Patient Subjective Assessment Research Articles

Tendovaginosis stenosans - was nützt die Injektionstherapie?

Symptoms, frequency of complaints, patient's subjective assessment, and relapse rate were evaluated in patients provided with injection therapy for stenosing tenovaginitis (ST). Fifty-five patients (34 women, 21 men) suffering from ST underwent injection therapy of 0.25 ml triamcinolone and 0.25 ml mepivacain hydrochloride administered under the A1 pulley. Symptoms, frequency of complaints, subjective assessment, and evidence of recurrent disease were monitored for 5 years following injection therapy. Patients were divided into 3 groups: injection therapy with good outcome, injection therapy with poor outcome, and injection therapy but subsequently operated. The middle finger (38 %) and the ring finger (31 %) were affected most commonly. ST afflicted more women than men. Twenty-seven patients (49 %) showed long-term relief of symptoms. Sixty-six percent of patients experienced short-term relief of symptoms. Therapy failure was more common in men, in younger patients, and in patients with diabetes. Better results were seen in women, in older patients, and in patients with rheumatism. Complications of injection therapy did not occur during this study. Injection therapy is a justifiable alternative to surgery in patients with ST. In this study, half of the patients treated described long-term relief of symptoms, and assessed the effects of injection therapy positively. Especially satisfied patients included women, older patients, and patients with rheumatism.

Thyroplasty Type I With Montgomery Implant among Native French Language Speakers with Unilateral Laryngeal Nerve Paralysis

To document the long-term results achieved with the Montgomery implant in 96 French speakers with a unilateral laryngeal nerve paralysis (ULNP). Retrospective series, inception cohort of 96 patients. Data regarding morbidity and functional results were obtained at regular visits to our clinic. All patients were followed for a minimum of 6 months or until death. Forty-two patients had a minimum of 12 months of follow-up. Early in the study, 36 patients were prospectively recorded under similar conditions before placement of the Montgomery implant and at 1, 3, 6, and 12 months postoperatively. None of the 96 patients died in the immediate postoperative period. The perioperative course was unremarkable in 94.8% of cases. Perioperative problems included failure to obtain a satisfactory phonatory result in three patients, difficulty to stabilize the implant posteriorly in one patient, and fracture of the inferior rim of the thyroid cartilage window in another patient. The primary immediate postoperative problem (within the first postoperative month) was laryngeal dyspnea, noted in four patients. According to the patient's subjective assessment, speech and voice was always improved in the immediate postoperative period. However, three patients had secondary degradation of speech and voice. Revision surgery under local anesthesia resulted in a 97.9% ultimate speech and voice success rate. According to the patient's subjective assessment, adequate swallowing in the immediate postoperative period was achieved in 94.2% of cases that had swallowing problems preoperatively. A significant statistical increase in the duration parameters (phonation time, phrase grouping, speech rate) together with a statistical significant decrease in both the jitter and shimmer values was noted when comparing the preoperative and the postoperative values at 1 month. Analysis of the evolution of the speech and voice parameters at 1, 3, 6, and 12 months postoperatively showed a significant decrease in the fundamental frequency and noise-to-harmonic ratio values but did not demonstrate any significant differences for the other speech and voice parameters. From the reported data, we conclude that the type I thyroplasty with Montgomery implant insertion is a safe and reproducible method to treat ULNP. Furthermore, this system achieves very good and stable phonatory results. Finally, the use of this technique and implant system appears safe in patients from various cultures with ULNP from a variety of causes and severe comorbidity. Over the past decade at our department, this procedure progressively replaced the use of the intracordal injection of autologous fat injection that was initially advocated in patients with ULNP.

Analysis of Outcomes of Anterior Cruciate Ligament Repair With 5-Year Follow-up: Allograft Versus Autograft

