Search PubMed⌕ Search

Biomedical subjects

C Maynard

Publications and source records attributed to C Maynard.

At least 55 records · Page 3Linked to original sources
PubMed1999

Utilization of services for mentally ill chemically abusing patients discharged from residential treatment.

Little is known about outcomes of treatment for individuals with mental illness and chemical dependencies. This article compares services utilization preadmission and postdischarge in 534 patients discharged from a residential treatment program in Washington State. A number of services, including chemical dependency detoxification, mental health crisis, inpatient psychiatric, medical emergency, and general medical inpatient hospitalization, were used less frequently in the period after discharge. The total reimbursement for all Medicaid services decreased by 44% from $5 million in the year prior to discharge to $2.8 million in the year after discharge. Also, individuals (32%) who completed the program were less likely to use costly, acute care services. This study was limited by the absence of a control group and posttreatment alcohol and drug use data. In addition, other unmeasured factors could have explained the association between program completion and better outcomes.

Adult↗
PubMed1999

Coronary artery stent outcomes in a Medicare population: less emergency bypass surgery and lower mortality rates in patients with stents.

BACKGROUND: Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice. METHODS AND RESULTS: This study uses information from the Medicare Provider Analysis and Review files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same- admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial infarction. Hospital mortality rates were similar in both years, but the use of same-admission coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocardial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results. CONCLUSIONS: This study documents improved short-term outcomes in older patients who undergo coronary stent placement. Stenting did not eliminate the finding of improved outcomes at high-volume centers.

Aged↗
PubMed1999

Evaluation of the efficacy of hand-held computer screens for cardiologists' interpretations of 12-lead electrocardiograms.

BACKGROUND: Newly designed computer-based applications and the development of wireless technology have allowed the transmission of 12-lead electrocardiogram (ECG) waveforms from remote locations to the hand-held computers of cardiologists. If these computer ECGs can be reliably interpreted, then the time to treatment for cardiac patients may be reduced. METHODS AND RESULTS: Twenty classic examples of cardiac abnormalities were chosen to test the efficacy of the hand-held computer's liquid crystal display (LCD) screen in the interpretation of 12-lead ECGs. Ten cardiologists interpreted these 20 ECGs on the hand-held computers and then twice later on traditional printed paper. The control intraobserver agreement between the sets of paper-displayed ECGs was measured against the agreement between each of the paper sets and the LCD-displayed set of ECGs. Eighty-nine percent (178/200) of the ECGs were interpreted identically by the participants between the 2 paper sets. When comparing the interpretations of the LCD-displayed ECGs with those of each of the paper sets of ECGs, 88.0% (176/200) and 87.5% (175/200) of identical diagnoses were noted. These differences of 1.0% and 1.5% in intraobserver agreement between paper-to-paper and each of the 2 paper-to-LCD comparisons were not significant (P =.75 and P =.88, respectively). CONCLUSIONS: The strong intraobserver agreement shows that cardiologists make the same diagnoses when viewing LCD-displayed ECGs as they do when viewing paper-displayed ECGs. A study to measure the intraobserver agreement of the decision regarding administration of reperfusion therapy after interpretation of ECGs of patients with acute chest pain is now underway.

Data Display↗
PubMed1999

Attribution of responsibility for injury and long-term outcome of patients with paralytic spinal cord trauma.

STUDY DESIGN: Survey. OBJECTIVE: To assess the association between patients' perceptions of responsibility for the injury and long term outcomes. SETTING: Duke University Medical Center Spinal Injury Service. METHODS: One hundred and forty patients, who suffered spinal cord injuries between 1985 and 1990, were selected to participate in the study, and 26 (19%), including eight with quadriplegia, completed a telephone interview. The mean age at interview was 39+/-12 years and 12% were women. The mean time from injury to completion of the study was 8.7+/-1.5 years. Attribution of cause of injury, the Craig Handicap Assessment Reporting Technique, and the SF36 mental health depression/vitality surveyed instruments attribution of responsibility for the injury, functional capacity, mental health depression, and vitality. RESULTS: The majority (18/26) of patients either totally blamed themselves or others for their injuries. Overall, there was no statistically significant association between attribution of injury and long-term outcomes. Outcomes were similar in patients who either totally blamed themselves or others for their predicament. CONCLUSION: In this study, long-term outcomes were not influenced by whether patients perceived themselves as being responsible for their injuries.

