Managing nutritional care is essential for managing total care.
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Aged↗
Biomedical subjects
L H Bernstein
Publications and source records attributed to L H Bernstein.
The Bridgeport Hospital experience with autologous transfusion in orthopedic surgery.
The transfusion records of 341 orthopedic patients who donated blood preoperatively in the years 1992 and 1993 were audited to review the transfusion practices associated with the surgical procedures. The study sample underwent 182 total knee (TKA), 123 total hip (THA) arthroplasties, and 33 laminectomies with fusion (LAM) and 3 without. Data used were age, gender, predonation hemoglobin concentration (Hbd), initial (Hbi) and final (Hbf) hemoglobin concentration, surgical procedure, surgical blood order (SBO), and estimated blood loss (EBL). We analyzed for means and associations and differences between covariates. The means of EBL (mL), transfused units, donated units, Hbi, (g/dL), Hbd, and Hbf (g/dL) for the most common procedures were: TKA--272, 1.1, 2.1, 10.4, 13.9, and 10.1; THA--951, 2.3, 2.4, 9.4, 13.8, and 9.9; and LAM--589, 1.5, 2.2, 12.0, 14.6, and 11.2. Phlebotomies for procedures with minimal blood loss, as for total knee arthroplasties, result in wastage. Autodonation under such circumstances takes patients to an unnecessary low hemoglobin concentration prior to either retransfusing the blood taken or discarding part of it. The number of preoperative autologous units donated can be reduced if predonation hemoglobin concentration is > 15 g/dL and expected blood loss is not > 2 g.
Blood Loss, Surgical↗
Practice guideline for cardiac profiling.
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Cardiology↗
The impact of immunonutrition.
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Adjuvants, Immunologic↗
Physician reimbursement: a practicing physician's perspective.
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Centers for Medicare and Medicaid Services, U.S.↗
Cholecystokinin-stimulated monocytes produce inflammatory cytokines and eicosanoids.
OBJECTIVES: Plasma cholecystokinin increases with enteral feeding. Cholecystokinin increases intracellular calcium in lymphocytes/monocytes and is a lymphocyte co-mitogen. We hypothesize that decreased cholecystokinin production with "bowel rest" and parenteral nutrition may be beneficial in inflammatory bowel disease by down-regulating gut immune/inflammatory mechanisms. The majority of cells observed in mucosa of inflammatory bowel disease are monocytes and neutrophils. Cholecystokinin effect was therefore measured on monocyte production of proinflammatory mediators (tumor necrosis factor alpha, interleukin-1 beta, interleukin-6) and neutrophil chemotaxins/activators (interleukin-8, granulocyte-macrophage colony stimulating factor, and leukotriene B4). METHODS: Peripheral blood monocytes (0.5 x 10(6)) from healthy donors in 1 mL of RPMI 1640 plus 5% fetal calf serum were cultured for 24 h in 5% CO2 at 37 degrees C with 5 micrograms/mL endotoxin, 1 x 10(-7) M cholecystokinin, or no agonist. Supernatants were analyzed by ELISA for cytokines and leukotriene B4. RESULTS: Endotoxin-stimulated monocytes produced 1130 pg/mL tumor necrosis factor versus 81 pg/mL for cholecystokinin, 612 pg/mL interleukin-1 versus 10 pg/mL, 694 pg/mL interleukin-6 versus 30 pg/mL, 4531 pg/mL of interleukin-8 versus 3848 pg/mL, 21 pg/mL granulocyte-macrophage colony stimulating factor versus 9 pg/mL, and 21 pg/mL leukotriene B4 versus 12 pg/mL. Controls produced no cytokines/eicosanoids (N = 8, p < 0.001). CONCLUSION: Cholecystokinin increase with enteral feeding may up-regulate gut immune response. Cholecystokinin suppression with parenteral alimentation may decrease inflammatory mediator production.
Cells, Cultured↗
Financial implications of malnutrition.
PEM or the possibility of developing PEM occurs in 30% to 50% of hospitalized patients, the frequency determined by the criteria used in its assessment and the case mix of patients in the hospital population. This condition exists independently of other medical conditions and results from preadmission or postadmission failure to meet nutrient requirements with associated loss of body weight and function, as well as impaired immunity. PEM also frequently arises in patients with a chronic condition and decreased functional reserve when a superimposed acute metabolic stress leads to accelerated nutrient depletion. Whether preexisting or not, PEM increases morbidity and mortality along with LOS and may be associated with complications such as pneumonia, sepsis, operative site infection, delayed wound healing, or decubitus ulcers. The cost of these complications and an extended LOS is a significant financial burden and a controllable medical liability for hospitals. Other costs include identifying patients at risk of PEM, providing nutrition support, not to mention treating any of its complications (mechanical, metabolic, and so forth). A proper analysis of the financial implications of late or untreated PEM versus nutrition support must therefore take into account not only the costs of complications or extended LOS due to the delay or failure to provide nutrition support but also the costs associated with this intervention itself. In this review, we described a model for examining the financial implications of malnutrition and nutritional therapy.
