Measuring quality of care for essential hypertension.

Published guidelines set the standard of care for essential hypertension. The authors offer an audit tool based on national standards to evaluate how actual treatment measures up to the published standard of care. The measure of quality of care is based on three assumptions: Recording essential observations is an integral part of optimal health care What is recorded took place and what is not recorded did not take place If documentation of essential events agrees with audit criteria, the outcome of care will most likely be optimal

Treatment of acute low back pain with the COX-2-selective anti-inflammatory drug nimesulide: results of a randomized, double-blind comparative trial versus ibuprofen.

STUDY DESIGN: A prospective, randomized double-blind comparative trial. OBJECTIVES: To evaluate the efficacy and tolerability of nimesulide, a cyclooxygenase (COX)-2-selective anti-inflammatory agent versus ibuprofen in patients with acute lumbosacral back pain. SUMMARY OF BACKGROUND DATA: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been more effective than placebo in patients with uncomplicated acute low back pain in previous randomized controlled trials. The efficacy and tolerability of a new COX-2-selective anti-inflammatory drug have not yet been established. METHODS: One hundred four patients aged 18-65 years with acute low back pain were enrolled. The patients were randomly allocated either to oral nimesulide (100 mg twice daily for 10 days) or oral ibuprofen (600 mg three times daily for 10 days). Outcome measures on a visual analog scale were an average of the pain intensity and the pain relief, stiffness in the back, functional status, and the results of physical examinations. All side effects were recorded at each visit. RESULTS: With both study therapies, there was a clear improvement in all measured parameters of the pain and back function parameters measured from the third day of treatment onward. The patients' capacity for daily tasks, showed improvement in both groups (P < 0. 001), but a statistically significant difference was found between the two groups in favor of the nimesulide group (P < 0.05) after 10 days. Nimesulide was more effective than ibuprofen in improved lateral bending measurements (P = 0.026). Nimesulide and ibuprofen provided similar degrees of improvement in the modified Schober tests and in the pain intensity and back stiffness scores. More gastrointestinal side effects were reported with ibuprofen than nimesulide, and the comparison showed a trend (P = 0.067). Ten side effects occurred in the nimesulide group in 7 (13%) patients and 13 in the ibuprofen group in 11 (21%) patients. CONCLUSIONS: The results confirmed that the COX-2-selective inhibitor nimesulide is an effective and well-tolerated agent for use in general practices to treat acute low back pain. The incidence of gastrointestinal side effects seems to be lower with nimesulide than with ibuprofen.

Effectively managing asthma in young and middle adulthood.

Revised national guidelines for managing asthma in nonpregnant young adults and adults stress education for self-management and include provisions for stepped care. These guidelines also include education on asthma pathophysiology; measures to control exacerbations; medications available to treat the disease; use of inhalers, spacers, holding chambers and self-monitoring; and peak expiratory flow meters. Treatment is based on frequency of exacerbations and readings from the peak flow meter. The stepped-care approach means aggressively treating patients at a higher step than current signs and symptoms may warrant, to gain rapid control over these signs and symptoms. The new guidelines suggest that patients with intermittent asthma use inhaled, short-acting bronchodilators, whereas those with persistent asthma should begin with daily inhaled, antiinflammatory medicines. Once control is maintained for weeks or months, dosages can gradually be reduced to the minimum effective level.

Assessing and planning primary care at college and university health centers.

The student body in colleges and universities is no longer homogeneous but represents many age groups and life styles. The results of the first national college health risk behavior survey reveal problem behaviors matched to demographic descriptions of these groups. Nurse practitioners can use this information along with relevant health care research to plan and provide preventive services as part of the student health center.

Hospitalized school-age children express ideas, feelings, and behaviors toward God.

Several published studies have reported that children are capable of having a relationship with God. There is little documentation of the influence of stressful situations such as hospitalization on this relationship. Twenty-eight hospitalized subjects (8 to 10 years old) were interviewed using a picture and storytelling technique. Three core processes were identified: how children told a story about a hospitalized child; attributes assigned to God; and responses of children to God in an illness situation. The findings suggest that the child's relationship with God could be helpful in coping with the fears and anxieties normally present during hospitalization. The findings also support those of others who found children can view illness as a punishment from God.

Dementia in medical wards.

