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Biomedical subjects

D J Marriott

Publications and source records attributed to D J Marriott.

At least 19 recordsLinked to original sources
PubMed1998

Behaviors predicting foot lesions in patients with non-insulin-dependent diabetes mellitus.

Associations between specific foot-care behaviors and foot lesions in patients with non-insulin-dependent diabetes mellitus were prospectively investigated. Data from a randomized controlled trial for preventing diabetic foot lesions were analyzed as a prospective cohort using logistic regression. Independent variables included foot-care behaviors, patient self-foot examination, going barefoot, availability of foot-care assistance, and visits to health-care providers. The dependent variable was a foot wound on each foot at follow-up. In the final multivariate model, patients who rarely lubricated their feet had an increased risk of foot lesions. Increasing patient use of emollients may be key to preventing foot lesions.

Diabetes Mellitus, Type 2↗
PubMed1998

Chronic cough in patients with HIV infection.

We retrospectively studied the clinical spectrum, course and outcome of 26 patients with HIV infection and chronic cough. All except 2 were homo-/bisexual males. 22 (85%) had AIDS. They had cough for a mean of 75 d with sputum production (88%) and dyspnoea (77%) being the commonest associated symptoms. Sputum examination and chest X-ray were useful initial investigations. CT scan of the chest and sinuses had a high rate of abnormal results for selected patients (89-100%). Cause of cough was found in 21 patients (81%): bronchopulmonary infections (17), Kaposi's sarcoma (5) and sinus infections (3). Patients with sinopulmonary infections tended to have longer duration of cough. Overall, 4 patients (15%) had significant improvement in the illness with cough during the study period. Four patients with bronchopulmonary infections died. We concluded that chronic cough is a heterogeneous clinical problem in advanced HIV-infected patients, most commonly caused by an infective process. Extrapulmonary disease, such as sinusitis, has to be considered and investigated. The clinical course and outcome is unfavourable for most of the patients.

Chronic Disease↗
PubMed1998

Beneficial and harmful effects of augmented feedback on physicians' clinical-teaching performances.

PURPOSE: To evaluate whether clinical-teaching skills could be improved by providing teachers with augmented student feedback. METHOD: A randomized, controlled trial in 1994 included 42 attending physicians and 39 residents from the Department of Medicine at the Indiana University School of Medicine who taught 110 students on medicine ward rotations for one-month periods. Before teaching rotations, intervention group teachers received norm-referenced, graphic summaries of their teaching performances as rated by students. At mid-month, intervention group teachers received students' ratings augmented by individualized teaching-effectiveness guidelines based on the Stanford Faculty Development Program framework. Linear models were used to analyze the students' mean ratings of teaching behaviors at mid-month and end-of-month. Independent variables included performance ratings, intervention status, teacher status, teaching experience, and interactions with baseline ratings. RESULTS: Complex interactions with baseline performance were found for most teaching categories at mid-month and end-of-month. The intervention-group teachers who had high baseline performance scores had higher student ratings than did the control group teachers with similar baseline scores; the intervention group teachers who had low baseline performance scores were rated lower than were the control group teachers with comparable baseline scores. The residents who had medium or high baseline scores were rated higher than were the attending physicians with comparable baseline scores; the performance of the residents who had low baseline scores was similar to that of the attending physicians with comparable baseline scores. CONCLUSION: Baseline performance is important for targeting those teachers most likely to benefit from augmented student feedback. Potential deterioration in teaching performance warrants a reconsideration of distributing students' ratings to teachers with low baseline performance scores.

Clinical Clerkship↗
PubMed1998

Factorial validation of a widely disseminated educational framework for evaluating clinical teachers.

PURPOSE: To examine an instrument for evaluating clinical teaching using factor analysis and to refine the validated instrument to a practical length. METHOD: Factor analysis on a split sample of 1,581 student evaluations rating 178 teachers. The instrument was based on the seven-category Stanford Faculty Development Program's (SFDP's) clinical teaching framework and contained 58 Likert-scaled items, with at least seven items per category plus five items measuring "teacher's knowledge." Standard methodology for survey item reduction was used to remove items with low or complex factor loadings and iteratively remove items with low item-scale correlation. Results were replicated on the second sample. RESULTS: The seven original categories emerged and items originally categorized under "knowledge" statistically combined with "promoting self-directed learning." Over 73% of the variance was explained. Item reduction resulted in 25 items with overall internal consistency over .97 and internal consistency of constructs ranging from .82 to .95. CONCLUSIONS: Factor analysis of student ratings validated the seven-category SFDP framework. An abbreviated instrument to measure the seven categories is described. Results suggest that students may not systematically distinguish between their teachers' knowledge and their teachers' ability to promote self-directed learning, an important finding for both administrators and faculty development programs.

