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At least 595 records · Page 33Linked to original sources
PubMed1996

Pediatric cervical spine injury: a three-year experience.

BACKGROUND: Traumatic injuries of the cervical spine are uncommon in pediatrics. Children less than 8 years of age are reported to have "exclusively" upper cervical injuries. Recent experience at The Children's Hospital of Alabama (TCHA) challenged both of these notions. METHODS: A concurrent retrospective chart review of all cervical spine injuries treated at TCHA between January 1, 1992 and December 31, 1994 was performed. Data collected included patient demographics, date and time of injury, mechanism and site of injury, presence of associated injuries, clinical management, and outcome. RESULTS: Thirty-four patients with cervical spine injuries were seen at TCHA in the 36-month study period. The leading mechanism of injury was motor vehicle crashes (23/34 or 68%). Head injuries were associated with cervical spine injury in 53% of patients. Of the 20 patients aged 8 years or less, 10 (50%) had "low" cervical spine injuries (below C4). Overall mortality was 41% (14/34). Of the 15 vehicle occupants, 12 were unrestrained or inappropriately restrained. Two of those appropriately restrained were young school-aged children in lap-shoulder belts who sustained isolated cervical spine injuries. CONCLUSIONS: 1. The number of pediatric cervical spine injuries in our institution appears to be increasing. 2. Cervical spine injury in children less than 8 years of age are not exclusively confined to the region above C4. 3. Occurrence of cervical spine injuries despite lap-shoulder belt use suggests that efforts should be focused on refinement of motor vehicle restraint devices in young school-aged children.

Accidents, Traffic↗
PubMed2006

Increased swelling complications associated with off-label usage of rhBMP-2 in the anterior cervical spine.

STUDY DESIGN/SETTING: Independent, retrospective clinical record review with a concurrent control. OBJECTIVE: To identify whether rhBMP-2 is associated with an increased incidence of clinically relevant postoperative prevertebral swelling problems in patients undergoing anterior cervical fusions. SUMMARY OF BACKGROUND DATA: Bone Morphogenetic Protein-2 (rhBMP-2) is FDA approved as a bone graft substitute in anterior lumbar interbody fusions. rhBMP-2 has also been used "off-label" in anterior cervical fusions. We suspected that rhBMP-2 might increase the incidence of adverse swelling events. METHODS: A total of 234 consecutive patients (ages 12-82 years) undergoing anterior cervical fusion with and without rhBMP-2 over a 2-year period at one institution comprised the study population. The incidence of clinically relevant prevertebral swelling was calculated. The populations were compared and statistical significance was determined. RESULTS: A total of 234 patients met the study criteria, 69 of whom underwent anterior cervical spine fusions using rhBMP-2; 27.5% of those patients in the rhBMP-2 group had a clinically significant swelling event versus only 3.6% of patients in the non-rhBMP-2 group. This difference was statistically significant (P < 0.0001) and remained so after controlling for other significant predictors of swelling. CONCLUSIONS: Off-label use of rhBMP-2 in the anterior cervical spine is associated with an increased rate of clinically relevant swelling events.

Adolescent↗
PubMed2003

Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship.

OBJECTIVE: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. SUMMARY BACKGROUND DATA: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. METHODS: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. RESULTS: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows' feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience "great -5" or "exceptional- 6." Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. CONCLUSION: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review.

Colonic Pouches↗
PubMed2005

Sequential platinum-based chemotherapy-thoracic radiotherapy in early stage non-small cell lung cancer.

Combined chemoradiotherapy (CTRT) is intended to reduce the risk of local regional recurrence and distant relapse in patients with early stage non-small cell lung cancer (NSCLC). Sequential CTRT allows full doses of each modality while avoiding the additive toxicity that occurs with concurrent therapy. This review will encompass studies in the three main settings where sequential CTRT has been applied in early stage NSCLC: as adjuvant therapy after resection, as neoadjuvant chemotherapy and surgery followed by radiotherapy, and in unresectable stage III disease.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1992

Observations and effects of educational consults on allopurinol prescribing.

