Pulmonary embolism presenting as syncope: case report and review of the literature.

Syncope as an initial presentation of pulmonary embolism occurs in about 10% of patients. A 68-year-old woman was admitted to the hospital with syncope. A right lower lobe infiltrate was found on a chest x-ray film, and results of a ventilation-perfusion scan were interpreted to mean that a high probability of pulmonary embolism existed. Other causes of syncope were excluded. A Doppler scan of the lower extremities revealed deep venous thrombosis. Intravenous heparin was administered, and then an inferior vena cava filter was placed to prevent pulmonary embolism from recurring. The patient has been well for 16 months since that episode. A review of 20 case reports in the literature of 10 women and 10 men with pulmonary embolism presenting as syncope revealed that female patients were younger than male patients and that the outcome was fatal in 40% of all cases. Syncope as a presenting symptom of pulmonary embolism is difficult to diagnose. Physicians must be vigilant with patients who have syncope, because this symptom may be the "forgotten sign" of life-threatening pulmonary embolism. The need for prompt diagnosis is clear, because with appropriate treatment the majority of patients may survive.

When the patient cannot come to the doctor: a medical housecalls program.

OBJECTIVES: To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems. PARTICIPANTS: Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home. PROGRAM EVALUATION: The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes. CONCLUSIONS: A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

The association between age of hospitalized patients and the delivery of advanced cardiac life support.

OBJECTIVE: To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. DESIGN: Retrospective cohort. SETTING: Urban teaching hospital. PATIENTS: One hundred twenty-two adult inpatients without a "do-not resuscitate" order who suffered cardiopulmonary arrest during 1993. MEASUREMENTS AND MAIN RESULTS: Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a "short ACLS trial") for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). CONCLUSIONS: Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics.

Physicians' utilization of health care.

OBJECTIVE: To describe how physicians attend to their own health care needs. SETTING: Rhode Island. PARTICIPANTS: A random sample of Blue Cross/Blue Shield providers. The 306 respondents (67% of 458) primarily (92%) had MD or DO degrees. The nonphysician providers were chiropractors, dentists, optometrists, and podiatrists. DESIGN: A mailed survey provided data describing the respondents' medical conditions and utilization of formal and informal care during a three-year period. Questions asked about provider visits, physical examinations, preventive and diagnostic tests, and medication use. The respondents indicated whether services had been initiated by themselves or by another physician. MAIN RESULTS: The physicians' overall use of formal health services was low; their number of office visits was a fourth of the national average. Two-thirds of the respondents reported having a primary care physician, and one-third had sought informal care. The respondents' use of preventive services was high. During the three-year period, 82% of the women physicians had received a Pap test, and 81% of the women physicians over the age of 40 years had received mammography. Cholesterol levels were checked for more than two-thirds of all the respondents. Medical examinations and laboratory tests tended to be ordered by another physician, although self-prescribing was not uncommon. Furthermore, 61% of the respondents had self-prescribed at least one medication. CONCLUSIONS: Physicians' care-seeking behavior covers a broad spectrum, ranging from self-care, to informal consultation, to formal treatment by another physician. Physicians appear to be low users of formal services overall, but high users of preventive care.

The impact of age on the quality of life in persons with HIV infection.

The authors administered the Medical Outcomes Study (MOS 20) Short Form Health Survey to 369 persons with HIV disease. The MOS survey measures six domains of health: physical function, role function, social function, mental health, health perception, and pain. Additional data included sociodemographics, HIV risk group, time since HIV diagnosis, symptoms (dyspnea, diarrhea, fever, chills, sweats, weight loss, weakness, numbness, memory trouble, seizures), and CD4 lymphocyte count within 3 months of the MOS survey. Bivariate analyses revealed worse MOS scores associated with older age in five health domains: physical function (p less than .01), health perception (p <.10), role function (n.s.), social function (n.s.), and mental health (n.s.). Older subjects reported less pain. When controlling for CD4 count and for sociodemographic and clinical variables, older age was significantly (p less than .05) associated with worse MOS scores in physical function, social function, and health perception, nonsignificantly associated with worse MOS scores in role function and mental health, and nonsignificantly associated with less reporting of pain.

