Endovascular Management of Acute Embolic Occlusion of the Superior Mesenteric Artery: A 12-Year Single-Centre Experience.

PURPOSE: Retrospective evaluation of 12-year experience with endovascular management of acute mesenteric ischemia (AMI) due to embolic occlusion of the superior mesenteric artery (SMA). MATERIALS AND METHODS: From 2003 to 2014, we analysed the in-hospital mortality of 37 patients with acute mesenteric embolism who underwent primary endovascular therapy with subsequent on-demand laparotomy. Transcatheter embolus aspiration was used in all 37 patients (19 women, 18 men, median age 76 years) with embolic occlusion of the SMA. Adjunctive local thrombolysis (n = 2) and stenting (n = 2) were also utilised. RESULTS: We achieved complete recanalization of the SMA stem in 91.9 %. One patient was successfully treated by surgical embolectomy due to a failed endovascular approach. Subsequent exploratory laparotomy was performed in 73.0 % (n = 27), and necrotic bowel resection in 40.5 %. The total in-hospital mortality was 27.0 %. CONCLUSION: Primary endovascular therapy for acute embolic SMA occlusion with on-demand laparotomy is a recommended algorithm used in our centre to treat SMA occlusion. This combined approach for the treatment of AMI is associated with in-hospital mortality rate of 27.0 %.

A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the upper extremity.

BACKGROUND: No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy. METHODS: We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week. RESULTS: As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055. CONCLUSIONS: Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home.

Establishment and evaluation of a post caesarean acute pain service in a perinatological center:retrospective observational study.

OBJECTIVE: The aim of this study was to determine the efficacy of establishing a Post Caesarean Acute Pain Service. DESIGN: Retrospective observational study. SETTING: University Hospital Brno. METHODS: We evaluated all patients undergoing delivery via Caesarean Section under anaesthesia in the periods 10/2009 - 9/2010 and 11/2010 - 10/2011. During the postoperative period at predefined times, we measured the Visual Analogue Scale, Additional Analgesic Requests, blood pressure, pulse rate and recorded any complications. We compared the Visual Analogue Scale Score and number of Additional Analgesic Requests in two groups of women, 212 patients before and 195 patients after the establishment of an Acute Pain Service in the first 72 hours after Caesarean Section. RESULTS: There was a statistically significant difference in Visual Analogue Scale Score between the groups (p<0.05). The number of Additional Analgesic Requests 24-72 hours after Caesarean Section decreased below one requirement per 24 hours. The most effective analgesic method after Caesarean Section during the first 24 hours postoperatively was epidural analgesia. There was no statistically significant difference 24-72 hours after Caesarean Section between the methods of analgesia used. CONCLUSION: In conclusion, implementation of a Post Caesarean Acute Pain Service led to decrease in Visual Analogue Scale Score postoperatively. KEYWORDS: Acute Pain Service, postoperative analgesia, Caesarean Section, non-opioid analgesia, opioid analgesia, epidural analgesia.

[New antithrombotics in the prevention of venous thromboembolia and new anti-platelet drugs]. / Nová antitrombotika v prevenci zilní tromboembolie a nové protidestickové léky.

We first present a brief overview of new antithrombotic agents that are assumed to replace coumarines and heparin in many indications; this overview provides information on pentasaccharides, direct thrombin inhibitors and direct factorXa inhibitors. Secondly, since the new drugs with antiplatelet effect act through blockade of the reactions involved in blood platelet activation, we review and discuss the substances that interfere with this process. The current antiplatelet therapy focuses mainly on an inhibition of platelet aggregation stimulated by ADP, reducing the risk of arterial occlusions.

[Venous thromboembolism prophylaxis after total hip arthroplasty]. / Prevence tromboembolické nemoci po implantaci totální endoprotézy kycelního kloubu.

