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PubMedDate not supplied

Quality of life outcomes in left ventricular assist system inpatients and outpatients.

This study empirically evaluates the quality of life (QOL) effects associated with hospital discharge among heart transplant candidates whose lives are maintained by left ventricular support systems (LVAS). Thirty-five LVAS inpatients (18 Novacor, 17 Thoratec) received structured QOL assessments approximately 1 month after device implant. Ten of the patients (8 Novacor, 2 Thoratec) were subsequently discharged to either home or a home-like outpatient facility where their QOL was reassessed. The QOL of LVAS patients, before and after discharge, was compared with that of demographically similar nonhospitalized heart transplant candidates (n = 55) and recipients (n = 97). Their caregivers' QOL was also assessed. The QOL of LVAS outpatients showed statistically significant (p<0.05) advantages over remaining LVAS inpatients and nonhospitalized heart candidates. Advantages appeared in physical, emotional, and social functioning domains. The QOL of LVAS outpatients also improved (p<0.05) over their own QOL before discharge, with the greatest change in physical functional and emotional status. The QOL of LVAS outpatients most closely resembled QOL in the transplant recipients. Family caregivers to LVAS outpatients reported some increases in caregiving burden after patient discharge, but their overall well being was not adversely affected. These data provide an empiric basis for the provision of outpatient programs as appropriate care for eligible LVAS patients.

Activities of Daily Living↗
PubMed1990

Self-assessed learning needs of oncology nurses caring for individuals with HIV-related disorders. A national survey.

A national survey of 10% of the members of the Oncology Nursing Society (ONS) was conducted to determine the knowledge and experience of oncology nurses caring for individuals with HIV-related disorders. This information was to serve as the framework for developing subsequent education and preparation of oncology nurses. A questionnaire containing 109 questions was mailed to 1,006 members of the ONS. Response rate was 70% (N = 693). Fifty-five of the 109 questions assessed clinical knowledge, experience, and care planning for adults. Additional questions elicited information about staff attitudes, problems in care delivery, priorities in nursing administration and research, and nurses' preferred methods of instruction. Results showed that oncology nurses are experienced in certain areas of importance to patients with AIDS but have educational and experiential deficits in the disease specifics associated with HIV-related disorders and in the nursing care of adults with multisystem involvement and in their treatment. Validity and reliability of this questionnaire were established (alpha = 0.93-0.97). Readers are encouraged to adapt this questionnaire to assess the learning needs of nurses in all specialty groups, and to develop appropriate educational programs to prepare nurses to provide care for this patient population.

Adult↗
PubMed1990

Herpes simplex and human papillomavirus genital infections: controversy over obstetric management.

Plasma inhibitory factors, high levels of sex hormones, and depression of cell-mediated immunity may interfere with the natural host resistance to viral infections during pregnancy. It is apparent that hormonal, immunologic, and vascular changes in pregnancy may account for increased replication of herpes and for enhanced growth of condylomatous lesions. The challenge is to develop a rational plan of management for pregnant patients with herpes simplex or human papilloma virus infection. There has been a reevaluation of previous recommendations for the management of herpes in pregnancy. Although the consequences of neonatal infection are severe or fatal, the value of routine weekly screening is questionable. This regimen is a poor predictor of neonatal exposure to herpes since only one fourth of women shedding virus at the time of delivery can be identified by routine cultures. The mode of delivery should therefore be based on the presence or absence of lesions at the time of confinement. Cesarean section should be reserved for patients with lesions or with prodromal symptoms of recurrent disease at the time of delivery. Patients with ruptured membranes and active genital lesions should also be delivered by cesarean section. The spectrum of HPV-related diseases in pregnancy is poorly understood. Many questions remain unanswered. It may not be practical to treat very large or extensive genital warts during pregnancy. A cesarean section may be the best choice in these cases. It may be premature to recommend cesarean section for delivery of all pregnant women with symptomatic genital HPV infection. More data are needed. We recommend laser ablation of condylomatous lesions when discovered during pregnancy. Laser vaporization is associated with minimal morbidity when used by experienced surgeons. Trichloroacetic acid is excellent for minimal disease or for treatment of recurrences in pregnancy. Since the immune system seems to play an important role in control of viral disease, we advise pregnant patients to adopt a lifestyle which promotes health. We advise a balanced diet, an appropriate exercise program, and an environment free of unnecessary stress. We suggest avoidance of cigarettes, drugs, and alcohol.

Female↗
PubMed2001

Complications of forefoot and midfoot fractures.

