Your reply to Reader's Digest.
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Dental Care↗
Biomedical subjects
R Levin
Publications and source records attributed to R Levin.
How to profit from .... practice analysis. A flat practice is a declining practice.
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Data Collection↗
A randomized trial of low osmolar ionic versus nonionic contrast media in patients with myocardial infarction or unstable angina undergoing percutaneous transluminal coronary angioplasty.
OBJECTIVES: The purpose of this study was to determine prospectively whether the differences in anticoagulant and antiplatelet effects of ionic and nonionic contrast media after angiographic or clinical outcomes in patients with unstable ischemic syndromes undergoing percutaneous transluminal coronary angioplasty. BACKGROUND: The interaction of platelets and thrombin with the endothelium of injured vessels contributes to thrombosis and restenosis after coronary angioplasty. Case reports and retrospective observations have reported an increased risk of thrombosis with the use of nonionic contrast media. METHODS: A total of 211 patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty were randomized to receive nonionic or ionic low osmolar contrast media. Coronary angiograms were assessed by a technician blinded to the study contrast media, and clinical events were monitored by an independent nurse for 1 month. RESULTS: Patients receiving the ionic media were significantly less likely to experience decreased blood flow during the procedure (8.1% vs. 17.8%, p = 0.04). After the angioplasty, residual stenosis, vessel patency, the incidence of moderate to large thrombi and use of adjunctive thrombolytic therapy were similar between the two groups. However, patients receiving ionic media had fewer recurrent ischemic events requiring repeat catheterization (3.0% vs. 11.4%, p = 0.02) and repeat angioplasty during the initial hospital stay (1.0% vs. 5.8%, p = 0.06). One month after angioplasty, patients receiving ionic contrast media reported significantly fewer symptoms of any angina (8.5 vs. 20.0%, p = 0.04) or of angina at rest (1.4% vs. 11.8%, p = 0.01) and a reduced need for subsequent bypass surgery (0% vs. 5.9%, p = 0.04), compared with patients receiving the nonionic media. CONCLUSIONS: These findings demonstrate that in patients with unstable ischemic syndromes undergoing coronary angioplasty, the use of ionic low osmolar contrast media reduces the risk of ischemic complications acutely and at 1 month after the procedure. Therefore, low osmolar ionic contrast media should be strongly considered when performing interventions in patients with unstable angina or myocardial infarction.
Angina, Unstable↗
Meckel's diverticulum. Internal hernia and adhesions without gastrointestinal bleeding--ultrasound and scintigraphic findings.
The results from an ultrasound study performed on an 11-year-old boy, who had several weeks of intermittent abdominal pain, showed a nonperistaltic loop of bowel near the umbilicus, which suggested either an internal hernia or a diverticulum. Tc-99m pertechnetate imaging showed a focal collection near the umbilicus, which was consistent with a Meckel's diverticulum. No evidence was found of gastrointestinal bleeding. Exploratory laparotomy showed a Meckel's diverticulum near the terminal ileum and attached to the anterior abdominal wall close to the umbilicus. Small bowel had herniated through the loop formed by the terminal ileum and the diverticulum.
Abdominal Pain↗
The advocacy role in hospital social work.
Hospital social workers were asked to describe their roles and functions, with particular emphasis on the amount of time spent doing traditional advocacy on behalf of patients. The results indicated that workers spent the least amount of time on advocacy as compared with other traditional social work roles. A case is made for emphasizing the advocacy role as a strategy to counteract the potentially negative effects on social work of organizational changes in Canadian hospitals. The implications of the findings for schools of social work, professional associations and employers of social workers are discussed.
Adult↗
Communicating with the schizophrenic superego.
