Journal of General Internal Medicine

Schmader, Kenneth E.; Studenski, Stephanie

doi: 10.1007/bf02602345pmid: 2540301

Study objective:To determine whether current therapies are useful in preventing postherpetic neuralgia (PHN) by analysis of study designs and pooled results.Design:Meta-analysis of all controlled studies investigating PHN prevention in the immunocompetent host. Articles were identified through MEDLINE, Index Medicus and bibliographic reviews of major texts and review articles. Studies meeting eligibility criteria were independently assessed using explicit methodologic criteria for validity and generalizability in clinical trials. Pooled analysis was also performed where appropriate.Measurements and main results:Twenty-one investigations met eligibility criteria and primarily addressed the use of antiviral agents and corticosteroids. Among studies with strong designs, no evidence of benefit was found for acyclovir or corticosteroids. Pooled results showed no significant effect of acyclovir on the prevention of PHN (odds ratio 0.81, 95% confidence interval 0.56, 1.11). The strongest studies that found potential efficacy in PHN prevention involved adenosine monophosphate and idoxuridine in dimethyl sulfoxide, but problems with clinical application limit the use of these compounds. Outcome definition, compliance assessment, power estimation, and method of randomization were infrequently addressed aspects of design.Conclusion:Currently there is no proven useful therapy for the prevention of PHN. The benefits of acyclovir and corticosteroids are limited but key questions remain regarding these medications. A clear consensus definition of PHN is needed to improve future investigations.

Schmader, Kenneth E.;Studenski, Stephanie

doi: 10.1007/BF02602345pmid: 2540301

Abstract Study objective:To determine whether current therapies are useful in preventing postherpetic neuralgia (PHN) by analysis of study designs and pooled results. Design:Meta-analysis of all controlled studies investigating PHN prevention in the immunocompetent host. Articles were identified through MEDLINE, Index Medicus and bibliographic reviews of major texts and review articles. Studies meeting eligibility criteria were independently assessed using explicit methodologic criteria for validity and generalizability in clinical trials. Pooled analysis was also performed where appropriate. Measurements and main results:Twenty-one investigations met eligibility criteria and primarily addressed the use of antiviral agents and corticosteroids. Among studies with strong designs, no evidence of benefit was found for acyclovir or corticosteroids. Pooled results showed no significant effect of acyclovir on the prevention of PHN (odds ratio 0.81, 95% confidence interval 0.56, 1.11). The strongest studies that found potential efficacy in PHN prevention involved adenosine monophosphate and idoxuridine in dimethyl sulfoxide, but problems with clinical application limit the use of these compounds. Outcome definition, compliance assessment, power estimation, and method of randomization were infrequently addressed aspects of design. Conclusion:Currently there is no proven useful therapy for the prevention of PHN. The benefits of acyclovir and corticosteroids are limited but key questions remain regarding these medications. A clear consensus definition of PHN is needed to improve future investigations.

Uhlmann, Richard F.;Rees, Thomas S.;Psaty, Bruce M.;Duckert, Larry G.

doi: 10.1007/BF02602346pmid: 2651606

Abstract The validity and reliability of auditory screening tests were evaluated in 34 demented and 31 non-demented elderly outpatients. In reference to an audiometric gold standard (40-dB HL bearing loss in speech frequencies), 512-Hz and 1024-Hz tuning forks, finger rub, and whispered voice tests performed well (ROC curve areas =0.82 to 0.94). Simultaneously high (>0.80) sensitivities and specificities were achievable for all these tests in demented patients. In non-demented patients, however, only the whispered voice test achieved simultaneously high specificity and sensitivity. The most accurate rule for air conduction screening audiometry was the inability to bear ≥ two of four 40-dB HL speech frequencies (sensitivity =1.0, specificity =0.75 in non-demented patients; sensitivity =0.97, specificity =0.74 in demented patients). Interobserver/test-retest reliability was generally high for tuning forks, finger rub, and whispered voice tests (range of intraclass correlation coefficients =0.38 to 0.90), and was somewhat higher in demented than in non-demented patients. These results suggest that some of the simple, traditional methods of auditory screening may have considerable validity and reliability in demented and non-demented older adults.

Thomas, David R.;Fischer, Rick G.;Nicholas, William C.;Beghe, Claudia;Hatten, Karl W.;Thomas, Jance N.

doi: 10.1007/BF02602347pmid: 2651607

Abstract Diabetic patients are traditionally taught to discard plastic syringe/needle units after a single use and to employ aseptic technique for administering insulin injections. We surveyed 87 diabetic outpatients for compliance with aseptic recommendations. We then studied prospectively the effects of reusing disposable syringes in 56 diabetic patients who reused syringes a mean of 6.6 times for 8.3 months and an aggregate of 23,664 injections. Almost half (49%) of diabetic patients in a combined university clinic and private practice reused supposedly disposable insulin syringes a mean of 3.9 times. Compliance with standard aseptic precautions was poor, with only 29% of patients following recommended practices. No adverse effect of syringe reuse was identified. The authors conclude that diabetic patients frequently reuse disposable syringes, without apparent harmful effect.

Guyatt, Gordon H.;Nogradi, Sharon;Halcrow, Susan;Singer, Joel;Sullivan, Michael J. J.;Fallen, Ernest L.

doi: 10.1007/BF02602348pmid: 2709167

Abstract The authors developed a new measure of subjective health status for patients with heart failure. Eighty-eight patients with heart failure were asked about the impact of their condition on 123 items related to physical and emotional function. The most frequently chosen and important items were included in a 16-item Chronic Heart Failure Questionnaire (CHQ) that examines dyspnea during daily activities, fatigue, and emotional function. The CHQ was tested in a controlled trial of digoxin in heart failure patients in sinus rhythm. When administered serially to 25 patients in the run-in phase of the trial, the CHQ proved reproducible. Subsequently, CHQ results distinguished those who reported improvement or deterioration from those who did not. The CHQ showed moderate correlations with patient global ratings, walk test scores, and clinical assessments of heart failure. The authors conclude that the CHQ may be useful for measuring health status in clinical trials in heart failure.

