PubMed Health⌕ Search

Biomedical subjects

C M Parenti

Publications and source records attributed to C M Parenti.

At least 19 recordsLinked to original sources
PubMed2000

Withdrawal of chronic systemic corticosteroids in patients with COPD: a randomized trial.

The benefits of chronic systemic corticosteroids for patients with chronic obstructive pulmonary disease (COPD) are not well established. To determine whether chronic corticosteroid treatment can be safely withdrawn in "steroid-dependent""COPD patients, we performed a double-blind, placebo-controlled study of 38 patients with steroid-dependent COPD. Patients were randomly assigned to receive their usual maintenance prednisone dose for 6 mo (continuous group) or to be withdrawn from prednisone at a rate of 5 mg per week (demand group). The number of COPD exacerbations per patient (primary outcome) was 2.5 +/- 2.7 (mean +/- SD) in the continuous group and 2.7 +/- 2.5 in the demand group (p = 0.60, 95% confidence interval for the difference: -1.1 to 1.7). Spirometric results, dyspnea, and health-related quality of life did not differ significantly in the two groups. The average daily corticosteroid dose was 10.7 +/- 5.2 mg in the continuous group and 6.3 +/- 6.4 mg in the demand group (p = 0.003). Weight decreased in the demand group by 4.8 +/- 2.0 kg, compared with an increase in the continuous group of 0.5 +/- 3.5 kg (p = 0.007). Discontinuation of chronic systemic corticosteroid treatment in steroid-dependent COPD patients did not cause a significant increase in COPD exacerbations, but did reduce total systemic corticosteroid use and body weight. Larger studies may be warranted to establish the relative risks and benefits of chronic corticosteroid treatment of patients with COPD.

Aged↗
PubMed1999

Physician risk assessment and APACHE scores in cardiac care units.

BACKGROUND: The need to correct outcome data for case mix is well recognized, but risk assessment for coronary care unit (CCU) patients remains problematic. HYPOTHESIS: This study determined the feasibility of using physicians' opinions to predict mortality for CCU patients and compared their results to Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. METHODS: A prospective observational study was performed on consecutive patients admitted to a university-affiliated Veterans Affairs Medical Center CCU over a 2-month period. Physician assessment of likely mortality during hospitalization, obtained using an MD Prognosis Score ranging from 1 (best) to 7 (worst), was compared with APACHE II scores. RESULTS: MD Prognosis Scores were obtained on 122 of the 237 eligible patients (51% response rate) and averaged 2.3 +/- 1.4 (mean +/- standard deviation). APACHE II scores on these patients averaged 9.9 +/- 4.8 (range 2-29) with very poor correlation between the two methods (r = 0.3). Of the four patients who died, three had MD prognosis scores of 7. None of the survivors had scores of 7 and only three had scores of 6. APACHE II did not predict a high likelihood that any of the patients would die (none with > 90% likelihood of mortality). CONCLUSIONS: APACHE scores are inadequate for cardiac patients. Although physicians can identify CCU patients most likely to die, reliance on physician scoring systems is limited by difficulties in obtaining their opinion. A new method of risk assessment for acutely ill cardiac patients is needed if CCU outcomes are to be compared across institutions.

APACHE↗
PubMed1995

The kaleidoscope of general internist careers: a challenge for internal medicine training.

As internal medicine residency programs struggle to produce general internists in greater numbers and assure that they are adequately prepared for practice, it is imperative that the graduate medical education system have a clear picture of what competencies will be expected of those entering general internist careers. Feedback from the practicing community and large managed care organizations in Minnesota has made it clear that general internists in that state are functioning in a variety of positions requiring a wide range of skills depending on the practice description, choice of practice setting, and the complement of other primary care providers. General internists functioning in nontraditional careers have special curricular needs. It is imperative that training programs constantly monitor the changing practice environment and stay current on the variety of new generalist career choices to adequately prepare their residents for generalist careers. The graduate medical education enterprise needs to be involved in determining the best teaching strategies for the broad range of ambulatory general medicine competencies and in determining how best to preserve the richness of the medical subspecialty experience critical to the training of excellent general internists.

Career Choice↗
PubMed1995

Training internal medicine residents in the community: the Minnesota experience.