To prospectively compare outcomes of primary anterior cruciate ligament (ACL) reconstruction with either Achilles tendon allograft with soft-tissue fixation or standard bone-patellar tendon-bone autograft with interference screw fixation. Prospective comparative case series. A group of 41 patients who underwent soft-tissue allograft reconstruction and a group of 118 patients who underwent autograft bone-patellar tendon-bone reconstruction were included in the final results. Patients were evaluated preoperatively and postoperatively at 1 to 2 weeks, 6 weeks, 3 months, 6 months, and then annually for 5 years. Objective measures of outcome included KT-1000 measurements, range of motion, ligamentous integrity, thigh atrophy, and International Knee Documentation Committee score. Subjective evaluations included patient completion of 5 questionnaires documenting functional status, pain, and health-related quality of life: (1) the short-form McGill Pain Questionnaire, (2) a patient subjective assessment of knee function and symptoms, (3) a patient subjective assessment follow-up, (4) a knee pain scale, and (5) the RAND 36-Item Health Survey. Mixed models analysis of variance was used to compare the outcomes of the treatment groups using baseline values of the study variables as a covariate. Autograft patients reported significantly more pain on the bodily pain subscale of the RAND-36 than the allograft group at 1 week (P = .0006), 6 weeks (P = .0007), and 3 months (P = .0270). Autograft patients reported more pain than allograft patients on the McGill Pain Scale visual analog scale at 1 to 2 weeks (P < .0001) and 6 weeks (P = .0147). Patient assessment of function and symptoms showed that a higher proportion of patients reported normal or nearly normal knee function in the allograft group than in the autograft group at 3 months (33% v 14%, P = .0558, respectively). Fewer activity limitations were reported by allograft patients than autograft patients at 6 weeks (P = .0501), 3 months (P = .0431), and 6 months (P = .0014). After reconstruction, the allograft group displayed significantly more laxity in KT-1000 measurements at all time points than the autograft group (P = .0520). These measurements decreased over time for both groups (P < .0001). Five-year follow-up of patients undergoing ACL reconstruction with allograft versus autograft were compared objectively and subjectively. Both groups of patients achieved similar long-term outcomes. Overall, the allograft patients reported less pain at 1 and 6 weeks after surgery, better function at 1 week, 3 months, and 1 year, and fewer activity limitations throughout the follow-up period. Level II, prospective cohort study.

FUNCTIONAL MAGNETIC STIMULATION FOR MIXED URINARY INCONTINENCE

In this study we determined the efficacy of functional magnetic stimulation (FMS) compared to placebo for treating women with mixed urinary incontinence (MUI). A total of 39 women with MUI were randomly assigned to the FMS group (23 patients) or to the placebo group (16 patients). FMS was applied continuously at 18.5 Hz day and night for 2 months. Conventional urodynamic studies were performed before and after stimulation. Outcome measures assessed were clinical (daytime frequency, nocturia, pad use, pad weight) and urodynamic variables (first sensation of bladder filling, maximum cystometric capacity, maximum urethral closure pressure), and patient subjective assessment (visual analogue scale). After 2 months of FMS significant decreases in voiding frequency (from 9.0 to 6.7, p = 0.0002), nocturia (from 2.6 to 1.4, p = 0.0007) and pad use (from 3.9 to 2.2, p = 0.007) were observed only in the FMS group. First sensation of bladder filling and maximum cystometric capacity increased significantly after stimulation compared with prestimulation levels only in the FMS group, p = 0.003 (from 118 to 174 ml) and p = 0.00004 (from 267 to 396 ml), respectively. A total of 18 women (78.3%) reported an improvement in symptoms after FMS with an average success rate of 41.9%. The success rate was significantly lower in the placebo group (p = 0.021) at 22.9%. Functional magnetic stimulation was useful and safe for treating women with MUI.

Die Trainierbarkeit von propriozeptiven und koordinativen Parametern bei der chronisch-funktionellen Sprunggelenkinstabilität

This study was aimed at assessing the outcome of physical therapy based on both subjective patient's satisfaction and objective measurement of peroneal reaction time in patients with chronic ankle instability. 25 patients with chronic ankle instability based on functional deficits were included. Physical therapy consisted in a 6 weeklong program with muscle strengthening and coordination exercises for one hour, three times a week. Before starting physical therapy as well as two weeks after finishing the program, patients underwent both a clinical exam as well as measurement of their peroneal reaction time. Following physical therapy peroneal reaction time of the long (p = 0.0001) and short (p = 0.0003) peroneal muscles significantly decreased. Prior to physical therapy the Kitaoka score was calculated to be 72.2 (+/- 18.7), the post treatment value was 93.3 (+/- 11.7) with a p-value of < 0.001. As for subjective patient's assessment on a scale of 1-10 with 1 being the least and 10 the most satisfied with therapeutical outcome, patients gave an average post treatment score of 8.3 (+/- 1.9). Measurement of PRT can be used as a helpful diagnostic parameter, as a parameter for quality control and for verification of therapy results. Specific physiotherapy leads to good clinical results and increased PRT.

