgical treatment of choice for tic douloureux.     

Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial

Objectives To evaluate the effects of early lumbar disc surgery compared with prolonged conservative care for patients with sciatica over two years of follow-up.Design Randomised controlled trial.Setting Nine Dutch hospitals.Participants 283 patients with 6-12 weeks of sciatica.Interventions Early surgery or an intended six months of continued conservative treatment, with delayed surgery if needed.Main outcome measures Scores from Roland disability questionnaire for sciatica, visual analogue scale for leg pain, and Likert self rating scale of global perceived recovery.Results Of the 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy. Of the 142 patients assigned to conservative treatment, 62 (44%) eventually required surgery, seven doing so in the second year of follow-up. There was no significant overall difference between treatment arms in disability scores during the first two years (P=0.25). Improvement in leg pain was faster for patients randomised to early surgery, with a significant difference between “areas under the curves” over two years (P=0.05). This short term benefit of early surgery was no longer significant by six months and continued to narrow between six months and 24 months. Patient satisfaction decreased slightly between one and two years for both groups. At two years 20% of all patients reported an unsatisfactory outcome.Conclusions Early surgery achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.Trial Registry ISRCT No 26872154.     

Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

ProblemDelay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.DesignAudit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.

Background and setting

The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.

Key measures for improvement

Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes

Strategies for change

In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).

Effects of change

Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.

Lessons learnt

Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework''s targets for door to needle times can be achieved.     

Safety And Efficacy of An Algorithm-Based Protocol In the Management of Diabetic Ketoacidosis

ObjectiveTo determine the efficacy of an algorithmbased protocol to manage diabetic ketoacidosis (DKA).MethodsOur study is a retrospective chart review of patients with DKA managed before and after implementation of an algorithm-based DKA protocol at a tertiary care hospital.ResultsThere were 88 patients managed 1 year prior (control group) and 70 patients managed one year after (study group) implementation of the algorithm-based DKA protocol. The DKA resolution time was significantly shorter (11.5 [8.1 to 17.1] hours versus 8.5 [5.8 to 12] hours; P = 0.008) and the hypoglycemic events were significantly less (P = 0.042) in the study group in comparison with the control group. There was no difference in the potassium abnormalities and rate of decline of glucose. A survey on a scale of 1 to 10 found the majority of physicians and nurses rated the protocol as safe (83%) and effective (96%). Fifty four percent of the nurses, however, found the protocol difficult to follow.ConclusionOur study showed that implementation of an algorithm-based protocol reduced the DKA resolution time and hypoglycemic events without compromising electrolyte imbalance, and was associated with improved clinical measures of DKA management. (Endocr Pract. 2012;18:842-846)     

Open Versus Arthroscopic Surgical Management for Recalcitrant Trochanteric Bursitis: A Systematic Review

BackgroundWhile excision of the trochanteric bursae to treat lateral hip pain has increased in popularity, no comparison exists between the surgical outcomes and complications of the open and arthroscopic techniques involving trochanteric bursectomy. The purpose of this study was to determine the efficacies and complication rates of arthroscopic and open techniques for procedures involving trochanteric bursectomy.MethodsThe terms “trochanteric,” “bursectomy,” “arthroscopic,” “open,” “outcomes,” and “hip” were searched in five electronic databases. Fifteen studies from 120 initial results were included. Patient-reported outcomes (PRO), pain, satisfaction, and complications were included for analysis.ResultsFive hundred-two hips in 474 total patients (77.7% female) were included in this study. The average age was 54. The fourteen distinct PRO scores that were reported by the included studies improved significantly from baseline to final mean follow-up (12-70.8 months for open; 12-42 months for arthroscopic) for both approaches, demonstrating statistically significant patient benefit in a variety of hip arthroscopy settings (P > 0.05). The complication rates of all procedures ranged from 0%-33% and failure to improve pain ranged from 0%-8%. Patient satisfaction with surgery was high at 95% and 82% reported a willingness to undergo the same surgery again. No significant mean differences were found between the open and arthroscopic techniques.ConclusionThe open and arthroscopic approaches for trochanteric bursectomy are both safe and effective procedures in treating refractory lateral hip pain. No significant differences in PROs, pain, total complications, severity of complications, and total failures were seen between technique outcomes.Level of Evidence: IV     

Patient Satisfaction with Methadone Maintenance Treatment in Vietnam: A Comparison of Different Integrative-Service Delivery Models

Background

Patient satisfaction is an important component of quality in healthcare delivery. To inform the expansion of Methadone Maintenance Treatment (MMT) services in Vietnam, we examined the satisfaction of patients with regards to different services delivery models and identified its associated factors.

