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Ann Intern Med 2003 Jan 7;138(1):33-9
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115-5899, USA. cleary@hcp.med.harvard.edu
Patients usually cannot assess the technical quality of their care; however, examining a hospitalization through the patients' eyes can reveal important information about the quality of care. Patients are the best source of information about a hospital system's communication, education, and pain-management processes, and they are the only source of information about whether they were treated with dignity and respect. Their experiences often reveal how well a hospital system is operating and can stimulate important insights into the kinds of changes that are needed to close the chasm between the care provided and the care that should be provided. This article examines the case of a patient admitted for ankle arthrodesis due to severe hemophilia-related arthritis. The surgery was successful, but the hospital stay was marked by inefficiency and inconveniences, as well as events that reveal fundamental problems with the hospital's organization and teamwork. These problems could seriously compromise the quality of clinical care. Unfortunately, most of these events occur regularly in U.S. hospitals. Relatively easy and inexpensive ways to avoid many of these problems are discussed, such as reducing variability in non-urgent procedures and routinely asking patients about their experiences and suggestions for improvement.
PMID: 12513042, UI: 22401332
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Br J Anaesth 2002 Dec;89(6):846-8
Department of Anaesthesia, North Devon District Hospital, Barnstaple EX31 4JB, UK. guy.rousseau@virgin.net
BACKGROUND: Uterine balloon thermal ablation is used to treat menorrhagia. We thought that intrauterine application of 2% lidocaine gel could reduce postoperative pain after this procedure. Before using this technique we wished to establish how much lidocaine is absorbed systemically from the uterine cavity after thermal ablation. METHODS: Ten ASA I-II patients (age 38-50 yr) underwent uterine balloon thermal ablation under general anaesthesia. They each had 11 ml of 2% lidocaine gel (Instillagel(TM)) inserted into the uterine cavity at the end of the procedure. Blood samples were taken at 5, 15, 30 and 60 min after insertion and lidocaine concentrations were measured using high-performance liquid chromatography. RESULTS: Mean (range) plasma lidocaine concentrations at 5, 15, 30 and 60 min were 40.3 (0-221.9), 66.3 (0-271.9), 64.9 (0-208) and 75 (0-212) ng ml(-1), respectively. CONCLUSION: There was minimal systemic absorption of lidocaine from the uterus following uterine balloon thermal ablation. Measured concentrations were well below the toxic plasma concentration for lidocaine (8-10 micro g ml(-1)).
PMID: 12453927, UI: 22340773
Cancer 2003 Jan 1;97(1 Suppl):311-7
Department of Pain and Palliative Services, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA. payner@mskcc.org
BACKGROUND: African-American women are at higher risk for breast cancer mortality compared with their white counterparts. Furthermore, African-American women present for diagnosis and treatment later in the disease process. It may be expected that this greater disease burden would impose more symptoms compared with women who present with earlier stage disease. However, the effect of breast cancer on the quality of life of African-American women largely has been unexplored. METHODS: A qualitative literature review was conducted to identify racial disparities in the palliative care of patients with cancer and their impact on quality of life for African-American women. A Medline search was done encompassing the years between 1985 and 2000 and included the following search terms: breast cancer, palliative care, pain management, quality of life, health care disparities, and African Americans. Relevant articles were read and summarized for inclusion in this review. RESULTS: Differences in treatment patterns, pain management, and the use of hospice care exist between African-American women and women in other ethnic groups. Explanations for these differences have not been researched well. In addition, the emotional, social, and other aspects of quality of life for African-American women with breast cancer are not well understood, in part due to the absence of a standardized quality-of-life measure. CONCLUSIONS: Physicians and other health care providers must be educated better about pain management and hospice care and, in turn, must inform their patients better about these issues. Physicians' and researchers' considerations of the influence of race and ethnicity on quality of life are critical. Furthermore, future research should be focused on the establishment of a standardized measure for quality of life that better encompasses its social, spiritual, and emotional aspects. Quality-of-life measures should be incorporated into routine health surveillance mechanisms, with an increased emphasis on minority and other under-served populations. Copyright 2003 American Cancer Society.DOI 10.1002/cncr.11017
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PMID: 12491494, UI: 22378382
Cephalalgia 2002 Jul;22(6):439-43
Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ 85259, USA.