The incidence of gastroesophageal reflux after transthoracic esophagocardio-myotomy without fundoplication: a long term follow-up

Evaluation of the long term results of Heller's myotomy performed over a lateral thoracotomy without additional fundoplication. Forty patients (17 males, 23 females; mean age 43.2 years; range: 14-63 years) were operated between 1985 and 2000. Preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and 24-h ph-metry. At the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. The mean duration of follow-up after surgery was 10.3 years, ranging from 3-16 years. The clinical scores improved significantly: Excellent relief from dysphagia was present in 86%, little or no regurgitation was found in 79%, little or no retrosternal spasms were reported by 72% of the patients. Esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. Endoscopically, 2.5% had candida-esophagitis, 5% showed signs of a GERD I, 92.5% had a macroscopically insuspect esophageal mucosa. Histologically, 53% showed a mild chronic inflammation. Manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; pH-metry showed moderate reflux in 46%. Transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. The patient's subjective assessment of the postoperative result was positive in the majority of cases. Although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux.

378Chronic prostatitis/chronic pelvic pain syndrome recurrence after initial effective phytotherapeutic treatment

MATERIAL & METHODS: Men with category IIIB CPPS were primarily randomized to Permixon and matched with a placebo-control group. The response to therapy was evaluated at 6 and 12 months. 3 years later, a follow-up study was conducted to reevaluate efficacy parameters including Patients Subjective Global Assessment (SGA), the total NIH Chronic Prostatitis Symptom Index (CPSI), the pain, voiding and quality of life/impact domains of the CPSI, safety data, PSA and prostate volume.

Effect of rurality on patients' satisfaction with out of hours care provided by a family doctor cooperative

Reacting to demand and supply pressures, European healthcare systems are undergoing significant structural changes to the organisation and delivery of out of hours care. Such pressures are of particular concern to rural practice. Although patient satisfaction with out of hours care has been extensively studied, the effect of rurality on satisfaction levels has not, to our knowledge, been previously examined. To investigate whether rurality has an influence on patient satisfaction with out of hours care provided by a family doctor co-operative. All patients contacting the service over a designated 24-day period were forwarded a postal questionnaire. Patients' satisfaction was measured using a version of the McKinley questionnaire, and rurality, by subjective patient assessment, distance from treatment centre or previous rota cover. The response rate was 55% (531/966). Overall satisfaction levels were high with 88% of patients rating the service as either good or excellent. 47.8% of respondents perceived themselves as living in a town, 14.6% as living in a village, and 37.6% as living in the countryside. Perceived rurality, distance from treatment centre or previous rota cover did not significantly affect satisfaction levels. Family doctor co-operatives have significantly altered the way out of hours care is delivered. Patients from rural areas are equally satisfied with the provision of out of hours care by co-operatives, as urban patients. Extension of co-operatives to rural areas need not be constrained by concerns regarding decreased patient satisfaction.

Development and validation of a new treatment outcome score for men with LUTS.

To develop, validate, and test elements of a new outcome score for men with lower urinary tract symptoms (LUTS). Elements of well-established questions from the International Prostate Symptom Score (IPSS) assessment were combined with both established noninvasive objective determinants of voiding function including maximum uroflow (Qmax), postvoid residual urine volume (PVR), total number voids, maximum voided volume (MVV) as well as a subjective patient assessment parameter, to create a new LUTS treatment outcome instrument which we have termed the "LUTS outcome score" (LOS). The LOS is comprised of eight items; each assigned a score of 0, 1, or 2. Thus, the score ranges from 0 (best) to 16 (worst). Patients were divided into surgical/non- surgical (pharmacologic or behavior modification) treatment groups. Content validity and cutoff values for cure/improve/fail were established by an expert panel. Criterion validity was established by comparison to the IPSS. Internal reliability analysis was performed to obtain information about the relationships between individual items in the scale. Individual LOS items were correlated with the subjective outcome score. We also calculated the correlations between the LOS, IPSS, subjective post-treatment response, and age. Internal consistency, based on the average inter-item correlation was calculated using Cronbach's alpha statistic. Associations between continuous variables were examined by calculating the Pearson correlation coefficient, and between ordinal variables, using Spearman's rho. Test-retest analysis was recorded to determine reproducibility of the patient subjective outcome score. Seventy-seven men who underwent treatment for LUTS for at least 6 months participated in the study. All completed a detailed pretreatment and post-treatment clinical evaluation consisting of history/physical, questionnaire, voiding diary, urinalysis, Q, PVR, and videourodynamic study. Subjective responses of cured/improved/failed status following treatment were assessed by independent investigators. A high level of internal consistency was observed among the LOS symptom questions, Cronbach's alpha = 0.81 for the total cohort. The LOS correlated directly and significantly with the patient's subjective post-treatment response (r = 0.75, P < 0.001), age (r = 0.27, P = 0.02), and with the total IPSS (r = 0.62, P < 0.001). The IPSS also correlated directly and significantly with the patient's subjective post-treatment response (r = 0.48, P < 0.001) but did not correlate with the patient's age (r = 0.10, P = 0.41). When the subjective parameter for post-treatment response was subtracted from the LOS, the resulting correlation (r = 0.52, P < 0.001) approximated that obtained using the IPSS. The LOS is valid and internally consistent. Unlike the IPSS, it combines subjective, semisubjective, and objective parameters. Because of the objective components, it diminishes the possibility of overestimating cure and underestimating improvement relying only on patient's symptoms. Further, we believe it will prove to be useful for post hoc analysis in patients who have not had pre-treatment assessment.

