The interface between nursing homes and emergency departments: a community effort to improve transfer of information.
Explore the source record for details and available documents.
Aged↗
Biomedical subjects
J Garrett
Publications and source records attributed to J Garrett.
Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid.
OBJECTIVE: To investigate the efficacy of an increased dose of inhaled steroid used within the context of an asthma self management plan for treating exacerbations of asthma. DESIGN: Randomised, double blind, placebo controlled, crossover trial. METHODS: Twenty eight children aged 6-14 years with asthma of mild to moderate severity were studied for six months. Eighteen pairs of exacerbations were available for analysis, during which subjects took an increased dose of inhaled steroids or continued on the same dose. RESULTS: There was no significant difference between increasing inhaled steroids or placebo on morning or evening peak expiratory flow rates (PEFRs), diurnal peak flow variability, or symptom scores in the two weeks following an asthma exacerbation. Difference (95% confidence intervals) in baseline PEFR on days 1-3 were 3.4% (-3.5% to 10.4%) and -0.9% (-4.7% to 2.9%) for inhaled steroid and placebo, respectively. Spirometric function and the parents' opinion of the effectiveness of asthma medications at each exacerbation were also not significantly different between inhaled steroid or placebo. CONCLUSION: This study suggests that increasing the dose of inhaled steroids at the onset of an exacerbation of asthma is ineffective and should not be included in asthma self management plans.
Acute Disease↗
Rapid onset asthma: a severe but uncommon manifestation.
BACKGROUND: Studies of asthma death and severe life threatening asthma (SLTA) include reports of patients who had rapid onset asthma. A study was undertaken to determine the relative frequency of rapid (< 6 hours duration) and slow (> or = 6 hours) onset attacks in patients admitted to hospital with acute severe asthma, and to establish whether those with rapid onset asthma differ in terms of risk factors for asthma morbidity and mortality such as indices of asthma severity/control, socioeconomic factors, health care, and psychological factors. METHODS: A cross sectional study was performed on 316 patients aged 15-49 years admitted with acute severe asthma and interviewed within 24-48 hours of admission. RESULTS: Patients underestimated the duration of the index attack. Only 27 (8.5%) were classified as rapid onset. There were more men in the rapid onset group than in the slow onset group (52% versus 26%), and there was evidence of socioeconomic advantage in the patients with rapid onset attacks. The rapid onset group had more previous episodes of SLTA and were more likely to present with SLTA, but there was no difference in length of stay in hospital. The rapid onset group were less likely to have presented to a GP during the index attack and were more likely to have used ambulance services. There was no difference between the groups in any psychological or health care measure. CONCLUSIONS: Rapid onset attacks are an important but uncommon manifestation of asthma that are more likely to present with SLTA in patients who are more likely to have had previous SLTA. Male subjects are at increased risk of rapid onset attacks, and socioeconomic disadvantage, deficiencies in health care (ongoing and acute), and psychological factors are no more common in these patients than in those with attacks of slow onset. These data are consistent with the hypothesis that there is a small proportion of patients with rapid onset severe asthma who do not have the usual risk factors associated with asthma morbidity or mortality, and thus require different management strategies.
Acute Disease↗
Application of asthma action plans to childhood asthma: a national survey.
AIM: To determine the frequency of asthma action plan use by doctors in the management of childhood asthma in New Zealand, and their recommendations about the application of an increased dose of inhaled steroids in those plans. METHODS: A postal survey was sent to all 236 paediatricians and paediatric registrars and to a random sample of 500 general practitioners (GPs) in New Zealand. Questions related to asthma action plan use, the inclusion of an increased dose of inhaled steroid in those plans and details of the way the inhaled steroid dose is adjusted. RESULTS: Valid responses were received from 168 (71%) paediatricians and paediatric registrars and 340 (68%) GPs. The majority (92.6%) of GPs and paediatricians and paediatric registrars used action plans and 83.6% included a step involving an increased dose of inhaled steroids. Compared with paediatricians and paediatric registrars, GPs gave action plans to a smaller proportion of asthmatic children in their care and included an increased dose of inhaled steroid more often (GPs = 94.5%, paediatricians and paediatric registrars = 57%). CONCLUSION: In New Zealand the use of asthma action plans is inconsistent with the recommendations contained in published consensus documents in that not all asthmatic children are advised about an action plan. Specific issues relating to this and to the use of an increased dose of inhaled steroids in action plans require clarification and further research.