Adult↗
PubMed1997

Scytalidium dimidiatum and Lecythophora hoffmannii: unusual causes of fungal infections in a patient with AIDS.

Immunocompromised patients are susceptible to infections by fungi that seldom cause disease in humans. We describe a human immunodeficiency virus-infected patient who had simultaneous infections with two fungi which are rare causes of serious infection: Lecythophora hoffmannii, causing chronic sinusitis, and Scytalidium dimidiatum, causing skin lesions, lymphangitis, and lymphadenitis. The clinical and pathologic findings are discussed.

AIDS-Related Opportunistic Infections↗
PubMed1997

Stroke patients' knowledge of stroke. Influence on time to presentation.

BACKGROUND AND PURPOSE: New treatments for acute stroke will likely have to be given soon after stroke onset. Little is known about stroke patients' general knowledge about stroke, their interpretation of stroke symptoms, and how these factors influence the timing of their decision to seek medical attention. METHODS: We interviewed consecutive stroke patients within 72 hours of stroke onset to define factors influencing time of arrival to the emergency department. Data recorded included demographic information, method of transportation, type of stroke symptoms, the patient's interpretation of the symptoms, previous stroke, and knowledge of stroke warning signs. Stroke severity was measured with the Barthel Index. Early arrival was defined as within 3 hours of awareness of symptoms. RESULTS: Sixty-seven patients were interviewed; 96% had an ischemic stroke and 4% a cerebral hemorrhage. Although 38% of patients professed to know the warning signs of stroke, only 25% correctly interpreted their symptoms. Patients with prior stroke were more likely to correctly interpret their symptoms (45% versus 16%; P = .03) but were not more likely to present early (19% versus 39%; P = .35). Eighty-six percent of patients presenting more than 3 hours after stroke onset thought that their symptoms were not serious. The 24% (n = 16) of early arrivals were more likely to arrive by ambulance (81% versus 38%; P = .003) and had more severe stroke (Barthel Index score of 49 versus 72; P = .01) than late arrivals. Arrival by ambulance was independently associated with early arrival (odds ratio, 5.55; 95% confidence interval, 1.37 to 22.6). CONCLUSIONS: Approximately one quarter of stroke patients correctly interpret their symptoms as representing a stroke. This knowledge is not associated with early presentation to the emergency department. Ambulance transport is independently associated with early arrival at the emergency department. Even when patients know that they are having a stroke, most present late because they perceive their symptoms as "not serious." Widespread public education of stroke-prone individuals may increase the proportion of patients eligible for new acute stroke treatments.

Aged↗
PubMed1997

The role of footwear in the prevention of foot lesions in patients with NIDDM. Conventional wisdom or evidence-based practice?

OBJECTIVE: To conduct a prospective evaluation of footwear characteristics as predictors of diabetic foot wounds. RESEARCH DESIGN AND METHODS: A total of 352 patients with NIDDM enrolled in a randomized controlled trial aimed at preventing diabetic foot lesions in an academic general medicine practice were studied. Foot wounds (n = 63) were modeled univariately and multivariably using generalized estimating equations. The dependent variable was a wound classified as a 1.2 or greater according to the Seattle Wound Classification System, indicating at least a superficial or healing minor lesion with no functional interruption of the protective cutaneous barrier. Independent variables included detailed measures of style and material of patients' indoor and outdoor shoes, appropriate length and width, sock fibers, whether the patient had bought new shoes in the past 6 months, and if the patient had been recommended for special shoes. Modeling controlled for intervention status and physiological measures (baseline wound, monofilament abnormalities, and serum HDL level). RESULTS: Initial screening (P < 0.20) suggested that a recommendation for special shoes, shoe length, and shoe width were indicative of wounds at follow-up (odds ratios [ORs] 2.19, 1.84, 1.86, respectively), while having bought shoes in the past 6 months was associated with no wound at follow-up (OR 0.60). The final multivariable model included only the recommendation for special shoes (OR 2.19; 95% CI 1.07-4.49). CONCLUSIONS: Many variables commonly cited as protective measures in footwear for diabetic patients were not prospectively predictive when controlling for physiological risk factors. Rigorous analyses are needed to examine the many assumptions regarding footwear recommendations for diabetic patients.