Complications of the forefoot and midfoot are not as common as injuries to the hindfoot. The problem areas that the author will focus on with these injuries will be open injuries, unstable fractures, slow or poor healing fractures, and neurovascular injuries. The author also will discuss the toes, metatarsals, tarsometatarsal, cuneiforms, and talonavicular areas. Because the forefoot and midfoot must support as much as four times the body weight, alterations caused by injury to the weightbearing surface can have significant consequences. Treatment rationale to maintain a sound weightbearing plantar surface will be discussed. Each region will be highlighted with respect to the complications that can occur. Anatomic alignment with stable fixation and good soft tissue coverage in an appropriate rehabilitation program are the principles that should be followed and discussed.

Acute Disease↗
PubMedDate not supplied

A comparative study of hearing screening procedures.

Three thousand, five hundred and ten children were screened with three pure-tone and two immittance techniques. All children in the study received follow-up audiological and medical examination within 2 days of the screening. Procedures, equipment, personnel, and environmental variables were controlled. The efficiency of the screening procedures is compared and the requirements for cost efficient and effective hearing screening are recommended. Reported is an indication of an optimal range of false positives emanating from a screening program and appropriate validators for auditory screening.

Acoustic Impedance Tests↗
PubMed1999

Naltrexone and communication skills in young children with autism.

OBJECTIVE: To evaluate the effect of naltrexone on communication skills of young children with autism. METHOD: Twenty-four children with autism, 3.0 to 8.3 years old (mean 5.1) who were living at home and attending appropriate school programs, participated in a randomized, double-blind, placebo-controlled, crossover trial. Naltrexone, 1.0 mg/kg, or placebo was administered daily for 2 weeks. Communication was evaluated from videotaped samples of seminaturalistic parent-child interaction. Child and parent language were assessed using similar measures. RESULTS: In this heterogeneous sample, the median number of words the child produced on placebo was 9.5 (range 0-124). The median proportion of utterances with echolalia was 0.16. No differences were found between the naltrexone and placebo conditions in any of the measures of children or parents' communication. Significant correlations were found between the child's number of words and developmental quotient (Spearman rho = 0.58, p = .003) and between the child's and parent's number of words (rho = 0.55, p = .005). CONCLUSIONS: Previous studies showed that naltrexone was associated with modest reduction in hyperactivity and restlessness in this group of children with autism. In this short-term study, the medication did not lead to improvement in communication, a core deficit of autism.

Autistic Disorder↗
PubMed1996

Physiology of the circadian system in animals and humans.

Virtually all organisms have developed an internal timing system capable of reacting to and anticipating environmental stimuli with a program of appropriately timed metabolic, physiologic, and behavioral events. The predominant biological rhythms coincide with the geophysical cycle of day and night-the circadian rhythms. The suprachiasmatic nuclei comprise the primary pace-maker in mammals, exhibiting the properties fundamental to a rhythm-generating structure. This article summarizes recent research that has elucidated mechanisms of signal transduction within the circadian system. The roles of various neurochemicals and hormones in transmitting the circadian timing signal are described. Properties of the circadian system, including photic and nonphotic entrainment, phase response curves, masking, and the intrinsic variability in the system are discussed.

Animals↗
PubMed1986

Histologic changes in gastroesophageal reflux.

Three aspects of the esophageal mucosal injury that occur in gastroesophageal reflux disease are discussed in this article. First, the histologic changes in the squamous epithelium-lined esophagus are variable. Some patients with reflux symptoms do not have histologic evidence of inflammatory cell infiltration within the mucosa, but rather may have more subtle effects of mucosal injury, namely, thickening of the basal regenerative layer, elongation of the papillae, or intraepithelial eosinophils. However, these more subtle findings often are merely confirmatory of other clinical indicators of gastro-esophageal reflux; they may have their most practical application to the research investigation of reflux disease. Second, the presence of esophageal mucosal inflammation may adversely affect lower esophageal sphincter function. This phenomenon can be demonstrated in the cat model. Whether it is operative in humans is unclear. Finally, the development of columnar metaplasia (Barrett's epithelium) is more than a histologic curiosity because this condition confers an increased risk of developing adenocarcinoma of the esophagus. Among several unanswered questions about Barrett's epithelium is what is an appropriate surveillance program for patients with Barrett's epithelium to detect the presence of, or predict the development of, cancer?

Adenocarcinoma↗
PubMed1994

Attitudes of surgical residents toward trauma care: a Canadian-based study.