PURPOSE OF THE STUDY The authors compare the frequency of thromboembolic disease in the patients receiving prophylactic therapy for 10 days with that in the patients having a prolonged course of preventive treatment recommended for up to 35 days after total hip arthroplasty (THA). MATERIAL The group first evaluated comprised patients undergoing total hip replacement in 2005 and 2006 when enoxaparin was administered for 10 days after surgery. Patients with revision THA were not included. The other group included patients operated on in 2008 who received preventive treatment for 35 post-operative days either with enoxaparin for the whole time, or with enoxaparin for 10 days of hospital stay and then warfarin up to the 35th day after surgery. Patients under going revision THA and those taking other prophylactic agents were not evaluated. METHODS The evaluation of the 2005/6 group included retrospective reviews of medical records, questionnaires sent to the patients and information received from their general practitioners. The 2008 group assessment was based on the information obtained at the patient's follow-up visit at 3 months and completed with data from the questionnaires and medical notes. We focused on the records of distal or proximal deep vein thrombosis in lower extremities and of pulmonary embolism including cases with a fatal outcome. Complications associated with pharmacological prevention were also recorded. RESULTS In the 2005/6 group including 478 patients with an average age of 67.2 years, 23 (4.8 %) patients developed thrombo- embolic disease within 3 months of surgery, six patients had pulmonary embolism of which two of them died. The thromboembolic complication developed at a median of 30.5 post-operative days, i.e., after patient discharge from hospital. In the 2008 group comprising 289 patients with an average age of 63.8 years, three patients (1 %) developed thromboembolic disease within 3 months of surgery. Of them, one woman had deep vein thrombosis in relation to a high factor VIII level; and one developed pulmonary embolism with no fatal outcome. Only the minority of patients (6.9 %) continued enoxaparin therapy, the majority (93.1 %) preferred conversion to warfarin after discharge from hospital. Of the total number of 289 patients evaluated, complications associated with prophylactic treatment were recorded in 52 patients (18 %), name- ly, in 35 patients (12.1 %) it was difficult to establish the correct dosage of warfarin, in 13 patients (4.5 %) warfarin caused minor bleeding or dyspepsia and in 4 patients (1.4 %) major bleeding was recorded. DISCUSSION In our study the patients receiving a 10-day prophylactic therapy showed a slightly higher occurrence of thromboembolic disease within 3 months of THA surgery (4.8 %) than the patients reported by Eikelboom et al. (4.3 %). The results of prolonged prophylactic treatment for at least 35 days were similar, thromboembolic disease was found in 1 % of the patients. The development of thromboembolic event was recorded in our study at a median of 30.5 post-operative days, as compared with a median of 17 days in the study by Liebermann et al. In both studies, most of the thromboembolic complications developed after the patients had been discharged from hospital. The majority of patients chose warfarin for prolonged preventive treatment. There was a high complication rate (18 %) due to not finding the correct warfarin dosage or because of its overdose CONCLUSIONS Patients undergoing THA are at high risk of developing deep vein thrombosis. The risk can be markedly reduced by prolonged pharmacological ophylaxis It is recommended that the use of warfarin for this prolonged therapy should be care- fully considered, because its optimal dose is difficult to establish and its overdose may cause serious complications.

Thrombelastography during an acute normovolemic hemodilution in patient undergoing radical retropubic prostatectomy.

The aim of our study was to monitor a patient undergoing radical prostatectomy (RP) with an extraordinary large blood loss of 3600 ml. The perioperative bleeding was minimalized through an acute normovolemic hemodilution (ANH). During the procedure we monitored the patient's hemocoagulation profile. ANH is one of the possibilities for practical and pragmatic hemotherapy. It is a safe and effective method when facing massive blood loss or when it is necessary to temporarily replace or substitute the blood with a fluid during the operation (through a transfusion of allogeneic blood); and the patient benefits from the procedure. We argue that during ANH, the hypercoagulatory state appears in the patient--and even during the introduction of a combined solution of both crystalloids and colloids. In fact, during ANH it should not be recommended to provide a substitute for the patient's blood using only a single crystalloid solution alone (Tab. 2, Ref. 16).

