Success Of Medical Treatment Research Articles

Proteinases of the cornea and preocular tear film

Maintenance and repair of corneal stromal extracellular matrix (ECM) requires a tightly coordinated balance of ECM synthesis, degradation and remodeling in which proteolytic enzymes (proteinases) perform important functions. There are natural proteinase inhibitors present in preocular tear film (PTF) and cornea simultaneously with proteinases that prevent excessive degradation of normal healthy tissue. Disorders occur when there is an imbalance between proteinases and proteinase inhibitors in favor of the proteinases, causing pathologic degradation of stromal collagen and proteoglycans in the cornea. Two matrix metalloproteinases (MMPs), MMP-2 and MMP-9, are of major importance in terms of remodeling and degradation of the corneal stromal collagen. Immunohistochemical studies have shown different origins of MMP-2 and -9. MMP-2 is synthesized by corneal keratocytes and performs a surveillance function in the normal cornea, becoming locally activated to degrade collagen molecules that occasionally become damaged. Alternatively, MMP-9 may be produced by epithelial cells and polymorphonuclear neutrophils following corneal wounding. Because the cornea is in close contact with the preocular tear film (PTF), proteinases have been evaluated in the PTF. In damaged corneas, total proteolytic activity in the tear fluid was found to be significantly increased compared to normal eyes and contralateral eyes. Studies analyzing the proteolytic activity in serial PTF samples during corneal healing led to the following conclusions: ulcerative keratitis in animals is associated with initially high levels of tear film proteolytic activity, which decrease as ulcers heal; proteinase levels in melting ulcers remain elevated leading to rapid progression of the ulcers. The success of medical and surgical treatment of the corneal ulcers is reflected by the proteolytic activity in tears. In animals, successful treatment leads to a rapid reduction in tear film proteolytic activity that corresponds with the improvement in the clinical signs of corneal ulceration. The in vitro effects of various compounds on proteolytic activity in the tear fluid of animals with ulcerative keratitis have been evaluated and their important inhibitory effects have been confirmed. Because these various compounds utilize different mechanisms to inhibit various families of proteinases, a combination of these proteinase inhibitors may be beneficial.

New aspects in the treatment of acute coronary syndromes without ST-elevation: ICTUS and ISAR-COOL in perspective

For treatment of patients with high-risk acute coronary syndromes, current guidelines recommend early coronary angiography and coronary revascularization, when feasible, irrespective of the primary success of medical treatment. Moreover, the results of a randomized trial (ISAR-COOL) suggested performing revascularization as early as possible. The concept of systematic coronary angiography and revascularization in high-risk acute coronary syndromes has been challenged recently by another randomized study (ICTUS) demonstrating an excess of myocardial infarction during 1-year follow-up with a routine-invasive strategy when compared with a selectively invasive strategy. This review intends to put the new trial results in perspective with evidence from previous studies.

