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Biomedical subjects

M R Pratter

Publications and source records attributed to M R Pratter.

At least 19 recordsLinked to original sources
PubMed1996

Rapid-eye-movement-specific sleep-disordered breathing: a possible cause of excessive daytime sleepiness.

Some patients referred for polysomnography with complaints of excessive daytime sleepiness (EDS) and clinically suspected obstructive sleep apnea (OSA) have a respiratory disturbance index (RDI) < 10. Many would consider these patients not to have OSA. We reviewed 34 such patients to determine whether respiratory disturbances confined primarily to rapid eye movement (REM) sleep correlated with an objective criterion for EDS: a mean sleep latency (MSL) < 10 min. REM-specific events were quantified with indices calculated for REM sleep alone. Univariate linear regression showed that a REM-specific respiratory disturbance index (REM-RDI) and the transient arousal index (TAI) computed for REM sleep (REM-TAI) were associated with a low MSL (R2 = -0.35, p = 0.001; and R2 = -0.27, p = 0.01, respectively). In our subjectively sleepy patients with an overall RDI < 10, a REM-RDI > or = 15 had the highest predictive accuracy (82%) for an MSL < 10 min. Seventeen of the 34 study patients had a REM-RDI > or = 15. Their mean MSL was 8.3 +/- 0.8 min. We conclude that within a group of patients with daytime sleepiness, suspected OSA, and a normal RDI, there may be a subset who have clinically significant REM-specific sleep-disordered breathing.

Arousal↗
PubMed1996

Comparison of wire-guided and nonwire-guided radial artery catheters.

OBJECTIVE: To determine if either wire-guided-catheters (WGC) or nonwire-guided catheters (non-WGCs) are associated with a higher rate of successful arterial cannulation overall or when evaluated by a variety of patient and operator characteristics. DESIGN: Prospective clinical trial in a ten-bed adult medical-surgical ICU in a 500-bed university hospital. PATIENTS: Adults requiring arterial cannulation for hemodynamic monitoring or frequent blood sampling. A total of 116 attempted arterial cannulations were recorded, and 112 in 67 patients were acceptable for statistical analysis. RESULTS: Overall, no difference in success rates could be demonstrated between WGC and non-WGC. WGCs were associated with a higher success rate in patients with pulses characterized as absent or weak (78% vs 37%; p=0.01). WGCs also had a greater success rate than non-WGCs for more experienced operators, whether defined by seniority (83% vs 44%; p=0.02) or by experience at arterial catheterization (81% vs 48%; p=0.02). CONCLUSION: WGCs were not associated with better success rates overall than were non-WGCs, although there were higher success rates in several subsets of patients and/or operators. Because of their significantly higher costs, WGCs cannot be recommended for routine use for arterial catheterization. In cases where successful catheterization is essential, however, there are circumstances under which they may be the preferred equipment, depending on patient characteristics and operator experience.

Adult↗
PubMed1996

Asthma: better outcome at lower cost? The role of the expert in the care system.

Asthma is a common disease for which morbidity and mortality have been increasing. This despite advances in the scientific understanding of asthma and in the pharmacologic armamentarium available to treat it. The dichotomy between knowledge and outcomes led us to review asthma from a systems perspective. We have presented data first to document failure in the current system of care and then to examine factors associated with improved outcomes. We found a disparity in outcome and costs when care given by experts was contrasted with care given by generalists. We conclude that "expert-based" care systems are superior from the perspective both of the patient and of the insurer; medical outcomes are better at lower overall cost. Managed care companies are in a unique position to identify asthmatics and to shift them from generalist to expert-based care when appropriate.

Asthma↗
PubMed1995

Music improves patient comfort level during outpatient bronchoscopy.

STUDY OBJECTIVE: To determine the effect of music during bronchoscopy on patient perception of the procedure. DESIGN: Prospective randomized trial. SETTING: University-based bronchoscopy suite. PATIENTS: Twenty-one patients received music (M+), and 28 patients served as controls (M-). MEASUREMENTS AND RESULTS: Physiologic responses, subjective patient perceptions, and administered medications were monitored. After the procedure, the technician and the physician both rated their impression of the patients' comfort levels to see how accurately they correlated with actual patient reports. There was no difference in physiologic responses between the M+ and M- groups. The M+ patients reported significantly greater comfort (p = 0.02) and less cough (p = 0.03) than the M- group, while there was no difference in reported dyspnea P = 0.21). Both physicians and technicians were very inaccurate in their assessments of patient level of comfort. Medications given did not differ for the two groups. CONCLUSION: Music during bronchoscopy is a simple and inexpensive nonpharmacologic way to improve patient comfort.

