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Biomedical subjects

J R Feussner

Publications and source records attributed to J R Feussner.

At least 91 records · Page 5Linked to original sources
PubMed1990

Improving physicians' recognition and treatment of depression in general medical care. Results from a randomized clinical trial.

A randomized clinical trial was performed to assess whether the results of a depression screening instrument, when provided to physicians, could influence their recognition and treatment of depression in a primary care setting. The intervention consisted of randomly informing or not informing physicians of the depression status of 100 patients who screened positively for depression on both the Zung Self-rating Depression Scale (SDS) and a DSM-III screen. For 12 months patients were followed to assess depression status, and medical records were audited to assess depression recognition and treatment. Results show that feedback to physicians of SDS scores of previously unrecognized depressed patients makes a significant difference in greater recognition (56.2% vs. 34.6%) and treatment (56.2% vs. 42.3%) of depression over the 12-month study period. This was especially true for patients with high somatic (P less than 0.05) or low psychologic symptoms of depression (P less than 0.05). These results suggest that routine use of a depression screening instrument can improve physician recognition of depression, with increased initiation of treatment.

Clinical Competence↗
PubMed1990

Impact of glucose self-monitoring on non-insulin-treated patients with type II diabetes mellitus. Randomized controlled trial comparing blood and urine testing.

The goal of this study was to compare the relative efficacy and cost of self-monitoring of blood glucose (SMBG) with routine urine testing in the management of patients with type II (non-insulin-dependent) diabetes mellitus not treated with insulin. Fifty-four patients with type II diabetes mellitus, not treated with insulin, who had inadequate glucose control on diet alone or diet and oral hypoglycemic agents were studied. Patients performed SMBG or urine glucose testing as part of a standardized treatment program that also included diet and exercise counseling. During the 6-mo study, both the urine-testing and SMBG groups showed similar improvement in glycemic control; within each group, there were significant improvements in fasting plasma glucose (reduction of 1.4 +/- 3.2 mM, P less than 0.03) and glycosylated hemoglobin (reduction of 2.0 +/- 3.4%, P less than 0.01) levels. Seventeen (31%) of 54 patients actually normalized their glycosylated hemoglobin values, 9 in the urine-testing group and 8 in the SMBG group. Comparisons between the urine-testing and SMBG groups showed no significant differences in mean fasting plasma glucose (P greater than 0.86), glycosylated hemoglobin (P greater than 0.95), or weight (P greater than 0.19). In patients with type II diabetes mellitus not treated with insulin, SMBG is no more effective, but is 8-12 times more expensive, than urine testing in facilitating improved glycemic control. Our results do not support widespread use of SMBG in diabetic patients not treated with insulin.

Aged↗
PubMed1989

Effect of a geriatric consultation team on functional status of elderly hospitalized patients. A randomized, controlled clinical trial.

STUDY OBJECTIVE: To evaluate the impact of a geriatric consultation team on the functional status of hospitalized elderly patients. DESIGN: Randomized controlled clinical trial. SETTING: University-affiliated referral Veterans Administration Medical Center. PATIENTS: One hundred and seventy-eight hospitalized elderly men 75 years or older admitted to medical, surgical, and psychiatry services, but excluding patients admitted to intensive care units. INTERVENTION: Eighty-eight intervention group patients received multidimensional evaluation by an interdisciplinary geriatric consultation team composed of a faculty geriatrician, geriatrics fellow, geriatric clinical nurse specialist, and a social worker trained in geriatrics. Results of the evaluation, including problem identification and recommendations, were given to the patients' physicians. Ninety control group patients received only usual care. MEASUREMENTS AND MAIN RESULTS: Intervention and control groups were comparable initially. The major outcome variable was the Index of Independence in the Activities of Daily Living (ADL) (Katz). Thirty-nine percent of the total study population was functionally independent on admission, 27% required assistance with one to three ADL, 22% required assistance with four to six ADL, and 12% were completely dependent. Many patients remained unchanged from admission to discharge: intervention group, 38%; control group, 39%. In the intervention group, 34% improved and 28% declined; in the control group, 26% improved and 36% declined. Although these changes reflected a trend toward greater improvement in the intervention group, the results were not statistically significant. CONCLUSIONS: Among elderly patients entering an acute-care hospital, approximately 60% had some degree of, and one third had serious functional disability. Such patients are at risk for further decline during hospitalization. A geriatric consultation team was unable to alter the degree of functional decline. Geriatric units or consultation teams may have to offer direct preventive or restorative services in addition to advice if improvements are to be made.

