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PubMed2001

The magnitude of fear of adverse effects as a reason for nonparticipation in drug treatment: a short review.

The extent and reasons for nonparticipation in preventive drug intervention programs were reviewed. Special attention was paid to the magnitude of "steroid-phobia" in cases of early treatment of asthma patients, with inhaled steroids. A Medline search yielded 11 studies. One study addressed the topic of treatment, with inhaled steroids, in early asthma patients. Nonparticipation rates to "early" drug treatment ranged from 0.3% to 48%. Fear of adverse effects and lack of knowledge about the treatment were given as the most important reasons for nonparticipation. Educational measures to increase knowledge about the drug were advised by most of the authors. In the asthma study a specific "steroid-phobia" was not indicated, possibly due to the continuous education about the steroid treatment throughout the study. Proper and repeating information about the safety and the minimal adverse effects of preventive drug treatment, especially inhaled steroids, seems essential to improve the treatment rate.

Administration, Inhalation↗
PubMed2001

Etiology, reasons for hospitalization, risk classes, and outcomes of community-acquired pneumonia in patients hospitalized on the basis of conventional admission criteria.

We performed an observational analysis of prospectively collected data on 533 nonseverely immunosuppressed adult patients who were hospitalized for community-acquired pneumonia on the basis of conventional admission criteria. For this population, we correlated etiology, reasons for admission, and outcomes using the Pneumonia Severity Index (PSI), to identify major discrepancies between the PSI risk class and the conventional criteria for deciding the site of care. PSI classes and corresponding mortality rates were as follows: class I, 51 patients (0%); class II, 62 (2%); class III, 117 (3%); class IV, 198 (10%); and class V, 105 (29%). We identified significant discrepancies between both methods. Overall, 230 patients (40%) who were hospitalized according to conventional criteria were assigned to low-risk classes. Of these 230 patients, 137 (60%) needed supplementary oxygen or had pleural complications; for the remaining patients, there were no irrefutable reasons for admission. This latter group deserves prospective evaluation in randomized studies that compare ambulatory and in-hospital management.

Adolescent↗
PubMed2002

Level of diagnostic confidence, accuracy, and reasons for mistakes in teleradiology for minor injuries.

The objective of this study is to determine whether eliminating uncertainty in diagnosis improves accuracy in teleradiology for remote trauma management and to assess the correlation between the probable reason for the mistake and the level of confidence. An emergency physician interpreted 2133 radiological series transmitted from a community hospital to an emergency department using videoconferencing equipment. He marked his level of confidence as 1 = sure positive; 2 = fairly sure positive; 3 = unsure; 4 = fairly sure negative; 5 = sure negative. The emergency physician also entered free-text comments, e.g., feeling tired, to enable a better understanding of what was happening. The accuracy, sensitivity, and specificity were 97.3% (98.6%), 94.48% (96.72%), and 98.63% (99.42%), respectively. Figures in brackets represent the 93.5% of cases in which the level of confidence was graded as sure. Boredom and hurry were the main reasons identified for mistakes. Reducing uncertainty in diagnosis may improve the accuracy of screen interpretation. This first series must be reproducible by others before any general use of such systems can be made for primary diagnosis. American College of Radiology standards must be met.

Adolescent↗
PubMed1998

HIV type 1 V3 serotyping of Tanzanian samples: probable reasons for mismatching with genetic subtyping.

