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Biomedical subjects

R Gonzales

Publications and source records attributed to R Gonzales.

At least 37 records · Page 2Linked to original sources
PubMed2000

Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments.

STUDY OBJECTIVE: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. METHODS: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. RESULTS: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43; 95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32; 95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. CONCLUSION: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of antibiotic resistance.

Adolescent↗
PubMed2000

Involuntary disenrollment from a Medicare managed care plan at an academic medical center: effect on patients.

OBJECTIVES: Little is known about the impact of mandatory (involuntary) disenrollment of patients from Medicare managed care organization (MCO) plans. We hypothesized that involuntary disenrollment raises significant concerns for patients, that younger enrollees (aged less than 65, "Medicare disabled") have different concerns than older patients, and that younger patients respond to termination of their plan within the MCO differently from older patients. We also examined other factors associated independently with enrollee decisions to stay in the MCO or return to Medicare fee-for-service. DESIGN: A cross-sectional telephone questionnaire. SETTING: A Medicare managed care plan at two outpatient clinics at an academic medical center in Denver, Colorado. PARTICIPANTS: Four hundred fifty enrollees recently notified of termination of their clinic's contract with a Medicare managed care plan were surveyed. MEASUREMENTS: Survey questions on demographics, patient concerns about disenrollment, and factors associated with staying at the academic medical center or switching to another clinic or plan associated with the MCO. RESULTS: Of 371 respondents, 57% switched to another plan within the MCO, including 65% of the Medicare disabled enrollees and 57% of the Medicare nondisabled enrollees. More than 60% of both Medicare disabled and older patients who switched felt that it was a significant problem for them. By multivariate analysis, age was not associated with switching, but a distant relationship with one's physician was associated with switching (odds ratio (OR) = 10.2; confidence interval (CI), 1.13-91.09) and having received care at the academic medical center for 1 year or longer (OR = 0.35, 95% CI, 0.17-0.69), postcollege education (OR = 0.34; CI, 0.16-0.69), and black race (OR = 0.29; CI, 0.13-0.68) were independently associated with not switching. Older and younger patients cited similar concerns raised by switching, but financial issues were identified as a major concern by more younger patients than older patients (P = .001). CONCLUSIONS: Involuntary disenrollment raised significant concerns for patients in a Medicare managed care plan.

Academic Medical Centers↗
PubMed1999

Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults.

CONTEXT: The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due, in part, to the excessive use of antibiotics for acute respiratory tract infections. OBJECTIVE: To decrease total antibiotic use for uncomplicated acute bronchitis in adults. DESIGN: Prospective, nonrandomized controlled trial, including baseline (November 1996-February 1997) and study (November 1997-February 1998) periods. SETTING: Four selected primary care practices belonging to a group-model health maintenance organization in the Denver, Colo, metropolitan area. PARTICIPANTS: Consecutive adults diagnosed as having uncomplicated acute bronchitis. A total of 2462 adults were included at baseline and 2027 adults were included in the study. Clinicians included 56 physicians, 28 physician assistants or nurse practitioners, and 9 registered nurses. INTERVENTION: The full intervention site received household and office-based patient educational materials, as well as a clinician intervention consisting of education, practice-profiling, and academic detailing. A limited intervention site received only office-based educational materials, and control sites provided usual care. MAIN OUTCOME MEASURE: Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods. RESULTS: Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period. During the study period, there was a substantial decline in antibiotic prescription rates at the full intervention site (from 74% to 48% [P = .003]), but not at the control and limited intervention sites (78% to 76% [P = .81] and 82% to 77% [P = .68], respectively). Compared with control sites, changes in nonantibiotic prescriptions (inhaled bronchodilators, cough suppressants, and analgesics) were not significantly different for intervention sites. Return office visits (within 30 days of the incident visit) for bronchitis or pneumonia did not change significantly for any of the sites. CONCLUSIONS: Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions.

Acute Disease↗
PubMed1999

The relation between purulent manifestations and antibiotic treatment of upper respiratory tract infections.

