Patients Surveyed Research Articles

Willingness for Weight Loss Intervention Among Overweight and Obese Inpatients

To determine whether overweight and obese inpatients are receptive to weight-loss interventions while hospitalized and whether interest in weight-loss intervention correlates with accurate self-perception of weight. We conducted a cross-sectional survey of overweight and obese patients admitted to the general medicine service at a large urban academic medical center from September 17, 2007 through October 16, 2007. Subjects were identified based on body mass index (BMI) on admission ≥25 and surveyed using a 14-question instrument. The main outcome measure was patient willingness to consider weight-loss intervention. Of 67 eligible patients, 64 (95.5%) agreed to be interviewed. BMI ranged from 25 to 50. Overall, 52.6% (10 of 19) of overweight patients did not believe they were overweight and 46.7% (21 of 45) of those with a BMI over 30 were unaware that they met criteria for obesity. Among all patients surveyed, 56.3% stated they would be interested in weight-loss intervention while hospitalized. In obese patients specifically, 68.9% expressed interest. Interest correlated with BMI (Pearson correlation coefficient (r) = 0.261, P = 0.04), accurate self-perception of weight (P = 0.03), diagnostic delays related to weight (P = 0.01) and a history of past weight-loss attempts (P = 0.04). None of the patients we interviewed received weight-loss intervention of any kind while hospitalized. Inpatients who recognize that they are overweight or obese are interested in pursuing weight-loss initiatives. Despite their interest, most do not receive weight-loss interventions while hospitalized.

Hospitalized patients' participation and its impact on quality of care and patient safety

To understand the extent to which hospitalized patients participate in their care, and the association of patient participation with quality of care and patient safety. Random sample telephone survey and medical record review. US acute care hospitals in 2003. A total of 2025 recently hospitalized adults. Hospitalized patients reported participation in their own care, assessments of overall quality of care and the presence of adverse events (AEs) in telephone interviews. Physician reviewers rated the severity and preventability of AEs identified by interview and chart review among 788 surveyed patients who also consented to medical record review. Of the 2025 patients surveyed, 99.9% of patients reported positive responses to at least one of seven measures of participation. High participation (use of >4 activities) was strongly associated with patients' favorable ratings of the hospital quality of care (adjusted OR: 5.46, 95% CI: 4.15-7.19). Among the 788 patients with both patient survey and chart review data, there was an inverse relationship between participation and adverse events. In multivariable logistic regression analyses, patients with high participation were half as likely to have at least one adverse event during the admission (adjusted OR = 0.49, 0.31-0.78). Most hospitalized patients participated in some aspects of their care. Participation was strongly associated with favorable judgments about hospital quality and reduced the risk of experiencing an adverse event.

Post-Thrombotic Syndrome: Assessment of Patient and Health Care Provider Knowledge and Awareness.