HIV-1 V3 serotyping is used to classify immunodeficiency viruses on the basis of antibody binding to V3 peptides derived from env genetic subtypes. Although it shows a reasonable overlap, it has been reported to be distinct from viral genetic subtypes. The aim of this study is to determine the feasibility of HIV-1 serotyping to predict genetic subtypes in an East African setting, where multiple HIV-1 subtypes have coexisted for many years. HIV-1 genetic subtypes of 86 AIDS patients in Mbeya Town, southwest Tanzania, were determined, using env nucleic acid sequencing as the basis for comparison. Those data were compared with V3 serotyping results obtained by four different methodologies. Four HIV-1 genetic subtypes were identified, including A (25, 29%), C (47, 55%), D (13, 15%), and G (1, 1%). The sensitivity and specificity of those serotyping assays varied considerably: sensitivity for genetic subtype A (40-48%), C (52-96%), and D (9-31%); and specificity for genetic subtype A (77-95%), C (46-63%), and D (97-100%). We further tried to identify reasons for the discrepancies between serotyping results and genetic subtypes. By means of logistic regression analysis three amino acid residues within the V3 loop (positions 12, 13, and 19; V, H, and A for serotype A, I, R, and T for serotype C) were found to be most important for antibody binding; a deviation from the subtype-specific amino acids was highly related to mismatched results. In addition, we have shown that phenetic analysis of V3 amino acid sequence data could be used to predict the majority of V3 serotypes (93-94%). Our data demonstrated that for the majority of specimens HIV-1 V3 serotyping results closely match the subtype of the analyzed sample as revealed by the V3 loop amino acid sequence. However, our data demonstrate that HIV-1 serotyping is not sufficiently accurate to predict genetic subtypes in Tanzania, where subtypes A, C, D, and G are circulating. This was due to highly similar amino acid sequences throughout the prevalent genetic subtypes, which caused the inability of HIV-1 V3 serotyping to differentiate subtype A from C as well as D from C. Instead, the serotyping results reflect the frequency distribution of V3 serotypes. To investigate HIV-1 genetic subtypes in population-based studies in this African setting additional or modified algorithms are needed.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Reasons for stopping antiretrovirals used in an initial highly active antiretroviral regimen: increased incidence of stopping due to toxicity or patient/physician choice in patients with hepatitis C coinfection.

Low adherence and toxicities among HIV-positive patients starting highly active antiretroviral therapy (HAART) can lead to discontinuation of therapy and treatment failure. Little is known about hepatitis C (HCV) status and discontinuation of HAART. Poisson regression was used to determine factors related to discontinuation of any part of an initial HAART regimen due to treatment failure (TF) or toxicities and patient/physician choice (TOX), and to investigate the relationship between HCV and discontinuation of a HAART regimen in 1198 patients staring HAART after 1999 from the EuroSIDA study. At 1 year after starting HAART, 70% of patients remained on their original regimen, 24% had changed, and 6% were off all treatment. The most frequent reason for discontinuation was toxicities (30.4%). There was no change over time in the proportion of patients discontinuing after stratification by reason for discontinuation (p = 0.18). Of patients 190 stopped at least one antiretroviral drug used in their initial HAART regimen due to toxicities; the toxicity reported did not vary according to HCV status (p = 0.90). Anti-HCV seropositive patients had a higher incidence of discontinuation due to TOX (IRR 1.46, 95% CI 1.13-1.88, p = 0.0042) compared to patients without HCV. Patients with HCV were more likely to discontinue all or part of their HAART regimens due to toxicity or patient/physician choice. Managing adverse events must remain a key intervention in maintaining HAART. There is a need for further studies to describe the relationship between HCV, specific antiretrovirals, and different treatment strategies.

Anti-HIV Agents↗
PubMed2005

Surviving, relieving, repairing, and boosting up: reasons for using complementary/alternative medicine among patients with advanced cancer: a thematic analysis.

BACKGROUND: Patients with advanced cancer commonly use complementary and alternative medicine (CAM), however, little research has been undertaken on their reasons for doing so. OBJECTIVES: This study sought to identify in detail the reasons for using CAM among patients with advanced cancer. DESIGN: Qualitative study using semistructured interviews. SETTING/SUBJECTS: Interviews conducted with 39 patients who were participating in a longitudinal study exploring the levels of palliative care received by patients with cancer in Brisbane, Australia. All participants were receiving or had received conventional cancer treatments. Sampling was based on the potential richness of the information provided by the participants and the variability in terms of the regularity of CAM use. RESULTS: Most participants self-treated with CAM and perceived CAM modalities as complementary rather than alternative to conventional cancer treatments. Within this context, this group of people used CAM to prolong their survival, palliate their symptoms or alleviate the side effects of conventional cancer treatments, detoxify their bodies, boost immunity and enhance their overall quality of life. CONCLUSION: When facing an incurable life-threatening illness such as advanced cancer, the decision to use CAM is a pragmatic one. Clinicians need to be aware of what their patients are doing and their rationale for doing so. Screening for physical, emotional, and spiritual discomfort associated not only with the disease but with some of the cancer treatments needs to be given a prominent place in the clinical encounter. Patients with cancer want to know more about how to maintain or improve their quality of life during and after surgery, radiation, or chemotherapy. Fostering an open non-judgmental communication with patients is part of good clinical practice.

