Biomedical subjects

P Sharkey

Publications and source records attributed to P Sharkey.

At least 19 recordsLinked to original sources

PubMed2002

Improving outcomes for patients hospitalized with CHF.

Congestive Heart Failure is a costly debilitating medical condition that affects millions of elderly people. This Clinical Practice Improvement study was under taken to determine how variation in patient characteristics and clinical processes impact patient outcomes including length of stay, total charges, and increased severity of illness during hospitalization. The AHCPR Guideline for Heart Failure was used to evaluate clinical care. Data on patient characteristics including severity of illness and process of care were analyzed to determine which variables had the greatest impact on outcomes of care. Results showed that patient characteristics including comorbidities, severity of illness, and noncompliance with diet were significantly related to longer lengths of stay, higher charges, and/or increased severity (all covariates, p < .05). In addition, process of care variables including medication use and patient education significantly (p < .05) impacted outcomes of care. Findings have implications for the development of practice guidelines designed to improve patient outcomes associated with CHF hospitalizations.

Adult↗

PubMed1997

Treatment of depression in older primary care patients in health maintenance organizations.

OBJECTIVE: To examine whether older HMO patients with depression are treated differently than younger patients in terms of diagnosis, treatment by specialty provider, and pharmacotherapy. DESIGN: Chart-review, Cross sectional study. SETTING AND PARTICIPANTS: Patients were selected from six HMOs in the United States who had one or more of five medical diagnoses: arthritis, asthma, otitis media, epigastric pain/ulcer, and hypertension, (n = 9143). From this group, chart diagnoses and pharmacy records were used to identify patients who also had a diagnosis of depression (n = 416) or who had a diagnosis of depression and/or treatment with antidepressant medication (n = 1286). MEASUREMENT: Medical records and computerized service and pharmacy records were reviewed to obtain diagnoses, office visits by provider type, and psychiatric medication prescription counts. RESULTS: Significant differences were found in treatment of depression for older versus younger patients. Although depression was identified at a similar rate for both groups, older patients received fewer mental health specialty visits and fewer prescriptions for SSRI antidepressants. Older patients with a diagnosis of depression were more likely to be treated with benzodiazepines (49.2% of older vs. 33.2% of younger) though they were less likely to receive long half-life benzodiazepines. CONCLUSIONS: Psychotropic medication management is an important target for improving quality of care for older patients with depression in HMOs. Decreasing inefficient minor tranquilizer use and increasing use of newer antidepressant medications may lead to improved outcomes for older depressed adults.

Adult↗

PubMed1997

Pelvic lysis and polyethylene wear at 5-8 years in an uncemented total hip.

The clinical and radiographic results of 160 primary, uncemented porous coated total hip replacements performed at 3 teaching hospitals were reviewed. Followup was obtained in 132 of 148 (89%) nondeceased patients. The acetabular component is a full hemisphere, fabricated of cobalt chrome with a sintered bead coating and was implanted with screws in all cases. A 32 mm cobalt chrome femoral head was used in all cases. At 2 to 4 years the incidence of pelvic lysis was 0 and no acetabular revisions had been performed. At 5 to 8 years followup, 3 of 132 (2%) femoral stems had been revised, while on the acetabulum side discrete expansile pelvic lytic lesions occurred in 15 cases (11%) with 8 cases (5%) requiring revision. Abrasion of the screwhead against the backside of the polyethylene liner was seen in all retrieved cases and may have contributed to the development of the lytic lesions seen. Use of this uncemented press fit hemispheric acetabular components, using adjunctive screw fixation resulted in an unacceptably high rate of polyethylene wear and aggressive pelvic lysis. While the results on the femoral side were good, the results with this uncemented acetabular system did not represent an improvement over previous cemented or uncemented acetabular components.

Acetabulum↗

PubMed1996

Rush immunotherapy: experience with a one-day schedule.

