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Biomedical subjects

P L Fine

Publications and source records attributed to P L Fine.

8 recordsLinked to original sources
PubMed2000

Vancomycin anaphylaxis and successful desensitization in a patient with end stage renal disease on hemodialysis by maintaining steady antibiotic levels.

BACKGROUND: Vancomycin anaphylaxis is a major management problem in patients with methicillin-resistant Staphylococcus aureus (MRSA) sepsis. Lerner et al in 1984 have described a protocol for desensitization to vancomycin; however, antibiotic blood levels have never been used as a guide in this process. CASE REPORT: A 46-year-old female with ESRD on hemodialysis who developed a dialysis-catheter related MRSA sepsis was found to have anaphylaxis to vancomycin. She underwent successful desensitization to vancomycin using Lerner's protocol. Periodic antibiotic blood levels were used to guide the amount and frequency of vancomycin infusion to successfully maintain desensitization thereafter. DISCUSSION: Lerner described loss of desensitization to vancomycin when antibiotic infusion was stopped after 18 hours followed by successful desensitization to the same drug via the same protocol. This observation points out that desensitization to vancomycin appears to be dependent on some minimal drug level. In our case report, we have for the first time used the concept of blood levels to maintain successful desensitization to an antibiotic. CONCLUSION: We hypothesize that desensitization to vancomycin can be induced and maintained by keeping a minimum antibiotic blood level. Further studies are needed to quantify this.

Anaphylaxis↗
PubMed1999

Enhancement of clinicians' diagnostic reasoning by computer-based consultation: a multisite study of 2 systems.

CONTEXT: Computer-based diagnostic decision support systems (DSSs) were developed to improve health care quality by providing accurate, useful, and timely diagnostic information to clinicians. However, most studies have emphasized the accuracy of the computer system alone, without placing clinicians in the role of direct users. OBJECTIVE: To explore the extent to which consultations with DSSs improve clinicians' diagnostic hypotheses in a set of diagnostically challenging cases. DESIGN: Partially randomized controlled trial conducted in a laboratory setting, using a prospective balanced experimental design in 1995-1998. SETTING: Three academic medical centers, none of which were involved in the development of the DSSs. PARTICIPANTS: A total of 216 physicians: 72 at each site, including 24 internal medicine faculty members, 24 senior residents, and 24 fourth-year medical students. One physician's data were lost to analysis. INTERVENTION: Two DSSs, ILIAD (version 4.2) and Quick Medical Reference (QMR; version 3.7.1), were used by participants for diagnostic evaluation of a total of 36 cases based on actual patients. After training, each subject evaluated 9 of the 36 cases, first without and then using a DSS, and suggested an ordered list of diagnostic hypotheses after each evaluation. MAIN OUTCOME MEASURE: Diagnostic accuracy, measured as the presence of the correct diagnosis on the hypothesis list and also using a derived diagnostic quality score, before and after consultation with the DSSs. RESULTS: Correct diagnoses appeared in subjects' hypothesis lists for 39.5% of cases prior to consultation and 45.4% of cases after consultation. Subjects' mean diagnostic quality scores increased from 5.7 (95% confidence interval [CI], 5.5-5.9) to 6.1 (95% CI, 5.9-6.3) (effect size: Cohen d = 0.32; 95% CI, 0.23-0.41; P<.001). Larger increases (P = .048) were observed for students than for residents and faculty. Effect size varied significantly (P<.02) by DSS (Cohen d = 0.20; 95% CI, 0.08-0.32 for ILIAD vs Cohen d = 0.45; 95% CI, 0.31-0.59 for QMR). CONCLUSIONS: Our study supports the idea that "hands-on" use of diagnostic DSSs can influence diagnostic reasoning of clinicians. The larger effect for students suggests a possible educational role for these systems.

Decision Support Techniques↗
PubMed1998

Polyclonal immunoglobulin G deposition disease: a unique entity.

We report a unique case of tubular polyclonal immunoglobulin G (IgG) deposition disease (PIDD) superimposed on diabetic nephropathy in an 84-year-old man presenting with subacute renal failure and proteinuria. The deposits were located exclusively between the tubular epithelial cells and the tubular basement membranes (TBMs) and stained intensely with antisera to IgG heavy chain and both kappa and lambda light chains. Electron microscopy revealed large predominantly extracellular electron-dense deposits with a distinctive curvilinear substructure. The associated light microscopic findings of tubular simplification with features of acute tubular necrosis implicate this tubulopathy as the cause of the acute renal failure. This appears to represent a unique entity that does not fit into any previously described category of renal tubular immune complex or immunoglobulin deposition disease.

Aged↗
PubMed1995

Do the criteria of resident selection committees predict residents' performances?

PURPOSE: To further the understanding of what factors residency selection committees consider when rating candidates and how well these ratings predict residents' performances. METHOD: The authors analyzed the application and residency files of 123 physicians who completed the internal medicine residency at the University of Michigan from 1989 through 1992; they also reviewed all 308 applications for 1993-94. Applications to the residency were reviewed by an intern selection committee (ISC) and given scores ranging from 0 (best) to 450 (worst). Multivariate analyses were used to evaluate the influences on ISC scores of seven factors: gender, internal medicine clerkship grade, number of honors in non-medicine clerkships, Alpha Omega Alpha (AOA) status, number of publications, score on the National Board of Medical Examiners (NBME) Part I examination, and medical school reputation. Each resident's performance was evaluated using the final overall evaluation score submitted by the program to the American Board of Internal Medicine. RESULTS: The most significant predictors of ISC score were internal medicine clerkship grade, AOA status, medical school reputation, and NBME I score (all four at p < .01; R2 = .66 for the full model of seven factors). The residents' final evaluation scores were moderately correlated with ISC scores at the time of application (r = -.52). In a multivariate analysis, the final scores were significantly associated only with internal medicine clerkship honors (p < .01) and graduation from the University of Michigan Medical School (p < .05), and there was a trend associating them with junior-year AOA election. CONCLUSION: The findings suggest that the intern selection committee overemphasized the predictive value of AOA election in the senior year, NBME I scores, and medical school reputation.

Bias↗
PubMed1992

The oxygen-evolving complex requires chloride to prevent hydrogen peroxide formation.

Illumination of PSII core preparations can cause the production of H2O2 at rates which approach 60 mumol of H2O2 (mg of Chl.h)-1. The rate of peroxide production is maximal at pH 7.2 at low sucrose concentrations and at concentrations of Cl- (1.5-3.0 mM) that limit the rate of the oxidation of water to O2. The rate of H2O2 production increased with pH from pH 6.8 to 7.2 and was inversely proportional to the oxidation of water to O2 from pH 6.8 to 7.5. While EDTA does not inhibit H2O2 production, this reaction is abolished by 5 mM NH2OH and inhibited by the same concentrations of NH3 that affect water oxidation which indicates that the oxygen-evolving complex is responsible for the production of peroxide generated upon illumination of PSII core preparations. These results support a mechanism in which bound Cl- in the S2 state is displaced by OH- ions which are then oxidized by the OEC to form H2O2. Thus, the OEC requires Cl- to prevent access to the active site of the OEC until four oxidizing equivalents can be generated to allow the oxidation of water to O2.

Anions↗