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Biomedical subjects

B Zimmerman

Publications and source records attributed to B Zimmerman.

At least 19 recordsLinked to original sources
PubMed2006

How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients?

Clinical and technological advances in medicine have resulted in more patients requiring multidisciplinary care and coordination of services. This is particularly challenging in pediatrics, given the dependency of children. Coordination of care is a key ingredient of quality care; when suboptimal, clinical outcomes and satisfaction can suffer. In this article we view coordination of care through the lens of complexity science in an effort to find new solutions to this healthcare challenge.

Child↗
PubMed2004

Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus).

Although 30-50% of constipated patients exhibit dyssynergia, an optimal method of diagnosis is unclear. Recently, consensus criteria have been proposed but their utility is unknown. To examine the diagnostic yield of colorectal tests, reproducibility of manometry and utility of Rome II criteria. A total of 100 patients with difficult defecation were prospectively evaluated with anorectal manometry, balloon expulsion, colonic transit and defecography. Fifty-three patients had repeat manometry. During attempted defecation, 30 showed normal and 70 one of three abnormal manometric patterns. Forty-six patients fulfilled Rome criteria and showed paradoxical anal contraction (type I) or impaired anal relaxation (type III) with adequate propulsion. However, 24 (34%) showed impaired propulsion (type II). Forty-five (64%) had slow transit, 42 (60%) impaired balloon expulsion and 26 (37%) abnormal defecography. Defecography provided no additional discriminant utility. Evidence of dyssynergia was reproducible in 51 of 53 patients. Symptoms alone could not differentiate dyssynergic subtypes or patients. Dyssynergic patients exhibited three patterns that were reproducible: paradoxical contraction, impaired propulsion and impaired relaxation. Although useful, Rome II criteria may be insufficient to identify or subclassify dyssynergic defecation. Symptoms together with abnormal manometry, abnormal balloon expulsion or colonic marker retention are necessary to optimally identify patients with difficult defecation.

Anal Canal↗
PubMed2003

Inverse relationship between density of cutaneous hair and pigmented lesion count in patients with malignant melanoma.

The aim of this study was to investigate whether there is an inverse relationship between the density of cutaneous hair and the number of pigmented lesions in patients with malignant melanoma, and to review the clinical and experimental findings with regard to this relationship. Cutaneous hair density and pigmented lesion counts were determined at nine sites by two physicians using specified criteria in 10 patients with a history of malignant melanoma and 22 control subjects. Study participants were Caucasian males of similar age, height and weight, and had similar occupational, ethnic, socioeconomic and sun exposure backgrounds. Statistical analysis was performed using combined data from all the sites and individual site data to determine whether an inverse relationship between cutaneous hair density and pigmented lesion counts exists. The results demonstrated statistically significant inverse relationships for the chest, upper back, upper arm and forearm in the melanoma patients, but not in the controls. For all the sites combined, both groups demonstrated statistically significant inverse relationships. The study findings are consistent with the hypothesis that some pigmented lesions may arise from the melanocytes of the hair follicle. This hypothesis may lead to new approaches to studying and treating melanoma.

Adult↗
PubMed2001

Systemic diseases associated with various types of retinal vein occlusion.

