ABSTRACT
The efficacy of the albumin/creatinine ratio (ACR) measurement in detection of significant proteinuria when performed in a high-risk antenatal clinic was compared with automated dipstick, protein/creatinine ratio (PCR), and 24-hour urine protein measurements. Both the ACR (DCA 2000) and PCR were strongly predictive for the presence or absence of significant proteinuria, with positive likelihood ratios (LRs) of 27.4 and 31.6 and negative LRs of 0.0 and 0.1, respectively. Both the ACR (DCA 2000) and PCR are effective tests for both identifying and excluding significant proteinuria in the outpatient setting. The ACR (DCA 2000) has the advantage of providing an immediate result.
Subject(s)
Ambulatory Care/standards , Point-of-Care Systems/standards , Pregnancy Complications/diagnosis , Proteinuria/diagnosis , Albuminuria/diagnosis , Creatinine/urine , Female , Humans , Pregnancy , Reagent Kits, Diagnostic , Sensitivity and SpecificityABSTRACT
SETTING: Urban community and jail. OBJECTIVES/DESIGN: Evaluate outcome and process of an extensive tuberculosis contact investigation, including completion of treatment of latent TB infection (TLTBI). RESULTS: Between April 2000 and September 2001, 18 epidemiologically-linked tuberculosis cases were identified; 15 were culture-confirmed, all with a matching 14-band DNA fingerprint pattern. The source case had cavitary pulmonary disease and had been incarcerated 4 months prior to diagnosis. Sixty-six of 67 (99%) community contacts and 221/344 (64%) jail contacts were evaluated. The presumed new infection rate was 56% for community contacts (11 cases, 25 tuberculin skin test [TST] positive) and 20% for jail contacts (6 cases, 32 TST converters). Screening results for 113 (33%) jail contacts were obtained in the jail TST registry upon rearrest. All identified cases completed treatment. Of 22 community contacts initiating TLTBI, 11 completed (44% of infected, 50% of initiators). Of 32 infected jail contacts, 12 initiated TLTBI (all who remained incarcerated), and 10 completed (31% of infected, 83% of initiators). None of 20 additional in-fected jail contacts, all of whose TST conversions were identified with re-arrest data, were subsequently located. Two additional related cases have been identified as of October 2003. CONCLUSIONS: Close health department/corrections collaboration facilitated this extensive contact investigation, which identified high Mycobacterium tuberculosis transmission rates and controlled the outbreak. Numerous contacts were identified and screened, but rates of treatment completion for infected contacts were low. Novel strategies are needed to maximize the number of infected contacts who are not only identified and evaluated, but completely treated.
Subject(s)
Carrier State/diagnosis , Contact Tracing , Outcome and Process Assessment, Health Care , Prisons , Tuberculosis/diagnosis , Tuberculosis/transmission , Urban Population , Adolescent , Adult , Aged , Baltimore , Carrier State/prevention & control , Child , Child, Preschool , Female , Humans , Infant , Male , Middle Aged , Tuberculin Test , Tuberculosis/prevention & controlABSTRACT
Worldwide, the case-fatality rate of smear-positive pulmonary tuberculosis among persons on treatment is 3.8%. We assessed the case-fatality rate among such patients in Baltimore between January 1993 and June 1998. Tuberculosis incidence was < 17/100 000 population, and 99% of patients received directly observed therapy. Of 174 patients, 42 (24%) died on treatment. Patients who died were older (mean age 62 vs. 47 years; P < 0.001) and were more likely to have underlying medical conditions. In multivariate analyses, older age, diabetes mellitus, and renal failure were independently associated with an increased risk of death. With effective control, tuberculosis may become concentrated in older persons with chronic diseases and be associated with high case-fatality rates. In such settings, acceptable treatment success rates may need to be revised.
