Biomedical subjects

T G Tape

Publications and source records attributed to T G Tape.

At least 19 recordsLinked to original sources

PubMed2001

How physicians diagnose urinary tract infections: the potential influence of laboratory regulations on test availability and use.

OBJECTIVE: Physician office laboratory regulations may decrease test availability. We examined the potential effects of regulations on test availability and whether the use of tests in diagnosing uncomplicated urinary tract infections is related to availability. STUDY DESIGN: We performed an analysis of a cross-sectional survey conducted in 1994 and 1995. Test availability and use were determined by physicians' reports. POPULATION: The survey respondents included practicing physicians in 3 specialties (family medicine, general internal medicine, and obstetrics and gynecology) from 4 states: Pennsylvania (which had longstanding office laboratory regulations), and Alabama, Minnesota, and Nebraska (states that were not regulated until the implementation of the Clinical Laboratory Improvement Amendment of 1988). OUTCOMES MEASURED: We determined whether 4 specific tests were available in the office and how the tests were used to diagnose uncomplicated urinary tract infections. RESULTS: Our analysis was based on the responses from the 1898 respondents to the survey. All tests were less commonly available in Pennsylvania; this included the dipstick, microscopic urinalysis, wet prep, and urine culture (odds ratio [OR]=0.20-0.34; all P values < .05). The availability of the microscopic urinalysis and culture increased their use (OR = 4.37 and 2.03, respectively; P=.001). The availability of microscopic urinalysis was associated with a decrease in ordering urine cultures (OR=0.42; P=.001), and the availability of the dipstick was associated with a decrease in the use of both the microscopic urinalysis (OR=0.36; P=.02) and the culture (OR=0.48; P=.05). CONCLUSIONS: We found lower test availability in the state with office laboratory regulations and a decrease in testing when availability is reduced, suggesting that laboratory regulations may influence physicians&rsquo diagnostic approach to urinary tract infections. Further study will be required to determine the level of testing that maximizes patient welfare.

Adult↗

PubMed1999

Variation by specialty in the treatment of urinary tract infection in women.

To determine practicing physicians' strategies for diagnosing and managing uncomplicated urinary tract infection, we surveyed physicians in general internal medicine, family practice, obstetrics and gynecology, and emergency medicine in four states. Responses differed significantly by respondents' specialty. For example, nitrofurantoin was the antibiotic of first choice for 46% of obstetricians, while over 80% in the other specialties chose trimethoprim-sulfamethoxazole. Most surveyed said they do not usually order urine culture, but the percentage who do varied by specialty. Most use a colony count of 10(5) colony-forming units or more for diagnosis although evidence favors a lower threshold, and 70% continue antibiotic therapy even if the culture result is negative. This survey found considerable variation by specialty and also among individual physicians regarding diagnosis and treatment of urinary tract infection and also suggests that some of the new information from the literature has not been translated to clinical practice.

Adult↗

PubMed1996

UNMC: taking steps toward better healthcare.

To be successful, the system will need to be easily modified. Do not dissolve the tailoring team when the clinician screens are "done." Anticipate constant change in how patients are cared for and plan to change the system accordingly. Communicate with the vendor so that the company understands your changing needs and so you can keep current with new functionality. Above all, listen to your clinician users--"The customer is always right."

Academic Medical Centers↗

PubMed1995

Procedural skills of practicing pulmonologists. A national survey of 1,000 members of the American College of Physicians.

We surveyed pulmonologists to determine which procedures they do in practice, where they learned the procedures, and how much training they recommend to attain and maintain clinical competence in each. We mailed a survey to a random sample of 1,000 members of the American College of Physicians who were identified as practicing pulmonologists; 755 (75%) responded. Respondents performed a variety of pulmonary procedures, an average of 17 of the 29 listed. Pulmonologists who were more recent graduates, who worked longer hours, and who were involved in critical care did a greater variety of procedures. Only 26% of practicing pulmonologists currently do all the procedures required for board certification in pulmonary medicine. For each of 13 specific procedures, the number reported done in the past year was generally unrelated to practice factors. Many respondents who learned procedures in practice did so without formal training or supervision. Respondents' recommendations regarding numbers of procedures required to attain or maintain competence did not vary greatly. Pulmonologists vary considerably in the types of procedures they do. Their opinions about the training needed for competence help to better define requirements for training programs. More attention should be focused on training and certifying practicing pulmonologists in procedures learned after formal fellowship training.

