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Biomedical subjects

J E Heffner

Publications and source records attributed to J E Heffner.

At least 19 recordsLinked to original sources
PubMed2001

Tracheostomy management in the chronically ventilated patient.

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Critical Care↗
PubMed2001

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.

OBJECTIVE: Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax. OPTIONS: Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging. OUTCOMES: Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence. EVIDENCE: Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel. VALUES: The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire. BENEFITS, HARMS, AND COSTS: The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation. RECOMMENDATIONS: Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care. VALIDATION: Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee. IMPLEMENTATION: The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs. SPONSORS: The ACCP.

Adult↗
PubMed2001

The role of tracheotomy in weaning.

Tracheotomy is commonly performed in ventilator-dependent patients. Disadvantages to the procedure are perioperative complications, long-term airway injury, and the cost of the procedure. Benefits ascribed to tracheotomy vs prolonged translaryngeal intubation include improved patient comfort, more effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased potential for speech, ability to eat orally, a more secure airway, accelerated ventilator weaning, reduced ventilator-associated pneumonia, and the ability to transfer ventilator-dependent patients from the ICU. None of these benefits, however, have been demonstrated in large-scale, prospective, randomized studies. It is proposed that there should be an anticipatory approach wherein tracheotomy is considered after an initial period of stabilization with the patient receiving mechanical ventilation when it becomes apparent that the patient will require prolonged ventilator assistance. Tracheotomy then is performed when the patient appears likely to gain one or more of the benefits ascribed to the procedure.

Airway Resistance↗
PubMed2001

Altering physician behavior to improve clinical performance.

Increasing public awareness of the need to improve quality in health care and to limit unexplained variations in clinical practice have promoted interest in altering physician behavior. Unfortunately, many programs for changing the practice patterns of providers have proven less effective than anticipated. Interventions have often been initiated without a clear understanding of their theoretical basis or the empiric data supporting their use. This article reviews the various interventions available for altering physician behavior and their evidence of effectiveness.

Behavior Therapy↗
PubMed2000

Transverse myelitis associated with restless legs syndrome and periodic movements of sleep responsive to an oral dopaminergic agent but not to intrathecal baclofen.

Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS) are related sleep disorders that occur with increased frequency in spinal cord disease. Effective treatment may be obtained with dopaminergic or opioid drugs, while anticonvulsants, benzodiazepines, and possibly baclofen may be helpful. This report describes a patient who developed RLS and PLMD after acute transverse myelitis associated with infectious mononucleosis, and failed to respond to intrathecal baclofen. All symptoms of RLS/PLMD resolved after treatment with pergolide.

Acute Disease↗
PubMed2000

Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions.

STUDY OBJECTIVES: To assess the accuracy of pleural fluid (PF) pH in predicting duration of survival of patients with malignant pleural effusions. DESIGN: Analysis of patient-level data from nine sources retrieved from a MEDLINE search and correspondence with primary investigators. STUDY SELECTION: Published and unpublished studies that report PF pH values and duration of survival of patients with malignant pleural effusions. DATA COLLECTION AND ANALYSIS: Primary investigators supplied patient-level data (n = 417), which was examined by receiver operating characteristic (ROC) analysis, logistic regression, and survival time modeling to determine the utility of PF pH for predicting survival compared with other clinical factors. The primary investigations were graded for study design. MEASUREMENTS AND RESULTS: Median survival (n = 417) was 4.0 months: PF pH (p < 0.0039) was an independent predictor of survival duration. A PF pH test threshold < or = 7.28 had the highest accuracy for identifying poor 1-, 2-, and 3-month survivals. The predictive accuracies of PF pH (area under the ROC curve range, 0.571 to 0.662) and a PF pH-high-risk tumor (lung, soft tissues, renal, ovary, gastrointestinal, prostate, and oropharynx) model (odds ratio range, 2.91 to 6.67), however, were modest for predicting 1-, 2-, and 3-month survival. Only 54.4% and 62.7% of patients identified by PF pH < or = 7.28 or the PF pH-high-risk tumor model to die within 3 months were correctly classified. Weaknesses of the primary data were identified. CONCLUSIONS: PF pH has insufficient predictive accuracy for selecting patients for pleurodesis on the basis of estimated survival.

