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S Weingarten

Publications and source records attributed to S Weingarten.

17 recordsLinked to original sources
PubMed1992

Enhancement or loss of the hypophagic effect of interleukin-1 upon chronic administration.

To further characterize the effect of interleukin-1 on food intake, we tested whether a tolerance to the hypophagic effect of recombinant human interleukin-1 beta (rhIL-1 beta) develops with repeated injections or continuous infusion in rats. Daily intraperitoneal (IP) injections of rhIL-1 beta (25,000 LAF units/kg b.wt.) for 4 days did not result in tolerance to rhIL-1 beta's hypophagic effect. The hypophagic effect of the same dose of rhIL-1 beta actually increased if injections were given every second day, when the hypophagic effect of the preceding injection had subsided. A dose of rhIL-1 beta that usually did not affect food intake (5000 LAF units/kg b.wt.) reduced food intake if injected repeatedly. Continuous infusion of rhIL-1 beta (25,000 LAF units/kg b.wt/day) via IP-implanted osmotic minipumps caused a strong initial suppression of feeding followed by the development of tolerance to the hypophagic effect of the infused rhIL-1 beta. Nevertheless, hypophagia caused by a subsequent IP injection of rhIL-1 beta (25,000 LAF units/kg b.wt.) was enhanced. As specific antibodies to rhIL-1 beta could be detected in sera of only three of 11 rhIL-1 beta-infused rats, the observed tolerance was probably not due to a humoral immune response. The results demonstrate that, dependent on test conditions, chronic administration of rhIL-1 beta in the rat can lead to an enhancement or to a loss of its hypophagic effect. The reasons for this difference remain unclear.

Animals↗
PubMed1992

The case for intensive dissemination: adoption of practice guidelines in the coronary care unit.

Medical practice guidelines are being embraced enthusiastically by subspecialty and government organizations, but although hundreds have been developed at great public and private expense, there are few examples of how they have improved the quality of care or reduced health care costs. This article reports documented experience in changing physician behavior after implementing medical practice guidelines in the coronary care unit without altering physician incentives or imposing the threat of sanctions. Guideline adoption did require significant attention to the implementation process, including endorsement of guidelines by local "opinion leaders," validation by local data, and an intensive and concurrent implementation strategy.

Chest Pain↗
PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗
PubMed1992

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units.

OBJECTIVES: Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness. DESIGN: A prospective, observational study. SETTING: The coronary care and intermediate care unit in an 1,100-bed community hospital. PATIENTS: A total of 217 patients hospitalized for chest pain cared for by noncardiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer. CONCLUSIONS: There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.

Age Factors↗
PubMed1992

The effectiveness of cerebral imaging in the diagnosis of chronic headache.

OBJECTIVE: The increasing availability of high-resolution cerebral imaging scanners has fueled enthusiasm for their use to "rule out" brain tumor and other serious neurologic conditions in patients with headache. The effectiveness of this practice, however, has not been tested since the advent of newer scanning equipment. Our objective was to measure the usefulness of cerebral imaging in patients with chronic isolated headache. DESIGN: A retrospective study with a 15- to 27-month follow-up period. SETTING: A group-model health maintenance organization. PATIENTS: Adult patients, 100,800, in a health maintenance organization and an enriched sample of 63 patients with neurosurgical conditions from other health maintenance organization hospitals. RESULTS: During 1990, 1083 cerebral computed tomographic scans were performed on 863 adults (0.9% of health maintenance organization adults). Eighty-nine patients were scanned for chronic isolated headache; none of the scans provided important new information (95% confidence interval, 0%, 3%). Long-term patient follow-up confirmed that this low yield could not be attributed to diagnostic work-up bias. Further attempts to support a policy of imaging patients with isolated headache were also unsuccessful. Review of an enriched sample of patients with malignant brain tumor and patients requiring craniotomy for other reasons (n = 40) demonstrated that no patient had headache alone at the time of diagnosis (95% confidence interval, 0%, 8%) and that only 5% (95% confidence interval, 0%, 12%) of these patients sought medical attention for headache alone. Sampling a second enriched sample of patients who were referred from other hospitals (n = 63) because of conditions requiring neurosurgical procedures demonstrated that only 6% of patients presented with chronic isolated headache alone (95% confidence interval, 0%, 12%). Uncertainty regarding the appropriateness of imaging patients with headache was illustrated by the extreme interphysician variability of this practice. CONCLUSION: Our study demonstrates the large potential cost and low (although not zero) yield associated with nonselectively imaging patients with chronic isolated headache.