Adult↗

PubMed1994

Ambulatory blood pressure monitoring during pregnancy with a new, small, easily concealed monitor.

Before establishing the utility of ambulatory blood pressure monitoring during pregnancy, we evaluated the accuracy of a small, easily concealed monitor. The 59 normotensive pregnant patients were between 13 and 26 gestational weeks. For each monitor reading, two trained observers independently and simultaneously recorded blood pressures using a mercury manometer connected to the monitor cuff. Seven readings in three positions (sitting upright, semirecumbent, standing) were performed on each patient. Averaged differences between the observers' and monitor readings varied from -2.2 to -0.9 mm Hg (systolic) and from -2.8 to -0.6 (fifth-phase diastolic), indicating slight but clinically unimportant overestimation by the monitor. Correlations between averaged observers' readings and the monitor ranged from 0.79 to 0.92 (systolic) and from 0.85 to 0.92 (fifth-phase diastolic). Overall, the observers agreed with the monitor within 5 mm Hg on 94% of systolic readings and 99% of fifth-phase diastolic readings. There was no statistically significant difference in accuracy with changes in body position. We conclude that this small, quiet, noninvasive device accurately determined blood pressures during pregnancy.

Adolescent↗

PubMed1993

Computerized medical records and preventive health care: success depends on many factors.

OBJECTIVE: To study the effect of a computerized medical record and other practice factors on the delivery of preventive health care. DESIGN: Prospective, controlled trial. SETTING: University general internal medicine teaching clinic. PARTICIPANTS: Forty-five internal medicine residents and their 4 supervising attending physicians. INTERVENTION: The study group used a computerized ambulatory medical record system that included health care maintenance reminders. The control group used a conventional paper record with a health care maintenance flow sheet. MEASUREMENTS AND MAIN RESULTS: The computer reminders significantly increased health care maintenance recommendations made to patients for proctosigmoidoscopy, tetanus vaccination, influenza vaccination, and pneumococcal vaccination, but not for fecal occult blood testing, mammography, Pap smears, or serum thyroxine screening in the elderly. First-year residents were nearly twice as successful as third-year residents in overall health care maintenance. Success scores varied markedly depending on which attending physician was supervising the residents. We found a strong interaction among group assignment, supervising attending, and level of training such that the reminders doubled success scores among first-year residents supervised by two of the attending physicians but had little effect on other subgroups. The time of year and the format of the reminder also had important effects for some of the maneuvers. CONCLUSIONS: Although computerized medical records markedly improved the performance of prevention maneuvers by committed physicians, many physicians using computer systems failed to make use of the resource. The reasons for this were complex. Future work in this area should carefully control for personal behaviors and focus upon administrative changes that more effectively implement these potentially powerful tools.

Aged↗

PubMed1993

Quantitative culture of bronchoalveolar lavage fluid for the diagnosis of bacterial pneumonia.

PURPOSE: A prospective study to determine the usefulness of quantitative bacterial cultures of fluid obtained via fiberoptic bronchoscopy and bronchoalveolar lavage as an aid in the diagnosis of bacterial pneumonia. PATIENTS AND METHODS: All patients undergoing fiberoptic bronchoscopy with bronchoalveolar lavage during a 6 1/2-month period. Presence of pneumonia was determined using clinical, radiographic, laboratory, and histologic data. Quantitative bacterial cultures of bronchoalveolar lavage fluid were determined using a 1-microL culture loop. RESULTS: Quantitative bacterial cultures of bronchoalveolar lavage (BAL) fluid were sensitive and specific predictors of bacterial pneumonia. Using 10(3) colony-forming units (cfu)/mL as the threshold value for a positive culture, we determined the sensitivity and specificity to be 90% and 97%, respectively. The data were also analyzed for the subgroups of patients who were intubated or were receiving antibiotics. The sensitivity and specificity were 78% and 96% for the group of patients receiving antibiotics and 100% and 82% for the group of patients intubated for more than 24 hours at the time of BAL. Values for the area under the receiver operating characteristic curve for the 3 groups were 0.94, 0.88, and 0.96, respectively. CONCLUSIONS: Quantitative bacterial cultures of BAL fluid are sensitive and specific in the diagnosis of bacterial pneumonia. The use of antibiotics at the time of BAL reduces the sensitivity of the test, and prolonged intubation reduces the specificity of the test.