Body Fluids↗
PubMed2000

Pleural fluid pH as a predictor of pleurodesis failure: analysis of primary data.

STUDY OBJECTIVES: To determine the predictive accuracy of pH for identifying patients with malignant pleural effusions who will fail pleurodesis. DESIGN: Analysis of published and unpublished individual patient-level data retrieved from a MEDLINE search and correspondence with primary investigators. STUDY SELECTION: Studies that reported pleural fluid pH values and outcomes of pleurodesis for patients with malignant pleural effusions. DATA COLLECTION AND ANALYSIS: Primary investigators supplied data for 433 patients. Receiver operating characteristic analysis and logistic regression estimated the predictive accuracy, decision thresholds, and value of pleural fluid pH compared with other clinical factors. The primary investigations were graded for study design. RESULTS: Pleural fluid pH was the only independent predictor of pleurodesis failure (odds ratio, 4.46; 95% confidence interval [CI], 2.69 to 7.45; p < 0.0001) and had an area under the receiver operating characteristic curve (decision threshold, < or = 7.28) of 0.671 (95% CI, 0.624 to 0.715). The pH model fit the data well (p = 0.48) with the probability of pleurodesis failure increasing as pH decreased; specificity and negative predictive values for pleurodesis failure exceeded 90% and 80%, respectively, with a positive predictive value of 45.7% at pH values < or = 7.15. The primary studies had several important design limitations. CONCLUSIONS: Using patient-level data, this study showed that pleural fluid pH has only modest predictive value for predicting symptomatic failure and should be used with caution, if at all, in selecting patients for pleurodesis. The limitations of the primary studies and low predictive accuracy should be considered when using pleural fluid pH for patient care.

Aged↗
PubMed2000

End-of-life care preferences of patients enrolled in cardiovascular rehabilitation programs.

STUDY OBJECTIVES: The study assessed the interests of ambulatory cardiac patients in advance planning and their willingness to participate in rehabilitation program-based end-of-life education. DESIGN: Observational survey study. SETTING: Fourteen outpatient cardiac rehabilitation programs in 11 states. PARTICIPANTS: Four hundred fifteen subjects enrolled in cardiac rehabilitation. MEASUREMENTS AND RESULTS: A questionnaire determined patient preferences for advance planning, completion of advance directives, completion of patient-physician discussions on end-of-life care, and effects of health status on patient acceptance of life-sustaining interventions. Seventy-two percent of patients wanted to direct their own end-of-life care, 86% desired more information on advance directives, 62% wanted to learn about life-sustaining care, and 96% were receptive to advance-planning discussions with their physicians. Seventy-two percent of patients had considered that they might require life-sustaining care in the future; acceptability of resuscitative care depended on health status and probability of survival. However, only 15% had discussed advance planning with their physicians, and 10% were confident that their physicians understood their end-of-life wishes. Physicians and cardiovascular rehabilitation programs were considered desirable sources of information on advance planning. CONCLUSIONS: Cardiac patients enrolled in rehabilitation programs want to learn more about end-of-life care and need more opportunities to discuss advance planning with their physicians. Patients consider cardiovascular rehabilitation programs to be acceptable sites for advance planning education.

Advance Directives↗
PubMed1999

Infection of the pleural space.

Parapneumonic effusions are common accompaniments of pneumonia that require proper management to prevent progression to empyema. Management decisions require thoughtful individualization of care because of the multiple factors that affect outcome; no one algorithmic approach exists for all patients. Basic principles of care, however, apply to all patients and center on the early detection of infected pleural fluid and the rapid completion of effective pleural drainage and lung re-expansion, when indicated to decrease morbidity and mortality.

Anti-Bacterial Agents↗