Biomedical subjects
Publications and source records attributed to R A Wright.
A 47-year-old man with cirrhosis developed a case of previously unreported olecranon bursitis due to Cryptococcus neoformans. Most patients with disseminated cryptococcosis have deficiencies in cell mediated immunity. Cirrhosis may be an independent risk factor because of impaired chemotaxis and phagocytosis.
BACKGROUND: Whether to perform periodic rectal examinations in asymptomatic men as a screening test for prostatic cancer remains controversial. A randomized clinical trial that tests the efficacy of further evaluation and treatment of men who have been found to have asymptomatic prostate nodules may never be carried out. Decision analysis was therefore used to further investigate this clinical issue. METHODS: A decision tree was developed to model the decision of whether to biopsy an asymptomatic prostate nodule found by digital rectal examination in a 65-year-old man by his primary care physician. Test operating characteristics, probabilities of disease at different stages, probabilities of side effects from various treatments, and average life expectancies were obtained from the medical literature. Utilities for the various possible health outcome states were obtained from ratings by two experienced primary care physicians using the Kaplan-Anderson Quality of Well-Being Scale. These were used to adjust the quality-of-life expectancies for each outcome state. Multiple sensitivity analyses were performed to assess the robustness of the conclusions. RESULTS: Disregarding patient utilities, the average survival benefit of evaluation and treatment is 1.1 months. When quality-of-life adjustments are included in the analysis, evaluation and treatment results in an average loss of 3.5 quality-adjusted months of life. Factors that shift the decision toward evaluation and treatment include a positive predictive value of a prostate nodule for cancer of 49% or greater, specificity of prostate biopsy of 98.3% or greater, and the availability of much more effective treatment for stage D cancers. Factors that do not substantially affect the decision are cancer-free life expectancy, the percentage of cancers that are stage B at time of discovery, the sensitivity of prostate biopsy, and more effective treatment for stage C cancer, assuming the same rate of adverse consequences from treatment. CONCLUSIONS: The evaluation and treatment of prostatic nodules found by digital rectal examination in asymptomatic men in the primary care setting does not lead to significant improvement in life expectancy and adversely affects quality of life. Digital rectal examination should not be performed by primary care physicians as a screening test for prostate cancer.
The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an 'appropriate' framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions.
As an academically based gastroenterologist, I performed 94 outpatient liver biopsies over a 42-month period, using the standard suction technique. Differential blood count and vital signs were monitored, with no statistically significant postbiopsy changes noted in the group at large. One patient required admission to the hospital for bleeding, and six patients required intramuscular analgesics for pain at the biopsy site. Four patients had bradycardia, and one of them required atropine for bradycardia and hypotension. Outpatient liver biopsy is a safe procedure with low morbidity and complication rate. It would appear that prolonged monitoring is not necessary.
Some investigators have postulated that patients with primary achalasia have a generalized upper gastrointestinal motility disorder. To evaluate gastric emptying in patients with primary achalasia, four patients were studied prospectively after successful brusque dilation. Gastric emptying of liquids and solids was normal in all patients. There is no defect in gastric emptying in patients with primary achalasia.
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Esophagobronchial reflexes have been demonstrated in both the cat and dog models. In order to determine if these reflexes are present in humans and if they are vagally mediated, a prospective sequential study was initiated. One hundred thirty-six individuals referred for esophageal manometric measurements were studied. Measurements of airway flow, arterial oxygen saturation, and pulse rate were performed before and after intraesophageal infusion of sterile water, normal saline solution, and 0.1 N hydrochloric acid. Highly significant reductions in heart rate, airway flow, and arterial oxygen saturation were noted after infusion of normal saline and 0.1 N hydrochloric acid compared with baseline water infusion (P less than 0.001). Graded responses were noted with heart rate: the more acidic the solution infused, the larger the decrement of heart rate. Atropine abolished postsaline/acid decrements of airway flow, arterial oxygen saturation, and heart rate. It is concluded that acid-induced, vagally mediated esophagobronchial reflexes are present in humans.
The interactive effects of success importance and task demand upon cardiovascular reactivity were investigated in 2 experiments. In Experiment 1, Ss learned that success on an easy or difficult memory task would allow them to avoid a mild or severe noise. As expected, pretask and task elevations in heart rate and systolic blood pressure increased with difficulty only when the noise was to be severe. In Experiment 2, Ss listened to a victim, attending either to how she must feel or to technical features of the presentation. Then they were given the chance to earn a donation by succeeding on an easy or difficult memory task. Pretask cardiovascular data accorded with predictions predicated on the assumption that the need to help would be greater among victim perspective Ss. For them, systolic elevations increased with difficulty, whereas for technical perspective Ss systolic elevations were low regardless of task demand.
The use of parenteral nutrition in patients with exacerbation of regional enteritis is controversial, the clinical dictum being bowel rest and nutritional repletion. In order to address this issue, on the short-term at least, a prospective randomized trial compared peripheral parenteral alimentation and elemental feedings for 2 weeks in patients hospitalized with regional enterities. Both groups had significant objective clinical improvement on their respective nutritional supplementation regimens pre- versus posttherapy as assessed by the Crohn's Disease Activity Index (CDAI) (p less than 0.05). However, there was no significant difference in improvement between parenteral versus enteral groups as assessed by the CDAI. Changes in nutritional assessment parameters, including retinol binding protein, nitrogen balance, total lymphocyte count, and transferrin, were related to the quantity of calories consumed rather than the mode of delivery. A positive nitrogen balance was obtained in all patients despite weight loss in the majority. The route of nutrient delivery in acute exacerbation of regional enteritis does not appear to have an impact on the short-term outcome.
