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Biomedical subjects

L J Baraff

Publications and source records attributed to L J Baraff.

At least 37 records · Page 2Linked to original sources
PubMed1995

Need and desire for preventive care measures in emergency department patients.

STUDY OBJECTIVE: To determine the need and desire for selected preventive care measures in an adult emergency department population, comparing patients with and without primary physicians. DESIGN: Written survey. SETTING: Urban university ED. PARTICIPANTS: English-speaking patients 18 years of age or older who did not arrive by ambulance, did not have a critical illness, and did not have a psychiatric complaint. RESULTS: The main outcome measures were past preventive care and desire to initiate preventive care measures as part of ED care. Nine hundred fifty-three surveys were distributed; 647 were completed and returned. Twenty-seven percent of patients knew their cholesterol level. Forty-three percent of men aged 40 years or older reported having had a prostate examination in the past year, and 39% of men aged 50 years or older reported having had an examination of stool for blood in the past year. Twenty-one percent of women reported taking calcium, and 67% of women aged 40 years or older had had a mammogram in the past 2 years. Sixty-three percent of patients had a primary physician; these patients were more likely to have received each of the preventive care measures studied (P < .025). Fifty-three percent of women not taking calcium requested information about osteoporosis prevention, and 30% requested prescriptions for calcium supplements. Sixty-two percent of women who did not have a current mammogram requested mammography information, and 60% requested referrals for mammography. Fifty-four percent of patients requested cholesterol and diet information. Patients requesting information, referrals, and prescriptions were given them. CONCLUSION: In a selected ED population, there was both need and desire for preventive health care measures to be initiated or provided as part of ED care, especially among patients who did not have primary physicians.

Adult↗
PubMed1995

Effect of routine emergency department triage pulse oximetry screening on medical management.

PURPOSE: To determine the utility of routine triage pulse oximetry screening in emergency department (ED) patients. DESIGN: Prospective study using pulse oximetry to measure oxygen saturation of ED patients at triage. Saturation values were disclosed to physicians only after they completed medical evaluations and were ready to discharge or admit each patient. We measured changes in medical management initiated after disclosure of pulse oximetry values. SETTING AND PARTICIPANTS: The study included 14,059 consecutive patients presenting to triage at a university ED. MEASUREMENTS: Changes in select diagnostic tests: chest radiography, CBC count, spirometry, arterial blood gases, pulse oximetry, and ventilation-perfusion scans; treatments: antibiotics, beta-agonists, supplemental oxygen; and hospital admission and final diagnoses that occurred after disclosure of triage pulse oximetry values. RESULTS: Of 1,175 patients having triage pulse oximetry values less than 95%, physicians ordered repeat pulse oximetry on 159 (13.5%), additional chest radiography on 5.4%, CBC count on 3.1%, arterial blood gases on 2.9%, spirometry on 0.9%, and ventilation-perfusion scans on 0.3%. Physicians ordered 178 new therapies on 134 patients (11.4%), including supplemental oxygen for 6.5%, antibiotics for 3.9%, and beta-agonists for 1.8%. Thirty-five patients (3.0%) initially scheduled for hospital discharge were subsequently admitted. Physicians changed or added diagnoses in 77 patients (6.6%). CONCLUSIONS: Providing physicians with routine triage pulse oximetry measurements resulted in significant changes in medical treatment of these patients.

Adolescent↗
PubMed1995

EDECS: the Emergency Department Expert Charting System.

EDECS, the Emergency Department Expert Charting System, integrates clinical guidelines into the everyday practice of medicine. By generating the medical record and patient aftercare instructions, it facilitates patient care. For this reason, doctors are willing to use it. While using it, the doctors are continually presented with advice regarding documentation, testing, and treatment. Unlike guidelines that attempt to modify behavior through traditional educational methods, these computerized guidelines are seen by the physician every time she sees a patient. We have demonstrated this by directly integrating the guidelines into the process of patient care; we can increase compliance with the guidelines [1]. At present EDECS exists for the chief complaints of occupational exposure to body fluids, acute low back pain, recurrent seizure, fever in children, and males with penile discharge or dysuria. Upon examining the patient, the physician proceeds to the computer, which prompts him for essential information regarding the history and physical examination. Certain items are required for all patients with the chief complaint, others are required based on the answers to these items. Data is analyzed by the computer, which provides advice regarding testing and treatment. Once testing is completed, the system suggests a probable diagnosis and aids in patient disposition and discharge planning. Finally, EDECS prints the medical record as well as patient-specific aftercare instructions. EDECS is a user friendly system; most data is entered via mouse. It is written in the OS-based expert system shell AM(TM) and can be run on an IBM compatible PC or PC network. Rules are generally written in an "if...then" format, but more sophisticated rule structures, including Bayesian models, are used when needed. Each module contains separate subroutines for the history, physical, laboratory ordering, treatment, and disposition. These modules call each other in a dynamic fashion. The system is currently being evaluated for its effect on documentation, appropriateness of use of ancillary tests, appropriateness of use of treatments, physician satisfaction, patient satisfaction, and patient outcomes. Initial results of the system's effect on documentation and use of ancillary tests and treatments show much promise [1]. The Occupational Exposure to Body Fluids module has shown a statistically significant, and sometimes rather dramatic, increase in the level of documentation for nearly all items. Further, the advice given by EDECS has caused an increase in the appropriate use of testing and treatments. For example, unnecessary ancillary tests dropped from 1.5 per patient without the computer to 0.1 per patient with the computer's aid. EDECS facilitates quality management activities and research since it collects standardized information and stores it in an easily retrievable database format. It can also be used to educate medical students and residents about the proper care of patients with a given chief complaint. At this session, EDECS will be demonstrated, and issues regarding the development of guidelines, the encoding of guidelines in rules, and the organizational structure of the software will be presented and discussed.