AbstractAbstract 3835 Background:Despite evidence demonstrating that the post-thrombotic syndrome (PTS) is a common and burdensome long-term complication of deep vein thrombosis (DVT), we hypothesized that patient and health care provider awareness of this condition was poor, thereby limiting the use of measures to prevent and screen for PTS. Objectives:We designed a quality improvement project to (1) identify existing gaps in health care provider and patient knowledge and awareness of PTS, and (2) use this information to guide the development and implementation of a PTS educational curriculum. Methods:Health care providers (internal medicine or family medicine physicians and anticoagulation pharmacists) at two clinical centers were asked to complete a brief survey about PTS knowledge and practice patterns. Patients diagnosed with proximal lower extremity deep vein thrombosis (DVT) who were managed in the Thrombosis Service at each center were asked to complete a brief survey with questions about basic PTS knowledge (University of Utah) or PTS education received and use of elastic compression stockings (ECS) for PTS prevention (Jewish General Hospital). Results:Provider survey: Of the 358 surveys sent to health care providers from both institutions, 77 surveys were completed (17/134 for the University of Utah, 60/224 for Jewish General Hospital). Survey respondents included 59 physicians or resident physicians, and 18 pharmacists. When asked to identify the average incidence of PTS after DVT, only 35% of providers responded correctly. Providers correctly identified that wearing ECS following DVT can prevent PTS in some cases (94% correct), and that diuretic medications are not used to treat PTS (100% correct). However, only 31% of providers at both institutions “always” or “frequently” discuss the risk of PTS with DVT patients, only 25% “always” or “frequently” prescribe ECS for PTS prevention following DVT, and only 26% “always or “frequently” evaluate patients for the development of PTS after DVT. The primary barrier that reportedly prevents providers from performing these functions more frequently is the lack of personal knowledge or expertise to discuss or diagnose PTS. The majority of providers surveyed report they have not received prior education about PTS. Patient survey: Patients at each institution completed a different survey, each exploring different aspects of PTS knowledge. At the University of Utah (n=106 completed surveys), 54% of patients surveyed reported they had never heard of PTS. Only 50% chose the correct answer when asked to identify signs and symptoms of PTS (leg pain and swelling), and only 25% correctly identified a risk factor for PTS (blood clot above the knee). The majority of patients correctly identified appropriate leg elevation technique (67%), and the fact that lower extremities do not always return to normal following DVT (82%). When asked about a possible treatment for PTS, 66% of patients correctly chose ECS, but only 44% correctly chose ECS as also a possible PTS preventive therapy. At Jewish General Hospital (n=60 completed surveys), only 38% of patients reported receiving PTS education, and this was done primarily in the form of verbal teaching by the physician or vascular lab staff. Additionally, 38% of patients reported they were prescribed ECS following DVT, and the majority of those patients did go on to purchase the stockings and wear them regularly. Conclusion:The results of our survey establish that there is tremendous potential to impact and improve both health care provider and patient knowledge of PTS. We found that the majority of providers underestimate the incidence of PTS, which is underscored by the fact that only 1/3 of providers routinely discuss the risk of PTS with DVT patients, and only 1/4 routinely prescribe ECS and/or assess DVT patients for the development of PTS. The gaps in provider knowledge correlate with those in DVT patients surveyed. Most patients have never heard of PTS, and therefore are largely unaware of PTS risk factors, signs and symptoms, and possible preventive methods. These data will be used in the second phase of our quality improvement project to inform the development of educational materials and tools specifically tailored to the learning needs of patients and health care providers. Disclosures:No relevant conflicts of interest to declare.

“You've Got Mail” … from your doctor?

Objective To determine interest in and details of electronic mail (e-mail) use by patients and residents in a residency primary care facility, and to uncover barriers, as well as areas of interests for its use. Methods A prospective survey of patients was initially used to establish patient interest in the project. Next, a four-month trial of e-mail exchange between physician and patient was attempted. After the trial, a second survey was distributed to evaluate specifics of e-mail use by patients, as well as family practice resident physicians' opinions on the topic. Finally, a statistical analysis of the results of the two surveys was performed. Results Of the 146 patients surveyed, 36% were interested in using the Internet to communicate with a physician. Patients appeared to be more optimistic than residents that e-mail is beneficial to the doctor-patient relationship. Of the interested patients, 43% felt a consent form was needed, whereas 79% of family practice residents felt it was needed. Seventy-one percent of patients and 53% of residents felt e-mail was a secure form of communication. One-hundred percent of patients felt physicians in training should have experience exchanging e-mail with their patients, but only 58% of the family practice residents felt this way. One-hundred percent of patients and residents felt that physician-recommended links to medical Internet sites would be beneficial. Sixty-four percent of patients said they would pay for the ability to e-mail their physician. Conclusions This study demonstrates that there is significant patient interest in exchanging e-mail with their physician, even in a medical residency program. Resident physicians are still trying to decide whether they are comfortable enough with the Internet to consider patient-physician e-mail a beneficial endeavor. Trials, errors, and time will eventually reveal whether e-mail will be a future staple communication tool for physicians and patients.

C-A2-02: Virtual Consult Use in an Electronic Medical Record: Descriptive Statistics at Mid-Point of Study

Ted E Palen, PhD, MD, MSPH, David W Price, MD, Kristin Wallace, MPH and Susan M Shetterly, MS Ted E Palen, PhD, MD, MSPH, Institute Kaiser Permanente Colorado; David W Price, MD, Kaiser Permanente Colorado; Kristin Wallace, MPH, Kaiser Permanente Colorado; Susan M Shetterly, MS, Kaiser Permanente Colorado

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia?