Administration, Inhalation↗
Mft52, an acid-bristle protein in the cytosol that delivers precursor proteins to yeast mitochondria.
We have identified a novel protein, Mft52, in the cytosol of yeast cells. Mft52 has a two-domain structure that includes a receptor-like carboxyl-terminal "acid-bristle" domain, which binds basic, amphipathic mitochondrial targeting sequences. Native Mft52, purified from the cytosol of yeast cells, is found as a large particle eluting in the void volume of a Superose 6 gel filtration column. Fusion proteins, consisting of mitochondrial targeting sequences fused to nonmitochondrial passenger proteins, are targeted to mitochondria in wild-type yeast cells, but defects in the gene encoding Mft52 drastically reduce the delivery of these proteins to the mitochondria. We propose that Mft52 is a subunit of a particle that is part of a system of targeting factors and molecular chaperones mediating the earliest stages of protein targeting to the mitochondria.
Amino Acid Sequence↗
Engaging and retaining women in outpatient alcohol and other drug treatment: the effect of referral intensity.
Women with alcohol or other drug (AOD) problems experience a range of barriers to inpatient treatment. Although research in the general population shows that high-intensity referrals are more effective than low-intensity referrals at engaging and retaining individuals in outpatient AOD treatment, the impact of referral intensity has not been assessed for women only. To examine this issue, a secondary analysis was conducted using an existing data set that included a sample of 109 women. Although intensity of referral was not related to entry into or relapse during treatment, high-intensity referral was associated with completion of treatment. In addition, women who relapsed during treatment were less likely to complete it, underscoring the need for relapse prevention training.
Adult↗
What is wrong with end-of-life care? Opinions of bereaved family members.
OBJECTIVE: To describe family perceptions of care at the end of life. METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care. RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%). CONCLUSION: Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.
Aged↗
Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project.
BACKGROUND: Low back pain is a common reason for visiting a physician. Authors of guidelines and insurance payers are currently scrutinizing use of radiography and computed tomography (CT) or magnetic resonance imaging (MRI). OBJECTIVE: To study the determinants of the use of lumbar spine radiography and either CT or MRI in patients with acute low back pain. DESIGN: Prospective cohort study. SETTING: Community-based practices in North Carolina in six strata: urban primary care physicians, rural primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and practitioners at a group-model health maintenance organization. PATIENTS: 1580 patients with acute low back pain. MEASUREMENTS: Telephone interviews done after the index office visit and at 2, 4, 8, 12, and 24 weeks or until complete recovery; survey of practitioners; and chart abstraction. RESULTS: During the acute back pain episode, 46% of patients had radiography and 9% had CT or MRI. Patient variables related to use of radiography included pain that began more than 2 weeks before the index visit and no previous episodes of low back pain. Practitioner variables associated with use of radiography were being a chiropractor or orthopedic surgeon and having a solo practice. Use of CT or MRI was associated with white race, neurologic deficit at baseline, sciatica, poor functional status at baseline, and small group-practice size. Practitioners' responses to clinical vignettes were associated with aggregate practitioner behavior: In the vignettes and in real life, practitioners were more likely to order CT for patients with sciatica. However, a practitioner's response to a vignette did not predict that practitioner's use of CT or MRI for similar patients in his or her own practice. CONCLUSION: Radiography is commonly used as a diagnostic test for patients with acute back pain. Clinical factors and provider specialty are major correlates of the use of imaging studies.
Acute Disease↗
Out of hours attendance for asthmatics.
Explore the source record for details and available documents.
Asthma↗
GNP1, the high-affinity glutamine permease of S. cerevisiae.
Glutamine uptake in S. cerevisiae is mediated by at least three transporters: high- and low-affinity glutamine permeases and the general amino-acid permease. We have isolated the gene encoding the high-affinity glutamine permease and named it GNP1. The amino-acid sequence of GNP1, and its hydropathy profile of 12 transmembrane domains, closely resemble those of known amino-acid permeases. The Km of GNP1 for glutamine uptake was determined to be 0.59 mM. Cells lacking GNP1 exhibit reduced levels of glutamine transport, and are resistant to a toxic analog of glutamine, L-glutamic acid gamma-monohydroxamate. Unlike other amino-acid permeases, whose expression is nitrogen-source limited, GNP1 is expressed on both rich and poor nitrogen sources.