Cost Considerations in the Medical Management of Glaucoma in the US

The aim of this study was to evaluate the cost effectiveness of glaucoma treatment with bimatoprost compared with other intraocular pressure (IOP)-lowering medications in adult patients with chronic glaucoma or ocular hypertension (IOP of between 22 mm Hg and 34 mm Hg), from a US healthcare payers' perspective. Estimated yearly costs and cost per treatment success for 0.03% bimatoprost once daily (Lumigan) were compared with 0.5% timolol twice daily (generic), 0.005% latanoprost once daily (Xalatan) and the fixed combination of 0.5% timolol and 2.0% dorzolamide twice daily (Cosopt). The model was based on year 2003 medical resource costs (physician visits and drug acquisition costs) and treatment success rates from published clinical trials. The clinical measure utilised was the percentage of patients achieving target IOPs. A higher percentage of patients achieved target IOPs with bimatoprost than with each of the other medications. At most target pressures, the cost per treatment success for patients starting treatment on bimatoprost was less than that for patients started on other drugs. This was true despite that, when looking at costs alone, the estimated yearly costs for bimatoprost (averaged over both patient success and patient failures) were similar to or greater than those for the other drugs. The greatest differences in cost per treatment success were seen at target pressures < or =15 mm Hg. For example, at a target pressure of 13 mm Hg, the cost per treatment success based on the model was 9238-10,229 US dollars for bimatoprost, 23,218 US dollars for timolol, 21,943 US dollars for latanoprost and 16,034 US dollars for timolol/dorzolamide. The incremental cost of achieving additional clinical success for bimatoprost ranged from 800 US dollars to 1,700 US dollars versus generic timolol, and from 300 US dollars to 3,100 US dollars versus timolol/dorzolamide. Bimatoprost was more effective and less costly than latanoprost. In our simplified model of cost per treatment success based on responder rates at varying IOPs, the greater efficacy of bimatoprost resulted in a cost per treatment success that was generally lower for bimatoprost than for timolol, latanoprost or timolol/dorzolamide. This was most pronounced at target pressures <15 mm Hg.

Treatment of Aortic Disease in Patients With Marfan Syndrome

Marfan syndrome (MFS) is a heritable disorder of the connective tissue with a prevalence of ≈1 in 3000 to 5000 individuals. The condition is inherited in an autosomal dominant manner with complete penetrance but demonstrates variable expression with significant intra- and interfamilial variation. Approximately 25% of patients do not have a family history and represent sporadic, new mutations for the condition. The cardinal features of MFS involve the cardiovascular, ocular, and skeletal systems. The most life-threatening complication of MFS is thoracic aortic aneurysms leading to aortic dissection, rupture, or both. This article focuses on medical and surgical treatment of aortic disease in patients with MFS and addresses the treatment of aortic disease in children and pregnant women with the condition. The most common cardiovascular complication in patients with MFS is progressive aortic root enlargement initially occurring at the sinuses of Valsalva. Ascending aortic aneurysm can precipitate acute type A aortic dissection, aortic rupture, aortic regurgitation (AR), or all 3, and these complications were the primary cause of death before the advent of successful preventive therapies. Treatment of the aorta consists of regular imaging to detect and quantify progression of aortic dilation, β-adrenergic receptor antagonist therapy, and prophylactic aortic repair when the dilation reaches a sufficient size to threaten dissection or cause AR. Before the era of open-heart surgery, the majority of patients with MFS died prematurely of rupture of the aorta, with an average life expectancy of 45 years.1 The success of current medical and surgical treatment of aortic disease in MFS has substantially improved the average life expectancy, extending it up to 70 years.2,3 Cardiovascular manifestations in MFS also include valvular disease involving the mitral valve, aortic valve, or both. Mitral valve prolapse is the most prevalent valvular abnormality, affecting 35% to 100% of patients.4 Mitral …

Profiles of matrix metalloproteinase activity in equine tear fluid during corneal healing in 10 horses with ulcerative keratitis

