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Biomedical subjects

J E Heffner

Publications and source records attributed to J E Heffner.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1999

Indications for draining a parapneumonic effusion: an evidence-based approach.

A patient with pneumonia who develops a parapneumonic effusion challenges the physician to determine the need for pleural fluid drainage. This determination is influenced by multiple factors including the patient's general state of health, the existence of comorbidities, the virulence of the underlying pathogen, and the extent of the pneumonia that dictate clinical outcome and the relative risks and benefits of drainage. The presence of intrapleural pus represents the only factor that clearly establishes the need for drainage, although most experts recommend draining pleural fluid that is positive by Gram's stain or culture for a pathogen. Other factors such as the extent of the patient's pneumonia, severity of systemic signs of inflammation, radiographic features of the effusion, and pleural fluid chemical profile assist clinical decision making. The fundamental principle that guides therapy is the need to promptly and effectively drain pleural fluid whenever it appears likely that it will progress to a frank empyema with antibiotic therapy alone.

Decision Trees↗
PubMed1998

Compliance with do-not-resuscitate orders for hospitalized patients transported to radiology departments.

BACKGROUND: Little is known about the effectiveness of do-not-resuscitate (DNR) orders during transport of hospitalized patients away from their rooms. OBJECTIVE: To determine compliance with DNR orders in radiology departments. DESIGN: Observational study. SETTING: 248 hospital-based radiology departments. PARTICIPANTS: 248 radiology department representatives. MEASUREMENTS: 10-item questionnaire examining the response of radiology personnel to patients with DNR orders who experience cardiopulmonary arrest. RESULTS: Written DNR protocols and structured procedures for communicating DNR status were used by 18.5% (CI, 13.7% to 23.4%) and 18.1% (CI, 13.3% to 23.0%) of departments, respectively. Medical chart review was the only source of information on DNR status for 41.5% (CI, 35.4% to 47.7%) of departments. It was found that 20.2% of respondents (CI, 15.2% to 25.2%) would resuscitate patients with DNR orders and that 38.3% (CI, 32.3% to 44.4%) had resuscitated patients with DNR orders in the past. CONCLUSIONS: Most radiology departments do not have formal procedures to prevent patients from undergoing unwanted or inappropriate resuscitative interventions, and DNR orders are frequently overruled.

Advance Directive Adherence↗
PubMed1998

Communicating do-not-resuscitate orders with a computer-based system.

BACKGROUND: Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form. METHODS: Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. RESULTS: For the 147 patients, the computer-based system in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was "substantial" or "almost perfect" as measured by the K statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff. CONCLUSION: A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.

Adult↗
PubMed1998

Evaluating diagnostic tests in the pleural space. Differentiating transudates from exudates as a model.

Physicians have a staggering variety of diagnostic tests available for directing their diagnostic and therapeutic decisions. Technologic advances in laboratory science have increased the sophistication of new tests and accelerated their rate of adoption into clinical practice. Unfortunately, studies that report the value of new diagnostic tests often fail to follow accepted methodologic standards for unbiased test assessment or provide clinicians with sufficient information for the intelligent evaluation of a test's performance and applicability. The following review of pleural fluid tests that discriminate between exudative and transudative effusions serves to highlight important methodologic considerations in the assessment of diagnostic tests.

Diagnosis, Differential↗
PubMed1998

Does evidence-based medicine help the development of clinical practice guidelines?

Formal methods for the development of clinical practice guidelines have emerged to address societal needs to decrease physician practice variation, slow the rise of health-care costs, monitor inappropriate care, assist clinicians to stay abreast of new clinical information, set research priorities, and promote better health-care outcomes. Evidence-based methods ensure that guidelines provide valid recommendations based on a critical appraisal of the best available evidence rather than informal, opinion-based processes.

Evidence-Based Medicine↗
PubMed1998

MRI of central venous anatomy: implications for central venous catheter insertion.

