PubMed Health⌕ Search

Biomedical subjects

R J Ackermann

Publications and source records attributed to R J Ackermann.

At least 19 recordsLinked to original sources
PubMed2001

Nursing home practice. Strategies to manage most acute and chronic illnesses without hospitalization.

Physicians who practice in the nursing home often must decide whether to hospitalize a patient with an acute illness or provide on-site treatment. Most medical problems--including urinary tract infection, pneumonia, venous thromboembolism, and exacerbations of congestive heart failure--can be successfully managed in the nursing home. An aggressive primary care approach can improve the quality of care for vulnerable older patients, reduce the need for hospitalizations, and make nursing home practice more efficient and satisfying. Most dying patients can also receive the bulk of their medical and palliative care in the nursing home.

Acute Disease↗
PubMed2000

Withholding and withdrawing life-sustaining treatment.

Withholding or withdrawing life-sustaining therapies is ethical and medically appropriate in some circumstances. This article summarizes the American Medical Association's Education for Physicians on End-of-life Care (EPEC) curriculum module on withholding or withdrawing therapy. Before reviewing specific treatment preferences, it is useful to ask patients about their understanding of the illness and to discuss their values and general goals of care. Family physicians should feel free to provide specific advice to patients and families struggling with these decisions. Patients with decision-making capacity can opt to forego any medical intervention, including artificial nutrition/hydration and cardiopulmonary resuscitation.

Cardiopulmonary Resuscitation↗
PubMed1998

Emergency department use by nursing home residents.

STUDY OBJECTIVE: To describe a community's experience with the use of emergency department services by nursing home residents. METHODS: We performed a retrospective chart review of a population-based cohort of nursing home residents in an urban county in central Georgia with 10 nursing homes (1,300 beds) and 4 hospital-based EDs. All ED visits by nursing home residents during 1995 were analyzed. Demographic data, timing of the visit, chief complaint, tests and treatments, disposition, and financial charges were recorded. Further, we calculated the number of ED visits per 100 nursing home patient-years. RESULTS: A total of 873 nursing home residents made 1,488 ED visits. Mean age was 76.0 years; 66.4% were female, and 55.2% were white. Of the transfers, 42.9% occurred during regular working hours. The most common chief complaints were respiratory symptoms (14.4%), altered mental status (10.1%), gastrointestinal symptoms (9.9%), and falls (8.2%); 101 patients (6.8%) were transferred for malfunction of a gastrostomy tube. The most common laboratory tests were complete blood cell count (69.5%), chest radiograph (52.0%), electrocardiogram (45.0%), urinalysis (42.7%), and determination of electrolytes (42.7%). A total of 42.4% of the ED visits led to admission to the hospital. From the 10 nursing homes, there were 110 ED visits per 100 patient-years. A 3.5-fold difference in ED use among these nursing homes could not be explained by age, gender, or other factors. The average .charge per ED visit was $1,239. CONCLUSION: Elders living in nursing homes are frequently transferred to EDs for costly medical evaluations, and more than 40% of such visits lead to admission to the hospital.

Aged↗
PubMed1998

The effect of a physician assistant on the hospitalization of nursing home residents.

OBJECTIVES: To describe the impact of regular visits to a nursing home by a gerontologist physician assistant (PA) on the hospitalization and medical costs of patients. DESIGN: A 6-year case series (1992-1997) incorporating events before and after introduction of a PA in May 1994. The PA visited the nursing home 3 to 4 times per week, provided nearly all of the acute medical care, and alternated routine visits with supervising physicians. SETTING: A 92-bed teaching nursing home in central Georgia. MEASUREMENTS: Demographics of the nursing home population; hospitalizations of residents, including major diagnosis and length of stay; number and site of all resident deaths; costs of physician and PA services and hospital costs. RESULTS: After the introduction of the physician assistant, the number of annual hospital admissions fell by 38.0%, and the total number of hospital days per 1000 patient years fell by 68.6% (from 4170 in 1992 to 1310 in 1997). The number of nursing home visits increased by 62.1%. Annual Medicare-allowed charges for MD and PA services increased by $22,304, but this was more than offset by a decline in hospital DRG reimbursements of $96,043. CONCLUSIONS: The introduction of regular visits to nursing home patients by a physician assistant can reduce hospitalization and medical costs of these frail older people.

Aged↗
PubMed1998

Deadtime correction for two multihead Anger cameras in 131I dual-energy-window-acquisition mode.

