Prescribing at the hospital--general practice interface.
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Drug Prescriptions↗
Biomedical subjects
J Shapiro
Publications and source records attributed to J Shapiro.
Vitamin D and osteocalcin levels in liver transplant recipients. Is osteocalcin a reliable marker of bone turnover in such cases?
Patients with advanced liver disease are at increased risk for the development of hepatic osteodystrophy in the form of either osteomalacia or osteoporosis. The pathogenesis of these two bone diseases is multifactorial and includes, among other factors, alterations in vitamin D metabolism, malnutrition and hypogonadism. Little is known regarding vitamin D metabolism and the osteoblastic activity in liver transplant recipients. In order to clarify these issues, vitamin D metabolites and osteocalcin levels were measured prior to and 30 days following liver transplantation in 30 cirrhotic patients of various etiologies. While the mean plasma concentrations of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D of the entire group of 30 patients were significantly greater prior to orthotopic liver transplantation (OLTx) as compared to those after OLTx (11.5 +/- 8.6 vs. 7.4 +/- 5.8 ng/ml, p = 0.0066 and 41.0 +/- 34.6 vs. 20.4 +/- 11.0 pg/ml, p = 0.0003, respectively), no significant changes in osteocalcin concentrations pre- or post-transplantation could be demonstrated (5.2 +/- 3.0 vs. 6.4 +/- 4.1 ng/ml, p = 0.51). Furthermore, no correlation between the plasma concentration of osteocalcin and either vitamin D metabolite, the prothrombin time or cyclosporine levels was found. The reasons for the normal levels of osteocalcin prior to OLTx can be explained by the fact that in vitamin-K-deficient states osteocalcin is predominantly decarboxylated and, therefore, a smaller proportion is bound to bone and/or the synthesis of osteocalcin is partially modulated by 1,25-dihydroxyvitamin D, the level of which has been found to be normal.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Goals and methods of research: the challenge for family medicine.
This article suggests that motivations to engage in research, as in any other human activity, are both explicit and implicit. Explicit motivations tend to be objective and rationalist, concerned with such goals as the advancement and organization of knowledge. But implicit motivations, the 'hidden agendas' of research, also exist and can influence the objectives, methods, and conclusions of the research process. In addition, a highly affectively charged activity such as research also develops its own set of symbolic meanings, which further complicate its various expressions. In this article, three such symbolic meanings are identified: purpose and seriousness; maturity and adulthood; and legitimacy and belonging. The article highlights qualitative research as a methodology compatible with much of family medicine's philosophy and theoretical foundations; and discusses the role of behavioural scientists in participating in a research agenda for the field. The article concludes with a plea for the discipline of family medicine to opt for authenticity in research, rather than settling for a superficial legitimacy in the eyes of other medical specialties.
Family Practice↗
Glucose utilization in a patient with hepatoma and hypoglycemia. Assessment by a positron emission tomography.
Tumor glucose use in patients with non-islet-cell tumors has been difficult to measure, particularly in hepatoma, because of hepatic involvement by neoplasm. We studied a patient with nonhepatic recurrence of hepatoma after successful liver transplantation. Tumor tissue contained messenger RNA for insulin-like growth factor-II (IGF-II), and circulating high molecular weight components and E-peptide of IGF-II were increased. Glucose use measured by isotope dilution with [3-3H]glucose was 7.94 mg/kg fat-free mass per min, and splanchnic glucose production was 0.93 mg/kg fat-free mass per min. Glucose uptake and glucose model parameters were independently measured in tissues by positron emission tomography with 18F-fluoro-2-deoxy-D-glucose. Glucose uptake by heart muscle, liver, skeletal muscle, and neoplasm accounted for 0.8, 14, 44, and 15% of total glucose use, respectively. Model parameters in liver and neoplasm were not significantly different, and glucose transport and phosphorylation were twofold and fourfold greater than in muscle. This suggests that circulating IGF-II-like proteins are partial insulin agonists, and that hypoglycemia in hepatoma with IGF-II production is predominantly due to glucose uptake by skeletal muscle and suppression of glucose production.
Adult↗
Evaluation and treatment of swallowing disorders.
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Deglutition↗
Resident psychosocial performance: a brief report.
This study investigated the psychosocial skills of 55 family practice residents conducting patient interviews in actual clinical settings. Results indicated that resident performance was at least adequate, demonstrating competence in basic interpersonal and medical interviewing skills on the majority of categories rated. However, residents performed less well in areas of greater psychosocial complexity, in particular in addressing the meaning or implications of illness with patients and families. Sex differences between male and female residents were also explored and in general found to be nonsignificant, although women residents tended to perform somewhat better in terms of empathy, open-ended questions, and reassurance.