Activities of Daily Living↗
PubMed1989

Management of general medical patients with symptoms of depression.

This article describes the management of depressive symptoms in a group of ambulatory patients in general medical care during a 1-year period. It also examines patient outcomes by types of management and aggressiveness of treatment. Subjects are 112 male patients longitudinally enrolled in a V.A. General Medical Clinic who screened positively on both the Zung Self-rating Depression Scale and the DSM-III criteria. Medical records were abstracted to obtain information on mental health management. During the follow-up year, 48% of the moderately depressed patients received some form of mental health management compared to 92% of the severely depressed patients. Of the treatment modes, only patients who had a mental health clinic visit and/or psychiatric consultation were significantly more improved than those not so treated--but only at 6 months (p = 0.09) and 9 months (p = 0.02). Actual treatment experience was then classified into three levels based on intensity, duration, and combinations of treatments. Of the three levels, only those patients in the moderately aggressively treated condition were significantly more improved at 3 months (p = 0.02) and at 6 months (p = 0.04) than those in the no-treatment condition.

Ambulatory Care↗
PubMed1989

Evaluation of a supervised exercise program in a geriatric population.

Most studies that assess the effects of exercise in the elderly involve subjects who are in good health. The objective of this prospective longitudinal study was to examine the impact of exercise on cardiovascular fitness, flexibility, and strength in an elderly population that included chronically ill individuals. Patients were recruited initially from a population of veterans over 64 years of age who use a VA outpatient clinic as their regular source of care. The exercise intervention consisted of 90 minutes of exercise 3 days per week at 70% of the patient's maximal capacity. Activities included stationary cycling, stretching, weight training, and walking. Of 69 patients who began the program, 49 (71%) reached 4-month follow-up. Most patients completing follow-up (76%) had at least one chronic disease, such as arthritis, hypertension, or heart disease. Patients who dropped out were more likely to have multiple chronic illnesses than those who remained in the program. Average weekly attendance was 65% and was stable over time. Improvements in cardiovascular fitness at 4-month follow-up were significant: Metabolic equivalents increased from 7.1 +/- 2.3 to 8.3 +/- 2.6 (P less than .001), treadmill time increased from 8.5 +/- 3.8 to 11.2 +/- 4.2 minutes (P less than .001), submaximal heart rate decreased from 123.7 +/- 18.8 to 118.8 +/- 19.4 beats per minute (P less than .001) and resting heart rate decreased from 68.1 +/- 10.6 to 63.3 +/- 11.6 beats per minute (P = .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

Does determining serum alcohol concentrations in emergency department patients influence physicians' civil suit liability?

Emergency physicians may incur liability when impaired patients who have been treated and released are subsequently involved in traffic crashes. We surveyed attorneys to assess their perception of how serum alcohol determinations might influence their liability in civil suits. Overall, 63.9% of the attorneys surveyed would advise patients that they received potentially negligent care if they were impaired following treatment in the emergency department and were involved in a traffic crashes. Perceived liability was altered by physician behavior as follows: 43.1% of attorneys would advise clients that they received potentially negligent care when impairment was documented by a test for serum alcohol concentration and no advice was given regarding drunk driving, and 17.3% of attorneys would give similar advice when impairment was not documented by a test for serum alcohol concentration and no advice was given regarding drunk driving. In contrast, only 3.5% of attorneys would suggest possible negligence when impairment was documented by a test for serum alcohol concentration and with advice subsequently given not to drive. The coupling of diagnosing impairment by the serum alcohol concentration and driving advice is medically sensible and might result in minimal civil liability.

Accidents, Traffic↗
PubMed1988

When and how to study the carotid arteries.