Levels of tear film matrix metalloproteinases (MMPs) activity are significantly elevated in horses with ulcerative keratitis and contribute to the excessive breakdown of stromal collagen. Changes in the amount of proteolytic activity in horse tear film during corneal healing and stromal remodeling have not yet been reported, but we hypothesize they should decrease. In the present study we analyzed serial tear fluid from horses with ulcerative keratitis to identify any changes in MMP activity during corneal healing and stromal remodeling. Samples of tear fluid were obtained from both eyes of 10 horses with ulcerative keratitis on the day of admission (day 1) at the hospital and then at various time points until complete healing of the cornea. Tear film MMP2 and MMP9 activity was determined by quantitative gelatin zymography. In all cases medical treatment included topical applications of equine serum, antibiotics, atropine and systemic administration of anti-inflammatory drugs. Surgical procedures were performed in several cases on day 2 in addition to the medical treatment. The mean total MMP activity (+/- SD) measured in relative standard units (RSU) in the tear fluid of the ulcerated eye (2.44 +/- 1.44) of the 10 horses was significantly higher than the mean in the contralateral eye (0.81 +/- 0.68) (P = 0.006), on the day of admission at the VMTH. The mean MMP activity in these ulcerated eyes significantly decreased (-82.4%) between the first day of admission and the day when the ulcer had completely healed (P = 0.0002). The activity level in the healed eye (0.43 +/- 0.17) was not significantly different to the one in the contralateral eye (0.36 +/- 0.18) on the day of complete corneal healing (P = 0.374). The level of MMP activity in the contralateral eye also decreased from 0.81 +/- 0.68-0.36 +/- 0.18 but this decrease (56%) was not significant (P = 0.069). Ulcerative keratitis in horses is associated with initially high levels of tear film proteolytic activity that decrease as the ulcers heal. The success of medical and surgical treatment of the corneal ulcers is reflected by the enzyme activity in tears. In horses successful treatment does lead to a rapid reduction in tear film proteolytic activity that corresponded with the improvement in the clinical signs of corneal ulceration. Measurement of MMP activity in the tear film might represent a way to monitor the progression of corneal healing in horses with ulcerative keratitis.

Cost-effectiveness of tamsulosin, doxazosin, and terazosin in the treatment of benign prostatic hyperplasia.

To evaluate the cost-effectiveness of tamsulosin, doxazosin, or terazosin as initial treatments for moderate benign prostatic hyperplasia (BPH) over a 3-year time horizon from a health-system-payer perspective. A decision-analytic model is used to project the course of treatment at 6-month intervals over 3 years following initiation of therapy with tamsulosin, doxazosin, or terazosin. Treatment failure is defined as failure to attain and maintain a 25% improvement in the American Urological Association (AUA) symptom score from baseline. In the model, finasteride is added for patients who fail on their initial therapy and, in the event of finasteride treatment failure, patients progress to transurethral resection of the prostate (TURP) and, if needed, a second TURP. The ranges of values for treatment failure rates and clinical event cost parameters used in the decision model are derived from the literature. Only direct medical costs related to BPH and its treatment are included. Since 2 comparators are available generically (doxazosin and terazosin) drug acquisition costs are defined by the list prices at Drugstore.com. All costs are discounted by 3% per year. Effectiveness is measured as successful medical treatment without surgery over 3 years. For base-case model parameters, discounted BPH-related total direct medical costs over 3 years are 4084 dollars, 4323 dollars, and 4695 dollars for generic terazosin, generic doxazosin, and tamsulosin, respectively. The model estimates a medical treatment success rate (no TURP) at 3 years of 72.3% for tamsulosin, compared with 68.2% for both terazosin and doxazosin. The incremental cost for tamsulosin versus terazosin is 610 dollars over 3 years, which yields an incremental cost-effectiveness ratio of 14,609 dollars per success. Generic doxazosin is dominated (higher cost but equal effectiveness compared with terazosin). Higher rates of twice-daily (or 2 units per day) dosing are associated with higher incremental cost-effectiveness ratios. The decision-model results also are sensitive to the estimated costs of TURP and hypotensive adverse events. As an initial medical therapy for moderate BPH, tamsulosin is more effective than generic terazosin or doxazosin, with an incremental cost of about 203 dollars per year (or about 17 dollars per month) over 3 years.

Benefits and risks of pharmacological agents used for the treatment of menorrhagia.

