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Biomedical subjects

D Thom

Publications and source records attributed to D Thom.

At least 19 recordsLinked to original sources
PubMed2001

Unsaid but not forgotten: patients' unvoiced desires in office visits.

OBJECTIVES: To examine patient, physician, and health care system characteristics associated with unvoiced desires for action, as well as the consequences of these unspoken requests. PATIENTS AND METHODS: Patient surveys were administered before, immediately after, and 2 weeks after outpatient visits in the practices of 45 family practice, internal medicine, and cardiology physicians working in a multispecialty group practice or group model health maintenance organization. Data were collected at the index visit from 909 patients, of whom 97.6% were surveyed 2 weeks after the outpatient visit. Before the visit, patients rated their trust in the physician, health concerns, and health status. After the visit, patients reported on various types of unexpressed desires and rated their visit satisfaction. At follow-up, patients rated their satisfaction, health concerns, and health status, and also described their postvisit health care use. Evaluations of the visit were also obtained from physicians. RESULTS: Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician. Patients with unvoiced desires evaluated the physician and visit less positively; these encounters were evaluated by physicians as requiring more effort. Holding an unvoiced desire was associated with less symptom improvement, but did not affect postvisit health care use. CONCLUSIONS: Patients' unvoiced needs affect patients' and physicians' visit evaluations and patients' subjective perceptions of improvement. Implications of these findings for clinical practice are examined.

Adult↗
PubMed2001

Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco.

BACKGROUND: We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP. METHODS: A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Network. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians. RESULTS: Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction. CONCLUSIONS: Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.

Adolescent↗
PubMed2001

When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust.

OBJECTIVE: Our goal was to identify physician and patient characteristics associated with patient-centered beliefs about the sharing of information and power, and to determine how these beliefs and the congruence of beliefs between patients and physicians affect patients' evaluations. STUDY DESIGN: Physicians completed a scale assessing their beliefs about sharing information and power, and provided demographic information. A sample of their patients filled out the same scale and made evaluations of their physicians before and after a target visit. POPULATION: Physicians and patients in a large multispecialty group practice and a group model health maintenance organization were included. Forty-five physicians in internal medicine, family practice, and cardiology participated, as well as 909 of their patients who had a significant concern. OUTCOMES MEASURED: Trust in the physician was measured previsit, and visit satisfaction and physician endorsement were measured immediately postvisit. RESULTS: Among patients, patient-centered beliefs (a preference for information and control) were associated with being women, white, younger, more educated, and having a higher income; among physicians these beliefs were unrelated to sex, ethnicity, or experience. The patients of patient-centered physicians were no more trusting or endorsing of their physicians, and they were not more satisfied with the target visit. However, patients whose beliefs were congruent with their physicians' beliefs were more likely to trust and endorse their physicians, even though they were not more satisfied with the target visit. CONCLUSIONS: The extent of congruence between physicians' and patients' beliefs plays an important role in determining how patients evaluate their physicians, although satisfaction with a specific visit and overall trust may be determined differently.

Adolescent↗
PubMed1998

Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type.

OBJECTIVES: Prevalence estimates for urinary incontinence among community-dwelling adults vary from 2 to 55%. A review of the literature was undertaken to investigate the degree to which differences in definitions of incontinence, age, and gender of the populations studied, response rates, measurement techniques, or location could explain differences in reported prevalences. DESIGN: A literature search was conducted to locate all studies published in English reporting the prevalence of urinary incontinence in a population-based sample of adults. MEASUREMENT: Information was abstracted for study size, response rate, type of survey, definition of urinary incontinence, and prevalence of incontinence by age group and gender. Prevalence by type of incontinence was also abstracted where available. Stratification was used to obtain prevalence estimates specific for age, gender, and frequency of incontinence. Data were examined for associations between prevalence and survey type, response rate, year, and location of survey. RESULTS: A total of 21 studies met inclusion criteria. Stratification of reported prevalence by frequency, gender, and age substantially reduced the variation in prevalence estimates. For older women, the estimated prevalence of urinary incontinence ranged from 17 to 55% (median = 35%, pooled mean = 34%), and for daily incontinence it ranged from 3 to 17% (median = 14%, pooled mean = 12%). For older men, incontinence prevalence was estimated to be 11 to 34% (median = 17%, pooled mean = 22%), and 2 to 11% reported daily incontinence (median = 4%, pooled mean = 5%). Within studies, the prevalence of any incontinence was 1.3 to 2.0 times greater for older women than for older men. Among middle-aged and younger adults, prevalence of incontinence ranged from 12 to 42% (median = 28%, pooled mean = 25%) for women and from 3 to 5% (median = 4%, pooled mean = 5%) for men. The ratio of prevalence of any incontinence for women to men in this age group ranged from 4.1 to 4.5. Stress incontinence predominated in younger women, whereas urge and mixed incontinence predominated in older women. There was a tendency for studies using in-person interviews to report higher prevalences. CONCLUSIONS: An accurate estimate of the prevalence of urinary incontinence depends on specifying the definition of incontinence and the age and gender groups of interest.

