Search PubMed⌕ Search

Biomedical subjects

P A James

Publications and source records attributed to P A James.

At least 19 recordsLinked to original sources
PubMed2003

Patients' case-notes: look but don't touch.

The purpose of this study was to ascertain whether viable bacteria could be cultured from patients' case-notes. Two hundred and twenty-eight current inpatients' notes were randomly sampled using contact plates to determine total viable counts, Gram-positive organisms, Gram-negative organisms and methicillin-resistant Staphylococcus aureus (MRSA). Bacteria were grown from 227. Most were 'environmental', however, nine notes grew S. aureus. No Gram-negative bacteria or MRSA were isolated. These results show that potentially pathogenic bacteria can be found on case notes and could act as a source of transmission or cross-infection to patients. We recommend that handwashing should occur after handling case notes before patient contact.

Bacteria↗
PubMed2001

'Drop in' dentistry.

Explore the source record for details and available documents.

Anti-Bacterial Agents↗
PubMed2000

Are clinical practice guidelines valid for primary care?

Development of evidence-based clinical practice guidelines has emphasized treatment efficacy under methodologically rigorous conditions; internal validity (i.e., efficacy) has been assessed well. Despite their experimental foundations, guidelines originally were considered physician education tools relevant to singular, idealized encounters. Now, in rushing to generalize, quantify, and regulate quality, guidelines are being applied to whole populations as quality review criteria. Clinical guidelines do not make operational how, or even make clear whether they should be so used. We studied the external validity, the generalizability and measurability for primary care, of a guideline for treatment of systolic heart failure. Patient and clinical factors reducing generalizability were examined. Imprecise definition and reliance on single measures of recommendations were studied as limits to measurability. Patient, physician, organizational, and system factors influenced guideline validity. Attention to myriad invalidity sources undermining implementation and evaluation of efforts to improve quality and outcomes of primary care is critical.

Heart Failure↗
PubMed2000

Streptococcus pneumoniae septic arthritis in adults.

Septic arthritis is a rarely reported manifestation of disease due to Streptococcus pneumoniae. We have reviewed our recent experience of this disease in 14 adult patients. Common features in patients with S. pneumoniae septic arthritis included advanced age (median=63 y), pre-existing joint disease (6/14), large joint disease (14/14), polyarthritis (6/14), and associated meningitis, pneumonia or both (6/14). Two patients with septic arthritis and meningitis, and another with Down's syndrome and sleep apnoea, died during treatment. In the remaining 11 patients, treatment for at least 19 d, predominantly with intravenous benzyl penicillin, plus joint lavage, resulted in cure.

Adult↗
PubMed2000

Clinical value of anaerobic blood culture: a retrospective analysis of positive patient episodes.

AIM: To investigate the clinical value of anaerobic blood culture. METHODS: Blood culture bottles (n = 25,185) submitted for culture over a two year period were reviewed. RESULTS: The bottles yielded 1992 positive patient episodes, a positive rate of 14.4/1000 hospital admissions. Significantly more isolations were obtained from aerobic than from anaerobic bottles. Twelve of the 38 anaerobic episodes were detected in aerobic bottles. Clinical management was influenced in one of 24 patients whose cultures yielded anaerobes from anaerobic bottles only. For a further six patients it was unlikely that the result had any effect on clinical management. CONCLUSIONS: If aerobic bottles were substituted for the anaerobic bottles, detection of positive patient episodes would increase by at least 6%. A higher yield would be achieved by using two aerobic bottles for routine culture and using anaerobic bottles only for patients where anaerobic culture may influence clinical management.

Bacteria, Aerobic↗
PubMed2000

The ultrasound-assisted physical examination in the periodic health evaluation of the elderly.

BACKGROUND: Except for specific procedures such as blood pressure measurement, the conventional physical examination (PE) does not have sufficient sensitivity to be useful as part of the periodic health evaluation. Ultrasound has demonstrated greater sensitivity and specificity in numerous studies but has been too expensive to be widely employed in health screening. The purpose of our study was to determine whether an examination in which conventional and ultrasound techniques are blended and applied by a primary care physician might be feasible and useful in the periodic health evaluations of senior citizens. METHODS: Seventy-two patients presenting to a community-based family physician for periodic health evaluations received an ultrasound-assisted physical examination (USA-PE) from a second family physician. The results were reported to the primary physician, and the outcomes were tracked for periods of up to 2 years. RESULTS: Twenty-two of the 72 patients (31%) had abnormalities found by the USA-PE that were not apparent during the conventional PE. Five of these patients (7%) had serious conditions that received prompt treatment with apparent benefit. Findings included endometrial carcinoma, abdominal aortic aneurysm, carotid stenosis, hydronephrosis, and urinary retention. CONCLUSIONS: The USA-PE found more abnormalities in this group of patients than conventional PE. Whether it can improve outcomes for senior citizens undergoing periodic health evaluations in a cost-effective manner is yet to be determined.