Patients aged 65 years and over admitted to one Department of Medicine in a University Hospital were evaluated for the frequency and types of dementia, and for the greater workload caused by the demented patients to the hospital. The frequency of moderate and severe dementia among consecutively admitted medical inpatients (N = 282) of all age groups was 12.1%. In the age-group 65-69 years it was 5.7%, and among the patients aged 80 and over 20.7%. Of all the patients at the wards in a one-day sample (N = 85), 40% were moderately or severely demented. Patients with vascular dementia constituted 69.4%, those with primary degenerative dementia 16.1%, and those with dementia due to specific causes 14.5% of all demented patients. The demented patients needed more daily nursing care and their mean hospitalization time was longer than that of the non-demented patients.

Short Portable Mental Status Questionnaire as a screening test for dementia and delirium among the elderly.

Pfeiffer's Short Portable Mental Status Questionnaire (SPMSQ) is a brief screening test for organic brain syndromes. The validity of the SPMSQ was evaluated in a random sample of 119 community residents and 282 consecutively admitted medical inpatients. The SPMSQ proved to be a sensitive and specific screening test for moderate to severe dementia both in the community and hospital. Using the cut-off point (number of errors accepted) of three errors, the sensitivity of the test was 86.2% and the specificity 99.0% among medical inpatients. The percentages in the community sample were 66.7% and 100%, respectively. The validity of the SPMSQ was not as good for delirium because of its variable clinical picture. For screening purposes lower cut-off points than previously recommended should be used: three errors for dementia and two errors for delirium. Among Finnish elderly people it was not necessary to use correction for education in the SPMSQ.

The incidence and prognosis of cerebrovascular disease in hospital patients in Helsinki, Finland, in the decade 1970-1980.

Over 21,000 hospital episodes due to cerebrovascular disease (CVD, ICD-8 nos. 430-438) were registered in the Helsinki hospitals in 1970-1980. Of those 17,629 were identified as new cases. The age-adjusted incidence of haemorrhagic and thrombotic stroke (430-433) declined during the period 1970-1975 from 221 to 139 cases/100,000 inhabitants, whereafter no further decrease was observed. The decline in incidence was significant in both sexes. Analysis by diagnosis group showed that the decrease was confined to the incidence of haemorrhagic stroke (430-432), whereas the incidence of thromboembolic stroke (433, 434) and transient ischaemic attacks (435) remained virtually unchanged. Survival was mainly determined by patient age and type of CVD. Intracerebral haemorrhage and occlusion of precerebral arteries exhibited the poorest short-term prognosis. About half of the patients hospitalised due to cerebral thrombosis and embolism survived over one year. Long-term prognosis of the major CVD groups was very poor with only 10% of the patients alive after eight years. Transient cerebral ischaemia and subarachnoid haemorrhage had a clearly better prognosis, the survival rates after eight years being 45 and 30%, respectively.

Cerebrovascular disease: declining incidence but increasing hospital utilisation.

A total of 20,680 patients hospitalised in Helsinki during 1970-1980 due to cerebrovascular diseases were found when screening the Finnish National Hospital Discharge Register. The material was categorised according to three-digit ICD-8 diagnosis codes and age, and was analysed for case-fatality, length of stay and discharge status. By identifying all new cases an assessment of the incidence development during the study period was also possible. A fall in the overall age-standardised incidence of cerebrovascular disease was demonstrated, in accordance with disease register studies. The main reason was decline in incidence of haemorrhagic stoke (ICD-8 no. 431) and less well defined types of stroke (436-438). Ischaemic stroke (433), on the other hand, did not decrease in frequency. The diagnostic shift, occurring parallel with a growing mean age of patients, lead to decreasing acute mortality, increasing institutionalisation rates and longer stays in hospital, thus resulting in growing figures of hospital utilisation in spite of the declining incidence.

Dementia among medical inpatients. Evaluation of 2000 consecutive admissions.

Two thousand consecutive patients aged 55 years and older admitted to a department of medicine in a large university hospital were examined for the presence of dementia. The occurrence of moderate and severe dementia was 9.1% for all age groups. It increased from 0.8% in the age group from 55 to 64 years to 31.2% in patients aged 85 years and older. Of the demented patients, 41.4% were delirious at admission, and 24.9% of all delirious patients were demented. Patients with vascular dementia constituted 72.4%, those with primary degenerative dementia 23.0%, and those with specific causes 4.6% of all demented patients. The mean hospitalization time for demented patients was significantly longer, and they needed significantly more daily nursing care, when compared with nondemented patients.