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Biomedical subjects

R H Fletcher

Publications and source records attributed to R H Fletcher.

At least 91 records · Page 5Linked to original sources
PubMed1985

The application of official policy. Prophylaxis recommendations for patients with mitral valve prolapse.

In 1977, the American Heart Association recommended that patients with mitral valve prolapse (MVP) and mitral insufficiency receive antibiotic prophylaxis prior to procedures that place them at risk for bacterial endocarditis. To study how clinicians conformed to this recommendation, the authors selected 126 patients with MVP admitted to a University Medical Center in 1978, the year following the official policy. Overall, only 47 patients (37%) had the antibiotic prophylaxis recommended. Furthermore, information that might have increased the certainty of diagnosis of MVP or the likelihood of mitral insufficiency did not influence the physician's decision: symptoms, previous history, procedures, sex, evidence for mitral insufficiency, other serious illnesses, or the use of cardiac medications. However, patients seen in consultation by a cardiologist were much more likely to have prophylaxis recommended (P less than 0.05). It was concluded that the application of an official policy about prophylaxis for a condition such as MVP, where the risks are uncertain, is likely to be guided by other factors, such as the opinions of local experts.

Adult↗
PubMed1984

The incidence of primary cardiac arrest during vigorous exercise.

To examine the risk of primary cardiac arrest during vigorous exercise, we interviewed the wives of 133 men without known prior heart disease who had had primary cardiac arrest. Cases were classified according to their activity at the time of cardiac arrest and the amount of their habitual vigorous activity. From interviews with wives of a random sample of healthy men, we estimated the amount of time members of the community spent in vigorous activity. Among men with low levels of habitual activity, the relative risk of cardiac arrest during exercise compared with that at other times was 56 (95 per cent confidence limits, 23 to 131). The risk during exercise among men at the highest level of habitual activity was also elevated, but only by a factor of 5 (95 per cent confidence limits, 2 to 14). However, among the habitually vigorous men, the overall risk of cardiac arrest--i.e., during and not during vigorous activity--was only 40 per cent that of the sedentary men (95 per cent confidence limits, 0.23 to 0.67). Although the risk of primary cardiac arrest is transiently increased during vigorous exercise, habitual vigorous exercise is associated with an overall decreased risk of primary cardiac arrest.

Adult↗
PubMed1984

Risk factors for strongyloidiasis. A case-control study.

Although infection with Strongyloides stercoralis is usually only mildly symptomatic, it can persist for many years and occasionally progress to the hyperinfection syndrome, with a resultant high mortality rate. We studied factors associated with S stercoralis infection by comparing 28 domestic cases of S stercoralis infection with 76 controls with negative stool samples for ova and parasites. The relative risk (RR) of S stercoralis infection was increased for white patients (RR = 5.6), men (RR = 3.9), and patients who had recently used corticosteroids (RR = 3.3), had a hematologic malignancy (RR = 5.28) or had prior gastric surgery (RR = 11.5). These risk factors might be for initial infection, persistence of infection, or both. Although they are not necessarily causal, knowledge of them may lead to earlier recognition of this dangerous and treatable disease.

Adrenal Cortex Hormones↗
PubMed1984

Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon.

Patients with chest pain and minimal or no coronary disease have a good prognosis for survival, yet many continue to have pain. In our experience with 821 medically treated patients there were three cardiac deaths (0.3%) and two nonfatal myocardial infarctions (0.2%) in the first year after angiography, which had revealed insignificant (less than 75% narrowing of the luminal diameter) or no coronary artery stenosis. In a subset of 548 patients selected with no apparent systematic difference from the inception cohort of 821 patients, there was complete absence of chest pain in 178 (33%) patients but 155 (28%) had similar or worse pain. From an analysis of clinical history and catheterization data entered in a stepwise logistic regression function, unimproved chest pain was significantly associated with female sex (p = 0.01) and an index of five chest pain descriptors (p = 0.0005). After adding selected behavioral variables available for a representative sample of 217 patients, a high hypochondriasis score (scale I from the Minnesota Multiphasic Personality Inventory) became the strongest determinant of continued pain (p less than 0.0001). In our experience, an exaggerated preoccupation with personal health is prospectively associated with continued chest pain in patients with minimal or no coronary disease.

Adolescent↗
PubMed1984

Habitual vigorous exercise and primary cardiac arrest: effect of other risk factors on the relationship.

To determine if the relationship between habitual vigorous exercise and primary cardiac arrest (PCA) is modified by the presence of other risk factors, we investigated 133 male cases of PCA, 25-75 years of age, without prior heart disease or co-morbidity, and 133 controls, identified from the same community. Persons who did not engage in high-intensity leisure-time activity for more than 20 min per week were classified as non-vigorous. The risk of PCA was more than doubled for non-vigorous males, both in the presence and absence of other risk factors taken individually, i.e. age greater than or equal to 60, hypertension, cigarette smoking, obesity, and family history. The incidence of PCA attributable to lack of vigorous activity was greatest for older, hypertensive, or obese males; for each of these subgroups, it exceeded 19 cases/10,000 persons/yr. Efforts to discourage clinically healthy persons at risk of PCA from continuing to engage in vigorous exercise may be inappropriate.

Adult↗
PubMed1984

Measuring the continuity and coordination of medical care in a system involving multiple providers.