Aged↗
PubMed1997

Independent physiological predictors of foot lesions in patients with NIDDM.

OBJECTIVE: To identify and quantify independent physiological risk factors for foot lesions in diabetic patients. RESEARCH DESIGN AND METHODS: There were 352 patients enrolled in a 1-year randomized controlled trial aimed at reducing risks for lower-extremity pathology through patient education and system interventions. Inclusion criteria were as follows: being age 40 years or over, being at or above ideal body weight, and having been diagnosed with NIDDM. Participants were predominantly African-American (76%), elderly (mean 60 years of age), indigent (77% with annual income < +10,000), or women (81%) who had diabetes for 10 years. Prospective multivariate modeling used baseline clinical signs (e.g., blood pressure, dermatological characteristics, and neuropathic measures) and laboratory values (e.g., lipid profiles and measures of glycemic control) to predict foot lesions rated using the Seattle Wound Classification. RESULTS: When controlling for intervention effects, only measures of neuropathy (monofilament testing [odds ratio ¿OR¿ 2.75, 95% CI 1.55-4.88] and thermal sensitivity testing [2.18, 1.13-4.21]) predicted wounds classified 1.2 (minor injury), but investigation of wounds rated at least 1.3 (nonulcerated lesions) indicated baseline wounds (13.41), 3.19-56.26), monofilament abnormalities (5.23, 2.26-12.13), and low HDL (1.63, 1.11-2.39) as predictors. Although fungal dermatitis, dry cracked skin, edema, ingrown nails, microalbuminuria, fasting blood glucose, and hemoglobin A1c were candidates for one or both of the multivariable models (P < 0.3), they were not significant multivariate predictors. CONCLUSIONS: Lesions may be preventable with aggressive screening for peripheral neuropathy and abnormal lipids. Also, these results provide empirical support for the commonly held belief that foot lesions prospectively predict future wounds.

Adult↗
PubMed1996

Development and ultrastructure of Trachipleistophora hominis n.g., n.sp. after in vitro isolation from an AIDS patient and inoculation into athymic mice.

Continuous culture was achieved in several cell lines of a microsporidium obtained from the skeletal muscle of an AIDS patient. Development in COS-1 and RK13 cells was prolific. Spores from the original biopsy were also inoculated into athymic mice by i.m. and i.p. routes. Infection was found in several organs as well as in skeletal muscle after a few weeks. All stages were surrounded by an electron-dense surface coat. Meronts had 2-4 nuclei and divided by binary fission. In sporogony the surface coat became separated from the plasma membrane to form a sporophorous vesicle, within which division into sporoblasts was effected by repeated binary fissions. The number of sporoblasts (and later spores) within the sporophorous vesicles varied from 2 to > 32 and the sizes of the vesicles varied, according to the number of spores contained therein, from 5 microns diameter to 14.0 x 11.0 microns. Spores measured 4.0 x 2.4 microns and had a prominent posterior vacuole. The parasite differs from the genus Pleistophora in that it does not form multinucleate sporogonial plasmodia and that the sporophorous vesicle enlarges during sporogony and its wall is not a multilayered structure. It is proposed to place it in a new genus and species Trachipleistophora hominis n.g., n.sp.

AIDS-Related Opportunistic Infections↗
PubMed1996

Nosocomial outbreak of tuberculosis in an outpatient HIV treatment room.

OBJECTIVE: To investigate a possible outbreak of tuberculosis in an outpatient HIV treatment facility in Sydney, Australia. DESIGN: Following the diagnosis of pulmonary tuberculosis in an attendee, a prospective screening program was instituted to investigate the potential outbreak. METHODS: Screening of 89 potentially exposed patients included chest radiographs (n = 89), and sputum examination (n = 37) over a period of 23 weeks. RESULTS: No cases of tuberculosis were detected by the screening program. However, three (3.4%) of this cohort developed pulmonary tuberculosis between 8 and 10 weeks following diagnosis of the index case. The incidence of active tuberculosis during the following-up period (median, 7.4 months) was 5.3 per 100 person years and represents the lower limit of possible tuberculous infection, as both latent infection, and undiagnosed tuberculosis among those who died could not be excluded. Mycobacterium tuberculosis strains isolated from the index case and three subsequent cases were found to be identical by DNA typing. CONCLUSION: Nosocomial transmission of tuberculosis in an outpatient treatment setting has been demonstrated. The risk of nosocomial transmission of tuberculosis is significant in institutions caring for HIV-infected patients even in countries with a low prevalence of tuberculosis infection, and highlights the importance of adherence to tuberculosis control guidelines.