[Peripheral arterial disease and diabetes]. / Ischemická choroba dolních koncetin a diabetes.

Peripheral arterial disease (PAD) is a disease characterised by narrowing and blockade of peripheral arteries, usually based on underlying obliterating atherosclerosis. According to the results of large epidemiological studies, the risk of PAD in patients with diabetes mellitus (DM) is fourfold higher compared to non-diabetic population. Patients with DM and PAD have a high risk of cardiovascular morbidity and mortality. Diabetes worsens the prognosis of patients with PAD; the onset of PAD in diabetics occurs at an earlier age, the course is faster than in non-diabetic patients and the disease is often diagnosed at its advanced stages. All these factors reduce the likelihood of revascularisation in DM patients with PAD. A range of factors (higher age, arterial hypertension, smoking, obesity, hyperfibrinogenaemia, insulin resistance etc.) contribute to the development of PAD in DM. Diabetes control is an independent risk factor of PAD as every 1% increase of hemoglobin A1C is associated with 28% increase of PAD. There are different clinical signs of PAD in diabetic and non-diabetic patients. In addition to the history of claudications, PAD diagnostic criteria include the presence of murmur over the large arteries, signs of chronic ischemia on the skin and distal ulcerations and gangrene. Among the imaging techniques, non-invasive investigations including Doppler pressure measurement, ankle brachial pressure index, color duplex ultrasonography, plethysmography, transcutaneous tension measurement, MR and CT angiography are preferred. Ankle brachial pressure index measurement is the easiest and the main investigation technique. The key principles of PAD treatment in diabetic patients include modification of risk factors, pharmacotherapy and revascularisation interventions aimed at improving clinical signs and prevention of cardiovascular morbidity and mortality. Antiplatelet treatment may prevent PAD progression and reduce cardiovascular events in DM patients. Early diagnosis of PAD in DM patients, rigorous prevention and aggressive management of the risk factors may significantly impact on the high incidence of amputations and decrease cardiovascular morbidity and mortality.

The importance of rheological parameters in the therapy of microcirculatory disorders.

Rheological conditions basically influence tissue perfusion, oxygen and nutrient supply, tissue regeneration and in its consequence the course of pathological processes, especially in microcirculation and partially even in macrocirculation. Haemorheotherapy has shown to be successful in several indications (critical disorders in microcirculation) when other methods of therapy have failed. In this study we describe the changes of effectivity indicators in haemorheopheresis treatment and their clinical importance in cases of eye microcirculation, statoacoustic apparatus and disorders of the lower extremities. We treated with haemorheopheresis (separator Cobe.Spetra + Evaflux filter) 24 patients (16 patients with age related macular degeneration, 5 with critical peripheral arterial foot disease, and 3 with acute hearing loss). After the procedures alpha2-macroglobulin decreases by about 58%, fibrinogen by about 69%, IgM by about 61%, LDL-cholesterol by about 77%, apolipoprotein B by about 76% and lipoprotein(a) by about 63%. It corresponds with a decrease in blood and plasma viscosity and clinical improvement in the observed patients, i.e. visual improvement, acceleration of tissue defect healing and improvement in hearing. We noticed 7.1% clinically insignificant side-effects. The method of haemorheopheresis was safe. It led to improvement in patients' clinical condition in the above mentioned indications when other methods of treatment failed.

[The profylaxis of venous thromboembolism in gynecology]. / Profylaxe venóizního tromboembolizmu v gynekologii.

The venous thromboembolism is a serious disease, but it is possible to some extend eliminate it by properthromboprophylaxis. The recommendations in gynecology result from guidelines not only in surgery and the internal medicine, but also from specific gynecologic conditions. The early and frequent mobilization is recommended for minor gynecological surgery and laparoscopic procedures. For major gynecological surgery and laparoscopic procedures in whom additional VTE risk factors are present, low molecular weight heparin is indicated. In major gynecological surgery for malignancy, low molecular heparin is needed in dose at least 4,000 antiXa IU. The prolonged prophylaxis for 28 days is also suitable in this setting.

