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Biomedical subjects

R M Wachter

Publications and source records attributed to R M Wachter.

70 records · Page 4Linked to original sources
PubMed1988

Attitudes of medical residents regarding intensive care for patients with the acquired immunodeficiency syndrome.

We recently surveyed the medical house staff at the University of California, San Francisco, and found that residents had a good understanding of the poor prognosis of patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia who require intensive care for respiratory failure, and tended to favor early discussions with patients regarding resuscitation and intensive care. We used the same questionnaire to survey the house staffs of four other programs varying in geography and exposure to patients with AIDS. We found a striking correlation between the number of patients with AIDS cared for by the residents, the assessment of the prognosis of patients with AIDS with P carinii pneumonia, and house-staff attitudes toward discussions about resuscitation and intensive care. The results of this study suggest that the intensity of exposure to patients with AIDS determines the assessment of prognosis, and that one or both of these factors strongly influences attitudes toward intensive care. Regardless of these attitudes, early discussion of resuscitation and intensive care between physicians and patients with AIDS and P carinii pneumonia seems warranted.

Acquired Immunodeficiency Syndrome↗
PubMed1987

Symptomatic hypotension induced by nifedipine in the acute treatment of severe hypertension.

The optimal acute treatment for severe hypertension remains controversial. In the last few years, the use of sublingual and oral nifedipine has been supported by a growing literature and clinical experience. Most reviews have minimized the risk of hypotension caused by nifedipine therapy. This report describes three patients who developed profound hypotension after acute treatment of hypertension with the usual doses of nifedipine. A review of the literature reveals no previous reports of symptomatic hypotension from the use of nifedipine alone in this setting. Clinicians should be aware of this potentially life-threatening toxicity and titrate doses and monitor patients accordingly.

Female↗
PubMed1986

Intensive care of patients with the acquired immunodeficiency syndrome. Outcome and changing patterns of utilization.

Eighty-two patients with the acquired immunodeficiency syndrome (AIDS) were admitted to the intensive care units (ICUs) at San Francisco General Hospital (SFGH) between March 1981 and December 1985. Of these patients, 69% died in the hospital, as did 87% of patients who required mechanical ventilation because of Pneumocystis carinii pneumonia and respiratory failure. Although the number of hospital admissions of patients with AIDS has increased steadily since the fourth quarter of 1982 (12 admissions) through the fourth quarter of 1985 (158 admissions), the number of admissions to the ICUs peaked at 17 in the second quarter of 1984 and decreased steadily, averaging 5 per quarter in 1985. This decrease was not explained by a reduction in the number of patients with P. carinii pneumonia or an improvement in their treatment. A survey of physicians at SFGH indicated that physicians are aware of the poor prognosis of patients with AIDS with P. carinii pneumonia and respiratory failure, believe that mechanical ventilation is infrequently indicated for this condition, and have become increasingly likely to discuss issues of resuscitation with their patients with AIDS. Therefore, possible explanations for this trend in ICU utilization include changing physician attitudes, in addition to more effective patient counseling and increased availability of hospital and community-based support services that provide alternatives to terminal intensive care.

Acquired Immunodeficiency Syndrome↗
PubMed1984

Strongyloides stercoralis hyperinfection masquerading as cerebral vasculitis.

Strongyloides stercoralis hyperinfection is a unique opportunistic infection in which the nematode disseminates widely to cause a multisystem illness. We treated a patient with systemic lupus erythematosus in whom ileus and fever developed and who later lapsed into coma. A xenon Xe 133 cerebral blood flow study showed a global reduction in flow, compatible with CNS vasculitis. The patient's condition failed to improve with high-dose steroid therapy, but he recovered rapidly after Strongyloides larvae were found in stool and sputum and treatment with thiabendazole was begun. We believe that hyperinfection explained the patient's symptoms and should be considered as a cause of diminished cerebral perfusion and mentation in immunosuppressed patients.

Brain Diseases↗
PubMedDate not supplied

Ethical dilemmas about intensive care for patients with AIDS.

AIDS presents ethical dilemmas about intensive care. Even with intensive care the outcome for patients with AIDS is poor. Care givers have no ethical or medical obligation to provide futile care. Decisions concerning competent patients should be made jointly by physicians and the informed patients themselves. For incompetent patients decisions should be made jointly by physicians and appropriate patient-surrogates in light of the previously expressed wishes of the patients. Care givers should encourage patients with AIDS to express their preferences about life-sustaining treatment in order to avoid dilemmas should these patients later become incompetent. The AIDS epidemic may force more explicit discussions about the allocation of limited health-care resources, such as intensive care. Such allocation decisions should not discriminate against patients with AIDS.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Hospitalist staffing requirements.

