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Biomedical subjects

P Kemper

Publications and source records attributed to P Kemper.

At least 19 recordsLinked to original sources
PubMed2002

[Late pulmonary manifestation of ovarian and breast cancer--which contribution provide immunohistochemical techniques?].

The two case studies are describing 2 females with tumor-suspicious lung opacities including pleural effusions. Both patients have had a smoking history of more than 20 packyears and both underwent surgery for a breast respectively an ovarian cancer 10/15 years before. Conventional staining of the biopsies does not allow in most cases the differentiation between a primary lung carcinoma or the metastasis of an extrapulmonary tumor. Immunohistochemical techniques can give clues as to the origin of the primary tumor. The contribution of these methods in finding the correct diagnosis in the two presented cases is discussed. The cooperation between clinician and pathologist should be emphasized. The transfer of all important information is essential.

Aged↗
PubMed2001

[Does the inhalation of a 1% L-menthol solution in the premedication of fiberoptic bronchoscopy affect coughing and the sensation of dyspnea?].

BACKGROUND: Inhalation of l-menthol inhibits cough and has been shown to reduce respiratory discomfort associated with loaded breathing. We investigated the effect of the inhalation of a 1% l-menthol solution in the premedication of fiberoptic bronchoscopy (FB) on the frequency of cough and the irritability of the tracheobronchial mucosa during FB in a blinded, randomized and placebo controlled study. METHODS: 64 pat. (30-78 yrs, 55 males) underwent routine FB. Premediction: atropine and hydrocodone s.c., inhalation of oxybuprocain by means of a jet nebulizer, sedation on demand. Verum-group: inhalation of 3 ml 1% l-menthol-solution. Placebo-group: 3 ml 0.05% l-menthol (to provide the typical smell). Before and after inhalation peak respiratory flow (PEF) was registered, during FB the frequency of cough was measured. The bronchoscopist scored the irritability of the tracheobronchial mucosa using a visual analog scale. The patients answered a questionnaire addressing their perception of dyspnea and cough on the day after FB compared to the day before. RESULTS: The cough counts didn't show a significant difference between the groups. The irritability of the mucosa was increased in the verum group (main bronchus verum 62.2 +/- 22, placebo 48.6 +/- 23 [mm vissual analog scale, p = 0.03]). Cough and dyspnea reported by the patients decreased on the day after FB significantly compared to the day before (no difference between the groups). The inhalation of 1% l-menthol induced a significant increase of the PEF (verum 307 +/- 103 pre, 329 +/- 84 post [l/min, p = 0.003]) compared to placebo. CONCLUSIONS: The inhalation of 1% l-menthol did not enhance the tolerability of the FB. However, l-menthol induced a significant increase of the PEF immediately after inhalation. Finally sensation of dyspnea was decreased in both groups at the day post FB.

Administration, Inhalation↗
PubMed2001

[Stabilization of two patients with brittle asthma by inhaled beclomethasone dipropionate with small particle size].

UNLABELLED: Two patients with brittle asthma whose bronchial obstruction was less variable during treatment with HFA-beclomethasone (HFA-BDP) solution aerosol than with other previous treatments are presented here. In order to evaluate whether this improvement was related to the smaller particle size of the new formulation (MMAD 1.1 mu vs 4 mu with the CFC-formulation) both patients participated in a prospective case study sequence. METHOD: During a 4 week run-in both patients inhaled 200 micrograms of HFA-BDP (Ventolair) BID from the Autohaler followed by 4 weeks of treatment with 500 micrograms CFC-BDP (Aerobec) BID from the Autohaler in study phase 1 and 4 weeks of treatment with 200 mcg HFA-BDP (Ventolair) BID from the Autohaler in study phase 2. During the entire study period other concomitant medications remained unchanged. The dose of CFC-BDP was chosen to be 2.5 times higher than the HFA-BDP dose to get approximately comparable amounts of intrabronchial deposition. During the study Peak-Flow and concomitant medications were recorded daily. RESULTS: Both patients showed significantly higher Peak-flow values during treatment with Ventolair (HFA-BDP) than during treatment with AeroBec (CFC-BDP). P-values were p < 0.0001 and p < 0.005 for patient 1 and 2 respectively. CONCLUSION: At a comparable intrabronchial dose these two cases of brittle asthma showed significant improvements in control of bronchial obstruction with a BDP-formulation of smaller particle size. This is an indicator that smaller airways in the periphery of the lung participate in the inflammatory process leading to bronchial obstruction and that deposition of inhaled steroids in this region could have therapeutic advantages.