We conducted a randomized controlled trial of orally administered amifloxacin versus trimethoprimsulfamethoxazole (TMP-SMX) as treatments of acute uncomplicated urinary tract infection in women. Amifloxacin at a dosage of 200 mg twice a day appeared as safe and effective as TMP-SMX, but amifloxacin at 400 mg twice a day tended to cause adverse events more frequently than did TMP-SMX.
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College-aged male subjects were presented with an easy or moderately difficult memorization task and were told that they could earn either a very low or a very high chance of obtaining a modest prize if they did well. Cardiovascular (heart rate, systolic blood pressure, diastolic blood pressure) and subjective measures were taken during an interval immediately preceding the task performance period. Results indicated greater systolic blood pressure and self-perceived energy in the moderately difficult condition than in the easy condition only when the probability of attaining the prize (if subjects did well) was high. When the probability of goal attainment (given success) was low, systolic responses and self-reported energy levels were minimal in both task conditions. Predictions regarding the impact of energy levels upon goal attractiveness ratings were not supported, possibly for methodological reasons.
Marketing in the health professions is a topic of considerable disagreement. A large scale survey in 1981 indicated strong physician opposition to any form of advertisement to obtain patients or promote services. High response rates to mail questionnaires indicated intense physician interest. A follow-up survey performed five years later revealed remarkable changes including tacit acceptance of physician and hospital promotional activities, and increasing usage of marketing techniques as a standard medical practice. While physicians still believe that patients select services without regard to cost and that it is difficult to advertise quality care, physicians are increasingly aware of the fact that marketing techniques are being utilized to promote high caliber care at cheaper rates. If the current trends continue, marketing will become an integral part of medical practice in the near future.
Outpatient intravenous therapy (OIT) offers a safe, practical, and cost-effective means for long-term antimicrobial treatment of certain infectious diseases. The author compares the efficacy, frequency of administration, and cost of the most suitable parenteral agents and cites criteria for patient selection. An efficient and safe OIT program requires a multidisciplinary approach that integrates support from the physician, nurse-educator, social services, and pharmacy. Several small studies indicate that OIT can result in an impressive savings when compared with inpatient costs.
We have described what we believe is the first reported case of primary melanoma of the common bile duct. The presenting sign was obstructive jaundice. An extensive evaluation for another primary source was unrevealing. Despite a Whipple procedure, the patient's condition deteriorated rapidly.
The authors conducted an eight-year longitudinal study to evaluate the effect of diagnostic criteria on efficient use of outpatient cultures. Efficiency was determined by monitoring alterations in culture use, yield (percent positive), and charges for four common ambulatory diseases: Group A streptoccocal pharyngitis; gonococcal urethritis and cervicitis; bacterial cystourethritis; and acute enterocolitis.The study demonstrated that the use of diagnostic criteria resulted in more efficient use of laboratory tests as reflected in the immediate and sustained decrease in culture use and associated charges, an increase in yield (percent positive), and a corresponding decrease in charge per test.
The effectiveness of nifedipine as first-line monotherapy for mild diastolic hypertension (range: 95 to 105 mm Hg) was tested in this placebo-controlled, double-blind, randomized trial. Fifty-six patients were enrolled and, after titration of the placebo or active drug, they were followed for 12 weeks. Significant declines in the sitting systolic and diastolic pressures of -19 +/- 4 mm Hg (standard error) and -13 +/- 2 mm Hg, respectively, were observed during this follow-up period. Overall, 75 percent of patients receiving active drug had diastolic pressures less than or equal to 90 mm Hg at the last treatment visit. Heart rate was not significantly changed in the sitting position during the treatment period, and the majority of patients (75 percent) showed a response to nifedipine doses of 10 or 20 mg orally three times daily in the capsule form. The levels of the systolic and diastolic pressures at entry were not predictive of the dose of nifedipine required for effective blood pressure control.
Sixty-four young women expected to perform an easy, moderately difficult, or extremely difficult memory task with the opportunity to earn a small incentive for good performance. Cardiovascular (heart rate, systolic and diastolic blood pressure) and subjective measures were taken immediately prior to task performance. Both systolic blood pressure (SBP) responses and ratings of goal attractiveness were nonmonotonically related to expected task difficulty, with the most pronounced SBP elevations and highest goal attractiveness in the moderately difficult task condition. Product-moment correlations among cardiovascular response measures revealed a strong positive association between systolic and diastolic pressure (but not heart rate) change in the easy condition, positive relationships among all measures in the moderately difficult condition, and no significant correlations in the extremely difficult condition. Subjective measures of arousal were not affected by the task difficulty manipulation. Principal findings are discussed in terms of a theoretical model proposed by Brehm (1979) that states that motivation varies as a nonmonotonic function of the difficulty of goal attainment. Intercorrelations among cardiovascular response variables are considered in terms of their possible indication of the mechanisms underlying blood pressure changes associated with variations in motivation.