Adult↗
PubMed2006

Is there no place like home? Caregivers recall reasons for and experience upon transfer from home hospice to inpatient facilities.

OBJECTIVE: To describe caregivers' reasons for transfer from home hospice to inpatient facilities, preferences for site of care and death, and their experiences during these transfers. DESIGN: Retrospective qualitative analysis of interviews with caregivers of deceased hospice patients who had undergone transfer. SETTING: A university-affiliated community hospice provider. SUBJECTS: Caregivers of deceased hospice patients who transferred to an acute care hospital, a freestanding inpatient hospice facility, or a nursing home while enrolled in hospice and died between January 2003 and February 2004. MEASUREMENTS: A semistructured interview protocol was developed and used for all interviews. Interviews were coded for reasons for transfer, preferences for site of care and death, and experience upon transfer using a grounded theory approach. RESULTS: Patients transferred because of an acute medical event, an uncontrolled symptom, imminent death, or inability to provide needed care safely at home. Although all caregivers expressed a strong preference for care at home, other concerns such as pain and symptom control, safety, and quality and quantity of life became more important with time. We found significant variation in specific preferences regarding care and site of death. Satisfaction with care at the transfer facilities was determined by clarifying goals of care, following treatment preferences, providing personalized care, and the patient's environment. CONCLUSIONS: Hospice patients usually transfer to facilities to accomplish goals consistent with good end-of-life care. We can improve their experience by treating patients and their caregivers as unique individuals, exploring and respecting treatment preferences, and creating a pleasant physical environment.

Adult↗
PubMed2002

Recruitment of anterior dorsolateral prefrontal cortex in human reasoning: a parametric study of relational complexity.

Reasoning and problem solving depend on the ability to represent and integrate complex relationships among stimuli. For example, deciding whether an animal is dangerous requires integrating information about the type of animal, its size, its distance from oneself, and one's proximity to shelter. Relational complexity increases with the number of such interdependent elements that must be simultaneously considered to solve a problem. We used functional magnetic resonance imaging to identify brain regions that respond selectively in processing high levels of relational complexity. Performance on nonverbal reasoning problems in which relational complexity was varied parametrically was compared with performance on control problems in which relational complexity was held constant while difficulty was manipulated by adding distractor forms to the problems. Increasing complexity and adding distractors both led to increased activation in parietal and in dorsolateral prefrontal cortex, with high levels of relational complexity selectively activating anterior left prefrontal cortex. Our data provide evidence that brain regions specific to integrating complex relations among stimuli are distinct from those involved in coping with general task difficulty and with working-memory demands.

Adult↗
PubMed2004

Analogical reasoning and prefrontal cortex: evidence for separable retrieval and integration mechanisms.

The present study examined the contributions of prefrontal cortex (PFC) subregions to two component processes underlying verbal analogical reasoning: semantic retrieval and integration. Event-related functional magnetic resonance imaging data were acquired while subjects performed propositional analogy and semantic decision tasks. On each trial, subjects viewed a pair of words (pair 1), followed by an instructional cue and a second word pair (pair 2). On analogy trials, subjects evaluated whether pair 2 was semantically analogous to pair 1. On semantic trials, subjects indicated whether the pair 2 words were semantically related to each other. Thus, analogy--but not semantic--trials required integration across multiple retrieved relations. To identify regions involved in semantic retrieval, we manipulated the associative strength of pair 1 words in both tasks. Anterior left inferior PFC (aLIPC) was modulated by associative strength, consistent with a role in controlled semantic retrieval. Left frontopolar cortex was insensitive to associative strength, but was more sensitive to integration demands than was aLIPC, consistent with a role in integrating the products of semantic retrieval to evaluate whether distinct representations are analogous. Right dorsolateral PFC exhibited a profile consistent with a role in response selection rather than retrieval or integration. These findings indicate that verbal analogical reasoning depends on multiple, PFC-mediated computations.