Menorrhagia affects the lives of many women. The assessment of menstrual flow is highly subjective and gauging the severity of the condition by objective assessment of menstrual blood loss is impractical. In treating menorrhagia, the primary aim should be to improve quality of life. Women are willing to undergo quite invasive treatment in order to achieve this. Drug therapy is the initial treatment of choice and the only option for those who wish to preserve their reproductive function. Despite the availability of a number of drugs, there is a general lack of an evidence-based approach, marked variation in practice and continuing uncertainty regarding the most appropriate therapy. Adverse effects and problems with compliance also undermine the success of medical treatment. This article reviews the available literature to compare the efficacy and tolerability of different medical treatments for menorrhagia. Tranexamic acid and mefenamic acid are among the most effective first-line drugs used to treat menorrhagia. Despite being used extensively in the past, oral luteal phase norethisterone is probably one of the least effective agents. Women requiring contraception have a choice of the combined oral contraceptive pill, levonorgestrel-releasing intrauterine system (LNG-IUS) or long-acting progestogens. Danazol, gestrinone and gonadotropin-releasing hormone analogues are all effective in terms of reducing menstrual blood loss but adverse effects and costs limit their long-term use. They have a role as second-line drugs for a short period of time in women awaiting surgery. While current evidence suggests that the LNG-IUS is an effective treatment, further evaluation, including long-term follow up, is awaited. Meanwhile, the quest continues for the ideal form of medical treatment for menorrhagia--one that is effective, affordable and acceptable.

Predictors of success in methotrexate treatment of women with unruptured tubal pregnancies.

The use of methotrexate (MTX) for the treatment of tubal ectopic pregnancy (EP) has become common practice, although the factors associated with a favorable outcome are not totally clear. The aim of this study was to investigate the predictors of successful MTX treatment. One hundred and thirty-seven women with unruptured tubal EP in whom the hematosalpinx could be directly visualized by pelvic ultrasound were studied. Women who met the inclusion criteria were treated with MTX either: 50 mg/m(2) intramuscularly (n = 70) or with 1 mg/kg injected directly into the hematosalpinx under sonographic guidance (n = 67). The associations between the outcome of the treatment and different factors studied (human chorionic gonadotropin (hCG) level, progesterone level, hematosalpinx diameter, hemoperitoneum volume and mode of MTX administration) were analyzed. The overall success rate, defined by a post-treatment normal hCG level (< 10 mIU/mL), was 79.6%. The initial hCG level and the route of administration of MTX appeared to be two independent factors that predicted success. Multivariate analysis demonstrated that the success rate was significantly better when MTX was administered locally: the odds ratio (OR) was 9.7 (95% CI, 3.1-30), and was significantly poorer when the hCG level was >/= 1000 mIU/mL (P < 0.002): the OR was 0.10 (95% CI, 0.07-0.49). Among selected women with tubal EPs, the route of administration of MTX and the initial level of serum hCG are the most important factors associated with the success of medical treatment.

Management of missed abortion: comparison of medical treatment with either mifepristone + misoprostol or misoprostol alone with surgical evacuation. A multi‐center trial in Copenhagen county, Denmark

To compare the efficacy of two different medical treatment regimens: mifepristone 600 mg orally + misoprostol 0.4 mg vaginally (Mf + Ms) or misoprostol 0.4 mg vaginally (Ms) with conventional surgical evacuation (SE) in women with missed abortion. Prospective crossover study with alternating regimens every 4 months. The three university clinics of Obstetrics and Gynecology in Gentofte, Herlev and Glostrup of Copenhagen County. During the period October 1999 to October 2000, 176 women with missed abortion accepted to participate in the study. The proportion of women who needed surgical evacuation after medical treatment, number of women who needed re-evacuation after primary surgical evacuation, duration of vaginal bleeding, treated infections, need of analgesics, and the subjective experiences from the participating women. Fifty-four, 73 and 49 patients were randomized to Mf + Ms, Ms and SE, respectively. Within 1 week, complete expulsion occurred in 40 (74%), 52 (71%), 47 (96%) of the three arms, respectively. Duration of bleeding was 6.9, 7.1 and 2.5 days in the three arms, respectively (p < 0.01). Women with an initial plasma chorionic gonadotrophine (p-hCG) between 2000 and 20 000 IU/l and a gestational age less than 75 days had a significantly better response to the medical treatment than those not fulfilling these two criteria. Initial p-progesterone did not correlate with success of medical treatment. Proportion of women who needed surgical evacuation after medical treatment, and the number of women who needed re-evacuation after primary surgical evacuation, duration of vaginal bleeding, treated infections, the need of analgesics, and subjective experiences from participating women. Vaginal misoprostol 0.4-0.6 mg is effective in most patients with missed abortion. Pre-treatment with the antiprogesterone mifepristone does not increase the success rate. The selection of women with missed abortion for medical treatment based on gestational age and initial p-hCG level may increase the success of medical treatment significantly.

