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Biomedical subjects

B Lo

Publications and source records attributed to B Lo.

At least 73 records · Page 4Linked to original sources
PubMed1994

Increasing the completion of the durable power of attorney for health care. A randomized, controlled trial.

OBJECTIVE: Wider use of written advance directives may prevent many ethical dilemmas about life-sustaining interventions for patients who have lost decision-making capacity. We investigated whether a simple educational intervention increased patient completion of the durable power of attorney for health care. DESIGN: A randomized, controlled trial. SETTING: A health maintenance organization. SUBJECTS: All patients aged 65 years and older and discharged from a hospital between January 1991 and May 1991 (n = 1101) were randomized to either an intervention group or a control group. INTERVENTION: An educational pamphlet on the durable power of attorney for health care and a durable power of attorney for health care form were mailed to all patients in the intervention group. The control group received conventional care only. MAIN OUTCOME MEASURE: Completion of the durable power of attorney for health care form. RESULTS: There were no significant baseline differences between the intervention group and the control group. Following our intervention, 18.5% of the subjects in the experimental group completed a durable power of attorney for health care form, compared with 0.4% of the control group (P < .0001). CONCLUSIONS: A simple educational intervention significantly increased the completion of the durable power of attorney for health care. Our findings should stimulate further efforts to empower patients to make informed decisions about their health care.

Advance Directives↗
PubMed1994

Effects of vaccine information pamphlets on parents' attitudes.

OBJECTIVES: To describe how parents actually use federally mandated vaccine information pamphlets and to evaluate the pamphlets' effects on parents' opinions about vaccination. DESIGN: A controlled trial of vaccine information pamphlets based on a survey mailed to parents who either received (n = 140) or did not receive (n = 167) the pamphlets. STUDY POPULATION: Parents of infants aged 2 to 8 months in a suburban, mainly upper-middle class private group practice in northern California. RESULTS: More than 90% of parents believed that they had enough information to decide whether their child should be vaccinated, even among those who did not receive the pamphlets. Among parents who received the pamphlets, fewer than half (38%) read them thoroughly, and most (63%) said that they should be distributed only on the first visit for vaccinations. Parents who received the pamphlets did not differ from those who did not in terms of the proportions who would have liked more time to be spent discussing vaccines (34% vs 34%) or who were anxious about how the diphtheria and tetanus toxoids and pertussis vaccine would affect their child (60% vs 52%). CONCLUSIONS: Vaccine information pamphlets, when used as an adjunct to discussions with physicians and nurses, have little effect on the opinions of well-educated parents. Future research and policy changes might focus on how to make the contents of the pamphlets less frightening and on allowing greater flexibility in how they are distributed.

Adult↗
PubMed1994

Characterization of cimetidine transport in LLCPK1 cells.

In this study, cimetidine uptake and its regulation by LLCPK1 monolayers were investigated. Uptake was temperature dependent with kinetic and specificity characteristics typical of a carrier-mediated mechanism. With cimetidine uptake in the presence of an excess concentration of the potent inhibitor quinidine as a measure of nonspecific transport, the estimated kinetic parameters for cimetidine uptake at 37 degrees C under steady-state conditions are Km = 32.3 +/- 6.4 microM and Vmax = 20.2 +/- 2.1 pmol/mg per minute. Amiloride, quinidine, and quinine inhibited cimetidine uptake, whereas N1-methylnicotinamide, tetraethylammonium, and guanidine did not. The uptake of cimetidine was increased in the presence of a cell-->lumen H+ gradient, consistent with the behavior of a cimetidine-H+ antiport system. Furthermore, the activity of both the Na(+)-H+ exchanger and H(+)-ATPase acted to dissipate the cell-->lumen H+ gradient, thereby decreasing net cimetidine transport. These results suggest that there is a cimetidine-H+ exchange system in LLCPK1 cells and that the net secretion of organic base in vivo may be regulated by luminal acidification mechanisms.

Amiloride↗
PubMed1993

Impact of a procedure-specific do not resuscitate order form on documentation of do not resuscitate orders.

BACKGROUND: Serious problems exist with respect to documentation of do not resuscitate (DNR) orders. We studied the impact of a procedure-specific DNR order form on documentation of these orders. METHODS: We prospectively compared DNR chart documentation during a 3-month period before and after implementation of a procedure-specific DNR order form. RESULTS: The order form was used in 41 (93%) of 43 charts after its implementation. Documentation of attending physician agreement with the DNR order form increased from 30 of 34 charts in which the order form was used). The number of orders where it was uncertain whether at least one component of acute cardiopulmonary life support-related procedures was to be performed decreased from 30 (88%) of 34 charts to three (7%) of 43 charts. The order form had no measurable impact on documentation of DNR discussion. Only 25% of the charts had any discussion of the risks and benefits of CPR. CONCLUSIONS: A procedure-specific DNR order form can improve documentation of DNR decisions. The reduction of uncertainty in these orders about the use of specific procedures can prevent errors in patient care.

Advance Directives↗
PubMed1993

A novel use of the link-file system for longitudinal studies of HIV infection: a practical solution to an ethical dilemma.

BACKGROUND: Longitudinal studies that collect sensitive data, such as test results for HIV antibodies, present difficult ethical problems for investigators. Personal identifiers are needed for longitudinal follow-up, but current regulations in the United States require that all subjects be informed of their HIV test results when identifiers are retained. Therefore, subjects who do not wish to learn their HIV status must be excluded from prospective research. Because these subjects may be at particularly high risk for HIV infection, this situation may lead to substantial bias. METHODS: We describe a new application of a methodology for blinding such studies, based on the link-file system used for protecting subjects' sensitive research data. This design enables investigators to hold each subject's HIV test result and survey data for multiple ascertainments over time while effectively severing any link between this information and the subject's identity. This objective is achieved by a process of sequential coding, using at least two coders who are not associated with the study. CONCLUSIONS: The method described in this paper permits investigators in the United States to perform important prospective epidemiologic studies while adhering to current regulations for the conduct of such investigations.