Amino Acid Sequence↗
Photodynamic therapy (PDT) of the ciliary body with silicon naphthalocyanine (SINc) in rabbits.
BACKGROUND AND OBJECTIVE: To investigate silicone naphthalocyanine (SINc; 0.5 mg/kg) for photodynamic therapy (PDT) of the ciliary body in pigmented rabbits. STUDY DESIGN/MATERIALS AND METHODS: SINc was dissolved in canola oil by heating, emulsified with Tween-80, and given by ear vein. Pharmacokinetics were studied in frozen sections by fluorescence microscopy using a CCD camera-based, low light detection system with digital image processing at 1 hr and 24 hr (12 rabbits, 24 eyes total). A Ti:Sapphire laser delivered light at 770 nm by contact fiberoptic (1,000 microns; 80 mW/cm2;20,40 and 80 J/cm2). Controls (5 rabbits), received laser light at 770 nm without SINc. For comparison, eyes received continuous wave Nd:YAG laser by fiberoptic contact (0.8-1.2 J). RESULTS: Localization studies showed intravascular distribution shifting to a ciliary body distribution at 24 hr. PDT at 1 hr and 24 hr postinjection showed a more selective destruction of the ciliary body at 24 hr. Ciliary processes treated at 24 hr showed infarction and marked edema with sparing of iris. Tissue thermal damage was minimal in PDT controls. Eyes treated with the Nd:YAG laser exhibited full-thickness thermal necrosis of iris, ciliary processes, and a fibrinous iridocyclitis. In contrast, eyes treated by PDT were quiet with thrombosis of superficial blood vessels. CONCLUSION: Tissue photon penetration is good at 770 nm and thermal effects from the exciting laser alone were minimal. The ciliary processes of pigmented rabbits exhibit a selective retention of SINc and on that basis can be selectively destroyed with a minimum on thermal damage to nontarget tissues.
Aluminum Oxide↗
Social phobia and PTSD in Vietnam veterans.
Posttraumatic stress disorder (PTSD) is the most prevalent psychological disorder experienced by Vietnam veterans. However, there are many other disorders and problems of adjustment, like social anxiety and social phobia, that have not been fully investigated in this population. This study examined the prevalence of social phobia and the comorbidity of social phobia and PTSD, and tested out a theory of the etiology of social anxiety in trauma victims. Forty one Vietnam combat veterans were interviewed and completed self-report measures assessing PTSD and social phobia. Adversity of homecoming was also assessed. Using a conservative multi-method assessment approach, 32% of the sample were found to be positive for both social phobia and PTSD. Veterans with PTSD were significantly more likely to carry an additional diagnosis of social phobia as compared to veterans without PTSD. Adversity of homecoming and shame about one's experience in Vietnam were significant predictors of current level of social anxiety over and above the effects of pre-military anxiety and severity of combat exposure. These observations suggest that social anxiety and social phobia may be significant problems among individuals with PTSD. Further, these findings offer preliminary support for the theory that posttrauma environment may impact upon the later development of social anxiety.
Adult↗
Alterations of end-tidal carbon dioxide during the intrahospital transport of children.
OBJECTIVE: To determine the effect of manual ventilation during intrahospital transport on end-tidal carbon dioxide concentrations in children. DESIGN: Prospective study in children who required tracheal intubation and mechanical ventilation/ hyperventilation to maintain an arterial partial pressure of CO2 (PaCO2) of 25 to 30 torr for control of intracranial pressure. SETTING: Pediatric intensive care unit. INTERVENTION: During patient transport with manual ventilation, end-tidal CO2 was monitored with a side-streaming aspirating, infrared device. The person responsible for manual ventilation was informed of the current ventilator settings and the need to maintain a PaCO2 of 25 to 30 torr, but was not allowed to see the end-tidal CO2 monitor. RESULTS: The study population included 12 patients ranging in age from seven months to 14 years (average age 6.9 years) and in weight from 6.5 to 57 kg (average weight 28.9 kg). A total of 1716 end-tidal CO2 values were recorded during 286 minutes of monitoring. Five hundred and thirty-one (31%) of the readings were in the intended range of 25 to 30 torr. Four hundred (23%) were less than 20 torr, 665 (39%) were in the 20 to 24 torr range, and 119 (6.3%) were greater than 30 torr. Only five were greater than 40 torr. CONCLUSIONS: Unintentional hyperventilation occurs during the intrahospital transport of children. End-tidal CO2 values less than 25 torr were noted 62% of the time.