Clinical Competence↗
Effects of famotidine on gastric pH and residual volume in pediatric surgery.
Aspiration pneumonitis is a severe complication of anesthesia. The objectives of this study were to determine if preoperative famotidine, a new histamine2-receptor antagonist, given by mouth either the evening before or the morning of elective surgery, reduced gastric residual volume and increased gastric pH in pediatric patients. Either famotidine or placebo (or both) were orally administered to 58 children (aged 2-17 years). The patients were randomly assigned to four groups: Famotidine-Famotidine, Placebo-Placebo, Placebo-Famotidine, and Famotidine-Placebo; subjects in the Famotidine-Famotidine group received two doses of famotidine (0.5 mg.kg-1 per dose), those in the Placebo-Placebo group, two doses of placebo, those in the Placebo-Famotidine and Famotidine-Placebo group, one dose of each by mouth. The Famotidine-Famotidine group received one dose of famotidine at 22:00 the evening before surgery and a second dose 60-90 min before the scheduled time of surgery. The Placebo-Placebo group received two doses of placebo at the same times as the Famotidine-Famotidine group. The Placebo-Famotidine group received a dose of placebo the night before surgery and a dose of famotidine the morning of surgery; the Famotidine-Placebo group received famotidine the night before surgery and placebo the morning of surgery. The administration of famotidine on the morning of surgery significantly increased gastric pH (4.8 vs. 1.3) in comparison with placebo, as did two doses of famotidine (6.6). Famotidine failed to reduce gastric residual volume significantly in any group. The administration of famotidine significantly reduced the number of pediatric patients considered at higher risk for aspiration pneumonitis, despite not decreasing gastric residual volume.
Administration, Oral↗
Intraoperative transesophageal echocardiography: an anesthesiologist's perspective.
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Anesthesiology↗
Outcomes of an AIDS prevention program for methadone patients.
Methadone maintenance patients are at risk of contracting or transmitting HIV through intravenous drug use and/or unsafe sexual practices. An outcome evaluation of a voluntary AIDS prevention program for methadone patients in three clinics (two experimental, one control) is reported. The prevention program included three components: didactic AIDS education, HIV antibody counseling/testing, and facilitated peer support groups. Participation in AIDS education was associated with increased knowledge of AIDS risks and with improved attitudes toward condoms. Peer group participation was associated with improved attitudes toward the use of condoms and with increased use of condoms. Learning of HIV seronegativity was related to increased self-efficacy and decreased intravenous drug use risk behaviors. Rates of participation in the prevention program were disappointing, but the program seemed beneficial for those patients who did become involved.
Acquired Immunodeficiency Syndrome↗
Applying the concept of the reflective practitioner to understanding and teaching family medicine.
This article contends that what makes family practice unique as a medical specialty is not so much its content (eg, continuity of care, broad range of patient population) as it is the process of clinical practice (ie, how the specialty is actually practiced in ongoing patient encounters). However, insufficient attention has been paid to critically analyzing and interpreting this process. We present a model derived from other "practice professions," such as architecture, known as reflection-in-action. This model is offered as a way of first apprehending and subsequently teaching the "professional artistry" which constitutes a critical component of family practice. Specific teaching approaches designed to enhance reflective medical practice are delineated.
Education, Medical↗
Strategies employed by HMOs to achieve hospital discounts: a case study of seven HMOs.
This article is a summary of seven health maintenance organization (HMO) case studies focusing on strategies used to obtain favorable prices for inpatient hospital services. All of the HMOs stressed that the effort should be based on the local environment and should accommodate the special circumstances of organization of physicians' practices and hospitals, as well as the structure of the HMO and its strategic plan for growth.
Health Care Coalitions↗
Does a behavioral science rotation change residents' self-assessed psychosocial attitudes and behavior?
The purpose of this study was to determine changes in self-assessed resident psychosocial attitudes and behavior after participation in a month-long behavioral science rotation. The four areas specifically investigated were 1) Personal Attributes, 2) Attitudes toward the Practice of Medicine, 3) Basic Psychosocial Skills of interviewing and assessment, and 4) Complex Psychosocial Skills, including counseling and brief psychological intervention. A total of 17 male and 9 female residents participated sequentially in 4-6 consecutive weeks of a specially designed behavioral science curriculum. Results demonstrated change in the positive direction in only two of the four areas, Personal Attributes (p. less than .05), and Psychosocial Assessment Skills (p. less than 000). Findings suggest that certain basic psychosocial assessment skills, especially those in which residents initially evaluate themselves as lacking mastery, can be successfully taught through a structured format. However, overall lack of clinically relevant improvement points to significant limitations in using structured coursework to address issues of values and attitudinal change. Further, such a structured approach does not seem to have been effective in teaching the skills requiring actual patient intervention.