Adult↗
PubMed2005

Ethical reasoning and mental health services with deaf clients.

Ethical problems encountered by mental health practitioners working with deaf clients are often complex and involve issues not fully addressed in professional codes of ethics. A principles-based ethical reasoning process can assist in resolving many of these ethical concerns. Principles such as beneficence, nonmaleficence, autonomy, fairness, integrity, and respect are found in the ethical codes of many disciplines; these can also create a common language or reference point when professionals from different fields attempt to deal with shared problems. This article discusses some applications of these principles in working with deaf individuals and proposes an ethical decision-making process that can provide a framework for ethical reasoning in thinking through complex problems.

Clinical Competence↗
PubMed2005

Reasons for terminating an exercise test provide independent prognostic information: 2014 apparently healthy men followed for 26 years.

AIMS: We wanted to study whether reasons for terminating an exercise test might influence long-term mortality of healthy men, a previously unreported subject. METHODS AND RESULTS: During 1972-75, 2014 men aged 40-59, free from somatic diseases and not using drugs, underwent an examination programme including case history, clinical examination, various blood tests, and a symptom limited exercise ECG-test. The following reasons for test termination were noted: impaired breathing, lower limb fatigue, exhaustion (=combined lower limb fatigue and impaired breathing), high heart rate, abnormal blood pressure response, heart arrhythmias, increasing chest pain during exercise, marked ST-depressions during the test, and refusal to continue. Follow-up was 26 years. When adjusting for age, men who stopped exercising exclusively because of impaired breathing (n=178) had a 1.86-fold increased risk (95% CI 1.34-2.60; P=0.0002) of dying from coronary heart disease (CHD), a 1.64-fold increased risk (95% CI 1.32-2.03; P<0.0001) of dying from any cause, and a 3.47-fold increased risk (95% CI 2.24-5.12; P<0.0001) of dying from pulmonary causes compared with men having defined exhaustion (n=1376). After adjustment for age, smoking, total serum cholesterol, fasting blood glucose, systolic blood pressure, and physical fitness, impaired breathing remained significantly associated to an increased risk of dying from CHD, pulmonary disease, or any causes. CONCLUSION: Healthy men who stop bicycle exercising only because of impaired breathing have a high long-term CHD-, pulmonary-, and total-mortality, and such men may need further diagnostic scrutiny and follow-up.

Adult↗
PubMed1992

Fever in general practice. II. Reasons for encounter, management and duration of fever conditions.

A sample of 80 direct and 36 telephone encounters for fever was established in 1988 as part of a Norwegian study on fever as a clinical problem in general practice. Reasons for encounter (ICPC) and clinical examinations were recorded along with clinical laboratory tests, treatment, management and follow up (IC-Process-PC). The doctors assessed the diagnostic process by means of visual analogue scale. Duration of the fever conditions was estimated through a postal questionnaire. Patients with direct encounters presented a wide range of reasons for the encounters. Fever was the most frequent single presenting complaint (31%). The general practitioners put major emphasis on the clinical examinations. They prescribed drugs in 68% of the direct encounters. Seventy per cent of the prescriptions were general systemic anti-infectives. Penicillin accounted for 58% of antibiotics. Six (8%) patients were hospitalized, and three (4%) were referred to a specialist. The mean time until complete recovery was 15 days for direct and 19 days for telephone encounters. Fever may be a sign even when it is not a presenting complaint. Major emphasis is probably put on the clinical examination of febrile patients because of the complexity of symptoms and the wide range of diagnoses associated with fever.

Anti-Infective Agents↗
PubMed2003

Longevity and health care expenditures: the real reasons older people spend more.

