Laboratory testing on cerebrospinal fluid.
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Adult↗
Biomedical subjects
R A Hayward
Publications and source records attributed to R A Hayward.
Laboratory testing on cerebrospinal fluid. A reappraisal.
555 consecutive cases in which cerebrospinal fluid (CSF) was sent for cell count were reviewed to determine which cerebrospinal-fluid tests affect diagnosis or therapy. Among 334 cases (60%) with a normal opening pressure, cell count, and protein, 1385 additional tests were done, but such tests were useful in only 3 patients (0.9%) with multiple sclerosis. Among 148 consecutive cases of bacterial, chronic infectious, and malignant meningitis the opening pressure, cell count, or protein was abnormal in all but 3 (2 childhood bacterial meningitis and 1 cryptococcal meningitis in a patient with the acquired immunodeficiency syndrome). If the opening pressure, cell count, and protein are normal, no additional CSF tests are needed in most instances; however, in immunocompromised patients and in those with possible multiple sclerosis or childhood bacterial meningitis additional tests may be indicated.
Adolescent↗
Measures of vibrotactile sensitivity in persons exposed to hand-arm vibration.
A group of 57 persons occupationally exposed to hand-arm vibration was studied in an investigation of factors affecting their vibrotactile thresholds. The group contained 42 persons with symptoms of vibration-induced white finger (VWF). Measures of finger thresholds and temperatures were obtained from both hands. It was found that vibrotactile thresholds were higher in subjects reporting VWF. A laboratory investigation indicated that finger temperature had a great effect on the thresholds but that this effect only occurred outside the range of temperatures found in the study of occupationally exposed persons. Laboratory research showed that vibrotactile thresholds should be expected to depend upon vibration exposure immediately prior to the test. The vibration frequency and general configuration of the vibrotactile apparatus also influenced threshold. An awareness of these factors allows guidelines for their control to be suggested.
Adult↗
A method for counting ectopic beats by computer analysis of R-R intervals.
A method is described for detecting and counting ectopic beats using a small computer. The occurrence of an ectopic beat is identified by the relative duration of adjacent pulse intervals as demonstrated by simple arithmetical procedures. The method was validated by manual counting of records from 18 patients. 89% of 1474 ectopics were correctly identified. There were few false positive identifications 42. Although the method is unsuitable for the diagnosis of arrhythmias it is likely to be of value in epidemiological studies of such disturbances.
Arrhythmias, Cardiac↗
Choosing between apples and apples: physicians' choices of prescription drugs that have similar side effects and efficacies.
OBJECTIVE: To examine physician choices of commonly used medications having similar side effects and efficacies, and to evaluate factors that may affect these choices. DESIGN/SETTING: Cross-sectional survey conducted in winter 1989-1990. PARTICIPANTS: 263 physicians at a university teaching hospital (response rate = 71%). MEASUREMENTS AND MAIN RESULTS: Physicians rated patient compliance, cost to patient, and patient preference as the three most influential factors in their selection of a particular agent from a class of similar drugs. Housestaff were less likely than faculty to consider cost to patient as a "very important" factor (33% vs. 60%; p less than 0.05), and only 11% of all physicians felt that cost to third-party payer was very important. Physicians reported that their choices of particular nonsteroidal anti-inflammatory drugs (NSAIDs), histamine-2 (H2) blockers, and inhaled beta-agonists were mainly determined by which drugs enhanced compliance or were used by others (the "traditional choice"); cost to patient was a less important influence in these instances. All physician subgroups were inaccurate in predicting the approximate prices of their first- and second-choice agents. For example, only 28% of those selecting naproxen as their preferred NSAID were within $10 of the range of the prices of a one-month supply, and 14% were within $10 for cimetidine. CONCLUSION: Although this group of physicians reported considering drug costs to be important when choosing between similar drugs, they acknowledged that cost was relatively unimportant in several specific instances studied and their knowledge of the absolute and relative prices of drugs they commonly prescribed was deficient.
Adrenergic beta-Agonists↗
Program directors' attitudes towards residents' care of patients who have AIDS.
OBJECTIVE: To evaluate the educational strategies and experiences of residency programs regarding the training of primary care providers in the care of patients who have AIDS. DESIGN: Cross-sectional, self-administered questionnaire survey. SETTING: Survey conducted November 1988-April 1989. PARTICIPANTS: All 771 non-military U.S. internal medicine and family medicine program directors were surveyed; 80% responded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While 91% of the directors felt that primary care of AIDS patients was an important educational experience and 94% reported that their programs usually had AIDS inpatients, only 16% reported that the majority of trainees cared for AIDS patients in their continuity clinics. Even at programs that typically had six or more AIDS inpatients, only 26% of directors reported that most residents had cared for an AIDS patient in their continuity clinics. Among the 57% who did not believe or were unsure whether their residents were adequately trained in AIDS ambulatory care, only 38% reported improving resident education in this area to be a high priority. Among the 39% who did not encourage residents' assumption of primary care, 60% had at least one of the following concerns: AIDS care too stressful for residents (24%), AIDS care too complicated for generalists (31%), or clinic faculty not qualified to supervise residents' caring for AIDS patients (39%). CONCLUSION: Although program directors view education in AIDS ambulatory care as important, most do not believe that residents are adequately trained, many do not encourage residents' assumption of primary care of AIDS patients, and residents usually have not provided such care in their programs. Strategies to augment residents' ambulatory experience in AIDS care are needed.