Allopurinol has been used in the management of hyperuricemic states for several years. Despite its efficacy for these indications, recent concerns have been raised regarding the unnecessary morbidity and mortality occasionally associated with its inappropriate use. In an effort to assess the utilization of allopurinol, a concurrent drug utilization review was undertaken. Fifty patients who were prescribed allopurinol were entered into the study and underwent health record review and patient interview, to determine appropriateness of therapy and the need for educational intervention. A number of inconsistencies with regard to established guidelines were identified. As well, 11 of 50 patients (22%) required intervention because of either lack of indication or excessive dose. Fifty-five percent of the educational interventions, performed by the pharmacist, were accepted as written. The current utilization of allopurinol at our facility differs substantially from guidelines developed for optimal utilization of allopurinol. Further, a pharmacy based intervention program can improve prescribing practices of allopurinol.

Aged↗
PubMed1985

Cost containment through therapeutic substitution of aminoglycosides.

A therapeutic substitution policy (TSP) for tobramycin and gentamicin sulfate was implemented at the University of Texas Medical Branch (UTMB). The policy was designed by various physician-chaired hospital committees and clinical departments that collaborated with the pharmacy service. The goal was to encourage the medical house staff to use the most economical yet safe and effective aminoglycoside, without limiting the medical team's prerogative to select among alternatives within this antibiotic group. Cost data from the first 6 months of aminoglycoside use under the new policy projected an annual savings of $139,071 in drug expenditures and $242,472 in patient charges. Following the implementation of the TSP, a concurrent drug utilization review (DUR) was performed in 50 consecutive inpatients prescribed amikacin, tobramycin, or gentamicin sulfate. The objectives were to identify those aspects of prescribing and monitoring of aminoglycosides by house staff that could be improved by specific policy and/or education, and to evaluate those specific cases in which attending physician's approval allowed house staff to prescribe an aminoglycoside other than designated in the TSP. The audit revealed that house staff were compliant with 72% of the DUR criteria; however, at least one instance (mean of 5.04 +/- 2.21) of noncompliance occurred during the treatment of each patient. The most frequently encountered deficiencies were failure to monitor for ototoxicity, incorrect orders for at least one set of serum aminoglycoside concentrations, and improper dosage adjustments for those patients with renal insufficiency. In three cases, the attending physician approved house staff use of tobramycin instead of gentamicin sulfate for reasons of organism resistance, pre-existing renal impairment, and long-term treatment of osteomyelitis.

Aminoglycosides↗
PubMed2001

Effective strategies for managing pharmacy benefits.

Prescription drug costs are among the fastest-growing healthcare costs. Effective plan design and benefit management strategies can help pharmacy benefit plans manage costs while maintaining quality and customer satisfaction. These strategies include using formulary management, intervention techniques, and cost sharing to encourage the use of generic drugs; employing a mail-service pharmacy benefit for maintenance medications; and implementing concurrent and retrospective review programs to ensure eligibility and plan compliance, identify practice patterns, and encourage appropriate drug selection.

Cost Sharing↗
PubMed1987

Cervical and vaginal pathology in women with vulvar condylomata.

All women referred to the Department of Obstetrics and Gynecology, School of Medicine, State University of New York at Stony Brook, for evaluation of vulvar condylomata were reviewed to identify concurrent cervical and vaginal pathology. Over the five-year period 1981-1985, referrals to our colposcopy clinic for vulvar condylomata increased from 7.8% to 29.2%. All patients underwent a thorough history, physical examination and colposcopic evaluation of the cervix, vulva and vagina. Of the patients with vulvar condylomata, 68% had biopsy-proven cervical and vaginal pathology. While 50% of patients with cervical disease had human papillomavirus infection alone, the other 50% had concurrent cervical intraepithelial neoplasia (CIN) or CIN only. Proper evaluation of patients with vulvar condylomata must include colposcopy of the cervix and vagina.

