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Biomedical subjects

K Kroenke

Publications and source records attributed to K Kroenke.

At least 19 recordsLinked to original sources
PubMed1992

Causes of persistent dizziness. A prospective study of 100 patients in ambulatory care.

OBJECTIVE: To determine the causes of persistent dizziness in outpatients. DESIGN: Consecutive adult outpatients presenting with a chief complaint of dizziness. SETTING: Four clinics (internal medicine, walk-in, emergency room, and neurology) in a teaching hospital. PATIENTS: Of 185 patients presenting during the 10-month study period, 51 (28%) had minimal or no dizziness at 2-week follow-up. Of the remaining 134 patients, 100 completed the study protocol (mean age, 62 years; range, 20 to 85 years). MEASUREMENTS: Evaluation included a detailed study questionnaire, standardized physical examination, vestibular testing by a neuro-ophthalmologist, laboratory tests, audiometry, and a structured psychiatric interview. Data were abstracted onto a standard form and reviewed by three raters. Raters independently assigned diagnoses using explicit criteria, with the final cause determined by consensus. RESULTS: Primary causes of dizziness included vestibular disorders (54 patients), psychiatric disorders (16 patients), presyncope (6 patients), dysequilibrium (2 patients), and hyperventilation (1 patient); dizziness was multicausal in 13 patients and of unknown cause in 8 patients. Many of those with a single primary cause, however, had at least one other condition contributing to their dizziness; only 52% of patients had a single "pure" cause. Thirty patients had a potentially treatable primary cause, the most common being benign positional vertigo (BPV) (16%) and psychiatric disorders (6%). Central vestibulopathies detected in 10 patients were presumably vascular or idiopathic in origin. No brain tumors or cardiac arrhythmias were found. CONCLUSIONS: Vestibular disease and psychiatric disorders are the most common causes of persistent dizziness in outpatients. In about 50% of patients with dizziness, more than one factor causes or aggravates symptoms. Life-threatening causes were rare, even in our elderly population.

Adult↗
PubMed1992

Symptoms in medical patients: an untended field.

Somatic symptoms are one of the leading reasons for medical outpatient clinic visits, with the most common symptoms having a prevalence of 10% or more. However, the usual diagnostic workups are often unproductive, with less than 1 in 5 symptoms having an organic explanation after the initial physical examination and laboratory testing. Therapy appears more effective for some symptoms than for others. Of patients with unspecified pain or gastrointestinal complaints, greater than 70% state that some type of treatment has been helpful, whereas less than 50% of individuals with fatigue, dizziness, numbness, insomnia, sexual dysfunction, anxiety, or depression report any relief. Future educational efforts and research need to focus on that majority of symptoms that are either psychiatric or unexplained, in order to improve our current evaluation and management strategies.

Humans↗
PubMed1992

Operative risk in patients with severe obstructive pulmonary disease.

BACKGROUND: We wanted to determine the risk of postoperative pulmonary complications and mortality in patients with severe chronic obstructive pulmonary disease. METHODS: We reviewed 107 consecutive operations performed in 89 patients with severe chronic obstructive pulmonary disease (forced expiratory volume in 1 second, less than 50% of predicted). RESULTS: Postoperative pulmonary complications occurred in 31 operations (29%) and were significantly related to the type and duration of surgery. Also, American Society of Anesthesiologists class approached significance as a predictor. Postoperative pulmonary complications occurred at higher rates in coronary artery bypass grafting and major abdominal procedures (60% and 56%) than in other operations involving general or spinal anesthesia (27%) or in procedures performed with the patient under regional or local anesthesia (16%). When the durations of the operations were classified as less than 1 hour, 1 to 2 hours, 2 to 4 hours, and more than 4 hours, the rates of postoperative pulmonary complications were 4%, 23%, 38%, and 73%, respectively. Regarding American Society of Anesthesiologists class, postoperative pulmonary complications occurred in 10% of patients in class II, 28% of those in class III, and 46% of those in class IV. In terms of life-threatening complications, there were six deaths and only two cases of nonfatal ventilatory failure. Notably, mortality clustered primarily in coronary artery bypass graft procedures. Five of 10 patients receiving coronary artery bypass grafts died, compared with one death after 97 non-coronary artery bypass graft operations (50% vs 1%). CONCLUSIONS: Although the risk of coronary artery bypass grafting deserves further study, noncardiac surgery carries an acceptable operative risk in patients with severe chronic obstructive pulmonary disease.