Methods

We interviewed 1,016 MMT patients at 5 clinics in Hanoi and Nam Dinh province. The modified SATIS instrument, a 10-item scale, was used to measure three dimensions: “Services quality and convenience”, “Health workers’ capacity and responsiveness” and “Inter-professional care”.

Results

The average score was high across three SATIS dimensions. However, only one third of patients completely satisfied with general health services and treatment outcomes. Older age, higher education, having any problem in self-care and anxiety/depression were negatively associated with patient’s satisfaction. Meanwhile, patients receiving MMT at clinics, where more comprehensive HIV and general health care services were available, were more likely to report a complete satisfaction.

Conclusion

Patients were highly satisfied with MMT services in Vietnam. However, treatment for drug users should go beyond methadone maintenance to address complicated health demands of drug users. Integrating MMT with comprehensive HIV and general health services together with improving the capacity of health workers and efficiency of services organisation to provide interconnected health care for drug users are critical for improving the outcomes of the MMT program.     

Patient Satisfaction with HIV/AIDS Care and Treatment in the Decentralization of Services Delivery in Vietnam

Objective

We evaluated the patient satisfaction with HIV/AIDS care and treatment and its determinants across levels of health service administration in Vietnam.

Methods

We interviewed 1016 patients at 7 hospitals and health centers in three epicenters, including Hanoi, Hai Phong, and Ho Chi Minh City. The Satisfaction with HIV/AIDS Treatment Interview Scale (SATIS) was developed, and 3 dimensions were constructed using factor analysis, namely “Quality and Convenience”; “Availability and Responsiveness”; and “Competence of health care workers”.

Results

In a band score of (0; 10), the mean scores of all domains were large; it was the highest in “Competence of health workers” (9.34±0.84), and the lowest in “Quality and Convenience” (9.03±1.04). The percentages of respondents completely satisfied with overall service quality and treatment outcomes were 42.4% and 18.8%, respectively. In multivariate analysis, factors related to higher satisfaction included female sex, older age, and living with spouses or partners. Meanwhile, lower satisfaction was found among patients who were attending provincial and district clinics; in the richest group; had higher CD4 count; and drug users.

Conclusion

This study highlights the importance of improving the quality of HIV/AIDS services at the provincial and district clinics. Potential strategies include capacity building for health workers, integrative service delivery, engagements of family members in treatment supports, and additional attention and comprehensive care for drug users with HIV/AIDS.     

Mothers' experiences of induction

Mothers of a random sample of 2182 legitimate live births were interviewed about their experiences of pregnancy, labour, and delivery. Of these, 24% reported that their labours were induced, and data about this from a subsample of mothers tallied with information obtained through the doctors in charge in 88% of cases. All but 3% of the mothers who were induced perceived some medical reason for the induction. The proportion of inductions in the 24 study areas ranged from 6% to 39%. A relatively small proportion of labours in “teaching” hospitals, small hospitals with less than 100 beds, and GP maternity hospitals were induced, but a comparatively high proportion of private patients had an induction. There was no clear association between induction and the mother''s age or parity. Despite being given more pain relief, those who were induced reported similar intensities of pain during the first and second stages of labour to those whose labour started spontaneously; they also reported that they had “bad pains” for a similar period. The period they had contractions was shorter for the induced than for those starting spontaneously, and the intensity of pain at delivery was rated somewhat less by those who were induced.There was no difference between induced babies and others in the proportion who were held by their mothers immediately after their birth. Two-fifths of the mothers who were induced would have liked more information about induction; and a similar proportion said they had not discussed induction with a doctor, midwife, or nurse during their pregnancy. Only 17% of the mothers who had an induction said they would prefer to be induced if they had another baby. This contrasts with 63% of those who had epidural analgesia who would opt for the same procedure next time, while 83% of those who had had a baby in hospital, and 91% of those having had a home birth, would want their next baby in the same type of place.     

Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study

Objective To estimate the one year prognosis and identify prognostic factors in cases of recent onset low back pain managed in primary care.Design Cohort study with one year follow-up.Setting Primary care clinics in Sydney, Australia.Participants An inception cohort of 973 consecutive primary care patients (mean age 43.3, 54.8% men) with non-specific low back pain of less than two weeks’ duration recruited from the clinics of 170 general practitioners, physiotherapists, and chiropractors.Main outcome measures Participants completed a baseline questionnaire and were contacted six weeks, three months, and 12 months after the initial consultation. Recovery was assessed in terms of return to work, return to function, and resolution of pain. The association between potential prognostic factors and time to recovery was modelled with Cox regression.Results The follow-up rate over the 12 months was more than 97%. Half of those who reduced their work status at baseline had returned to previous work status within 14 days (95% confidence interval 11 to 17 days) and 83% had returned to previous work status by three months. Disability (median recovery time 31 days, 25 to 37 days) and pain (median 58 days, 52 to 63 days) took much longer to resolve. Only 72% of participants had completely recovered 12 months after the baseline consultation. Older age, compensation cases, higher pain intensity, longer duration of low back pain before consultation, more days of reduced activity because of lower back pain before consultation, feelings of depression, and a perceived risk of persistence were each associated with a longer time to recovery.Conclusions In this cohort of patients with acute low back pain in primary care, prognosis was not as favourable as claimed in clinical practice guidelines. Recovery was slow for most patients. Nearly a third of patients did not recover from the presenting episode within a year.     

Efficacy of injections with Disci/Rhus toxicodendron compositum for chronic low back pain--a randomized placebo-controlled trial

Background

The effectiveness of injection therapy for low-back pain is still debatable. We compared the efficacy of local injections of the homeopathic preparation Disci/Rhus toxicodendron compositum (verum) with placebo injections and with no treatment in patients with chronic low back pain.

Methodology/Principal Findings

In a randomized controlled partly double blind multicenter trial patients with chronic low back pain from 9 German outpatient clinics were enrolled and randomly allocated in a 1∶1∶1 ratio to receive subcutaneous injections (verum or placebo) into painful sites on the lower back over 12 treatment sessions within eight weeks, or no treatment (rescue pain medication with paracetamol or NSAIDs). All trial personnel and participants were masked to treatment allocation. The primary outcome measure was the average pain intensity over the last seven days on a visual analogue scale (0–100 mm, 0 = no pain, 100 = worst imaginable pain) after eight weeks. Follow-up was 26 weeks. Primary analysis was by intention to treat. Between August 2007 and June 2008, 150 patients were randomly allocated to three groups (51 verum, 48 placebo and 51 no treatment). The mean baseline-adjusted low back pain intensity at week eight was: verum group 37.0 mm (97.5% CI 25.3;48.8), no treatment group 53.0 (41.8;64.2), and placebo group 41.8 (30.1;53.6). The verum was significantly superior to no treatment (P = 0.001), but not to placebo (P = 0.350). No significant side effects were reported.

Conclusions/Significance

The homeopathic preparation was not superior to placebo. Compared to no treatment injections resulted in significant and clinical relevant chronic back pain relief.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00567736","term_id":"NCT00567736"}}NCT00567736     

Subjective Follow-up of Patients from a Surgical Intensive Therapy Ward

One-hundred consecutive patients who had been treated in the surgical intensive therapy ward completed a form recording their impressions of their stay. Most patients had a reasonable idea of how long they had spent in the ward and few remembered being in pain or excessively worried by any of the procedures carried out. Those who had been artificially ventilated had little recollection of this period; most either did not realize that their breathing had been artificially maintained or had no idea of the duration of ventilatory support. Very few of the patients who had tracheal suction via endotracheal or tracheostomy tubes were unduly worried by this, but 60% of the patients who needed nasopharyngeal suction to help sputum clearance had been considerably worried by this.Most of the patients were very pleased with the medical and nursing attention they had received and did not find the “intensive” nature of their care unduly disturbing.     

