A randomized trial of magnesium in the emergency department treatment of children with asthma.

STUDY OBJECTIVE: Magnesium sulfate has been shown to benefit asthmatic children and adults with poor responses to initial beta(2)-agonist therapy in the emergency department. We sought to determine whether the routine early administration of high-dose magnesium would benefit moderate to severely ill children with acute asthma. METHODS: This was a randomized, double-blind, placebo-controlled trial of 54 children 1 to 18 years of age who presented to the ED of a tertiary care children's hospital with a moderate to severe asthma exacerbation. After receiving a nebulized albuterol treatment (0.15 mg/kg) and methylprednisolone (1 mg/kg), patients were randomly assigned to receive either 75 mg/kg of magnesium sulfate (maximum 2.5 g) or placebo. Thereafter, all patients were treated with frequent nebulized albuterol following a structured protocol. The main outcome was degree of improvement as assessed by Pulmonary Index scores over 120 minutes. Secondary outcomes included hospitalization rates and time required to meet discharge criteria. RESULTS: The mean change in Pulmonary Index score from baseline to 120 minutes was 2.83 for the magnesium group compared with 2.66 for the placebo group (95% confidence interval -1. 24 to 1.60). Eleven (46%) of 24 magnesium-treated patients were hospitalized compared with 16 (53%) of 30 in the placebo group (95% confidence interval -19% to 34%). There were no statistically significant differences between the groups with respect to time required to meet discharge criteria. CONCLUSION: The routine administration of high-dose magnesium to moderate to severely ill children with asthma, as an adjunct to initial treatment with albuterol and corticosteroids, was not efficacious.

Utility of commercial systems for identification of Burkholderia cepacia complex from cystic fibrosis sputum culture.

Performances of several commercial test systems were reviewed to determine their relative levels of accuracy in identifying Burkholderia cepacia complex isolates recovered from cystic fibrosis sputum culture. Positive predictive values ranged from 71 to 98%; negative predictive values ranged from 50 to 82%. All systems misidentified B. cepacia complex. The species most frequently misidentified as B. cepacia was Burkholderia gladioli. These data support the results of previous studies that recommend confirmatory testing, including the use of DNA-based methods, for sputum culture isolates presumptively identified as B. cepacia.

Relationship of cognitions to fear of somatic symptoms: a test of the cognitive theory of panic.

The relationship between fear of physical anxiety symptoms and cognitive misinterpretation of those symptoms, as measured by responses to the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire, respectively, was examined for two samples of outpatients with panic disorder. Factor analytic and correlational analyses demonstrated that the patients' self-rated fear of specific physical and psychological symptoms was related to the frequency of specific logically related catastrophic thoughts (e.g., fears of heart palpitations or chest pressure with thoughts of a heart attack). This specific relationship between the somatic sensations and the catastrophic thoughts experienced by agoraphobic individuals provides further support for the cognitive theory of panic disorder. When the responses to the two questionnaires were factor-analyzed together, four factors were identified: symptoms and thoughts relevant to cardiovascular, neurological, gastrointestinal, and behavioral control systems, respectively. These findings suggest that the nature of panic-related fears varies across patients, and that the use of specific treatment interventions designed to modify the specific variations in their expression may be advisable.

MedEthEx Online: a computer-based learning program in medical ethics and communication skills.

BACKGROUND: Bioethics education often focuses on lectures and discussions to set a foundation for ethical decision making. Our goal was to bridge the gap between classroom learning and bedside competence through computer-assisted instruction. This article assesses the efficacy of MedEthEx Online, a computer-based learning program as part of a required Bioethics course. DESCRIPTION: Of 173 American medical students, 89 in Section 1 attended 8 bioethics lectures and 8 small-group discussions. Eighty-four in Section 2 had a similar course, although two group discussions were replaced with computerized learning. We compared (a) final exam scores, (b) topic-specific question scores, (c) performance with standardized patients, (d) self-assessments, and (e) course evaluations. EVALUATION: Exam scores were comparable, although computerized-learning students scored higher in specific exam areas, felt somewhat more clinically prepared, and rated the course slightly better. Standardized patient interactions differed, although they were comparable overall. CONCLUSION: MedEthEx Online is a viable option for fostering effective communication and problem resolution skills.