Surgical residents (n = 330) registered in training programs in the province of Ontario, Canada were surveyed about their attitudes toward trauma care related issues. Questionnaires were returned by 48%. Overall, 84% felt that their clinical exposure to trauma was adequate; 78% noted that the emphasis placed on trauma topics in their educational programs was appropriate; 50% spend > 10% of their current clinical time in trauma care. Orthopedic residents (n = 43) were different; 79% devoted > 10% and 29% > or = 30% of their time to trauma. Future clinical activity in trauma as practicing surgeons was expressed by 83% of the trainees: 31% intended < 10%, 46% 10%-30%, and 6% > 30% of their future practices to be related to trauma. The major positive factors of trauma were the scope and excitement of trauma care. The major negative factors were the night/weekend activity and the time away from family. We are encouraged by the results of this survey in that a significant number of residents perceive trauma as a clinical endeavor to be incorporated into their future surgical practices.

Adult↗
PubMed1996

The os acromiale: another cause of impingement.

Impingement of the shoulder is a relatively common clinical entity. The os acromiale anomaly is an uncommon one (1-8%) but can be an important cause of the impingement syndrome. The most common place of nonfusion is between the meso- and meta-acromion. The key to diagnosis is a history and physical examination compatible with the impingement syndrome and appropriate radiologic studies (i.e., an axillary view or profile view or computed tomographic scan if necessary). After diagnosis, the initial treatment is conservative with rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), injections of corticosteroids in the subacromial space, and most importantly, an appropriate rehabilitation program. If unsuccessful, treatment should be planned based on the size of the unfused fragments. Small fragments (< 4 cm) may be removed by either arthroscopic or open means. Larger fragments may require an attempt at bone grafting and fixation since their removal may result in loss of strength of the deltoid.

Acromion↗
PubMed1994

Asymptomatic genitourinary Chlamydia trachomatis infection in women seropositive for human immunodeficiency virus infection.

OBJECTIVE: To evaluate the prevalence of asymptomatic Chlamydia trachomatis genitourinary infection in women with human immunodeficiency virus (HIV) infection. METHODS: The prevalence of asymptomatic chlamydial genitourinary infection in HIV-seropositive women was compared with both HIV-seronegative controls and women with unknown HIV status. Chlamydia trachomatis was isolated in cell culture from endocervical and urethral specimens. RESULTS: The prevalence of genitourinary C trachomatis infection among HIV-seropositive women was 18.3% (21 of 115), a rate significantly higher than in both HIV-negative women (11 of 136; P = .016) and controls with unknown HIV status (18 of 326; P = .0001). Crude odds ratios for endocervical and urethral chlamydial infection in HIV-seropositive women compared to HIV-seronegative controls were 2.6 (95% confidence interval [CI] 1.13-6.08) and 3.3 (95% CI 1.15-9.67), respectively. After adjustment for variables related to sexual habits, there was no difference in the risk of cervical C trachomatis infection between HIV-seropositive cases and HIV-seronegative controls (Mantel-Haenszel odds ratio 1.04, 95% CI 0.93-1.14; P = .41). Finally, in HIV-seropositive patients, both the severity of immunosuppression evaluated by CD4+, CD8+, and total lymphocyte counts and the detection of p24 HIV-related antigen did not correlate with the presence of chlamydial infection. CONCLUSIONS: Women infected with HIV are at high risk for asymptomatic genitourinary chlamydial colonization. To prevent a possible "epidemic" of pelvic inflammatory disease, appropriate screening programs and therapeutic strategies should be planned.