OBJECTIVES: In this study, we investigated the relative contributions of both age and time to death to health care expenditures for elderly Medicare beneficiaries. We also analyzed differences in expenditure patterns by age and time to death for various service types and payers. METHODS: We conducted graphical analysis of person-month level data on 25,994 elderly persons from the 1992-1998 Medicare Current Beneficiary Survey Cost and Use files. RESULTS: Monthly health care expenditures for elderly people increase substantially with age primarily because mortality rates increase with age and health care expenditures increase with closeness to death. Time to death is the main reason for higher inpatient care expenditures, whereas aging is the main reason for higher long-term care expenditure. DISCUSSION: Both increases in the absolute number of elderly persons and in their longevity will increase future Medicare expenditures. Yet, the expected increase in per person health care expenditures caused by greater longevity of Medicare beneficiaries will be less than expected because of the concentration of expenditures at the end of life rather than during extra years of a relatively healthy life. The latter conclusion may be altered, however, because of other underlying considerations, such as technological change.

Age Factors↗
PubMed2003

Preconception sex selection for non-medical reasons:a representative survey from Germany.

BACKGROUND: Preconception sex selection for non-medical reasons raises serious moral, legal and social issues. The main concern is based on the assumption that a freely available service for sex selection will distort the natural sex ratio and lead to a severe gender imbalance. However, for a severe gender imbalance to happen, at least two conditions have to be met. First, there must be a significant preference for children of a particular sex, and second, there must be a considerable demand for preconception sex selection. To ascertain whether or not these two conditions are met, we have conducted a survey in Germany. METHODS: As a representative sample of the German population, 1094 men and women aged 18-45 years were asked about their gender preferences and whether or not they could imagine selecting the sex of their children through flow cytometric separation of X- and Y-bearing sperm followed by intrauterine insemination. RESULTS: 58% of respondents stated that they do not care about the sex of their offspring. 30% wish to have a family with an equal number of boys and girls. 4% would like to have more boys than girls, 3% more girls than boys, 1% only boys and 1% only girls. For first-borns, however, there is still a preference for boys over girls. While 75.6% claimed to have no gender preference, 14.2% would like their first child to be a boy and 10.1% would like their first child to be a girl. Whereas 6% could imagine taking advantage of preconception sex selection, 92% found this to be out of the question. Even in the hypothetical case that a medication for sex selection were ever to become available, 90% stated that they would not want to use it. CONCLUSION: Given that a majority does not seem to care about the sex of their offspring and only a minority seem to be willing to select the sex of their children, a freely available service for preconception sex selection for non-medical reasons is rather unlikely to cause a severe gender imbalance in Germany.

Adult↗
PubMed1998

Clinical reasoning in the evaluation and management of undiagnosed chronic hip pain in a young adult.

This case report describes the clinical reasoning used to manage chronic left hip pain in a 21-year-old woman who was recreationally active. The patient had a history of possible congenital hip dysplasia (CHD) and known recurrent lateral (external) patellar subluxations on the left side. She complained of experiencing hip pain when walking, sitting, playing soccer, and doing "step aerobics." Hip range of motion (ROM), muscle force, and joint stability problems were assessed. Abnormal movement patterns were observed during gait and step aerobics. Intervention was based on the working hypothesis that periarticular stiffness and muscle weakness from earlier trauma were superimposed on joint instability from CHD. Following intervention, the patient's hip ROM and muscle force improved concurrently with reduction of hip pain, increased ability to participate in recreational activities, and improvement in the movement pattern during step aerobics. An eclectic approach to analysis of the problem was used, combining data unique to the patient with knowledge of CHD and concepts proposed by Cyriax, Maitland, Sahrmann, and others. The clinical reasoning used to establish a basis for treatment and its limitations are discussed.

Adult↗
PubMed1993

Morbidity and psycho-social reasons for absence among high school students in Holon, Israel.

Absence of children from school for either health or social reasons, can serve as a parameter for general well-being. Minimal school absence rates reflect a good physical and psycho-social status. The present survey compares the rate of absenteeism as a result of various diseases among 972 adolescent pupils in a high school. The average absenteeism of a pupil during the year is 8.67 +/- 2.93 days. Medical circumstances responsible for absenteeism are discussed. The incidence of absenteeism in chronic diseases is 5.5 times greater than that of healthy children. The ratio of absence caused by medical reasons decreases with maturity, probably as a result of increasing efficiency in coping with the diseases together with stronger motivation for studies. The school physician cognizant of pupil absenteeism can fulfil a valuable role in the early recognition and treatment of psychosocial pathologies.