Aged↗
PubMed1991

Chronic fatigue syndrome: is it real?

Epstein-Barr virus is no longer considered an important cause of chronic fatigue syndrome. Instead, the disease is probably related to an underlying psychiatric disorder, subtle immunologic dysfunction, or an interaction between these two factors. A carefully taken history, physical examination, and simple laboratory testing are usually sufficient to establish the diagnosis. Therapy with antidepressants or nonsteroidal anti-inflammatory drugs may be effective in selected patients. Thorough follow-up conducted with empathy and optimism is important in all cases.

Fatigue Syndrome, Chronic↗
PubMed1991

Handouts: making the lecture portable.

Previous medical literature on preparing lecture handouts has focused on their use in student education, where as part of a course there is a series of lectures followed by an examination. Conversely, resident and practising physicians usually attend single lectures on individual topics in order to update and improve their clinical skills. Handouts designed for the latter type of lecture can serve as a useful resource in subsequent day-to-day teaching and patient care. This article examines the purpose, distribution, structure, and substance of such handouts. Guidelines to assist the speaker in preparing lecture handouts are discussed.

Education, Medical↗
PubMed1991

The adverse effects of hospitalization on drug regimens.

To determine the effect of hospitalization on errors in patients' drug regimens, 157 consecutive patients discharged on regimens of four or more drugs were identified, of whom 94 were eligible for study. Thirty-four (79%) of 43 local patients were interviewed within 1 month after discharge, and 28 (55%) of 51 patients who were mailed a questionnaire responded. Regimen errors were detected in 50% of both groups. Overall, 20 (32%) of 62 patients had incorrectly added or deleted a drug, and 11 (18%) were taking the correct drugs but had errors in dosing. Twelve potentially serious errors were detected. Patients with regimen errors had been discharged taking more drugs (6.1 vs 5.10) and tended to have more drug changes during hospitalization (2.7 vs 1.90). Particular attention should be paid to drug regimens during hospitalization and in subsequent follow-up visits.

Aged↗
PubMed1990

The prevalence of symptoms in medical outpatients and the adequacy of therapy.

Common symptoms account for substantial patient disability and health services utilization. To determine the prevalence of 15 symptoms and the adequacy of therapy, 500 medical outpatients were surveyed. The 410 respondents indicated which symptoms were "major problems" and what therapy, if any, had been helpful. Each symptom was present in at least 10% of patients, with the most prevalent symptoms being fatigue (33%) and back pain (32%). Patients were clustered into three groups: (1) 140 were asymptomatic or monosymptomatic, (2) 135 reported 2 or 3 symptoms, and (3) 135 had 4 or more symptoms. The majority (77%) of these symptoms had been previously reported to a physician. Whereas 80% of patients with pain syndromes and gastrointestinal complaints had obtained some therapeutic benefit, only 39% of the individuals with fatigue, dyspnea, dizziness, insomnia, sexual dysfunction, depression, and anxiety reported any relief. Better therapy is needed for these common outpatient complaints.

Adult↗
PubMed1990

Reducing polypharmacy in the elderly. A controlled trial of physician feedback.

A prospective, controlled trial to reduce polypharmacy in patients 65 years or older was carried out in the residents' clinic of a teaching hospital. Of 272 elderly patients surveyed, 89 (33%) were taking five or more prescription drugs. Recommendations to discontinue medications or to simplify regimens were formulated for 79 polypharmacy patients. Compared to 41 controls, the 38 patients whose physicians were informed of the recommended changes demonstrated a small but significant reduction in the mean number of drugs, the complexity, and the cost of their regimens. Physicians complied with eight (100%) of eight recommendations to simplify a dosage schedule, eight (62%) of 13 recommendations to substitute a new drug for the old one, and only eight (40%) of 20 recommendations to stop a medication (P = .04). Noncompliance usually resulted from patient refusal or from medications being prescribed by another provider. Whereas feedback to the primary physician is beneficial, more substantial reductions in outpatient polypharmacy may require overcoming patient barriers and limiting the number of prescribing physicians.

Aged↗
PubMed1989

Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome.