Changes in the pattern of drug overdoses.

OBJECTIVE: To describe changes in the pattern of patients with drug overdoses hospitalized over the past two decades. DESIGN: Retrospective data review. SETTING: A 719-bed university-affiliated hospital. PATIENTS: All adults admitted to the hospital with drug overdoses in 1968, 1979, and 1989. PRIMARY OUTCOME MEASURES: Changes in demographics, drugs used, and discharge disposition. RESULTS: A majority of patients admitted with drug overdoses have had previous suicide attempts; and while women predominate, they make up a decreasing proportion of admissions over time (76% in 1968 to 52% in 1989 (p = 0.003). Benzodiazepines were the drugs most commonly used in 1979 and 1989, and cocaine has shown a marked increase in use over time, while barbiturate overdoses have progressively decreased. The use of two or more drugs is common and has been consistent over time, as has been the concomitant use of alcohol. The mortality rate has remained low at 1%, but mean length of stay has decreased dramatically from 6.6 days in 1979 to 3.2 days in 1989 (p < 0.001) and discharge disposition has shifted from out-patient to inpatient psychiatric care. CONCLUSIONS: The majority of patients admitted to a general acute care hospital following a drug overdose have a history of previous suicide attempts and are followed by a mental health professional. The changing pattern of drugs used over two decades reflects trends in drugs used in the community in general and by patients with mental illness in particular. Discharge disposition has changed over time and is related to patients' insurance status.

Who pays for published research?

OBJECTIVE: To determine the extent of unfunded research published in major medical journals. DESIGN: Review of original research completed in the United States and published in 23 official journals of internal medicine and neurology during 1 month in 1991. Investigators were contacted to confirm lack of funding. MAIN OUTCOME MEASURE: Percentage of unfunded, published original research. RESULTS: One hundred ninety-six articles were evaluated. There was at least one unfunded study in 78% of journals. Forty-five published studies (23%) were unfunded. Among those 45 studies, 7% were clinical trials, 9% were cohort studies, 18% were cross-sectional or case-control studies, 53% were case series, and 13% were surveys. Thirteen unfunded studies involved procedures that presumably were performed for research purposes and not as part of routine patient care. CONCLUSIONS: Nearly one quarter of original research published in major medical journals was unfunded. Seven percent of published research involved direct clinical costs that were not accounted for by the investigators. These costs may have been passed on to study participants or third-party payers.

Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island.

OBJECTIVES: Diabetic acidosis (DA) and the diabetic hyperosmolar state (DHS) are generally considered to be two distinct clinical entities. However, clinical experience and the literature suggest that there may be some overlap. The purposes of this study were 1) to establish the proportion of overlap cases, 2) to identify any occurrence of DHS in diabetic patients under the age of 30 years (likely type I) and any occurrence of DA in diabetic patients over the age of 60 years (likely type II), 3) to describe clinical factors associated with the development of DA and DHS, and 4) to identify factors that influence the prognosis of DHS. PATIENTS AND METHODS: 613 cases were identified by retrospective chart review, using discharge information from all 15 Rhode Island community hospitals during 1986, 1987, and part of 1988. DA alone [serum glucose (glu) greater than 300 mg/dL, bicarbonate (HCO3) less than 15mEq/L, calculated total serum osmolarity (osm) less than or equal to 320 mOsm/L] was the diagnosis for 134 subjects (22%), DHS alone (glu greater than 600 mg/dL, HCO3 greater than or equal to 15mEq/L, osm greater than 320 mOsm/L), for 278 subjects (45%), and a mixed case (glu greater than 600 mg/dL, HCO3 less than 15 mEq/L, osm greater than 320 mOsm/L), for 200 subjects (33%). Information about serum or urinary ketones was available for 109 subjects who had DA alone [103 had diabetic ketoacidosis (DKA)] and 144 subjects who had mixed DA and DHS (131 had mixed DKA and DHS). All the data were also analyzed using the effective osmolarity and a cutoff of 310 mOsm/L for this alternative case definition. RESULTS: Patients with DA alone were younger (mean age 33 years) and patients with DHS alone were older (mean age 63 years). However, 28 (10%) of the 278 cases of DHS alone and 72 (36%) of the 200 cases of mixed DA and DHS occurred in patients under the age of 30. Eighteen cases (13%) of DA alone and 62 cases (31%) of mixed DA and DHS occurred in patients over the age of 60. The results were not substantially changed when effective osmolarity greater than 310 mOsm/L was used to define hyperosmolarity and when only cases with documented DKA were included. An infection was the most common precipitating factor of DA (30%), DHS (27%), and mixed cases (32%). Other common associated factors included noncompliance with treatment (20% for DA, 12% for DHS, and 22% for mixed cases) and previously undiagnosed diabetes (24% for DA, 18% for DHS, and 10% for mixed cases). Nursing home residents accounted for 0.7% of DA cases, 18% of DHS cases, and 4.5% of mixed cases. Mortality was 4% for DA, 12% for DHS, and 9% for mixed cases. The mortality for DHS is the lowest reported in the literature, continuing a downward trend that began in the 1970s. Nonsurvival was associated with older age, higher osmolarity, and nursing home residence. Survival was associated with the presence of an infection. CONCLUSIONS: 1) many patients experience mixed DA (DKA) and DHS rather than either condition alone, 2) both DA (DKA) and DHS occur in young and old diabetic persons, 3) infection is the most common predisposing factor for either condition, and 4) higher osmolarity, older age, and nursing home residence are associated with nonsurvival in DHS.

