Without sampling information, data lack impact.
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Colony Count, Microbial↗
Biomedical subjects
A M Pheley
Publications and source records attributed to A M Pheley.
Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.
BACKGROUND: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.
Adult↗
Dobutamine stress echocardiography for the detection of significant coronary artery disease in renal transplant candidates.
Prophylactic coronary revascularization may reduce the risk for cardiac events in diabetic renal transplant candidates. No published data exist on the accuracy of dobutamine stress echocardiography (DSE) for the diagnosis of angiographically defined coronary artery disease (CAD) in renal transplant candidates. The purpose of this study is to examine the accuracy of DSE for the detection of CAD in high-risk renal transplant candidates compared with coronary angiography. Fifty renal transplant candidates with diabetic nephropathy (39 patients) or end-stage renal disease (ESRD) from other causes (11 patients) underwent prospectively performed DSE, followed by quantitative coronary angiography (QCA) and qualitative visual assessment of CAD severity. Twenty of 50 DSE tests were positive for inducible ischemia. Twenty-seven patients (54%) had a stenosis of 50% or greater by QCA, 12 patients (24%) had a stenosis of greater than 70% by QCA, and 16 patients (32%) had a stenosis greater than 75% by visual estimation. The sensitivity and specificity of DSE for CAD diagnosis were respectively 52% and 74% compared with QCA stenosis of 50% or greater, 75% and 71% compared with QCA stenosis greater than 70%, and 75% and 76% for stenosis greater than 75% by visual estimate. On long-term follow-up (22.5 +/- 10.1 months), 6 of 30 patients (20%) with negative DSE results and 11 of 20 patients (55%) with positive DSE results had a cardiac death, myocardial infarction (MI), or coronary revascularization. Six of 27 patients (22%) with a QCA stenosis of 50% or greater had a cardiac death or MI compared with none of the 23 patients (0%) with QCA stenosis less than 50% (P = 0.025). We conclude that DSE is a useful but imperfect screening test for angiographically defined CAD in renal transplant candidates.
Adult↗
Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing.
A single-blind, randomized, placebo-controlled study was performed to evaluate auricular acupuncture (AAc) in the treatment of cocaine addiction. Two linked but concurrent studies were done. In Study 1, residential clients (N = 236) were randomized to true acupuncture (Ac), sham Ac, and conventional treatment without Ac. Treatment group subjects received Ac at three ear points considered to be specific for the treatment of substance abuse (SA). Control subjects received three nonspecific (sham) points. In Study 2, day treatment clients (N = 202) were randomized to one of three dose levels of true Ac (28, 16, or 8 treatments). Subjects received Ac at five, rather than three, specific ear points. Nonspecific (sham) points were not used in Study 2. With rare exception, the data failed to identify significant treatment differences among the true and sham Ac, and psychosocial groups. Furthermore, no differences were observed among the three dose levels of true Ac.
Acupuncture Points↗
Short-term outcomes of treatment for musculoskeletal disorders in a hospital-based alternative and complementary medicine clinic.
OBJECTIVE: Musculoskeletal (MS) disorders are among the more common conditions for which patients seek relief. The treatment of choice for MS disorders in Western medicine is the administration of nonsteroidal anti-inflammatory (NSAID) agents. However, patients in increasing numbers are seeking out complementary/alternative medicine (CAM) for MS disorders. This report presents the results of a systematically conducted, short-term evaluation of MS patients seen in a hospital-based outpatient clinic that provides acupuncture and other alternative modalities. DESIGN: During a 1.5-year period, 797 patients in our CAM clinic completed a structured questionnaire on their initial visit. The questionnaire elicited demographic and health history information and information regarding the nature and severity of the patients' health complaints. One-month after this baseline measurement and the beginning of CAM treatment, patients rated their complaint severity, improvement in the condition being treated and helpfulness of the CAM treatments. Of the 797 patients, 398 were treated for MS complaints and provide the basis for this report. RESULTS: At the 1-month follow-up, severity of primary complaints diminished an average of 2.0 points (SD = 2.4) on a 10-point numerical scale (P<0.001). Thirty percent of the patients reported severity reduction to 50% or more of baseline. Although self-reported improvement and change in severity were moderately correlated, baseline severity was inversely related to therapeutic helpfulness (P = 0.013). Improvement increased with number of treatments (P<0.001); however, due to time constraints, treatment frequency was limited. CONCLUSIONS: Nearly half of the patients visiting our clinic sought relief for MS complaints. Our findings suggest that acupuncture treatment provides significant improvement of presenting symptoms within a short time period. Although discerning the long-term treatment effects was not the intent of this study, these findings contribute toward a consensus opinion that CAM therapies can help alleviate the pain and discomfort of MS disorders.