Palliative pharmaceutical care: a randomized, prospective study of telephone-based prescription and medication counseling services for treating chronic pain.

OBJECTIVE: To evaluate the effects of providing a unique telephone-based pharmaceutical care program to a sample of patients enrolled at a university pain clinic in Philadelphia, Pa. We hypothesized that in comparison to routine pharmaceutical care, the telephone-based pharmaceutical care program would have a positive impact on delivery of medication, quality of life, and overall satisfaction with the pain clinic program. PATIENTS: One hundred seven pain clinic patients were randomly assigned to the control and intervention groups. Seventy-four patients (control group, n = 36; intervention group, n = 38) met inclusion criteria. METHOD: The control group continued to receive care and prescription services through the same means as prior to the study. There were 2 components to the pharmaceutical care program offered to the intervention group. The first component consisted of a palliative care pharmacy company, PainRxperts, providing specialized prescription services tailored to the needs of a pain medicine clinical practice. The second component involved the palliative-trained pharmacist's proactive monitoring of patient pharmacotherapy for potential or actual drug related problems (DRPs). RESULTS: Intervention patients perceived that they had better access to medication, more efficient processing of prescriptions, and fewer stigmatizing experiences. They also endorsed pharmacists' behavioral interventions such as medication counseling, availability to answer medication-related questions, and non-judgmental attitudes when managing opioid prescriptions. CONCLUSION: This study suggests that the palliative-trained pharmacist can play an important collaborative role in managing chronic pain. Application of the pharmaceutical care model in pain medicine centers can improve satisfaction and remove some of the barriers to good pharmaceutical care facing patients with chronic pain disorders

Where nontradition is the norm: are sex and age determinants of practicing primary care specialties?

We studied the gender, age at graduation, and specialty of 2329 graduates of The Medical College of Pennsylvania (MCP) to determine if women and older graduates of a historically female institution tend to practice primary care specialties. Four of the primary care specialties studied, obstetrics and gynecology, family practice, general internal medicine, and pediatrics, are actively engaged in promoting women's health. MCP graduates were selected for study because of the institution's commitment to women's health and its association with admitting qualified, nontraditional students whose gender and age may have inhibited acceptance elsewhere. Seventy-two percent (1672) of the 1970-1992 graduates responded to an alumnae/i questionnaire. Chi-square tests revealed that female graduates were more likely to practice family practice, pediatrics, and obstetrics-gynecology but not more likely to practice general internal medicine. There was no relationship between age and practicing any of the four specialties. As more females graduate from U.S. medical schools, it is likely that they will retain their tendency to practice primary care specialties. These specialties offer women the opportunity to practice various aspects of comprehensive, lifelong women's healthcare. We should not expect older graduates schooled in environments favorable to women's health and careers to practice primary care medicine.

Oral versus intravenous corticosteroids in children hospitalized with asthma.

BACKGROUND: Previous studies have demonstrated that in the emergency treatment of an asthma exacerbation, corticosteroids used in conjunction with beta-agonists result in lower hospitalization rates for children and adults. Furthermore, orally administered corticosteroids have been found to be effective in the treatment of outpatients with asthma. However, similar data in inpatients is lacking. OBJECTIVE: The purpose of this study was to determine the efficacy of oral prednisone versus intravenous methylprednisolone in equivalent doses for the treatment of an acute asthma exacerbation in hospitalized children. METHODS: We conducted a randomized, double-blind, double-placebo study comparing oral prednisone at 2 mg/kg/dose (maximum 120 mg/dose) twice daily versus intravenous methylprednisolone at 1 mg/kg/dose (maximum 60 mg/dose) four times daily in a group of patients 2 through 18 years of age hospitalized for an acute asthma exacerbation. All patients were assessed by a clinical asthma score 3 times a day. The main study outcome was length of hospitalization; total length of stay and time elapsed before beta-agonists could be administered at 6-hour intervals. Duration of supplemental oxygen administration and peak flow measurements were secondary outcome measures. RESULTS: Sixty-six patients were evaluated. Children in the prednisone group had a mean length of stay of 70 hours compared with 78 hours for the methylprednisolone group (P =.52). Children in the prednisone group were successfully weaned to beta-agonists in 6-hour intervals after 59 hours compared with 68 hours for the methylprednisolone group (P =.47). Patients receiving prednisone required supplemental oxygen for 30 hours compared with 52 hours for the methylprednisolone group (P =.04). CONCLUSION: There was no difference in length of hospital stay between asthmatic patients receiving oral prednisone and those receiving intravenous methylprednisolone. Because hospitalization charges are approximately 10 times greater for intravenous methylprednisolone compared with oral prednisone, the use of oral prednisone to treat inpatients with acute asthma would result in substantial savings.