INTRODUCTION: Rush immunotherapy is a method for rapidly desensitizing patients to inhalant allergens. The frequency of systemic reactions during rush immunotherapy is similar to conventional immunotherapy when premedication is used. The most rapid protocol for rush immunotherapy reported to date requires one and one-half days which is inconvenient to patients and clinic schedules. To improve this situation and decrease the cost of giving rush immunotherapy, we have developed a 1-day protocol. METHODS: for this ongoing study, 22 allergic patients received rush immunotherapy consisting of eight injections over six hours followed by two hours of observation in an outpatient clinic. Five had rhinitis and the rest has asthma, seven of whom were steroid-dependent. All were premedicated with astemizole, ranitidine, and prednisone for three days including the day of rush immunotherapy, and peak expiratory low rates were monitored. RESULTS: Systemic reactions were seen in five of 22 (23%). They occurred following the sixth injection (1), seventh injection (2), or the final one (2) and consisted primarily of rhinitis or pulmonary symptoms with one episode of mild anaphylaxis. A systemic reaction was seen in only one steroid-dependent asthmatic patient. A local reaction preceded a systemic reaction in only one patient. All but three reached a maintenance dose in one day. All systemic reactions responded to epinephrine and all patients could go home after rush immunotherapy. Only one patient had a systemic reaction during the three months after rush immunotherapy. CONCLUSION: One day rush immunotherapy is tolerated by most patients with a systemic reaction rate comparable to conventional immunotherapy. All patients were able to reach a maintenance dose months sooner than weekly schedules. With refinement of this procedure, rush immunotherapy may become a widely used method for desensitizing patients with inhalant allergens, and could make immunotherapy less expensive and more convenient.

Adolescent↗

PubMed1995

Variation in ophthalmic testing prior to cataract surgery. Results of a national survey of optometrists. Cataract Patient Outcome Research Team.

OBJECTIVE: To assess variation in optometrists' use of ophthalmic tests in the evaluation of patients being considered for cataract surgery who have no history of other eye disease. DESIGN/PARTICIPANTS: National survey of a systematic sample of practicing members of the American Optometric Association (St Louis, Mo), who had referred at least one patient to an ophthalmologist for consideration of cataract surgery in 1991. RESULTS: Ninety-two of 130 eligible responding optometrists reported that they routinely performed preoperative testing on patients being considered for cataract surgery. Of these 92 optometrists, 91 (99%) frequently or always performed refraction, and 82 (89%) frequently or always performed a dilated fundus examination in their evaluation of patients being considered for cataract surgery who had no history of other eye disease. None of these 92 optometrists reported using B-scan ultrasonography or electroretinograms frequently or always, and few used A-scan ultrasonography or visual evoked responses frequently or always. A substantial percentage frequently or always used formal visual field testing (47%), formal color vision testing (40%), fundus photography (24%), potential acuity measurement (25%), glare testing (23%), contrast sensitivity testing (19%), and specular microscopy (14%), while 11% to 81% of optometrists never performed these tests on such patients. More recent graduation from optometry school was associated with a decreased frequency of use of potential acuity measurement and contrast sensitivity testing and with an increased use of dilated fundus examinations. CONCLUSION: There is a substantial variation in optometrists self-reported use of a number of ophthalmic tests in the preoperative evaluation of patients being considered for cataract surgery who have no history of other eye disease.

Adult↗

PubMed1995

Cataract surgical techniques. Preferences and underlying beliefs.