Two side-by-side energy windows, one at the photopeak and one at lower energy, are sometimes employed in quantitative SPECT studies. We measured the count-rate losses at moderately high activities of 131I for two multihead Anger cameras in such a dual-window-acquisition mode by imaging a decaying source composed of two hot spheres within a warm cylinder successively over a total of 23 days. The window locations were kept fixed and the paralyzable model was assumed. In addition, for the Picker Prism 3000 XP camera, the source was viewed from three different angles separated by 120 degrees and the final results are from an average over these three angles. For the Picker camera, the fits to the data from the individual windows are good (the mean of the squared correlation coefficient equals 0.98) while for the Siemens Multispect camera fits to the data from head 1 and from the lower-energy, monitor window are relatively poor. Therefore, with the Siemens camera the data from the two windows are combined for deadtime computation. Repeated autopeaking might improve the fits. At the maximum count rate, corresponding to a total activity of 740 MBq (20 mCi) in the phantom, the multiplicative deadtime correction factor is considerably larger for the Picker than for the Siemens camera. For the Picker camera, it is 1.11, 1.12, and 1.12 for heads 1-3 with the photopeak window and 1.10 for all heads with the lower-energy monitor window. For the Siemens camera, the combined-window deadtime correction factor is 1.02 for head 1 and 1.03 for head 2. Differences between the deadtime correction factor for focal activity and for the total activity do not support the hypothesis of count misplacement between foci of activity at these count rates. Therefore, the total-image dead time correction is recommended for any and all parts of the image.

Equipment Design↗
PubMed1998

Is primary care physician supply correlated with health outcomes?

Assessment of the relation between life indicators and health outcomes is a complex problem. The authors' analysis uses descriptive canonical correlation, and their solution suggests that socioeconomic factors play a major role in health outcomes. The supply of primary care physicians has a lesser but still important role: canonical correlation suggests no apparent role in enhancing health outcomes among the elderly but a larger role in improving health among the young. The authors' analysis does support the notion that specialist physician supply has no correlation with a wide range of health outcomes.

Adult↗
PubMed1998

Esophagogastroduodenoscopy performed by a family physician. A case series of 793 procedures.

BACKGROUND: Primary care physicians are performing an increasing number of gastrointestinal endoscopies. The purpose of this research is to present a large case series of diagnostic esophagogastroduodenoscopies (EGDs) performed by a family physician in a solo rural practice. METHODS: We present a retrospective chart review, including demographic characteristics, indications, endoscopic and pathologic findings, and complications for every EGD performed by a family physician over a 7-year period. RESULTS: Seven hundred ninety-three EGDs were performed on 602 patients (421 women, 181 men), with a mean age of 51.8 years. In 99% of procedures, the second portion of the duodenum was intubated. The most common indications for EGD were abdominal pain (60.5%), gastrointestinal bleeding (23.0%), dysphagia (11.6%), and heart-burn (10.7%). A total of 451 biopsies were obtained in 385 procedures, mostly from the distal esophagus (38%) or gastric antrum (37%). Common endoscopic diagnoses were gastritis (54%), esophagitis (25%), and normal study (15%). There were only two malignancies detected, one gastric lymphoma and one carcinoma metastatic to the stomach. One minor complication (0.13%) occurred, an immediate urticarial rash after intravenous meperidine. CONCLUSIONS: Experienced family physicians can safely and competently perform diagnostic EGD and provide this important service to their community.

Adolescent↗
PubMed1997

A new technique for placement of nasoenteral feeding tubes using external magnetic guidance.

OBJECTIVE: To evaluate a new technique in which a hand-held external magnet is used to maneuver nasoenteral feeding tubes through the pylorus and into the duodenum. DESIGN: Prospective case series. SETTING: Critical care units and medical and surgical wards of a university-affiliated community hospital. PATIENTS: Thirty-five patients were entered into the study after the attending physician requested assistance in tube placement. INTERVENTIONS: A standard 12-Fr, 114-cm flexible nasoenteral feeding tube was modified by inserting a small magnet into the distal tip. The tube was inserted per nares into the stomach, using traditional technique. Next, an external magnet was placed over the right upper abdominal quadrant, at the midclavicular line to attract the tube tip along the lesser curvature of the stomach, through the pyloric sphincter, and into the duodenum. Portable abdominal radiography performed immediately after the procedure confirmed the anatomic location of the tube tip. MEASUREMENTS AND MAIN RESULTS: Forty-two intubations were performed in 35 patients (in seven patients, the tube had to be reinserted due to inadvertent removal or surgery). In 37 (88%) of 42 intubations, the tube was passed through the pyloric sphincter and into the duodenum on the first attempt. The mean procedure time was 15 +/- 9 mins (range 10 to 45). There were no complications related to the procedure during the study period. CONCLUSIONS: This report describes a novel technique of enteral feeding tube placement, using external magnetic guidance. Transpyloric placement was achieved in 88% of cases. This reliable and convenient bedside method for rapid placement of the tube into the duodenum allows prompt and safe initiation of enteral nutrition.