HIV-positive women: reasons they are tested for HIV and their clinical characteristics on entry into the health care system.

STUDY OBJECTIVE: To describe the reasons for the HIV testing of HIV-positive women and their clinical presentation and to make specific laboratory comparisons between women intravenous drug users (IVDUs) and non-IVDUs who were heterosexually infected (HTs). DESIGN: Consecutive case series. SETTING: Four primary care sites associated with the Brown University AIDS Program. PARTICIPANTS: 140 consecutive HIV-seropositive women. RESULTS: The most common reason for HIV testing in both groups was self-perception of risk. Presenting T-helper lymphocyte counts, leukocyte counts, and hematocrits did not differ significantly between the groups. Intravenous drug users were significantly more likely than HTs to have evidence of hepatitis B virus exposure (p less than 0.0001) and to report the history of a sexually transmitted disease (p = 0.005). Twenty percent of HTs versus 10% of IVDUs were tested only after they had HIV-related symptoms. The most frequent clinical presentation for both groups was Centers for Disease Control Group IV/A constitutional symptoms. CONCLUSIONS: Many HIV-seropositive women do not enter the health care system until they are symptomatic, but those infected heterosexually and those using parenteral drugs have similar laboratory indices at presentation. AIDS education strategies toward all women at risk must include information about manifestations of HIV disease in women, as well as preventive measures, to ensure early access to the health care system.

Differences in access to zidovudine (AZT) among symptomatic HIV-infected persons.

OBJECT: To evaluate socioeconomic factors that determine whether symptomatic HIV-infected persons are offered zidovudine (AZT). DESIGN: Cross-sectional survey conducted as part of the Robert Wood Johnson Foundation's AIDS Health Services Program. SETTING: Public hospital clinics and community-based AIDS organizations in nine American cities. PATIENTS: 880 HIV-seropositive outpatients interviewed between October 1988 and May 1989. MAIN RESULTS: Males were more likely to have been offered AZT than were females (adjusted odds ratio 2.99; 95% confidence interval 1.67 to 5.36), those with insurance were more likely to have been offered AZT than were those without (adjusted odds ratio 2.00; 95% confidence interval 1.25 to 3.21), and whites more likely to have been offered AZT than were non-whites (adjusted odds ratio 1.73; 95% confidence interval 1.11 to 2.69). Intravenous drug users were less likely to have been offered AZT than were non-drug users (adjusted odds ratio 0.44; 95% confidence interval 0.28 to 0.69). Persons who had had an episode of Pneumocystis carinii pneumonia were more likely to have been offered AZT than were persons who had AIDS and had not had Pneumocystis carinii pneumonia (adjusted odds ratio 2.95; 95% confidence interval 1.71 to 5.11). CONCLUSION: The authors conclude that traditionally disadvantaged groups have less access to AZT, the only antiretroviral agent demonstrated to increase survival of patients who have symptomatic HIV infection.

