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Biomedical subjects

K C Stange

Publications and source records attributed to K C Stange.

At least 73 records · Page 4Linked to original sources
PubMed1994

The clinical utility of a day of hospital observation after switching from intravenous to oral antibiotic therapy in the treatment of pyelonephritis.

BACKGROUND: This study was undertaken to investigate the clinical utility of a widespread practice: the 24-hour in-hospital observation period that commonly follows when the treatment of patients hospitalized with acute pyelonephritis is switched from intravenous to oral antibiotics. A preliminary survey of infectious disease specialists confirmed the pervasiveness of this practice and the lack of scientific evidence to support it. METHODS: The clinical utility of in-hospital observation was examined by means of a retrospective chart review of 138 consecutive nonpregnant adult patients who were between the ages of 17 and 65 and had been admitted to a university hospital with a diagnosis of acute pyelonephritis. The progress notes, temperature charts, and laboratory test results were reviewed for any evidence of clinical relapse or adverse reaction to the antibiotic that occurred in the 24-hour period after the switch from intravenous to oral antibiotic therapy. RESULTS: Only two (1%) patients had evidence of clinical relapse within the study period. Five (4%) patients had adverse reactions to their oral antibiotic, none of which were serious. The 95% confidence interval for the percentage of patients who might experience a clinical relapse was from 1% to 5%; for adverse antibiotic reaction, 1% to 8%. CONCLUSIONS: This study shows the limited usefulness of an in-hospital observation period. Savings resulting from avoiding an extra day of hospitalization could amount to millions of dollars annually in the United States.

Acute Disease↗
PubMed1994

Family physicians' disagreements with the US Preventive Services Task Force recommendations.

BACKGROUND: The 1989 recommendations of the US Preventive Services Task Force (USPSTF) represent an emerging consensus about which clinical preventive services should be delivered. However, practicing physicians disagree with a number of the recommendations in the Task Force prevention guidelines, and the reasons for disagreement have not been widely explored. METHODS: A survey questionnaire assessing physician agreement or disagreement with the USPSTF recommendations was sent to all 1784 active members of the Ohio Academy of Family Physicians in October 1990. A factor analysis was performed on the items with which at least 5% of physicians disagreed. Associations of physician demographics and attitudes with the factor scores were then examined. RESULTS: At least 5% of the 898 responding physicians disagreed with 67 of 150 USPSTF recommendations. Physicians disagreed with the USPSTF recommendations in three ways: (1) they believed that screening for some cancers is appropriate, even though not recommended by the USPSTF; (2) they believed that screening for other diseases in some populations is appropriate, even though not recommended by the USPSTF; and (3) they disagreed with some USPSTF recommendations for screening that is considered time-consuming or intrusive. Further analyses showed that practice setting and experience with the USPSTF guidelines were predictive of all three disagreement factors. Physician age, race, residency training, and reasons for disagreement were associated with two of the three factors. CONCLUSIONS: Physician disagreement with the USPSTF recommendations was not random but clustered into three distinct factors. An opportunity exists to design educational interventions for targeted subgroups of physicians. The views of practicing physicians should be incorporated into future guidelines.

Adult↗
PubMed1994

How do family physicians prioritize delivery of multiple preventive services?

BACKGROUND: In spite of the recommendations of experts, little is known about the priority that physicians assign to various preventive services provided to patients within the time pressures and competing demands of the office visit. METHODS: A survey presenting the case of a 53-year-old woman was sent to a national random sample of 480 practicing family physicians. Physicians were asked which items on a list of preventive services they would provide during 5 minutes remaining at the end of an illness visit for sinusitis, and during a visit for a 30-minute physical examination. Descriptive analyses rank ordered the most commonly provided services. Additional analyses using chi-square and analysis of variance were used to characterize physicians who performed high and low levels of services recommended and not recommended by the US Preventive Services Task Force (USPSTF). RESULTS: Among 268 responding physicians, more than 50% provided smoking cessation advice, blood pressure, height, and weight measurements, and the scheduling of a return visit during the illness visit. During a physical examination visit, many other services, including breast examination, Papanicolaou test, pelvic examination, and ordering a mammogram were also commonly chosen. Physicians performing a high level of USPSTF-recommended preventive services and a low level of not recommended services were characterized by their young age, residency training, not being in solo practice, and greater experience with USPSTF recommendations. CONCLUSIONS: Physicians offer more preventive services during patient visits for physical examinations than during visits for illness. Physician characteristics associated with the delivery of recommended levels of preventive services may be useful in identifying interventions that will direct medical resources toward the most effective preventive services.

Adult↗
PubMed1994

Competing demands of primary care: a model for the delivery of clinical preventive services.