The syndrome of orthostatic (low pressure) headaches is well described and most commonly occurs following deliberate violation of the dura (e.g. lumbar puncture). This syndrome can also occur spontaneously and results from the leakage of CSF. We describe three patients who suffered from spontaneous CSF leaks secondary to bony pathology of the cervical spine, and propose that this may be a more common aetiology than originally thought. Often these patients are difficult to manage medically, and surgery may be necessary for symptomatic relief.
PMID: 12133043, UI: 22128462
Cephalalgia 2002 Jun;22(5):395-400
University of Witten/Herdecke, Germany.
The objective was to determine headache patients' knowledge, prevalence of use and perceived effectiveness of complementary and alternative medicine. Seventy-three patients with headache syndromes attending a head and neck pain clinic were interviewed using a standardized questionnaire. Alternative medical therapies were used by 85% of surveyed patients for the relief of their head pain. In 60%, the therapies were perceived to have a benefit. Almost 100% of the patients were familiar with one or more of the presented alternative treatments. Eighty-eight per cent perceived at least one of the complementary treatments to be an effective remedy for headache pain. Exposure to and interest in alternative treatments are common among patients with headache syndromes, despite the lack of scientific evidence of benefit and assessments of risks for many of the treatments. Neurologists and general physicians should be aware of the increasing role of alternative medicine in the healthcare system. There is still an urgent need for objective, integrative and critical research with regard to complementary and alternative medicine.
PMID: 12110115, UI: 22105529
Cephalalgia 2002 Jun;22(5):333-9
Institut Universitaire Veille-Sommeil, Faculte de Medecine et Pharmacie, Poitiers, Department of Neurology, CHU La Miletrie, Poitiers, France. jph.neau@chu-poitiers.fr
There is still a controversy regarding the relationship between sleep apnoea syndrome and headaches, especially morning headaches. Our objectives were: (i) to compare the prevalence and the clinical data of headaches in sleep apnoea syndrome (SAS) and control (snorers) groups defined by polysomnographic recording; (ii) to analyse the clinical improvement of headaches with appropriate treatment; and (iii) to correlate headaches with mood disorders, and nocturnal respiratory and architectural sleep parameters in order to understand the underlying pathophysiological mechanisms. This is a prospective study of 324 consecutive patients referred to our sleep centre for snoring. Of these, 312 patients who underwent sleep polysomnography were finally included. Patients and controls were interviewed about their medical past, headache history and clinical characteristics, their daytime sleepiness (Epworth's sleepiness scale) and their mood disorders (Zerssen's scale). Follow-up of patients with headaches (SAS and control groups), treated or not, was also assessed. According to our definition of SAS, patients were dissociated in SAS (n=164) and snorers (n=148). Fifty-three SAS patients had headaches, of whom 58.5% (n=30) suffered from morning headaches. However, there was no statistical difference between the two groups concerning the prevalence and the clinical characteristics of headaches. In addition, headaches and morning headaches were not correlated with nocturnal respiratory and architectural sleep parameters, nor with excessive daytime sleepiness, but were strongly correlated with mood disorders. In 36 SAS patients, headaches improved under treatment, but this was not statistically different from what was found among untreated snorers. Headaches and morning headaches are common in patients with SAS but may be considered as a non-specific symptom. The underlying mechanisms are not fully elucidated but depression could play an important role. Despite this absence of specificity, the treatment of SAS, especially nasal continuous positive airway pressure, leads to an improvement in headaches in several cases.