Adult↗
Mass transit strike effects on access to medical care.
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Analysis of Variance↗
Can we predict recovery in chronic fatigue syndrome?
PURPOSE: To determine if selected demographic or clinical features of chronic fatigue syndrome (CFS) are associated with recovery. PATIENTS AND METHODS: A follow-up questionnaire was mailed to 341 patients who had been ill on average for nine years to ascertain "recovery" rate (defined as self-reported recovery on a visual analog scale). Baseline demographic and clinical features (functional status and psychological status) recorded at the time of the initial (baseline) clinical visit were analyzed for their association with recovery at the time of follow-up. RESULTS: Of the 177 patients who responded to the follow-up questionnaire, only 21 (12%) reported "recovery." Patients with higher levels of physical and social functioning and lower levels of anxiety and obsessive-compulsiveness at baseline were more likely to report recovery at follow-up (p < 0.05). No specific demographic characteristics were associated with recovery. CONCLUSION: These findings support previous research that complete recovery from CFS is rare and that patients with less severe illness at the initial clinic visit are more likely to have a positive prognosis for recovery. However, considerable overlap in illness severity was observed between the recovered and nonrecovered groups, suggesting that accurate prediction of recovery in individual CFS patients is not currently feasible.
Activities of Daily Living↗
Hunger in midwestern inner-city young children.
OBJECTIVE: To determine the characteristics of hunger in young children who attend ambulatory pediatric clinics in a midwestern city. DESIGN: Consecutive sample. SETTING: Ambulatory pediatric clinics of an inner-city teaching hospital. PARTICIPANTS: English-speaking caregivers of 2578 children younger than 5 years. MAIN OUTCOME MEASURE: Structured survey measures of hunger, family characteristics, assistance program use, child feeding practices, and anthropometrics. RESULTS: In this population, 171 (6.6%) were hungry, and 842 (32.7%) were at risk for hunger. Hunger status was associated with increased age (P<.001), decreased maternal education level (P=.013), maternal nonwhite race (P<.002), a history of homelessness (P<.001), and parental unemployment (P<.001). Hunger status was associated with use of Aid to Families with Dependent Children (P<.001) and food stamps (P<.001) but not with participation in The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Results of anthropometrics indicated that mean growth percentiles were no different between hunger categories. CONCLUSIONS: Housing, dietary, and family characteristics are identifiable risk factors for early childhood hunger. Hunger cannot be identified, however, using anthropometrics. It is disconcerting that fewer hungry children and children at risk for hunger participate in WIC compared with other programs. These data suggest the potential for more aggressive identification and intervention at the primary care and social service levels to benefit hungry children.
Anthropometry↗
Characteristics and complaints of patients seeking therapy at a hospital-based alternative medicine clinic.
BACKGROUND: Patient use of complementary and alternative medicine (CAM) is on the rise. With millions of Americans using CAM, it has become imperative from the public health point of view to undertake a coordinated research effort that will thoroughly evaluate the role and effectiveness of CAM modalities. METHODS: We developed a prospective data-collection system to capture presenting complaints, patient health histories, and demographic information on the patients of a hospital-based alternative medicine clinic. RESULTS: Of 760 patients in the present cohort, 248 different complaints or complaint combinations were entered. Of 16 major categories, the largest was musculoskeletal, followed by the addictions, psychiatric, and nonspecific categories. Slightly more than one in five patients requested treatment on the recommendation of their physician. Over two-thirds of patients in this study group were female. CONCLUSIONS: Given the growing interest and use of complementary and alternative therapies, a system such as described can demonstrate the types of patients presenting for treatment, a more detailed picture of their complaints, and, over time, measurable outcomes.