Administration, Inhalation↗
PubMed2000

Does type of health insurance affect health care use and assessments of care among the privately insured?

OBJECTIVE: To inform the debate about managed care by examining how different types of private insurance-indemnity insurance, PPOs, open model HMOs, and closed model HMOs-affect the use of health services and consumer assessments of care. DATA SOURCES/DATA COLLECTION: The 1996-1997 Community Tracking Study Household Survey, a nationally representative telephone survey of households, and the Community Tracking Study Insurance Followback Survey, a supplement to the Household Survey, which asks insurance organizations to match household respondents to specific insurance products. The analysis sample includes 27,257 nonelderly individuals covered by private insurance. STUDY DESIGN: Based on insurer reports, individuals are grouped into one of the four insurance product types. Measures of service use include ambulatory visits, preventive care use, hospital use, surgeries, specialist use, and whether there is a usual source of care. Consumer assessments of care include unmet or delayed care needs, satisfaction with health care, ratings of the last physician visit, and trust in physicians. Estimates are adjusted to control for differences in individual characteristics and location. PRINCIPAL FINDINGS: As one moves from indemnity insurance to PPOs to open model HMOs to closed model HMOs, use of primary care increases modestly but use of specialists is reduced. Few differences are observed in other areas of service use, such as preventive care, hospital use, and surgeries. The likelihood of having unmet or delayed care does not vary by insurance type, but the reasons that underlie such access problems do vary: enrollees in more managed products are less likely to cite financial barriers to care but are more likely to perceive problems in provider access, convenience, and organizational factors. Consumer assessments of care-including satisfaction with care, ratings of the last physician visit, and trust in physicians-are generally lower under more managed products, particularly closed model HMOs. CONCLUSIONS: The type of insurance that people have-not just whether it is managed care but the type of managed care-affects their use of services and their assessments of the care they receive. Consumers and policymakers should be reminded that managed care encompasses a variety of types of insurance products that have different effects and may require different policy responses.

Adult↗
PubMed2000

The Community Tracking Study analyses of market change: introduction.

OBJECTIVE: To introduce two articles and describe methods that are common to them. DATA SOURCES/STUDY SETTING: Interviews conducted in person in 1996/1997 with leaders of organizations involved in the financing and delivery of healthcare. STUDY DESIGN: As part of the Community Tracking Study, 12 metropolitan statistical areas (MSAs) were selected randomly from MSAs with populations over 200,000. Researchers made baseline site visits to these communities and conducted from 36 to 60 interviews, depending on the size of the site. The communities were compared to identify common patterns of change and differences across communities. DATA COLLECTION/EXTRACTION METHODS: Researchers conducted interviews with a broad cross-section of leaders in each community. Interview modules were designed to obtain multiple perspectives on a question. PRINCIPAL FINDINGS AND CONCLUSIONS: Fundamental changes in the way care is actually delivered is likely to lag behind the extensive changes in organizational relationships that are taking place.

Community Health Services↗
PubMed2000

Do HMOs make a difference?

The growth of managed care has prompted questions about the effects of health maintenance organizations (HMOs) on consumers. This Issue Brief reports the results from a large national study of the privately insured population. No detectable difference was found between HMOs and other types of insurance in the use of three costly services--inpatient care, emergency room use and surgeries--and differences in reports of unmet need or delayed care are negligible. Differences for other measures pose a trade-off for consumers: HMOs provide more primary and preventive services and lower financial barriers to care, but they provide less specialist care and raise administrative barriers to care. In addition, patients in HMOs report less satisfaction, less trust in physicians and lower ratings of physician visits. These findings have implications for the current policy debate about managed care.

Community Participation↗
PubMed1999

Changes in the scope of care provided by primary care physicians.

BACKGROUND: Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. METHODS: We analyzed data from the 1996-1997 Community Tracking Study Physician Survey. Telephone interviews were conducted with 12,385 physicians (reflecting a response rate of 65 percent) who were drawn from a representative random sample of physicians providing direct patient care in the continental United States and not employed by the federal government. The analysis was based on responses from the 7015 primary care physicians and 5092 specialists who had been in practice for at least two years. RESULTS: Thirty percent of the primary care physicians and 50 percent of the specialists reported that the scope of care provided by primary care physicians had increased during the previous two years. Twenty-four percent of the primary care physicians and 38 percent of the specialists reported that the scope of care expected to be provided by primary care physicians was greater than it should be. According to multivariate analysis, primary care physicians other than general or family practitioners (i.e., pediatricians and general internists), those who were in one- or two-physician practices, those who received revenues from capitation, and those who served as gatekeepers for their patients' care were significantly more likely to report that the scope of care they were expected to provide was greater than it should be. CONCLUSIONS: The finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouses concern about the potential impact of changes in the delivery of health care. The associations we found between financial and administrative aspects of managed care and physicians' concern about the scope of care they provide to their patients deserve careful consideration.