PMID: 12110108, UI: 22105522
Cephalalgia 2002 Jun;22(5):331-2
PMID: 12110107, UI: 22105521
Spine 2002 Dec 1;27(23):2742; author reply 2742
PMID: 12461403, UI: 22350496
Spine 2002 Dec 1;27(23):2741; author reply 2741
PMID: 12461402, UI: 22350495
Spine 2002 Dec 1;27(23):2726-33
ORTON Orthopaedic Hospital, Invalid Foundation, Helsinki, Finland. teija.lund@invalidisaatio.fi
STUDY DESIGN: Evaluation of a possible correlation of clinical symptoms of chronic low back pain (LBP) patients before and after application of external spinal fixation (ESF) with three-dimensional motion patterns. OBJECTIVE: To determine whether the intervertebral kinematics in chronic LBP patients correlate with pain relief after stabilization of the suspected painful segments. SUMMARY OF BACKGROUND DATA: Chronic LBP is a complex clinical entity with mechanical, biochemical, and psychosocial components. Although clinically controversial, ESF has been shown to reduce intervertebral motion, and thus, it provides a mechanism to investigate the mechanical aspect of LBP. METHODS: Thirty-four chronic LBP patients were tested with ESF of the suspected painful segments. The subjective pain relief experienced by the patients during the test and 2 years after spinal fusion surgery was determined, along with the Oswestry Disability Index. Before removal of ESF, the three-dimensional intervertebral kinematics of the painful segments (specifically range of motion, coupling patterns, and motion asymmetries) were analyzed with a precision optoelectronic camera system during active trunk motions. A series of linear correlations were performed between the clinical measures and the motion parameters. RESULTS: The subjective pain relief during the ESF test was nominally, but not significantly, associated with lateral bending asymmetry ( = 0.22) and "abnormal" axial rotation-lateral bending coupling ( = 0.13). The improvement in the Oswestry Disability Index both post-test and at 2 years after lumbar fusion surgery was significantly correlated with the extension range of motion ( = 0.049 and = 0.036, respectively) and the extension-to-flexion range of motion ratio ( = 0.035 and = 0.044, respectively). CONCLUSIONS: The "abnormal" motion patterns of chronic LBP patients did not correlate with subjective pain relief after ESF of the suspected symptomatic levels or with the midterm outcome of subsequent lumbar fusion surgery. The results suggest that preserved motion of the symptomatic segments before surgery is positively correlated with the clinical result of the subsequent spinal fusion in case of a positive ESF test result.
PMID: 12461400, UI: 22350493
Spine 2002 Dec 1;27(23):2715-9
Workers Compensation Board of British Columbia, Vancouver, British Columbia, Canada.
STUDY DESIGN: One hundred fifty-nine subacute low back work-injured patients completed a full medical assessment at baseline. A full repeat examination was performed 3 months later, when return-to-work status was determined. OBJECTIVE: To determine the prognostic value of a comprehensive medical assessment for the prediction of return-to-work status. SUMMARY OF BACKGROUND DATA: A systematic review of the work disability prediction literature of low back trouble prognosis revealed that no high-quality studies included a full medical history and physical examination in the design. The results of studies included in the systematic review were equivocal with respect to predictive usefulness of medical variables. METHODS: Participants completed medical history questionnaires and then were clinically examined by one of six experienced examiners (three physicians and three physiotherapists). Return-to-work status was measured 3 months later, and predictive validity was evaluated using logistic regression modeling. RESULTS: Medical variables (, medical history subscales, physical examination subscales, and lumbar range-of-motion tests) showed modest correct classification rates varying between 61.6% and 69.1% for participants. CONCLUSIONS: Comprehensive medical assessments play a crucial role in the early identification of serious pathology after low back trouble. We were unable to identify, however, any medical evaluation variables that would account for significant proportions of variance in return to work. The weight of evidence obtained in this study suggests that injured workers' subjective interpretations and appraisals may be more powerful predictors of the course of postinjury recovery than exclusively medical assessments.
PMID: 12461398, UI: 22350491
Spine 2002 Dec 1;27(23):2674-83
Spine Section, Department of Orthopedic Surgery, University Hospital of Aarhus, Denmark. fbc@dadlnet.dk
STUDY DESIGN: A prospective randomized clinical study with a 2-year follow-up period was conducted. OBJECTIVE: To analyze the effects of circumferential fusion using ALIF radiolucent carbon fiber cages and titanium posterior instrumentation on functional outcome, fusion rate, complications, and lumbar lordosis. SUMMARY OF BACKGROUND DATA: Circumferential fusion has become a common procedure in lumbar spine fusion, both as a primary and salvage procedure. However, the claimed advantages of ALIF plus PLF over conventional PLF lack scientific documentation. METHODS: From April 1996 through November 1999, a total of 148 patients with severe chronic low back pain were randomly selected for either posterolateral lumbar fusion with titanium CD-Horizon (posterolateral group) or circumferential fusion with a ALIF Brantigan cage plus posterior instrumentation. The Dallas Pain Questionnaire (DPQ), the Low Back Pain Rating Scale (LBPR), and a questionnaire concerning work status assessed their outcomes. RESULTS: Both groups showed highly significant improvement in all four categories of life quality (DPQ) as well as in the back pain and leg pain index (LBPR), as compared with preoperative status. There was a clear tendency toward better overall functional outcome for patients with the circumferential procedure ( < 0.08), and this patient group also showed significantly less leg pain at the 1-year follow-up evaluation ( < 0.03) and less peak back pain at 2 years ( < 0.04). Sagittal lordosis was restored and maintained in the circumferential group ( < 0.01). The circumferential fusion patients showed a higher posterolateral fusion rate (92%) than the posterolateral group (80%)( < 0.04). The repeat operation rate including implant removal was significantly lower in the circumferential group (7%) ( < 0.009) than in the posterolateral group (22%). CONCLUSIONS: Circumferential lumbar fusion restored lordosis, provided a higher union rate with significantly fewer repeat operations, showed a tendency toward better functional outcome, and resulted in less peak back pain and leg pain than instrumented posterolateral fusion. The clinical perspective of the current study implies a recommendation to favor circumferential fusion as a definitive surgical procedure in complex lumbar pathology involving major instability, flatback, and previous disc surgery in younger patients, as compared with posterolateral fusion with pedicle screws alone.