STUDY OBJECTIVE: To appraise critically the clinical indications for diagnostic evaluation of carotid artery disease and the efficacy, safety, limitations, and relative costs of commonly used noninvasive diagnostic tests. DESIGN: Formal decision analysis to determine the relative value of several diagnostic strategies and information synthesis of studies evaluating noninvasive diagnostic tests. SETTING: We did a secondary analysis of the literature, using available data to generate estimates for the probability of selected, clinically important events and the utilities of relevant outcomes observed in patients when carotid artery disease is present or absent, and we critically appraised studies reported since 1980 to estimate the sensitivity and specificity, safety, limitations, and costs of diagnostic tests. MAIN RESULTS: For patients with asymptomatic neck bruits who are and who are not being considered as candidates for other vascular surgery, no diagnostic testing is recommended. For symptomatic patients with anterior-circulation transient ischemic attacks or previous minor strokes, noninvasive diagnostic testing is recommended if surgical treatment is being considered. Patients who previously had minor strokes could be directly referred for selective carotid angiography because they have a higher likelihood of a surgically approachable carotid lesion. Patients with nonlateralizing signs and symptoms of ischemia do not need diagnostic evaluation of possible carotid artery disease unless their symptoms are related to ischemia in the carotid artery circulation. The preferred noninvasive diagnostic test is duplex ultrasound, which has a sensitivity of approximately 85% and a specificity of 90%. If duplex ultrasound is not available, an alternative noninvasive test is carotid Doppler ultrasound. CONCLUSIONS: We recommend a conservative diagnostic approach in patients with suspected carotid artery disease. Noninvasive diagnostic testing is indicated only for symptomatic patients with transient ischemic attacks in the anterior circulation who are considered candidates for carotid endarterectomy, when knowledge of the vessel anatomy is necessary.

Algorithms↗
PubMed1988

Erythrocyte anisocytosis. Visual inspection of blood films vs automated analysis of red blood cell distribution width.

An improved anemia classification may be available by combining measures of red blood cell size variability with mean corpuscular volume. Visual inspection of the peripheral blood film allows semiquantitative description of anisocytosis while quantitative measures are determined from electronic cell counter analyzers' red blood cell distribution width. We evaluated correlations between semiquantitative and quantitative measures of anisocytosis for different groups of observers. Hematologists', medical students', and medical residents' semiquantitative assessment of anisocytosis correlated with the quantitative red blood cell distribution width. The interobserver variability demonstrated that all observers correlated with each other, while the intraobserver variability of semiquantitative anisocytosis demonstrated that observers were more precise than could be predicted by chance. However, the extreme precision of the red blood cell distribution width strongly suggests that it should be the "gold standard" for measuring red blood cell size variability.

Anemia↗
PubMed1988

Blood alcohol measurements in the emergency department: who needs them?

We surveyed North Carolina emergency physicians to determine current medical practices regarding the use of blood alcohol concentrations using a hypothetical scenario. Most physicians (88 per cent) would not have obtained blood alcohol concentrations in a patient who had alcohol on his breath but was coherent and cooperative. For marginally impaired patients, more liberal use of blood alcohol concentrations and explicit instructions to avoid driving while impaired might improve patient care and promote highway safety.

Adult↗
PubMed1988

Patient characteristics and eligibility in a Veterans Administration ambulatory care triage clinic.

We surveyed 5,225 consecutive patients presenting to a Veterans Administration (VA) Ambulatory Care Triage Clinic to ascertain the characteristics of patients and to assess the role of eligibility in determining disposition from triage. Most patients (66 per cent) had non-service connected (low eligibility) conditions and had no health insurance (64 per cent). Lack of service connected priority (high eligibility) did not influence access to hospitalization (8.3 per cent) or longitudinal outpatient care (24.5 per cent). The study suggests that veterans with no health insurance, with low eligibility for VA service, use the VA triage clinic for episodic medical care.

Aged↗
PubMed1988

Screening for pseudohypertension. A quantitative, noninvasive approach.

We studied 36 hypertensive men, aged 60 years or older, and compared direct intra-arterial diastolic blood pressure (BP) measurements, indirect cuff mercury sphygmomanometer measurements, and automatic infrasonic recorder (IR) measurements. We used a receiver operating characteristic curve to determine whether a difference between the cuff and IR diastolic BP could identify patients likely to have pseudo-hypertension (cuff-intra-arterial diastolic BP difference of 10 mm Hg or greater). We found that a cuff-IR difference of 4 mm Hg could identify the majority of patients with pseudo-hypertension (sensitivity, 93%; specificity, 64%; positive predictive value, 62%; negative predictive value, 93%). We concluded that the IR is an accurate, quantitative, noninvasive substitute for intra-arterial measurements and may be the preferred technique for screening and monitoring of blood pressure in elderly hypertensive patients.

Aged↗
PubMed1987

Age trends of lung cancer stage at diagnosis. Implications for lung cancer screening in the elderly.