Child↗
PubMed1994

Incorporating patient preferences into practice guidelines: management of children with fever without source.

STUDY OBJECTIVE: To evaluate parent preferences for the therapy of young children with fever without source. PARTICIPANTS: Consecutive parents, not in a medical profession, of children less than 36 months old. SETTING: Pediatric clinic of a university teaching hospital. DESIGN: During individual interviews at the time of their child's clinic visit, parents were presented with a case scenario and two treatment options and the risks, outcomes, and cost associated with each. MAIN OUTCOME MEASURE: Parent preferences for alternative treatment strategies. RESULTS: All parents correctly identified the management strategy with the higher probability of an adverse outcome. Seventy-one percent chose the option with less testing and treatment and the greater risk of an adverse outcome. Parents' reasons for this choice were fewer painful tests and procedures (36%), less time waiting (32%), smaller chance of unnecessary antibiotics (23%), and ability to return if their child's condition deteriorated (22%). Thirty-two percent of parents indicated that cost was a factor in their decision. Age, gender, education, and/or number of children was not associated with parents' treatment preferences. CONCLUSION: Parents' preferences may be considered when determining how to manage febrile infants and children.

Age Factors↗
PubMed1993

Advance directives. Effect of type of directive on physicians' therapeutic decisions.

BACKGROUND: Despite growing support for advance directives, there are few data validating their utility. We conducted this study to determine if the type of advance directive influences physicians' willingness to withhold specific therapies and if physicians are equally willing to withhold these therapies. METHODS: The 444 full-time faculty of the department of medicine of a university medical center were presented with patient scenarios and accompanying advance directives in three separate surveys that were mailed. They were asked if they would withhold each of 12 specific therapies based on their interpretation of the advance directive. Three types of advance directives were studied: general statement, therapy specific, and therapy specific combined with designation of a proxy and prior patient-physician discussion. RESULTS: The mean proportion of all 12 therapies that were withheld varied by type of advance directive: general-statement advance directive, 55%; therapy-specific advance directive, 71%; and therapy-specific advance directive with proxy and prior patient-physician discussion, 83%. Respondents were more likely to withhold cardiopulmonary resuscitation when given a therapy-specific advance directive vs general-statement advance directive, 84% vs 73%, respectively. With a therapy-specific advance directive that was supported by a proxy and prior patient-physician discussion, 100% of physicians were willing to withhold cardiopulmonary resuscitation. With the therapy-specific advance directive that was supported by proxy and prior patient-physician discussion, physicians were not equally willing to withhold all therapies, ie, mechanically assisted ventilation, 98%; intravenous fluids, 82%; antibiotics, 80%; simple tests, 70%; and pain medications, 13%. CONCLUSIONS: Detailed advance directives with a supportive proxy, coupled with physician-patient discussion, furnish the most reliable medical directives. Even with such directives, physicians are more likely to withhold life-saving therapies than simple tests, treatments, and pain medications.

Advance Directive Adherence↗
PubMed1993

Stress distributions in vascular aneurysms: factors affecting risk of aneurysm rupture.