Controlled Trial of Azathioprine and Prednisone in Chronic Renal Disease

Patients with various forms of glomerulonephritis, but excluding those with minimal glomerular changes, were admitted to a controlled trial of a regimen which combined azathioprine in a dosage of 2·5 mg/kg/day with prednisone in a dosage of 20 mg/day (adults) or 0·5 mg/kg/day (children). Of 149 patients included, 32 of them under the age of 15, 72 were randomly allocated to the “treatment” group and 77 to the “control” group. There was no evidence of benefit from the treatment group as a whole; and the mortality was in fact higher in the treated group.     

Clinical Outcomes and Cost Effectiveness of Accelerated Diagnostic Protocol in a Chest Pain Center Compared with Routine Care of Patients with Chest Pain

Aims

The aim of this study was to compare in patients presenting with acute chest pain the clinical outcomes and cost-effectiveness of an accelerated diagnostic protocol utilizing contemporary technology in a chest pain unit versus routine care in an internal medicine department.

Methods and Results

Hospital and 90-day course were prospectively studied in 585 consecutive low-moderate risk acute chest pain patients, of whom 304 were investigated in a designated chest pain center using a pre-specified accelerated diagnostic protocol, while 281 underwent routine care in an internal medicine ward. Hospitalization was longer in the routine care compared with the accelerated diagnostic protocol group (p<0.001). During hospitalization, 298 accelerated diagnostic protocol patients (98%) vs. 57 (20%) routine care patients underwent non-invasive testing, (p<0.001). Throughout the 90-day follow-up, diagnostic imaging testing was performed in 125 (44%) and 26 (9%) patients in the routine care and accelerated diagnostic protocol patients, respectively (p<0.001). Ultimately, most patients in both groups had non-invasive imaging testing. Accelerated diagnostic protocol patients compared with those receiving routine care was associated with a lower incidence of readmissions for chest pain [8 (3%) vs. 24 (9%), p<0.01], and acute coronary syndromes [1 (0.3%) vs. 9 (3.2%), p<0.01], during the follow-up period. The accelerated diagnostic protocol remained a predictor of lower acute coronary syndromes and readmissions after propensity score analysis [OR = 0.28 (CI 95% 0.14–0.59)]. Cost per patient was similar in both groups [($2510 vs. $2703 for the accelerated diagnostic protocol and routine care group, respectively, (p = 0.9)].

Conclusion

An accelerated diagnostic protocol is clinically superior and as cost effective as routine in acute chest pain patients, and may save time and resources.     

Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.     

Psychological Antecedents to Conception Among Abortion Seekers

At a university hospital, 642 women seeking induced abortion for an unwanted pregnancy were surveyed before the procedure regarding their perception of what psychological and behavioral factors, if any, played a role in their becoming pregnant: 35 percent said they had had intercourse during what they believed was a “safe period”; 33 percent believed that they had experienced a contraceptive failure; 29 percent indicated fear of side effects influenced their use of a contraceptive method; 27 percent and 21 percent, respectively, indicated that they had thought pregnancy “couldn''t happen to me” or had “put the thought of pregnancy out of my mind.” The women''s responses indicated that a number of additional attitudes, beliefs, and behaviors were also important and that for any individual woman at least three or four factors had often combined in a dynamic sequence to greatly increase her risk of pregnancy. The implications of the findings for educational and counseling programs are discussed.     

Cortical activities of heat-sensitization responses in suspended moxibustion: an EEG source analysis with sLORETA

Moxibustion is under active research as a complementary and alternative treatment for various diseases such as pain. “Heat-sensitization” responses have been reported during suspended moxibustion, whose occurrence is associated with significantly better therapeutic effects. The present study aimed to investigate the cortical activities of this interesting phenomenon by a standardized low-resolution brain electromagnetic tomography. We performed electroencephalography recording in a group of patients with chronic low back pain before, during, and after moxibustion treatment at Yaoyangguan (DU3) areas. 11 out of 21 subjects experienced strong heat-sensitization during moxibustion, which were accompanied with significant decreases of current densities in the beta frequency bands in prefrontal, primary and second somatosensory, and cingulate cortices, as well as increased current densities in the alpha2 band in the left insula. No changes were detected in patients without sensitization responses, or in the post-moxibustion phase of either group. These data indicated widespread activity changes across different frequency bands during heat-sensitization. Cortical oscillatory activities could be used to evaluate the “heat-sensitization” responses during suspended moxibustion.