Absenteeism↗
PubMed1982

Reasons for failure of MOPP to cure Hodgkin's disease: The importance of dose and schedule.

Thirty-six patients with advanced Hodgkin's disease who were treated primarily with MOPP were evaluated to determine the reasons for MOPP failure. Complete remission was achieved in 22 (61%) of the patients, and the predicted 5-year survival rate for all patients is 60%. Reasons for the failure of MOPP to cure patients in this series included: 1) Idiosyncratic drug reactions in 2 patients (6%). MOPP was discontinued after one cycle because of drug-related hepatitis or skin rash; 2) Resistant disease in 8 patients (22%). Primary treatment failure was significantly associated with the presence of B symptoms (p = .005) and age greater than 40 years (p = .02); 3) Death from complicating infection in 5 patients (14%). Four patients died without evidence of Hodgkin's disease while responding to MOPP from pneumocystis pneumonia, viral pneumonia, bacterial pneumonia, or bacterial septicemia. One patient died in complete remission from sudden, overwhelming sepsis; 4) Relapse from complete remission in 4 patients (11%). All patients who relapsed had deviations from the planned dose or timing of MOPP. Remission duration was shorter (p = .06) in patients with documented deviations in MOPP administration than in patients without such changes. It appears that new treatment approaches are needed for patients with B symptoms, and that failure to deliver MOPP on schedule in the planned dose increases the risk of relapse.

Adolescent↗
PubMed2001

Laparoscopic surgery for Crohn's disease: reasons for conversion.

OBJECTIVE: To examine factors influencing conversion from a laparoscopic to an open procedure in patients requiring surgery for Crohn's disease. SUMMARY BACKGROUND DATA: Laparoscopic management of patients with complications of Crohn's produces better outcomes than traditional open approaches, but it is difficult to determine before surgery who will be amenable to laparoscopic management. In this series, a laparoscopic approach was offered to virtually all patients to determine reasons for laparoscopic failure. METHODS: Data regarding patients who underwent attempted laparoscopic procedures for Crohn's (January 1993 to June 2000) were collected prospectively. The bowel was mobilized laparoscopically and extracorporeal anastomoses were performed. Conversion to open surgery was defined as creation of an incision of more than 5 cm. RESULTS: One hundred ten patients (age 37 +/- 1.1 years, 58% female) underwent 113 attempted laparoscopic interventions. Indications for surgery included obstruction (77%), failure of medical management (35%), fistula (27%), and perineal sepsis (4%). Sixty-eight procedures (60%) were completed laparoscopically. Procedures completed laparoscopically included ileocecectomy (n = 46), small bowel resection (n = 22), fecal diversion (n = 7), intestinal stricturoplasty (n = 7), resection of prior ileocolonic anastomosis (n = 5), segmental colectomy (n = 1), and lysis of adhesions (n = 1). Forty-five procedures (40%) were converted as a result of adhesions (n = 21), extent of inflammation or disease (n = 9), size of the inflammatory mass (n = 7), inability to dissect a fistula (n = 5), or inability to assess anatomy (n = 3). Factors associated with conversion were internal fistula as an indication for surgery, smoking, steroid administration, extracecal colonic disease, and preoperative malnutrition. In laparoscopic patients, mean times to passage of flatus and first bowel movement were 3.6 +/- 0.2 days and 4.4 +/- 0.2 days, respectively. Mean time to discharge was 6 +/- 0.2 days. CONCLUSIONS: Attempted laparoscopic management is safe and effective if there is an appropriate threshold for conversion to an open procedure. Conversion factors identified in this study largely reflect technical challenge and severity of disease. Patients taking steroids and those with known fistulas or colonic involvement threaten laparoscopic failure, but many of these patients can be managed laparoscopically and have better outcomes. By understanding the reasons for conversion, it is hoped that the chances of laparoscopic success can be improved by modifying standard preoperative medical management or using additional technological capabilities (e.g., robotics).

Adult↗