Macrocytosis in Down syndrome.

The mean corpuscular volume of erythrocytes in persons with Down syndrome is larger than normal in the absence of anemia. The mean mean corpuscular volume among our 61 subjects with trisomy 21 was 99.08 fl (range = 90 to 107). Red blood cell survival half-time was substantially shorter than normal in many of these patients. These findings suggest that erythrocytes have a younger mean age in persons with Down syndrome. The increased red blood cell turnover in this population may indicate an accelerated aging process of red blood cells.

The diabetic hyperosmolar state.

The diabetic hypersomolar state is defined by a serum glucose greater than 600 mg/dl and a serum osmolarity greater than 320 m Osm/L. Ketoacidosis or lactic acidosis may co-exist with DHS in the same patient. The incidence of this acute complication of diabetes is high enough (17.5 cases per 100,000 person-years) for primary care physicians to encounter a case every year or two. Predisposing factors include older age, female sex, nursing home residence, and infection. A substantial proportion of cases occur in patients with no prior history of diabetes. Common presenting signs include fatigue or weakness, polydipsia, polyuria, nausea, and alteration of consciousness. The mainstay of therapy is intravenous fluid replacement with close monitoring of glucose and electrolytes in a hospital setting. Current mortality figures are high, at 10% to 20%, and the chance of survival is adversely affected by older age, higher osmolarity, and the presence of an associated severe illness. Prevention includes screening for diabetes, educating diabetic patients and their care givers about the symptoms of hyperglycemia, prompt treatment of any infection in a diabetic person, avoidance of drugs that increase carbohydrate intolerance in diabetic people, and encouraging compliance with treatment of diabetes.

Patient characteristics associated with the use of mechanical restraints.

STUDY OBJECTIVE: To compare the characteristics of restrained patients with those of unrestrained patients by assessing a number of medical, behavioral, and cognitive variables including a disruptive-behavior inventory. DESIGN: Case-control study. SETTING: A 719-bed university-affiliated teaching hospital. PATIENTS: The 80 cases were patients identified by the nursing staff as having had a restraint applied within the last 24 hours prior to entry in the study. The 80 unrestrained controls were selected from the rooms adjacent to the cases' in order to match for proximity to the nursing station and nurse staffing. MEASUREMENTS AND MAIN RESULTS: Demographic data, data on diagnoses and treatments, results of the Folstein Mini-Mental State (MMS) test and an eight-item disruptive-behavior inventory, and outcome information were obtained for each patient using a standardized procedure. Three important patient characteristics were significantly associated with restraint use in a multiple logistic regression model: disruptive behaviors, nursing assessment of risk of falling, and cognitive impairment. Cases were older than controls, but age was not an independent characteristic associated with restraint use when controlling for cognitive impairment, risk of falling, and disruptive behaviors. CONCLUSIONS: Restraint use was more likely in patients with disruptive behaviors, at risk of falling, and with cognitive impairment. Attention to these factors and alternative strategies for dealing with them may reduce the use of physical restraints.

Practice guidelines to reduce testing in the hospital.

OBJECTIVE: To reduce testing among hospitalized patients using practice guidelines for any of 14 medical problems. DESIGN: Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition, the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines were not developed. SETTING: Acute care hospital. PATIENTS/PARTICIPANTS: 1,638 hospitalized patients and their 79 physicians. INTERVENTION: Implementation of practice guidelines for the care of hospitalized patients. MEASUREMENT AND MAIN RESULTS: Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group, laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p = 0.001). The non-participating physicians who were higher test users during both years of the study also achieved significant (p less than 0.05) but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up of the participating physicians during the six months after the end of the intervention revealed that testing remained at the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines. CONCLUSIONS: 1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These self-selected physicians were willing to use the guidelines (or allow the housestaff to use them) while caring for their patients. 3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not, persisted for at least six months beyond the end of the period of implementation.