QJM : monthly journal of the Association of Physicians
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We reviewed the published and unpublished international literature to determine the influence of salaried payment on doctor behaviour. We systematically searched Medline, BIDS Embase, Econlit and BIDS ISI and the reference lists of located papers to identify relevant empirical studies comparing salaried doctors with those paid by alternative methods. Only studies which reported objective outcomes and measures of the behaviour of doctors paid by salary compared to an alternative method were included in the review. ⋯ Therefore, we were unable to draw conclusions on the likely impact of salaried payment on efficiency and equity. However, the limited evidence in our review does suggest that payment by salaries is associated with the lowest use of tests, and referrals compared with FFS and capitation. Salary payment is also associated with lower numbers of procedures per patient, lower throughput of patients per doctor, longer consultations, more preventive care and different patterns of consultation compared with FFS payment.
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Survival for myeloma has improved from a median of 7 months in the 1950s to about 30 months today. Progress in chemotherapy has contributed a great deal to this improvement, although it may also, in part, reflect the improved treatment of infections, renal failure and hypercalcaemia as well as earlier diagnosis. For over 30 years, the gold standard of treatment has been oral melphalan and prednisolone, producing a clinical response in approximately 60% of patients and a median survival of around 36 months. ⋯ They should therefore be considered for trials of newer agents, drug combinations and therapeutic interventions such as cytokine manipulation or gene therapy. The lack of effective, curative treatment options for patients with myeloma places great importance on effective palliation. While improving survival duration remains elusive in this condition, all possible efforts must be made to ensure quality of life is maximized.
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Clinical Trial
Treatment of compulsive behaviour in eating disorders with intermittent ketamine infusions.
We have previously shown that eating disorders are a compulsive behaviour disease, characterized by frequent recall of anorexic thoughts. Evidence suggests that memory is a neocortical neuronal network, excitation of which involves the hippocampus, with recall occurring by re-excitement of the same specific network. Excitement of the hippocampus by glutamate-NMDA receptors, leading to long-term potentiation (LTP), can be blocked by ketamine. ⋯ Clinical response was associated with a significant decrease in Compulsion score: before ketamine, mean +/- SE was 44.0 +/- 2.5; after ketamine, 27.0 +/- 3.5 (t test, p = 0.0016). In six patients (non-responders) the score was: before ketamine, 42.8 +/- 3.7; after ketamine, 44.8 +/- 3.1. There was no significant response to at least five ketamine treatments, perhaps because the compulsive drive was re-established too soon after the infusion, or because the dose of opioid antagonist, nalmefene, was too low.
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The aims of the Chest Pain Clinic were: to establish rapid-access, 'same-day', referral and attendance without a waiting list; to provide a diagnosis, treatment and follow-up plan for each patient; and to optimize the use of hospitalization for appropriate patients. Prospective data were collected from 1001 consecutive General Practitioner referrals to the Chest Pain Clinic over a 22-month period. Hospital admissions were reduced from an estimated 268 to 145 patients. ⋯ A firm diagnosis was provided in 92% of cases (919 patients) with 42% (418) diagnosed as having ischaemic heart disease. The provision of a Chest Pain Clinic reduces the hospitalization of patients with benign non-cardiac chest pain whilst facilitating the identification of those patients with acute coronary syndromes requiring in-patient care. The Chest Pain Clinic service has a higher diagnostic yield for ischaemic heart disease than open access exercise electrocardiography, provides the General Practitioner with a firm clinical diagnosis in over 90% of cases, and identifies those patients requiring further treatment and invasive investigation.
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Review
Evolving strategies in the treatment of sepsis and systemic inflammatory response syndrome (SIRS).
In recent years, much basic science research has investigated the predisposing factors, initiation, propagation, and resolution of Gram-negative sepsis, endotoxaemic shock, and the newly defined entity of systemic inflammatory response syndrome (SIRS). A major cause of morbidity and mortality in the post-surgical, neonatal, and geriatric hospital population, sepsis has proven itself notoriously resistant to classical modes of therapy, including antibiotics, fluid/pressor and respiratory support. ⋯ For these reasons, there is much interest in alternative treatment modalities which focus upon the endotoxin molecule itself and the systemic inflammatory response it provokes via the cytokine, complement, and coagulation cascades. In this review, recent experimental approaches to the therapy of sepsis and SIRS are discussed in light of each step in the complex inflammatory cascade and in comparison to traditional approaches to prevention and therapy of Gram-negative bacteraemia and septic shock.