To characterize the intraoperative procedures employed by cataract surgeons in the United States and the beliefs underlying the practices, a standardized questionnaire was sent to a systematic random sample of members of the American Academy of Ophthalmology in 1992. Of 667 surveyed ophthalmologists, 550 completed the questionnaire (response rate, 82.5%). Phacoemulsification was used for more than 75% of routine cataract surgery by 46% of respondents, whereas standard extracapsular surgery was used for more than 75% of routine cataract surgery by 41% of respondents. Preferential use of phacoemulsification was independently associated with more recent graduation from medical school and higher reported annual surgical volume. Continuous tear capsulotomy was employed by 52% of ophthalmologists. Preference for this technique was independently associated with both the use of phacoemulsification and higher annual surgical volume. Seventy-one percent of respondents used retrobulbar anesthesia, whereas 28% used peribulbar anesthesia. Use of peribulbar anesthesia was independently associated with both greater surgical volume and performance of surgery in an ambulatory surgical center. Beliefs regarding comparative safety and effectiveness were reported to influence surgeons' preferences strongly among all of the competing techniques studied. Those performing phacoemulsification, in comparison with those performing extracapsular cataract extraction, reported that the expectation of reduced astigmatism and shorter recovery time strongly influenced their choice of procedure. Variation in preferred intraoperative techniques is substantial for cataract surgery and the beliefs that underlie the preferences. Such variation highlights the need to determine which techniques maximize patient outcomes and are most cost-effective.

Adult↗

PubMed1995

Preoperative functional expectations and postoperative outcomes among patients undergoing first eye cataract surgery.

OBJECTIVE: To describe the relationship between patients' preoperative expectations regarding the outcome of cataract surgery and actual postoperative experience. METHODS: A longitudinal study of 772 patients undergoing first eye cataract surgery recruited from 75 ophthalmology practices in three metropolitan areas was conducted. Prior to surgery and approximately 4 months after surgery, a detailed interview was conducted that included general and vision-specific health status measures (including the Visual Function 12-Item Scale [VF-12]), patient-reported level of trouble and satisfaction with vision, and questions addressing patients' preoperative expectations regarding the outcomes of surgery. In addition, detailed clinical data were collected preoperatively and postoperatively. A total of 552 patients had only single eye cataract surgery by 4 months postoperatively and are included in this analysis. RESULTS: Patients' preoperative expectations regarding the impact of cataract surgery were very high and were unrelated to their demographic or ocular characteristics. The preoperative VF-12 score, however, was positively correlated with expected postoperative VF-12 score (Spearman correlation, .45, P < .001). Only 61% of patients achieved or surpassed their expected level of postoperative functioning. The difference between expected and actual postoperative VF-12 scores was not associated with patients' demographic characteristics or provider-related variables. Older patients (> 75 years) and patients with ocular comorbidity had a larger difference between expected and actual postoperative functioning than younger patients and those without ocular comorbidity. CONCLUSION: Expectations regarding visual functioning after cataract surgery are very high, and in most cases such expectations are fulfilled. In selected cases, more comprehensive counseling may reduce the discrepancy between expectations and actual outcomes of cataract surgery.

Aged↗

PubMed1995

Cataract surgery in one eye or both. A billion dollar per year issue.

PURPOSE: To measure the relative effect of cataract surgery in the second eye compared with the first eye on functional impairment, satisfaction, and vision problems. METHODS: Seventy-five randomly selected ophthalmologists in three cities in the United States were enrolled in a National Study of Cataract Outcomes. They, in turn, referred eligible, sequential patients scheduled for first-eye cataract surgery. Interviews were conducted at enrollment, 4 months after first-eye surgery, and 12 months after first-eye surgery. An attempt was made to conduct a special, preoperative interview of those patients scheduled to undergo second-eye surgery before the 4-month interview. Each interview included administration of the VF-14 (a 14-item questionnaire that assessed visual function), as well as questions about symptoms possibly related to cataract, "trouble with vision," and satisfaction with vision. RESULTS: Seven hundred seventy-two patients were enrolled in the study, and interview data to 12 months were obtained from 669 (86%) patients. Of these patients, 243 (36%) underwent cataract extraction in the second eye during the 12-month period of observation. Overall, subjects who underwent cataract surgery in both eyes during the 12-month period had 61% greater improvement in VF-14 score (P < 0.001), 27% more decline in trouble with vision (P < 0.001), and 24% greater improvement in satisfaction with vision (P < 0.001) compared with those who underwent surgery in only one eye. CONCLUSIONS: Cataract surgery in the second eye of patients with bilateral cataract is associated with clinical and statistically significant improvement in functional impairment, trouble with vision, and satisfaction with vision.