Oral Continuous Positive Airway Pressure for Sleep Apnea: Effectiveness, Patient Preference, and Adherence

Nasal continuous positive airway pressure (CPAP) is the most definitive medical therapy for obstructive sleep apnea (OSA). Many patients have difficulty tolerating nasal CPAP due to nasal airway problems, mouth leak, and general discomfort from the mask and headgear. These limitations may be overcome by an oral mask (Oracle; Fisher & Paykel Healthcare; Languna Hills, CA) that does not require headgear. We performed a study to compare the Oracle mask to conventional nasal and oronasal masks in the effectiveness of CPAP delivery and patient satisfaction and adherence. Ninety-eight, consecutive CPAP-naïve patients with OSA diagnosed by overnight polysomnography (apnea-hypopnea index [AHI] > 5) were referred for CPAP therapy. All patients were presented with a variety of CPAP masks, including nasal, oronasal, and Oracle, and reasons for mask choice were documented. After 3 weeks of acclimatization to the mask of their choice, patients had a CPAP titration sleep study to determine their optimal CPAP level. Further follow-up was obtained 2 months and 6 months later with a subjective patient assessment of CPAP use and efficacy, mask comfort, and upper airway dryness. Patients were predominantly male (70%), middle aged (50.6 +/- 11.7 years), and moderately obese (body mass index, 32.5 +/- 9.0) with severe OSA (AHI, 40.6 +/- 25.8/h) [mean +/- SD]. Patients were classified into three groups based on their choice of mask: nasal (66%), Oracle (27%), and oronasal (7%). Baseline characteristics did not differ significantly between groups. Optimal CPAP was not significantly different between mask groups (nasal, 7.7 +/- 2.1 cm H(2)O; Oracle, 8.0 +/- 2.0 cm H(2)O; oronasal, 9.7 +/- 3.2 cm H(2)O; p = 0.267). Subjective ratings of adherence, efficacy, and mask comfort were also similar between groups. However, the Oracle group had more complaints of upper airway dryness and "rain-out." The oronasal group had a disproportionately greater number of dropouts from CPAP therapy than the Oracle group (57% vs 19%, p = 0.046). Nine patients changed from the Oracle mask to a nasal mask during the study, whereas no patients changed from their nasal or oronasal masks. The Oracle mask is an efficacious interface for long-term CPAP therapy in patients with OSA. The main limitations of the mask are upper airway dryness and rain-out associated with heated humidification, which may be improved by further technical modifications. Oracle may be more acceptable than oronasal masks for patients who cannot rely exclusively on the nasal airway for CPAP therapy.