Despite a high level of support for the importance of clinical prevention, physician delivery of preventive services falls well below recommended levels. Competing demands faced by physicians during the medical encounter present a major barrier to the provision of specific preventive services to patients. These demands include acute care, patient requests, chronic illnesses, psychosocial problems, screening for asymptomatic disease, counseling for behavior change, other preventive services, and administration and management of care. This paper outlines how competing demands affect physician delivery of clinical preventive services and provides a model designed to help practicing physicians improve the delivery of preventive services. This model can be helpful in the planning of preventive interventions in primary care settings and can facilitate a better understanding of physician behavior.

Attitude of Health Personnel↗
PubMed1993

Use of antibiotics in preventing recurrent acute otitis media and in treating otitis media with effusion. A meta-analytic attempt to resolve the brouhaha.

OBJECTIVE: To determine the efficacy of antibiotics for prophylaxis of recurrent otitis media and treatment of otitis media with effusion (OME) in children. DATA SOURCES: MEDLINE from 1966 through April 1993, textbooks, Current Contents, and bibliographies of selected articles. STUDY SELECTION: Thirty-three studies initially identified were reviewed by three blinded reviewers assessing study quality and suitability for inclusion. Twenty-seven met inclusion criteria for the meta-analyses. DATA EXTRACTION: We abstracted quantitative data and calculated rate differences (RDs) using tympanometry as the preferred outcome measure. DATA SYNTHESIS: Nine studies of antibiotic prophylaxis of recurrent otitis media with 958 subjects had an RD of 0.11 (95% confidence interval [Cl], 0.03 to 0.19) favoring antibiotic treatment. Twelve studies of short-term patient outcomes of OME with 1697 subjects had an RD favoring antibiotics of 0.16 (95% Cl, 0.03 to 0.29), while eight studies using the ear as the outcome measure with 2052 ears studied had an RD of 0.25 (95% Cl, 0.10 to 0.40). No significant difference was shown between placebo and antibiotics (RD, 0.06; 95% Cl, -0.03 to 0.14) in the eight studies of longer-term outcome of OME. Subgroup analyses by antibiotic grouping, duration of treatment, and duration of disease did not show significant differences. CONCLUSIONS: Antibiotics appear to have beneficial but limited effect on recurrent otitis media and short-term resolution of OME. Longer-term benefit for OME has not been shown. The findings are limited by the failure of most studies to consider potential confounders and by inability to identify groups of patients most likely to benefit.

Acute Disease↗
PubMed1993

Severe megaloblastic anemia in a patient receiving low-dose methotrexate for psoriasis.

Severe megaloblastic anemia with a normal white blood cell and platelet count developed in a patient with psoriasis vulgaris who was receiving long-term, low-dose methotrexate. We believe she had methotrexate-induced folate deficiency anemia with isolated inhibition of the erythrocytic bone marrow line. We review hematologic toxicity from low-dose methotrexate. Physicians caring for patients who receive low-dose methotrexate should be aware that an increase in the erythrocyte mean corpuscular volume may be a useful indicator of folate deficiency and impending toxicity. In addition, folate supplementation may prevent this toxicity (even in patients who do not appear clinically to be folate deficient), although whether methotrexate efficacy diminishes is controversial.

Adult↗
PubMed1992

The importance of biopsychosocial factors in the development of duodenal ulcer in a cohort of middle-aged men.

This study prospectively evaluated psychosocial as well as biologic, behavioral, and demographic factors in the development of duodenal ulcer. Baseline data were collected in 1963 on 8,458 Israeli men over age 40 years who had no history of duodenal ulcer. The subjects were followed for 5 years, and 254 reported the development of radiographically proven duodenal ulcer. The average annual incidence was six per 1,000 subjects. Multivariable logistic regression analysis confirmed several previously reported risk factors: smoking (odds ratio (OR) = 1.64, 95% confidence interval (Cl) 1.25-2.16), greater age (60 years and over) (OR = 1.85, 95% Cl 1.25-2.74), lower salary (OR = 1.50, 95% Cl 1.14-1.96), and lower systolic blood pressure (less than 140 mmHg) (OR = 1.58, 95% Cl 1.16-2.15). In addition, logistic regression analysis revealed a significant association of duodenal ulcer incidence with preceding measures of family stress, emotional support, and coping style. These were: increased family problems (OR = 1.60, 95% Cl 1.19-2.16), low level of perceived love and support from subject's wife (OR = 2.06, 95% Cl 1.05-4.05), and restraining retaliation when hurt by coworkers (OR = 1.89, 95% Cl 1.19-3.00). This study confirms several previously reported risk factors and underlines the importance of stress, lack of social support, and coping style in the development of duodenal ulcer.