Adolescent↗
PubMed1997

Use and accuracy of state death certificates for classification of sudden cardiac deaths in high-risk populations.

In a large cohort of patients with known or suspected coronary disease, we evaluated the characteristics of 407 patients who died after hospital discharge and tested whether the state death certificate can be used to classify deaths as sudden cardiac versus nonsudden. Compared with a paramedic classification system based on heart rhythm, the death certificate-based classification resulted in a sensitivity that ranged from 78% to 85% and a specificity that ranged from 25% to 58%. We conclude that the death certificate can be used to identify cases of sudden cardiac death in patients at high risk; however, there is a substantial rate of false-positive sudden death classification.

Aged↗
PubMed1997

Effects of a self-administered previsit questionnaire to enhance awareness of patients' concerns in primary care.

OBJECTIVE: To determine if a self-administered previsit questionnaire designed to increase awareness of patients' concerns alters the visit duration, content of the discussion, and patient and physician satisfaction. DESIGN: A balanced, two-arm trial in which physicians were randomized. SETTING: Two primary-care clinics affiliated with a university hospital. PATIENTS/PARTICIPANTS: Ten physicians and 201 continuity-care patients. INTERVENTIONS: In intervention visits, patients completed a previsit questionnaire asking about the desire for medical information, psychosocial assistance, therapeutic listening, general health advice, and biomedical treatment. Physicians reviewed questionnaires with patients during the visit. MEASUREMENTS AND MAIN RESULTS: We used audiotapes of encounters to quantify the duration of the encounter and measured the number and type of diagnoses discussed in the visit, and patient and physician satisfaction with the encounter. Intervention visits were 34% longer (increase of 6.8 minutes; 95% confidence interval [CI] 0.4, 13.2) than control visits with most of the additional time spent in discussion of biomedical diagnoses (3.35 minutes; 95% CI 0.00, 6.72) and in the performance of the physical examination (2.7 minutes; 95% CI 0.5, 4.9). The number of diagnoses discussed per visit was 30% higher in intervention visits (increase of 1.7 diagnoses per visit; 95% CI 0.3, 3.2), but patients' satisfaction with these visits tended to be lower. CONCLUSIONS: Using a previsit questionnaire to increase awareness of the patients' concerns may entail a trade-off between conflicting goals: trying to respond to patient concerns while not significantly increasing the cost per visit. A future challenge is to develop and refine techniques with sufficient efficacy to justify the expense of implementing the intervention and the longer visit needed to respond adequately to patients' concerns.

Adult↗
PubMed1994

Lower respiratory tract infection with Chlamydia pneumoniae.

Chlamydia pneumoniae, also known as TWAR, is a common respiratory pathogen that can cause pneumonia, bronchitis, sinusitis, and pharyngitis. The clinical similarities between C pneumoniae infection and infection with other respiratory pathogens together with the lack, until recently, of readily available diagnostic tests for C pneumoniae have hindered its recognition and treatment in the outpatient setting. In this report, three patients with acute C pneumoniae infection from the Acute Respiratory Disease Study at the University of Washington are described, and the microbiologic characteristics, epidemiologic characteristics, clinical presentations, diagnosis, and treatment of acute C pneumoniae infection are considered.