Adult↗
PubMed2004

Doctor-patient interaction for irritable bowel syndrome in primary care: a systematic perspective.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) is defined by specific validated symptom criteria and encompasses several different underlying pathophysiological mechanisms that express a common set of symptoms. However, IBS is poorly understood by patients. We aimed to explore how a diagnosis of IBS affects the interaction between patients and their physicians. METHODS: A comprehensive literature search for studies in the English language addressing this issue was conducted using Medline, PubMed, Cochrane Database, Psychinfo, Cinahl, Embase, Web of Science and manual recursive search of reference lists. Investigators reviewed and abstracted data from articles fulfilling our inclusion criteria: primary care patients, all ages, gender and ethnic groups diagnosed with IBS by a general practitioner (GP). RESULTS: Retrieval of 121 articles generated only four that met inclusion criteria. Research methods of three studies relied solely on qualitative subjective, anecdotal patient narratives, a bias in favor of patients' negative opinion, absence of objective physician diagnostic criteria, pre-testing questions for two studies, follow-up and patient verification of accounts for accuracy. The fourth study included objective physician diagnostic criteria, quantitative measures, a pre-testing questionnaire, and both patient and doctor perspectives. There was a disparity between patient and GP perception regarding the nature, severity and consequences of IBS in primary care, leading patients to perceive this interaction as one of dissatisfaction. The fourth study revealed GP management of IBS mostly meets patient's expectations areas of concern centered on etiology, diagnostic criteria and dietary advice. Disparity seems to lie with the physician, who needs to provide more trust, knowledge, and sympathy, create rapport and be forthcoming with information, while keeping information simple and understandable. Patient dissatisfaction stems from the actual information provided and how this is communicated. CONCLUSIONS: There is evidence that some IBS patients in primary care experience dissatisfaction and negative attitudes in GP interactions. Future research should take into account personality attributes and cross-situational stability in addition to methodological implications of studies. GPs may be the first avenue for IBS patients to vent their frustration, and appropriate education programs for optimal management of patients with IBS are needed in primary care.

Attitude of Health Personnel↗
PubMed2000

Diagnosis and prevention of hyponatremia at an ultradistance triathlon.

OBJECTIVE: To evaluate a method of medical care at an ultradistance triathlon, with the aim of reducing the incidence of hyponatremia. DESIGN: Descriptive research. SETTING: New Zealand Ironman triathlon (3.8 km swim, 180 km cycle, 42.2 km run). PARTICIPANTS: 117 of 134 athletes seeking medical care after the triathlon (involving 650 race starters). INTERVENTIONS: A prerace education program on appropriate fluid intake was undertaken. The number of support stations was decreased to reduce the availability of fluid. A body weight measurement before the race was introduced as a compulsory requirement, so that weight change during the race could be included in the triage assessment. An on-site laboratory was established within the race medical tent. MAIN OUTCOME MEASURES: Numbers of athletes and diagnoses, including the incidence of symptomatic hyponatremia (defined as symptoms of hyponatremia in association with a pretreatment plasma sodium concentration [Na] < 135 mmol/L); weight changes; and changes in [Na]. RESULTS: The common diagnoses in the 117 athletes receiving attention were exercise-associated collapse (27%), musculoskeletal complaints (26%), and dehydration (12%). There was a significant reduction in the number of athletes receiving medical care for hyponatremia, from 25 of the 114 athletes who received care in 1997 (3.8% of race starters) to 4 of the 117 athletes who received care in 1998 (0.6% of race starters). Mean weight change among athletes in the 1998 race was -3.1 kg, compared with -2.6 kg in 1997. CONCLUSION: A preventive strategy to decrease the incidence of hyponatremia, including education on fluid intake and appropriate placement of support stations, was associated with a decrease in the incidence of symptomatic hyponatremia.

Bicycling↗
PubMed1994

Using occupational mortality data for surveillance of work-related diseases of women.

A recently developed source of occupational mortality data from 28 states for the years 1979 through 1990 can be used to meet goals for the surveillance of women's work-related diseases. A proportionate cancer mortality ratio analysis is used to illustrate use of the data to address the goals of identifying previously unrecognized work-related disease and targeting consultation or health promotion programs to appropriate occupations. Strengths of the data include broad geographical coverage and coverage of all causes of death and numerous industries and occupations. The data set is current and very large, with annual additions. The data have certain limitations. Death certificate information collected regarding occupation and cause of death may not be accurate; furthermore, death certificates have little information on potential confounding factors, such as smoking.

Death Certificates↗
PubMed2003

Improved classification of recent HIV-1 infection by employing a two-stage sensitive/less-sensitive test strategy.

Current serologic techniques for the classification of recent HIV-1 infection produce some misclassifications, and, together with the loss to follow-up of individuals, results in decreased enrollment of HIV-infected persons into appropriate intervention programs. We report on the development of a sensitive/less sensitive (S/LS) test strategy that includes a rapid assay to quickly identify persons most likely to have recent infection, followed by an enzyme immunoassay (EIA) with exquisite specificity. The Uni-Gold Recombigen HIV rapid assay (UG; Trinity Biotech, Dublin, Ireland) was procedurally-modified and calibrated as an LS test to differentiate recent (<133 days) from established HIV infections using 178 samples from persons with known dates of infection. This method correctly classified 83.0% of recent infections, but with a high misclassification rate of persons with established infection. By performing the rapid test followed by a modified S/LS EIA, the positive predictive value of the combined results for recent infections was increased to 100%. This two-stage testing algorithm can result in an increased efficiency for the enrollment of recent infection cases over a standard EIA S/LS method alone due to provisional enrollment during an initial testing visit, and because of an increased accuracy for identifying truly recent infections. We conclude that the rapid S/LS assay provides a tool for capturing recent infection cases quickly and is particularly valuable in resource-limited settings, and that the two-stage strategy provides a more accurate identification of persons with recent HIV infection.