Adaptation, Psychological↗
PubMed1992

The focused physical examination. Should checkups be tailor-made?

The "complete physical examination" taught in medical schools is not always the best approach to clinical assessment of asymptomatic adults. The authors of this article review the controversy surrounding the utility of routine physical examination, advocating evolution in medical practice from use of the complete physical examination toward the focused physical examination.

Aged↗
PubMed1992

Physician agreement with US Preventive Services Task Force recommendations.

BACKGROUND: No large-scale work has yet assessed the reactions of physicians to the report of the US Preventive Services Task Force (USPSTF), despite its potential for fostering a consensus among practitioners. This study undertook a survey of family physicians to assess their agreement with the recommendations of the Task Force. METHODS: A survey containing the verbatim summary recommendations of the USPSTF was mailed to all 1784 active members of the Ohio Academy of Family Physicians. RESULTS: No evidence of selection bias was found among the 898 responding physicians. The average physician agreed with 88% of the recommendations. For a number of recommendations, however, particularly those in which the Task Force differed with the American Cancer Society, there was a high level of disagreement. Physician disagreement with the recommendations was associated with older age, not having completed a residency, male sex, less prior exposure to the USPSTF guidelines, and greater perception of the impracticality of applying them. CONCLUSIONS: The high level of agreement with most USPSTF recommendations implies that they represent an emerging consensus about which preventive services should be delivered. Attempts at USPSTF guideline dissemination should focus on recommendations with high agreement. Additional research is needed to assess the reasons for disagreement.

Age Factors↗
PubMed1992

Lead poisoning in a child after a gunshot injury.

Lead poisoning is a common disease that, if not detected, can lead to developmental delay and other serious sequelae. We report the case of a child with retained intracranial lead pellets from a gunshot injury, in whom elevated blood lead levels were detected approximately 1 year after the injury. No environmental source of lead was found, and a twin sister living in the same dwelling had considerably lower lead levels. The patient's lead levels diminished after each of four courses of chelation, but rebounded each time to potentially toxic levels after termination of therapy. Physicians should be particularly alert in screening for elevated lead levels in children with retained bullet fragments. In patients in whom removal of the bullet fragments is impractical, the potential risks of long-term chelation therapy must be weighed against the risks of lead toxicity.

Chelation Therapy↗
PubMed1991

Preventive medicine in primary care. Moving from theory to practice.

Primary care physicians are in a unique position to offer preventive services. They have access to patients when intervention may be most successful, and they see most patients over a long period, which allows for adequate follow-up. The challenges are choosing the most effective interventions and organizing records and office staff to facilitate delivery of preventive services. Preventive medicine may not be as dramatic or as immediately successful as curative medicine, but it can have a tremendous long-term impact on health and well-being.

Humans↗
PubMed1991

Health and illness behavior of Type A persons.

The complex and controversial relationship of type A behavior to myocardial infarction and other illnesses may be mediated through health habits and illness behavior. We hypothesized that type A persons tend to reject the sick role, delay in seeking medical care, seek convenient medical care facilities, are impatient for recovery, return to work before they have fully recovered, and are less likely to engage in positive health habits. A cross-sectional survey was conducted at a large corporation in Cleveland, Ohio. A detailed questionnaire that examined health-promoting and illness behaviors was sent to 385 managers, 54% of whom responded. Models tested using path analysis supported the hypotheses that type A persons are more likely than are type B employees to reject the sick role, delay in seeking medical care, be impatient for recovery, and return to work before a full recovery. The study findings imply that type A employees may be less likely to miss work for minor illnesses, but they may be prone to adverse outcomes from illnesses that require early care or assumption of the sick role. The hypothesis that type A persons are less likely to engage in positive health-habits behavior was not supported.

Adult↗
PubMed1991

Adverse reactions to amantadine prophylaxis of influenza in a retirement home.

OBJECTIVE: Controversy exists about the safety of following the recommendation of the Immunization Practice Committee of the Centers for Disease Control that nursing home residents be given amantadine prophylaxis during influenza outbreaks. This study was undertaken to define the incidence of adverse reactions to amantadine in the elderly and to identify risk factors for side effects. DESIGN: A retrospective cohort study. SETTING: A retirement home which offered amantadine prophylaxis to its residents during a presumed influenza outbreak. PARTICIPANTS: Of the 96 elderly residents, 79 accepted the offer of amantadine prophylaxis. MAIN OUTCOME MEASURES: Attributable adverse health outcomes as assessed by chart review. RESULTS: 41% of the people receiving amantadine had attributable adverse reactions, of which 22% were classified as severe. Severe adverse reactions were associated with residence in the assisted living section of the facility (P = 0.002), a greater number of underlying diagnoses (P = 0.009), congestive heart failure (P = 0.02), and high serum creatinine (P = 0.02). A person with none of these risk factors had a 7% chance of having a severe adverse outcome compared to a 70% chance for someone with all four risk factors. CONCLUSION: The findings raise concern that the prophylactic administration of amantadine to all elderly residents of nursing and retirement homes may be associated with a high incidence of unacceptable reactions, particularly among less healthy residents.