PURPOSE: To investigate systemic diseases associated with various types of retinal vein occlusion. METHODS: We investigated prospectively in 1090 consecutive patients with retinal vein occlusion, almost all Caucasian (consistent with the racial pattern here), the prevalence of associated systemic disorders before or at the onset of various types of retinal vein occlusion. The patients were categorized into six types of retinal vein occlusion based on defined criteria: nonischemic and ischemic central retinal vein occlusion, nonischemic and ischemic hemi-central retinal vein occlusion, and major and macular branch retinal vein occlusion. The patients had a detailed ophthalmic and systemic evaluation according to our protocol. For data analysis, patients were divided into three age groups: young (younger than 45 years), middle-aged (45 to 64 years), and elderly (65 years or older). The observed prevalence rates of major systemic diseases were compared among central retinal vein occlusion, hemi-central retinal vein occlusion, and branch retinal vein occlusion using a polytomous logistic regression analysis adjusting for gender and age. Logistic regression adjusting for age and gender was also used to compare the observed prevalence of systemic disease between nonischemic and ischemic in central retinal vein occlusion and hemi-central retinal vein occlusion and between major and macular branch retinal vein occlusion. These observed prevalence rates were also compared with those expected in a gender-matched and age-matched control population from estimates from the US National Center for Health Statistics. RESULTS: There was a significantly higher prevalence of arterial hypertension in branch retinal vein occlusion compared with central retinal vein occlusion (P < .0001) and hemi-central retinal vein occlusion (P = .028). Branch retinal vein occlusion also had a significantly higher prevalence of peripheral vascular disease (P = .0002), venous disease (P = .011), peptic ulcer (P = .031), and other gastrointestinal disease (P < .0001) compared with central retinal vein occlusion. The proportion of patients with branch retinal vein occlusion with cerebrovascular disease was also significantly (P = .049) greater than that of the combined group of patients with central retinal vein occlusion and patients with hemi-central retinal vein occlusion. There was no significant difference in prevalence of any systemic disease between central retinal vein occlusion and hemi-central retinal vein occlusion. A significantly greater prevalence of arterial hypertension (P = .025) and diabetes mellitus (P = .011) was present in the ischemic central retinal vein occlusion compared with the nonischemic central retinal vein occlusion. Similarly, arterial hypertension (P = .0002) and ischemic heart disease (P = .048) were more prevalent in major branch retinal vein occlusion than in macular branch retinal vein occlusion. Relative to the US white control population, the combined group of patients with central retinal vein occlusion and patients with hemi-central retinal vein occlusion had a higher prevalence of arterial hypertension (P < .0001), peptic ulcer (P < .0001), diabetes mellitus (in ischemic type only, P < .0001), and thyroid disorder (P < .0001). The patients with branch retinal vein occlusion showed a greater prevalence of arterial hypertension (P < or = .005), cerebrovascular disease (P = .007), chronic obstructive pulmonary disease (P = .012), peptic ulcer (P < .0001), diabetes (in young only, P = .0005), and thyroid disorder (P = .003) compared with the US white control population. CONCLUSIONS: The findings of our study revealed that a variety of systemic disorders may be present in association with different types of retinal vein occlusion and in different age groups, and that their relative prevalence differs significantly, so that the common practice of generalizing about these disorders for the entire group of patients with retinal vein occlusion can be misleading. The presence of a particular associated systemic disease does not necessarily imply a cause-and-effect relationship with that type of retinal vein occlusion; the particular disease may or may not be one of the risk factors in a multifactorial scenario predisposing an eye to develop a particular type of retinal vein occlusion. Based on our study, we think that apart from a routine medical evaluation, an extensive and expensive workup for systemic diseases is unwarranted in the vast majority of patients with retinal vein occlusion.

Adult↗
PubMed2001

Ipsilateral recurrence of nonarteritic anterior ischemic optic neuropathy.