Activities of Daily Living↗
PubMed1999

Intracellular accumulation of detergent-soluble amyloidogenic A beta fragment of Alzheimer's disease precursor protein in the hippocampus of aged transgenic mice.

To study amyloid beta-protein (A beta) production and aggregation in vivo, we created two transgenic (Tg) mouse lines expressing the C-terminal 100 amino acids of human amyloid precursor protein (APP): Tg C100.V717F and Tg C100.WT. Western blot analysis showed that human APP-C100 and A beta were produced in brain and some peripheral tissues and A beta was produced in serum. Using antibodies specific for the A beta C terminus we found that Tg C100.V717F produced a 1.6-fold increase in A beta42/A beta40 compared with Tg C100.WT. Approximately 30% of total brain A beta (approximately 122 ng/g of wet tissue) was water-soluble. The remaining 70% of A beta partitioned into the particulate fraction and was completely sodium dodecyl sulfate-soluble. In contrast, human Alzheimer's disease brain has predominantly sodium dodecyl sulfate-insoluble A beta. Immunohistochemistry with an A beta(5-8) antibody showed that A beta or A beta-containing fragments accumulated intracellularly in the hippocampus of aged Tg C100.V717F mice. The soluble A beta levels in Tg brain are similar to those in normal human brain, and this may explain the lack of microscopic amyloid deposits in the Tg mice. However, this mouse model provides a system to study the intracellular processing and accumulation of A beta or A beta-containing fragments and to screen for compounds directed at the gamma-secretase activity.

Aging↗
PubMed1999

The management of chronic wounds: factors that affect nurses' decision-making.

This study sought to determine how registered nurses make decisions regarding the management of chronic wounds. A self-administered questionnaire consisting of both Likert-type and open-ended questions was used to survey registered nurses working in hospitals and community services in a large Australian city. A total of 140 questionnaires were returned from a variety of clinical settings. The study revealed that registered nurses had a significant role in chronic wound management. However, they relied primarily on their own experience and that of colleagues for decision making in which they had varying degrees of autonomy. The authors conclude that nurses and medical staff require more objective, research-based education on wound assessment and management.

Bandages↗
PubMed1999

Thrombolysis versus primary angioplasty in older patients with acute myocardial infarction.

Although it is effective for appropriate older patients with acute myocardial infarction (AMI), only about 25% of patients 65 years and older are eligible for thrombolytic therapy. Primary percutaneous transluminal coronary angioplasty (PTCA) may be a suitable alternative reperfusion therapy, particularly for older patients with high risk of intracerebral haemorrhage or cardiogenic shock. Randomised trials of primary PTCA versus thrombolytic therapy have demonstrated better efficacy for primary PTCA, whereas the 2 therapies produced comparable results in observational studies. In subset analyses in 2 randomised trials, there were trends toward better outcomes with primary PTCA, although these studies had small numbers of older patients. Results from 3 AMI registries (the Cooperative Cardiovascular Project, the Myocardial Infarction Triage and Intervention Registry, and the National Registry of Myocardial Infarction 2) indicated trends toward improved hospital or 30 day death rates in patients 75 years and older receiving primary PTCA. Older patients who are at high risk of bleeding complications may do better with primary PTCA, although for others with moderate or minimal risk, the 2 therapies are equivalent. More data about long term follow-up and the association between outcomes and hospital and operator volumes for primary PTCA in older patients are needed before a definitive recommendation can be made.