Levofloxacin for chronic prostatitis/chronic pelvic pain syndrome in men: a randomized placebo-controlled multicenter trial

Objectives To perform a Canadian multicenter randomized placebo-controlled trial to evaluate the safety and efficacy of 6 weeks of levofloxacin therapy compared with placebo in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Uncontrolled studies have supported the use of antibiotics in CP/CPPS. Methods Men with a National Institutes of Health (NIH) diagnosis of CP/CPPS (specifically, no infection localized to the prostate) were randomized to levofloxacin (500 mg/day) or placebo for 6 weeks in 11 Canadian centers. Patients were assessed at baseline and at 3, 6, and 12 weeks with the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and global patient assessments (subjective global assessment and patient assessment questionnaire). Results Eighty men (average age 56.0 years, range 36 to 78; duration of symptoms 6.5 years, range 0.6 to 32) were randomized to receive levofloxacin (n = 45) or placebo (n = 35). All were evaluated in an intent-to-treat analysis. Both groups experienced progressive improvement in symptoms as measured by the NIH-CPSI. However, the difference in response was not statistically or clinically significant at end of treatment (6 weeks) or at the end of the follow-up visits (12 weeks). No patients withdrew because of adverse events. One patient withdrew before the 6-week assessment. Adverse events (all mild) were reported in 20% of the levofloxacin group and 17% of the placebo group. Conclusions This pilot placebo-controlled study showed that 6 weeks of levofloxacin therapy in men diagnosed with CP/CPPS resulted in symptom improvement that was not significantly different from that with placebo at end of treatment or follow-up. The clinical ramifications of these findings need to be addressed.

On being a good listener: setting priorities for applied health services research.

In the last decade, explicit priority setting has become an integral part of health care systems. Indeed, there is even an International Society on Priorities in Health Care, created in 1997 (Ham 1997). Whether it is Oregon's priority ordering of symptom treatment pairs to maximize the impact of a limited Medicaid budget (Fox and Leichter 1991), England's National Institute for Clinical Excellence's assessing priorities for new therapeutic innovations in the National Health Service (Rawlins 1999), or New Zealand's setting priorities for patients' access to cardiovascular treatment (Hadorn and Holmes 1997), techniques for judging the relative worth of different health service investments abound.As these techniques are refined, the most common addition is the incorporation of public values as part of the assessment. Priority setting is increasingly seen as combining an objective assessment of costs and effects with a more subjective assessment of patient or public preferences (Lenaghan, New, and Mitchell 1996; Lomas 1997; National Institute for Clinical Excellence 2002; Stronks et al. 1997).

The use of nasal spirometry as an objective measure of nasal septal deviation and the effectiveness of septal surgery

Nasal spirometry, after decongestion, was used to assess the severity of septal deviation in 31 patients before and after nasal septal surgery. Patients were divided into two groups on the basis of their preoperative nasal partitioning of airflow ratio (NPR). The NPR ranges from 0.00 (equality of airflow) to 1.00 (total unilateral obstruction) with the normal range defined as 0.00-0.34. In 14 patients with a preoperative NPR within the normal range, the median NPR was not influenced by surgery (preop 0.14 to postop 0.12, P= 0.07). In 17 patients with a preoperative NPR outside the normal range, there was a significant reduction of the median NPR after surgery (preop 0.50 to postop 0.16, P < 0.01). The correlation of NPR with subjective assessment of the deviation was r = 0.85 (P < 0.01), and with patient subjective symptom assessment r= 0.94 (P < 0.01) preoperatively and r= 0.51 (P < 0.01) postoperatively. The findings indicate that nasal spirometry may be useful in patient selection for septal surgery.

Center of Excellence for Headache Care: Group Model at Kaiser Permanente

To evaluate the effectiveness of a disease management model for primary headache by: (1) assessing improvement in patients' quality of life, (2) decreasing headache-related visits to primary care and emergency departments, and (3) maintaining high levels of patient and physician satisfaction. Patients with headache regularly seek health care but, in general, are dissatisfied with the care they receive. Patients with primary headaches utilize resources and cost health plans more than patients with other chronic diseases. Primary care visits are time restricted, prohibiting adequate headache evaluation and management. Practice guidelines are inconsistently followed, and access to headache specialists is limited. This headache management program implemented an alternative means of delivering care to manage large volumes of patients with headache. A multidisciplinary team approach coordinated by a neurologist, utilizing education and a nurse practitioner as the main provider of care, was the central process of the program. This was a pilot study involving a prospective cohort with defined outcome measures. Inclusion criteria were adult patients with primary headaches. Patients initially attended an educational session instructed by a neurologist and a nurse practitioner. The patient was subsequently evaluated by the nurse practitioner who developed and coordinated a comprehensive individual treatment plan. The Migraine-Specific Quality of Life and the Medical Outcomes Study 36-Item Short Form Questionnaires were completed at baseline, at follow-up visits, and 6 months after completion of the program. Subjective patient assessment of improvement in their headaches, chart review for tabulation of headache-related visits, and primary care physician satisfaction surveys were measured. Both the Migraine-Specific questionnaire and the Short Form-36 measurements demonstrated a statistically significant improvement at 8 weeks, and this was maintained for 6 months after completing the program. At completion of the program, 92% of patients reported subjective improvement. Patient visits for headaches to primary care and emergency departments showed a significant decrease. High levels of satisfaction for primary care physicians were achieved. A disease management model using a multidisciplinary team improved individualized patient care. This model increased patient/provider rapport and communication through an educational class. It empowered the patient to take control of their health care by utilizing shared decision making. Patient satisfaction improved and overall health care utilization was reduced.