Use of a paper-cut as an adjunct to teaching the Whipple procedure by video.

BACKGROUND: Medical students often experience difficulty comprehending anatomic relationships of complex operations to which they are exposed during surgical clerkship. Pancreaticoduodenectomy, the Whipple procedure, is one such operation. Although video recordings are available to facilitate the learning of the Whipple procedure, commercially available tapes are not self-explanatory to the uninitiated. Since we have previously demonstrated that third-year medical students could learn the operative steps of inguinal herniorraphy by a paper-cutting exercise, we set out to determine whether an exercise of similar design could enhance a student's comprehension of the Whipple procedure. METHODS: Using Adobe Illustrator 5.5 for MacIntosh, an exercise was developed on a 8.5 x 11-inch paper that could be distributed to students for self-administration. The exercise was performed using a #15 scalpel or an iris scissors. Thirty-seven students were randomized into two groups. Each student received a pretest of questions focusing on the Whipple procedure. Group I was shown an 18-minute commercially available teaching video on the Whipple procedure. Group II was given the Whipple origami exercise, which required 20 minutes to complete. A first posttest was administered to each group. Next, the groups switched exercises, and a second posttest was administered. RESULTS: There was no significant difference between the groups' pretest scores (two-tailed t test, P = 0.290). Group I improved its score from an average of 64.21 (SD 14.27) to 67.89 (SD 13.16) after watching the video, and further to 77.89 (SD 14.37) after completing the paper-cut exercise. Group II improved from 60.00 (SD 9.43) to 78.95 (SD 11.00) after performing the paper-cut, but derived no additional measurable benefit from watching the video, average score 74.74 (SD 18.37). After the first exercise, students who performed the paper-cut showed a significantly greater improvement in test scores compared with students who saw the video (P = 0.0035 by Mann-Whitney U). After both groups had completed the exercises, the mean changes from baseline were no longer significantly different (P = 0.58 by Mann-Whitney U). CONCLUSION: As a single educational intervention, the paper-cut exercise was a more effective teaching device than the video in the given time frame. The origami model may be generalized to a variety of surgical procedures and appears to be a valuable adjunct to traditional teaching.

Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine: a physician survey.

BACKGROUND: Survey studies have shown that physicians believe managed care is having significant impact on many of their professional obligations. METHODS: Primary care physicians were asked about the impact of managed care on: (1) physician-patient relationships, (2) the ability of physicians to carry out their professional ethical obligations, and (3) quality of patient care. In 1996 we surveyed 1011 primary care physicians in Pennsylvania. The survey group's responses were graded on a Likert scale. Space was provided for respondents to include written comments. The SPSS statistical software (SPSS Inc, Chicago, Ill) was used to analyze the data. RESULTS: The response rate was 55%. Most respondents indicated that under managed care physicians are less able to avoid conflicts of interest and less able to place the best interests of patients first. The majority responded that quality of health care is compromised by limitations in location of diagnostic tests, length of hospital stay, and choice of specialists. A significant minority (27%-49%) noted a decrease in the physician's ability to carry out ethical obligations, to respect patient autonomy, and to respect confidentiality in physician-patient communication. Most physicians expressed that managed care made no impact on ability to obtain informed consent or to provide information. There were small but statistically significant sex differences, with female physicians more negative toward managed care. CONCLUSIONS: Many physicians surveyed believe managed care has significant negative effects on the physician-patient relationship, the ability to carry out ethical obligations, and on quality of patient care. These results have implications for health care system reform efforts.

