Randomised controlled trial of hydroquinine in muscle cramps.
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Glomerular Filtration Rate↗
Biomedical subjects
J R Curtis
Publications and source records attributed to J R Curtis.
HIV risk screening in the primary care setting. Assessment of physicians skills.
OBJECTIVE: To assess the content and extent of HIV risk assessment by primary care physicians across a diverse panel of patients with unidentified HIV risk behaviors. DESIGN: Standardized patient examination to assess primary care physicians' skills at identifying and managing HIV infection and overall clinical skills. In a day of testing, physicians saw 13-16 standardized patients (SPs) with diverse case presentations. In analyses presented here, physician performance was examined with nine SPs who had unidentified risks for HIV, which they offered if asked. SETTING: An academic clinic. PARTICIPANTS: We randomly selected 134 paid volunteers (general internists and family/general practitioners) after stratifying by specialty, experience caring for patients with HIV infection, and year of medical school graduation. MEASUREMENTS AND MAIN RESULTS: Performance at initiating HIV risk screening and identifying patients' HIV risk behaviors were the main outcome measures. Physicians performed variably at HIV risk screening with different patients and across different HIV risk screening topics. Although physicians initiated screening with 60% of patients, they identified only 49% of risk behaviors and included HIV in the differential diagnosis for less than half of at-risk patients. Physicians performed better with cases in which there was a higher probability of HIV infection based on symptoms, but often did not screen at-risk patients without obvious symptoms suggestive of HIV. Board-certified general internists initiated screening and identified risk behaviors with more patients than board-certified family practitioners. Medical school graduation year also influenced performance. CONCLUSIONS: Our data suggest that primary care physicians do not routinely perform HIV risk assessments with patients who have risk behaviors for HIV infection. Methods are needed to develop, standardize, and disseminate better screening techniques to identify patients with or at risk of developing HIV infection, such as written HIV risk screening questions for use in medical intake forms.
Adult↗
Barriers to communication about end-of-life care in AIDS patients.
OBJECTIVE: Patients and physicians do not adequately discuss patients' preferences for medical care at the end of life. Our objective was to perform a qualitative study using focus groups to identify barriers and facilitators to communication about end-of-life medical care for patients with AIDS and their physicians. PARTICIPANTS: Patients with AIDS and physicians with moderate or extensive HIV experience were recruited from clinics and community-based settings using network sampling. A total of 47 patients participated in six focus groups and 19 physicians participated in three groups. MEASUREMENTS AND MAIN RESULTS: Patients or physicians identified 29 barriers and facilitators to communication about end-of-life care. Many patients and physicians expressed discomfort talking about death and dying, and some felt that discussing end-of-life care could cause harm or even hasten death. Several patients expressed the view that a living will obviated the need for discussion with their physician. Previous experience of discrimination from the health care system was a strong barrier to end-of-life communication for some patients with AIDS. Some patients hesitate to bring up end-of-life issues because they want to protect their physicians from uncomfortable discussions. Many patients identified the quality of communication as an important facilitator to these difficult discussions. CONCLUSIONS: Improving the quality of patient-physician communication about end-of-life care will require that physicians identify and overcome the barriers to this communication. To improve the quality of medical care at the end of life, we must address the quality of communication about end-of-life care.
Acquired Immunodeficiency Syndrome↗
Care for the patient with AIDS in the ICU: outcomes and ethics.
HIV infection and AIDS are common diagnoses in many intensive care units (ICUs) in the United States. Although Pneumocystis carinii currently represents only one quarter of all diagnoses for which HIV-infected persons are admitted to the ICU, it is the disease with the most clinically applicable outcome data and, therefore, is a model for ethical decision-making regarding patients with HIV infection in the ICU. Despite advances in diagnosis and treatment of HIV-related P. carinii, recent studies show that only 20% to 25% of the patients with acute respiratory failure survive to hospital discharge. Although many clinical markers correlate with survival, none of the individual markers or prediction scoring systems have the accuracy needed in clinical practice. One goal of predicting outcome in the ICU is to aid both the patient and the physician in making decisions about when to pursue aggressive therapy and when to withhold or withdraw such therapy. Because our ability to predict outcome is limited, advance directives and communication with patients and families about end-of-life medical care are of utmost importance. Even though it is not always possible for patients to predict, in advance, what they would want done in various hypothetical health care scenarios, quality communication between physicians, patients, and families with realistic discussion of outcomes and maintenance of hope and dignity can facilitate decisions about the use of intensive care for patients with AIDS.
Acquired Immunodeficiency Syndrome↗
Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis.
Life expectancy for individuals with cystic fibrosis (CF) has increased dramatically in the last 30 yr, but it is unclear whether the improved survival has applied equally to individuals with different health insurance status. We developed a retrospective inception cohort of all 189 patients with CF born 1/1/55 to 12/31/70 who had at least one hospitalization at a university referral center. The median survival for patients with CF who were without health insurance was 6.1 yr compared with 20.5 yr for those with Medicaid and 20.5 yr for those with private insurance. Using multivariate Cox regression, health insurance and increased socioeconomic status were independently associated with longer survival. The adjusted relative risk of death was greater for the absence of health insurance than for factors previously shown to predict mortality in individuals with CF (female sex and presentation with meconium ileus). In summary, the absence of health insurance was associated with increased mortality rate in children with CF and was a stronger predictor of mortality than variables previously shown to be associated with mortality for CF. If increasing numbers of children with CF lose health insurance coverage, our results suggest that their life expectancy will decrease dramatically.