PMID: 12461393, UI: 22350486
Spine 2002 Dec 1;27(23):2654-61
Department of Orthopedics, Lund University Hospital, Lund, Sweden. ragnarjohnsson@spray.se
STUDY DESIGN: Randomized efficacy trial comparing two types of noninstrumented posterolateral fusion between L5 and S1 in patients with L5 spondylolysis and vertebral slip less than 50%, as evaluated by radiostereometric analysis. OBJECTIVE: To determine whether osteogenic protein-1 (BMP-7) in the OP-1 Implant yields better stabilizing bony fusion than autograft bone. SUMMARY OF BACKGROUND DATA: Animal studies of osteoinductive proteins in noninstrumented posterolateral fusions have shown high fusion rates. No similar conclusive study on humans has been performed. METHODS: For this study, 20 patients were randomized to fusion with either OP-1 Implant or autograft bone from the iliac crest, 10 in each group. The patients were instructed to keep the trunk straight for 5 months after surgery with the aid of a soft lumbar brace. At surgery 0.8-mm metallic markers were positioned in L5 and the sacrum, enabling radiostereometric follow-up analysis during 1 year. The three-dimensional vertebral movements, as measured by radiostereometric analysis induced by positional change from supine posture to standing and sitting, were calculated with an accuracy of 0.5 to 0.7 mm and 0.5 degrees to 2.0 degrees. Conventional radiography was added. RESULTS: No significant difference was noted between the radiostereometric and radiographic results of fusion with the OP-1 Implant and fusion with autograft bone. There was a significant relation between reduced vertebral movements and better bone formation. No adverse effects of the OP-1 Implant occurred. Persistent minor pain at the iliac crest was noticed in one patient. CONCLUSIONS: There was no significant difference between the two fusion versions. Thus, the OP-1 Implant did not yield better stabilizing bony fusion than autograft bone.
PMID: 12461391, UI: 22350484
Spine 2002 Nov 1;27(21):E476-7
Department of Neurosurgery, Temple University Hospital, Philadelphia, Pennsylvania, USA. Wfymd@aol.com
STUDY DESIGN: A case report of transient blindness after lumbar epidural steroids is presented. OBJECTIVE: To report the diagnosis and treatment of a case of blindness after administration of lumbar epidural steroids. SUMMARY OF BACKGROUND DATA: Nine previous cases of blindness after lumbar epidural injection for back pain were identified. Retinal hemorrhages were identified on ophthalmologic examination in all cases. METHODS: The 1-year follow up evaluation of a 39-year-old male who sustained transient blindness after administration of lumbar epidural steroids is reported. RESULTS: At 1 year, the patient had significant return of vision, but it did not improve back to baseline. CONCLUSIONS: Transient blindness is a rare complication of lumbar epidural injection. The pathophysiology and prevention of this rare entity is reviewed.