Bacterial Infections↗

PubMed1993

Discrimination and reproducibility of an information maximizing multivariable model.

Predictor variables for multivariate rules are frequently selected by methods that maximize likelihood rather than information. We compared the discrimination and reproducibility of a prediction rule for pneumonia derived using extended dependency analysis (EDA), an information maximizing variable selection program, with that of a validated rule derived using logistic regression. Discrimination was measured by receiver-operating characteristic (ROC) analysis, and reproducibility by rederivation of the rule on 200 replicate samples of size 250 and 500, generated from a training cohort of 905 patients using Monte Carlo techniques. Four of the five predictor variables selected by EDA were identical to those selected by logistic regression. With each variable weighted by its conditional contribution to total information transmission, EDA discriminated pneumonia and nonpneumonia in the training cohort with an ROC area of 0.800 (vs 0.816 for logistic regression, p = 0.60), and in the validation cohort with an area of 0.822 (vs 0.821 for logistic regression, p = 0.98). EDA demonstrated reproducibility comparable to that of logistic regression according to most criteria for replicability. Replicate EDA models showed good discrimination in the training and testing cohorts, and met statistical criteria for validation (no significant difference in ROC areas at a one-tailed alpha level of 0.05) in 80.8% to 94.2% of cases. We conclude that extended dependency analysis selected the most important variables for predicting pneumonia, based on a validated logistic regression model. The information-theoretic model showed good discriminatory power, and demonstrated reproducibility according to clinically reasonable criteria. Information-theoretic variable selection by extended dependency analysis appears to be a reasonable basis for developing clinical prediction rules.

Cohort Studies↗

PubMed1992

The influence of treatment descriptions on advance medical directive decisions.

OBJECTIVE: To determine whether the wording of the descriptions of life-sustaining interventions would affect the choices elderly patients make when completing advance directives. METHODS: Survey. SETTING: General community in Omaha, Nebraska. PATIENTS: Two hundred one community-dwelling elderly were selected from a population-based sample. MAIN OUTCOME MEASURES: Subjects were asked whether they would accept or reject three life-sustaining interventions: cardiopulmonary resuscitation, mechanical ventilation, or tube feeding in three separate hypothetical case scenarios. The three life-sustaining interventions were each described positively, negatively, and exactly as they are worded in a widely used advance directive. Subjects reviewed each scenario three times with three different descriptions of the three interventions. RESULTS: For the three interventions presented in three scenarios, subjects opted for the intervention 12 percent of the time when it was presented negatively, 18 percent of the time when it was phrased as in an advance directive already in use and 30 percent of the time it was phrased positively. One hundred fifty-five of the 201 subjects (77 percent) changed their minds at least once when given the same scenario but a different description of the intervention. Of these 155, 33 percent changed decisions one to three times, 33 percent changed decisions four to seven times, and another 34 percent changed decisions eight to seventeen times based solely on the description of the intervention. CONCLUSION: The decisions patients make about whether to accept or reject life-sustaining treatments are affected by the descriptions of the treatments. These findings emphasize the critical importance of doctor-patient consultation when patients execute advance directives.

Advance Directives↗

PubMed1992

Implementing guidelines in ambulatory practice.

As we understand the process of ambulatory care better, the need to effectively implement standards of practice becomes more apparent. To facilitate successful use of practice guidelines, we have integrated an artificial intelligence system of Medical Logic Modules into our computerized medical record. A rule shell allows rapid development and prototyping of rules which can be practice reminders, information gathering utilities, or standing orders. A set of utilities allows non-programmer clinicians to develop and maintain the rule set. We will demonstrate these enhancements in the context of the comprehensive patient record.