Adult↗
PubMed1990

Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial.

OBJECTIVE: To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN: Prospective, controlled, interventional trial using an alternate month study design. SETTING: A large teaching community hospital. PATIENTS: Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS: During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS: Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS: The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Aged↗
PubMed1990

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients.

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Aged↗
PubMed1989

Barriers to influenza vaccine acceptance. A survey of physicians and nurses.

The Immunization Practices Advisory Committee (ACIP) recommends that health care providers who contact high-risk patients receive influenza immunization annually. There are few available data on hospital employees' acceptance of these recommendations or their attitudes about influenza immunization. In a hospital where no formal influenza immunization program was in place, a survey of 193 nursing personnel and physicians showed that only 2.1% received the 1986-1987 trivalent influenza vaccine and 3.2% the monovalent A/Taiwan/1/86 vaccine before the 1986-1987 influenza season. An influenza-like illness developed in a total of 35.3% of hospital employees during the influenza season, and 76.6% of them cared for patients while ill. Fear of adverse reactions, avoidance of medications, and the inconvenience of vaccine administration were frequently cited reasons for declining immunization. Hospital employees would be more inclined to receive future influenza immunization if vaccine administration were more accessible and if they were informed that immunization were a national health care policy. During the influenza season, nurses and physicians should be considered a uniformly susceptible reservoir of infection capable of transmitting influenza to patients. Moreover, ACIP guidelines alone probably will not lead to acceptable immunization rates among health care providers; organized institutional efforts to promote immunization of health care providers may be required.

Attitude of Health Personnel↗
PubMed1988

Influenza surveillance in an acute-care hospital.

The epidemiology, significance, and clinical consequences of influenza in the hospital setting were studied in a prospective surveillance of adults in an acute-care hospital during the 1986-1987 influenza season, specifically searching for cases of nosocomial influenza. A total of 43 cases of influenza A were identified; 17 cases occurred among working hospital employees, 14 cases occurred among patients in the emergency room or clinics, ten were community-acquired cases among hospitalized patients, and two cases were nosocomially acquired. The nosocomial influenza attack rate was 0.3 per 100 hospital admissions. Both cases of nosocomial influenza were associated with secondary pneumonias and prolongation of hospital stay. These cases might have gone unrecognized in the absence of an influenza surveillance program. A potential reservoir of infection was the health care providers caring for the hospitalized patients. Further systematic influenza surveillance is needed to assess the global medical and economic impact of nosocomial influenza on hospitals, rather than simply relying on reports of institutional outbreaks.

Adult↗
PubMedDate not supplied

Do hospital employees benefit from the influenza vaccine? A placebo-controlled clinical trial.

Although current guidelines target hospital employees who contact high-risk patients as a high priority for influenza immunization, there are few data to support or refute this recommendation. Therefore, the authors enrolled 179 hospital employees in a randomized double-blind placebo-controlled clinical trial during the 1985-1986 influenza season. Influenza immunization was performed without serious adverse reactions and there was no increase in absenteeism attributable to the vaccination. Among those who developed clinical influenza, there was a trend toward fewer days of illness in the vaccinated group compared with the placebo group (6.0 vs. 8.0, p = 0.07). There were no statistically significant differences between subjects receiving influenza vaccine and those receiving the placebo when comparing incidences of influenza-like illness, severities of illness, and sick absenteeism. Influenza immunization of hospital employees was performed at minimal cost and risk but provided little benefit, most likely because of an unexpected drift of the prevalent influenza strain away from the vaccine type.

Absenteeism↗