A retrospective study of the success of medical and surgical treatment of wild Australian raptors

To evaluate the results of medical and surgical regimens utilised to treat injured and diseased wild Australian raptors presented at our practice, and to determine if the time, effort and cost of treating the birds was justified in terms of the outcomes achieved. All the practice's clinical records relating to the examination and treatment of wild raptors were reviewed for the period April 1994 to December 1998. The species of birds, the aetiology of their injuries or diseases, the treatment protocols and the outcomes of those treatments were correlated and tabulated for evaluation. Fifteen Australian species of raptor were examined and treated. Complete records were available for 104 birds of prey, 73 being Accipitriformes and 31 Strigiformes. The poorest prognosis was for birds involved in motor vehicle impacts, while birds suffering malnutrition or starvation had higher survival rates. The overall rate of survival was 50%. Based on the severity of diseases and injuries at the time of presentation, the survival rate was considered acceptable. Veterinary involvement in the treatment of the wild raptors was necessary for the maintenance of the birds' welfare, and to determine appropriate treatments. Intangible benefits included increased practice staff satisfaction, and improving the veterinary professions' public image by providing pro bono treatment for Australian wildlife.

Prognostische Relevanz linksventrikulärer diastolischer Funktionsparameter bei dilatativer Kardiomyopathie

Patients with dilated cardiomyopathy (DCM) generally have an impaired functional capacity and poor long-term out-comes. A mortality of 5-15% per year has been described actually. Aim of this study was to verify the prognostic relevance of invasive and non-invasive parameters of diastolic function in patients with DCM. In 33 patients with DCM, cardiac catheterization was performed and left ventricular systolic (ejection fraction (EF; %)); left ventricular enddiastolic pressure (LVEDP; mmHg) and diastolic function (time constant of relaxation (T, ms); the constant of myocardial stiffness (b) were derived from biplane laevocardiography and simultaneous micromanometric registration of pressure-volume curves. For evaluation of clinical out-come, the follow-up period was defined as beginning on the day after cardiac catheterization and ending on the most recent date or with a cardiac event (death or cardiac transplantation). All patients were reevaluated for NYHA functional class and completed a standard questionnaire. The following hemodynamic parameters were evaluated: invasive parameters of left ventricular diastolic function (constant of relaxation: tau (ms), constant of myocardial stiffness: b)), as well as parameters of systolic function (ejection fraction (EF; %)), left ventricular pressure (LVEDP; mmHg), left ventricular muscle mass index (LVMMI; g/m2), left ventricular enddiastolic volume index (LVEDVI; ml/m2) and non-invasive parameters of morphological data, left ventricular systolic (fractional shortening (FS, %) and ejection fraction) and diastolic parameters with echocardiography. During the follow-up period of 36 months, 11 of 33 patients experienced a major cardiac event (cardiac death n = 8, heart transplantation n = 3). The major cause of death was progressive pump failure. The remaining 22 patients were further classified with respect to changes in functional status. While clinical symptoms could be improved medically in patients with moderate increase of myocardial stiffness, patients with severe increase of myocardial stiffness (b: 76.1 +/- 12.1 vs 17.9 +/- +8.1, p < 0.001) could not be improved and suffered more cardiac events. Doppler echocardiographic measurements in these patients showed a restrictive filling pattern (VE 0.91 +/- 0.21 vs 0.64 +/- 0.18 m/s; p < 0.01; VA 0.52 +/- 0.23 vs 0.57 +/- 0.24 m/s; p < 0.01, deceleration time 129 +/- 17 vs 211 +/- 14 ms; p < 0.01). The medical heart failure therapy was comparable in both groups. In patients with cardiac events, the diastolic left ventricular variables did not significantly differ between patients who underwent heart transplantation and those who died. Patients who demonstrated a sole impairment of relaxation (tau: > 50 ms) suffered no cardiac events. Impaired diastolic function contributes to the clinical picture of congestive heart failure. Parameters of left ventricular diastolic function are powerful and important predictors of major cardiac events in patients with DCM, like heart transplantation and non-sudden death, and may indicate future clinical success of medical treatment. Invasive and non-invasive parameters of diastolic function reveal comparable information for the estimation of prognosis of patients with DCM in order to initiate early therapy.