Ambulatory Care↗

PubMed1991

Increasing physician acceptance and use of the computerized ambulatory medical record.

Because physicians have been reluctant to accept computerized medical records systems, we sought to identify the barriers to acceptance and redesigned our ambulatory records system accordingly. We identified several problems physicians encounter in using our computerized medical record system (COSTAR), including physicians' hesitation to use a computer in front of their patients, physicians' poor keyboard skills, and the structural organization of the computerized medical record. We formed a users group to educate users and the group has helped identify solutions to these problems. We equipped the exam room terminals with a user-friendly, patient-specific menu. We created a new physician interface for COSTAR that was organized to function similarly to a patient's chart and features user-friendly menus that provide cues to the unsophisticated user. Physician use of exam room terminals tripled after the installation of the exam room menu. The new physician interface doubled physician use of COSTAR's scheduling features. Acceptance of the new interface as gauged by a user survey was excellent, with the majority stating it improved their patient care.

Academic Medical Centers↗

PubMed1990

Clinical prediction rule for pulmonary infiltrates.

OBJECTIVE: To derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness. DESIGN: Prevalence studies in three settings. SETTING: Emergency departments of the University of Illinois Hospital at Chicago, the University of Nebraska Medical Center at Omaha, and the Medical College of Virginia at Richmond. PATIENTS: Symptoms, signs, comorbidity data, and chest roentgenogram results were recorded for 1134 patients from Illinois (the derivation set), 150 patients from Nebraska, and 152 patients from Virginia (the validation sets). All patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints. MEASUREMENTS AND MAIN RESULTS: Within the training set, temperature greater than 37.8 degrees C, pulse greater than 100 beats/min, rales, decreased breath sounds, and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model (P = 0.001). The logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic (ROC) area of 0.82. In the validation sets, the rule discriminated pneumonia and nonpneumonia with ROC areas of 0.82 and 0.76 after adjusting for differences in disease prevalence (P greater than 0.2 compared with the training set). The predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings. CONCLUSIONS: Among adults presenting with acute respiratory illness, a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia, and was used in two other samples of patients without significant decrement in discriminatory ability. This rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease.

Acute Disease↗

PubMed1990

Procedural skills of practicing nephrologists. A national survey of 700 members of the American College of Physicians.

OBJECTIVE: To determine which procedures nephrologists do in practice, where they learned the procedures, and how much training they recommend to achieve and maintain clinical competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 700 members of the American College of Physicians who were identified as practicing nephrologists; 516 (74%) responded. RESULTS: Acute peritoneal dialysis, acute hemodialysis, continuous arteriovenous hemofiltration, and percutaneous renal biopsy were done by 95%, 97%, 87%, and 91% of the respondents, respectively. Except for hemofiltration, procedures were learned by most respondents during fellowship training. Compared with general internists, fewer nephrologists did most of the 19 general procedures included in the survey. The number of nephrology procedures done during the past year varied considerably among respondents, as did the minimum number of procedures they recommended for achieving and maintaining competence. Neither the variation in number of procedures done nor recommendations regarding certification were explained by differences in practice characteristics. Median recommendations remained relatively constant among subgroups. CONCLUSIONS: Nearly all nephrologists do the four nephrology procedures included in the survey. Their opinions about the training needed for competence help to better define requirements for training programs. More attention should be focused on training and certifying practicing nephrologists in procedures learned after formal fellowship training.

Biopsy, Needle↗

PubMed1989

Procedural skills training in internal medicine residencies. A survey of program directors.