Age Factors↗
PubMed1998

A comparison of percutaneous transluminal coronary angioplasty in the Department of Veterans Affairs and in the private sector in the State of Washington.

Coronary angioplasty is performed > 1,000 times daily in a variety of health care settings in the public and private sectors in the USA. How outcomes for this procedure differ in the Department of Veterans Affairs and the private sector is unknown. The purpose of this study was to compare outcomes of coronary angioplasty performed in hospitals in the Department of Veterans Affairs and the State of Washington. This study used administrative data from the Department of Veterans Affairs patient treatment file (n = 8,326) and the State of Washington episode of illness file (n = 6,666) and included men who underwent coronary angioplasty in 1993 and 1994. Outcomes included (1) in-hospital mortality and mortality at 10 and 30 days after hospital admission, and (2) the use of coronary artery bypass surgery at similar intervals. Patients with a principal diagnosis of acute myocardial infarction were analyzed separately. Men in the Department of Veterans Affairs had more comorbid conditions than their counterparts in Washington State, and the length of hospital stay was longer in the former group. After using logistic regression to adjust for patient differences, mortality rates for the 2 groups of patients with acute myocardial infarction were similar, although bypass surgery was used more frequently in patients in Washington State. For patients without myocardial infarction, hospital and 10-day mortality did not differ with respect to health care system, and the use of bypass surgery subsequent to angioplasty was similar. In the Department of Veterans Affairs, most hospitals had low institutional caseloads (< 150 procedures per year), whereas > 40% of Washington State hospitals performed > or = 300 procedures per year. Although there were greatly differing institutional caseloads, mortality and the need for early bypass surgery were similar in the 2 systems.

Adult↗
PubMed1998

Coronary angioplasty outcomes in the Healthcare Cost and Utilization Project, 1993-1994.

It is estimated that >400,000 percutaneous transluminal coronary angioplasty (PTCA) procedures are performed in the Unites States annually. This study reports patient characteristics and outcomes for 163,527 PTCAs performed in 214 hospitals in 17 states from 1993 to 1994. These hospitals were a 20% random sample of hospitals in the Healthcare Cost and Utilization Project, which was designed to reflect hospitalization in the United States, generally. Cases with International Classification of Diseases, 9th Revision, Clinical Modification procedure codes 36.01, 36.02, and 36.05 were defined as PTCA and were categorized as to whether acute myocardial infarction (AMI) was the principal discharge diagnosis. The average age of 44,270 AMI discharges (27%) was 62 +/- 12 years and that of 119,257 no-AMI cases (73%) was 64 +/- 11 years; 1/3 of both groups were women, 88% were white, and almost 90% had Medicare or private insurance as the primary payer. The states contributing the most cases were Florida (26%), California (12%), and Wisconsin (10%). Hospital mortality was 1.7% overall and was 3.8% for AMI and 0.8% for no-AMI cases. Bypass surgery performed during the same admission was 3.4% overall and was 4.5% and 3.0% for AMI and no-AMI cases, respectively. Multivariate analysis showed that advanced age, diabetes, female gender, and Medicaid payer status were associated with increased risk of mortality. National estimates from this 20% sample indicate that >850,000 PTCAs were performed in the 2 years, with 452,319 cases estimated for 1994. In 1994 there were an estimated 2,789 deaths and 9,903 bypass surgeries in the no-AMI subset of 327,856 procedures. For the AMI group of 124,463 procedures, there were 4,486 deaths and 5,799 bypass surgeries in 1994. This study of PTCA outcomes contains the largest number of cases as well as the most representative sample reported to date.

Angioplasty, Balloon, Coronary↗
PubMed1998

Primary care physician compensation method in medical groups: does it influence the use and cost of health services for enrollees in managed care organizations?