Health Care Costs↗
Determination of malnutrition in hospitalized patients with the use of a group-based reference.
We clustered a selected population of patients at Bridgeport (Conn) Hospital into distinct nutritional classes using critical decisions points for the serum concentrations of aspartate aminotransferase activity, cholesterol, total protein, albumin, and prealbumin. The decision points that divided the populations with the highest efficiency were delineated by the information in the data set. At these decision values the hospital population adjusted malnutrition rate was just more than 30%. This was lower than the reported prevalence of malnutrition in the hospital population and was better in agreement with global estimates of malnutrition. The study identified a problem in the assignment of decision values that are used for nutritional support which has implications for nutritional interventions.
Blood Proteins↗
Marketing home i.v. antibiotic therapy to physicians.
Home intravenous antibiotic therapy (HIVAT) is a safe, efficient, and cost-saving alternative to hospitalization--and the program of choice among patients and their families. Before the full spectrum of benefits can be realized, home infusion companies face the challenge of educating primary care physicians in HIVAT patient selection, antibiotic considerations, and the home care provider team approach.
Anti-Bacterial Agents↗
Functional facts: a public health approach to functional assessment.
Too often patient evaluation focuses on diseases and symptoms. The author developed this tool to help caregivers conduct a simple, informal evaluation of a patient's ability to perform daily activities and thus help promote awareness of wellness and prevention among patients and caregivers.
Activities of Daily Living↗
Diagnostic efficiency of carcinoembryonic antigen and CA125 in the cytological evaluation of effusions.
In our previous study, the combination of the concentrations of carcinoembryonic antigen (CEA) and CA125 and the findings from cytological examination in 189 benign and malignant pleural and peritoneal effusions was useful in the diagnosis/classification of malignant effusions. Sensitivity of CEA (level, greater than 5 ng/mL) was 68%; specificity was 99% for the diagnosis of malignant effusions secondary to carcinoma of the lung, breast, gastrointestinal tract, and mucinous carcinoma of the ovary. Sensitivity of CA125 (level, greater than 5000 U/mL) was 85%; specificity was 96% for the diagnosis of malignant effusions in carcinoma of the ovary, fallopian tube, and endometrium. We now expanded the study to include 840 pleural and peritoneal effusions (benign, n = 520; malignant, n = 320) and analyzed the data by the statistical method of Rudolph and colleagues. Based on new cutoff values, ie, CEA level at 6.3 ng/mL and CA125 level at 3652 U/mL, the sensitivities for detection of malignant effusions secondary to carcinomas of the lung, breast, and gastrointestinal tract and mucinous carcinoma of the ovary varied between 75% and 100%; specificity was 98%. Sensitivity of CA125 for detection of malignant effusions from müllerian epithelial carcinoma was 71%; specificity was 99%. The elevated CEA fluid level alone helped to diagnose malignant effusions of the gastrointestinal tract in 54%, breast in 19%, and lung in 16%. The high CA125 fluid level was predictive of müllerian epithelial carcinoma. Adjunctive use of CEA and CA125 levels in fluid enhances the sensitivity of cytological diagnosis and may be predictive of the primary site in patients who present with carcinoma of an unknown primary source.
Antigens, Tumor-Associated, Carbohydrate↗
Vincent's violent vertigo. An analysis of the original diagnosis of epilepsy vs. the current diagnosis of Meniére's disease.
The authors propose to correct the historical misimpression that Vincent van Gogh's medical problems resulted from epilepsy. Rather, the authors propose his main medical problem was Meniére's disease. The authors have reviewed the 796 personal letters written by van Gogh. The symptoms of his Vertigo attacks, their presentation and duration as described in these letters, taken as a whole, are consistent with the clinical picture of Meniére's disease, not epilepsy. They point out that Prosper Meniére's description of his syndrome was not well known at the time of van Gogh's death, and was often misdiagnosed as epilepsy. During the last years of his life, van Gogh was labeled epileptic, although no rigid criteria for this diagnosis are evident. This diagnosis is still prevalent in the art history literature today. His symptoms included episodic vertigo and dizziness, physical imbalance, hearing symptoms, ear noises (tinnitus) as well as a presumed secondary psychological reaction to his physical symptomatology. van Gogh's diagnosis of epilepsy is based on written diagnosis in his medical records in 1889 when he was interred (voluntarily) in St. Remy at an asylum for epileptics and lunatics.
Art↗
An update on home intravenous antibiotic therapy.
Home intravenous antibiotic therapy (HIVAT) has proven to be a safe, effective, and cost-saving method to treat appropriately selected patients with bone, soft tissue, respiratory, genitourinary, and cardiac infections. Further, the acceptance of HIVAT by both physicians and patients has been enhanced by the availability of new venous access devices and home IV therapy companies. In determining when to use HIVAT, it is important to carefully consider the individual patient, the disease or medical condition, and antibiotic selection. HIVAT requires a team approach, with the physician, pharmacist, IV therapy nurse, and others playing critical roles in successful treatment plans.
Anti-Bacterial Agents↗
Van Gogh had Menière's disease and not epilepsy.