CONTEXT: The use of hospitalists--physicians who spend a substantial portion of their time providing in-hospital care to the patients of primary care physicians--has been proposed as a way to decrease costs and increase the quality of inpatient care. COUNT: Number of full-time hospitalists. CALCULATIONS: Average daily census = annual admissions x length of stay divided by 365. Number of hospitalists = (average daily census divided by patients per hospitalist) + 1 extra hospitalist for night coverage. DATA SOURCES: The average number of patients per hospitalist was obtained from a National Association of Inpatient Physicians membership survey. A low estimate of 10 patients per hospitalist was used to account for the extra manpower needed for coverage during vacations and other time off. RESULTS: A hospital with 3000 admissions per year and an average length of stay of 5 days would have an average daily census of 41 patients and would need 5 full-time hospitalists. Hospitals with a lower patient volume would need fewer hospitalists and would probably need to find persons other than hospitalists to cover some nights and weekends. CONCLUSIONS: Simple calculations based on hospital admissions and length of stay can estimate the number of hospitalists required for adequate staffing. Requirements will vary with the hospitalists' workload; the patient case complexity; and the duties other than inpatient care that are required of hospitalists, such as consultations, skilled nursing facility coverage, quality improvement work, teaching, and research.

Health Services Research↗
PubMedDate not supplied

The benefits of using hospitalists.

A good hospitalist program will more than pay for itself by improving outcomes, reducing length of stay, and enhancing hospital efficiency. Moreover, the program can often attract primary care physicians who prefer to use the service of a hospitalist.

Cost Control↗
PubMedDate not supplied

Caregiver perceptions of the reasons for delayed hospital discharge.

CONTEXT: Financial pressures have increased the emphasis on expeditious hospital discharge. Identification of barriers to timely discharge may help direct efforts to decrease unnecessary hospital days. OBJECTIVE: To identify caregivers' perceptions of reasons for discharge delays at an academic medical center. DESIGN: Survey and free-form written responses using a convenience sample (overall response rate, 68%). RESPONDENTS: 104 housestaff, 34 attending physicians, and 33 nurses. RESULTS: Nurses were much more likely than housestaff or attending physicians to cite inadequate communication as a reason for discharge delays. Nurses were also more likely to attribute delays to rounds and other conferences (48% vs. 22% and 9%, respectively; P = 0.05). Physicians, however, were more likely to cite delays in testing and availability of subacute care beds. Almost all housestaff and attendings thought that discharge decisions were generally made in the morning, and over 60% felt that discharge orders were usually written before noon. In contrast, none of the nurses thought that orders were usually written before noon. CONCLUSIONS: Caregivers at the same institution perceived different barriers to discharge and believed that discharge-related activities occurred at different times. To facilitate hospital discharge, communication gaps should be addressed and traditional morning routines should be reexamined.

Attitude of Health Personnel↗
PubMedDate not supplied

Critical care of patients with AIDS.

OBJECTIVE: We sought to review the clinical and ethical issues surrounding critical care for patients with the acquired immunodeficiency syndrome (AIDS). DATA SOURCES: We reviewed published studies and abstracts dealing with the outcome of critical care for patients with AIDS, decision making about life-sustaining treatments in patients with AIDS, and infection control in the intensive care unit. We also consulted with a number of experts in the field. STUDY SELECTION: We selected outcome studies in which patients with documented AIDS or infection with the human immunodeficiency virus (HIV) were analyzed. We rejected data concerning patients with suspected or presumed AIDS and data concerning presumed cases of Pneumocystis carinii pneumonia (PCP). DATA SYNTHESIS: Most AIDS patients who require critical care do so because of respiratory failure caused by PCP. Although studies early in the epidemic reported survival rates to hospital discharge of 0% to 14%, recent studies demonstrate improved survival rates of 36% to 55%. Treatment for patients with PCP and respiratory failure should include either intravenous trimethoprim-sulfa-methoxazole or pentamidine isethionate, as well as adjuvant corticosteroids. Patients with AIDS may require critical care for many other indications, including seizures, sepsis, and hypotension, or reasons unrelated to their immunodeficiency. In general, such patients have a better prognosis than those with respiratory failure. CONCLUSION: The provision of critical care for PCP and respiratory failure specifically or AIDS generally cannot be considered futile. Therefore, decisions about the use of critical care should be guided by the particular clinical situation and the patient's preferences. More research is needed to elucidate the reasons for the improving survival for patients with PCP and respiratory failure and the predictors of such survival.

Acquired Immunodeficiency Syndrome↗