The University of Minnesota Internal Medicine Residency Program has developed ambulatory general medicine rotations in rural community settings and urban managed care settings in Minnesota. Based on what had been learned from community focus groups, from discussions with residents about what they perceived to be training holes in the traditional curriculum, and from resident evaluations of pilot rotations, an educational framework for the rotations was established. The authors describe the process of developing these rotations, their educational rationale and objectives, the structure of the rotations, teaching strategies, faculty development, and the evaluation system, and outline the important elements of the successful implementation of these new rotations. The community practice setting has offered a unique, important, and previously untapped resource for residency training, and the community rotations have been highly valued both by housestaff and by community preceptors. As residency programs begin to offer more community-based ambulatory care opportunities for their trainees, the impact of this trend on quality of training, residents' career choices, and patient outcomes will need to be evaluated.

Ambulatory Care↗
PubMed1994

Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project.

BACKGROUND: We had previously observed that a large proportion of peripheral intravenous (i.v.) catheters placed in patients on a regular medical ward at our hospital were unnecessary. We conducted the current study to assess the effect of a quality improvement project led by medicine house staff on the prevalence of unnecessary peripheral i.v. catheters (those without any therapeutic use, referred to as idle). METHODS: All patients on four regular-care medical wards of a large university-affiliated veterans hospital were included in the study. The proportion of i.v. catheter episodes in which catheters were idle 2 or more consecutive days (idle episodes) and the proportion of patients exposed to an idle catheter episode were determined by direct observation, chart review, and patient interview before and after a multidisciplinary quality improvement task force defined guidelines for appropriate i.v. catheter use and made recommendations for hospital policy changes related to i.v. catheter use. RESULTS: The proportion of all i.v. catheter episodes that were idle catheter episodes decreased significantly after the intervention (42% before vs 29% after, P < .01), as did the proportion of patients with an i.v. catheter who had at least one idle i.v. catheter episode (43% vs 27%, P < .001). CONCLUSIONS: This quality improvement effort successfully reduced unnecessary i.v. catheter use. We suspect that house-staff involvement in the intervention was critical. We encourage other academic medical centers to involve house staff in quality improvement activities to improve patient care and to enhance the education of house staff regarding quality improvement processes.

Catheterization, Peripheral↗
PubMed1994

Prescription drug costs as a reason for changing physicians.

The authors conducted a telephone survey of 200 patients who had recently transferred their health care to a Veterans Affairs (VA) medical center. Of the study patients, 56% considered prescription drug costs to be the main reason or a major contributing reason for transfer (95% confidence interval 49% to 63%). The mean out-of-pocket prescription drug cost for these patients was $139 per month, compared with $47 per month for patients for whom drug costs were a minor reason or not a reason at all (p < 0.001). Drug costs are a principal reason for patients to transfer their health care to the VA.

Aged↗
PubMed1994

Ruptured abdominal aortic aneurysm: the internist as diagnostician.

PURPOSE: To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. PATIENTS: All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD: Chart review. RESULTS: We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS: In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.

Aged↗
PubMed1993

High yield of chest radiography in walk-in clinic patients with chest symptoms.

PURPOSE: To assess the yield of chest radiography among a group of symptomatic adults presenting to a walk-in clinic. PATIENTS AND METHODS: Outpatients presenting to a walk-in clinic for evaluation of cough, shortness of breath, or pleuritic chest pain were interviewed by nurses who recorded clinical data pertaining to the present illness and past medical history. Chest radiographs were then obtained prior to physician evaluation. RESULTS: A total of 221 patients were enrolled in the study; 97% were men and the mean age was 62 (+/- 10.3) years. New clinically important radiographic abnormalities, defined as those necessitating acute intervention and/or follow-up evaluation, were identified for 77 (34.8%) of the 221 patients studied. Abnormalities included 39 (17.6%) cases of infiltrates, 23 (10.4%) cases of nodules or mass lesions, and 19 (8.6%) cases of cardiomegaly or congestive heart failure. Evaluation of clinical data obtained during the triage interview revealed no statistically significant difference between those patients with and those without new radiographic abnormalities on their chest x-rays. CONCLUSION: Adult patients similar to those described in this study who present to a walk-in clinic with a chief complaint of cough, dyspnea, or pleuritic chest pain have a high likelihood of having new clinically important abnormalities found on their chest radiographs. Since patient characteristics did not predict which patients were more likely to have abnormal findings, the practice of obtaining chest radiographs for such individuals at the time of triage and prior to physician evaluation appears justified.

Cardiomegaly↗
PubMed1993

Effects of a night float system on housestaff neuropsychologic function.