PURPOSE: To report the prevalence of recurrence of nonarteritic anterior ischemic optic neuropathy (NA-AION) in the same eye and possible contributing risk factors. DESIGN: Cohort study. METHODS SETTING: Institutional. STUDY POPULATION: The study includes 594 consecutive patients (829 eyes) with a diagnosis of NA-AION and follow-up of at least two months after the onset of NA-AION, examined in the Ocular Vascular Clinic since 1973. Simple progression of visual loss during an episode of NA-AION was not considered a fresh episode. INTERVENTION OR OBSERVATION PROCEDURES: Every patient had ophthalmic evaluation, including visual acuity, visual fields with a Goldmann perimeter, intraocular pressure, and slit lamp and ophthalmoscopic evaluation at initial visit and at each follow-up visit. The patients also had systemic evaluation; some patients had echocardiography (166 patients) and 24-hour ambulatory blood pressure (BP) monitoring-the latter was investigated in 80 patients (17 with and 63 without recurrence of NA-AION) who consented to participate in this study which was started in 1989. While optic disk edema was present, the patients were followed every 2 to 3 weeks. Once the optic disk edema resolved, they were followed up after 3 months, 6 months, and then at yearly intervals unless they had some new visual complaint. MAIN OUTCOME MEASURES: Prevalence of a fresh episode of NA-AION in the same eye, and comparison of ocular and systemic risk factors between patients with and without recurrence of NA-AION in the same eye. RESULTS: Of the 594 patients (829 eyes) in the study, recurrence of NA-AION in the same eye occurred in 45 patients (53 eyes) with a median follow-up of 3.1 years (range 2 months to 30.5 years) from the first onset of NA-AION. The Kaplan-Meier survival curve showed cumulative percentage of recurrence of NA-AION from first episode to second episode at three months 1.0%+/-0.4%(SE), at 6 months 2.7%+/-0.7%, at one year 4.1%+/-0.9%, and 2 years 5.8%+/-1.1%. There was no significant association between recurrence of NA-AION and the systemic conditions that were examined, except for nocturnal arterial hypotension. Overall patients with a recurrence of NA-AION had a significantly lower mean nighttime minimum diastolic BP (P =.003) and greater mean percentage drop during sleep in diastolic BP (P =.011) than those with no recurrence of NA-AION; all other measures of nocturnal hypotension were not significantly predictive. CONCLUSIONS: Recurrence of NA-AION in the same eye is uncommon (6.4%). Our study indicates that nocturnal diastolic arterial hypotension may be a risk factor; however, since this is a multifactorial disease, other so far unknown risk factors may also play a role. The role of various risk factors which may contribute to the recurrence of NA-AION is discussed.

Adult↗
PubMed2001

Stress and symptoms in patients with interstitial cystitis: a life stress model.

Objectives. Stress-related exacerbation of interstitial cystitis (IC) symptoms has frequently been reported. Previous research has found stress-related IC symptom exacerbation in an experimental model. However, this relationship has not been objectively examined with daily life stressors. We used a prospective daily symptom diary method to investigate the relationships among stress and bladder symptoms in patients with IC and age-matched healthy controls.Methods. Forty-five previously diagnosed female patients with IC completed a bladder symptom and stress diary nightly for 1 month; 31 female age-matched healthy controls completed a similar diary for 7 days. The symptom questions were modified from the Interstitial Cystitis Data Base study.Results. Patients reported greater mean daily stress, bladder pain, urgency, and daytime and nocturnal frequency than controls (all P values less than 0.001). Among all patients, a significant relationship between stress and urgency was observed. In addition, a significant relationship between stress and pain was observed among patients with moderate and severe disease. As the disease severity increased, more pronounced relationships between stress and the symptoms of urgency and pain were evidenced. Greater stress was associated with greater nocturnal frequency among patients with more severe disease. These stress-symptom relationships were not observed among the controls.Conclusions. Higher levels of stress were related to greater pain and urgency in patients with IC but not in the controls. In addition, the relationship of stress and these IC symptoms was stronger among patients with more severe disease. The results indicate that life stress is associated with greater IC symptoms, particularly among patients whose disease is not well controlled.

Activities of Daily Living↗
PubMed2000

Developing and communicating a long-term treatment plan for asthma.

The treatment of asthma, according to current guidelines, requires complex treatment regimens that change as clinical conditions improve or deteriorate. We have developed a practical way to communicate long-term treatment plans in chart form in the primary care setting that is easy for patients to follow and use. The chart has been an important element in two interventions that have resulted in positive changes in health behavior and health outcomes in children with asthma. The plan provides recommendations for patients and families to make adjustments in medication based on changes in symptoms or peak expiratory air flow, or both, that are consistent with the Asthma Guidelines Expert Panel Report 2, 1997. The plan also indicates when the number and dosage of drugs should be increased or decreased and when emergency care should be sought, consistent with the Asthma Guidelines. By placing considerable control in the family's hands and by clearly delineating the conditions under which medicines can be reduced or discontinued, the physician provides incentives for families to adhere to the long-term treatment plan for asthma.

Anti-Asthmatic Agents↗
PubMed2000

Use of the MS-sensor to discriminate between different dosages of garlic flavoring in tomato sauce.