Subject(s)
Antitubercular Agents/therapeutic use , Mortality , Outcome Assessment, Health Care/statistics & numerical data , Tuberculosis, Pulmonary/mortality , Tuberculosis, Pulmonary/prevention & control , Age Factors , Aged , Antitubercular Agents/administration & dosage , Baltimore/epidemiology , Cohort Studies , Directly Observed Therapy/statistics & numerical data , Female , Humans , Incidence , Male , Middle Aged , Retrospective StudiesSubject(s)
Clinical Trials as Topic/economics , Conflict of Interest , Research Support as Topic , Clinical Trials as Topic/standards , Conflict of Interest/legislation & jurisprudence , Industry/economics , Investments/standards , Truth Disclosure , United States , United States Food and Drug AdministrationSubject(s)
Equipment Reuse , Equipment and Supplies, Hospital , Ethics, Professional , Cost Savings , Disposable Equipment , Equipment Design , Equipment Failure , Equipment Reuse/economics , Equipment Reuse/legislation & jurisprudence , Equipment Reuse/standards , Equipment and Supplies, Hospital/economics , Equipment and Supplies, Hospital/standards , Hospital Costs , Humans , Risk Factors , Sterilization , Truth Disclosure , United States , United States Food and Drug Administration/legislation & jurisprudenceSubject(s)
Scientific Misconduct , History, 20th Century , Humans , Interinstitutional Relations , National Institutes of Health (U.S.)/legislation & jurisprudence , Scientific Misconduct/legislation & jurisprudence , United States , United States Office of Research Integrity/legislation & jurisprudenceSubject(s)
Audiovisual Aids , Biomedical Engineering/education , Ethics, Professional , Learning , Videotape Recording , Adult , Anxiety/psychology , Attitude , Conflict, Psychological , Decision Making , Goals , Humans , Interpersonal Relations , Learning/physiology , Motivation , Problem Solving , Teaching/methods , Truth DisclosureSubject(s)
Suicide, Assisted , Adult , Humans , Male , Oregon , Suicide, Assisted/legislation & jurisprudenceSubject(s)
Ethics, Medical , Patents as Topic , Philosophy, Medical , Technology Assessment, Biomedical , Animal Rights , Animals , Animals, Genetically Modified , Commodification , Ecosystem , Europe , Genetic Engineering , Humans , Plants, Genetically Modified , Public Policy , Risk Assessment , Social Values , United StatesSubject(s)
Ethics, Medical , Organ Transplantation , Animals , Brain Death , Developing Countries , Humans , Marketing of Health Services , Morals , Organ Transplantation/economics , Physician-Patient Relations , Social Responsibility , Tissue Donors/supply & distribution , Transplantation, Heterologous , United StatesABSTRACT
The Björk-Shiley convexo-concave artificial heart valve has a significant risk of failure which is often fatal.Elective explantation has a mortality of approximately 5%. Follow-up studies provide the basis for clinical decision making whether or not to explant the valve. So far, the contribution of technical, organizational, ethical, and professional considerations to success or failure of any risk control strategy have hardly been considered. A string of six consecutive deaths due to valve failure initiated a systemic rather than an epidemiological analysis of the problem. Systemic failure analysis not only yields sound explanations, but also warrants acceptable solutions on the basis of assembling multidisciplinary knowledge and experience.
ABSTRACT
It is difficult to study failed medical devices because of a lack of data. Routine device retrieval and analysis (DRA) is essential to performance evaluation, which, in turn, is essential to good patient care. We argue for the development of a national DRA program and medical device database and discuss the major ethical and policy issues associated with this proposal.
Subject(s)
Equipment Failure , Ethics, Medical , Government Regulation , Product Surveillance, Postmarketing , Consumer Product Safety/legislation & jurisprudence , Databases, Factual , Disclosure , Equipment Safety , Federal Government , Humans , Program Development , Prostheses and Implants/adverse effects , Prostheses and Implants/standards , United States , United States Food and Drug Administration , Voluntary ProgramsABSTRACT
The following actual cases illustrate a disturbing trend in medicine, one that raises ethical issues that are especially important when considering how economic incentives and disincentives may affect the practice of medicine.
Subject(s)
Civil Rights , Ethics, Professional , Hospital-Physician Relations , Peer Review, Health Care/standards , Withholding Treatment , California , Disclosure , Managed Care Programs , Patient Advocacy , Prejudice , Professional Misconduct , United States , WhistleblowingSubject(s)
Conflict of Interest , Disclosure , Duty to Warn , Heart Valve Prosthesis , Information Dissemination , Patient Advocacy , Risk Assessment , Commerce/legislation & jurisprudence , Equipment and Supplies/standards , Federal Government , Government Regulation , Heart Valve Prosthesis/standards , Humans , Legislation, Medical , Paternalism , Prosthesis Design , Prosthesis Failure , United States , United States Food and Drug AdministrationABSTRACT
Psychoanalytic practice can benefit from a coherent theory of cognition that is more comprehensive than, but which includes the related concepts of primary/secondary processes. For reasons not yet understood, cognition has not received the continuing attention it deserves in psychoanalytic theory. As demonstrated, Piaget's empirical studies of cognition can potentially help the practicing psychoanalyst to clinically differentiate those patients suitable for psychoanalytic treatment. It appears that Piaget's theory may hold greater utility for psychoanalysis than has been evidenced to date and analysts may be able to eventually describe defensive operations as well as other ego functions in terms of the cognitive functions delineated by Piaget.