Adolescent↗
Assessment of practical knowledge of self-management of acute asthma.
AIMS: To develop an instrument for the measurement of, and to determine the level of, practical knowledge of self-management of acute asthma. METHODS: Eighty patients with moderate/severe asthma attending a hospital-based asthma clinic responded to an interviewer-administered questionnaire. Subjects were asked to describe the action they would take in response to each of two hypothetical evolving attacks: (1) one of gradually increasing severity and (2) the other developing rapidly. Responses were scored according to the appropriateness of actions taken relevant to the stage of the attack. Transcripts of the responses were scored independently by three of the investigators according to a system based on Thoracic Society of Australia and New Zealand (TSANZ) and British Thoracic Society (BTS) consensus statements on asthma management. A 25-point scale was used on which 0 represented a total lack of appropriate responses and a score of 25 was an optimal response. RESULTS: Interrater and intrarater reliability were excellent. Mean (+/- SD) scores for the slow and rapid onset attacks were 12.8 +/- 4.0 and 13.9 +/- 4.8, respectively. The scores for the two scenarios were predicted by each other (p = 0.002) and by the interviewer's rating of asthma management knowledge (p = 0.0004, p = 0.0001), but not by age, sex, race, previous asthma morbidity, depression, or anxiety. In both scenarios, most patients indicated that they would increase inhaled beta-agonist (85% for slow-onset scenarios and 94% for rapid-onset scenarios, respectively) and use their action plan and/or seek urgent medical advice at an appropriate time (74% and 70%). Although some would measure peak expiratory flow (PEF) initially (54% and 30%), only a minority would continue to monitor PEF in the context of worsening acute asthma (30% and 24%). When a severe life-threatening situation was described, only 50% and 64%, respectively, indicated that they would call emergency services. CONCLUSIONS: Scenarios describing hypothetical asthma attacks are a useful and reproducible method of assessing practical knowledge of self-management of acute asthma. Patients presented with scenarios frequently made errors in their hypothetical responses. The errors made with scenarios, which parallel errors reported in real clinical situations, occurred despite the fact that this patient population had received considerable education and training about how to manage asthma. Most indicated they would not monitor PEF even in an exacerbation of asthma and would not call emergency services despite life-threatening asthma. These scenarios may allow us to explore the gap between knowledge about treatment and actual practice, and perhaps to help close that gap and thus reduce asthma morbidity and mortality.
Acute Disease↗
Differential influences on asthma self-management knowledge and self-management behavior in acute severe asthma.
AIM: While asthma education increases knowledge, it is less clear whether education influences actual patient behavior. To determine whether there are differences between asthma self-management knowledge and the actual behavior of patients during an acute severe asthma attack and to determine which clinical and psychosocial factors are associated with knowledge and behavior. METHODS: Validated hypothetical scenarios describing the development of life-threatening asthma and patients' reported actual behavior were scored (out of 25) using a system based on Thoracic Society of Australia and New Zealand and British Thoracic Society criteria. RESULTS: In 137 patients admitted to the hospital with severe asthma, the pattern of the index attack was slow onset (> or = 6 h) in 96%. The score for the hypothetical attack (knowledge) was 13.8 +/- 4.6, while that for the timeline (behavior) was 10.2 +/- 3.9 (p < 0.001) with 56% and 84%, respectively, having a score of less than 15 (regarded as inadequate). Certain components showed marked discrepancy (eg, appropriately seeking medical help 82% vs 52% (p < 0.001) and calling ambulance 61% vs 23% (p < 0.001). Factors such as physician-patient relationship, previous asthma morbidity, availability of peak flowmeter, action plan, and oral steroids correlated positively with both measures. Knowledge was negatively associated with being non-European, with anxiety, pessimism, and stigmatization. Behavior (but not knowledge) was negatively associated with lack of knowledge of what to do in the index attack, previous emotional counseling, and business failure. Those factors associated with the difference between knowledge and behavior scores (knowledge-behavior gap) were being non-European, anxiety, pessimism, and stigmatization, concerns about medical costs, and the only income for the household being a Social Security benefit. CONCLUSION: There are marked differences between patients' self-management knowledge and their actual behavior, particularly in terms of potentially life-saving actions. Psychological, health-care, and socioeconomic factors have a powerful and differential influence on knowledge and behavior. Improved understanding of the discrepancies between knowledge and behavior and which factors influence them may lead to more effective asthma educational interventions.