Aneurysm rupture occurs when local wall stresses exceed the tensile strength of vascular tissues. Knowledge of vascular wall stresses, and insight into the factors that change wall stresses, will lead to a better understanding of how aneurysms grow and rupture. In this study, stress distributions in the walls of small aneurysms were calculated using finite element analysis (FEA), a numerical technique able to predict stress distributions with greater accuracy than the Law of Laplace. Stresses were calculated for an initial small aneurysm and compared to stresses produced by increasing the aneurysm diameter, decreasing the wall thickness, and changing the material properties of the aneurysm wall. FEA calculations indicate that wall stresses are generally greatest on the inner surface of an aneurysm, and decrease nonlinearly as the outer wall is approached. Maximum wall stresses occur along the region of greatest diameter, and circumferential stresses tend to be significantly greater than longitudinal stresses. Doubling the diameter of an aneurysm produced a twofold increase in the maximum wall stress. Decreasing the wall thickness by half also produced a doubling of the maximum wall stress. Changing material properties produced no appreciable change in wall stresses. However, weaker materials fail at lower stresses, thus halving material strength would be equivalent to doubling wall stresses. We conclude that the Law of Laplace is inaccurate in predicting the complicated stress distributions that exist in aneurysm walls, and that more sophisticated tools, such as FEA, will be needed to understand this complex phenomenon. We also conclude that proportional changes in the diameter, wall thickness, or aneurysm tissue strength have roughly equivalent effects on aneurysm growth and rupture.

Aneurysm↗
PubMed1993

Practice guideline for the management of infants and children 0 to 36 months of age with fever without source. Agency for Health Care Policy and Research.

STUDY OBJECTIVE: To develop guidelines for the care of infants and children from birth to 36 months of age with fever without source. PARTICIPANTS AND SETTING: An expert panel of senior academic faculty with expertise in pediatrics and infectious diseases or emergency medicine. DESIGN AND INTERVENTION: A comprehensive literature search was used to identify all publications pertinent to the management of the febrile child. When appropriate, meta-analysis was used to combine the results of multiple studies. One or more specific management strategies were proposed for each of the decision nodes in draft management algorithms. The draft algorithms, selected publications, and the meta-analyses were provided to the panel, which determined the final guidelines using the modified Delphi technique. RESULTS: All toxic-appearing infants and children and all febrile infants less than 28 days of age should be hospitalized for parenteral antibiotic therapy. Febrile infants 28 to 90 days of age defined at low risk by specific clinical and laboratory criteria may be managed as outpatients if close follow-up is assured. Older children with fever less than 39.0 C without source need no laboratory tests or antibiotics. Children 3 to 36 months of age with fever of 39.0 C or more and whose WBC count is 15,000/mm3 or more should have a blood culture and be treated with antibiotics pending culture results. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics. CONCLUSION: These guidelines do not eliminate all risk or strictly confine antibiotic treatment to children likely to have occult bacteremia. Physicians may individualize therapy based on clinical circumstances or adopt a variation of these guidelines based on a different interpretation of the evidence.

Algorithms↗
PubMed1993

Emergency department immunization of the elderly with pneumococcal and influenza vaccines.

STUDY OBJECTIVE: To determine the feasibility of immunizing unvaccinated elderly patients with influenza and pneumococcal vaccines in the emergency department. PARTICIPANTS AND SETTING: A convenience sample of elderly patients presenting to an urban university-affiliated ED. DESIGN AND INTERVENTIONS: Elderly ED patients were asked about prior influenza and pneumococcal immunization. Nonimmunized patients were given information sheets, were informed of the changes for vaccination, and were asked if they desired immunization as part of their ED care. Those desiring immunization who lacked contraindications were immunized. RESULTS: One hundred thirty-three patients were enrolled. Eighty-two percent had not been immunized with pneumococcal vaccine; 62% of these nonimmunized patients stated they desired pneumococcal vaccination, and 58% were immunized. Sixty-three percent of the 133 patients had not received current influenza vaccine; 54% of these nonimmunized patients stated they desired influenza vaccine, and 50% were immunized. CONCLUSION: The majority of elderly ED patients are not immunized adequately with influenza and pneumococcal vaccines as recommended by the Centers for Disease Control and Prevention. Most elderly patients will accept immunization with these vaccines as part of their ED care. These vaccines can be delivered effectively to elderly patients in the ED.

Aged↗
PubMed1993

Effect of emergency department information on patient satisfaction.

STUDY HYPOTHESIS: Patient satisfaction with emergency department care is enhanced by information distributed to patients on ED arrival. PARTICIPANTS AND SETTING: A convenience sample of 200 alert, English-speaking, adult ED patients. DESIGN AND INTERVENTION: ED information was distributed on alternate days to all ED patients. The ED information described ED function and patient evaluation time. Patients not receiving ED information served as controls. A research assistant administered a satisfaction questionnaire to all patients immediately after discharge. MEASUREMENTS AND MAIN RESULTS: Patients who received ED information rated their overall satisfaction higher than did the control group (P < .0001). Other items rated significantly higher were physician skill and competence (P = .0112), physician concern and caring (P = .0062), whether the patient would use the same ED again (P < .0001), appropriateness of ED time (P = .01), information received (P < .0001), ability of staff to decrease anxiety (P < .0001), physician's explanation of illness and treatment (P = .0366), and ease and convenience of care (P = .0014). CONCLUSION: ED information has a significant effect on patients' perceptions of the quality of care and overall satisfaction.