Background Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair. Methods We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors. Results Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain ( P = .05), feeling of lump ( P = .02), and foreign body perception ( P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group ( P = .26). Conclusions A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.

Management of test results in family medicine offices.

We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management. Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes. We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness-a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption-the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements). Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.

Die „Entschuldigungstendenz” bei Krankenhauspatienten

The primary purpose of this study was to analyse the extent to which inpatients excuse the errors and inconveniences that take place during their hospital stay and how this "tendency to excuse" affects their assessment of the hospital services. The data, which provided the basis for this study, were obtained from a postal survey that was sent to 1 548 patients who had been treated in one of three hospitals in Germany. The survey itself was conducted within the scope of the research project entitled "Organizational Governance Using Biopsychosocial Indicators" (U-BIKE-Study) and contained various modules of the Cologne Patient Questionnaire (CPQ). For the purpose of the analyses, the "tendency to excuse" was subdivided into "excuser,""medium excuser" and "non-excuser". A total of 855 patients completed and returned the questionnaire (55.2% response rate). Descriptive analyses showed that nearly half of the patients surveyed were willing to excuse many of the hospital's errors and inconveniences. Each of the "tendency-to-excuse" types assessed the hospital services differently. The "excuser" almost always provides the most positive of assessments and the "medium excuser" almost always provides the most negative. The analyses revealed that fewer patients than initially expected on the basis of the traditional concept of the patient role excuse hospital errors and inconveniences. This can be seen as an indication that many inpatients do not take on the assumed patient role. While interpreting patient surveys, the "tendency-to-excuse" types can shed light on possible means of optimising hospital services. The "tendency to excuse" patients therefore aid in providing more valid measurements when conducting patient surveys.

Point prevalence survey for healthcare-associated infections within Canadian adult acute-care hospitals

A survey of adult patients 19 years of age and older was conducted in February 2002 in hospitals across Canada to estimate the prevalence of healthcare-associated infections (HAIs). A total of 5750 adults were surveyed; 601 of these had 667 HAIs, giving a prevalence of 10.5% infected patients and 11.6% HAIs. Urinary tract infections (UTI) were the most frequent HAI, shown by 194 (3.4%) of the patients surveyed. Pneumonia was found in 175 (3.0%) of the patients, surgical site infections (SSI) in 146 (2.5%), bloodstream infections (BSI) in 93 (1.6%) and Clostridium difficile-associated diarrhoea (CDAD) in 59 (1%). In this first national point prevalence study in Canada, the prevalence of HAI was found to be similar to that reported by other industrialized countries.

Consequences of diagnostic delays in type 1 Gaucher disease: The need for greater awareness among Hematologists–Oncologists and an opportunity for early diagnosis and intervention

Gaucher disease (GD) is a progressive macrophage lipidosis capable of causing disabling and life-threatening complications. Anecdotal experiences suggest that GD may go undiagnosed for many years, leading to severe complications that are preventable or reversible by enzyme replacement therapy (ERT) with imiglucerase. We conducted surveys of patients and Hematology-Oncology specialists to assess the frequency of diagnostic delays. Additionally, we report a series of patients who suffered diagnostic delays and as a result developed disabilities including potentially life-threatening manifestations of GD. Of 136 patients surveyed, the average time from first appearance of GD symptoms to final diagnosis was 48.7 +/- 123.6 months. More than two-thirds were evaluated and managed by a hematologist-oncologist (Hem-Onc). A global survey of 406 Hem-Oncs found that only 20% considered GD in the differential diagnosis for all of its classic symptoms (cytopenia, hepatosplenomegaly, bone pain); the diagnosis considered most likely included leukemia, lymphoma, and multiple myeloma. To illustrate actual consequences of diagnostic delays, we describe 14 patients with GD who suffered from symptoms for up to 10 years before correct diagnosis. Diagnostic delays led to complications that are preventable or reversible with ERT (i.e., avascular necrosis, severe bleeding, chronic bone pain, life-threatening sepsis, pathologic fractures, growth failure, liver pathology). Patients homozygous for N370S mutation in this series were vulnerable to diagnostic delays. In conclusion, prolonged diagnostic delays occur in GD and may result in severe disease manifestations. Our findings suggest that physician education will increase the likelihood of prompt detection of GD and improve its management with ERT with imiglucerase when indicated.