A method has been developed to discriminate between different dosages of garlic flavoring in tomato sauce with the help of a mass spectrometry based sensory system. Four fragment ions m/z 73, 81, 114, and 120 were selected as "sensor array" during direct injection of the sample headspace into the mass spectrometer. Tomato sauces blended with different types of flavoring could be discriminated, and concentration gradients could be monitored. Fragment ions were chosen after volatile components had been analyzed and identified by SPME-GC/MS and HS-GC/MS (full scan). HS-GC/MS profiles of m/z 73, 81, 114, and 120 were recorded in the selected ion monitoring mode.

Flavoring Agents↗
PubMed2000

Induced sputum: comparison of postinfectious cough with allergic asthma in children.

BACKGROUND: Cough persisting after a respiratory infection is common in children and is often managed as asthma. However, little is known about the pathophysiologic mechanisms of such cough and how it compares with asthma. OBJECTIVE: We used the technique of induced sputum to examine the inflammatory index values associated with persistent cough or allergic asthma in children. We hypothesized that the sputum from children with persistent postinfectious cough would differ from that of children with allergic asthma in that the former would lack eosinophils compared with the latter. STUDY DESIGN: Sputum production was induced with hypertonic saline solution in 34 children: 12 with cough persisting for 1 month or more after an apparent respiratory tract infection, not treated with corticosteroid; 11 with untreated atopic asthma, not using inhaled corticosteroid; and 11 with treated atopic asthma using inhaled corticosteroid. RESULTS: The percentage of eosinophils in the sputum of children with cough was significantly lower than in the sputum of children with untreated allergic asthma (median 0.5% vs 14.5%, P <.0001). Similarly, the percentage of eosinophils in the sputum of children with asthma treated with inhaled steroids was significantly lower compared with untreated asthmatic children (1.5% vs 14.5%, P <.0001). The peripheral blood eosinophils, serum eosinophil cationic protein, and nasal percent eosinophils of the patients with cough were also significantly lower than those from patients with untreated asthma. Methacholine challenge in 6 of the 11 cough patients tested showed mild-to-moderate hyperresponsiveness, whereas the other 5 had a negative methacholine challenge. CONCLUSIONS: Children with persistent postinfectious cough do not have airway eosinophilia typical of untreated asthma. Despite the absence of eosinophilic inflammation, some of the patients with chronic cough had reactive airways. These results suggest that postinfectious cough in children has different pathophysiologic features than allergic asthma and probably represents a different disease.

Asthma↗
PubMed2000

Stress and symptomatology in patients with interstitial cystitis: a laboratory stress model.

PURPOSE: Although patients with interstitial cystitis frequently report symptom exacerbation due to stress, to our knowledge this association has not been empirically examined. We evaluated the effects of a laboratory mental stress challenge on symptoms of urgency and pain in patients with interstitial cystitis and healthy controls. MATERIALS AND METHODS: A total of 14 females with interstitial cystitis and 14 age matched controls participated in a laboratory session, including a 60-minute baseline measurement, 25 minutes of mental stress tasks and 75 minutes of recovery. Acute symptoms of pain and urgency were assessed at voiding 15 minutes before the stressor, and 25, 70 and 100 minutes after stressor onset. Chronic symptoms were evaluated by questions from the Interstitial Cystitis Data Base survey. RESULTS: Patients reported significantly greater pain and urgency than controls at all 4 voidings (p <0.005). Pain increased in patients from the prestressor point to 25 minutes after stressor onset (p <0.005), remained elevated at 70, and decreased between 70 and 100. At 100 minutes patient pain remained significantly elevated above baseline (p = 0.018). Patient urgency was significantly elevated over baseline by 70 minutes after stressor onset (p <0.001) and significantly decreased between 70 and 100 minutes (p <0.002). Controls had no symptom changes with stress. CONCLUSIONS: These findings indicate that an acute stressor evokes increased symptoms of pain and urgency in patients with interstitial cystitis but not in controls. Findings are consistent with sympathetic effects on inflammatory processes in interstitial cystitis. However, further evaluation of the mechanisms underlying stress related interstitial cystitis symptom exacerbation is needed to provide a more comprehensive understanding of these phenomena.