Predicting the Success of Medical Treatment of Ectopic Pregnancy

The treatment of tubal ectopic pregnancies with methotrexate is gaining in popularity, but many of the determinants of its success are unknown. This

A consultant looks at the NHS todayPart 2 of a text based on a lecture delivered by the author at The Royal London Hospital, England, UK

Distinguished colleagues, Ladies and Gentlemen, fifty years ago decisions were made by clinicians and not academics, managers nor politicians and, for the first few years of the NHS, it was run efficiently and at low cost. Patients were only too well aware that the service that they were receiving was excellent and they were grateful. Although the academics, the managers and the politicians have caused medicine to be replaced by a costly, inefficient and incompetent health industry, the blame lies initially at the door of those clinicians who were too concerned with patient care to see the takeover which was occurring. Lord Platt, in his Harveian oration ‘Medical „science: master or servant?’, points out that academic departments had not been responsible for nor even seriously involved in many of the discoveries in therapeutics or preventive medicine (Platt 1967). He goes on to state that ‘the phenomenal success of modern medical treatment seems to have depended almost wholly on non-clinicians, often non-medical scientists, frequently working in, or in close collaboration with, the pharmaceutical industry, and it would be a serious mistake to think that the role of industry has been largely in the field of commercial development. A great deal of the basic scientific work, especially chemical isolation, analysis and synthesis, has taken place there.’ It should be consolation for hard-working „clinicians today to read Platt’s confirmation that ‘ideas come from lucky accidents or from the inspiration of men of imagination’ and ‘a great deal of modern Practice in medicine and surgery has been evolved from men whose researches were part of their daily clinical tasks’. So-called non-academic physicians may find amusing the friend of Lord Platt who talked about some form of research being ‘occupational therapy for the university staff’. A mild comment by myself that the active invasion of the teaching hospitals by the universities had not been an unmixed blessing (Fowler 1985) produced a dismissive response (Booth 1986).

A consultant looks at the NHS today.

Distinguished colleagues, Ladies and Gentlemen, fifty years ago decisions were made by clinicians and not academics, managers nor politicians and, for the first few years of the NHS, it was run efficiently and at low cost. Patients were only too well aware that the service that they were receiving was excellent and they were grateful. Although the academics, the managers and the politicians have caused medicine to be replaced by a costly, inefficient and incompetent health industry, the blame lies initially at the door of those clinicians who were too concerned with patient care to see the takeover which was occurring. Lord Platt, in his Harveian oration ‘Medical „science: master or servant?’, points out that academic departments had not been responsible for nor even seriously involved in many of the discoveries in therapeutics or preventive medicine (Platt 1967). He goes on to state that ‘the phenomenal success of modern medical treatment seems to have depended almost wholly on non‐clinicians, often non‐medical scientists, frequently working in, or in close collaboration with, the pharmaceutical industry, and it would be a serious mistake to think that the role of industry has been largely in the field of commercial development. A great deal of the basic scientific work, especially chemical isolation, analysis and synthesis, has taken place there.’ It should be consolation for hard‐working „clinicians today to read Platt’s confirmation that ‘ideas come from lucky accidents or from the inspiration of men of imagination’ and ‘a great deal of modern Practice in medicine and surgery has been evolved from men whose researches were part of their daily clinical tasks’. So‐called non‐academic physicians may find amusing the friend of Lord Platt who talked about some form of research being ‘occupational therapy for the university staff’. A mild comment by myself that the active invasion of the teaching hospitals by the universities had not been an unmixed blessing (Fowler 1985) produced a dismissive response (Booth 1986).