Aged↗
PubMed1999

Measuring instructional quality in community-orientated medical education: looking into the black box.

OBJECTIVES: Decentralizing medical education to community settings has raised issues of instructional quality. The need to evaluate community-based instruction accents the need to adopt a systems perspective, moving beyond factors known to comprise general clinical teaching effectiveness to include factors that focus on instruction as a process. Application of evaluation models using traditional input-output analysis can be flawed. This approach--dubbed the 'black box'--typically examines inputs and outputs, but often ignores throughputs. DESIGN: In this article we open the black box, using theory to examine the underlying processes that define community-based medical education. We first describe the components and processes of an instructional model that is framed by the philosophy of quality and grounded in experiential learning theory. Without examining the critical processes at work inside the black box - i.e. how students come to acquire clinical knowledge and how behaviours are influenced - it is difficult to assess which programme features contribute to success. Tensions created by the absence of consensus on the outcomes of instruction and the challenge of developing adequate measures are highlighted. SETTING: State University of New York at Buffalo. SUBJECTS: Clinician-teachers, learners and patients in the environment. RESULTS AND CONCLUSIONS: We conclude with describing a tool for evaluating community-based instruction that is guided by the context of our model.

Community Medicine↗
PubMed1999

Readiness for Medicaid managed care reform initiatives: a profile of rural family physicians.

Medicaid managed care is now an important factor in the financing of rural health care delivery. The participation of rural family physicians in Medicaid managed care is vital for the rural poor to access health services. This study examined 855 family physicians practicing in nonmetropolitan counties across the United States to determine their readiness to participate in Medicaid managed care. Physicians were asked about their experience with prepaid programs and the factors that would influence their participation in such a program. A shortage of health care providers and low reimbursement rates were most frequently cited as barriers to successful implementation. Physicians who had participated in prepaid programs in the past but were no longer participating had the most negative opinions about the potential for Medicaid managed care programs to enhance care for the poor in their communities. Overall, physicians reported potential for the program to improve access and quality of care, but they also expressed reservations about the financial and administrative effects on their practices. These results reveal that negative attitudes were associated with prepaid programs that failed to meet expectations, but physicians also expressed an optimism about the potential to serve the poor within a managed care model.

Analysis of Variance↗
PubMed1999

A measure of medical instructional quality in ambulatory settings: the MedIQ.

BACKGROUND AND OBJECTIVES: Concerns exist about the quality of medical student training outside the academic medical center. Yet, measures of this quality are lacking. This study introduces an instrument to measure instructional activities in primary care settings, based on a learner-centered model. The study also examines the instrument's ability to predict specific learner outcomes. METHODS: The MedIQ is a 25-item instrument designed to assess preceptor activities, environmental interactions, learning opportunities, and learner involvement in patient care. The MedIQ was administered in third-year generalist clerkships at one medical school, and the results were compared to extant measures of precepting effectiveness, student grades, specialty choice, and National Board of Medical Examiners scores. RESULTS: The results revealed strong reliability for all scales, moderate construct validity, and weak criterion-related validity. Additionally, some scores predicted specialty choice. CONCLUSION: The MedIQ is a promising measure of instructional quality in ambulatory medical settings.

Ambulatory Care↗
PubMed1999

Exploring instructional quality indicators in ambulatory medical settings: an ethnographic approach.

BACKGROUND AND OBJECTIVES: As medical education moves to community settings, the quality of learning is influenced by differences in the practice environment, organization, resources, patient case mix, and demographics. This ethnographic study identified experiences and processes that influence student learning in community-based practice settings. METHODS: Trained field researchers conducted participant observation in eight community teaching sites. Data were analyzed using a qualitative, grounded theory approach. RESULTS: Three dominant themes emerged: 1) the preceptor's role in situating learning opportunities, 2) the learner's role in transforming experience into learning, and 3) the practice organization as a classroom setting. The findings highlight the importance of exploiting learning opportunities and the contributions of other medical staff and patients in facilitating unique learning experiences. CONCLUSIONS: This research suggests the need to move beyond the typical student ratings of teacher effectiveness to consider and assess additional important factors and processes that affect instructional quality.