The procedure reported here, which I have called "conversations with superegos," raises a number of important questions, both about ordinary versus psychopathological psychic structure, and about technique. There is no space to enter into a lengthy discussion, but a few brief points may be in order. First, let us consider the issue of psychic structure. I have argued that the superego is a hostile agency within the mind whose operations are essentially inimical to the patient's growth and well-being. (As an element of psychic structure, the superego can be distinguished from the ego ideal on the basis of the associated affect, that is, guilt rather than shame. Similarly, it is possible that the superego may be constructed on the basis of identifications that are different than those that may form the basis of the ego ideal). Further, I have argued that the superego is neither a force for true moral development nor a platform for the voice of the patient's "better" nature, (although it purports to be until challenged). A structure that lies, manipulates, threatens, and appears to be motivated in the end solely by its own continued existence, must certainly be considered suspect as an authority on morality. On the contrary, I see true morality originating in the patient's ego, because in that structure lies the ability to identify with others. One could object, however, that this way of viewing the matter is an artifact of working with a particular patient population. That is to say, it might be the case that in psychotic and borderline psychotic conditions, the superego does function this way, whereas in healthy or neurotic conditions it does not. In a similar vein, it could be argued that a pattern of development that was sufficiently skewed so as to result in psychosis would be more than likely to have been peopled by hostile, punitive, and essentially destructive identification figures, such as could form the basis for a pathological superego, whereas in normal or neurotic development this might not be the case. I would disagree on the following basis: I believe that the course of development is laid out by nature; that is, events like the separation-individuation phase, the oral, anal, phallic, and oedipal phases occur in all of us. It is what happens in the course of that development that will lead either to normalcy or various degrees of pathology. For example, we all project. But it is whether we project an expectation that the next person we meet is a decent, civilized human being or a monster out to destroy us that causes us happiness or pain. That said, my own view of the matter is that the general principal holds for conditions other than the patients reported here, with the difference being one of degree. Where identification figures are essentially benign and foster the development of the self, then their strictures, whether moral or merely practical, would be likely to become assimilated into the ego, without the telltale restriction of reflection and autonomy together with the accompanying guilt that characterize the superego's activity, in which case, we are not talking about superegos at all. What distinguishes psychotic and neurotic development, in my view, is not the issue of whether superego operations are benign or not, but the degree to which the ego is compromised with the resulting formation of fantasy-introjects. I have found, as if it were a principal of physics, that the stronger the ego, the weaker the superego and vice versa. And when some energy of the superego is released, it appears to go directly into the ego without my intervention, though I sometimes ask the "brain's" opinion. The second issue concerns technique. In psychosis, the voice of the superego is very loud, so much so that there are times when I have had to shout to be heard. On the other hand, my patients report that the voice of the ego may be so quiet that the patient hasn't heard it at all, or hears it as a whisper. (ABSTRACT TRUN
Adult↗
Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race.
OBJECTIVES: This study measured compliance and related demographic factors in a retrospective cohort of 4068 elderly outpatients newly starting antihypertensive therapy from 1982 through 1988. METHODS: Logistic regression modeling of data from the New Jersey Medicaid program was used. RESULTS: These patients filled antihypertensive prescriptions covering an average of only 179 days in the 365-day follow-up period (49%) Good compliance (> or = 80%) was associated with advanced age (odds ratio [OR] = 2.12, for patients 85 or older) and White race (OR = 0.55 for Blacks). There was no relationship between compliance and gender. CONCLUSIONS: Despite the efficacy of antihypertensive therapy in preventing cardiovascular morbidity, such high rates of noncompliance may contribute to suboptimal patient outcomes.
Age Factors↗
Temporal variation in drinking water turbidity and diagnosed gastroenteritis in Milwaukee.
Daily counts of diagnosed gastroenteritis (gastrointestinal events) in Milwaukee County, Wisconsin, from January 1992 through April 1993 were compared with reported daily turbidity from the two drinking water treatment plants serving the county. Turbidity in both plants was associated with an increased number of gastrointestinal events even after exclusion of a major documented outbreak of cryptosporidiosis. During the 434-day period prior to the outbreak, an increase in turbidity of 0.5 nephelometric turbidity units at one of the plants was associated with relative risks for gastrointestinal events of 2.35 among children (95% confidence interval [CI] = 1.34, 4.12) and 1.17 among adults (95% CI = 0.91, 1.52).
Adolescent↗
Altered contractility of rabbit penile corpus cavernosum smooth muscle by hypoxia.