Adult↗
PubMed1993

Outcomes of bacterial meningitis in children: a meta-analysis.

We abstracted the results of all English language reports of the outcomes of bacterial meningitis published after 1955. We used hierarchical Bayesian meta-analysis to determine the overall and organism-specific frequencies of death and persistent neurologic sequelae in children 2 months to 19 years of age. A total of 4920 children with acute bacterial meningitis were included in 45 reports that met the inclusion criteria. Children described in the 19 reports of prospectively enrolled cohorts from developed countries had lower mortality (4.8% vs. 8.1%) and were more likely to have no sequelae (82.5% vs. 73.9%). In these 19 studies 1602 children were evaluated for at least 1 sequela after hospital discharge. The mean probabilities of these sequelae were: deafness, 10.5%; bilateral severe or profound deafness, 5.1%; mental retardation, 4.2%; spasticity and/or paresis, 3.5%; seizure disorder, 4.2%; and no detectable sequelae, 83.6%. Mean probabilities of outcomes varied significantly by etiologic bacteria, e.g. mortality: Haemophilus influenzae, 3.8%; Neisseria meningitis, 7.5%; Streptococcus pneumoniae, 15.3%.

Adolescent↗
PubMed1993

Management of infants and children 3 to 36 months of age with fever without source.

The evidence and guidelines presented in this article are meant to assist clinicians who manage children with FWS. However, physicians may choose to individualize therapy based on unique clinical circumstances or to adopt a variation of these guidelines based on a different interpretation of the evidence concerning these issues. No guidelines can eliminate all risk nor confine antibiotic treatment only to children likely to have occult bacteremia. The optimal management strategy reduces risk to a minimum at a reasonable cost and can be used in most practice settings.

Acute Disease↗
PubMed1993

Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia.

OBJECTIVE: To quantify the effect of antibiotic therapy on the probability of subsequent bacterial meningitis in children with fever without source treated as outpatients. DESIGN: Bayesian meta-analyses. REPORTS INCLUDED: All reports of the organism-specific prevalence of occult bacteremia in children with fever without source treated as outpatients, and the organism-specific prevalence of subsequent meningitis in children with occult bacteremia initially treated as outpatients stratified by type of antibiotic therapy. RESULTS: The mean probabilities of subsequent meningitis in children with occult bacteremia were 9.8%, 8.2%, and 0.3% in the no antibiotic, oral antibiotic, and parenteral antibiotic therapy groups, respectively. All cases of bacterial meningitis in children with occult bacteremia treated with oral antibiotics were due to Haemophilus influenzae. There were no cases of culture-positive bacterial meningitis in 139 bacteremic children treated with ceftriaxone (mean probability, 0.3%; 95% confidence interval, 0.0% to 1.5%). The mean probabilities of bacterial meningitis in a child with fever without source treated as an outpatient without antibiotics were: Streptococcus pneumoniae, 0.21%; and H influenzae, 0.06%. CONCLUSIONS: Antibiotic therapy is effective in preventing meningitis in children at risk of occult bacteremia.

Administration, Oral↗
PubMed1992

Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss.

The authors conducted this study to: (1) determine the effect of age on orthostatic vital signs; and (2) to define the sensitivity and specificity of alternative definitions of "abnormal" orthostatic vital signs in blood donors sustaining an acute 450-mL blood loss. The population studied were 100 healthy adult volunteer blood donors and 100 self-sufficient ambulatory citizens attending a senior citizens daytime activity center. Subjects with a history of orthostatic hypotension were excluded. Subjects were first placed in the recumbent position and their rate pulse and blood pressure were determined after 1 minute; these same parameters were measured in the same arm beginning 30 seconds after standing. In blood donors measurement of orthostatic vital signs was repeated immediately after blood donation. Blood donors served as their own controls in the determination of sensitivities and specificities. Mean orthostatic vital sign changes were as follows: pulse rate, 2 +/- 7 beats per minute; systolic blood pressure, -3 +/- 9 mm Hg; and diastolic blood pressure, 1 +/- 7 mm Hg. There was no clinically meaningful variance in orthostatic blood pressure changes with age. For a given specificity, pulse rate increase was the most sensitive of the orthostatic vital signs used alone; a pulse rise of greater than 20 beats per minute had a sensitivity of 9% with a specificity of 98%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