CONTEXT: Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization. OBJECTIVE: To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician. DESIGN: Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees. SETTING: Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington. STUDY PARTICIPANTS: Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200 931 adult plan enrollees. INTERVENTION: The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression. MAIN OUTCOME MEASURES: Total visits, hospital days, and per member per year estimated costs. RESULTS: Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P<.001), female gender (P<.001), and plan benefit level (P<.001) were significantly positively related to visits, hospital days, and per member per year costs. The primary care physician's age was significantly negatively related (P<.001) to all 3 dependent measures. CONCLUSIONS: Compensation method was not significantly related to use and cost of health services per person. Enrollee, physician, and health plan benefit factors were the prime determinants of utilization and cost of health services.

Capitation Fee↗
PubMed1998

Randomized, controlled trial of RheothRx (poloxamer 188) in patients with suspected acute myocardial infarction. RheothRx in Myocardial Infarction Study Group.

BACKGROUND: Patients with acute myocardial infarction (AMI) who are not eligible for thrombolytic therapy or primary coronary angioplasty are distinguished by advanced age, complicated medical histories, relatively frequent use of prior revascularization procedures, and worse outcomes than their counterparts who are eligible for reperfusion therapy. METHODS AND RESULTS: The purpose of this randomized, controlled trial was to determine whether RheothRx, a hemorheologic agent, reduced myocardial infarct size and improved left ventricular function in patients who had suspected AMI at the time of hospital admission and were not eligible for reperfusion therapy. Patients were randomly assigned to RheothRx (n = 97) or placebo (n = 99). Patients in the two groups were similar with respect to age, sex, medical history, and clinical presentation. Enzyme evidence of AMI was present in 69% of the treatment group and 70% of the placebo group. Infarct size measured before hospital discharge was similar in the two groups (14.1% +/- 18.5% vs 11.7% +/- 14.1%, p = 0.60), although left ventricular ejection fraction was lower in the treatment group (47 +/- 14 vs 52 +/- 11, p = 0.026). Hospital mortality rate was 11.3% and 7.1% in patients receiving RheothRx and patients receiving placebo, respectively (p = 0.30). There was a higher occurrence of acute renal dysfunction in the RheothRx group (12% vs 2%, p = 0.005). Because of changes in drug dosage necessitated by the occurrence of acute renal dysfunction, the trial was stopped. CONCLUSIONS: In this study of patients who had suspected AMI and were not eligible for thrombolytic therapy, RheothRx did not decrease infarct size or favorably alter outcome. The need for effective treatment for this large patient population remains largely unmet.

Acute Kidney Injury↗
PubMed1998

Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the Myocardial Infarction Triage and Intervention (MITI) Project.

OBJECTIVES: We sought to determine whether the prehospital electrocardiogram (ECG) improves the diagnosis of an acute coronary syndrome. BACKGROUND: The ECG is the most widely used screening test for evaluating patients with chest pain. METHODS: Prehospital and in-hospital ECGs were obtained in 3,027 consecutive patients with symptoms of suspected acute myocardial infarction, 362 of whom were randomized to prehospital versus hospital thrombolysis and 2,665 of whom did not participate in the randomized trial. Prehospital and hospital records were abstracted for clinical characteristics and diagnostic outcome. RESULTS: ST segment and T and Q wave abnormalities suggestive of myocardial ischemia or infarction were more common on both the prehospital and hospital ECGs of patients with as compared with those without acute coronary syndromes (p < or = 0.00001). Those with prehospital thrombolysis were more likely to show resolution of ST segment elevation by the time of hospital admission (14% vs. 5% in patients treated in the hospital, p = 0.004). In patients not considered for prehospital thrombolysis, both persistent and transient ST segment and T or Q wave abnormalities discriminated those with from those without acute coronary ischemia or infarction. Compared with ST segment elevation on a single ECG, added consideration of dynamic changes in ST segment elevation between serial ECGs improved the sensitivity for an acute coronary syndrome from 34% to 46% and reduced specificity from 96% to 93% (both p < 0.00004). Overall, compared with abnormalities observed on a single ECG, consideration of serial evolution in ST segment, T or Q wave or left bundle branch block (LBBB) abnormalities between the prehospital and initial hospital ECG improved the diagnostic sensitivity for an acute coronary syndrome from 80% to 87%, with a fall in specificity from 60% to 50% (both p < 0.000006). CONCLUSIONS: ECG abnormalities are an early manifestation of acute coronary syndromes and can be identified by the prehospital ECG. Compared with a single ECG, the additional effect of evolving ST segment, T or Q waves or LBBB between serially obtained prehospital and hospital ECGs enhanced the diagnosis of acute coronary syndromes, but with a fall in specificity.