Adult↗
PubMed1995

The physiologic effects of inhaled amphotericin B.

Our institution used an experimental protocol for the use of inhaled amphotericin B as a prophylactic measure to prevent fungal disease in severely immunocompromised patients. We did a prospective study of the physiologic effects of amphotericin B administration. We looked specifically at oxygen saturation levels, peak flow values, and symptoms of patients given amphotericin B. We collected data on a series of 18 patients and of 132 amphotericin B administrations. Four (22%) of the patients stopped treatments because of nausea and vomiting which were believed to be due to the inhaled amphotericin B. For the remaining patients, no treatment was stopped because of symptoms or physiologic changes caused by amphotericin B, although there were 9 instances of clinically significant bronchospasm as defined by a drop in peak flow of 20% or more, 9 clinically relevant increases in cough, and 3 clinically relevant increases in dyspnea. Forty-eight percent of the clinically relevant changes occurred in patient 8. Another 16% occurred in asthmatic subjects who were significantly more likely (p = 0.03) to experience a 20% or more drop in peak flow than were patients without asthma. The physiologic profile of the response to inhaled amphotericin B is acceptable.

Administration, Inhalation↗
PubMed1994

Respiratory care practitioners' attitudes toward patients with AIDS.

OBJECTIVE: To assess attitudes of respiratory care practitioners about AIDS and patients with AIDS. DESIGN: A questionnaire that explored attitudes about AIDS was disseminated throughout southern New Jersey. Identity of individual responders was protected carefully. RESULTS: One hundred fifty-nine responses were received. The majority of responders favored identification of patients with AIDS, segregation of those patients into AIDS wards, and then avoidance of the AIDS wards. There was some bias against patients with known high-risk behaviors (especially drug abuse), but once a patient had AIDS the fear of getting AIDS was the only factor that correlated (p = 0.001) with the desire to avoid AIDS patients. Thirty-nine percent of responders said that they used universal precautions less than 90 percent of the time, and no factor (including fear of AIDS and markers of education) predicted which therapists did not consistently use them. CONCLUSIONS: The desire to avoid AIDS represents a rational desire not to become infected with the HIV virus. This study documents an identify-and-avoid philosophy in lieu of careful use of universal precautions. Educational efforts need to emphasize that the use of precautions represents the only truly effective means of preventing infection with the AIDS virus and other communicable diseases.

Acquired Immunodeficiency Syndrome↗
PubMed1993

An algorithmic approach to chronic cough.

OBJECTIVES: To evaluate a stepwise approach to chronic cough that emphasized initial treatment of all patients with an antihistamine-decongestant for postnasal drip and to determine the value of routine bronchoprovocation challenge in the evaluation of chronic cough. DESIGN: Prospective trial using an algorithm for chronic cough in immunocompetent nonsmoking out-patients. SETTING: University-based pulmonary practice. PATIENTS: Forty-five patients met the inclusion criteria. The mean duration of cough was 140 weeks (range, 3 to 2080 weeks), and the mean severity of cough as assessed by patients on a four-point scale was "severe." RESULTS: Marked improvement and resolution (mean, 3.1 and 7.1 weeks, respectively), with resolution in 96% of patients. Antihistamine-decongestant therapy was beneficial in 39 of 45 patients and was the only therapy needed for 16 patients. Bronchoprovocation challenge had a negative predictive value of 100% and a positive predictive value of 74% for cough caused by asthma. No significant relationship was found between the time to cough resolution and duration or severity of cough. Eighteen percent of patients experienced a recurrence of cough at a follow-up interval of 3 months. CONCLUSIONS: A sequential approach to chronic cough that emphasizes initial treatment with an antihistamine-decongestant is effective. Bronchoprovocation challenge is useful in evaluating patients with chronic cough but can be delayed until the initial response to antihistamine-decongestant therapy has been assessed. The 18% incidence of recurrence highlights the fact that cough often is the manifestation of a chronic or recurring process that requires chronic or episodic therapy.

Adolescent↗
PubMed1993

The lack of a role for saline solution inhalation in bronchoprovocation challenge.