Complementary Therapies↗
Denial of health insurance due to preexisting conditions: how well does one high-risk pool work?
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Analysis of Variance↗
Complications of endoscopic biliary sphincterotomy.
BACKGROUND: Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. METHODS: We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. RESULTS: Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). CONCLUSIONS: The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
Age Factors↗
Motivation for participation in clinical trials of drugs for the treatment of asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis.
BACKGROUND: While previous studies of enrollment motivation have been conducted with either healthy subjects or subjects with certain other diseases, little is known about the motives of subjects with asthma or rhinitis symptoms who seek to enter clinical trials. OBJECTIVE: This study was conducted to assess the self-reported role that altruism, healthcare receipt, and financial gain play in the motivation of subjects with symptoms of bronchial asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis who attempted to enroll in clinical trials. METHODS: Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis who sought to enroll in phase III clinical trials completed surveys from December 1991 to August 1992 (n = 295). The importance of altruistic and nonaltruistic motives was rated on numerical scales. RESULTS: Improved control of symptoms and learning more about the illness and medications for treatment were the most important nonaltruistic motives (P less than .05). Financial motives and second opinion were moderately important but less important than healthcare motives (P less than .05). This population as a whole agreed that the altruistic motives listed in the survey were reasons to enroll. CONCLUSION: Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis entered clinical trials for altruistic reasons and to receive healthcare treatment for their chronic illness including related health education. For the entire group, self-reported financial motives were less important than illness-related healthcare.
Adolescent↗
Omeprazole use at an urban county teaching hospital.
To determine the appropriateness of use of omeprazole, all outpatient prescriptions over one year from a single county hospital pharmacy were analyzed. Appropriateness of omeprazole use was assessed by literature review and expert opinion. Two hundred twenty-one prescriptions were evaluated; 112 (56%) were inappropriate. Women received more inappropriate prescriptions (61% vs 44%, p = 0.01) and received endoscopy less frequently (52% vs 71%, p < 0.02) than did men. When age, gender, and prescribing clinic were examined as predictors of inappropriate use, only gender was significant (OR = 2.01, 95% CI = 1.52-2.66). This study, from a single institution, showed a high rate of inappropriate omeprazole use.
Drug Utilization Review↗
Effect of hypoxia or hyperbaric oxygen on cerebral edema following moderate fluid percussion or cortical impact injury in rats.
This study was designed to evaluate the production of cerebral edema [as measured by tissue specific gravity (SpG)] following moderate fluid percussion (FP) and cortical impact (CI) injury in rodents. To determine the effects of a secondary systemic insult, hypoxia (13% oxygen for 30 min) was added to some experimental groups immediately after head injury. To determine the effects of hyperbaric oxygen (HBO) on injured cortical tissue, additional animal groups were exposed to HBO (1.5 atm, for 60 min), beginning 4 h after head trauma. Both injury models produced equal amounts of tissue edema at the site of injury (mean SpG +/- SEM = 1.035 +/- 0.001), when measured 6 h posttrauma. There was no significant edema at the tissue sites immediately adjacent to the trauma sites. The addition of hypoxia to either injury system did not increase edema formation beyond that produced by injury alone. HBO reduced the water content of the trauma site in animals that had received FP, but not in animals receiving CI. We conclude that with the injury parameters used in this protocol, both FP and CI appear to produce focal cerebral edema at the site of trauma. Hypoxia does not worsen edema. HBO appears to reduce edema produced by FP, but not by CI.
Animals↗
Evaluation of a nurse-based hypertension management program: screening, management, and outcomes.
This article reports the experience of patients with elevated blood pressure scheduled to be seen in a nurse-based hypertension management program in a large multispecialty group practice. The hypertension management program is a screening and follow-up program designed to improve the measurement and management of patients' blood pressure with standardized protocols. The cohort for this study of the effectiveness of the hypertension management program consisted of 200 patients with elevated blood pressure (140 referred directly for management and counseling, 60 entered through screening). At entry, only 17% of the patients had blood pressure within controlled limits (< 140/90 mm Hg). One year after entry in the management phase of the program, systolic pressure had decreased an average of 6.20 mm Hg (P < 0.01), and 44% of patients had blood pressure within controlled limits (P < 0.001). These results suggest that the use of standardized screening techniques using multiple measurements helps to ensure that patients will not be unnecessarily treated. Furthermore, patients who entered the program successfully lowered their blood pressure and maintained the reduction over time.