Aged↗
PubMed1991

Effect of the white blood count on the clinical management of the febrile infant.

BACKGROUND: The white blood count is commonly used in the evaluation of the febrile infant without a focal source of infection. This study describes the physician's use of diagnostic tests in this clinical situation and also evaluates the effect of an elevated white blood count (WBC) on diagnostic test ordering and patient management. METHODS: A case scenario describing a febrile infant was mailed to all 294 pediatric, family, general, and emergency physician members of the Academy of Medicine of Cleveland. Questions about test ordering and case management were asked, both before and after the patient's WBC was known. Physicians were randomly assigned to receive a case scenario with either a normal or an elevated WBC. RESULTS: Of the 294 physicians contracted, 196 (67%) returned usable questionnaires. Physicians ordered an average of 1.4 tests in the initial management of the case, for an average cost of $82. Emergency physicians ordered more tests than other physicians (2.4 vs 1.2 tests, P = .001). Once the WBC was known, physicians in the high WBC group ordered more additional tests than the normal WBC group (0.89 vs 0.33 tests, P less than .001), and were more likely to change to a more aggressive therapeutic management strategy (P less than .001). CONCLUSIONS: The cost of physician-ordered laboratory testing is significant for the clinical scenario of a febrile infant without a localizing source. An elevated WBC affects physician management by causing more tests to be ordered and by influencing some physicians to choose more aggressive management strategies.

Clinical Laboratory Techniques↗
PubMed1991

Demographic and health characteristics of participants and nonparticipants in a work site health-promotion program.

Work site health-promotion programs represent an increasingly common attempt by industry to improve the health of employees. The potential impact of programs is limited by nonparticipation, especially among demographic subgroups and those who could most benefit from health behavior change. The present study prospectively examined the relationship of personnel data and self-reported health habits and health status to participation in the health-promotion program at a research and development work site. Thirty-four percent of the 505 employees enrolled in the health-promotion program. White employees were 2.47 times as likely to participate as nonwhites (95% confidence interval, 1.59, 3.83). Those with health maintenance organization health insurance were 1.43 times as likely to participate as were employees with fee-for-service insurance (1.11, 1.84). There was no difference between participants and nonparticipants in self-reported health status, and only slightly more positive health habits were noted among participants. Seatbelt use was 1.65 times more common among participants (1.10, 2.49). The study results are reassuring that such programs do not enroll only the very healthy or those with healthy habits. However, the diminished enrollment of nonwhite employees supports concern that health-related programs may not equally reach all segments of the work force.

Adult↗
PubMed1991

Psychosocial predictors of participation in a work site health-promotion program.

An understanding of psychosocial factors associated with participation in health promotion programs could lead to targetted interventions to increase enrollment. This study used questionnaires to measure employees' perception of program efficacy, health attitudes, beliefs, social support, and stress prior to the introduction of a comprehensive health promotion program at a research and development work site. The association of these factors with enrollment in the program was then prospectively determined. In addition, open-ended questionnaires were used retrospectively to determine additional factors associated with participation. Of the above factors, only program efficacy was significantly associated with participation in the entire sample. Perceived social support was associated with participation among non-white employees. In open-ended questionnaires, a desire for health information, a desire for help with behavior change, and concern about health status were the most commonly given reasons for participating. The study findings imply that environmental factors operating during the enrollment period at the work site may be more powerful than preexisting attitudes and beliefs in determining participation.

Community Participation↗
PubMed1987

Moonlighting policy and practice in family practice residencies.

Moonlighting by residents is a controversial, but little-studied topic. A survey on moonlighting policy and practice was sent to all family practice residency program directors, and an 87 percent response rate obtained. Moonlighting is permitted by 97 percent of nonmilitary programs and is generally thought of by program directors as a positive educational experience. It is practiced by over two thirds of the second- and third-year residents in programs that monitor moonlighting. These residents spend an average of 28 hours each month moonlighting. The most commonly used moonlighting sites are hospital emergency rooms, followed by coverage for private practice physicians. Seventy percent of programs require approval for extracurricular work activity. Only 23 percent of residencies limit moonlighting for all residents, but 47 percent have had occasion to deny moonlighting privileges to individual residents.

Data Collection↗