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F A Lederle

Publications and source records attributed to F A Lederle.

At least 37 records · Page 2Linked to original sources
PubMed1994

Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project.

BACKGROUND: We had previously observed that a large proportion of peripheral intravenous (i.v.) catheters placed in patients on a regular medical ward at our hospital were unnecessary. We conducted the current study to assess the effect of a quality improvement project led by medicine house staff on the prevalence of unnecessary peripheral i.v. catheters (those without any therapeutic use, referred to as idle). METHODS: All patients on four regular-care medical wards of a large university-affiliated veterans hospital were included in the study. The proportion of i.v. catheter episodes in which catheters were idle 2 or more consecutive days (idle episodes) and the proportion of patients exposed to an idle catheter episode were determined by direct observation, chart review, and patient interview before and after a multidisciplinary quality improvement task force defined guidelines for appropriate i.v. catheter use and made recommendations for hospital policy changes related to i.v. catheter use. RESULTS: The proportion of all i.v. catheter episodes that were idle catheter episodes decreased significantly after the intervention (42% before vs 29% after, P < .01), as did the proportion of patients with an i.v. catheter who had at least one idle i.v. catheter episode (43% vs 27%, P < .001). CONCLUSIONS: This quality improvement effort successfully reduced unnecessary i.v. catheter use. We suspect that house-staff involvement in the intervention was critical. We encourage other academic medical centers to involve house staff in quality improvement activities to improve patient care and to enhance the education of house staff regarding quality improvement processes.

Catheterization, Peripheral↗
PubMed1994

Prescription drug costs as a reason for changing physicians.

The authors conducted a telephone survey of 200 patients who had recently transferred their health care to a Veterans Affairs (VA) medical center. Of the study patients, 56% considered prescription drug costs to be the main reason or a major contributing reason for transfer (95% confidence interval 49% to 63%). The mean out-of-pocket prescription drug cost for these patients was $139 per month, compared with $47 per month for patients for whom drug costs were a minor reason or not a reason at all (p < 0.001). Drug costs are a principal reason for patients to transfer their health care to the VA.

Aged↗
PubMed1994

Ruptured abdominal aortic aneurysm: the internist as diagnostician.

PURPOSE: To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. PATIENTS: All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD: Chart review. RESULTS: We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS: In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.

Aged↗
PubMed1994

Design of the abdominal aortic Aneurysm Detection and Management Study. ADAM VA Cooperative Study Group.

PURPOSE: This study describes the design of an ongoing randomized trial intended to determine which of two strategies is superior for managing small abdominal aortic aneurysms (AAA). METHODS: Patients aged 50 to 79 years with AAA 4.0 to 5.4 cm in diameter as determined by computed tomography (CT) who are not at high surgical risk are randomized to either repair of the AAA, called "immediate surgery," or follow-up of the AAA with ultrasonography or CT every 6 months, reserving surgery for those aneurysms that enlarge to 5.5 cm, enlarge rapidly, or become symptomatic, called "selective surgery." RESULTS: The primary outcome measure is all-cause death, and secondary outcome measures are AAA-related death, morbidity, and general health status. The study design calls for 1350 patients to be randomized and monitored for a mean of 5 years. A second objective of the study is to accurately define the prevalence and risk factors for AAA with use of information from the large screening program established to detect AAA for recruitment into the randomized trial. CONCLUSIONS: By the end of 1993, 38,697 patients had been screened with ultrasonography, accounting for about three fourths of new randomizations, and 330 patients had been enrolled (70% of the target rate).

Aged↗
PubMed1992

The idle intravenous catheter.

OBJECTIVE: To assess the prevalence of idle peripheral intravenous (IV) catheters (those without any therapeutic use) on regular-care medical wards. DESIGN: Observation, interviews, and chart review. SETTING: A university-affiliated VA medical center. PATIENTS: All 959 inpatients on 4 regular-care medical wards during a 6-week period, including 484 IV catheter episodes and 2983 patient-days of IV catheter use. MAIN OUTCOME MEASURE: Idle IV catheter use. RESULTS: Thirty-five percent of all IV catheter episodes (95% CI, 32% to 38%) had 2 or more consecutive idle days. In only 6 of these (1%) could a specific reason for the catheter be determined. Seventeen percent of all patients on regular-care medical wards (CI, 15% to 19%) had an idle IV catheter for 2 or more consecutive days. Twenty percent of all patient-days of IV catheter use were idle (CI, 19% to 21%). CONCLUSIONS: Our data suggest that IV are frequently used unnecessarily. Future efforts to reduce IV catheter complication rates should focus on reducing unnecessary use as well as on improving techniques to reduce infection rates when use is appropriate.

Catheterization, Peripheral↗
PubMed1991

Stealth steroids.

Explore the source record for details and available documents.

Adrenal Cortex Hormones↗
PubMed1990

Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose.