OBJECTIVE: To describe the clinical features of patients diagnosed with upper respiratory tract infections (URIs), and determine which clinical features are associated with antibiotic use. DESIGN: Prospective cohort study. SETTING: Three ambulatory care practices at a group-model HMO in the Denver metropolitan area. PATIENTS: Adults (aged 18 years or older) seeking care for acute respiratory illnesses. MEASUREMENTS: Clinical features were documented on standardized encounter forms. Clinician type, secondary diagnoses, and antibiotic treatment were extracted from administrative databases. Results are presented as adjusted odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS: Antibiotics were prescribed to 33% (95% CI 28%, 38%) of patients diagnosed with URI, after excluding patients with coexisting antibiotic-responsive conditions (e.g., sinusitis, pharyngitis) or a history of cardiopulmonary disease. Multivariate logistic regression analysis identified tobacco use (OR 2.8; 95% CI 1.5, 5.1), history of purulent nasal discharge (OR 2.0; 95% CI 1.1, 3.6) or green phlegm (OR 4.8; 95% CI 2.1, 11.1), and examination findings of purulent nasal discharge (OR 5.2; 95% CI 2.4, 11.2) or tonsillar exudate (OR 3.7; 95% CI 1.1, 12.1) to be independently associated with antibiotic use. The majority of patients treated with antibiotics (82%) had at least one of these factors present. CONCLUSIONS: Antibiotic treatment of URIs is most common when purulent manifestations are present. Efforts to reduce antibiotic treatment of URIs should educate clinicians about the limited value of purulent manifestations in predicting antibiotic-responsive disease.

Acute Disease↗
PubMed1999

Public beliefs and use of antibiotics for acute respiratory illness.

OBJECTIVE: To better understand public beliefs and use of antibiotics for acute respiratory illnesses. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Three hundred eighty-six adult members (aged 18 years or older) of a group-model HMO in the Denver metropolitan area. MEASUREMENTS AND MAIN RESULTS: Two hundred seventy-three (70%) of the respondents reported that antibiotics were beneficial for bacterial respiratory illnesses, 211 (55%) reported that antibiotics were beneficial for viral respiratory illnesses, and 82 (21%) reported that antibiotics were beneficial for bacterial but not for viral illness. Multivariate regression analysis identified consulting an advice nurse (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.7, 5.3), ever being told by a provider that antibiotics were not needed for a respiratory illness episode (OR 2.0; 95% CI 1.2, 3.6), having a chronic medical condition (OR 2.0; 95% CI 1.0, 3.9), and believing antibiotics to be helpful for viral (OR 2.5; 95% CI 1.3, 4.7) or bacterial (OR 2.6; 95% CI 1.2, 6.7) respiratory illnesses to be independently associated with antibiotic use for respiratory illnesses during the previous year. There was a trend toward lower previous antibiotic use among those believing antibiotics to be helpful for bacterial illness but not for viral illness. CONCLUSIONS: A lack of understanding about antibiotic effectiveness exists in the community. Increased previous antibiotic use among those believing antibiotics to be effective for viral illnesses suggests that improvements are needed in communications to patients and the public about antibiotic appropriateness.

Adult↗
PubMed1999

What to do when functional and legal families disagree.

In Case 1, a nurse describes a scenario in which a patient's functional and legal families disagree about who has the right to make consent decisions. Case 2 reveals the situation's legal and ethical implications for nurses and how they can facilitate a resolution.

Advance Directives↗
PubMed1999

The mechanism of delayed selfing in Collinsia verna (Scrophulariaceae).

Collinsia verna, blue-eyed Mary, has floral attributes of an outcrossing species, yet most flowers readily self-pollinate under greenhouse conditions. Here we describe the mechanism of self-pollination in C. verna via changes in relative positions of the stigma and anthers and late timing of receptivity, resulting in delayed selfing. Each flower contains four anthers that dehisce sequentially over ∼1 wk. Pollen that is not collected by pollinators accumulates in the keel petal and retains high viability (>80% pollen germination) up to the time of corolla abscission. The stigmatic surface does not become receptive until after the third anther dehisces. This overlap in the sexual phases is concurrent with a change in herkogamy during floral development. In most flowers (70%), the stigma has moved to the front of the keel and is positioned near the anthers when the third anther dehisces. Under field conditions, fruiting success of plants within pollinator exclosures was ∼75% of the fruiting success in open-pollinated plants (33% fruiting success via autogamy vs. 44% fruiting success, respectively). Collinsia verna plants in pollinator exclosures exhibit variation in autogamy rates within natural populations (range 0-80%). In addition, only half of naturally pollinated, receptive flowers examined had pollen tubes growing in their styles. In contrast, shortly after corolla abscission, nearly all flowers examined (96%) had pollen tubes in their styles. Thus we find that in C. verna, autogamy occurs late in floral development, which has the potential to provide substantial reproductive assurance, and that individuals vary in their ability to set fruit through this mechanism. We suggest that delayed selfing mechanisms may be overlooked in other species and that variable pollinator availability may play a significant role in the maintenance of mixed mating in species with delayed selfing, such as C. verna.