Is There a Place for Laparoscopic Antireflux Surgery in The Netherlands?

Background: Antireflux surgery has not gained wide acceptance in The Netherlands in the past two decades. The introduction of laparoscopic fundoplication seems to have had no impact on the number of antireflux operations performed per year. Methods: The SIG data were consulted in order to compile an inventory on the number of antireflux operations performed in The Netherlands between 1977 and 1995. The data were compared with those kindly supplied by the Laparoscopic Societies of the Scandinavian countries. Results: The number of antireflux operations per year in The Netherlands, 1.7/100,000 per year, is far less than reported in the four Scandinavian countries, 15/100,000 per year, and also far below the 10/100,000 per year needed for antireflux surgery on a yearly basis. Conclusions: In The Netherlands, 1.7/100,000 inhabitants per year undergo antireflux surgery. This figure has remained virtually stable in the past two decades, i.e. it has not changed even since the introduction of H 2 -receptor antagonists, proton-pump inhibitors and laparoscopic antireflux surgery. The success of medical treatment and personal, anecdotal, experience of gastroenterologists with patients they have referred for surgery explain the low number of antireflux operations performed. Currently, a randomized trial is being conducted in The Netherlands comparing the effectivity, costs and quality of life after conventional Nissen fundoplication with the laparoscopic approach. All operations are performed or supervised by a limited number of experienced surgeons who have gone through the learning curve of both the open and conventional technique.

Nonconventional medicine in Israel: Consultation patterns of the Israeli population and attitudes of primary care physicians

This paper reports the findings of a study of nonconventional medicine in Israel. Data regarding patterns and correlates of consultations with alternative medicine practitioners were obtained from structured face-to-face interviews with a representative sample of 2030 Jewish adults aged 45 to 75. In addition, in-depth open-ended interviews were conducted with a convenience sample of 20 primary care physicians in order to explore their beliefs, attitudes and behaviors regarding nonconventional medicine. Six percent of the respondents interviewed in the population study visited an alternative practitioner in the year prior to the interview. For most of them, the consultation was a consequence of disappointment with the lack of success of conventional medical treatment. Most felt that the alternative medicine treatment had helped. Nearly 40% were seeing their regular primary care physician at the same time as they were seeing an alternative medical practitioner. Women were more likely than men to consult an alternative medicine practitioner; consulters rated their health status more negatively than non-consulters. Consulters had a higher level of education than non-consulters, but the two groups did not differ in terms of age or economic status. Nearly all of the physicians stated that they refer patients to alternative practioners; in most cases, the referrals are in response to patients' requests. Although skeptical of the scientific basis of alternative medicine therapies, most of the physicians believed that some therapies, even if only because of the “placebo effect”, were effective in some cases. Almost all felt that the Ministry of Health, which today does not recognize any form of alternative medicine, should establish control over the training and practice of alternative medical practitioners. The findings from both parts of the study suggest that patients and primary care physicians in Israel do not view nonconventional medicine as a threat to conventional medicine, but rather as complementary to it.