Adult↗
PubMed1999

Cytomegalovirus transmission in child care homes.

BACKGROUND: Children attending child care centers have high rates of cytomegalovirus (CMV) excretion. Women exposed to such children have an increased risk of acquiring CMV infection, and primary infection places the offspring of such women at risk of congenital CMV infection. We studied family child care homes to determine if this child care alternative might represent a safe haven from CMV. METHODS: One hundred thirty-two women providing care in their homes were studied using a latex agglutination method to determine the rate of CMV seropositivity at baseline. Women who were seronegative for CMV were then sampled prospectively at 6-month intervals between March 1991 and August 1994 to determine the annual rate of CMV acquisition. A point prevalence of CMV excretion in family homes was determined by sampling 106 children from 25 randomly selected homes. Cytomegalovirus isolates were compared by molecular analysis using polymerase chain reaction-based methods to identify transmission. RESULTS: At baseline, 57.6% of the 132 providers were seropositive for CMV. Seropositive providers were more likely to be caring for toddlers (aged 1-2 years) (67% vs 46%; P=.02) and had worked in child care somewhat longer (median of 28.5 vs 21.5 months; P=.11). Using stepwise logistic regression, the strongest predictors of seropositivity at baseline were caring for children aged 1 to 2 years (odds ratio [OR] =2.37; P=.02) and number of months as a child care provider (OR= 1.17 for an increase of 24 months as provider; P=.08). Six or more years as a provider was highly associated with seropositivity (OR=3.27; P=.02). During follow-up, 5 of 51 seronegative providers seroconverted, yielding an annual infection rate of 6.8%. The point prevalence survey of children from the 25 homes (14 had seropositive providers) identified 8 CMV-excreting children. Three children in 1 home had indistinguishable isolates by polymerase chain reaction mapping. The provider seroconverted and excreted an isolate with a molecular profile indistinguishable from that of the children. CONCLUSIONS: The prevalence of CMV excretion is low among children attending child care homes (8% vs 15% in prior studies of child care centers; P=.07), and only 1 (20%) in 5 of the homes had CMV-excreting children. However, the overall CMV seroconversion rate of home child care providers was comparable to the rate observed among providers in child care centers. Families who use family home child care as an alternative to large child care centers are exposed to a low and unpredictable risk of CMV infection.

Adult↗
PubMed1999

A comparison of biomarkers of ozone exposure in human plasma, nasal lavage, and sputum.

We examined ozone-induced upper and lower airway inflammatory responses and the concentrations of hydroxylated salicylate metabolites using nasal lavage fluid and induced sputum, in order to identify noninvasive and sensitive biomarkers for ozone exposure and effects. A time course for plasma concentration of 2, 3-dihydroxybenzoic acid (2,3-DHBA, a salicylate metabolite and an indicator for hydroxyl radical) in response to 0.12 ppm ozone was also studied. Healthy, young, nonsmoking volunteers were given acetylsalicylic acid (ASA, 975 mg) or placebo orally. Subjects were exposed to ozone (0.12 or 0.4 ppm) or filtered air in an environmental chamber for 2 h, while performing intermittent exercise. Blood was collected hourly over a 4-h period. After exposure, nasal lavage fluid was collected, and sputum was induced using hypertonic saline. Results show that in sputum the percentage of neutrophils was significantly higher after the subjects were exposed to 0.4 ppm ozone (p<.05) than after they were exposed to filtered air or 0.12 ppm ozone. The absolute number and the percentage of macrophages were significantly lower at 0.4 ppm ozone than for filtered air control or 0.12 ppm ozone. The percentage of lymphocytes in sputum was also significantly lower at 0.4 ppm ozone than for filtered air control or 0.12 ppm ozone. The sputum cellular responses to ozone were not significantly altered by ASA treatment. In nasal lavage, cell counts and differentials did not change significantly after exposure to ozone in comparison to filtered air control. The cellular data indicate an acute inflammation developed during ozone exposure in the lower respiratory tract. The concentrations of total protein and interleukin-8 and the activity of N-acetyl-beta-D-glucosaminidase (a lysosomal enzyme) in nasal lavage and sputum did not change significantly following exposure to ozone in comparison to filtered air control. Plasma 2,3-DHBA concentration increased significantly following exposure to 0.12 ppm ozone in an exposure-dependent temporal pattern. Salicylate metabolites in nasal lavage fluid and sputum did not increase significantly following exposure to ozone. There was a marked variation of 2,3-DHBA concentrations in airway fluids. Data suggest that plasma 2,3-DHBA is a sensitive marker indicating acute ozone exposure, even at an ozone concentration that causes minimal observable airway effects in healthy subjects.