Aged↗

PubMed1994

The VF-14. An index of functional impairment in patients with cataract.

OBJECTIVE: To describe the development and the performance of a brief questionnaire designed to measure functional impairment caused by cataract (the VF-14). DESIGN: Observational cross-sectional study. Patients were recruited between July 15 and December 15, 1991. SETTING: Patients were recruited from the practices of 70 ophthalmologists, located in Columbus, Ohio (N = 21), St Louis, Mo (N = 26), and Houston, Tex (N = 23). PATIENTS: Seven hundred sixty-six patients undergoing cataract surgery for the first time. MAIN OUTCOME MEASURES: Preoperative best corrected visual acuity in each eye; scores on the VF-14, a new index of functional impairment in patients with cataract; patient reports of overall trouble and satisfaction with their vision; and scores on the Sickness Impact Profile, a measure of general health status. RESULTS: The VF-14 has high internal consistency (Cronbach's alpha = .85) and correlates more strongly with the overall self-rating of the amount of trouble and satisfaction patients have with their vision than do several measures of visual acuity or the Sickness Impact Profile score. The VF-14 score is moderately correlated with visual acuity in the better eye. CONCLUSIONS: The VF-14 is a reliable and valid measure of functional impairment caused by cataract and provides information not conveyed by visual acuity or a general measure of health status.

Cataract↗

PubMed1994

Variation in ophthalmic testing before cataract surgery. Results of a national survey of ophthalmologists.

Little information is available either for the clinical value of many ophthalmic tests performed preoperatively in the evaluation of patients for cataract surgery or for variation in ophthalmologists' use of such tests. To assess variation in ophthalmologists' use of ophthalmic tests, we conducted a national survey of American Academy of Ophthalmology members. Thirty-three percent, 17%, 37%, and 19% of the respondents reported that they "frequently" or "always" perform glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy, respectively, in patients being considered for cataract surgery who have no history of eye disease other than cataract. In contrast, 27%, 54%, 24%, and 48% of respondents reported that they never perform each of these four tests in such patients. Two ophthalmologist characteristics--a surgical volume of greater than 200 cataract extractions per year and performance of surgery in an ambulatory surgical center or private office (as opposed to a hospital)--were independently associated with an increased probability of performing each of these four tests frequently or always. Ten percent or less of the respondents reported that they frequently or always perform electroretinography, visual evoked response testing, photography of fundus or anterior segment, B-scan ultrasonography, formal color vision testing, and formal visual field testing in such patients. Thus, there is considerable variation in ophthalmologists' use of glare testing, contrast sensitivity testing, potential acuity measurement, and specular microscopy. A small percentage of ophthalmologists may be overusing several other tests in the evaluation of patients being considered for cataract surgery.

Adult↗

PubMed1994

The effect of early surgical intervention on mortality and cost-effectiveness in burn care, 1978-91.

A 14-year (1978-91) single centre analysis was performed involving 3561 patients. Several variables thought to influence burn outcome were included in the analysis, as was length of stay, interval between surgical interventions on each patient, and cost of care. Mortality rate declined by over 2 per cent (from 9.8 per cent during the first 7 years to 7.3 per cent in the second 7 years, P < 0.001). Multiple regression showed that percentage burn, presence of inhalation injury, and age had a significant effect on mortality. These variables, as well as the DRG distribution, were statistically evenly distributed over the 14-year study. There was a statistically significant decrease in length of stay (23 days in 1979 to 14.2 days in 1990), which significantly correlated with a decrease in interval between surgical interventions (14.76 days in 1979 to 6.12 days in 1990). The average annual increase of hospital charges for burn care grew at 9.6 per cent annually, higher than the consumer price index during the same time (5.8 per cent) but substantially lower than the hospital market as a whole (10.8 per cent). Mortality rate of major burns has decreased significantly in this study, while burn severity indices remained constant. Increase in cost of care was substantially lower than that of general hospital care. This apparent cost efficiency is driven by a decreased length of stay closely correlated with aggressive surgical intervention for closure of the burn wound.