PURPOSE: To investigate the effects of severe hypoxia on trabecular smooth muscle contractility. MATERIALS AND METHODS: Strips of rabbit corpus cavernosum were mounted in organ chambers to measure isometric tension. In some experiments intracellular free Ca2+ concentration and tension were measured by the intracellular fluorescent dye FURA-2 and isometric tension recording simultaneously. RESULTS: Contractions elicited by norepinephrine, endothelin-1 or potassium were attenuated under hypoxic conditions (pO2 approximately 10 mm. Hg). Strips contracted with 20 mM. K+ under normoxic conditions and then exposed to hypoxia consistently lost the potassium-induced tone. The hypoxia-induced relaxation was not affected by the removal of the endothelium, by treatment with the cyclooxygenase blocker, indomethacin, or with the guanylate cyclase blocker, methylene blue. The potassium channel opener, cromakalim, and adenosine relaxed potassium contracted strips; however, the potassium channel blockers glibenclamide, apamin, barium chloride and charybdotoxin or the adenosine receptor antagonist 8-(p-sulfonyl)theophylline were unable to prevent hypoxia-induced relaxation. Tetraethylammonium, a potassium channel blocker, and the depolarizing agents ouabain and high potassium (80 mM.), partially prevented hypoxia-induced relaxation. The calcium ionophore, ionomycin, had no effect on hypoxia-induced relaxations. Hypoxia, within 2 to 6 minutes, caused a large accumulation in intracellular calcium, concomitant with a loss of trabecular smooth muscle tone. Both these effects could be reproduced by inhibiting oxidative phosphorylation with 2,4,dinitrophenol. Reoxygenation resulted in an immediate recovery of both tone and intracellular calcium levels. Tissues under hypoxic conditions for 30 minutes had a 24% and 67% decrease in the ATP/ADP ratio and in creatine phosphate concentrations, respectively. CONCLUSION: Hypoxia causes a simultaneous increase in intracellular calcium and relaxation which, we propose, is the consequence of inhibition of oxidative phosphorylation with loss of high energy phosphates, necessary for the homeostasis of Ca2+ and the contractile mechanism of the cavernosal smooth muscle.
Adenosine Diphosphate↗
The impact of Jewish identity on the psychological adjustment of Soviet Jewish immigrants to Israel.
The following study investigated the role which Jewish identity plays in the psychological adjustment of recent Soviet Jewish immigrants to Israel. Five hundred Soviet Jews ages 18-53 who immigrated to Israel within anywhere from two months to approximately two years were selected from various "ulpan" settings (Hebrew language courses), absorption centers and community centers in several cities, and administered a detailed questionnaire. Subjects with weakest levels of Jewish identity were significantly most distressed and least satisfied with Israel. These findings confirm the importance of the role which Jewish identity plays in the adjustment of Soviet Jewish immigrants to Israel. Clinical and empirical implications are discussed in light of the findings.
Acculturation↗
Preserving fee-for-service dentistry.
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Advertising↗
Prevalence of antibodies against hepatitis A virus among new immigrants in Israel.
Israel, located in a region endemic for hepatitis A virus (HAV), recently absorbed a large population of immigrants who came from the former USSR. To assess the risk of high morbidity in this population a serosurvey of HAV antibodies was undertaken. Serum samples were collected from 965 new immigrants, of whom 664 came from the European, non-endemic region, and 301 from the Asian and Caucasian endemic regions of the former Soviet Union. They were compared to 240 Israelis. Each population was divided into six age groups: 1-9, 10-19, 20-29, 30-39, 40-49, and 50 years of age and older. The Asian/Caucasian immigrants and the Israeli population were found to share similar characteristics. In both groups, antibodies to HAV (anti-HAV) were present in the 1-9-year-old age group and reached maximum prevalence (90% and 86.7%, respectively) in the 20-29-year-old age group. In contrast, among the European immigrants anti-HAV was first found in the 10-19-year-olds and peaked (93%) in the age group of 50 years and older. It is concluded that immigrants originating from the European part of the former USSR may require vaccination against hepatitis A.
Adolescent↗
The collagens and their urologic implications.
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Animals↗
Use of patient-controlled analgesia with alfentanil for extracorporeal shock wave lithotripsy.
STUDY OBJECTIVE: To compare the efficacy of patient-controlled analgesia (PCA) to physician-controlled analgesia in patients undergoing extracorporeal shock wave lithotripsy (ESWL). DESIGN: Prospective, randomized trial. SETTING: New Jersey Kidney Stone Treatment Center at Robert Wood Johnson University Hospital, New Brunswick, NJ. PATIENTS: 62 ASA I, II, and III patients undergoing ESWL. INTERVENTIONS: The control group (n = 29) received physician-controlled analgesia with continuous infusions (0.75 mcg/kg/min) and intermittent boluses (5 mcg/kg) of alfentanil. PCA patients (n = 33) initially received alfentanil 0.5 mcg/kg followed by a continuous background infusion (0.2 to 0.5 mcg/kg/min) and self-administered alfentanil (3 to 5 mcg/kg) with a 5-minute lockout period. Bolus doses and infusion rates were determined by patient comfort and cardiorespiratory response to alfentanil. MEASUREMENTS AND MAIN RESULTS: Prior to the procedure, the patients completed two questionnaires (State-Trait Anxiety Inventory and Multidimensional Health Locus of Control Scales). During ESWL, blood pressure, heart rate, respiratory rate, oxygen saturation, end-tidal CO2, and pain and sedation levels were measured at 0, 800, 1,600, 2,400, and 3,000 shock waves. The total doses of alfentanil administered were calculated. PCA patients received 31% less alfentanil than control group patients (p < 0.0001). Patients with more preoperative anxiety required larger doses of alfentanil (p < 0.05). The pain level was slightly higher in the patients receiving PCA (p > 0.05) but most patients reported either no or only mild pain. Side effects from the therapy, such as nausea and vomiting, were either not present or were mild in both groups, with one patient (3% to 4%) in each group reporting mild nausea. Both patients and urologists were very satisfied with the pain management in both groups. CONCLUSIONS: PCA is a useful alternative to physician-controlled analgesia during ESWL since it provides equivalent pain control while using less alfentanil.