PURPOSE AND PATIENTS AND METHODS: Many symptoms in outpatient practice are poorly understood. To determine the incidence, diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of 1,000 patients followed by house staff in an internal medicine clinic over a three-year period. The following data were abstracted for each symptom: patient characteristics, symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed, and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated by means of the schedule of prevailing rates for Texas employed by the Civilian Health and Medical Program of the Uniformed Services for physician reimbursement. RESULTS: A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation were noted, with 38 percent of the patients reporting at least one symptom. Although diagnostic testing was performed in more than two thirds of the cases, an organic etiology was demonstrated in only 16 percent. The cost of discovering an organic diagnosis was high, particularly for certain symptoms, such as headache ($7,778) and back pain ($7,263). Treatment was provided for only 55 percent of the symptoms and was often ineffective. Where outcome was documented, 164 (53 percent) of 307 symptoms improved. Three favorable prognostic factors were an organic etiology (p = 0.006), a symptom duration of less than four months (p = 0.009), and a history of two or fewer symptoms (p = 0.001). CONCLUSION: The classification, evaluation, and management of common symptoms need to be refined. Diagnostic strategies emphasizing organic causes may be inadequate.

Ambulatory Care↗
PubMed1988

Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome.

Although fatigue is one of the most common complaints in ambulatory care, research has been minimal. Of the 1159 consecutive patients surveyed in two adult primary-care clinics, 276 (24%) indicated that fatigue was a major problem. Fatigue was more prevalent in women than in men (28% vs 19%). Extensive clinical, laboratory, psychometric, and functional data were gathered for 102 fatigued patients and 26 controls. Laboratory testing was not useful in detecting unsuspected medical conditions or in determining the cause of fatigue. Depression or somatic anxiety or both were suggested by screening psychometric instruments in 82 fatigued patients (80%) compared with three controls (12%). Global dysfunction was marked, as reported by patients on the Sickness Impact Profile. The mean score on the Sickness Impact Profile of 11.3 for fatigued patients is similar to that reported for patients with major medical illnesses. After one year of follow-up, only 29 fatigued patients (28%) had improved. The high prevalence, persistence, and functional consequences of fatigue mandate a search for effective therapy.

Adult↗
PubMed1988

The unproven utility of preoperative urinalysis. Clinical use.

We investigated the utility, ie, relevance to clinical outcome, of routine preoperative urinalysis with a retrospective study of 200 clean-wound, orthopedic, nonprosthetic knee procedures. Physicians primarily order a preoperative urinalysis to detect infection, because of the purported relationship between remote infection and surgical wound infection. We found that preoperative urinalysis is uniformly ordered, with a high prevalence of abnormal results (15%) but a low physician-response rate (29%). Wound infection was rare, but there was no difference in frequency of wound infection between patients with normal and abnormal results of urinalysis. We conclude that the utility of routine preoperative urinalysis is unproven. Current practice does not agree with the rationale for ordering this test, nor does published literature support it. Although data are inadequate to fully define the appropriate use of preoperative urinalysis, we suggest clinical recommendations and avenues for further research.

Adult↗
PubMed1987

Poster sessions.

Explore the source record for details and available documents.

Communication↗
PubMed1987

Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization.

Most studies of modifying test ordering have focused on costs. Questions not addressed are whether programs to reduce testing lead to a higher proportion of clinically indicated tests and is underutilization an adverse outcome of such programs? To investigate this, we studied the house staff's ordering of three common laboratory tests at baseline and after educational and administrative interventions. Over a 2-year period, 3,603 urine cultures, sputum cultures, and admission urinalyses were reviewed. A lecture emphasizing the indications for these tests followed by chart audit and weekly feedback increased the proportion of clinically indicated tests. Subsequently, an administrative intervention requiring the intern to list the reason for ordering the test on the laboratory request form further improved test ordering. Underutilization, defined as a failure to order a potentially indicated test, was assessed during two representative periods. The "underutilization rate" (omitted tests per 100 patients) was no worse during maximal intervention than it was 9 months after the last intervention (7.7 vs. 11.1, NS). No immediate adverse consequences resulted from tests not ordered. Our findings indicate that it may be possible to selectively reduce the ordering of unnecessary tests without sacrificing quality of care.

Clinical Laboratory Techniques↗