Lung cancer increases in incidence with increasing age and is the leading cause of cancer death in the United States. While mass screening for lung cancer is not indicated, selective screening of high-risk target groups may be beneficial. We tested the hypothesis that lung cancer is initially seen at a less advanced stage with increasing age using incidence cases (N = 22,874) from the Centralized Cancer Patient Data System. The percent of lung cancer patients with local stage disease increased from 15.3% of those aged 54 years or younger, to 19.2% of those aged 55 to 64 years, to 21.9% of those aged 65 to 74 years, and to 25.4% of those aged 75 years or older. The percent with distant stage decreased from 48.7%, to 44.5%, to 40.3%, and to 36.7% for the same age groups, respectively. These age-stage trends persisted in subgroup analysis by sex, race, and histological subtype. Furthermore, analysis of 6332 patients who underwent surgical staging showed a greater likelihood of local stage disease with increasing age. Thus, compared with the young, the group aged 65 years or older is at a greater risk for lung cancer and has a higher proportion of lung cancer initially seen at local stage. The efficacy of selective screening for lung cancer in this target group warrants additional study.

Age Factors↗
PubMed1987

Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team.

As part of a controlled clinical trial of a geriatric consultation team (GCT), we investigated whether a GCT could affect the incidence of hospital-acquired complications in elderly patients. One hundred eighty-five patients, aged 75 years and older, were randomized into an intervention (N = 92) and a control (N = 93) group. Members of the intervention group received a GCT consultation and were routinely followed up throughout their hospitalization. The incidence of hospital-acquired complications for the entire study population was 38%. The type and rate of hospital-acquired complications in the intervention and control groups were not significantly different. Functional status on admission and admission to the psychiatry service were predictive for the occurrence of a hospital-acquired complication. In a broadly selected population such as this, the intensity of care available through a GCT was unable to reduce the occurrence of hospital-acquired complications. However, since this is only one aspect of a GCT function, and others may be of great importance, such aspects, and more targeted populations, must be evaluated before final conclusions can be reached about GCT efficiency.

Aged↗
PubMed1987

The value of clinical findings in the detection of normal pressure hydrocephalus.

We conducted a retrospective study of 627 individuals with dementia to determine whether clinical characteristics could identify individuals with normal pressure hydrocephalus (NPH) on computed tomography (CT) brain scanning. Fifty (8%) individuals had classical clinical characteristics of NPH: dementia, urinary incontinence, and gait disturbance. When this clinical trial was present, 12% of individuals had NPH on CT scan; when absent, only 3% had NPH. The clinical findings identified individuals with a 4-fold increase (p less than .001) of NPH on CT scan. Of the 50 individuals with the clinical trial, 6 had both clinical and CT scan findings consistent with NPH; 2 of these had shunt surgery, and 1 improved clinically. None of the 577 individuals without clinical findings had shunt surgery performed, including those with CT scan abnormalities consistent with NPH. We conclude that clinical characteristics can be used to identify individuals who need CT scanning for detection of NPH.

Aged↗
PubMed1987

A quantitative analysis of palliative care decisions in acute nonlymphocytic leukemia.

With the increasing incidence of cancer in elderly patients, decisions to adopt palliative care become particularly relevant to this patient population. In order to define characteristics of decisions to adopt palliative care, including those factors influencing whether a particular patient received palliation, the frequency of this therapeutic posture, and the duration of this treatment period, we performed a retrospective analytical survey of all patients with acute nonlymphocytic leukemia (ANLL) treated at Duke University Medical Center over the past ten years. Logistic regression analysis identified several potentially significant variables influencing the decision to adopt palliative care. Using a stepwise logistic model, the only independent variable associated with adoption of palliative therapy was initial treatment off a research protocol (P = 0.0001). Initial treatment off a research protocol was itself associated with older age (P = 0.0002), nonspontaneous onset of leukemia (P = 0.005), female sex (P = 0.003), and the absence of dependent children (P = 0.01) when examined by multivariate logistic regression. The palliative treatment interval was defined as the time between the discontinuation of aggressive treatment and the patient's death. Fifty-one percent, 119 of 235 patients, received palliative care; of these, 47% were palliated from the time of diagnosis and 53% were palliated only after receiving remission induction therapy. The median duration for the palliative care period was 46 days (50 days for the initially palliated group, 24 days for the group receiving aggressive therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