PMID: 12439000, UI: 22327380
Spine 2002 Nov 1;27(21):2396-408
Hughston Spine Service, The Hughston Clinic, Columbus, Georgia 31908-9517, USA. jkb66@knology.net
STUDY DESIGN: A prospective, nonblinded, multicenter study of outcomes in patients undergoing single-level anterior lumbar discectomy and interbody fusion with InFUSE Bone Graft. OBJECTIVE: To determine the safety and effectiveness of InFUSE Bone Graft applied to an absorbable collagen sponge in anterior lumbar interbody fusion with threaded cortical allografts. SUMMARY OF BACKGROUND DATA: In primates, InFUSE Bone Graft used with allograft dowels was shown to increase rates of interbody fusion by promoting osteoinduction and enhancing incorporation of the allograft. Recently, in a small series of human patients undergoing anterior lumbar interbody fusion with a tapered cylindrical metal fusion cage, InFUSE Bone Graft has been shown to promote osteoinduction and fusion. METHODS: Forty-six patients underwent a single-level anterior lumbar discectomy and interbody fusion at five investigational sites. They were randomly assigned to one of two groups, and the results in the investigational patients who received threaded cortical allograft dowels with InFUSE Bone Graft were compared with those in the control patients who received threaded allograft dowels with autogenous iliac crest bone graft. Patients' clinical outcomes were assessed using neurologic status, work status, and Oswestry Low Back Pain Disability, Short Form-36, and back and leg pain questionnaires. Anteroposterior, lateral, flexion-extension radiographs, and computed tomography scans were used to evaluate the progression of fusion at 6, 12, and 24 months after surgery. RESULTS: All patients who received InFUSE Bone Graft showed radiographic evidence of bony induction and early incorporation of the cortical allografts. All patients in this group had fusions at 12 months that remained fused at 24 months. At 12 and 24 months, the investigational group showed higher rates of fusion and improved neurologic status and back and leg pain when compared with the control group. There were no unanticipated adverse events related to the use of InFUSE Bone Graft. CONCLUSION: The use of InFUSE Bone Graft is a promising method of facilitating anterior intervertebral spinal fusion, decreasing pain, and improving clinical outcomes in patients who have undergone anterior lumbar fusion surgery with structural threaded cortical allograft bone dowels.
PMID: 12438990, UI: 22327370
Support Care Cancer 2003 Jan;11(1):66-9
The Harry R. Horvitz Center for Palliative Medicine, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Center, 9500 Euclid Avenue, M-76, Cleveland, OH 44195, USA.
[Medline record in process]
Side effects of morphine are common when it is given in titrated doses to control severe pain in advanced cancer. We describe a case of severe back pain resistant to parenteral morphine accompanied by muscle spasm, in which the addition of diazepam both had an opioid-sparing effect and provided superior symptomatic relief. Diazepam appears to have a specific role as an adjuvant analgesic for pain due to skeletal muscle spasm associated with painful vertebral metastases.
PMID: 12527958, UI: 22415910
Support Care Cancer 2003 Jan;11(1):35-40
Palliative Advisory Team, Linkoping University Hospital, 58185 Linkoping, Sweden, per-anders.heedman@lio.se
The aim of this study was to contrast two opposed groups, namely palliative cancer patients who were suffering significant pain (VAS>/=4) and palliative cancer patients with no pain (VAS = 0) in hospital-based home care and, retrospectively, to study possible differences in relation to demographic, biological and treatment factors. The ESAS (Edmonton Symptom Assessment Scale) was used to assess 191 palliative cancer patients on admission and after 1 week of home care. Fifty-two (27%) had pain (mean 5.5+/-1.7) and 72 (38%) had no pain on admission [the middle group ( n=67) had VAS 1-3]. Activity was more severely affected (5.4 vs 4.2, p<0.01) and nausea less well controlled in patients with pain (2.3 vs 0.7, P<0.0001). Pain was associated with the diagnosis of prostate cancer ( P<0.01) and the presence of skeletal metastases ( P<0.001), whereas pain-free patients, with or without analgesics, more often had colorectal cancer ( P<0.01) or melanoma ( P<0.05). The medication profiles differed between the two groups: 22 (42%) of the 52 patients with pain were on step 3 of the WHO analgesic ladder and 24 of 51 (47%) were receiving antiemetics, whereas 42 (58%) of the 72 patients with no current pain had no analgesic prescribed and only 25% of them had antiemetics prescribed, indicating biological differences. If pain was present on admission a pain analysis was formally documented in 23 (44%) of the 52 cases and the medication was changed in 27 of the 52 (52%). The patients improved after 1 week (5.4+/-1.6 vs 3.9+/-2.3, P<0.001), and the improvement was significant even when a pain analysis was not documented or when medication was not changed. In conclusion, the results of this study indicate biological differences in pain alleviation and the need for a more structured way of working.
PMID: 12527952, UI: 22415904