Journal Article↗
PubMed1998

Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis.

CONTEXT: The spread of antibiotic-resistant bacteria is associated with antibiotic use. Children receive a significant proportion of the antibiotics prescribed each year and represent an important target group for efforts aimed at reducing unnecessary antibiotic use. OBJECTIVE: To evaluate antibiotic-prescribing practices for children younger than 18 years who had received a diagnosis of cold, upper respiratory tract infection (URI), or bronchitis in the United States. DESIGN: Representative national survey of practicing physicians participating in the National Ambulatory Medical Care Survey conducted in 1992 with a response rate of 73%. SETTING: Office-based physician practices. PARTICIPANTS: Physicians completing patient record forms for patients younger than 18 years. MAIN OUTCOME MEASURES: Principal diagnoses and antibiotic prescriptions. RESULTS: A total of 531 pediatric office visits were recorded that included a principal diagnosis of cold, URI, or bronchitis. Antibiotics were prescribed to 44% of patients with common colds, 46% with URIs, and 75% with bronchitis. Extrapolating to the United States, 6.5 million prescriptions (12% of all prescriptions for children) were written for children diagnosed as having a URI or nasopharyngitis (common cold), and 4.7 million (9% of all prescriptions for children) were written for children diagnosed as having bronchitis. After controlling for confounding factors, antibiotics were prescribed more often for children aged 5 to 11 years than for younger children (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.13-3.33) and rates were lower for pediatricians than for nonpediatricians (OR, 0.57; 95% CI, 0.35-0.92). Children aged 0 to 4 years received 53% of all antibiotic prescriptions, and otitis media was the most frequent diagnosis for which antibiotics were prescribed (30% of all prescriptions). CONCLUSIONS: Antibiotic prescribing for children diagnosed as having colds, URIs, and bronchitis, conditions that typically do not benefit from antibiotics, represents a substantial proportion of total antibiotic prescriptions to children in the United States each year.

Adolescent↗
PubMed1998

Factors associated with antibiotic use for acute bronchitis.

OBJECTIVES: To describe the clinical features of adults diagnosed with acute bronchitis, and to identify clinical variables associated with antibiotic treatment of acute bronchitis. DESIGN: Prospective, cohort study. SETTING: Primary care office practices at a group-model HMO in the Denver metropolitan area. PATIENTS/PARTICIPANTS: Patients were adults seeking care for acute respiratory illnesses. Participating clinicians included internists, family medicine physicians, nurse practitioners, physician assistants, and registered nurses. MEASUREMENTS AND MAIN RESULTS: Clinicians voluntarily completed encounter forms for patients presenting with acute respiratory illnesses between February and May, 1996. Acute bronchitis was the primary diagnosis in 16% of acute respiratory illness visits (n = 1,525). The most frequent symptoms of acute bronchitis were cough (92%), phlegm production (63%), "runny nose" (50%), and throat pain (50%). The most frequent physical examination findings were pharyngeal erythema (45%), cervical lymphadenopathy (19%), wheezes (18%), and rhonchi (17%). Antibiotics were prescribed to 85% of patients diagnosed with acute bronchitis. Purulent nasal discharge by patient report, and sinus tenderness on physical examination were moderately associated with antibiotic treatment (p = .06 and .08, respectively). Antibiotic prescription rates did not vary by patient age or gender, duration of illness, days of work lost due to illness, or clinician type. CONCLUSIONS: Acute bronchitis is frequently treated with antibiotics in ambulatory practice. The clinical factors we identified to be associated with antibiotic use for acute bronchitis appear to play a minor role in explaining the excessive use of antibiotics for this condition. These findings suggest that clinicians use the diagnosis of acute bronchitis as an indication for antibiotic treatment, despite clinical trials and expert recommendations to the contrary.

Acute Disease↗
PubMed1997

Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.