Comparison of simulated patient and didactic methods of teaching HIV risk assessment to medical residents.

INTRODUCTION: Physicians need to be well trained in HIV risk assessment interview skills. Little has been written in the literature concerning training methods for this specialized interview. METHODS: One model to teach the HIV risk assessment interview has been developed and has been used to teach third-year medical students. We compared this interactive model, which uses simulated patients to teach HIV Risk Assessment, to a didactic one. Twelve medical residents were taken through either the interactive session or the didactic session. Pre-post changes from questionnaires were calculated to determine any differences in sessions. Also, Objective Structured Clinical Examinations (OSCEs) were used to grade all residents 2 weeks after their sessions. RESULTS: All pre-post changes were calculated and no statistically significant differences were seen (P > 0.50). OSCE interpersonal skills scores and content scores were calculated. The interactive group had statistically significantly higher scores (P < 0.05). CONCLUSION: The data supports the conclusion that an interactive method is more effective to use to train HIV risk assessment interview skills to medical residents when compared to the didactic method.

Pain of local anesthetics: rate of administration and buffering.

STUDY OBJECTIVE: To determine the impact of administration rate and buffering on the pain associated with subcutaneous infiltration of lidocaine. METHODS: Forty-two adult volunteers employed at a tertiary care center participated in this prospective, single-blinded study. Each subject received four lidocaine injections prepared and administered as follows: slow, buffered (SB); slow, unbuffered (SU); rapid, buffered (RB); rapid, unbuffered (RU). Buffering was accomplished by mixing 1% lidocaine with 8.4% sodium bicarbonate in a 9:1 ratio. Slow administration was 30 seconds and rapid was 5 seconds. Needle size (27-gauge), injection depth (.25 inch), lidocaine volume (1.0 mL), and temperature (room) were the same for each of the four injections. In all four conditions, the needle remained in the forearm for 30 seconds, to ensure blinding. The main outcome measure was the mean pain score for each condition, as recorded on a 10-cm visual analog scale. RESULTS: The lowest pain scores (mean +/- SE) were recorded for the SU and SB conditions at 1.49 +/- 29 and 1.48 +/- 26, respectively, and they were significantly lower than the scores for RB (2.34 +/- 28; P < .01) or RU (3.11 +/- 33; P < .001). Each of the slow conditions was reported to be the "least painful" of the four significantly more often than either rapid condition. CONCLUSION: This is the largest blinded study to assess administration rate and the pain of a local anesthetic. We found that administration rate had a greater impact on the perceived pain of lidocaine infiltration than did buffering.

The effect of incorporating women's health into a PBL curriculum on students' tendencies to identify learning issues in an ambulatory care setting.

PURPOSE: To investigate whether the incorporation of women's health into problem-based learning (PBL) cases affects students' tendency to identify learning issues related to women's health as they encounter patients in an ambulatory care setting. METHOD: Students in the PBL curriculum at the Allegheny University of the Health Sciences, MCP-Hahnemann School of Medicine, participate in a nine-week primary care practicum at the end of their first year, during which they spend three half-days per week in an ambulatory setting examining patients and completing patient logs that include any learning issues identified. Patient logs from 23 first-year PBL students who had not been exposed to a new women's health education program prior to their practicum in 1993 and from 22 first-year PBL students who had been exposed to the program prior to their practicum in 1994 were reviewed. For each women's health learning issue identified, the sex of the student and the sex, specialty, and practice setting of the student's preceptor were recorded. Data were analyzed with several statistical methods. RESULTS: There was no statistically significant difference in the numbers of men and women students or preceptors between the two years. In 1993 an average of 59% of the patients seen per student were women; in 1994 the average was 61%. The mean numbers of total learning issues identified (including women's health learning issues) were similar in the two years, but the mean percentage of clinical women's health learning issues identified increased significantly between 1993 and 1994, as did the mean percentage of community/preventive health women's health learning issues identified. There was a significant student-sex-by-preceptor-sex interaction for the total number of women's health learning issues identified (p = .024): for both years, the students paired with a preceptor of the same sex identified a higher number of women's health learning issues than did the students paired with a preceptor of the opposite sex. CONCLUSION: The results suggest that PBL is an effective way to increase students' awareness of women's health issues in a primary care clinical setting. More studies are needed to define the effect of PBL on the kind of reading and learning students will do when they get to the clinical setting.