Patients often receive medical care from many different providers. Consequently, the various episodes of care may not be integrated into a meaningful whole, and the quality of care may suffer. Before this possibility can be evaluated, it is necessary to develop a measure of the integrating process. The authors studied the continuity and coordination of care for 197 patients attending the General Medicine Practice within a large teaching hospital. Each patient had one internist as primary physician; however, a broad array of special services were available at the hospital and were often required. Of 1,768 total visits to the hospital, 62.2% were scheduled to the practice, whereas 92.9% were with the primary physician. For visits outside the practice, coordination (defined as the percent of visits for which the primary and other physicians were aware of each other's contact with shared patients) was 35.2%. Only 74.4% of all visits were either continuous or coordinated. Continuity with a single provider may be determined by patients' needs for services by others. A combined measure of continuity with coordination, such as the one used in this study, is more appropriate for a setting with multiple providers.

Continuity of Patient Care↗
PubMed1984

Attitudes of internal medicine subspecialty fellows toward primary care.

Subspecialists deliver a substantial proportion of primary care but little is known about how their training affects their attitudes toward this role. We surveyed a department of medicine to determine fellows' (N = 34) attitudes toward primary care and how these compared with the attitudes of house staff (N = 45) and faculty (N = 66). Continuous, coordinated, and accessible care as departmental policy was almost unanimously endorsed by all physicians. In contrast, fellows less often supported the provision of such care for their own patients in actual clinical situations. Fellows were also less likely than either house staff or faculty to endorse primary care attributes for their own patients. Departments of medicine should examine how negative attitudes toward primary care develop in subspecialty fellows and whether these attitudes persist after fellowship.

Academic Medical Centers↗
PubMed1983

Patients' priorities for medical care.

Relatively little research has been done on the importance patients attach to various aspects of their medical care when their options are constrained. We studied priorities for care among 225 patients attending the medical clinics of a university teaching hospital. Eight attributes of medical care were considered: continuity, coordination, comprehensiveness, availability, convenience, cost, expertise, and compassion. Priorities were established by the method of paired comparisons. Continuity of care was the highest priority for these patients, while cost and convenience were lowest. Priorities varied in subgroups of patients defined by demographic, illness, and utilization characteristics. Patients with acute problems preferred coordination and expertise, while those with chronic problems ranked continuity higher. Patients younger than 30 years old valued coordination most; older patients preferred continuity and comprehensiveness. Since all aspects of medical care cannot be provided to all people, and choices are necessary, patients' priorities should be considered when planning health services.

Adolescent↗
PubMed1982

Primary health care: perspective of the faculty of a department of medicine.

A full-time faculty in one dependent of medicine, 66 (85%) of whom are subspecialists, were surveyed to determine standards for provision and attitudes toward the teaching and practice of primary health care (PHC). A 40-item questionnaire on specific attributes of PHC provision was given to 70 eligible faculty members; 66 (94%) responded. Of 17 standards, nine were supported by 50 (75%) or more of the faculty and eight by from 24 (44%) to 48 (73%) faculty members. However, 51 faculty members (77%) indicated some discomfort with primary responsibility for the complete, ongoing care of their patients. Most frequent reasons for this discomfort were clinic inefficiency (31 votes [47%]) and competing commitments (29 votes [44%]). Few faculty indicated they did not enjoy PHC (eight [12%] of the faculty) or considered PHC inappropriate for academic physicians (ten [15%] of the faculty). These results indicate the complexity of faculty attitudes toward PHC and point to a need for departments of medicine to examine thier teaching and practice of PHC.

Attitude of Health Personnel↗
PubMed1981

Role disagreement in primary care practice.

To measure the extent of disagreement on roles between nurse practitioners (NPs) and physicians working together and to look for characteristics of joint practices that are associated with disagreement, patient vignettes were sent to 15 NP/M.D. dyads, and both M.D.s and NPs were asked how appropriate it would be for them and for their co-practitioner to provide care for the problem presented in each vignette. Measures of disagreement on patient care roles were developed by comparing responses within the dyad. For all practices, there was moderate agreement on roles, and this agreement seemed to favor a complementary practice. Disagreement on the NP's role was most often in the direction of NP feeling capable of providing more care than the M.D. felt she could provide. Various factors, such as job satisfaction, age differences between providers, and training level of the NP, were associated with the disagreement that was found. Some disagreement on roles exists between NPs and M.D.s practicing together. Resolution of these differences may lead to greater job satisfaction and more effective interaction between providers.

Adult↗
PubMed1979

Clinical research in general medical journals: a 30-year perspective.

Little is known about the frequency with which various research designs appear in the clinical literature and how this frequency has changed in recent years. This study describes the research designs used in 612 articles randomly selected from original research published in three general medical journals from 1946 to 1976. Cross-sectional studies increased from 25 to 44 per cent, cohort studies declined from 59 to 34 per cent, and clinical trials increased from 13 to 21 per cent of articles (P less than 0.001). Randomized controlled trials comprised 5 per cent of articles published in 1976 and were not represented 30 years before. In 1976, 37 per cent of articles reported on 10 subjects or less, and this number has not changed substantially since 1946. The frequency of studies with weak research designs has increased in these general medical journals over the past 30 years. The trend deserves critical attention.

Clinical Trials as Topic↗
PubMed1979

Patients' understanding of prescribed drugs.

Patients must understand their physicians' recommendations if they are to follow medical advice. This study assesses the degree to which patients and physicians share basic information about medications. Patients who regularly attended the medical clinics of a large, urban teaching hospital were asked to recall the identity, purpose, and dose schedule of medications that were prescribed for them. Patients' responses were compared to the medications actually prescribed by their physicians. Patients identified 90% of medications prescribed during the visits, knew the purpose 83%, and the correct dose schedule for 80%. Only 58% of patients knew the dosage schedule of all their medications correctly. Patients' knowledge of prescribed drugs was inversely related to the number of their medical problems and the number of medications prescribed. Lack of effective communication between physicians and patients about medications may be an important reason why patients do not follow medical advice.

Aged↗