CONTEXT: Antibiotic use is associated with increased rates of antibiotic-resistant organisms. A previous study has shown that colds, upper respiratory tract infections, and bronchitis account for nearly one third of all antibiotic prescribing by ambulatory care physicians. How frequently antibiotics are prescribed for these conditions and for and by whom is not known. OBJECTIVES: To measure antibiotic prescription rates and to identify predictors of antibiotic use for adults diagnosed as having colds, upper respiratory tract infections, and bronchitis in the United States. DESIGN: Sample survey of practicing physicians participating in the National Ambulatory Medical Care Survey, 1992. SETTING: Office-based physician practices. SUBJECTS: Physicians (n=1529) completing patient record forms for adult office visits (n=28787). MAIN OUTCOME MEASURES: Antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis. RESULTS: Office visits for colds, upper respiratory tract infections, and bronchitis resulted in approximately 12 million antibiotic prescriptions, accounting for 21% of all antibiotic prescriptions to adults in 1992. A total of 51 % of patients diagnosed as having colds, 52% of patients diagnosed as having upper respiratory tract infections, and 66% of patients diagnosed as having bronchitis were treated with antibiotics. Female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.05-2.62) and rural practice location (OR, 2.25; 95% CI, 1.33-3.80) were associated with greater antibiotic prescription rates, whereas black race (OR, 0.44; 95% CI, 0.21-0.93) was associated with lower antibiotic prescription rates. Patient age, Hispanic ethnicity, geographic region, physician specialty, and payment sources were not associated with antibiotic prescription rates in the bivariate analysis. Multivariate logistic regression analysis identified only rural practice location (adjusted OR, 2.58; 95% CI, 1.39-4.76) to be independently associated with more frequent antibiotic prescriptions for colds, upper respiratory tract infections, and bronchitis. CONCLUSION: Although antibiotics have little or no benefit for colds, upper respiratory tract infections, or bronchitis, these conditions account for a sizable proportion of total antibiotic prescriptions for adults by office-based physicians in the United States. Overuse of antibiotics is widespread across geographical areas, medical specialties, and payment sources. Therefore, effective strategies for changing prescribing behavior for these conditions will need to be broad based.

Adult↗
PubMed1996

Hypothermia in hypoxic animals: mechanisms, mediators, and functional significance.

A basic tenet of biology is that body temperature (Tb) has a marked effect on oxygen uptake of resting animals. For most animals, the temperature coefficient (Q10) is >> 2.5; e.g., resting oxygen uptake changes about 11% per degree C change in Tb. An important consequence of this dependence is that hyperthermia could be deleterious for hypoxic animals, particularly for oxygen sensitive organs, e.g., heart and brain. Conversely, a moderate degree of hypothermia could be beneficial during hypoxia. This concept is not new. Forced hypothermia is sometimes used in surgical procedures, particularly for heart and brain surgery. However, in many situations where hypothermia might have benefits, e.g., pediatric intensive care, it is not permitted. This is due in part to dogma and in part to the real and potential disadvantages of hypothermia, even in severely hypoxic animals. Among these in ventricular fibrillation. This is apparently preventable if blood pH is allowed to rise following the "Buffalo Curve." Another important disadvantage, were it to occur, is elevation of oxygen demand due to a thermogenic responses. However, at least in some species, the thermogenic response is blunted during hypoxia; e.g., in young rats. Furthermore, even if a thermogenic response occurs, this takes place primarily in muscles (shivering) and brown fat (non-shivering) and not in the O2-sensitive organs, heart and brain. A third disadvantage, for prolonged hypothermia, might be impairment of the immune response, a serious problem if hypoxia is combined with infection. This paper will review four aspects of behavioral fever and hypothermia: the occurrence among animals, the mechanisms and mediators that might trigger behavioral responses, and the functional significance.

Adaptation, Physiological↗
PubMed1995

Modified ilioinguinal node dissection for metastatic melanoma.

BACKGROUND: Standard ilioinguinal node dissection for melanoma has substantial cost and morbidity. Beginning in 1988, we modified the procedure in hopes of reducing side effects without compromising survival. PATIENTS AND METHODS: Dissection was standard except for preservation of saphenous vein and femoral sheath and omission of sartorius muscle transfer. To date, 19 patients with recurrent melanoma in the groin have had the procedure, 6 for N1 disease and 13 for N2, M1 metastases. RESULTS: Average hospital stay was 4.5 days (range 3 to 7). Postoperative edema occurred in 1 (5%) patient. Disease-free survival at 40 months was 66% for N1 disease and 26% for N2, M1 metastases. CONCLUSION: Modified ilioinguinal node dissection appears to reduce cost and morbidity of treating recurrent melanoma in the groin without compromising survival.

Adolescent↗