Recurrence of Hemifacial Spasm after Microvascular Decompression

The success of medical and surgical treatment for hemifacial spasm, and involuntary paroxysmal unilateral contraction of the facial muscles, has been mixed. Although microvascular decompression has the greatest reported success, symptom recurrence affects many patients in whom treatment was initially successful. In this study, we report the results of 34 patients who underwent microvascular decompression of the facial nerve from 1976 to 1989 as well as review the literature concerning the incidence and timing of recurrence in more than 600 patients who underwent microvascular decompression. In this series, 94% of 34 patients had continuous relief of spasm after surgical treatment (mean duration, > 6 yr). Of those patients whose spasms were completely initially relieved, 10.3% developed some degree of recurrent spasm; however, no patient developed a recurrence after 24 months without spasm. Our review of the literature discloses that 86% of all recurrences occurred within 2 years of surgery. Patients who have no recurrence of symptoms 2 years after surgical treatment have only a 1% chance of developing recurrent hemifacial spasm. We also comment on possible causes of treatment failure and recurrence of hemifacial spasm after surgical treatment.

In pursuit of excellence: Pain management at the scientific watershed

No one would argue with the premise that some form of measurement to assess the quality and success of treatment should be in place in any medical practice. Conventional wisdom would insist that this instrument incorporate scientific principles by paying rigorous attention to group selection; avoiding bias by the appointment of disinterested or blinded observers; planning all aspects prospectively; and last, but not least, using a statistical paradigm that is appropriate to the type of data being collected. The acquisition of such patient outcome information is obviously important, not just as a reflection of the success or failure of medical treatment, but to provide a foundation for either consolida­ tion or change, as the case may bey ,8 The rapid and exponential growth of pain medicine in the last 30 years has placed it squarely before the bench of medical opin­ ion, where professional and lay juries still have difficulty in defining its parameters of practice. In the focus article, David Brown addresses the whole issue of medical review, not just as it relates to pain medicine, but in the general context of medical delivery. The very complexity of contemporary medical practice lends itself, more than ever, to the instruments of indus­ trial measurement and Although still an art in many ways, medicine has subsumed the industri­ al model, a fact that has enabled the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to oversee issues of quality and improvement. The ulti­ mate marker-outcome-however, remains elusive. While the mandate of JCAHO has been to accredit hos­ pitals, it has expanded its oversight function to include ambulatory tacilities.? Nevertheless, as is emphasized by Brown, the JCAHO is mainly interested in the stan­ dardization of organizational performance. Pain medi

Quality of Life in Pediatric Psychiatry: A New Outcome Measure

Chronic medical illness in childhood and adolescence is an increasingly prevalent contributor to psychiatric and behavioral disturbances encountered by child and adolescent psychiatrists, yet the traditional clinical tools of categorical psychiatric diagnosis and treatment do not adequately address the needs of this population. The child and adolescent psychiatrist is an essential contributor to the comprehensive care of the chronically ill child and his or her family. The “quality of life” construct represents both an advance in the development of newer tools of diagnosis and treatment for this unique population, and perhaps more importantly, a recognition in the area of clinical investigation that the emotional life of a child is as important a measure of the success of medical treatment as the response of a tumor mass to chemotherapy or the reduction in blood urea nitrogen following dialysis. Crucial advances in psychoneuroimmunology, group and family psychotherapy, pediatric psychopharmacology, and related disciplines can now be more effectively applied to chronically ill children and their families with the advent of novel outcome measures such as “quality of life” and related approaches to this unique population.

'Harm Reduction' Approach May Be Middle Ground

ABSTRACT MEDICINE has been given a back seat in this country's so-called on drugs.Dealing with drug addiction was once primarily the purview of physicians. But since the initiation of prohibition in the early part of this century, and especially since the war on drugs was declared in the 1970s, drug use, abuse, and addiction have been treated primarily as crimes and only secondarily as a public health problem. Critics say this makes the public health problem worse.Medicine as Cornerstone Medicine, however, is the cornerstone of an alternative approach to drug policy referred to as harm reduction. This approach emphasizes comprehensive and compassionate treatment for addiction, with physicians providing medical therapy and not viewing abstinence as the only worthy outcome.International comparison studies suggest that the success of medical treatment for heroin addiction is related to the quality of the treating staff, especially the involvement of physicians, says John