Improving access to HCV treatment: External jugular venepuncture can overcome problems with difficult venous access

Many patients requiring antiviral treatment of chronic hepatitis C (HCV) have a background of significant injection drug use (IDU). In a proportion of patients, IDU results in difficulty with blood collection from conventional sites. We audited patients from the Liver Clinics and Drug Health Pharmacotherapy Service of The Royal Prince Alfred Hospital (RPAH) to determine the incidence of difficulty with blood collection. This survey identified the need for an innovative venous access strategy to better manage this group of patients. An external jugular venepuncture (EJV) protocol and education package was developed in collaboration with the Department of Anaesthetics, Gastroenterology and Liver Centre and HCV clinical nurse consultants (CNC). RPAH policy and procedure committee approved the protocol and patient information sheet. Patients with a history of difficulty with blood collection were eligible for the protocol. Patient satisfaction surveys were conducted. The initial survey of patients from the liver clinics and pharmacotherapy service identified that 48 percent had difficulty with blood collection from conventional sites. In the period October 2002 to July 2006, 29 patients (89 percent with history of IDU) were referred for EJV assessment. Major indications for EJV were for blood testing for initiation and monitoring of antiviral therapy and ongoing assessment of HCV infected patients. No adverse events resulted from the procedure. All patients surveyed report high levels of satisfaction with the technique compared to previous venous access attempts. EJV improves access to antiviral therapy and is a safe and effective technique for patients with difficult venous access (DVA). In addition, we have utilised EJV for post-transplant care of patients and used external jugular vein cannulation as vascular access for contrast imaging in hepatocellular carcinoma (HCC) assessment.

Long-term Results After Surgery for Autoimmune Sclerosing Pancreatitis

Autoimmune sclerosing pancreatitis (ASP) is a recently recognized cause of chronic pancreatitis. The role of operative intervention in this disease is controversial. A single center experience with 161 consecutive pancreatic resections for chronic pancreatitis was retrospectively reviewed. Operative specimens were reanalyzed and assessed for histological features of ASP. Long-term outcome was assessed by patient survey. Eight patients were identified with histological changes consistent with ASP. The pancreatic anatomic configuration according to intraoperative findings and preoperative radiographic evaluation was categorized into (1) diffusely enlarged pancreas (n = 4), (2) localized mass (n = 2), or (3) refractory pancreatic duct disruption without pancreatic enlargement (n = 2). Five patients underwent pancreaticoduodenectomy and three patients underwent distal pancreatectomy. Perioperative morbidity, operative time, and intraoperative estimated blood loss were similar to the same operation for other etiologies of chronic pancreatitis. Biliary obstruction occurred in two patients. Seven patients were alive 5 ± 0.4 years after operation. Good quality of life measured by the SF-36 questionnaire was present in 4 of 7 patients surveyed. Good pain control was achieved with return to work in 5 of 7 patients. Two patients with poor pain control received glucocorticosteroids therapy without improvement in symptoms. Patients with ASP and a mass suspicious for malignancy or refractory duct disruption require operative intervention. Early postoperative outcome, long-term pain control, and improvement in quality of life appear to be good.

Consequences of Diagnostic Delays in Type 1 Gaucher Disease: A Unique Opportunity among Hematologists/Oncologists for Early Diagnosis and Intervention.