Adult↗
PubMed1997

Colonoscopy performed by a family physician. A case series of 751 procedures.

BACKGROUND: Colonoscopy, including biopsy and polypectomy, is a procedure not commonly performed by primary care physicians. The purpose of this research was to present a large case series of colonoscopic procedures performed by a family physician in a rural practice. METHODS: A chart review of every colonoscopy procedure performed by a family physician over a 7-year period determined the demographic characteristics, indications, findings, and complications for each procedure. RESULTS: A total of 751 colonoscopies were performed on 555 patients (347 women and 208 men), with a mean age of 53.8 years. In 91.5% of procedures, the cecum was intubated. The most common indications for colonoscopy were bleeding (49.9%), polyp follow-up (20.9%) abdominal pain (11.7%), diarrhea (11.6%), and abnormal findings on flexible sigmoidoscopy (8.4%). Three hundred sixteen benign polyps were discovered and removed by either biopsy or polypectomy. There were 184 adenomatous colorectal polyps found in 134 (17.8%) colonoscopies. Of these 184 adenomatous polyps, 106 (58%) were potentially within reach of the flexible sigmoidoscope. Only three adenocarcinomas were discovered during the entire study period. There was only one major procedural complication: a patient experienced blood oozing from a polypectomy stump; cautery stopped the bleeding, and the patient was hospitalized overnight, with no further intervention or transfusion required. There were five other self-limited complications, including adverse reactions to sedation and infiltration at the intravenous site. CONCLUSIONS: Colonoscopy with polypectomy that was safely and competently performed in a solo rural practice adds to the evidence that experienced family physicians can provide this important service to their community.

Adenocarcinoma↗
PubMed1997

Enhancing procedural training in a family practice residency.

BACKGROUND AND OBJECTIVES: Teaching outpatient procedures is a major responsibility of family practice residencies. This requires equipment, faculty expertise, and curricula. This report documents one residency program's attempt to enhance the teaching of outpatient procedures. METHODS: We tabulated all office procedures completed during the years 1993 through 1996 at a family practice residency program in the southeastern United States. We compared the number of procedures and dollar charges before and during an educational intervention designed to increase the number of procedures performed and to improve procedural training of residents. The intervention consisted of hiring a full-time procedural nurse and new procedural equipment. RESULTS: The residency program spent $177,000 over 4 years to improve procedural training, but income from procedures was estimated to be only $127,000. From 1993 to 1996, the total number of annual procedures increased from 322 to 540. Both the number of procedures and procedural income declined in the final year of the project when the procedural nurse assumed other clinical and administrative duties. CONCLUSIONS: Volume and teaching of common procedures in a family practice residency program can be enhanced by a dedicated effort, but this effort requires considerable staffing and financial resources.

Costs and Cost Analysis↗
PubMed1996

Bacteremic urinary tract infection in older people.

OBJECTIVES: To describe patients with bacteremic urinary tract infections, compare characteristics of young and older patients, and suggest appropriate empiric antibiotic therapy for this clinical condition. DESIGN: Case series, with an observation period of 3 years. SETTING: A large southeastern community hospital. PARTICIPANTS: One hundred eighty patients more than 18 years old (101 older than age 65) with urine and blood cultures simultaneously positive for bacterial organisms. MEASUREMENTS: Chart review-determined demographic characteristics, clinical data, bacterial organism and antibiotic susceptibility, number of medical diagnoses, use of a urinary catheter, admission source, and mortality. RESULTS: The 180 patients experienced bacteremias caused by 183 bacterial organisms. Sixty-one patients were aged 65 to 79 years, and 40 were 80 years of age or older; 63.9% of patients were female; 62.2% were black. Gram-negative organisms accounted for 80.3% of bacterial isolates, with Escherichia coli accounting for 54.1% of cases. Gram-positive organisms accounted for 19.7% of isolates, including Staphylococcus aureus (13.1%) and Enterococcus (5.5%). Older patients had a distribution of Gram-positive and Gram-negative organisms similar to that of younger patients. Men and patients with chronic urinary catheters had higher proportions of Gram-positive organisms and non-E. coli Gram-negative rods. Organisms showed excellent susceptibilities to commonly used antibiotics. In-hospital mortality was 16.1%, with higher mortality in patients with chronic urinary catheters, in patients who were admitted from nursing homes, and when a Gram-positive organism was identified. Advanced age was not associated with higher mortality. CONCLUSIONS: Concomitant illness and especially the use of urethral catheters, but not advanced age itself, are associated with a higher mortality from bacteremic urinary tract infection. Single agent empiric antimicrobial therapy such as ceftriaxone may be appropriate in older patients with presumed urosepsis, except in catheterized patients or those with other risk factors for Gram-positive or resistant Gram-negative infections.