Cervix Uteri↗
PubMed1979

Harvey A.K. Whitney lecture. The patient's pharmacist.

The concept of the patient's pharmacist, the clinical pharmacist who directs his efforts to the individual patient with prospective and concurrent drug use review, is discussed. A patient's pharmacist is familiar with the patient's medical and social history and his present health problems, and ensures that the patient's drug therapy is appropriate at all times. His knowledge base includes an understanding of the clinical use and actions of drugs, pharmacokinetics, optimum clinical response expected from drug therapy, monitoring and evaluating clinical response and communication skills for medication counseling. The patient information the pharmacist needs is discussed in detail. The pharmacist should record his patient care activities in the medical record; this record can serve as a basis for evaluating the pharmacist's activities.

Drug Information Services↗
PubMed1981

Self-care habits and disease-state understanding of diabetic patients.

Diabetic patients who had never participated in a formal diabetes education program were surveyed to assess their self-care patterns and knowledge of diabetes. A sample of 142 men was selected from the diabetes clinic of a VA hospital. Patients were interviewed, a questionnaire was given to the insulin-dependent patients, and medical records were reviewed to determine concurrent use of antidiabetic medications and other drugs. The majority of patients (91%) were aware of the effects of alcohol, glucose rich foods, and lack of medication on diabetic control. However, 42% of the patients were aware of the effects of excessive exercise, and only 52% were aware of the effects of omitting meals. The most frequently cited problems involved factors of dietary control such as the use of food measurements, exchange lists, and caloric allotments. Patient knowledge of urine testing techniques was greater than knowledge of other areas. Only 24% of the patients knew the symptoms of hyperglycemia. The importance of foot care was understood by 44% of the patients, but only 13% knew how to remove corns and calluses correctly. The results of the supplemental questionnaire showed that the lowest levels of knowledge concerned insulin measurement and conversions. The appropriate aseptic procedures were known by the majority of the patients, and the time of insulin administration was understood by 97%. Medical records revealed that 23 patients were taking thiazides concurrently with their antidiabetic medication. An inverse relationship was found between age and knowledge scores, and a direct relationship was found between educational level and knowledge scores. These results should be useful in developing educational programs for diabetic patients.

Alcohol Drinking↗
PubMed1998

HIV seroprevalence among male prison inmates in the Wisconsin Correctional System.

OBJECTIVE: To estimate HIV seroprevalence and the acceptance of voluntary HIV testing among male inmates entering the Wisconsin Correctional System during July 1, 1994-June 30, 1995, and compare these estimates with similar data obtained in 1987-1988. METHODS: A blinded HIV seroprevalence survey concurrent with a review of voluntary HIV antibody testing records. RESULTS: HIV test results were obtained for 3,681 (89%) male prison entrants during the study period; 26 (0.7%) were HIV-1 seropositive. Based on this estimate and the total number of male prison entrants (4,134), an estimated 29 HIV-1 seropositive male inmates entered the Wisconsin Correctional System during the study period. Eighty-four percent of all inmates were tested voluntarily. Among inmates testing HIV-1 seropositive, 69% were tested voluntarily. CONCLUSIONS: These data suggest that HIV-1 seroprevalence among male prison inmates in Wisconsin is low, and is unchanged from the late 1980s; however, a large increase in the prison population has resulted in a substantial increase in the absolute number of HIV-1 seropositive inmates entering the correctional system. Although overall acceptance of voluntary HIV testing is high, nearly one third of HIV-1 seropositive inmates declined voluntary HIV testing.

AIDS Serodiagnosis↗
PubMed1998

Performance of liquid-based, thin-layer cervical cytology: correlation with reference diagnoses and human papillomavirus testing.