Blood Pressure↗
The Yale-Brown Obsessive-Compulsive Scale: measures of internal consistency.
We examined the construction of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and performance of subscale items based on data from 204 patients with obsessive-compulsive disorder (OCD) who participated in a multicenter drug treatment study. Factor analysis was used to examine the relationship among the 10 items that make up the Y-BOCS instrument. Models were computed in which both two- and three-factor solutions were estimated. Within the two-factor solution analyses, the factor distribution was not so consistent as in the three-factor solution analyses, and a shift in the factor distribution was noted after treatment. In the three-factor solution analyses, an independent resistance construct emerged in addition to the obsessive and compulsive constructs. Examination of the postreatment factor scores showed that the Y-BOCS resistance items did not assess OCD symptom change as sensitively as the rest of the Y-BOCS items did.
Adult↗
Changes in orders limiting care and the use of less aggressive care in a nursing home population.
OBJECTIVE: To examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited. DESIGN: Retrospective chart review. SETTING: All nursing homes in Hennepin County, Minnesota that care for Medicaid patients. PATIENTS: A random sample of 1605 residents of Hennepin County, MN nursing homes from 1984 and 1988 who were also Medicaid beneficiaries. The sample was stratified by year and by whether the resident died in that year. The residents were sampled disproportionately to allow approximately 400 individuals in each stratum. A total of 1405 charts (87%) was reviewed; the remainder had either been lost or destroyed. MAIN OUTCOME MEASURE: Orders limiting care (do not resuscitate, supportive care only, etc.), care that was less aggressive than care usually given to a person of that age (eg, not using antibiotics for a clear infection or not sending a resident to the hospital for an illness for which someone would "usually" be sent to the hospital), determined implicitly through chart review. RESULTS: The demographic characteristics of the nursing home population did not change between 1984 and 1988, but the population had significantly greater severity of illness in 1988. The percentage of residents with 'do not resuscitate' orders (DNR) increased from 12% to 37% (P < 0.0001), and the use of other orders to limit care (do not hospitalize, supportive care only, etc.) increased from 12% to 17% (P < 0.05). The use of CPR did not change between the two years but the percentage of residents who were found to receive less aggressive care through implicit chart review increased from 31% to 40% (P < 0.01). The year the resident was in the nursing home, the severity of illness, functional status, and dementia were significant predictors of DNR status. Factors that predict receipt of less aggressive care were similar except that age was also a significant predictor. CONCLUSIONS: The nursing home population received less aggressive care in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that residents with DNR orders had care limited beyond the withholding of CPR.
Advance Directives↗
Effects of mild exercise on cytokines and cerebral blood flow in chronic fatigue syndrome patients.
Chronic fatigue syndrome (CFS) is an idiopathic disorder characterized by fatigue that is markedly exacerbated by physical exertion. In the present study, we tested the hypothesis that mild exercise (walking 1 mph [1 mile = 1.609 km] for 30 min) would provoke serum cytokine and cerebral blood flow abnormalities of potential pathogenic importance in CFS. Interleukin-1 beta, interleukin-6, and tumor necrosis factor alpha were nondetectable in sera of CFS patients (n = 10) and healthy control subjects (n = 10) pre- and postexercise. At rest, serum transforming growth factor beta (TGF-beta) levels were elevated in the CFS group compared with the control group (287 +/- 18 versus 115 +/- 5 pg/ml, respectively; P < 0.01). Serum TGF-beta and cerebral blood flow abnormalities, detected by single-photon emission-computed tomographic scanning, were accentuated postexercise in the CFS group. Although these findings were not significantly different from those in the control group, the effect of exercise on serum TGF-beta and cerebral blood flow appeared magnified in the CFS patients. Results of this study encourage future research on the interaction of physical exertion, serum cytokines, and cerebral blood flow in CFS that will adopt a more rigorous exercise program than the one used in this study.
Adult↗