Gaucher disease (GD) is a progressive lysosomal storage disease that can lead to life-threatening complications. Anecdotal experiences of patients and physicians suggest that symptoms and signs of the disease may go undiagnosed for many years, resulting in severe yet preventable complications. We conducted surveys of patients and Hematology/Oncology specialists to assess the frequency of diagnostic delays. Furthermore, we reviewed a series of patients in whom prolonged misdiagnosis resulted in serious complications of GD. Of 136 patients surveyed, the average time from first appearance of GD symptoms to final diagnosis was 3–4 years. Up to 86% of patients reported having visited a Hematologist/Oncologist (Hem/Onc) concerning their condition and two thirds reported current management of their symptoms by a Hem/Onc. The frequency of intial symptoms at presentation to Hem/Oncs is depicted in Table 1. In a global survey of 406 Hem/Oncs, only 20% of respondents considered GD in the differential diagnosis when presented with all six classic symptoms: anemia, thrombocytopenia, hepatomegaly, splenomegaly, bone pain, bone crisis. In contrast, the diagnoses considered more frequently for this constellation of symptoms were leukemia (65%), lymphoma (36%), and multiple myeloma (22%). When asked to list additional signs and symptoms of GD other than the six classic symptoms, 47% could not list any additional manifestations; the common signs and symptoms of easy bruising and bleeding, fatigue, and pathological fractures were identified by 9%, 5%, and 4% of respondents, respectively. Fifty-three percent of surveyed Hem/Oncs considered their specialty the best equipped to manage Gaucher patients and their self-assessed knowledge of GD on a scale of 1 (not at all knowledgeable) to 10 (extremely knowledgeable) was 4.1±2.4, with responses showing normal distribution around the mean. In a review of 14 patients with GD in whom up to 10 years elapsed from the appearance of symptoms to final diagnosis of GD, reversible or preventable complications occured including avascular necrosis, bleeding, chronic bone pain, life-threatening sepsis, pathologic fractures, growth failure and liver pathology. In this series, patients with GBA genotype N370S/N370S, which is typically associated with a mild GD phenotype, were most vulnerable to diagnostic delays. In conclusion, prolonged diagnostic delays occur frequently in GD that may result in severe complications. Physician education is needed to increase early detection of patients with GD and improve its management, and Hem/Oncs have a unique opportunity for timely diagnosis and optimal management of this treatable disorder.Table 1Symptoms of Patients Presenting to Hematologists/OncologistsSigns and SymptomsPercentage of Patients (n = 92)Easy bruising or bleeding51.1%Enlarged abdomen46.7%Fatigue31.5%Pain in bone and joints/bone fractures26.1%Delayed growth17.4%Other*29.3%*Including thrombocytopenia, anemia, epistaxis, chronic infection, leg pain, enlarged liver and/or spleen

Quality of life and return to work following electrical burns

To investigate the psychosocial outcomes following electrical burns, a cross-sectional survey of electrical burn patients was done using three outcome tools: the Burn Specific Health Scale brief version (BSHS-B), the Coping with Burns Questionnaire (CBQ), and the Pain Patient Profile (P3 ®). Questionnaires were mailed to electrical burn patients discharged from an adult regional burn centre, and also distributed to attendants of an electrical utility conference in Toronto. Twenty-six of 88 patients who were discharged from the regional burn centre during the study period with updated residential information were contacted and 14 (54%) completed the questionnaires. Twenty questionnaires were also distributed at the conference and 8 (40%) were completed; leaving a total of 22 (48%) patients for the study. The average patient age was 44.0 ± 11.7 years; 21 (96%) were men, and the average time from injury to survey completion was 5.3 ± 4.9 years. Five (23%) of the 22 patients returned to the same work duties, 10 (45%) changed duties, and 7 (32%) did not return to work. BSHS-B scores were low for all patients. Participants with high voltage burns (>1000 V) had worse sexuality scores ( p < 0.05), while those with larger burns (>10% TBSA) had worse physical scores ( p < 0.05). Patients surveyed >5 years from injury showed improvement in physical scores. CBQ scores indicated that optimism was the most commonly used coping strategy. P3 ® showed significant levels of emotional distress in all patients, with anxiety being more common in high voltage injuries ( p < 0.05). The data suggests that electrical burn patients may have a limited ability to return to work and an overall poor quality of life. Emotional distress is the dominant feature influencing long-term outcome in these patients. Further studies are warranted to validate these findings.