Adult↗
PubMed1990

Driver workload during differing driving maneuvers.

Motorcycle-automobile accidents occur predominantly when the car driver turns left across the motorcyclist's right-of-way. Efforts to decrease this specific collision configuration, through an increase in motorcycle conspicuity, have concentrated on the physical characteristics of the motorcycle and its rider. The work reported here examines the behavior of car drivers during different driving sequences, in particular during left-turn maneuvers. An experiment is reported that used simultaneous video-taping of the driver and the forward-looking scene. Subjects followed a preset on-road course and were observed for head movements to determine the possibility of structural interference eye-blink frequency, probe-response time, and probe response error, as measures of cognitive or mental workload. In addition, the subjects completed two major subjective workload evaluations as reflections of effort directed to different components of the driving task. Results indicated that there were significant increases in head movements and mental workload during turn sequences compared to straight driving. This result of higher driver workload may be responsible for increasing the potential for detection failure. Such a propensity is also fostered by the higher structural interference that may be expected during turns. Failures to observe during turning sequences have differing outcomes depending on the presence of opposing traffic, as during the left turn, compared with the absence of such opposition, as occurs in the right turn. Also, the less conspicuous the oncoming vehicle in the left turn scenario, the higher the probability of detection failure. At the present time the least conspicuous powered vehicle is the motorcycle.

Accidents, Traffic↗
PubMed1981

Activity levels and properties of acid alpha-glucosidase from liver and neutral alpha-glucosidase from sera of cystic fibrosis patients and controls.

The average activity levels of acid alpha-glucosidase are comparable in liver supernatant fluids for 15 cystic fibrosis patients and 12 controls (401 +/- 131 and 347 +/- 109 nmol/h/mg protein, respectively) and no significant differences were found for the cystic fibrosis and control liver acid alpha-glucosidases in their (a) apparent Km values for the 4-methylumbelliferyl substrate (1.1 mmol/l), (b) pH optima (4.2) and thermostability curves and (c) isoelectric profiles (one form with an isoelectric point of 4.5 +/- 0.2). In contrast, average neutral alpha-glucosidase activity levels were significantly increased (p less than 0.0002) in sera from 21 cystic fibrosis patients compared to 15 controls (10.7 and 2.7 nmol/h/ml). This increased activity is not due to (a) different stability upon storage at --20 degrees C, (b) the presence of activators in cystic fibrosis sera or inhibitors in normal sera (as determined by mixing studies), (c) altered Km values or (d) altered pH optima curves. Cystic fibrosis serum neutral alpha-glucosidase appears to be more thermostable and has a consistently altered isoelectric profile (greater percentage of activity above pI 4.8) when compared to the normal serum enzyme. This altered isoelectric composition may reflect changes in neutral alpha-glucosidase which contribute to its increased activity in cystic fibrosis sera.

Cystic Fibrosis↗
PubMed1979

Fibronectin distribution in epithelial and associated tissues of the rat.

Specific antiserum was used to investigate the distribution of the extracellular glycoprotein, fibronectin, in rat skin and tongue tissue by light and electron microscopy with immunofluorescence and immunoperoxidase techniques. We conclude that fibronectin is absent from stable, differentiated parts of tissues, such as the sebaceous glands or the matrix, medulla, cortex, and cuticles of the hair and the inner and outer root sheaths, or even in tissues in which there is some cell movement, such as the epidermis. It is, however, characteristic of sites at which cell division is occurring in contact with an extracellular scaffolding, such as basement membrane or loose connective tissue. Conspicuous examples were in the glassy membrane and connective tissue sheath associated with the follicular epithelium, the basement membrane underlying vascular endothelial cells, the connective tissues surrounding and investing nerve and muscle fibre bundles, and the dermal connective tissue where fibronectin was often associated closely with collagen fibres. At the basement membrane of the dermal/epidermal junction, fibronectin occurred at the plasma membrane of the basal cells and in the lamina lucida area. There was no correlation with specific areas of cell-substrate adhesion, such as the hemidesmosomes. The endoplasmic reticulum of fibroblasts stained strongly suggesting that these cells represent a major site of synthesis.

Animals↗