Adult↗
Patient-assessed health outcomes in chronic lung disease: what are they, how do they help us, and where do we go from here?
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Chronic Disease↗
Variations in medical care for HIV-related Pneumocystis carinii pneumonia: a comparison of process and outcome at two hospitals.
BACKGROUND: Institutional variation in the quality of medical care may be evaluated by examining process measures, such as use of diagnostic procedures or treatment modalities, or outcome measures, such as mortality. We undertook this study to examine variations in both process and outcome of care for patients with HIV-related Pneumocystis carinii pneumonia (PCP) at two geographically diverse, HIV-experienced, public municipal hospitals. DESIGN: Retrospective review of hospitalized patients diagnosed as having PCP cared for at two municipal hospitals from 1988 to 1990. At hospital A, charts of all patients diagnosed as having PCP were abstracted (n=209); at hospital B, a random sample of 15% were abstracted (=136). RESULTS: Among all hospitalized patients diagnosed as having PCP, the frequency of making a definitive diagnosis of PCP (as opposed to treating empirically) differed markedly at the two hospitals (85% in hospital A vs 26% in hospital B; p<0.001), as did the use of intensive care (18% vs 3%; p<0.001) and "do-not-resuscitate" orders (39% vs 14%; p<0.001), although the timing of starting anti-Pneumocystis medications (89% vs 88% within the first 2 hospital days) and the use of corticosteroids (21% vs 23%) were similar. Despite differences in the process of care, survival rates were similar at the two institutions (75% vs 76%; p=0.8) and remained similar when logistic regression was used to control for demographic variables and severity of illness (odds ratio for survival, hospital B vs A, 1.2 [95% confidence interval, 0.7, 2.0]). The 95% confidence intervals (0.7, 2.0), however, were consistent with a considerable (and clinically significant) disparity in survival (from 30% lower to a twofold higher odds of survival). Sample size calculations showed that a sample of 10 cases in each hospital would be required to detect the observed difference in definitive diagnosis rates (85% vs 26%), but 722 cases in each hospital would be required to detect a relevant difference in mortality. CONCLUSIONS: The process of care for hospitalized patients with PCP in these two institutions differed considerably, but the survival rates were not significantly different, even after adjusting for confounding factors. While sample sizes available at the individual institutions were sufficient for evaluation of the process of care, they did not provide the power necessary to evaluate outcomes. Comparisons of outcomes such as mortality between individual hospitals may not have the statistical power to exclude important differences.
AIDS-Related Opportunistic Infections↗
U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals.
Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.
AIDS-Related Opportunistic Infections↗
Rapid diagnosis of pleural tuberculosis by polymerase chain reaction.
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Humans↗
Ability of primary care physicians to recognize physical findings associated with HIV infection.
OBJECTIVE: To assess the ability of primary care physicians to identify physical findings associated with human immunodeficiency virus (HIV) infection. DESIGN: Standardized patient examination. PARTICIPANTS: A total of 134 general internists and family practitioners were randomly selected after stratifying by year of medical school graduation, specialty, and experience caring for patients with HIV infection. MAIN OUTCOME MEASURES: Recognition of physical findings of Kaposi's sarcoma, oral hairy leukoplakia, and diffuse lymphadenopathy. RESULTS: Despite being directed by presenting histories to sites of prominent physical abnormalities, only 23 (25.8%) of 89 physicians evaluating a patient with Kaposi's sarcoma and 22 (22.7%) of 97 physicians evaluating a patient with oral hairy leukoplakia detected and correctly diagnosed the abnormalities. Twenty-three (17%) of 133 physicians detected diffuse lymphadenopathy in a patient complaining of fatigue, fever, and arthralgias. Physicians with the most experience treating patients with HIV infection more frequently identified oral hairy leukoplakia, but HIV experience did not influence identification of Kaposi's sarcoma or detection of lymphadenopathy. There were no differences between general internists and family practitioners or among physicians by year of medical school graduation in identifying the three physical findings associated with HIV infection. CONCLUSIONS: Primary care physicians may frequently miss important physical findings related to HIV infection during patient examinations.
Clinical Competence↗
Use of the medical futility rationale in do-not-attempt-resuscitation orders.