Data Collection↗
PubMed1999

[Withdrawal from the respirator (weaning) in long-term ventilation. The results in patients in a weaning center].

BACKGROUND AND OBJECTIVE: Patients subjected to an increased load and with a decreased capacity of their respiratory muscles may be difficult to wean from mechanical ventilation. Using a weaning strategy with a focus on unloading respiratory muscles may be successful even after long-term mechanical ventilation. In a prospective uncontrolled study, we examined the outcome of our weaning protocol. PATIENTS AND METHODS: Under prolonged mechanical ventilation in outlying intensive care units (44.3 +/- 38.1 days) 232 patients (64.8 +/- 12.7 years, 149 males, 83 females) with the following underlying diagnoses were investigated: chronic obstructive pulmonary disease (54.3%), neuromuscular diseases (16%), thoracic restriction (10.8%), chronic left heart failure (7.3%), postsurgical ventilatory failure (6.9%) and miscellaneous conditions (4.7%). Our weaning strategy was focused on type of mechanical ventilation, endotracheal tubes, non-invasive interface, oxygen supply and transport capacity, body position and home mechanical ventilation, if an increased load or a decreased capacity of the respiratory muscles remained after weaning. RESULTS: Altogether 65% of the patients (n = 152) were weaned in a mean duration of 7.5 days. Intermittent home mechanical ventilation followed in 45 patients (19.4%). In our hospital died 64 patients (27.6%). After a stay of 19.7 +/- 12.2 days in our hospital 72.4% of the patients (n = 168) were discharged. The postdischarge 3-month mortality of the cohort was 36.5%. CONCLUSION: Applying our weaning strategy about 65% of the patients requiring long-term mechanical ventilation were successfully weaned. Weaning was achieved in approximately one fifth of the time previously spent on mechanical ventilation. However, the 3-month mortality of the investigated cohort was 36.3%.

Aged↗
PubMed1999

[Current value of intrapleural fibrinolysis in the treatment of exudative fibrinous pleural effusions in pleural empyema and hemothorax].

Intrapleural administration of fibrinolytic agents has been in use for fifty years; it has, however, been of clinical importance only for the last twenty years. Parallel to clinical reports procoagulant and fibrinolytic activities in pleural effusions are studied. Most types of pleural injury are characterised by fibrin deposition in the pleural space promoted by concurrent local abnormalities of pathways of fibrin formation and its clearance. Many of the studies of intrapleural fibrinolytics are uncontrolled and retrospective or small and are therefore of limited statistical value. Only five of the studies which are presented in the table are controlled and comparative studies. Intrapleural fibrinolytic therapy was used in exudative fibrinous multi-loculated pleural effusions, pleural empyemas and haemothorax. The global success rate of the studies cited were between 44% and 100%, in most cases more than 80%. The great differences in success rates are due to variations in the pleural diseases and stages of the clinical course, different success criteria, different dosages of fibrinolytic agents, different durations of clamped chest tube drainage and different starting points of therapy during the hospital course. The number of patients enrolled in each study ranged from 8 to 98, the number of children ranged from 2 to 9. Intrapleural fibrinolytic treatment is associated with rare adverse effects. There is no significant systemic fibrinolytic activity of intrapleural fibrinolysis. Intrapleural administration of streptokinase has been reported to lead to antibody formation. Hence, intrapleural fibrinolytic therapy is a useful adjunct in the management of exudative fibrinous multi-loculated pleural effusions, pleural empyemas and haemothorax. There is an increased volume of pleural fluid drainage during the treatment phase, and intrapleural fibrinolysis may reduce the need for more invasive surgical procedures. On the basis of the data of literature we recommend to use a single daily dose of 250,000 U streptokinase or 100,000 U urokinase in 50-100 ml normal saline instilled into a chest tube and to maintain dwell times of 2 to 4 hours. Therapy can be continued up to 2 weeks. The pleural space can be drained by large bore chest tubes or small drainage catheters, both radiologically guided, without preference for one method.

Empyema, Pleural↗
PubMed1999

The scope of care expected of primary care physicians: is it greater than it should be?