Attitude of Health Personnel↗
Patterns of psychosocial performance in the doctor-patient encounter: a study of family practice residents.
Doctor-patient psychosocial interactions were studied for a group of 34 family practice residents. Analysis of the data of 102 patient encounters indicated that a continuum of psychosocial skills existed, with residents exhibiting generally strong performance in certain areas, and generally weak performance in others. Specifically, residents appeared more competent with basic psychosocial interactions than with those requiring a more in-depth encounter with the patient's phenomenological reality. Differences by year of resident were noted, with third year residents generally performing better in areas requiring more complex and intimate interactions. Differences according to sex of resident were also observed, with women residents outperforming male residents in many of the more complex areas of psychosocial interaction.
Clinical Competence↗
Large scale optimization of beam weights under dose-volume restrictions.
The problem of choosing weights for beams in a multifield plan which maximizes tumor dose under conditions that recognize the volume dependence of organ tolerance to radiation is considered, and its solution described. Structures are modelled as collections of discrete points, and the weighting problem described as a combinatorial linear program (LP). The combinatorial LP is solved as a mixed 0/1 integer program with appropriate restrictions on normal tissue dose. The method is illustrated through the assignment of weights to a set of 10 beams incident on a pelvic target. Dose-volume restrictions are placed on surrounding bowel, bladder, and rectum, and a limit placed on tumor dose inhomogeneity. Different tolerance restrictions are examined, so that the sensitivity of the target dose to changes in the normal tissue constraints may be explored. It is shown that the distributions obtained satisfy the posed constraints. The technique permits formal solution of the optimization problem, in a time short enough to meet the needs of treatment planners.
Humans↗
Contracts between hospitals and health maintenance organizations.
This article describes the contractual relations that are emerging between health maintenance organizations (HMOs) and hospitals. Six HMOs in four large metropolitan areas provided information on 102 hospital contracts. The authors found that the HMOs are becoming more aggressive in placing hospitals in competition with each other for HMO patients. Staff and network HMOs are able to obtain a higher concentration of patients and substantially larger discounts for inpatient services than are individual practice association (IPA) plans in this study.
Competitive Bidding↗
Changing physician behavior: does medical review of Part B Medicare claims make a difference?
This study attempts to determine whether the implementation of mandatory review of Medicare Part B claims for medical necessity has resulted in physicians submitting fewer medically unnecessary claims. After summarizing the literature on the effectiveness of various methods for changing physician practices, we compare the rate at which physicians submitted medically unnecessary claims before and after HCFA imposed mandatory review screens. We find that, consistent with expectations from the literature, the screens are only marginally effective (at best) in reducing the rate at which medically unnecessary claims are submitted. We make some suggestions for lowering this rate.
Cost Control↗
Hypertension after operative correction of club-foot deformity.
Severe hypertension occurred as a postoperative complication after correction of a club-foot deformity in four children (seven feet) who were between the ages of two and three years and had no history of hypertension. The hypertension subsided slowly after administration of antihypertensive medications or more rapidly after release of the correction that had been obtained operatively.
Child, Preschool↗
Rehabilitation of children and infants with osteogenesis imperfecta. A program for ambulation.
Management of children and infants with osteogenesis imperfecta (OI) poses difficult decisions for pediatricians, orthopedists, and physiatrists. These children are frequently frail with disabling bone and joint deformities and fractures. In an eight-year cumulative management of 12 children with OI, a comprehensive program included strengthening exercises to the pelvic girdle and lower extremity muscles, in addition to pool exercises and molded seating to support upright posture. Long leg braces were fitted when the children were able to sit unsupported. All 12 were fitted with braces; nine were functional ambulators, and three were home ambulators. Six children required femoral plating or rodding, two of whom subsequently had the metal removed. Lower extremity fractures averaged one and one-half per year prior to bracing for nine children who had fractures. There was 0.83 fracture per year for the ten children who had fractures after bracing. The degree of femoral bowing increased in four, decreased in four, and remained unchanged in four, while the degree of tibial bowing increased in two, decreased in nine, and remained unchanged in one during the observation period. A comprehensive rehabilitation program and long leg bracing with surgical operations on the femur result in a high level of functional activity for children with OI with an acceptable level of risk for fracture.
Braces↗