Poor perceptions and expectations of asthma control: Results of the International Control of Asthma Symptoms (ICAS) survey of patients and general practitioners

To assess current levels of asthma control and to identify barriers to optimal asthma management. A survey was conducted of 802 asthma patients (via computer-aided telephone interviewing) and 809 general practitioners (GPs; via the internet) from the UK, Italy, France, Germany, Spain, Canada and Australia. Over three-quarters (82%) of patients surveyed reported an absence of asthma control, with the vast majority (80%) experiencing subsequent lifestyle restrictions. Although most (58%) GPs questioned believed that total asthma control was possible, half (52%) agreed that their patients were not achieving best possible asthma control. Action is required to encourage patients to view their asthma more seriously and to be more proactive in reporting symptoms to their GP. These actions, coupled with greater prompting of patients by GPs about their asthma, should help to optimize asthma management.

Alcohol dependence and driving: A survey of patients' knowledge of DVLA regulations and possible clinical implications

Aims and MethodA survey of 58 patients with alcohol dependence was carried out to ascertain how much knowledge such patients have about the Driver and Vehicle Licensing Agency (DVLA) regulations. Patients completed a questionnaire about whether they follow DVLA regulations, what information health professionals had given to them and whether they would still seek treatment if they knew doctors might inform the DVLA.ResultsThe majority of patients surveyed were continuing to drive. Very few had any knowledge of DVLA regulations regarding alcohol dependence. With the knowledge that doctors have a duty to notify the DVLA in certain circumstances, a significant proportion said they would be less likely to seek treatment or would stop attending for treatment.Clinical ImplicationsHealth professionals may be avoiding discussions of the DVLA regulations with patients suffering from alcohol dependence in an attempt to preserve the doctor–patient relationship.

High Prevalence of Complementary and Alternative Medicine Use Among Cancer Patients: Implications for Research and Clinical Care

In this issue, Hyodo et al report that herbs and other dietary supplements are used by substantial numbers of cancer patients in Japan— 44.6% of 3,100 patients, as opposed to 25.5% of 361 noncancer (benign tumor) patients surveyed. These data are consistent with results from numerous prior surveys on complementary and alternative medicine (CAM) use in oncology. A 1998 systematic review examined 26 surveys of cancer patients from 13 countries and reported an average prevalence of 31%, with rates ranging up to 64%. Subsequent studies report even higher prevalence, depending on the definition of CAM used. Reports of prevalence often are exaggerated because surveyors include many aspects of life, such as spirituality, attention to diet, and routine self-care, that from our perspective are not complementary therapies. Nonetheless, use of complementary therapies by cancer patients is substantial. Virtually all studies conducted internationally, such as that reported here, indicate that people who seek complementary therapies are better educated, of higher socioeconomic status, and more likely to be female and younger than those who do not. Data from Hyodo et al show that herbs and supplements, which are directed primarily at cancer control, are used much more commonly in Japan than are the symptom management complementary therapies more typically sought in North America. This difference is also of interest because, despite some promising agents, most herbs and other supplements as currently available are of questionable value, whereas substantial evidence from randomized trials supports the use of complementary therapies for symptom control in patients with cancer, including acupuncture, massage, music therapy, and relaxation techniques. In the survey by Hyodo et al, more than 96% of patients used Chinese herbs, mushrooms, shark cartilage, vitamins, and so on (Table 3 of Hyodo et al ). Not mentioned in this article, however, are Japan’s Kampo products, which are based on traditional Chinese herbal formulas. Kampo botanicals are produced at a pharmaceutical grade, available in pharmacies by prescription, and commonly prescribed by physicians in Japan. This survey excluded Kampo products, explicitly defining CAM as remedies used without the approval of relevant government authorities and not covered by health insurance. Many Kampo products, conversely, are approved by the Japanese government and are covered by health insurance. Essentially, they are high-quality, standardized, government-regulated versions of herbal medicines, which in the West are termed dietary supplements. In North America, however, dietary supplements do not meet the same standards as do the governmentregulated Kampo products in Japan. Ours are poorly standardized, often contaminated, usually not evidence based, and unregulated, and may be dangerous in the oncology setting. Herbs and other supplements are not required to meet standards of safety, efficacy, and consistency, and their use has important implications for clinical care. The continuing availability of such products in the United States results in large part from the 1994 Dietary Supplement and Health Education Act, which created a protective new category for the approximately 20,000 vitamins, minerals, herbs, and other agents sold as supplements before October 1994. Spurred by supplement industry lobbying, the act protects supplements from government scrutiny and mandates that the US Food and Drug Administration prove harm before distribution of a product can be regulated. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 23 NUMBER 12 APRIL 2

A survey of breast cancer patients' views on entry into several clinical studies.