[Prevention of venous thromboembolism in internal medicine and neurology]. / Prevence zilní tromboembolické nemoci ve vnitrním lékarství a v neurologii.

Many hospitalized patients are under an increased risk of venous thromboembolism. They should have adequate pharmacological prophylaxis. Clinical studies including meta-analyses prove that low molecular weight heparin prophylaxis of venous thromboembolisms is equally effective as that employing unfractionated heparin and it features less bleeding complications. The effectiveness of pharmacological prophylaxis with low molecular weight heparin in hospitalized patients at internal medicine departments has been proven by the MEDENOX study when enoxaparin in a dose of 40 mg was administered subcutaneously and the PREVENT study when subcutaneous dalteparin 5 000 units j. was administered daily. In the MEDENOX study, enoxaparin administration was confirmed to decrease the relative risk of venous thromboembolisms by 63% without increasing any adverse effects during the prophylaxis and the PREVENT study showed that dalteparin administration was followed by a highly significant reduction of asymptomatic venous thromboses in hospitalized patients. According the ACCP guideline for thromboprophylaxis in hospitalized internal medicine patients with clinical risk factor of venous thromboembolism (tumors, heart failures, sepsis, VTE history and serious pulmonary condition), low molecular weight heparin or mini-doses of unfractionated heparin are to be administered. The recent recommendations discourage the use of acetyl-salicylic acid in monotherapy treatment for venous thromboembolism prevention.

[Prevention of venous thromboembolism in psychiatry]. / Prevence zilní tromboembolické nemoci v psychiatrii.

The hospitalized patients of the psychiatric wards represent a risk group for the development of venous thromboembolism. Apart from sedative administration, total movement reduction, bad life style and daily routine and increased body weight, there is negative impact of dehydration, prolonged hospitalization and sometimes immobilisation in consequence of mechanical restraints. A large amount of patients are treated with antipsychotics that have a series of adverse effects. Depending of the drug used, the most frequent of them are somnolence, fatigue, extrapyramidal syndrome, hypotension, hepatotoxicity, increased body weight, prolongation of the QT interval of the ECG with a risk of ventricular arrhythmias, hematopoietic disorders, lipid or glycide metabolism disorders or hyperprolactinemia. Another potential adverse effect of these drugs is the heightened risk of venous thromboembolism development (deep vein thrombosis and/or pulmonary embolism). There is the risk of a pathological blood clotting event in psychiatric patients, especially those treated with antipsychotics. Although it is not high, it can have fatal consequences when combined with a relatively frequent pulmonary embolism and difficult diagnostics of thromboembolism. An algorithm for thromboembolism prevention has been developed. It involves important general risk factors of venous thrombosis (VTE history, immobilisation, malignancy, age over 75 years etc.) and also markers (physical restraints, dehydration, obesity, antipsychotics use) that can participate in the pathogenesis of venous thrombosis in the hospitalized psychiatric patients with limited motility. The authors believe that this prophylaxis is indicated, safe, effective and that it improves the quality of life at relatively low costs.

[Acetylsalicylic acid (ASA) resistance in patients with ischemic heart disease (IHD) as bioindicator of the treatment strategy]. / Rezistence na kyselinu acetylosalicylovou u nemocných s ischemickou chorobou srdecní jako bioindikátor lécebné strategie.