The purpose of this study was to look prospectively at the practice of prefacing methacholine bronchoprovocation challenge (BPC) with diluent challenge using physiologic saline solution (NaCl) as the diluent. We wished to determine whether NaCl challenge added to the safety or diagnostic accuracy of BPC. We studied 108 consecutive patients undergoing methacholine BPC. We determined (1) the FEV1 response of all patients to the inhalation of NaCl (the difference between the FEV1 before NaCl and the FEV1 after NaCl), and (2) the correlation between the response to saline solution and bronchial hyperresponsiveness (BHR) measured using methacholine. Paired Student's t testing demonstrated a small but significant difference between the values for FEV1 before and after NaCl for the group as a whole (n = 108; mean change, -0.9 +/- 4 percent [+/- SD]; p = 0.023). When the mean changes in the FEV1 after NaCl for the group with increased BHR (BHR+) (n = 62; mean, -1.1 +/- 4.9 percent) and the group with no increase in BHR (BHR-) (n = 46; mean, -0.6 +/- 2.4 percent) were contrasted, there was no significant difference between the two groups (p = 0.46). Only 4 of 108 patients had a drop in FEV1 of 10 percent or more after NaCl, with the greatest drop being 16 percent. All four patients were BHR+, but none had marked BHR. For the BHR+ group, there was no correlation between response to saline solution and subsequent response to methacholine (r = 0.02). We conclude that saline solution challenge adds time and expense to BPC without increasing the safety or yield of BPC. We suggest that NaCl challenge can be omitted from the standard performance of BPC.

Adolescent↗
PubMed1993

Bronchodilator reversal of bronchospasm and symptoms incurred during methacholine bronchoprovocation challenge. Documentation of safety and time course.

We undertook a prospective study of bronchoprovocation challenge (BPC) to look at issues of safety and reversibility of bronchospasm and symptoms induced by BPC. Over a 14-month interval, we documented 62 consecutive cases of bronchial hyperresponsiveness. During BPC, there was a statistically significant but clinically modest increase in both cough and dyspnea. Both bronchospasm and symptoms were readily reversed with a simple protocol of inhaled albuterol using a metered-dose inhaler with a spacer. Routine protocol was effective in every case; there was never a need for individualized physician intervention. Our prospective data document the safety of BPC; we could find no reason why BPC would need to be confined to the hospital. We conclude that BPC is a valuable clinical test which merits wider dissemination and use.

Adolescent↗
PubMed1992

Chronic cough as the sole manifestation of Hodgkin's disease.

A patient presented with a cough of three months' duration as the sole manifestation of mediastinal Hodgkin's disease. Systematic evaluation resulted in prompt diagnosis and specific successful treatment of both the Hodgkin's disease and the cough. This case emphasizes that specific therapy based upon an accurate diagnosis almost always results in effective treatment of chronic cough.

Adult↗
PubMed1992

Inpatient management of status asthmaticus.

We examined physician management of patients hospitalized for status asthmaticus at a university hospital. A retrospective review of consecutive admissions for status asthmaticus covering a 13-month period yielded 130 charts for review. We found that practice patterns with respect to documentation of severity of illness, medications, and documentation of efficacy of therapy fell short of the current state of knowledge with respect to treatment of asthma. Asthma is a treatable disease, and physician education needs to bridge the gap between current practice patterns and standards of optimal therapy as defined in the literature.

Adult↗
PubMed1991

Effect of triiodothyronine-induced thyrotoxicosis on airway hyperresponsiveness.

To determine whether thyrotoxicosis has an effect on the asthmatic state in subjects with mild asthma, airway responsiveness, lung function, and exercise capacity were measured in a randomized double-blind placebo-controlled trial before and after liothyronine (triiodothyronine, T3)-induced thyrotoxicosis. Baseline evaluation of 15 subjects with mild asthma included clinical evaluation, thyroid and routine pulmonary function tests, airway responsiveness assessment by methacholine inhalation challenge, and a symptom-limited maximal exercise test. For all subjects, the initial testing revealed that the dose of methacholine which provoked a 20% fall in forced expiratory volume in 1s (PD20) was in a range consistent with symptomatic asthma. There was no significant change in pulmonary function tests, airway reactivity (PD20), or exercise capacity in either the placebo or the T3-treated groups. Thyroid function tests confirmed mild sustained thyrotoxicosis in the T3-treated groups. We conclude that mild T3-induced thyrotoxicosis of 4-wk duration had no effect on lung function, airway responsiveness, or exercise capacity in subjects with mild asthma.

Adult↗