The performance of thin-layer cervical cytology with the use of ThinPrep (Cytyc Corporation, Boxborough, MA) was assessed by comparing the original independent diagnosis of ThinPrep slides and conventional smears prepared from 1780 split samples with the most abnormal diagnosis per patient on the basis of an independent pathologist's masked review and with the detection of cancer-associated types of human papillomavirus (HPV) DNA. Cases were selected on the basis of the original diagnoses to include all discordant pairs (those diagnosed as atypical squamous cells of undetermined significance or higher grade, n = 1017), all concordant abnormal pairs (n = 444), and a random 5% of concordant normal pairs (n = 319). In screening centers, thin-layer cytology detected 135 (70.3%) of 192 women diagnosed as having squamous epithelial lesions or a higher grade in the independent review, whereas locally read smears detected 91 (47.4%) of these patients (P < .001). In hospital-based cytology laboratories, thin-layer cytology detected 308 (86.3%) of 357 women diagnosed with SILs or a higher grade in the independent review, compared with 283 (79.3%) diagnosed with smears (P = .011). Cancer-associated types of HPV DNA were detected in a slightly higher proportion of women with smears diagnosed as SILs than in women with thin-layer cytology diagnosed as SILs, whereas the overall number of HPV-associated SILs diagnosed was higher with thin-layer cytology. These data suggest that the ThinPrep method detects a higher percentage of SILs as defined in a masked, independent review than do concurrently prepared smears and that diagnoses of SILs rendered with ThinPrep correlate with the detection of cancer-associated types of HPV.

Cytological Techniques↗
PubMed2001

Underutilization of acute care settings in a tertiary care hospital.

OBJECTIVE: To estimate underutilization of acute care settings in a tertiary care hospital. DESIGN: A retrospective and concurrent cohort study using chart reviews and the Intensity of service, Severity of illness, Discharge screen for Acute Care (ISD-AC(R)) tool to measure appropriateness of acute care for patients who were receiving care in a less acute setting, as an indicator of underutilization. SETTING: A 450-bed tertiary care teaching hospital. STUDY PARTICIPANTS: Patients discharged from the emergency department, patients discharged from acute care inpatient units and patients in acute, non-critical care settings. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The percentage of patients discharged from the emergency department who did not meet the criteria for acute care discharge screens; the percentage of patients discharged from an acute care inpatient unit who did not meet the criteria for discharge screens; and the percentage of patients who were in acute, non-critical care beds and who met the criteria for critical care. RESULTS: It was found that six out of 168 patients [3.57%; 95% confidence interval (CI), 1.32-7.61%] did not meet the discharge screens at the time of discharge from the emergency department. Four out of 156 patients (2.56%; 95% CI, 0.70-6.43%) did not meet the discharge screens at the time of discharge from an acute care inpatient service and two out of 156 acute care patients (1.33%; 95% CI, 0.02-4.73%) who were in non-critical care beds met the criteria for critical care. CONCLUSION: These findings of underutilization may help to quantitate an unmet need in health care.

Acute Disease↗
PubMed2002

The potential pitfalls of concurrent rhinoplasty and endoscopic sinus surgery.

OBJECTIVE: As the largest portion of the population is becoming middle aged and our society becomes increasingly interested in youth and appearance, so does the number of esthetic surgeries. Rhinoplasty is being performed with increased frequency in recent years. Many surgeons are performing rhinoplasty combined with endoscopic sinus surgery as a means to decrease operating times, healing times, as well as patient cost. Many surgeons may be unaware of several potential life-threatening complications when these two safe procedures are performed concurrently. STUDY DESIGN: A rare but illustrative case depicting a serious complication of concurrent surgery. A retrospective review of our experience and an extensive literature review were performed documenting the type and incidence of minor and serious postoperative complications. RESULTS: A case demonstrating multiple near-fatal complications after rhinoplasty and endoscopic sinus surgery, which are two safe, commonly performed procedures when performed individually. A review of our 268 rhinoplasties performed between 1997 and 2001 demonstrated 11 cases with concurrent surgery. There were no complications noted in this population. CONCLUSION: We conclude and agree with the literature that concurrent surgery is safe and effective.

