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Biomedical subjects

M A Fox

Publications and source records attributed to M A Fox.

At least 37 records · Page 2Linked to original sources
PubMed1998

Measuring critical care redesign: impact on satisfaction and quality.

This report describes restructuring on four critical care units at an acute, tertiary care hospital in South-east Pennsylvania. Utilizing a Patient Centered Care conceptual framework that had been successfully applied in the medical-surgical areas, restructuring involved three main areas: revamping of work processes, inclusive of redesigned staff roles; environmental and facility changes; and enhancement of telecommunication and information systems. Preliminary analyses six months post redesign revealed improvements and maintenance in four outcomes areas--satisfaction, quality and efficiency, and costs of care.

Critical Care↗
PubMed1998

The evaluation of hospital restructuring efforts: satisfaction, quality, and costs.

This article reports on study evaluating the effects of hospital restructuring on patient satisfaction, nurse satisfaction, cost of care, and clinical quality. The restructuring involved facility redesign, telecommunications enhancement, and implementation of patient care processes incorporating multiskilled personnel and case facilitation systems. The results indicate improved patient and nurse satisfaction, decreased length of stay and variable cost per patient day, and good clinical outcomes.

Hospital Bed Capacity, 500 and over↗
PubMed1997

Attitudes toward genetic carrier screening for cystic fibrosis among pregnant women: the role of health beliefs and avoidant coping style.

In this study we examined the relations among psychosocial factors associated with pregnant women's attitudes toward genetic carrier testing for cystic fibrosis (CF). A sample of 511 pregnant women attending various health clinics for general prenatal care were educated about CF. Women's health beliefs, coping styles, and attitudes toward CF carrier screening were assessed. Results from structural equation modeling analyses indicated that women who perceived themselves as more likely to be carriers of the CF gene and who perceived greater benefits of screening were positively inclined toward genetic screening. Perceived barriers to screening were negatively associated with women's attitudes toward CF genetic testing. In addition, the findings suggest that some types of avoidant coping styles may indirectly influence one's decision to undergo genetic screening through perceptions of risk, benefits, and barriers. Given the advent of genetic screening options for many diseases, in this study we address some issue in women's attitudes toward prenatal screening that are relevant to a variety of genetic screening programs.

Adaptation, Psychological↗
PubMed1997

PCR-based screening for cystic fibrosis carrier mutations in an ethnically diverse pregnant population.

As the most common lethal autosomal recessive disorder in North America, cystic fibrosis (CF) is an obvious candidate for general population carrier screening. Although the identification of the causative gene has made detection of asymptomatic carriers possible, the extreme heterogeneity of its mutations has limited the sensitivity of the available DNA screening tests and has called into question their utility when they are applied to patients with no family history of the disease. The purpose of this study was to determine the technical feasibility, patient acceptance and understanding, and psychosocial impact of large-scale CF carrier screening in an ethnically diverse pregnant population. A total of 4,739 pregnant women attending prenatal clinics located in both an academic medical center and a large HMO were invited in person to participate. Of this group, 3,543 received CF instruction and assessments of knowledge and mood, and 3,192 underwent DNA testing for the six most common CF mutations, by means of a noninvasive PCR-based reverse-dot-blot method. Overall participation rates (ranging from 53% at the HMO to 77% at the academic center) and consent rates for DNA testing after CF instruction (>98%) exceeded those of most other American studies. The PCR-based screening method worked efficiently on large numbers of samples, and 55 carriers and one at-risk couple were identified. Understanding of residual risk, anxiety levels, and overall satisfaction with the program were acceptable across all ethnic groups. Our strategy of approaching a motivated pregnant population in person with a rapid and noninvasive testing method may provide a practical model for developing a larger CF screening program targeting appropriate high-risk groups at the national level, and may also serve as a paradigm for population-based screening of other genetically heterogeneous disorders in the future.

Academic Medical Centers↗
PubMed1996

Gastroesophageal reflux and tracheobronchial contamination after cardiac surgery: should a nasogastric tube be routine?

Nasogastric (NG) tubes are routinely used in patients undergoing cardiac surgery. This randomized study was designed to assess gastroesophageal reflux (GER) without a NG tube (control) compared with a NG tube managed either by gravity drainage (gravity) or continuous low-grade suction (suction). Antimony pH probes were placed in the lower esophagus and trachea after induction of anesthesia in 51 patients, and pH was recorded every 5 s until the time of tracheal extubation. GER was defined as reversible decrease in esophageal pH to less than 4.0. No significant difference was found between groups in age, weight, gender, duration of postoperative ventilation, morphine use, or antiemetic use. All indicators of GER were seen more frequently in the gravity group compared with the two other groups (P < 0.001). One episode of sudden decrease in tracheal pH was observed in a patient in the gravity group, indicating tracheal aspiration, which was associated with delayed extubation and postoperative pneumonia. The absence of a NG tube is not associated with reflux, probably since the gastroesophageal sphincter remains competent. NG tubes are not routinely necessary for cardiac surgery in patients without risk factors for GER, and increase reflux risk if managed without low-grade suction.