AIDS-Related Opportunistic Infections↗
PubMed1996

Bile acid malabsorption in HIV infected patients with chronic diarrhoea.

AIMS: To look for the presence of bile acid malabsorption in HIV infected patients with chronic diarrhoea and determine whether bile sequestering agents may have a role in palliating this common problem. METHODS: Nineteen HIV infected patients with chronic diarrhoea (duration > one month) poorly controlled on conventional treatment were investigated using the seven day retention of 75seleno-23-homocholic acid taurine (SeHCAT) as a measure of bile acid loss from the enterohepatic circulation. Patients with evidence of bile acid malabsorption were offered cholestyramine. RESULTS: Sixteen (84%) had evidence of bile acid malabsorption (< 15% retention at seven days). Ten of the 16 patients with bile acid malabsorption had terminal ileal biopsies-six had ileitis and four normal histology, suggesting that malabsorption is not always related to terminal ileitis. Thirteen patients with bile acid malabsorption have been treated with cholestyramine and 11 have reported a symptomatic response. CONCLUSIONS: Bile acid malabsorption can be demonstrated in some cases of HIV associated chronic diarrhoea and we suggest a therapeutic trial of a bile sequestering agent in patients whose symptoms are not well controlled using conventional anti-diarrhoeal agents.

Adult↗
PubMed1996

Myositis associated with a newly described microsporidian, Trachipleistophora hominis, in a patient with AIDS.

Microsporidia are zoonotic protozoa which were rare human pathogens prior to 1985, when Enterocytozoon bieneusi was described in human immunodeficiency virus-infected patients with chronic diarrhea. Another species, Encephalitozoon (Septata) intestinalis, is associated with diarrhea and chronic sinusitis, and approximately 25 cases have been reported in the literature. However, other microsporidial infections in human immunodeficiency virus-infected patients remain extremely rare. We report the first case of a Pleistophora sp.-like microsporidian infection presenting as a progressive severe myosotis associated with fever and weight loss. The organism was demonstrated by light microscopy and electron microscopy in corneal scrapings, skeletal muscle, and nasal discharge. Electron microscopy showed an electron-dense surface coat with "sunflare"-like projections surrounding all stages of development of meronts (two to four nuclei, dividing by binary fission), sporonts, and sporoblasts. Division of sporonts, in which sporonts separate from the thick outer coat, creating a sporophorous vesicle, is by binary fission, differentiating this organism from Pleistophora sp. The spore measures 4.0 by 2.5 microns and has a rugose exospore. A new genus and species, Trachipleistophora hominis, has been established for this parasite. The patient was treated with albendazole, sulfadiazine, and pyrimethamine, and the clinical symptoms resolved.

AIDS-Related Opportunistic Infections↗
PubMed1995

Disseminated microsporidiosis due to Septata intestinalis in nine patients infected with the human immunodeficiency virus: response to therapy with albendazole.

Disseminated microsporidiosis due to the newly described species Septata intestinalis in nine patients infected with human immunodeficiency virus is described. All patients were male homosexuals; the mean age was 41 years (range, 35-58 years). They were all severely immunocompromised, with a mean CD4 lymphocyte count of 15/mm3 (range, 0-32/mm3). Infection by S. intestinalis was seen in duodenal biopsy specimens from all patients, and dissemination was demonstrated by the presence of microsporidial spores in urine (9 of 9 patients), sinonasal secretions and/or nasal mucosal biopsy specimens (6 of 6), and sputum (6 of 6). Seven patients were treated with albendazole (400 mg twice daily), resulting in significant dissipation or complete resolution of diarrhea for six patients and abatement of symptoms for the six patients with chronic rhinosinusitis. There was a parallel parasitological response, with clearance of S. intestinalis infection from almost all sites.

AIDS-Related Opportunistic Infections↗