BACKGROUND: The interest in aspirin resistance has been increasing during the last few years, with researchers earnestly pursuing alternative anti-platelet therapies and devices for measuring platelet aggregation. The recent studies suggest that 5-45% of patients taking aspirin do not experience adequate anti-platelet effects. METHODS AND RESULTS: There is scant evidence proving that aspirin resistance has some clinical consequences. To assess the prevalence of aspirin resistance in patients with ischemic heart disease (IHD) two independent methods were used: platelet aggregation in platelet rich plasma (PRP) after induction by propylgallate (CPG), and assessment of platelet function by PFA 100 method. The study population consisted of 424 patients treated for IHD on the 2nd Dept. of Medicine, Teaching Hospital, Hradec Kralove. The age, gender, diagnosis and effect of therapy were characterized in this group of the patients. Daily ASA dose was 100 mg. We used two methods to monitor ASA treatment efficacy: a) thrombocyte aggregation after induction by CPG, b) the assessment of platelet function by PFA 100 method. a) Of the patients studied by CPG platelet aggregation, 51 (12.1%) pts were resistant to ASA dose 100 mg/day, and 32 (7.6%) pts remained resistant even after increasig the dose to 200 mg/day. In 80 (20%) pts, the daily ASA dose of less than 100 mg was sufficient to inhibit platelet function. b) Although the PFA-100 system is not able to detect the difference between low and high ASA dose, we found 53 (15.2%) patients aspirin resistant using this method. CONCLUSIONS: In the patients with IHD treated with 100 mg of ASA per day, our study has shown that the prevalence of aspirin resistance was 12.1% using CPG method, and 15.2% using PFA-100 method. Aspirin resistance was dose dependent. Prevalence of ASA resistance in patients treated with 200 mg of ASA per day was only 7.6% using the CPG method.

[The activation of haemostasis during radiofrequency catheter ablation]. / Aktivace hemostázy behem katetrizacní radiofrekvencní ablace.

The aim of the study was to investigate chosen haemostasis activation markers during electrophysiologic study (EPS) with consequent radiofrequency catheter ablation (RFA). Sixty-three patients were studied prospectively. Indications for EPS and RFA were supraventricular tachycardias with the arrhythmogenic substrate located in the right atrium. Blood samples were drawn 24 hours before the procedure (T -1), at the beginning of the procedure (T0), at the end of EPS (T1), 30 minutes after completion of RFA (T2), and 24 hours after the procedure (T3). To study coagulation, fibrinolytic and platelet activation were measured concentrations of thrombin-antithrombin III (TAT), D-dimers (DD), platelet count and parameters, and circulating platelet aggregates (CPAi). During the EPS and RFA, TAT levels increased from the baseline 5.03 +/- 2.53 microg/l (T -1) to 12.90 +/- 12.83 microg/l at T0 (p < 0.001) to 36.07 +/- 15.59 microg/l at T1 (p < 0.001) and decreased to 28.85 +/- 13.14 microg/l at T2 (p < 0.001). Levels of DD increased from 0.30 +/- 0.20 mg/l at T0 to 0.44 +/- 0.25 mg/l at T1 (p < 0.001) and to 0.87 +/- 0.74 mg/l at T2 (p < 0.001). The number of platelets was significantly decreased (-13.7%) before and during the procedure (T -1 vs. T3; p < 0.001). Marked platelet activation (CPAi 0.62 +/- 0.32) was observed before the procedure opposite to the physiological values (CPAi 1.0 +/- 0.1), without changes during the procedure (CPAi at T2 0.69 +/- 0.23). Our results confirmed activation of several haemostasis parameters during EPS and RFA, and support eligibility of the antithrombotic prevention in patients indicated for EPS and RFA.

[The occurrence of occult malignancy in patients less than 50 years of age with venous thromboembolism: which diagnostic screening methods to use?]. / Výskyt skryté malignity u nemocných s zilní tromboembolickou nemocí mladsích 50 let: jaké diagnostické screeningové metody pouzívat?