To examine the effect of a night float call system (NFS), a battery of neuropsychologic tests was administered to housestaff after call during an overnight call system (ONCS), and the results were compared with the results obtained during a NFS. Although NFS housestaff were less sleep-deprived, results of tests of psychomotor function were not different. Importantly, both groups had high depression, hostility, and anxiety scores. NFS housestaff had small but significantly lower depression scores, which, if not due to time of year, may represent a positive effect of the NFS. Future investigation should be directed at clarifying the aspects of residency training that adversely affect housestaff mood.

Adult↗
PubMed1993

Changing the fourth-year medicine clerkship structure: a successful model for a teaching service without housestaff.

The fourth-year medicine clerkship was restructured at one of four sites. Teams consisting of one attending physician and three students cared for eight new patients per week. The overall experience of the restructured clerkship was rated significantly more positively than the experiences at all other sites and the teaching effectiveness of the faculty more positively than those at two of the other sites. This clerkship structure was perceived by students to be a positive experience. It could serve as a model for housestaff training programs to successfully care for patients without housestaff.

Clinical Clerkship↗
PubMed1993

A process for identifying marginal performers among students in a clerkship.

PURPOSE: To evaluate a review process for identifying marginal performers among students in a clerkship. METHOD: To better identify the marginal performers among the students participating in the medicine clerkship at the University of Minnesota Medical School--Minneapolis, the Medicine Clerkship Committee reviewed in 1990-91 and 1991-92 all students rated by faculty or housestaff as below expectations for any of nine areas of clinical performance (27 students of 890, 3%). (In the past, a student was considered to be a marginal performer only if he or she was assigned an unsatisfactory numerical grade, calculated from the nine ratings, or if written comments by housestaff and faculty and the opinions of the attending faculty and clerkship site coordinator indicated that the student should fail.) Chi-square analysis was used to compare the number of students judged to be marginal performers under the review process with the number of marginal performers in 1988-89 and 1989-90. The two groups were also compared based on their preclerkship performances on standardized examinations. RESULTS: Ten of those reviewed (37%) were judged to have performed marginally. Although the study group's performance on standardized examinations was not different from that of students during the previous two years, significantly fewer students were identified as marginal performers before the review process began than afterwards (2 of 867, 0.2%, versus 10 of 890, 1.1%, p < .05). CONCLUSION: Without changing the way in which faculty and housestaff evaluated students, the review process improved the medicine clerkship evaluation system by identifying significantly more students who were marginal performers.

Achievement↗
PubMed1992

The idle intravenous catheter.

OBJECTIVE: To assess the prevalence of idle peripheral intravenous (IV) catheters (those without any therapeutic use) on regular-care medical wards. DESIGN: Observation, interviews, and chart review. SETTING: A university-affiliated VA medical center. PATIENTS: All 959 inpatients on 4 regular-care medical wards during a 6-week period, including 484 IV catheter episodes and 2983 patient-days of IV catheter use. MAIN OUTCOME MEASURE: Idle IV catheter use. RESULTS: Thirty-five percent of all IV catheter episodes (95% CI, 32% to 38%) had 2 or more consecutive idle days. In only 6 of these (1%) could a specific reason for the catheter be determined. Seventeen percent of all patients on regular-care medical wards (CI, 15% to 19%) had an idle IV catheter for 2 or more consecutive days. Twenty percent of all patient-days of IV catheter use were idle (CI, 19% to 21%). CONCLUSIONS: Our data suggest that IV are frequently used unnecessarily. Future efforts to reduce IV catheter complication rates should focus on reducing unnecessary use as well as on improving techniques to reduce infection rates when use is appropriate.

Catheterization, Peripheral↗
PubMed1992

Faculty evaluation of student performance: a step toward improving the process.

Most clerkship evaluation systems give the greatest evaluative weight in deriving grades to some form of evaluation by faculty and housestaff, although few studies have been reported concerning which elements of performance are most important or which discriminate best. The results of this study show that a select group of faculty, heavily involved with assessment of student performance, agreed that certain aspects of performance were more important and/or discriminated better between average and superior medicine clerks. We suggest that those aspects of performance be given more consideration when designing curricula, providing student feedback, and assigning grades for medicine clerkships and that medical educators engage faculty and housestaff in the formal discussion of issues surrounding evaluation.

Clinical Clerkship↗
PubMed1991

High prevalence of positive antibodies to Legionella pneumophila among outpatients.