Bundle-Branch Block↗
PubMed1998

Use of angiotensin-converting enzyme inhibitors at discharge in patients with acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2.

OBJECTIVES: This study was undertaken to examine recent trends in the use of angiotensin-converting enzyme (ACE) inhibitor therapy in patients discharged after acute myocardial infarction (AMI) and to identify clinical factors associated with ACE inhibitor prescribing patterns. BACKGROUND: Clinical trials have demonstrated a significant mortality benefit in patients treated with ACE inhibitors after AMI. Numerous studies have demonstrated underuse of other beneficial treatments for patients with AMI, such as beta-adrenergic blocking agents, aspirin and immediate reperfusion therapy. METHODS: Demographic, procedural and discharge medication data from 190,015 patients with AMI were collected at 1,470 U.S. hospitals participating in the National Registry of Myocardial Infarction 2. RESULTS: Prescriptions for ACE inhibitor therapy at hospital discharge increased from 25.0% in 1994 to 30.7% in 1996. Patients with a left ventricular ejection fraction < or =40% or evidence of congestive heart failure while in the hospital were discharged with ACE inhibitor treatment 42.6% of the time. Of patients experiencing an anterior wall myocardial infarction and no evidence of heart failure, 26.1% of patients were discharged with this treatment. Of the remaining patients, 15.6% received ACE inhibitors at discharge. ACE inhibitors were prescribed more often to elderly and diabetic patients as well as those requiring intraaortic balloon pump placement. This therapy was given less often to patients who underwent revascularization with coronary angioplasty or coronary artery bypass graft surgery or were treated with calcium channel blocking agents. CONCLUSIONS: Physicians are prescribing ACE inhibitors in patients with myocardial infarction with increasing frequency. Those patients with the greatest expected benefit receive ACE inhibitor treatment most often. However, the majority of even these high risk patients were not discharged with this life-saving therapy.

Adrenergic beta-Antagonists↗
PubMed1998

Specificity of electrocardiographic myocardial infarction screening criteria in patients with nonischemic cardiomyopathies.