Aged↗
PubMed1996

The taste of intravenous thiopentone.

Patients sometimes notice an onion or garlic taste before losing consciousness with thiopentone. An assessment of 113 patients revealed that 42% of patients noticed this taste. The effect was observed less in older patients. There was no statistically significant difference in the incidence between men and women. Premedicated patients had a lower incidence, but this was explained by the greater proportion of older patients receiving a premedication. If the taste effect of thiopentone is genetically determined then it is a different gene to thiocarbamate which has about 75% tasters.

Adolescent↗
PubMed1994

Transmitral Doppler assessment of left ventricular diastolic function during coronary artery bypass surgery.

OBJECTIVE: To evaluate which Doppler transmitral velocity indices of left ventricular diastolic function change with alteration of left ventricular filling pressure. METHODS: Twenty-two patients undergoing coronary artery bypass surgery. The effect of fluid loading on indices derived from the transmitral Doppler waveform, recorded by a trans-oesophageal echocardiography, was evaluated using a generalised linear statistical model. RESULTS: E-wave maximum velocity, E-wave acceleration time and slope, E-wave deceleration slope, A-wave maximum velocity and E/A wave maximum velocity ratio showed significant changes after alterations in left ventricular filling pressure. E-wave deceleration time and E-wave maximum velocity/time velocity integral showed no significant change after fluid loading. CONCLUSION: Several commonly used Doppler derived indices of left ventricular diastolic function are significantly affected by changes in filling pressure of the left ventricle. This may limit the usefulness of the Doppler method for serial assessment of diastolic function when the left ventricular filling pressure has changed between assessments. Only the E-wave deceleration time did not show significant changes and might be a useful Doppler index for the serial measurement of left ventricular compliance but this needs to be confirmed with haemodynamic measurements.

Adult↗
PubMed1994

Renal function and proteinuria after cardiopulmonary bypass: the effects of temperature and mannitol.

We studied three groups of patients without previous renal impairment, undergoing elective coronary artery bypass surgery. Group H (n = 7) underwent open heart surgery using moderate hypothermia (28 degrees C); Groups N and M (n = 8, each) were managed at normothermia. The extracorporeal circuit was primed with Hartmann's solution 2.5 L with the addition of mannitol 0.5 g/kg in Group M. Serum concentrations of sodium and creatinine, and the urinary concentrations of microalbumin and N-acetyl-beta-D-glucosaminidase (NAG) were measured in each patient at six different time intervals: T0, 6 h prior to surgery; T1, between sternotomy and 45 min into cardiopulmonary bypass (CPB); T2, in the interval from 45 min into, to prior to weaning off CPB; T3, from coming off CPB to skin closure; T4, in the first 6 h in the intensive care unit; and T5, at 6 days postoperatively. Creatinine clearance (CCR) and fractional sodium excretion (FENA) were calculated at each time point. Urine output during CPB at Interval T2 was significantly higher in Group H compared to Group N (P = 0.03) but not Group M. We found no significant differences in CCR, FENA, microalbuminuria, and urinary NAG among the three groups at any time. However, there were overall significant changes in measured variables over time compared to baseline. We conclude that CPB is associated with a significant alteration in renal function as shown by increased FENA, microalbuminuria, and urinary NAG. The use of hypothermic or normothermic CPB and the use of prophylactic mannitol did not produce any significant modification of these changes.

Coronary Artery Bypass↗
PubMed1993

Filtration of shed mediastinal blood.

Re-infusion of shed blood carries the risk of re-infusing cellular debris. All re-infusion devices have some sort of integral filtration which is variably supplemented with a second intravenous filter. Using electron microscopy we have observed what debris is collected by secondary filtration. In 12 patients studied, nine out of 12 filters had significant amounts of cellular debris present, but not clearly related to increased rates of postoperative bleeding. Noncellular debris, silicon and strands of cellulose were also observed. Although we have not detected any clinically significant embolic phenomena from re-infusion of shed mediastinal blood, it seems prudent to include a second filter prior to re-infusion.