Algorithms↗
PubMedDate not supplied

Causes and treatment of burns from grease.

A large number of burns are sustained every year as the result of kitchen grease. A review of a 13-month period at the Joseph M. Still Burn Center in Augusta, Georgia, revealed 60 cases (9.4% of acute burn admissions). Forty-five (75%) of these patients were adults and 25% were children. There were 23 females and 37 males. Forty-two percent of the adults and 33% of the children had some percentage of third-degree injury. The average total body surface area burn in adults was 5.9% and in children 6.3%. There were no deaths in this series. Burns usually occurred as the result of scalds with grease while cooking. Spilling grease on children in the kitchen was a frequent problem. Burns due to ignition of grease was also a cause of injury. Most of the injuries were potentially preventable, and therefore the importance of burn appropriate safety programs is stressed.

Accidents, Home↗
PubMed2004

Improving quality through identifying inappropriate care: the use of guideline-based utilization review protocols in the Washington State Workers' Compensation System.

Utilization review (UR) is widely instituted to ensure that medical treatment is clinically necessary and appropriate. UR programs have been criticized for their failure to promote quality and for relying on proprietary review criteria that are rarely subject to external, independent evaluation or validation. In fashioning its UR program for workers' compensation, the Washington State Department of Labor and Industries sought to address these shortcomings. Working collaboratively with the state medical association, the Department of Labor and Industries developed treatment guidelines and then used these guidelines to formulate review criteria for UR. From 1993 through 1998, 100,005 UR reviews were conducted, half of which used the guideline-based review criteria. We analyzed these reviews to examine the patterns of denied requests. The overall denial rate for the guideline-based reviews was 7.3%. The highest denial rates were for thoracic outlet syndrome surgery (19.1%) and lumbar fusion (17.7%). The use of guideline-based UR protocols may improve the effectiveness of UR as a tool to identify potentially inappropriate care.

Adult↗
PubMed2005

Systems model guided balance rehabilitation in an individual with declarative memory deficits and a total knee arthroplasty: a case report.

BACKGROUND AND PURPOSE: The clinical management of functional mobility problems of individuals with primary musculoskeletal impairments is complicated by the concurrent presence of neurologic diagnoses. There are few case descriptions present in the literature of clinical decision making in the context of combined musculoskeletal and neurologic impairments. The purpose of this case report is to describe the application and use of a systems model of motor control for defining the appropriate rehabilitation program for an individual with both orthopedic and neurologic impairments leading to complaints of frequent losses of balance and falls during community mobility. DESCRIPTION: RG was a 67-year-old male referred to physical therapy because of balance problems. Review of his previous medical history revealed that he had suffered an anoxic brain injury 5 years earlier but had recovered full independence in activities of daily living (ADLs) with shortterm memory deficits being the primary residual effect of the brain injury. His balance problems developed only after having undergone a unilateral total knee arthroplasty 4 months prior to his initial physical therapy examination. Through examination and evaluation, RG's problems were determined to be consistent with postsurgery induced deconditioning coupled with anoxic brain injury related motor and cognitive deficits. INTERVENTION AND OUTCOMES: Physical therapy intervention focused on increasing RG's strength, decreasing the range of motion limitations in his lower extremities, balance exercises specific to his dynamic balance deficits, as well as increased amounts of practice to maximize procedural learning. Upon completion of his initial episode of care, RG's musculoskeletal impairments had improved; his scores on balance tests had increased, and his frequency of falls had decreased. Following his discharge, RG continued with a physical therapist designed secondary prevention program. DISCUSSION: This case report describes the successful rehabilitation of an individual with concurrent orthopedic and neurologic diagnoses. Important components of this rehabilitation course include: (1) the application of a systems model of motor control to guide clinical interventions, (2) the consideration of the effects of memory deficits on rehabilitation outcomes, and (3) the utilization of a secondary prevention program to prevent reoccurrence of balance problems.

Aged↗