The United States has long relied on specialist physicians more heavily than other countries, and some policy experts have repeatedly recommended that the share and role of primary care physicians (PCPs) be increased as a way of providing cost-effective care. The growth of managed care, changing practice arrangements and new medical technology are forces that may be increasing the role of PCPs. This Issue Brief reports findings published in the New England Journal of Medicine showing that many physicians believe the scope of care provided by PCPs without referral to specialists is increasing. Moreover, almost a quarter of PCPs report that the scope of care they are expected to provide is greater than it should be. The likelihood of PCPs' concern is related to specific managed care techniques, practice size and specialty, among other factors.

Forecasting↗
PubMed1998

Ability to obtain medical care for the uninsured: how much does it vary across communities?

CONTEXT: Communities differ in the way that medical care for medically indigent persons is organized and delivered, which is likely to result in differences across communities in the ability of uninsured persons to obtain medical care. Changes in the health care system, many of which are driven locally, may further exacerbate these differences. OBJECTIVE: To examine the extent of variation across US communities in the ability of uninsured persons to obtain medical care and the extent to which health status and other characteristics of the uninsured population account for these differences. DESIGN: Analysis of the 1996-1997 Community Tracking Study Household Survey. SETTING: A nationally representative sample of the US civilian, noninstitutionalized population residing in 60 randomly selected communities. Larger sample sizes were obtained for 12 of these communities, which were randomly selected to represent metropolitan areas in the United States with more than 200000 persons. PARTICIPANTS: A total of 60 446 individuals and 7200 uninsured persons. MAIN OUTCOME MEASURES: The percentage of persons who either did not obtain needed medical care in the previous year or postponed receiving needed medical care in the previous year. RESULTS: Differences between communities with the highest percentage of uninsured persons reporting difficulty obtaining care and communities with the lowest percentage were more than 2-fold (41.4% vs 18.5%, P<.05). Little of the variation across communities is accounted for by differences in health status or sociodemographic characteristics of the uninsured population. The pattern of variation across communities in the ability of uninsured persons to obtain medical care is not correlated with variations in the ability of privately insured persons to obtain care (Pearson r, 0.04). Simulation results indicate that expanding private or public insurance coverage would not only increase the ability of uninsured persons to obtain medical care but would also reduce the variation across communities. CONCLUSIONS: If people are uninsured, where they live is an important factor in determining the difficulty they have in obtaining care. This is likely to persist given that care for uninsured persons is driven largely by state and local policy, and health system changes are constraining clinicians' ability and willingness to serve uninsured persons in many parts of the country.

Data Collection↗
PubMed1998

The uninsured getting care: where you live matters.

A substantial number of Americans--41 million people--do not have health insurance; this represents a 16 percent increase in the uninsured since 1990. Further, many studies show that the uninsured have significantly more difficulty than the insured in getting needed care. This Issue Brief discusses Health System Change (HSC) findings from its Community Tracking Study showing that the ability of those without coverage to get needed care varies considerably across communities. In addition, HSC's study shows that the personal characteristics of the uninsured explain very little of this regional variation. These findings are the first step in helping decision makers understand how the dynamics of communities and the safety nets within them affect the medically indigents' ability to obtain needed care.

Community Health Services↗
PubMed1998

[Bleomycin-induced pulmonary fibrosis following chemotherapy of ovarian granulosa cell tumor].

Bleomycin is used in the cytostatic therapeutical management of a variety of malignant tumours. The development of an interstitially accentuated pulmonary disease is a dreaded complication; this side effect may occur dose-related or not dose-related. We report on a 52-year old female patient with recurrent tumour after adnexectomy because of granulosa cell tumour, surgical re-intervention and subsequent polychemotherapy with cisplatin, etoposid and bleomycin (PEB regimen). Following this, the patient developed rapidly progressing lung fibrosis. There was no improvement in spite of combined high dose antibiotic and corticosteroid therapy. The patient finally died of respiratory insufficiency. Upon autopsy, apart from a circumscribed loco-regional tumour recurrence the clinical diagnosis of well advanced interstitial lung fibrosis presenting as so-called cytostatic pneumopathy was found. Immunohistochemical investigations using so-called proliferation markers revealed a markedly increased, centrifugally accentuated proliferative activity of both mesenchymal cells and of atypical pneumocyte regenerates, originating in areas of advanced parenchymal transformation and proceeding towards areas of supposedly intact lung tissue, a finding seen as an impressive histomorphological correlate of the clinically observed rapid progression of the disease. The development of a so-called bleomycin lung ist demonstrated from the formal pathogenetical point of view and correlated with the clinical course. The comparatively rapid shift of an expression of mediator systems with inflammatory properties towards local pulmonary or mesenchymal cells must be interpreted as the reason for the course of the disease, which in later phases could no longer be influenced by anti-inflammatory medication. These findings underline impressively the importance of early detection of developing pulmonary complications following cytostatic therapy. Apart from imaging techniques such as chest x-rays and HRCT, monitoring by 99mTc-DPTA inhalation is a very promising method for early demonstration of pulmonary alterations caused by cytostatically acting medication. This method registers precisely disturbances in pulmonary membrane permeability by measuring the radio nucleotide absorption rate along the alveolar-capillary membrane. In a therapeutical approach, next to the standard procedure of high-dose administration of corticosteroids, the influence of non-steroidal antiphlogistics and antioxidants is analysed, the growing knowledge on the cellular and molecular level possible leading to future therapeutical strategies, although the complex interactive mechanisms are still not completely understood.