Acquired Immunodeficiency Syndrome↗
Patients' desires and expectations for medical care: a challenge to improving patient satisfaction.
Patients' desires and expectations for medical care warrant scrutiny because of their potential influence on health care use and patient satisfaction and their effects on patients' perceptions of quality of care. To determine if desires and expectations for selected elements of medical care and specialty referral differ between VA outpatients and non-VA outpatients, we conducted a cross-sectional survey of patients at a VA medical center site and 2 primary care sites of its university affiliate. Of 390 eligible patients at the VA medical center site, 270 (69%) consented to participate and returned completed self-administered questionnaires. At its university affiliate sites, 119 (73%) of the 162 eligible patients completed questionnaires. Overall, patient desire and expectation for elements of medical care and specialty referral were similar and high at all study sites. Desire ranged from 33% for a blood test to check for anemia to 80% for heart auscultation. Desire for specialty referral for hypothetical scenarios averaged 71% and 61% among VA Medical Center patients and university affiliate patients, respectively. Patient demographics and socioeconomic status were poor predictors of desire for care. These results suggest (a) that VA medical center outpatients' desires and expectations for preventive medical care are not significantly different from those of non-VA outpatients, (b) that desire is often high for both highly recommended care and care that is not generally recommended or is controversial, and (c) that high levels of desire are not limited to patients of higher levels of socioeconomic status. In an effort to improve satisfaction, it is important to examine ways in which to address patients' desires and expectations for medical care, even while faced with competing health care spending priorities.
Aged↗
What is an error?
CONTEXT: Launched by the Institute of Medicine's report, "To Err is Human," the reduction of medical errors has become a top agenda item for virtually every part of the U.S. health care system. OBJECTIVE: To identify existing definitions of error, to determine the major issues in measuring errors, and to present recommendations for how best to proceed. DATA SOURCE: Medical literature on errors as well as the sociology and industrial psychology literature cited therein. RESULTS: We have four principal observations. First, errors have been defined in terms of failed processes without any link to subsequent harm. Second, only a few studies have actually measured errors, and these have not described the reliability of the measurement. Third, no studies directly examine the relationship between errors and adverse events. Fourth, the value of pursuing latent system errors (a concept pertaining to small, often trivial structure and process problems that interact in complex ways to produce catastrophe) using case studies or root cause analysis has not been demonstrated in either the medical or nonmedical literature. CONCLUSION: Medical error should be defined in terms of failed processes that are clearly linked to adverse outcomes. Efforts to reduce errors should be proportional to their impact on outcomes (preventable morbidity, mortality, and patient satisfaction) and the cost of preventing them. The error and the quality movements are analogous and require the same rigorous epidemiologic approach to establish which relationships are causal.
Causality↗
Residents' experiences in, and attitudes toward, the care of persons with AIDS in Canada, France, and the United States.
OBJECTIVE: To evaluate resident physicians' experiences in, and attitudes toward, the care of persons with the acquired immunodeficiency syndrome (AIDS) in Canada, France, and the United States. DESIGN: Cross-sectional survey, using a self-administered, mailed questionnaire to residents in 10 American states, three French regions, and all 10 Canadian provinces, with follow-up surveys of nonresponders in France and the United States. SUBJECTS: Systematic samples of residents in the last year of internal medicine or family medicine residencies prior to subspecialization or entry into medical practice. RESULTS: While the majority of residents had provided inpatient and outpatient care to persons with AIDS, most believed that their training in ambulatory care of persons with AIDS had been deficient. The rate of blood-contaminated needle-sticks from human immunodeficiency virus-infected patients ranged from 4% for internal medicine residents in Canada to 14% in the United States (P less than .05). The majority recognized an ethical obligation to treat AIDS, but 4% in France, 14% in Canada, and 23% in the United States indicated that they would not care for persons with AIDS if they had a choice (P less than .001). A substantial minority of US physicians reported that a patient of theirs had been refused care by a medical specialist (19%) or a surgeon (39%), but less than 10% of French physicians reported such refusals (P less than .001). CONCLUSION: Concerns about caring for AIDS patients were common and many physicians reported that patients were refused care. While most residents acknowledged an obligation to treat human immunodeficiency virus infection, many did not, and viewpoints varied considerably across the countries studied. The lower level of reluctance to treat AIDS patients in France and Canada makes it clear that the higher rate in the United States is far from optimal and needs to be addressed.
Acquired Immunodeficiency Syndrome↗