OBJECTIVE: To describe the use of the medical futility rationale in do-not-attempt-resuscitation (DNAR) orders written for medical inpatients. DESIGN: Structured interviews with medical residents. METHODS: Second- and third-year internal medicine residents (n = 44) were telephoned weekly and briefly interviewed about each patient who received a DNAR order in the preceding week. SETTING: Two university-affiliated hospitals: a veterans affairs medical center and a municipal hospital. PATIENTS: One hundred forty-five medical inpatients for whom DNAR orders were written during their hospitalization. RESULTS: Residents stated that the medical futility rationale applied for 91 patients (63%), but this rationale was invoked independent of patient or surrogate choice for only 17 patients (12%). Of the 91 patients for whom futility applied, both quantitative futility (low probability of success) and qualitative futility (poor quality of life if cardiopulmonary resuscitation [CPR] were performed) applied to 45 (49%), quantitative futility alone to 30 (33%), and qualitative futility alone to 16 (18%). Residents report that they discussed resuscitation issues with all communicative patients for whom the medical futility rationale was invoked. Among patients for whom quantitative futility applied, residents' predictions of the probability that patients would survive to hospital discharge after CPR varied from 0% (for 60% of patients) to 75%. For 32% of these patients, residents predicted survival at 5% or more. Logistic regression modeling showed that the presence of organ failure (odds ratio [OR], 8.9; 95% confidence interval [CI], 3.3 to 23.9), the residents' estimates of the probability of surviving CPR (OR, 0.94; 95% CI, 0.88 to 0.99), and nonwhite race (OR, 2.7; 95% CI, 1.1 to 6.3) were associated with the determination of quantitative futility. In one third of the cases where qualitative futility applied, residents made the judgment of qualitative futility without discussing quality of life with communicative patients. Logistic regression modeling showed immobility (OR, 3.2; 95% CI, 1.1 to 9.0) and age > or = 75 years (OR, 0.3; 95% CI, 0.1 to 0.8) to be associated with the determination of qualitative futility. CONCLUSIONS: While residents did not appear to use the medical futility rationale to avoid discussing DNAR issues with patients, we found evidence of important misunderstandings of the concepts of both quantitative and qualitative futility. If the futility rationale is to be applied to withholding or withdrawing medical interventions, practice guidelines for its use should be developed, and education about medical futility must be incorporated into medical school, residency training, and continuing medical education programs.
Cardiopulmonary Resuscitation↗
Ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia.
This study assesses the ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP's HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim - sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.
Clinical Competence↗
Do primary care physicians screen patients about alcohol intake using the CAGE questions?
The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner.
Alcoholism↗
New developments in tuberculosis and HIV infection: an opportunity for prevention.
As we approach 2010, the year by which we were to have eliminated TB, we find this ancient disease is making a comeback. This comeback is due to many factors, but the role of HIV infection is clearly important. HIV infection can result in changes in the pathogenesis and presentation of infection with the tubercle bacillus. Consequently, as health care providers, we must respond with changes in our usual methods of prevention, treatment, and infection control. Whereas the increase in TB is currently limited to certain geographic areas, it is likely to spread more widely. All health care providers should be aware of the changing face of TB and have a high clinical index of suspicion for this disease.
AIDS-Related Opportunistic Infections↗
Internal medicine residents' skills at identification of HIV-risk behavior and HIV-related disease.
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Alcohol Drinking↗
Pulmonary rehabilitation in chronic respiratory insufficiency. 7. Health-related quality of life among patients with chronic obstructive pulmonary disease.
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Chronic Disease↗
Changing use of intensive care for HIV-infected patients with Pneumocystis carinii pneumonia.
Clinicians' approach to acute respiratory failure from Pneumocystis carinii pneumonia (PCP) is hypothesized to have gone through three phases: aggressive management due to an absence of data on prognosis (1981-84), withholding of intensive care based on a few small studies showing high case fatality (1985-87), and an increase in intensive care to an intermediate level (1988 forward). Unfortunately, studies of survival from acute respiratory failure among such patients have been small and have been limited to patients in the intensive care unit. To determine whether this three-phase scenario has empirical support, we performed a retrospective chart review of all patients with human immunodeficiency virus (HIV) infection and PCP at a university-affiliated municipal hospital from 1983 to 1990. We identified 180 patients, representing 218 episodes of PCP. The previously hypothesized relationship between intensive care and year of diagnosis was confirmed: intubation rates were 30% before 1985, 0% in 1987, and 12% after 1988 (p = 0.03). Among all patients, the percentage dying in the hospital without intensive care had the opposite relationship with year of diagnosis, increasing from 0% in 1984 to 21% in 1987 and then declining to 0% in 1990 (p = 0.001). Overall mortality from an episode of PCP was 25% and did not change significantly over time. Disease severity also did not change significantly over time. In summary, the significant swings in the use of intensive care for HIV-infected patients with PCP suggest that judgments about the futility of intensive care were strongly influenced by incorrect perceptions of survival.
AIDS-Related Opportunistic Infections↗
Emergent assessment and management of acute respiratory failure in COPD.
Acute respiratory failure in patients with COPD is a common cause of emergent medical intervention and can be difficult to assess and manage. Assessment is complicated by the imposition of acute respiratory failure on chronic respiratory failure and by the large number of problems that can tip a carefully compensated patient with COPD toward acute respiratory failure. Management must include correcting life-threatening hypoxemia and life-threatening acidosis, treating the underlying disease processes, and preventing and treating complications. Management can be enhanced by an understanding of the prognosis of acute respiratory failure in COPD and by incorporation of some ethical and societal issues.
Acidosis↗