Adult↗
PubMed2006

Concurrent lymphocytic hypophysitis and pituitary adenoma. Case report and review of the literature.

Lymphocytic hypophysitis (LyH) is an uncommon intrasellar lesion characterized by lymphocytic infiltration of the adenohypophysis. Evidence suggests that the cause is autoimmune, and the symptoms are usually related to either a mass effect or endocrine dysfunction. Lymphocytic hypophysitis has been described rarely in the setting of other simultaneous pathological processes that involve the pituitary and sella turcica, and is postulated to arise from an intrinsic inflammatory response. The authors report the case of a 43-year-old woman who presented with a 2-month history of galactorrhea and pseudohyperprolactinemia secondary to a 10-mm lesion within an enlarged pituitary gland. She was nulliparous and had no contributory medical history. Serial neuroimaging performed over a 2-year period demonstrated lesion growth, and visual deficits had developed; together these warranted surgical intervention. A transsphenoidal resection was performed. Microscopic and immunohistopathological examinations revealed a nonsecreting pituitary adenoma with concurrent lymphocytic adenohypophysitis. This is the first documented case of LyH in the setting of a null-cell pituitary adenoma. The authors review the related literature and outline potential mechanisms for the concurrent development of LyH and a pituitary adenoma.

Adenoma↗
PubMed2004

The Centre for Addiction and Mental Health Concurrent Disorders Screener.

OBJECTIVES: To review the characteristics of psychiatric screening tools currently available in addiction treatment services for rapid assessment of comorbid pathology and to introduce the Centre for Addictions and Mental Health Concurrent Disorders Screener (CAMH-CDS), a computer-administered questionnaire that screens for the occurrence of 11 Axis I disorders plus all substance use disorders, as well as for a history of conduct disorder. METHODS: We describe the structure, contents, and application of the CAMH-CDS. We undertook a sensitivity and specificity trial involving 171 subjects, a test-retest reliability study with 301 participants, and an open-label concordance study with 656 respondents. All subjects were regular clients of a major addiction treatment facility. RESULTS: The CAMH-CDS was easily and effectively used by addiction counsellors with limited or no mental health training. It has a low rate of false-negative responses, and it yields excellent test-retest reliability figures. It is highly sensitive to identifying persons with psychiatric disturbances; however, its ability to discriminate among specific disorders appears to be more limited. CONCLUSIONS: The CAMH-CDS can be reliably used to rule out the presence of psychiatric comorbidity in addiction service populations. As with other psychiatric screening instruments, its sensitivity values are stronger than its specificity values. The use of nonstructured clinical evaluations as the gold standard for diagnosis and a likely variance in the patients' symptom reports between the 2 examinations may have contributed to the latter finding.

Adult↗
PubMed2002

Late appearance of t(1;19)(q11;q11) in myelodysplastic syndrome associated with dysplastic eosinophilia and pulmonary alveolar proteinosis.

We report a case of myelodysplastic syndrome (MDS), which developed marked eosinophilia and pulmonary alveolar proteinosis after the appearance of t(1;19)(q11;q11). Chromosomal analysis of the peripheral eosinophils identified the same chromosome abnormality in all metaphases to that of bone marrow blast cells. Review of the literature revealed three reported cases of concurrent MDS and pulmonary alveolar proteinosis. We reviewed four cases of concurrent MDS and pulmonary alveolar proteinosis, including the present case. Interestingly, all but one of these patients also had evidence of eosinophilia and abnormality of chromosome 1p. These findings, together with morphologic abnormalities of eosinophils observed in this case, indicate clonal involvement of eosinophils in the MDS clone, and that the eosinophilia was derived from the neoplastic clone with the translocation. We postulate that this chromosomal rearrangement is involved in the development of eosinophilia and pulmonary alveolar proteinosis in MDS.

Bone Marrow Cells↗