Subjective and quantitative assessment of patient fitness for cadaveric kidney transplantation: the "equity penalty".

Patient fitness at the time of organ allocation has an impact on graft survival equivalent to the effect of human leukocyte antigen (HLA) matching. The variation between institutions in assessment of fitness is not known, nor is the potential impact on mean graft survival of incorporating patient fitness into local adult cadaveric-kidney transplant-allocation algorithms. Data from the Collaborative Transplant Study (CTS, 1985-2000) were reviewed. Quantitative criteria (QC) of patient fitness based on national transplant society guidelines were compared with subjective categorization (SC) of each patient on the current local transplant waiting list (n=109) determined by their supervising nephrologist. Five-year cadaveric graft survival was 70%, 61%, and 53% for good-, moderate-, and poor-risk patients in the CTS data set (n=102, 612), equivalent to half lives of 12.7, 9.8, and 8.7 years, respectively, with similar results from the local program. The distribution of local waiting-list patients into fitness categories A (good), B (moderate), C (poor), and D (unacceptable) was 51%:31%:13%:5% by SC and 25%:40%:27%:8% by QC. At one hospital, 61% (n=51) of patients were classified category A by SC, and falling to 16% by QC (P<.0001). Compared with preferential category A recipient allocation, an unrestricted allocation policy was estimated to sacrifice 1.5 years of overall program-mean graft survival. Use of QC may reduce the variation in subjective patient assessment seen between institutions. Any proposed changes in organ allocation methods should address the "equity versus efficiency" balance in an open fashion and predict the impact on the overall graft survival for the program by quantifying the "equity penalty."

Fluorescein-Potentiated Argon Laser Therapy Improves Symptoms and Appearance of Corneal Neovascularization

To evaluate patients' self-assessment of their symptoms and cosmetic appearance after fluorescein-potentiated argon laser treatment (FPAL) for corneal inflammation associated with neovascularization. To describe the objective effects of FPAL therapy on established corneal neovascularization with secondary corneal edema and lipid keratopathy. Fifteen patients with corneal neovascularization resulting from various infectious and traumatic etiologies were enrolled in an open, nonrandomized pilot study. Treatment consisted of repeated sessions of intravenous fluorescein, a photosensitizer, combined with blue-green argon laser applications to abnormal corneal vessels. Patients completed a written survey to grade their symptoms and cosmetic appearance prior to treatment and at the end of the follow-up period. Objective changes in signs after FPAL treatment were described by two nonmasked ophthalmologists after slit-lamp examinations and review of serial corneal photographs. Clinical symptoms of blurred vision (p <or= 0.003), photophobia (p <or= 0.03), and cosmetic appearance ( p <or= 0.02) were found to be significantly improved by the patient's subjective assessment survey. There was a trend toward pain reduction (p <or= 0.06) but no apparent reduction in tearing or foreign body sensation (p <or= ns). Objective signs of corneal edema, neovascularization, and lipid keratopathy appeared to be reduced after FPAL therapy. FPAL therapy for corneal neovascularization, edema, and lipid keratopathy resulted in a significant reduction in symptoms and improved quality of life for 14 of 15 (93%) patients. A controlled clinical trial to confirm the reported improvement in signs observed in this pilot study should be considered.