STUDY OBJECTIVES: To determine normative values for superior vena cava (SVC) length and the utility of radiographic landmarks for identifying the boundaries of the SVC for assisting central line placement. DESIGN: Cross-sectional study. SETTING: Urban tertiary care medical centers. PATIENTS: Patients undergoing thoracic MRI scanning for various indications. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The SVC dimensions and relationship to radiographic landmarks were determined from MRI scans of 42 patients (22 men, 20 women; median age, 57 years). The median length of the SVC was 6.8 cm (range, 4.4 to 10.0 cm) and did not correlate with gender or other measured cardiovascular dimensions. The right tracheobronchial angle was the best radiographic landmark for determining the cephalad origin of the SVC being always caudad and within a median of 1.5 cm (range, 0.1 to 3.8 cm) of the upper SVC. It was always at least 2.9 cm above the atriocaval junction. The right superior heart border was formed by the left atrium in 38% (95% confidence interval, 23 to 53%) of patients and did not reliably identify the atriocaval junction. CONCLUSIONS: The right tracheobronchial angle is the most reliable landmark for the upper margin of the SVC. Venous catheters placed caudad to this landmark and cephalad to the right superior cardiac silhouette or no more than 2.9 cm caudad to the tracheobronchial angle result in catheter tips within the SVC.

Aged↗
PubMed1998

Methodologic standards for diagnostic test research in pulmonary medicine.

STUDY OBJECTIVES: To determine conformance with methodologic standards in the evaluation of diagnostic tests. DATA SOURCES: MEDLINE database search (1992 to 1997) of nine prominent general medicine and six subspecialty journals for articles that report discriminative properties of diagnostic tests in pulmonary medicine. STUDY SELECTION: Articles were eligible if they reported discriminative properties of diagnostic tests in humans, diagnostic tests were intended for the detection of existing conditions, and the target disorder was relevant to pulmonary medicine. DATA EXTRACTION: Each study was critically reviewed independently by two observers. DATA SYNTHESIS: Of the 1,029 retrieved articles, 41 met study inclusion criteria. The median number of the 12 major standards for design fulfilled by study articles was 6 (range, 1 to 12, 25th to 75th percentile, 5.0 to 8.5) and only 2 articles fulfilled all 12 standards. Seven (17%) articles did not report any standard measures of diagnostic accuracy and 7 (17%) provided data only for sensitivity and specificity. Only 4 of 17 articles (24%) that compared different tests used standard statistical methods. CONCLUSION: These results indicate that greater methodologic rigor is needed for studies that evaluate diagnostic tests in pulmonary medicine. Existing deficiencies in methodology risk the introduction of invalid tests into clinical practice.

Area Under Curve↗
PubMed1998

End-of-life ethical issues.

COPD is a progressive disorder characterized by intermittent episodes of acute exacerbations, each of which has the potential for producing respiratory failure and a need for mechanical ventilation. The decision to intubate a patient with severe underlying COPD requires a blending of the physician's estimation of prognosis with the patient's life goals, values, and self-perceived quality of life. Decisions regarding intubation and life support are aided by initiating a patient-caregiver dialogue during periods of good or stable health before a medical crisis occurs. These discussions can inform patients about the likely outcome of life support and promote meaningful and valid advance directives.

Advance Directives↗
PubMed1997

Publications in subspecialty journals on end-of-life ethics.