Acute Disease↗
The influence of indemnification by workers' compensation insurance on recovery from acute backache. North Carolina Back Pain Project.
STUDY DESIGN: A prospective observational cohort was recruited from 208 randomly selected North Carolina practices. OBJECTIVE: To compare the course of compensation claimants with gainfully employed patients not so insured from the time when they first sought care for acute back pain. SUMMARY OF BACKGROUND DATA: The human and financial cost attributable to disabling chronic low back pain identified by worker's compensation programs continues to escalate. We explored the antecedents to this phenomenon. METHOD: Consecutive patients with acute low back pain were interviewed by telephone within 1 week of first seeking care and in follow-up calls after 2, 4, 8, 12, and 24 weeks to monitor functional and work status. RESULTS: Of the 1633 patients enrolled, 505 were insured by workers' compensation. These were compared with 861 who had been employed on any job for pay within 3 months of the onset of their backache but whose care was not so underwritten. Those with compensable back pain were more likely to categorize their tasks as physically demanding and had taken more time off work in the month before the baseline interview (P = 0.02). Recovery of the sense of wellness they enjoyed before this episode of back pain was delayed (Cox Model: Hazard Ratio = 0.822; P < 0.001; confidence interval: 0.733, 0.923), but recovery of function or return to work was not. This delay was independent of type of health care and perception of task demand and beyond that which could be ascribed to the quality of back pain. CONCLUSION: Each of these associations is a reproach to the fashion in which workers' compensation insurance for regional back pain serves the ethic that is its raison d'être.
Adult↗
The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina Back Pain Project.
BACKGROUND: Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. METHODS: Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. RESULTS: The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study (95 percent). The times to functional recovery, return to work, and complete recovery from low back pain were similar among patients seen by all six groups of practitioners, but there were marked differences in the use of health care services. The mean total estimated outpatient charges were highest for the patients seen by orthopedic surgeons and chiropractors and were lowest for the patients seen by HMO and primary care providers. Satisfaction was greatest among the patients who went to the chiropractors. CONCLUSIONS: Among patients with acute low back pain, the outcomes are similar whether they receive care from primary care practitioners, chiropractors, or orthopedic surgeons. Primary care practitioners provide the least expensive care for acute low back pain.
Acute Disease↗
Reporting of acute low back pain in a telephone interview. Identification of potential biases.
STUDY DESIGN: This was a survey of 235 individuals with and 132 individuals without documented low back pain. OBJECTIVES: To approximate the magnitude of potential reporting biases in estimates of prevalence of and medical care use in low back pain. SUMMARY OF BACKGROUND DATA: The use of survey techniques presents several possible biases in the reporting of acute symptoms. These biases are especially pertinent in musculoskeletal symptoms, which often are recurrent and not life-threatening. METHODS: Two-hundred-thirty-five patients with acute low back pain were contacted by telephone 4-16 months after their physician visit and surveyed regarding the presence and date of back pain episodes. One-hundred-thirty-two patients who had no functionally disabling back pain on physician interview were interviewed. RESULTS: Of the patients who had sought care for back pain, 21% indicated they had not had back pain when interviewed 4-16 months later. Episodes of pain that occurred more than 8 months before the interview tended to be recalled as occurring more recently than they actually occurred, confirming "forward telescoping" of the illness episode. Only 3% of the individuals without functionally impairing pain reported such pain on a separate interview. CONCLUSIONS: Lack of recall occurs regarding acute low back pain, usually a self-limited illness. This potential under-estimate of back pain prevalence may be balanced by forward telescoping of the date of illness occurrence.
Acute Disease↗