Trousseau was the first who describe an association of venous thromboembolism (VTE) with malignancy. The prevalence of occult cancer in patients with secondary VTE is comparable with the prevalence of cancer in general population (2-3%), while the prevalence of occult cancer in patients with idiopathic VTE is 4-10%. It has been demonstrated that the frequency of malignancy is higher in the first 6 to 12 months after diagnosis of VTE. 113 consecutive patients (50 males, 63 females) with first or recurrent VTE before the age 50, mean age (mean age 34.1 at time of VTE diagnosis) were followed retrospectively. Patients with known cancer were excluded for follow-up. The presence of known malignancy and concomitant cancer at the time of diagnosis of VTE and during follow-up (average 29 months) was investigated. The use of routine or extensive screening detection of occult cancer was also assessed. Extensive screening was performed in 61% of patients and compared with 39 % of routine screening. Overall of occult cancer was 1.8 %. The incidence of occult cancer was 1.2% during one year follow-up, and the prevalence at the time of diagnosis of VTE was 0.9%. The authors confirmed the low prevalence of occult cancer in cohort of consecutive young patients with VTE under the age of 50. It seems that only routine investigation with careful history taking, physical examination and simple laboratory tests are sufficient to detect of occult cancer in this age population. The authors recommend the follow-up of these patients, mainly those with idiopathic VTE. Inherited thrombophilia much more prevails in this young thrombophilia patients but risk of occult malignancy exists as well.

Qualitative research for the study of cancer and age.

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence.

BACKGROUND: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option. OBJECTIVES: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence. SUBJECTS: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions. MEASURES: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention. RESULTS: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600. CONCLUSIONS: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

Coping with breast cancer in later life: the role of religious faith.

PURPOSE: To identify and examine religious and spiritual coping strategies among elderly women with newly diagnosed breast cancer. METHODS: A convenience sample of 33 women age 65 years was recruited within 6 months of diagnosis. Respondents participated in a structured interview with open-ended questions. Transcripts of the interviews were analysed independently by three researchers and themes were discussed until consensus was reached. RESULTS: Participants' religious background was varied: 17 Protestant, five Catholic, six Jews, and four Other. There was great variation in the frequency of religious service attendance. Religious and/or spiritual belief either increased or stayed the same during the time of health crisis. Analysis of transcripts revealed three themes. Religious and spiritual faith provided respondents with the emotional support necessary to deal with their breast cancer (91%), with social support (70%), and with the ability to make meaning in their everyday life, particularly during their cancer experience (64%). CONCLUSIONS: Religious and spiritual faith provides elderly women newly diagnosed with breast cancer with important tools for coping with their illness and should be recognized by diagnosing physicians. It may be important to encourage these patients to seek religious support and/or to reconnect with their religious community.

A randomized controlled trial of facilitating information giving to patients with chronic medical conditions: effects on outcomes of care.

BACKGROUND: The purpose of this study was to assess the impact of an intervention to facilitate information giving to patients with chronic medical conditions on outcomes of care. METHODS: A consecutive sample of 276 eligible patients with chronic medical conditions at a family medicine clinic was randomized to control and experimental interventions. A total of 205 completed the study. Experimental group patients received copies of their medical record progress notes, and they completed question lists for physician review, while control group patients received health education sheets and completed suggestion lists for improving clinic care. Self-reported physical functioning, global health, and patient satisfaction and adherence were measured at enrollment and after the interventions. Visit lengths and patient response to medical record sharing after the interventions were also measured. RESULTS: After the intervention, experimental group patients reported 3.7% better overall physical functioning than did control patients (mean = 83.6, standard deviation [SD] = 17.6 vs mean = 79.9, SD = 25.3; P = .005 after adjusting for covariates). The experimental group was more satisfied with their physician's care (mean = 31.4, SD = 4.6 vs mean = 31.3, SD = 5.2; P = .045 after adjusting for covariates). They were also more interested in seeing their medical records than were control patients (mean = 12.0, SD = 2.8 vs mean = 11.2, SD = 2.8; P = .002 after adjusting for covariates). Experimental group patients also reported an 8.3% improvement in overall health status (postintervention mean = 3.0, SD = 1.1) compared with their pre-intervention health status (mean = 2.8, SD = 1.0; P =.001). Visit lengths for patients in the experimental group did not differ from those of the control group. CONCLUSIONS: A simple patient-centered intervention to facilitate information giving in the primary health care of patients with chronic medical conditions can improve self-reported health, physical functioning, and satisfaction with care.

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.