Adult↗

PubMed1994

National study of cataract surgery outcomes. Variation in 4-month postoperative outcomes as reflected in multiple outcome measures.

BACKGROUND: Although ophthalmologists have long recognized that visual acuity alone is an inadequate measure of visual impairment, the need for and outcomes of cataract surgery historically have been assessed in terms of visual acuity. PURPOSE: To examine the relation among different cataract surgery outcome measures, including a 14-item instrument designed to measure functional impairment caused by cataract (the VF-14), at 4 months after cataract surgery. METHODS: The authors performed a longitudinal study of 552 patients undergoing first eye cataract surgery by 1 of 75 ophthalmologists practicing in Columbus, Ohio, St. Louis, Missouri, or Houston, Texas. Patients were interviewed, and clinical data were obtained preoperatively (July 15, 1991-March 14, 1992) and 4 months postoperatively. RESULTS: The percentage of patients judged to be improved at 4 months after cataract surgery varied by the outcome measure used: Snellen visual acuity (96%); VF-14 score (89%); satisfaction with vision (85%); self-reported trouble with vision (80%); and Sickness Impact Profile score (67%). The change in patients' ratings of their trouble with vision and their satisfaction with vision were correlated more strongly with the change in VF-14 score than with the change in visual acuity (operated eye or better eye). The average change in VF-14 score was unrelated to the preoperative visual acuity in the eye undergoing surgery. CONCLUSION: Estimates of the proportion of patients benefiting from cataract surgery vary with the outcome measure used to measure benefit. Change in VF-14 score, a measure of functional impairment related to vision, may be a better measure of the benefit of cataract surgery than change in visual acuity.

Aged↗

PubMed1993

In vitro translation of RNA from the German cockroach Blattella germanica.

The translation of mRNA within total RNA of German (Blattella germanica) cockroaches was performed using a rabbit reticulocyte lysate system. Analysis of the translation products by SDS-PAGE and combined autoradiography revealed several synthesized proteins with apparent molecular weights ranging from 20 kD to 110 kD. SDS-PAGE/Western blotting of non-radiolabeled translation products and incubation with human serum with IgE to cockroach allergens showed the presence of a 36 kD and 50 kD allergen. The confirmation of the translation of the cockroach allergens from total RNA is an important first step in the cloning of cockroach allergens.

Allergens↗

PubMed1991

A possible role for superoxide production in the pathogenesis of contact dermatitis.

Superoxide generation by blood monocytes was examined in patients with irritant, nickel, and chromate hand dermatitis. Phorbol myristate acetate stimulated monocytes generated significantly more superoxide in patients with nickel dermatitis, as did patients with hand eczema generally. No significant stimulation of monocyte superoxide generation occurred with either opsonized zymosan or PMA in the presence of excess superoxide dismutase in any of the groups of hand dermatitis. The results indicate a biochemical stimulation of superoxide which may accentuate the immunological damage in the skin that is observed in nickel and perhaps chromate dermatitis.

Adolescent↗

PubMed1990

The importance of severity of illness in assessing hospital mortality.

Each year, the Health Care Financing Administration (HCFA) releases a report comparing hospital mortality rates with predicted rates. Some argue that the HCFA's prediction model does not adequately account for patient severity. We tested this hypothesis by comparing the HCFA's model (replicated as closely as we could) to a second that added a severity measure (the Stage of Principal Diagnosis at Admission, a subscale of the Severity of Illness Index). In our simulation, the HCFA's model had very limited capacity to predict mortality (average R2, 2.5%). Patients grouped according to admission severity had markedly different mortality rates, which the HCFA's model's predictions could not differentiate. The HCFA model also failed to predict large differences in mortality between hospitals with low- and high-severity admissions. Adding severity to the HCFA's model yielded more than an eightfold increase in the R2, to 21.5%, and reduced instances of higher than expected hospital mortality to chance levels. These findings suggest that the HCFA's mortality release needs to be made much more sensitive to admission severity before it can be used to make valid inferences about the quality or effectiveness of hospital care.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1988

Oral fluconazole therapy for patients with acquired immunodeficiency syndrome and cryptococcosis: experience with 22 patients.