BACKGROUND: The 32-point, 54-criteria Selvester QRS scoring system has been successfully used to estimate the size of nonacute myocardial infarction (MI). Three criteria of the system have been shown to be sensitive for the identification of nonacute MI and specific in normal control subjects. The validity of the system has not been tested in patients with cardiomyopathy of nonischemic origin. The purpose of this study was to examine the electrocardiographs (ECGs) of patients with abnormal left ventricular function but no presence of coronary disease to determine the diagnostic specificity of the MI screening criteria subset of the Selvester QRS scoring system. METHODS AND RESULTS: Six hundred ninety patients were considered. Exclusion criteria included age <10 years, cardiac transplantation, thrombolytic therapy, any angiographic evidence of coronary disease, left ventricular ejection fraction (LVEF) >60%, or history of myocardial revascularization. ECG exclusion criteria included left ventricular hypertrophy, right ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular pacing, left anterior fascicular block, left posterior fascicular block, ventricular preexcitation, and low voltage, because these confounding factors could mimic an infarct on the ECG. The 261 remaining patients were then examined for the presence of the MI screening criteria subset: (1) inferior location: Q > or =30 msec in aVF, (2) anterior location: either any Q or R< or =0.1 mV and < or =10 msec in V2, and (3) posterior location: R> or =40 msec in V1. Thirty-two of the 261 patients falsely met at least 1 of the 3 MI screening criteria, resulting in an overall specificity of 88% (vs 95% in normal control subjects, P=.0006). A specificity of 98% (n = 256) was achieved for the inferior MI screening criterion alone, whereas the anterior and posterior MI screening criteria alone achieved significantly lower specificities: 94% (n = 245) and 95% (n = 249), respectively. When the patient population was divided into LVEF <30% and LVEF > or =30%, no significant association was found between MI screening criteria and LVEF with specificities of 87% and 88%, respectively, for the 2 groups (P= .34). CONCLUSIONS: The MI screening criteria subset is relatively specific in patients with nonischemic cardiomyopathy, falsely identifying only 12% with nonacute MI. However, this specificity is lower than the 95% achieved in normal subjects. Regional accumulation of scarring caused by cardiomyopathy could result in false-positive indication of MI in the present population. Another possibility could be that some patients could have hypertrophy of the myocardium insufficient to produce positive ECG criteria for left ventricular hypertrophy or right ventricular hypertrophy but sufficient to mimic infarction.

Adult↗
PubMed1998

Psychiatric hospitalization of persons with dual diagnoses: estimates from two national surveys.

Individuals with both mental illness and alcohol or drug use disorders present distinctive treatment and human service problems, including increased risk for psychiatric hospitalization in community hospitals. Using national hospital discharge abstract data for 1990 and 1994, this study compared differences in psychiatric hospitalization in community hospitals of patients with mental illness only and those with mental disorders and substance use disorders. Individuals with dual diagnoses were younger, and a greater proportion were men. Medicaid was the primary payer for a larger percentage of those with dual diagnoses. Nationally, the number of community hospitalizations for dually diagnosed patients increased 15 percent from 1990 to 1994, and total hospital charges increased from $1.9 to $2.2 billion.

Adult↗
PubMed1998

Inter-regulated balance between gelatinases and tissue inhibitor (TIMP-1) in isolated human glomeruli.

Leukocyte infiltration inside glomeruli necessitates basement membrane collagen i.v. breakdown and leads to mesangiolysis, cell proliferation and extracellular matrix synthesis during the repair process as observed in the course of acute glomerulonephritis, vasculitis and acute graft rejection. Two matrix metalloproteinases, MMP-2 and MMP-9 gelatinases, are expressed and co-secreted in balance with the tissue inhibitor of metalloproteinases-1 (TIMP-1) by activated neutrophils as well as by glomerular cells and are aimed to control basement membrane collage i.v. deposition. Using a conventional double mesh sieving method, pure populations of glomeruli were isolated from fresh human cortex specimen and maintained in short-term cultures. ELISA, zymography and immunoblotting of conditioned serum-free media revealed glomerular MMP-2, MMP-9 and TIMP-1 secretion and activity while reverse transcription-polymerase chain reaction amplification of cellular RNA demonstrated glomerular transcripts coding for these enzymes and their inhibitor. When purified neutrophils were allowed to adhere onto Transwell apparatus in contact with glomerular suspensions, neutrophil 92 kDa gelatinase seemed apparently inhibited mainly because the production of TIMP-1 was enhanced on both sides of the insert. Glomerular 72 kDa and 92 kDa gelatinases were activated shortly (1 to 6 h) after neutrophils had interacted with glomeruli and furthermore upon activation by inflammatory or vasoactive mediators such as phorbol. Decreased neutrophil MMP-9 activity together with reduced MMP-9 mRNA levels and protracted TIMP-1 transcription and secretion during cell-cell interaction could participate to cell detachment from degraded basement membranes and to increased collagen i.v. deposition leading to glomerulosclerosis after initial glomerular injury by inflammatory cells.

Cells, Cultured↗