Anonymous Testing↗
PubMed1993

How house officers cope with their mistakes.

We examined how house officers coped with serious medical mistakes to gain insight into how medical educators should handle these situations. An anonymous questionnaire was mailed to 254 house officers in internal medicine asking them to describe their most important mistake and their response to it; 45% (N = 114) reported a mistake and completed the questionnaire. House officers experienced considerable emotional distress in response to their mistakes and used a variety of strategies to cope. In multivariate analysis, those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress. House officers who coped by escape-avoidance were more likely to report defensive changes in practice. For house officers who have made a mistake, we suggest that medical educators provide specific advice about preventing a recurrence of the mistake, provide emotional support, and help them understand that distress is an expected concomitant of learning from the experience.

Adaptation, Psychological↗
PubMed1993

Advance directives for patients with human immunodeficiency virus infection.

A consensus has emerged in recent years that decisions about life-sustaining treatment made by informed, competent patients should be respected. Advance directives are expressions of a patient's preferences regarding life-sustaining treatments made while the patient is still competent, to be used if the patient loses competence. Patients infected with HIV have a high mortality rate and frequently lose competence as their disease progresses to AIDS. Therefore, the completion of advance directives in this patient group is vitally important.

Advance Directives↗
PubMed1992

Health care workers infected with the human immunodeficiency virus. The next steps.

The tragedy of five patients who contracted human immunodeficiency virus (HIV) infection from a seropositive dentist has alarmed the public. The Centers for Disease Control (CDC) recently revised its recommendations for preventing the transmission of HIV infection to patients during invasive procedures. The CDC abandoned a previous plan to list exposure-prone invasive procedures that HIV-infected health care workers should not perform. The CDC said "expert review panels" should decide on a case-by-case basis whether seropositive health care workers may perform invasive procedures. As of February 1992, the revised recommendations were under review by the US Department of Health and Human Services. Many issues remain to be clarified, such as how these panels will operate and whether decisions will be consistent in similar cases. Disregarding the CDC guidelines or infection-control precautions may further erode public trust and lead to draconian restrictions on HIV-infected health care workers. Physicians and dentists should respond more effectively to public fears about HIV transmission. The challenge is to protect patients while respecting the privacy and livelihood of health care workers.

Centers for Disease Control and Prevention, U.S.↗
PubMed1992

How strictly do dialysis patients want their advance directives followed?

OBJECTIVE: The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed. DESIGN: Interview study. SETTING: Seven outpatient chronic dialysis centers. PARTICIPANTS: One hundred fifty mentally competent dialysis patients. INTERVENTION: Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them. RESULTS: Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs. CONCLUSIONS: Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.

Adolescent↗
PubMed1992

PACS clinical experience at Georgetown University.

Georgetown University Hospital has been operating an image management and communications system (IMACS or PACS) for 3.5 years. This work was initially funded under the Army Medical Research and Development Command Digital Imaging Network Systems (DINS) project. The system was taken from a research system supporting only radiology tasks to one extended to clinical use, and has been used in clinical work for 3 years. This paper will summarize our PACS clinical experience and will describe the operational features implemented and those still necessary.

Computer Systems↗
PubMed1992

Physician-patient sexual contact. Prevalence and problems.

To document the current prevalence of physician-patient sexual contact and to estimate its effect on involved patients, 10,000 family practitioners, internists, obstetrician-gynecologists, and surgeons were surveyed. Of the 1,891 respondents, 9% acknowledged sexual contact with 1 or more patients. Even in the unlikely case that none of the nonrespondents had sexual contact with patients, its prevalence among all 10,000 physicians surveyed would still be 2%. Of respondents, 23% had at least 1 patient who reported sexual contact with another physician; 63% thought this contact was "always harmful" to the patients. Almost all (94%) responding physicians opposed sexual contact with current patients; 37% also opposed sexual contact with former patients. More than half of respondents (56%) indicated that physician-patient sexual contact had never been addressed in their training; only 3% had participated in a continuing education course focusing on this issue. Clear and enforceable medical ethics codes concerning physician-patient sexual contact are needed, as well as preventive educational programs for medical schools and residency programs.

Ethics, Medical↗
PubMed1991

Beyond the Cruzan case: the U.S. Supreme Court and medical practice.

In a landmark decision, the U.S. Supreme Court affirmed a Missouri ruling that sharply limited family decisions about life-sustaining treatment for incompetent patients. The Court held that the Constitution protects the refusal of life-sustaining treatment by competent patients. For incompetent patients, states may require "clear and convincing" evidence of refusal, specifically for the withdrawal of tube feedings, if such a person were in a persistent vegetative state. The ruling left many clinical questions unanswered, such as whether life-sustaining treatment must be given to terminally ill incompetent patients, whether patients may refuse artificial feedings, and what constitutes clear and convincing evidence of refusal. The decision also has potentially harmful consequences. It may undermine family decision making, encourage cynicism and disregard of the law, and promote defensive medicine. Physicians can minimize such consequences by encouraging patients to provide advance directives, such as the durable power of attorney for health care, by urging legislative action, and by setting national practice standards for decisions regarding incompetent patients.

Adult↗
PubMed1991

Do house officers learn from their mistakes?

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.

Analysis of Variance↗