A serologic survey of antibodies to Legionella pneumophila serogroups 1 through 6 was performed to assess the prevalence of positive antibody titers among outpatients and to evaluate the association between elevated antibody titers and previously identified risk factors for legionellosis. Subjects were recruited from outpatient clinics at the Minneapolis VA Medical Center. Each participant completed a self-administered questionnaire which asked about their general health and any recent symptoms of illness. Medical records were also audited for all participants to provide additional information on medical history and known risk factors for Legionella infection. Single samples of serum were obtained from each subject, and antibody titers to L pneumophila serogroups 1 through 6 were assayed. Three hundred ninety-six subjects were enrolled in the study. They had a mean age of 67 years, and 98 percent were male subjects. Overall, 36 percent of the subjects had positive antibody titers (greater than or equal to 1:128) to L pneumophila. There were no differences between those with and without elevated titers with respect to recent systemic symptoms or other previously established risk factors for legionellosis. We conclude that positive anti-Legionella antibodies are a frequent occurrence among these outpatients. This has important implications for the interpretation of single or static antibody titers from patients who are acutely ill.

Aged↗
PubMed1991

Effect of a change in house staff work schedule on resource utilization and patient care.

Concern is frequently expressed by health care providers and consumers that the work environment of physicians-in-training may adversely affect their performance. This article documents the effects of changing from a traditional rotational overnight call schedule for house staff to a schedule designed to reduce sleep deprivation, distribute admissions more evenly throughout the week, and improve continuity of inpatient care on the internal medicine service of a large, university-affiliated Veterans Affairs Medical Center. In a prospective, time-series study, the hypothesis that this change would improve the efficiency and quality of medical care was evaluated by comparing the hospital course of the patients admitted during 4-week periods prior to and following the change in work schedule. The patients in the preintervention group do not differ significantly from those in the postintervention group in any identifiable clinical characteristics. The length of stay was shorter (10.9 vs 9.3 days) and the number of laboratory tests ordered per patient was smaller (24.0 vs 19.0) for patients cared for under the new work schedule compared with those cared for under the traditional work schedule. Resident physicians also committed fewer medication errors under the new work schedule (16.9 vs 12.0 per 100 patients discharged). We conclude that altering the house staff work schedule affects patient care and can lead to a decrease in utilization of health care resources.

Continuity of Patient Care↗
PubMed1989

Long-term pulmonary sequelae after Legionella pneumophila infection in the hamster.

It has been reported that infections with Legionella pneumophila can lead to chronic inflammatory and fibrotic reactions in the human lung. To better characterize the nature of the residual abnormalities caused by this bacterium, we inoculated Syrian hamsters intratracheally with 10(8) serotype 1 L. pneumophila organisms and assessed histologic, functional, and biochemical changes at intervals up to 180 days. Acutely, L. pneumophila caused an intense alveolar macrophage (AM) and polymorphonuclear leukocyte (PMN) response within the lower air spaces, air-filled lungs were noncompliant, and there was an associated 25 to 50% increase in the lung content of collagen and elastin after 10 days. An inflammatory response, consisting principally of AM and centered around the terminal bronchioles, was still prominent in some infected lungs after 90 and 180 days, and the severity of the inflammation was correlated with a persistent restrictive defect in the elastic behavior of the lung. However, by histologic examination, fibrosis was not prominent, and the more representative abnormality was one of mild, diffuse air-space enlargement. Frank emphysematous changes were present focally in some lungs. In addition, an irregularly distributed lymphocytic infiltrate and goblet cell metaplasia were present in the larger bronchi of infected animals. We conclude that a single infection with L. pneumophila is capable of causing long-term inflammatory reactions in the lung, with morphologic features of both fibrosis and emphysema.

Animals↗
PubMed1989

Bronchoscopy to evaluate hemoptysis in older men with nonsuspicious chest roentgenograms.

Six of 106 older men with hemoptysis and a nonsuspicious chest roentgenogram who underwent fiberoptic bronchoscopy were found to have cancer. Four of the five bronchogenic carcinomas appeared to be surgically resectable. Cancer patients were significantly older, had smoked within the last five years, and had a significantly higher frequency of central abnormalities on chest roentgenogram. Six additional bronchogenic carcinomas were diagnosed at follow-up. Two of these were probably present but not detected at the time of bronchoscopy. We conclude that (1) hemoptysis with a nonsuspicious chest roentgenogram carries an appreciable risk of cancer in older men with substantial smoking histories, (2) these cancers are often resectable, (3) a chest roentgenogram in which the central lung fields are obscured in any way should not be considered negative in patients with hemoptysis, and (4) a negative bronchoscopic examination does not exclude the possibility of cancer in these patients.

Aged↗