Adolescent↗
PubMed1999

Reproducibility of measures of overuse of cataract surgery by three physician panels.

BACKGROUND: Assess the reproducibility of methods to measure overuse of cataract surgery. OBJECTIVES: The objectives of this study are: (1) To determine the extent of agreement about clinical scenarios among, between, and within three physician panels; (2) to apply ratings of clinical scenarios from three panels to actual surgeries; and (3) to assess reproducibility of rates of appropriate use and overuse. METHODS: Three physician panels scored 2,894 clinical scenarios for the appropriate use of cataract surgery. One thousand and twenty charts were abstracted and assigned to the clinical scenario that best corresponded to the patient's clinical situation. Two hundred and fifty nine clinical scenarios were required to assign the cases. Weighted kappa values, confidence intervals, and percentages of agreement were used to measure agreement among, between, and within panels. RESULTS: The all ophthalmologist panel (OP) and the convened multispecialty panel (CM) each rate 92% of the cases as appropriate use, compared with 70% by the mail-in multispecialty panel (MM). The MM have higher uncertain (26% vs. 8% and 7%) and higher inappropriate use (3.5% vs. 0.1% and 1.9%). For the clinical scenarios, the CM and the MM have similar percentages of overuse (6.6%, 7.3%), in contrast to the OP (0.4%). The weighted kappa value for the overall level of agreement about the clinical scenarios among the three panels is 0.53, consistent with moderate agreement. CONCLUSIONS: Study results demonstrate reproducibility for assessment of appropriate use of surgery between the OP and CM. However, both multispecialty panels rate more clinical scenarios as inappropriate use than the ophthalmologist panel. Thus, reproducibility between the CM and the OP may be attributable to the low percentage of overuse of cataract surgery in the study population. The overall level of agreement about the clinical scenarios among the panels is moderate.

Aged↗
PubMed1998

Epidemiology of congenital cytomegalovirus infection: maternal risk factors and molecular analysis of cytomegalovirus strains.

To determine factors that influence the occurrence of congenital cytomegalovirus (CMV) infection, the authors surveyed prospectively 8,254 infants born in eastern Iowa between October 1989 and June 1994. The authors conducted a case-control study to identify maternal risk factors, matching each CMV-infected infant with three uninfected infants according to hospital and date of birth. CMV strains were compared by using the polymerase chain reaction (PCR) to identify common sources of infection. Of the 7,229 infants cultured successfully for CMV, 35 (0.48%) were congenitally infected. Mothers of CMV-infected infants were more likely to be single (odds ratio (OR) = 3.05, p = 0.016), to work in sales (OR = 4.93, p = 0.008), or to be students (OR = 5.01, p = 0.017). Conversely, women who worked in health-care professions were less likely to have a congenitally infected infant (OR = 0.14, p = 0.049). PCR analysis indicated 27 distinct strains of CMV, but two groups of infants (two infants per group) excreted strains with indistinguishable molecular patterns. One of these pairs of infants had older siblings who attended the same child-care center during their mothers' pregnancies. The authors concluded that demographic and occupational factors influenced the risk of giving birth to an infant with congenital CMV infection. Many distinct CMV strains were identified, suggesting that major point source outbreaks had not occurred. Nonetheless, point source acquisition of CMV from child-care environments did account for some cases of congenital CMV infection in eastern Iowa.

Adult↗