STUDY OBJECTIVE: To obtain the opinions of internal medicine residency program directors about which procedural skills residents master during training and the amount of training needed to attain and maintain competence in each procedure. DESIGN: A mailed survey to all program directors in the United States. RESPONDENTS: Program directors or their designees from 389 of 431 (90%) internal medicine residency programs. RESULTS: For several procedures, 40% more respondents said all residents should master the procedure than said all their residents do master the procedure. Some procedures commonly done in practice were perceived as mastered by all residents in fewer than half of the programs. There were few differences in procedures learned by size or type of program. A fellowship program did affect exposure to some procedures in the field covered by the program. Median recommendations of training needed to master each procedure were similar to those of practicing internists for most procedures. CONCLUSIONS: Current residency training does not assure competency in all of the procedures the general internist does in practice. Program directors should examine which skills are adequately taught, test competence, and ways to improve residents' skills. Practicing general internists should have access to supervised training in procedural skills.

Clinical Competence↗

PubMed1986

The utility of routine chest radiographs.

Although admission and preoperative chest radiography has been done for many years in various settings, existing data do not support its utility in enhancing patient care. Calculations based on estimates of the accuracy of chest radiographs and the likelihood of disease suggest that routine chest radiography may result in many more misleading than helpful results. Patients in whom chest radiographs are likely to improve outcome are best identified by a careful history and physical examination. We recommend that the practice of doing routine chest radiographs on admission and preoperatively be stopped and that the procedure be reserved for patients with clinical evidence of chest disease and patients having intrathoracic surgery.

Adult↗

PubMedDate not supplied

How useful are routine chest x-rays of preoperative patients at risk for postoperative chest disease?

The authors studied the value of routine chest x-rays in the management of patients admitted for vascular surgery, a population likely to have comorbid chest disease. Patient records from 341 admissions were reviewed to determine the relationship between chest x-ray results and postoperative chest complications. Patients who had major abnormalities had a 40% postoperative complication rate, compared with 9% for those with normal x-rays; but only 13% of the complications occurred in patients with major abnormalities. Nine patients had x-ray findings that led to clinical action: three with potentially beneficial management changes (congestive heart failure in 2, fibrosis in 1) and six with potentially detrimental clinical action (false diagnosis of tuberculosis in 2, false diagnosis of nodules in 2, falsely normal chest x-ray in 2). None of 50 surgical cancellations occurred as a result of an abnormal x-ray. All the beneficial effects attributable to preoperative chest x-rays accrued to patients who had clinical evidence of chest disease. The authors conclude that routine chest x-rays were not helpful in improving patient outcomes. They recommend ordering preoperative chest x-rays based on clinical indications so that the likelihood of false positives and false negatives and their associated detrimental effects can be minimized.

Adult↗

PubMedDate not supplied

Echocardiography, endocarditis, and clinical information bias.

Although clinical information provided to the interpreter of imaging tests may improve disease detection, it may also bias the interpreter towards certain diagnoses, increasing the chance of false positives. To determine the possibility of this bias, the authors studied patients who were referred for echocardiography with a clinical suspicion of endocarditis. Hospital charts from a two-year period were reviewed to determine clinical data available to the echocardiographer, echocardiogram results, and the final diagnosis. Four clinical features, when present at the time of echocardiography, were associated with increased numbers of false-positive results. Test specificity was 97% (34/35) for patients without any of these features, but dropped to 80% (16/20) when two or more features were present. The authors conclude that clinical information may bias echocardiogram interpretations such that both test specificity and the posttest probability of disease may be overestimated when tests are used in clinical practice.

Echocardiography↗

PubMedDate not supplied

Medical students' and residents' estimates of cardiac risk.

Resident physicians' and medical students' perceptions of atherosclerotic heart disease (ASHD) risks and their understanding of risk appraisal concepts were studied. Subjects estimated the average risks of death from ASHD, from motor vehicle accidents, and from all causes for men in three age groups. Given a patient with severe hypertension, they then estimated relative risk and used their estimates to calculate individual patient risks. Risk estimates varied widely. Only 36% of the subjects were consistently accurate estimators of ASHD and all-causes risks. Subjects who had family histories of heart disease performed significantly better than others. Only about half the subjects were able to compute the hypertensive patient's risk correctly. Thus, residents and students were not adept at estimating the average risks of death from various causes or using the estimates to assess a patient's risk. Better physician understanding of these concepts might lead to improved patient counseling in risk factor reduction.

Accidents, Traffic↗