PURPOSE: The purpose of this study was to evaluate the use of sorbitol as an inexpensive alternative to lactulose for treating constipation in the elderly. PATIENTS AND METHODS: Thirty men aged 65 to 86 with chronic constipation were studied in a randomized, double-blind, cross-over trial in which lactulose and 70% sorbitol (0 to 60 mL daily) were each given for 4 weeks preceded by a 2-week washout period. RESULTS: The average number of bowel movements per week was 6.71 with sorbitol and 7.02 with lactulose (95% confidence interval of the difference: -0.43 to 1.06), and the average number of days per week with bowel movements was 5.23 with sorbitol and 5.31 with lactulose (95% confidence interval of the difference: -0.32 to 0.48). Eleven patients stated a preference for sorbitol, 12 for lactulose, and seven had no preference. On a visual analogue scale measuring severity of constipation (0 to 100 mm), the average score for sorbitol was 35.6 mm versus 37.1 mm for lactulose (95% confidence interval of the difference: -6.4 to 9.3). The sorbitol and lactulose treatment periods were also similar in percent of bowel movements recorded as "normal," frequency and severity of symptoms such as bloating, cramping, and excessive flatulence, and overall health status as assessed by a previously validated five-category questionnaire. There were no significant differences between sorbitol and lactulose in any outcome measured except nausea, which was increased with lactulose (p less than 0.05). CONCLUSION: These results support the hypothesis that sorbitol and lactulose have no clinically significant differences in laxative effect. Sorbitol can be recommended as a cost-effective alternative to lactulose for the treatment of constipation in the elderly.

Aged↗
PubMed1989

Bronchoscopy to evaluate hemoptysis in older men with nonsuspicious chest roentgenograms.

Six of 106 older men with hemoptysis and a nonsuspicious chest roentgenogram who underwent fiberoptic bronchoscopy were found to have cancer. Four of the five bronchogenic carcinomas appeared to be surgically resectable. Cancer patients were significantly older, had smoked within the last five years, and had a significantly higher frequency of central abnormalities on chest roentgenogram. Six additional bronchogenic carcinomas were diagnosed at follow-up. Two of these were probably present but not detected at the time of bronchoscopy. We conclude that (1) hemoptysis with a nonsuspicious chest roentgenogram carries an appreciable risk of cancer in older men with substantial smoking histories, (2) these cancers are often resectable, (3) a chest roentgenogram in which the central lung fields are obscured in any way should not be considered negative in patients with hemoptysis, and (4) a negative bronchoscopic examination does not exclude the possibility of cancer in these patients.

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PubMed1988

Selective screening for abdominal aortic aneurysms with physical examination and ultrasound.

Abdominal aortic aneurysm (AAA) is an important cause of preventable death in older persons. Persistently high rupture mortality rates indicate that these deaths can be prevented only by early detection and treatment of AAA. In an effort to develop an effective and efficient program of AAA detection, we selectively screened a high-risk population. Men aged 60 to 75 years with hypertension and/or coronary artery disease were randomly selected from a general medicine clinic and screened with physical examination and ultrasound. Eighteen previously unsuspected aneurysms, 3.6 to 5.9 cm in size (mean, 4.4 cm), were detected in 201 patients, for a prevalence of 9% (95% confidence interval: 4.7% to 13.3%). The specificity and positive predictive value of ultrasound were each 100%. Abdominal palpation detected only half of these aneurysms, but missed none in patients with an abdominal girth less than 100 cm (n = 6). This degree of sensitivity did not occur with "routine" examinations and requires that the examination be directed specifically toward AAA detection. We conclude that undiagnosed AAAs are common in this large subgroup of the clinic population, that ultrasound is an excellent screening test for AAAs, and that physical examination may be adequate for screening thin patients. We recommend that every two or three years persons over the age of 50 years undergo careful abdominal palpation aimed at detecting AAAs, as part of the periodic health examination. We further recommend that obese older men at high risk for AAA have at least one-time screening with abdominal ultrasound, regardless of findings on physical examination.

Abdomen↗
PubMed1987

Tapering of corticosteroid therapy following exacerbation of asthma. A randomized, double-blind, placebo-controlled trial.

Systemic corticosteroids are effective in the treatment of acute asthma, but the optimal schedule for steroid withdrawal following an asthma exacerbation has not been determined. This study was designed to test the hypothesis that tapering the corticosteroid dosage over a longer period of time reduces the number of reexacerbations. Non-steroid-dependent adult men hospitalized for asthma exacerbations during a one-year period (n = 43) were randomly assigned to corticosteroid tapering regimens of one or seven weeks, following an eight-day course of high-dose corticosteroid therapy. There were no significant differences between the long-taper and short-taper groups in rate of reexacerbation (41% vs 52%) or readmission (22% vs 21%) during the 12-week study period. Patients who did not have a reexacerbation during the 12 weeks were evaluated with spirometry, with no significant differences occurring between the two groups. More patients in the long-taper group reported corticosteroid side effects (41% vs 14%). Patients who required mechanical ventilation during the initial hospitalization (n = 7), or who reported more than two days of worse than usual dyspnea in the 12-week period (n = 20), had high rates of reexacerbation (86% and 80%, respectively). These results provide reasonable certainty (90%) that a long taper does not result in a large reduction (50% or more) in reexacerbations compared with a short taper. We conclude that the relapse rate is high in this population regardless of the corticosteroid tapering regimen used, and that a long taper does not appear to provide enough benefit to justify its routine use.

Adrenal Cortex Hormones↗