Antibiotics, Antineoplastic↗
PubMed1997

The amount, distribution, and timing of lifetime nursing home use.

OBJECTIVES: Information on lifetime nursing home use is needed to design and evaluate long-term care financing reforms. Whereas a number of studies have estimated mean lifetime use or its distribution, very little is known about variation in use among subgroups of the population, the timing of use, the number of distinct episodes of care experienced by nursing home users, and the risk and expected use at ages other than age 65. The purpose of the study was to fill these gaps in knowledge. METHODS: The study used a data base constructed to represent decedents who used nursing homes. The sample was derived from the sample of discharges collected as part of the 1985 National Nursing Home Survey. Weights were constructed for the purpose of making projections of remaining lifetime nursing home use at selected ages in 1995. RESULTS: There was considerable variation in lifetime use among demographic groups. Overall, estimates of the amount of use remaining at selected ages tended to be relatively constant at approximately 1 year. Mean years until nursing home admission, however, decreased sharply from almost 40 years at age 45 to approximately 5 years at age 85. CONCLUSIONS: The distribution of lifetime use was highly skewed, providing support for efforts to spread risk through public or private insurance. With roughly one quarter of all use occurring after 5 years of nursing home residence, however, a substantial share of use would exceed benefit maximums that are part of many proposals for public financing of long-term care as well as private insurance policies.

Adult↗
PubMed1996

[Intermittent self-ventilation in torsion scoliosis. Possibilities and limits].

BACKGROUND: In patients with hypercapnic respiratory failure due to restrictive lung diseases home mechanical ventilation leads to improvement of daytime blood gases and symptoms. In this paper we regard the possible pitfalls and complications associated with intermittent mechanical ventilation in patients with kyphoscoliosis. PATIENTS AND METHODS: From 1990 to 1994 we treated 30 patients suffering from severe kyphoscoliosis with home mechanical ventilation. RESULTS AND CONCLUSIONS: 1. As our cases show in the prehospital phase before initiating home mechanical ventilation there is still room for the outpatient pneumologists to improve their knowledge and awareness of symptoms and treatment of chronic respiratory failure. 2. In the subsequent inpatient phase and specialised center must be aware and experienced in regarding possible problems inherent with home mechanical ventilation. 3. After discharge during chronic home mechanical ventilation a good cooperation between the center, patient, relatives, general services and general pulmolgists is necessary. The centers should offer training courses for the caring persons and general pneumologists.

Adult↗
PubMed1996

[Intermittent self-ventilation after respirator weaning].

BACKGROUND: Weaning from the mechanical ventilator often proves to be difficult after prolonged ventilation due to excessive load or decreased capacity of the respiratory muscles. In the present retrospective study we examined the impact of the nocturnal mechanical ventilation during the "post-weaning-period" of long-term ventilated patients. PATIENTS AND METHODS: We studied 43 patients (23 men, 59.1 +/- 14.6 years) with chronic respiratory failure who were transmitted from external ICUs after a mechanical ventilation period of 57.5 +/- 60.3 days. The weaning regime consisted of an individually adapted volume-cycled ventilation. If the patients were hypercapnic (pCO2 > 48 mm Hg) after the first 24-hour-period of spontaneous breathing without supplemental oxygen nocturnal mechanical ventilation was initiated. RESULTS AND CONCLUSIONS: In a retrospective study we could show that the decision to initiate invasive or noninvasive nocturnal mechanical ventilation after successful weaning primarily depends on the question whether a chronic hypercapnic respiratory failure persisted also after weaning from long-term mechanical ventilation. In about 40% of unselected patients nocturnal mechanical ventilation stabilized the weaning success whereas 60% of the patients did not need any further nocturnal mechanical ventilation.

Adult↗