9:20 Correlation of patient and physician assessment of outcome for fusion in the treatment of lumbar degenerative disc disease

Purpose of study: The purpose of this study was to examine patient and physician assessment of outcomes in patients undergoing fusion procedures of lumbar degenerative disc disease.Methods used: The National Spine Network (NSN) database was examined for patients who had undergone fusion procedures as treatment for a primary diagnosis of lumbar degenerative disc disease. Patients required preoperative and at least 1-year postoperative Short Form (SF)-36, Oswestry Disability Index and physician and patient subjective assessment of improvement data. Data were obtained and examined regarding correlation between patient and physician interpretation of a successful outcome.of findings: Information on 35 patients meeting criteria was obtained from the NSN database. Procedures included 19 anterior lumbar interbody fusions, 11 posterior lumbar interbody fusions and 5 circumferential fusions. Physician assessment included 16 patients with “major improvement,” 16 “minor improvement” and 3 “no change.” No patients were evaluated as worse. Patient assessment showed 4 “much better,” 10 “somewhat better,” 12 “about the same,” 7 “somewhat worse” and 2 “much worse.” Physician-interpreted outcomes of “major improvement” and patient determination of “much better” was compared. Similarly, “minor improvement” and “somewhat better” were also compared. Overall, patient versus physician rating of clinical outcome revealed poor correlation (kappa 0.02). Bodily Pain: The mean subset improvement in the 16 patients with “major improvement” by physician evaluation was 30.3. Four patients who self assessed themselves as “much improved” had a mean score of 59.5. Physician-evaluated “minor improvement” patients (n=16) had a mean of 2.2 compared with the patients who assessed themselves as “somewhat better” (n=10) who had a mean of 26.3. Physical Function: The mean subset improvement in the 16 patients with “major improvement” by physician evaluation was 30.5. Four patients who assessed themselves as “much improved” had a mean improvement of 41.7. Physician-determined “minor improvement” patients (n=16) had a mean improvement of 15.3 compared with the “somewhat better” patient assessment group (n=10) of 31.7. Oswestry Disability Index: Mean improvement in the 16 patients with “major improvement” by physician evaluation was 25.2 The four patients self-assessed as “much improved” had a mean improvement of 38.3. Physician-determined “minor improvement” patients (n=16) had a mean improvement of 6.9 versus the self-assessed “somewhat better” patients (n=10) whose mean improvement was 20.8.Relationship between findings and existing knowledge: The findings of this study reveal differences between patient and physician measurement of success. This relationship has been documented in other disease processes and surgical procedures but to our knowledge not examined in this group.Overall significance of findings: The data reveal a wide discrepancy between patient and physician interpretation of what constitutes a successful outcome. The discrepancy holds true throughout the examined SF-36 and Oswestry Disability Index data examined as poor correlation was throughout all parameters studied. The results highlight the need for more study of this disease process and its treatment as well as the differences between patient and physician assessments of outcomes. The acceptance of successful results must be considered from the viewpoint of the interpreting physician and the needs of the patient.Disclosures: No disclosures.Conflict of interest: No conflicts.

Change in olfaction after radiotherapy for nasopharyngeal cancer—A prospective study

Purpose: To evaluate the changes in olfactory function in patients with nasopharyngeal carcinoma who have received radiation to the head and neck. Materials and Methods: Olfactory function of consecutive patients with nasopharyngeal carcinoma was assessed prospectively before irradiation and serially up to 1 year after radiotherapy by the Sniffin' Sticks (Erlangen, Germany) olfactory function test and by a patient symptom visual analogue scale. Results: Fifty-eight patients were recruited before radiotherapy was commenced. Three patients could not give a reliable response to the Sniffin' Sticks test even in this first assessment, and 7 patients did not return for evaluation after irradiation. Forty-eight patients were available for follow-up assessment. Mean olfactory threshold scores by the Sniffin' Sticks test were found to deteriorate significantly at 12 months when compared with the scores before irradiation (8.3 at 12 months vs 11.5 before irradiation; P =.001). Scores for olfactory discrimination and for identification did not exhibit any significant changes when assessed at 12 months (P >.05 for both). Subjective patient assessment of olfactory function with the visual analogue scale at 12 months did not demonstrate any significant differences when compared with patients' assessment before irradiation (P =.90). An increase in discharge was the only nasal symptom that demonstrated a significant change at 12 months when compared with the assessment before irradiation (P < 001). Conclusions: Deterioration in olfactory threshold scores was found at 12 months after irradiation and was not noticed by the patients. (Am J Otolaryngol 2002;23:209-214. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Defining and assessing professional competence.

Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.

Competence Is a Habit

Context Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. Objectives To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. Data Sources We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. Study Selection We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. Data Extraction Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. Data Synthesis We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. Conclusions In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.