PURPOSE: Cryptococcus neoformans causes infections in up to 10 percent of patients with the acquired immunodeficiency syndrome (AIDS). Nearly 50 percent of AIDS patients with previously treated cryptococcal meningitis will experience a relapse within six months. To reduce the likelihood of relapse, a maintenance regimen of amphotericin B is often administered weekly. However, the drug's intravenous route of administration and considerable toxicity have led to a search for alternative antifungal agents. In this report, we document our experience with fluconazole, a new oral triazole antifungal agent. PATIENTS AND METHODS: Twenty-two patients with AIDS and various forms of cryptococcosis were treated in an open-label study with 50 to 400 mg/day of fluconazole. The following laboratory studies were done on a monthly basis: complete blood cell count, liver function tests, serum creatinine level, serum cryptococcal antigen level, and serum fluconazole level. Lumbar puncture was performed in patients with meningitis every four to eight weeks to evaluate cerebrospinal fluid cryptococcal antigen, India ink preparation findings, fungal culture, fluconazole level, and protein, glucose, and cell count. RESULTS: Of seven patients with active culture-positive infections, four showed clinical and microbiologic responses (three of four with meningitis, one of three with extraneural cryptococcosis). Fifteen patients who had already undergone successful amphotericin B therapy for either meningitis (n = 14) or pneumonia (n = 1) received fluconazole as prophylaxis against relapse. Fourteen patients remained free of infection during 11 to 64 weeks of suppressive therapy; one patient with meningitis experienced relapse after 26 weeks of treatment. Reverse reactions were limited to increases in hepatic enzyme levels in four patients. CONCLUSION: These results appear sufficiently encouraging to warrant further trials of this oral agent in the suppression of chronic cryptococcosis and perhaps in the treatment of acute infection.

Acquired Immunodeficiency Syndrome↗

PubMed1988

Calcaneal fracture with compartment syndrome of the foot.

We report the unusual case of a compartment syndrome of the foot that developed after a calcaneal fracture in a 68-year-old man. The diagnosis was suspected clinically because of pain in excess of his injury and was confirmed with direct tissue pressure measurements. Surgical decompression of all the compartments was required with evacuation of a plantar hematoma.

Aged↗

PubMed1987

Hypokalemia after cardioversion from ventricular tachycardia induced in the electrophysiology laboratory.

Serum potassium is often low after resuscitation from out-of-hospital ventricular fibrillation. We hypothesized that hypokalemia develops after ventricular tachycardia induced by programmed electrical stimulation. We measured serum potassium in 10 patients before induction of ventricular tachycardia and 15 minutes, 45 minutes, and 3 hours following cardioversion from ventricular tachycardia. Ventricular tachycardia rate was 243 +/- 71 bpm and duration was 57 +/- 87 seconds. Mean serum potassium (mEq/L) decreased from 4.1 +/- 0.3 at baseline to 3.8 +/- 0.5 at 15 minutes (p less than 0.01 vs baseline) and 3.7 +/- 0.6 at 45 minutes (p less than 0.005 vs baseline), but returned to 4.1 +/- 0.5 at 3 hours. Although no patients were hypokalemic (potassium less than 3.5 mEq/L) at baseline, 33% were hypokalemic at 15 minutes and 40% were hypokalemic at 45 minutes (p = 0.06 vs baseline). A low serum potassium was found in several of these patients immediately after the clinical arrhythmia that led to electrophysiologic study, and rapid resolution of the hypokalemia was observed. Thus, serum potassium decreases rapidly in man after resuscitation from brief but hemodynamically significant ventricular tachycardia. This suggests that patients with hypokalemia after resuscitation from out-of-hospital ventricular fibrillation have hypokalemia secondary to the event. The electrophysiologic effects of post-cardioversion hypokalemia are unknown.

Aged↗