Anthropology, Cultural↗
PubMed1999

Heart failure in primary care: measuring the quality of care.

BACKGROUND: Concerns exist about the quality of care provided to heart failure patients by primary care physicians. Using an evidence-based clinical guideline, we evaluated the care given to patients with systolic heart failure. METHODS: We retrospectively reviewed the medical records of 420 patients from 25 primary care practices in upstate New York who had received a diagnosis of heart failure. Chart documentation confirmed the diagnosis (n = 395). We excluded patients with noncardiogenic volume overload or correctable valvular disease (n = 338). Performance profiles measured use of diagnostic tests, left ventricular ejection fraction (LVEF) measurement, patient education, and prescription of angiotensin-converting enzyme (ACE) inhibitors. For treatment recommendations, patients were classified according to LVEF status. RESULTS: Only 82% of the patients studied had an LVEF test result documented in their charts. Of these, 49% had an LVEF < or = 40%. ACE inhibitor use was greater among patients with low LVEF (91%) than among those with a normal LVEF (62%). Among patients with systolic heart failure taking ACE inhibitors, 87% were at target doses. Adherence measures were low for laboratory evaluation and patient-education criteria. CONCLUSIONS: Heart failure with normal LVEF was as prevalent as systolic heart failure in these primary care practices. Performance profiles for the physicians' prescriptions of ACE inhibitors exceeded those published in the literature. Patients who did not have a documented measure of LVEF, however, received lower quality of care as measured by this disease-specific guideline. This underscores the importance of measuring LVEF.

Aged↗
PubMed1998

Diamorphine and bupivacaine mixtures: an in vitro study of microbiological safety.

A small survey confirms that epidural infusions are often prepared by clinicians and solutions may be changed each day because of fears of microbiological contamination. We have assessed the microbiological safety of six mixtures of diamorphine (0.01-1.0%) and bupivacaine (0.1-0.5%) representing the spectrum of clinically useful concentrations for use as extradural infusions. The solutions were studied for antibacterial activity against common contaminants of fluids: Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis and a coagulase negative Staphylococcus sp. A saline control was included. Challenge experiments used an inoculum of approximately 5.0 x 10(6) cfu/ml. Mixtures were incubated at 30 degrees C for up to 7 days. Viable counts of all organisms decreased with time for all the formulations tested. Formulations containing 0.5% bupivacaine were rapidly bactericidal, and increasing diamorphine concentrations increased this effect. Formulations with 0.5% bupivacaine had more activity than those with 0.1% bupivacaine. Mixtures of diamorphine and bupivacaine in concentrations used clinically have bactericidal activity against commonly encountered skin organisms. The common practice of changing every day epidural infusions containing these drugs is unnecessary.

Analgesia, Epidural↗
PubMed1998

Patient-centered clinical decisions and their impact on physician adherence to clinical guidelines.

BACKGROUND: This study was undertaken to assess the impact of traditionally unmeasured patient-centered factors on primary care physicians' decisions to adhere to an evidence-based clinical practice guideline for heart failure. METHODS: Experimental and control scenarios were developed to test three patient-centered factors hypothesized to influence physician nonadherence to a heart failure guideline: patient concerns about finances, quality of life, and location of care. Each factor represented an implicit patient goal potentially in conflict with a goal of the guideline recommendations. A control scenario for one factor and an experimental scenario for a second were placed within a cross-sectional survey and questionnaires were mailed by random assignment to 978 Upstate New York family physicians. Experimental and control responses were compared by chi square. RESULTS: The response rate was 47% (n = 456). Each hypothetical patient-centered factor resulted in significant reductions in physicians' predicted adherence. Reductions in reported pharmaceutical usage and testing of left ventricular (LV) function were associated with patient financial difficulties (P < .01). The poor quality-of-life scenario was associated with reduced testing for LV function but increased discussion of advance directives (P < .01). The clinical scenario limiting access to services for a rural patient was associated with decreases in physician choice of LV function tests and cardiology referrals (P < .05). CONCLUSIONS: Patient-specific factors are associated with physician decisions to comply with guideline recommendations. These findings suggest that performance profiles measuring physician adherence to guidelines should be interpreted with caution, and that current case-mix methodologies may not adequately control for patient-centered factors that may influence health care quality.

Aged↗