During the course of their treatment and follow-up, women with breast cancer are likely to be asked to join a number of different clinical studies. Some local research ethics committees have expressed concerns about entry of individual patients into multiple research studies. A survey was undertaken to improve understanding of patients' own perceptions of participation in several clinical studies. A total of 96 patients who had previously undergone surgery for breast cancer from January to June 2000 were sent a questionnaire 6-12 months after completion of primary treatment. Eighty four per cent of questionnaires were returned of which 62% were from patients who had been approached to enter at least one clinical study. Sixty-four per cent of patients believed that there should not be a limit on the number of clinical studies offered to patients. Furthermore, three quarters of all patients would have considered entering more than one study if adequate explanation and written information were provided. Most patients felt that their participation in a clinical study was worthwhile and no patients surveyed regretted their decision to take part in a study. Almost two-thirds of patients who returned questionnaires believed there should not be a maximum number of studies offered to them. This survey suggests that the majority of patients are prepared to participate in more than one clinical study when adequate information and explanation are provided.

Noninvasive Wrinkle Reduction with the Nlite Laser: A Study of 50 Consecutive Patients

Introduction: Selective nonablative wrinkle reduction by laser is an exciting and appealing concept. The Nlite laser is a 585-nm pulsed dye laser that works on the concept that mild laser light injury of microvessels in the skin induces production of new collagen and may cause reduction in depth and visibility of wrinkles. This study reports on the author's experience with this new technology and the 6-month evaluation of 50 consecutive patients in his practice. Materials and Methods: Fifty consecutive patients were treated with the Nlite laser according to the parameters suggested by the manufacturer. All patients had preoperative photographs taken and their wrinkles graded according to the Fitzpatrick and Glogau score. Three observers performed postoperative evaluation of 37 patients at 6- to 9-month intervals using photographs. Patient survey of 42 patients was completed with statistical analysis of the results. Results: Three observers were asked to evaluate pretreatment and posttreatment photographs and to determine if any detectable improvement had occurred after treatment. A total of 54%, 27%, and 37% of patients were found to have detectable improvement, respectively, for the periorbital, forehead, and perioral areas (marionette and lip lines). Patients surveyed on their results indicated detectable improvement in 70%, 62%, and 70% of patients, respectively, for the periorbital, forehead, and perioral areas. Most patients and observers graded the improvement as 0–25%. Discussion: The Nlite laser is a noninvasive treatment that improves skin wrinkles in some patients as noted by observer evaluation of pretreatment and posttreatment photographs and by patients as perceived by patient survey. The degree of improvement does not appear to be as great as that claimed by the laser manufacturer.

Survey of patients' views of domiciliary nebuliser treatment for chronic lung disease

There is some controversy amongst respiratory physicians over the value of domiciliary nebuliser use for chronic lung conditions. Most recommendations for assessment of suitability for this form of treatment rely upon response to lung function tests and reported improvements in exercise ability. Relatively little emphasis has been placed upon the patient view of this therapy. This survey examined the subjective views of patients receiving domiciliary nebulisers regarding this treatment. A postal questionnaire was sent to 82 patients using home nebuliser treatment provided by the respiratory clinic at Whipps Cross University Hospital, London. It consisted of 29 structured questions covering topics of well-being and symptom control, self-confidence, dependency, time and technical issues, as well as side effects and compliance. Most patients surveyed had chronic obstructive lung disease. For almost all sections of the questionnaire patients reported overwhelmingly that the benefits of using a nebuliser outweighed potential disadvantages. The main perceived advantages were the ability for patients themselves to control symptoms and to be less dependent on General Practitioners, hospitals and carers. Compliance was generally excellent, and the reported side effects were minor and relatively infrequent. The results strongly support the view that nebulisers are helpful in managing chronic lung disease in the community, with benefit to patient well-being and potential health cost savings.