We intend to correct the historical error that Vincent Van Gogh's medical problems resulted from epilepsy plus madness, a diagnosis made during his life but for which no rigid criteria are apparent. Review of 796 personal letters to family and friends written between 1884 and his suicide in 1890 reveals a man constantly in control of his reason and suffering from severe repeated attacks of disabling vertigo, not a seizure disorder. His own diagnosis of epilepsy was made from the written diagnosis by Dr Peyron, the physician at the asylum of St Remy (France), wherein on May 9, 1889, Van Gogh voluntarily committed himself to the asylum for epileptics and lunatics. However, the clinical descriptions in his letters are those of a person suffering from Meniere's disease, not epilepsy. The authors point out that Prosper Meniere's description of his syndrome (an inner-ear disorder) was not well known when Van Gogh died and that it often was misdiagnosed as epilepsy well into the 20th century.
Art↗
Measurement of CA125, carcinoembryonic antigen, and alpha-fetoprotein in ovarian cyst fluid: diagnostic adjunct to cytology.
This study used CA125, carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) to classify ovarian cysts by measuring the levels of the three antigens; this information was useful when fluid obtained through laparoscopic puncture of ovarian cysts was submitted for cytologic examination from patients for whom tissue was unavailable for classification. We studied 136 consecutive cyst fluids (108 benign, 28 malignant) and correlated the findings with the tissue diagnosis. All three antigens were very low (CEA, less than 0.5 ng/ml; CA125, 55-2,143 mu/ml; and AFP, less than 4.8 ng/ml) in follicular and lutein cysts. Markedly elevated CA125 (296-1,950,000 mu/ml) and low CEA (0.5-220 ng/ml) and AFP (less than 4.8 ng/ml) levels were seen in patients with serous neoplasms, both benign and malignant. Elevated CEA (greater than 600 ng/ml) and CA125 (56-65,330 mu/ml) levels were seen in primary mucinous cystadenoma and cystadenocarcinoma. Two patients with colonic carcinoma metastatic to the ovary had an elevated CEA (greater than 600 ng/ml) and a normal CA125. Only one patient, with a malignant teratoma, had an elevated AFP. The adjunctive use of CEA and CA125 is recommended for the classification of ovarian cysts.
Antigens, Tumor-Associated, Carbohydrate↗
The provision of home health services through health maintenance organizations: the role of the physician.
The authors report the results of a comprehensive national study of the provision of home health care (HHC) through health maintenance organizations (HMOs), funded by a 1987 grant from the National Center for Health Services Research. The initial study included a literature review, interviews of 125 HHC providers and researchers, case studies of 6 HMOs, and a survey of 103 HMOs with Medicare contracts (as of March 1988). Upon discovery of controversy over the role of the HMO physician, the authors conducted an additional substudy of 30 primary care physicians. The article focuses on findings concerning the HMO physician in HHC and the implications for physicians generally, in light of what the larger study and additional data (January 1989-January 1990) show about HMO development and home health care.
Attitude of Health Personnel↗
What constitutes a laboratory quality monitoring program?
A program of quality assurance for the laboratory is described that addresses both process and outcome validation. It begins by an analyses of the workload processing sequence, i.e., ordering, collecting, transporting, analyzing specimens, reporting tests results in a timely manner, and reduction of instrument, staff, and system-related errors in the generation of laboratory information. The observable medical staff requirements for effective utilization of the laboratory is the basis for defining outcome measures.
Clinical Laboratory Techniques↗
Medically significant concentrations of prostate-specific antigen in serum assessed.
We used the method of Rudolph et al. (Clin Chem 1988; 34:2031-8) to find information in the data from correlated determinations of acid phosphatase (PAP, EC 3.1.3.2; DuPont aca) and prostate-specific antigen (PSA, Hybritech). We described there how we assign medical decision limits for two or more correlated variables and convert the database to a binary coded message, allowing separation of a selected disease class with minimum error. The decision point, analogous to a percentile upper limit on the ordered values of each variable in the reference group, satisfies the maximum entropy constraints of reference, producing a minimum entropy for the binary coded patient database. We found maximum entropy decision points at PAP = 0.75 U/L and PSA = 22.8 micrograms/L. Patients with PSA values exceeding 22.8 micrograms/L had no benign prostatic disease except for five patients with benign prostate hyperplasia (BPH) with adjacent colon carcinoma (95.3), BPH with infarction (27.6), BPH (23.4) 28.1), or acute prostatitis (34.6). We consider PSA exceeding 22.8 micrograms/L as indicative of carcinoma of the prostate, stage C or D, in the absence of disconfirming evidence. Another decision value for PSA is 11.3 micrograms/L. This bounds the region between 11.3 and 22.8 micrograms/L, where the frequency of BPH is 1.5 times that for adenocarcinoma. At PSA less than 11.3 micrograms/L there is a high frequency of BPH. PSA concentration is not correlated with prostatic size (mass) or with prostatitis. A metastatic carcinoma is as likely to be nonprostatic as prostatic when the PSA concentration is less than 11.3 micrograms/L.
Acid Phosphatase↗