Woolliscroft, James O.;Calhoun, Judith G.;Billiu, Geoffrey A.;Stross, Jeoffrey K.;MacDonald, Merril;Templeton, Bryce

doi: 10.1007/BF02602349pmid: 2709168

Abstract The relationships among physicians’ interviewing techniques, the amount and type of data gathered, and patients’ perceptions of the interviewing process were studied. Thirty-one Internal Medicine house officers each interviewed one of three standardized patients. The house officers’ thoroughness of data collection was assessed by the patients and by a trained evaluator. A videotape of each interview was analyzed at the National Board of Medical Examiners using the interaction analysis system for interview evaluation, ISIE-81, to define house officers’ interviewing techniques. From the physicians’ problem-solving perspective, data elicitation was positively related to the length of the interview, asking psychosocial questions, the use of narrow questions, and the amount of time the patient talked. The patients’ assessments of house officers’ data-gathering thoroughness were also positively influenced by interview length, the use of narrow questions, and inquiries about their psychosocial histories. The use of broad questions by the house officer was positively related to the patient’s feelings about and reaction to the interaction. This study potentially explains some of the differences that appear to exist between patients’ and physicians’ judgments about and perceptions of the medical interviewing process.

Dunn, Patrick M.;Parker, Dorothy F.;Levinson, Wendy;Mullooly, John P.

doi: 10.1007/BF02602350pmid: 2496210

Abstract Attempts to explain the high cost of care in teaching hospitals have yielded conflicting results. This study was conducted to compare hospital charges and lengths of stay for two groups of patients: one cared for by a resident team and the other cared for by attending physicians. The study was conducted at a university-affiliated hospital in Portland, Oregon. An initial group of 5,451 admissions was examined, considering type of doctor (resident or attending), severity of illness, and patient demographic characteristics. A regression analysis revealed that total charges were similar in the two groups, but only 14% of the variance in log total charges was explained. A subgroup of 1,058 admissions in the eight most common diagnosis-related groups (DRGs) was further evaluated. In this analysis total charges for the resident patient group were 52% higher than charges for the patient group cared for by attending physicians. Forty-one per cent of the variance was explained, with type of doctor and severity of illness accounting for 5% and 10%, respectively. Further examination of one DRG indicated that additional factors not included in previous studies, such as extent of preadmission evaluation, ethical factors influencing treatment options, and patients expectations for care, may be important determinants of hospital charges. This study demonstrates that the high cost of resident care is not fully explained by currently available measures.

Rost, Kathryn;Gordon, Geoffrey H.

doi: 10.1007/BF02602351pmid: 2709169

Abstract Objective:The objective of the study was to determine the effect of a faculty development course in teaching medical interviewing on participants’ ability to provide effective feedback to interviewers. Design:The study used a non-concurrent control group design which randomized subjects into two groups before the intervention. The two groups completed different pretests; each group then completed the other group’s pre-test as its post-test. The post-course scores of one group were compared with the pre-course scores of the other group to establish differences. Setting:The research was conducted at the 1985 faculty development course sponsored by the SGIM Task Force on the Medical Interview. Participants:49 of 52 teachers of medical interviewing attending the course completed the study. Intervention:The week-long intervention consisted of a variety of educational activities which assisted the participants in defining and actively pursuing their learning objectives in interviewing, teaching, and self-awareness. Measurements and Main Results:In their assessment of two videotaped segments of initial medical visits, participants were more likely after the course to comment on the interviewer’s lack of attention to patient affect (69.0% versus 27.2%, p=0.005 in one segment) and somewhat more likely to identify teaching strategies that actively involved the interviewer (47.2% vs. 35.0%, p=0.09 in one segment). Both shifts were congruent with assessments made by course faculty. Conclusions:Faculty development can influence teachers to recognize the need to provide feedback on skills that expert teachers would emphasize. The non-concurrent control group design provides an innovative approach to common constraints in evaluating faculty development courses.

Howell, Joel D.

doi: 10.1007/BF02602352pmid: 2651599

Abstract During the early twentieth century American physicians considered several different ways to identify medical specialists. The first autonomous specialty board was incorporated in 1924, and over the next few decades the board system became the accepted system for credentialing specialists. In 1936 the American Board of Internal Medicine (ABIM) became the twelfth specialty board. It was intended to recognize only a few outstanding internists, for the ABIM’s founders believed that general practitioners should continue to deliver the vast majority of care. However, World War II greatly increased the importance of the ABIM and of the specialty boards system. The army medical services emphasized the importance of board certification, thus encouraging physicians to receive residency training and to sit for a specialty board. After the war, the expanding VA hospital system provided them a place to do so. Specialty training and board certification became the norm, not the exception. Also, the national exigencies of World War II forced Congress to devise a new system to distribute federal funds for biomedical research to universities. That system, continued as the National Institutes of Health, supported the subsequent growth of internal medicine in general, as well as its subspecialties. Both the ABIM and the other specialty boards were formed at a particular time and place in response to the specific interests of individuals and organizations, and their histories reflect both the ideals of their founders and the long-term structural effects of war.

Anders, David L.

doi: 10.1007/BF02602353pmid: 2709170