Blood Cells↗
PubMed1993

The Australian Incident Monitoring Study. Problems before induction of anaesthesia: an analysis of 2000 incident reports.

The first 2000 incidents reported to the Australian Incident Monitoring study (AIMS) were examined to identify those incidents which occurred preoperatively (defined as occurring prior to the commencement of general or regional anaesthesia). The 35 incidents, representing 1.7% of the total, which occurred in this time period were analysed with a view to identifying areas in which current practice could be improved. Almost all incidents led to significant delays in operating lists, and 9 resulted in cancellation of surgery. A number of areas of concern specific to the preoperative period were identified. Inadequate coordination between surgical and anaesthetic staff in patient preparation was a frequent cause of preoperative incidents. Improvement in this area may reduce surgical delays and patient morbidity. Problems with premedication drugs resulted in 8 of the 35 incidents, and care must be taken in the prescription and administration of these drugs to minimise adverse effects on patients. Only 2 cases of incorrect patient identification were reported. However, in view of its disastrous consequences, vigilance in patient identification by all members of the operating team, including the anaesthetist, is essential.

Accidents↗
PubMed1993

The Australian Incident Monitoring Study. Problems with regional anaesthesia: an analysis of 2000 incident reports.

There were 160 incidents associated with regional anaesthesia amongst the first 2000 incidents reported to the Australian Incident Monitoring Study. They were categorised into 6 groups; epidural anaesthesia (83), spinal anaesthesia (42), brachial plexus blocks (14), intravenous local anaesthesia (4), ocular blocks (3), and local infiltration (14). The largest single cause of incidents involved circulatory problems; these occurred in all the groups except brachial plexus block (30 cases of hypotension, 7 of arrhythmias, 3 of cardiac arrest, 2 of hypertension and 1 of myocardial ischaemia). There were 24 drug errors, of which 10 involved the "wrong drug" and 4 "inappropriate use". With the exception of these, all the remainder involved problems specific to regional anaesthesia: 26 inadvertent dural punctures; 19 failed or inadequate blocks; 14 dural puncture headaches (all cured by blood patches); 10 inadvertent total or high spinal blocks (of which 7 required artificial ventilation); 5 blocks on the wrong side or in the wrong patient; 3 late hypoxic incidents and a variety of miscellaneous problems. Three-quarters of all incidents occurred in the presence of an anaesthetist and over 90% in patients of ASA Groups I-III. Rapid recognition by the anaesthetist prevented many potentially life threatening events, and the only death was as a result of surgical bleeding.

Accidents↗
PubMed1993

The Australian Incident Monitoring Study. Physical injuries and environmental safety in anaesthesia: an analysis of 2000 incident reports.

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 56 (3%) involved environmental hazards or injuries to patients or staff. There were 17 cases of oral trauma (14 of tooth loss or damage, in 7 of which poor dentition played a role), 10 incidents involving problems with the operating table, 6 cases of skin or eye damage and 6 cases in which an electrical hazard was identified. Five incidents occurred during transport, and there were 4 cases of monitor induced trauma, 4 "needlestick" injuries and 4 miscellaneous incidents. Recommendations are made for trying to avoid or reduce the incidence of some of these problems.

Accidents↗
PubMed1993

The Australian Incident Monitoring Study. Problems associated with vascular access: an analysis of 2000 incident reports.

There were 65 incidents involving access to the vascular system amongst the first 2000 reported to the Australian Incident Monitoring Study. Thirty-three involved peripheral venous access (14 cases of extravascular extravasation, 8 of unintended arterial cannulation, 6 of disruptions to intravenous lines, and 5 of problems with infusion lines, taps, pumps and connectors). Eighteen cases involved central venous access (9 cases of arterial puncture with haematomas, 5 with morbidity and/or prolonged admission), 5 of catheter misplacement and pneumo- or hydro-thorax and 4 of problems arising from operator inexperience. Thirteen cases involved peripheral arterial access (5 involved equipment problems (3 with possible air embolism), 3 of mistaking an arterial for a venous line (drugs were injected in 2), 3 of losing arterial lines or signals, and 2 in which the presence of an arterial line placed the patient at risk). The anaesthetist should always question the continued integrity of any vascular access system, even when it has recently been shown to be functioning, and the possibility of later "migration" and misplacement should always be borne in mind. Whenever possible, correct placement of the tip should be checked (e.g. by visual inspection of the site, use of test doses, aspiration of blood, pressure measurement, X-rays). When there is more than one line, all lines and sites of access (e.g. 3-way taps) should be clearly labelled and checked before anything is injected or infused.

Accidents↗