Adult↗
PubMed1996

Mercer University School of Medicine: a successful approach to primary care medical education.

Mercer University School of Medicine in Macon, Ga, is the nation's youngest medical school. It has been training physicians since 1982, with an emphasis on meeting the health care needs of rural and other underserved areas of Georgia. Ninety-six (32%) of Mercer's 303 graduates through 1995 have chosen residency training in family practice, and 63% of graduates are entering one of the traditional primary care residencies. Additionally, the practice rates for 151 graduates from the classes of 1986-1991 are comparable at 36% for family practice and 64% for the primary care specialties. This paper presents information about the career choices of graduates from this medical school and discusses aspects of the admission policies and medical school curriculum that may have contributed to Mercer's success in graduating large percentages of students who ultimately practice primary care medicine.

Career Choice↗
PubMed1995

Triple-head SPECT with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG): initial evaluation in oncology and comparison with FDG PET.

PURPOSE: In patients with cancer, performance was assessed of a commercially available triple-head gamma camera fitted with ultra-high energy parallel-hole collimators performing single photon emission computed tomography (SPECT) with 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG). Results were compared with those of positron emission tomography (PET) with FDG. MATERIALS AND METHODS: Performance characteristics were first determined in phantom studies for FDG PET and triple-head gamma camera SPECT systems. In 13 patients with malignancies, FDG PET was followed by SPECT of the same region, and imaging results were independently assessed. RESULTS: Sensitivity of the PET and SPECT systems was 58.3 counts/MBq/min and 4.5 counts/MBq/min, respectively. Reconstructed spatial resolution was approximately 7 mm for PET and 20 mm for SPECT. All known cancer foci were detected at PET. SPECT depicted 11 of the 22 lesions detected at PET, but only five of the 14 lesions less than 3 cm in diameter. CONCLUSION: FDG SPECT performed with a specially collimated triple-head gamma camera depicted some cancers but had an unacceptably low sensitivity compared with PET for lesions less than 3 cm in diameter. PET is preferable for detecting small cancers.

Deoxyglucose↗
PubMed1995

Simultaneous transmission-emission thallium-201 cardiac SPECT: effect of attenuation correction on myocardial tracer distribution.

UNLABELLED: This study evaluates the effect of attenuation correction on regional myocardial tracer distributions defined by 201TI cardiac perfusion SPECT images obtained from healthy volunteers and patients with coronary heart disease. METHODS: A three-detector SPECT system equipped with an 241Am line source and a fanbeam collimator was used for simultaneous transmission/emission (201TI) tomography on 40 patients and 10 normal volunteers. Uncorrected emission images were reconstructed using filtered backprojection (FBP), whereas the attenuation corrected images were iteratively reconstructed with a regularized, least-squares algorithm utilizing the attenuation map computed from the transmission data. Both sets of images were reoriented into short-axis and vertical long-axis slices. Circumferential profile analysis was applied to both datasets of short-axis slices. RESULTS: The normal volunteers demonstrated improved homogeneity in tracer distribution. For a basal short-axis slice, the lateral-to-posterior activity ratio improved from 1.17 +/- 0.12 for FBP to 1.01 +/- 0.07. Basal attenuation appeared properly compensated as the peak basal-to-apical slice activity gradient along the posterior-inferior wall changed from 1.15 +/- 0.12 for FBP to 1.01 +/- 0.09. The apex of the attenuation corrected images showed a significant decrease in activity relative to the base which appeared consistent with anatomic wall thinning. For the inferior and basal septal regions, the defect severity was slightly less in the attenuation corrected images, but the defects were more sharply defined compared to the FBP image defects. CONCLUSION: These results indicate that attenuation correction is clinically feasible and accurately corrects for photon attenuation. Clinical validation, however, is necessary to define the diagnostic benefits.

Coronary Disease↗