Dyspnea management in alpha-1 antitrypsin deficiency: effect of oxygen administration.

BACKGROUND: A deficiency of alpha-1 antitrypsin (AAT) can lead to pulmonary disease in middle-aged adults in whom dyspnea management can be a significant issue. OBJECTIVE: The research addressed whether short-term oxygen (O2) administration during activities might decrease dyspnea and improve exercise performance in nonhypoxemic patients with emphysema caused by a deficiency of alpha-1 antitrypsin. METHOD: This was a double-blind, randomized crossover study of 31 subjects with a deficiency of AAT (mean + SD, age = 47 +/- 7), moderate emphysema and a resting PaO2 > 70 mm Hg. Oxygen saturation (SpO2), 6-minute walk distance, and end of walk dyspnea were measured during three practice walks and during walks with nasal cannula administration of O2 (intervention) and compressed air (control). RESULTS: Repeated measures analysis of variance (ANOVA) showed significant differences across the walks for SpO (F= 18.9, p = 0.0001), 6-minute walk distance (F= 6.07, p = 0.004), and dyspnea (F= 4.44, p = 0.016). Using post hoc contrasts, SpO2 was the only variable that differed between 20, and compressed air (p < 0.0001). There was, however, an interaction effect of gender with O2 for dyspnea (F= 9.85, p = 0.004). Mean values showed that men did not benefit from O2 (p = 0.87). However, women experienced less dyspnea when receiving O2 as compared with compressed air (p = 0.0025), and although not statistically significant, the lower dyspnea with O2 corresponded with an increased walk distance of 79 feet. CONCLUSIONS: O2 administration may be useful for reducing dyspnea during exercise in selected populations.

[Vaccination project for vocational students]. / Impfprojekt für Berufsschüler.

As part of a North-Rhine-Westphalian state project the district of Unna developed a vaccination programme for continuation schools in 1996. The reason for this programme realized for the first time in a vocational school, was a considerable lack of protection by vaccination in ninth year classes. The present results from the first vocational school show a significant lack of standard vaccination as well as boosters. To improve the current situation it will be necessary to authorize and enable the Public Health Services to carry out even more standard and indication vaccinations at secondary and vocational schools as well as at institutions for the handicapped.

Continuous quality improvement for continuity of care.

BACKGROUND: Continuous quality improvement (CQI) techniques have been used most frequently in hospital operations such as pharmaceutical ordering, patient admitting, and billing of insurers, and less often to analyze and improve processes that are close to the clinical interaction of physicians and their patients. This paper describes a project in which CQI was implemented in a family practice setting to improve continuity of care. METHODS: A CQI study team was assembled in response to patients' complaints about not being able to see their regular physician providers when they wanted. Following CQI methods, the performance of the practice in terms of provider continuity was measured. Two "customer" groups were surveyed: physician faculty members were surveyed to assess their attitudes about continuity, and patients were surveyed about their preferences for provider continuity and convenience factors. RESULTS: Process improvements were selected in the critical pathways that influence provider continuity. One year after implementation of selected process improvements, repeat chart audit showed that provider continuity levels had improved from .45 to .74, a 64% increase from 1 year earlier. CONCLUSIONS: The project's main accomplishment was to establish the practicality of using CQI methods in a primary care setting to identify a quality issue of value to both providers and patients, in this case, continuity of provider care, and to identify processes that linked the performance of health care delivery procedures with patient expectations.

Validity of the Family APGAR in patients with irritable bowel syndrome.

BACKGROUND: This study explores the validity of the Family APGAR (adaptability, partnership, growth, affection, and resolve), a test of family function, in persons with irritable bowel syndrome (IBS). Previous studies have reported increased stress in persons with IBS in the form of marital and interpersonal relationships. METHODS: The Family APGAR and the MMPI were completed by 198 persons, including 58 who sought care for IBS, 67 with IBS who did not seek care, and 73 who did not have the disorder. Family APGAR scores were compared for the three groups using analysis of variance. Multiple regression analysis was used to compare Family APGAR scores with both IBS group status and MMPI K and L scales. An odds ratio was calculated for the two groups with IBS. RESULTS: Mean Family APGAR scores were in the normal range for all three groups and differed by less than 1 point among the groups. The Family APGAR score did not differentiate among persons with IBS but was strongly related to the MMPI K score, a measure of defensiveness in test taking. CONCLUSIONS: The failure of the Family APGAR to detect the family dysfunction found by psychological interviewing and the strong relationship with the MMPI K scale lead us to question the construct validity of the APGAR. More sophisticated test construction is necessary to measure family dysfunction in patients who may tend to respond defensively.

Dermatologic adverse drug reactions in a family medicine setting.

To determine the prevalence of dermatologic adverse drug reactions in a family medicine outpatient practice setting, identify associated drug classes, and describe associated patient demographics and risk factors, we reviewed the charts of 557 patients in a university-based family medicine center who were diagnosed with a dermatologic condition. The study population included all patients diagnosed during a 1-year period. Thirty-five patients (6.3%) were identified as having dermatologic adverse drug reactions, of which the two most common types were exanthematous eruptions (n = 18 [51.4%]) and generalized erythroderma (n = 6 [17.1%]), with antibiotic use accounting for the majority (n = 21 [60.0%]) of reactions. Patient characteristics most commonly associated with a dermatologic adverse drug reaction were race (African-American), gender (female), and age (70 years and older). These data should provide insight into the types of cutaneous drug reactions commonly seen in community practice. Educational programs in all health-care disciplines, particularly medicine, pharmacy, and public health, that incorporate pharmacoepidemiologic strategies into their curricula are necessary to improve the overall process of monitoring and reporting of adverse drug reactions.