BACKGROUND: Factors that impede patient adoption of advance directives and inhibit physician-patient discussions about end-of-life issues remain incompletely defined. Determination of publication rates of articles on end-of-life ethics in different subspecialty journals may provide insight into physicians' reluctance to promote advance directives for their patients, which appears to vary between subspecialty fields. OBJECTIVE: To determine publication rates of items on end-of-life issues and other ethics topics. METHODS: We surveyed core journals from 1976 to 1995 in cardiology (n = 5), critical care medicine (n = 1), nephrology (n = 4), oncology (n = 7), and pulmonary medicine (n = 2). RESULTS: Critical care medicine (50.4%; 95% confidence interval [CI], 45.0%-55.8%) and pulmonary medicine (27.6%; 95% CI, 22.7%-32.5%) journals published considerably more articles on end-of-life issues than journals in cardiology (4.1%; 95% CI, 0.8%-7.4%), nephrology (11.0%; 95% CI, 7.9%-14.1%), or oncology (6.9%; 95% CI, 1.5%-12.3%). Oncology (30.7%; 95% CI, 25.3%-36.1%), critical care medicine (29.6%; 95% CI, 24.2%-35.0%), and pulmonary medicine (21.5%; 95% CI, 16.6%-26.4%) journals published more items pertaining to all ethics-related topics compared with cardiology (11.0%; 95% CI, 7.3%-14.7%) or nephrology (7.3%; 95% CI, 4.2%-10.4%) journals. Oncology journal ethics articles most often pertained to informed consent or research issues. CONCLUSIONS: Different internal medicine subspecialty fields demonstrate markedly different patterns of publishing items on topics pertaining to end-of-life issues.

Editorial Policies↗
PubMed1997

Outcomes of advance directive education of pulmonary rehabilitation patients.

We performed a two-site prospective, controlled interventional study of patients enrolled in pulmonary rehabilitation to assess effects of advance directive education on completion of (1) living wills, (2) durable powers of attorney for health care (DPAHC), (3) patient-physician discussions about advance directives, and (4) discussions about life support, in addition to (5) patient impressions that their physicians understood their end-of-life preferences. The educational group had an increase (p < 0.05) in all five study outcomes compared with baseline values; the control group had an increase in three of five outcomes. The effect strength was greater in the educational compared with the control group for completion of DPAHC (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.1 to 12.9), advance directive discussions (OR = 2.9, 95% CI 1.1 to 8.3), initiation of life-support discussions (OR = 2.7, 95% CI 1.0 to 7.7), and development of patient assurance that their physicians understand their preferences (OR = 3.7, 95% CI 1.3 to 13.4). The educational intervention was an independent explanatory factor by multivariate analysis. We conclude that patients enrolled in pulmonary rehabilitation are receptive to advance care planning, which is promoted by education on end-of-life issues.

Adult↗
PubMed1997

Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators.

STUDY OBJECTIVE: To (1) determine appropriate decision thresholds and diagnostic accuracies for pleural fluid (PF) tests that discriminate between exudative and transudative pleural effusions, and (2) evaluate the quality of the primary investigations. DESIGN: Formal meta-analysis of studies that report the diagnostic value of pleural fluid tests. SETTING: Data collected from international academic medical centers. PATIENTS: Hospitalized patients undergoing thoracentesis for pleural effusions. INTERVENTIONS: Primary investigators were requested to transmit original data from patients described in their studies. MEASUREMENTS AND RESULTS: Eight primary studies described 1,448 patients with one or more of the following tests: protein (P)-PF, P-PF/serum ratio (R), bilirubin (BILI)-R, lactate dehydrogenase (LDH)-PF, LDH-R, cholesterol (C)-PF, C-R, and albumin gradient. We found that all eight tests had similar diagnostic accuracies when evaluated by receiver operating characteristic (ROC) analysis except for BILI-R, which was less diagnostically accurate. Decision thresholds determined by ROC analysis differed from previously reported values for LDH-PF (>0.45 upper limits of normal) and C-PF (>45 mg/dL). Paired and triplet test combinations tended to have higher diagnostic accuracies compared with individual tests, but examination of the odds ratios with 95% confidence intervals did not identify a clearly superior test combination. Limitations of the primary studies presented a high likelihood of bias affecting their results. CONCLUSIONS: Several strategies exist for clinicians in utilizing PF tests to classify effusions as exudates or transudates but accurate interpretations of these test results will require better designed studies.

Albumins↗