Adult↗
Differential work assignments of social work practitioners in hospitals.
This article reports the results of a survey concerning the differential assignment of tasks to social workers with bachelor of social work (BSW) and master of social work (MSW) degrees by social work directors in Canadian hospitals. It also provides data relative to the variation in amount of supervision provided to workers in those settings where both BSW-level and MSW-level workers perform the same tasks. It is intended that this study will yield useful information to assist the profession in defining the appropriate assignment of tasks to hospital social workers.
Adult↗
Trends in medication choices for hypertension in the elderly. The decline of the thiazides.
We studied the evolution in choice of antihypertensive therapy in the elderly over a seven-year period and defined factors associated with such prescribing. To accomplish this, we performed a retrospective analysis of 8428 enrollees older than 65 years of age in the New Jersey Medicaid and Medicare programs newly begun on antihypertensive therapy between 1982 and 1988. Diuretics were the most common agents prescribed (51%), followed by calcium channel blockers (14%), beta-blockers (13%), central adrenergic antagonists (11%), and angiotensin-converting enzyme inhibitors (5%). However, the use of diuretics declined sharply during the latter part of the time interval studied. Using logistic regression modeling, we determined that the odds of a subject being started on a diuretic compared with any other antihypertensive drug decreased from 1.0 during the referent years 1982 to 1984 to 0.75 in 1985 to 1986 and to 0.41 in 1987 to 1988, after controlling for demographics, comorbidity, and hospital and physician visits (P < .001). The relative odds of diuretic use were significantly increased (P < .05) for the oldest subjects (odds ratio, 1.28 for age 85 and older versus ages 65 to 74 odds), women (odds ratio, 1.15), and blacks (odds ratio, 1.14). Despite the growing evidence during the study interval of the efficacy of diuretics in treating hypertension in the elderly, diuretic use diminished throughout this period in relation to other antihypertensive drugs. Subject characteristics (oldest subjects, women, and blacks) were important determinants of physicians' choice of antihypertensive therapy.
Aged↗
The use of heated citric acid for dialyzer reprocessing.
Dialyzer reprocessing with heated water (100 to 105 degrees C) for 20 h can be used safely in lieu of chemical methods for disinfection. All infective agents including spores are destroyed and depyrogenation may occur. However, these temperatures may result in structural damage to the dialyzer, limiting reuse. Dialyzer reprocessing by using 1.5% citric acid heated to 95 degrees C for 20 h is an alternative method that produces equivalent microbiologic effects. Citric acid is well known as a disinfecting agent used for dialysis equipment. Because there is little structural damage to dialyzer components at 95 degrees C, reuse statistics are improved (mean reuse increased to 12.8). Both small and large molecule clearances and the sieving coefficient for protein are insignificantly altered by the process. Whereas the procedure is relatively simple, quality-assurance indicators are essential. The method has appeal because it avoids the use of chemical germicides. However, at present it has only been tested thoroughly in polysulfone dialyzers with heat-resistant polycarbonate casings and polyurethane resin. The clinical experience is favorable.
Citric Acid↗
Relations of oral imagery to thought disorder in subjects with frequent nightmares.
Oral imagery was examined in the Rorschach protocols of 60 female subjects, 30 who experienced at least one nightmare per week and 30 who had no more than one nightmare in the past year. Mean number of oral responses did not differ between the groups. In subjects with nightmares, Rorschach orality was significantly related to many personality measures, including state and trait anxiety, Beck Depression Inventory scores, five subscales of a schizotypy inventory, the Rorschach penetration score, and two measures of pathological thinking on the Rorschach. In the 30 subjects without nightmares, the number of significant correlations did not exceed that expected by chance. The results are discussed within the context of empirical and theoretical reports about the links between the oral personality and pathological behavior.
Adolescent↗