Group screening for cognition disorders in elderly persons.

Prevalence rates of cognitive impairment in persons aged 75 to 85 years are in the range of 10 to 19 percent, and 20 to 47 percent after the age of 85 years. Screening for dementia in persons aged 75 years and older would therefore identify a significant number of impaired persons. When screening for dementia, group testing would be more cost-effective than individual testing. We modified the Folstein Mini-Mental State examination (MMSE) for screening in a group setting. Community volunteers were tested at a geriatric health fair and at a special exercise class for the elderly. Subjects were subsequently tested individually using the standard Folstein MMSE. Analysis using Pearson correlation and a paired t-test indicates a high degree of concurrent validity between the two methods of administering the MMSE. This pilot study suggests that when screening elderly persons for dementia, a group-administered instrument can be a useful method to obtain a preliminary sample of cognitively impaired individuals.

Drug-related admissions to a family medicine inpatient service.

Admissions to a family medicine inpatient service were monitored retrospectively over a one-year period to determine the incidence of drug-related hospitalizations. Of the 293 admissions, 45 (15.4%) were identified as drug related; in 29 admissions (9.9%), a drug-related problem was identified as the primary cause of hospitalization. The two patient characteristics associated with a drug-related admission (DRA) were marital status (divorced) and age (older patients). The two most common types of DRAs were adverse drug reactions (17/45, 37.8%) and drug abuse (14/45, 31.1%), with alcohol being the most commonly abused agent. Adverse drug reactions were most commonly implicated in DRAs for patients over 70 years old, with drug abuse more evenly distributed among age groups. Educational programs that incorporate pharmacoepidemiologic strategies into all health care disciplines are necessary to address this public health issue.

Effect of an educational intervention on oral cephalosporin use in primary care.

The prescribing of oral cephalosporin antibiotics in an ambulatory setting was evaluated before and after an educational intervention. A drug utilization review used previously developed criteria to study the indications, processes, complications, and outcome for oral cephalosporins in the outpatient setting. Baseline data were collected for one year in the initial phase of the study. Only one prescription (1.4%) in the initial phase (0.96% of the total) met the criteria for appropriate use. However, during the year after an educational intervention by a clinical pharmacist explaining the proper use of oral cephalosporins, the prescribing of these agents decreased substantially. Educational strategies in medical schools and residency programs that seek to improve drug-prescribing behavior should combine drug utilization review programs with specific education about the appropriate use of pharmacologic agents.

Effect of case mix on provider continuity.

A random sample of 265 patient charts was selected to assess the degree of provider continuity at the University of North Carolina Family Practice Center from July 1, 1983, to June 30, 1984. Continuity was measured using usual provider continuity, the ratio of the number of visits with the assigned physician divided by total visits. Usual provider continuity rates varied as predicted for three types of visits: acute illness (0.55), chronic illness (0.76), and health maintenance (0.86). The average rate of usual provider continuity was 0.68. Case mix had a statistically significantly effect on provider continuity when comparing acute care with either chronic or health maintenance care (P less than .01). Because case mix is relevant and varies from site to site, a method of rate standardization was suggested using data on case mix from the National Ambulatory Medical Care Survey. Direct rate adjustment, a standard epidemiologic technique, would make continuity rates directly comparable for sites with different case mixes.

A technique for measuring family physician priorities for patient care.

Family physicians frequently choose which elements of patient care to emphasize in order to balance the idealized principles of medical care with the real constraints of medical practice. Colleagues at several residency programs agreed to help us to find out if these choices can be quantified and whether personal characteristics of respondents or the acuteness or chronicity of the patient's illness influence these priorities. Two sets of 15 forced-choice item pairs, one set in reference to chronic illness and one set in reference to acute illness, were used in the study. Responses from 346 family physicians and non-physician colleagues ranked six hypothetical elements of patient care for acute and chronic illness: continuity, comprehensiveness, family orientation, community orientation, coordination and prevention. The data were analyzed using the psychometric scaling technique of paired comparisons. The analysis yielded a set of rankings which showed that these choices were quantifiable and made with a high degree of individual consistency and greater intragroup agreement than would result from chance. Patterns of choice differed for acute and chronic illness in a manner consistent with observed clinical practice.

Inside the chart review.

The study on which this article is based was conducted at the University of North Carolina's Family Practice Center to analyze the content of teaching that occurred in the face-to-face chart review sessions. Data were collected from a sample of 276 chart reviews and processed by a microcomputer program that compiled reports of types of problems encountered by residents, topics of discussion pertinent to those problems, and learning needs defined as a result of those discussions. Reports were generated for faculty members nad residents, and summary reports were produced for the teaching encounters. This system of computerized data analysis can be used to identifying learning needs of residents and areas of teaching emphasis for faculty. The information can be used for educational planning and faculty development.