Enhancement of 131I-mediated cytotoxicity by caffeine.

In cell culture, caffeine has been shown to enhance the lethality of DNA-damaging agents including ultraviolet rays, X-irradiation, and alkylating agents. We have previously reported a Phase I clinical trial demonstrating the feasibility of intraperitoneal radioimmunotherapy in patients with refractory ovarian cancer using 131I-labeled monoclonal antibody OC125. We are now exploring the possibility of using caffeine to enhance the toxicity of 131I-irradiation in target cells. As an in vitro model we tested this hypothesis using Chinese hamster ovary (CHO) cells exposed to 131I-labeled human serum albumin at various doses (4 to 70 microCi/ml) for 24 hr followed by 24 hr of incubation with caffeine. Cytotoxicity was measured by clonogenic survival and a nuclear fragmentation assay. The results show that caffeine, at a concentration of 7.7 mM, significantly enhances the cytotoxicity of 131I-irradiation.

Impact of a standardized patient intervention to teach breast and abdominal examination skills to third-year medical students at two institutions.

BACKGROUND: This study examined whether a single intervention with standardized patients (SPs) as a supplement to traditional teaching during the surgery clerkship would enhance the breast and abdominal examination skills of third-year medical students. METHODS: During the academic year 1994-1995, 153 students from two institutions were assigned to control or experimental groups. At institution A, all students underwent pretests and posttests with SPs; at institution B, no pretest was conducted. All experimental students received group and one-to-one instruction with SPs during the intervention session. RESULTS: At posttest, the experimental group performed better than the control group on breast examination (P = 0.002), professionalism during this examination (P <0.001), abdominal examination (P <0.001), and professionalism during the latter examination (P = 0.050). The improvement from pretest to posttest at institution A was significantly greater in the experimental group than the control group for the breast examination (P = 0.036) and the abdominal examination (P <0.001). Analyses on a variety of specific tasks within each examination were also performed. CONCLUSION: A single intervention with SPs teaching breast and abdominal examinations resulted in significant enhancement of these clinical skills.

Advantage of high-surface-area charcoal for gastrointestinal decontamination in a human acetaminophen ingestion model.

OBJECTIVE: To compare the abilities of low-surface-area (LSA) vs 2 types of high-surface-area (HSA) activated charcoal given orally to adsorb acetaminophen in the gastrointestinal (GI) tract, as demonstrated by the impact of these agents on the serum levels and area under the curve (AUC) in a simulated human overdose model. METHODS: The main arm of the study was a prospective double-blind crossover trial in which 6 volunteers, serving as their own controls, ingested acetaminophen (50 mg/kg), followed randomly in 10 minutes by either powdered LSA charcoal (950 m2/g) or powdered HSA charcoal (2,000 m2/g) in a charcoal:drug ratio of 8:1. In a second arm of the study, 3 subjects additionally ingested an equal dose of a granular preparation of the HSA charcoal. Serial serum acetaminophen levels were analyzed at various intervals (30, 60, 90, 120, 180, 240, and 300 minutes postingestion), and a 5-hour AUC was calculated. The subjects also rated the charcoal preparations for palatability. RESULTS: Serum acetaminophen levels were lower at all measured times in the groups receiving both forms of the HSA charcoal vs the LSA product. With the powdered HSA charcoal, comparison serum levels were significantly lower at 120 minutes postingestion and all times thereafter (p < 0.05), reaching high significance at 4 and 5 hours (p < 0.001). The subjects receiving the granular HSA charcoal also had consistently lower serum acetaminophen levels than did those receiving the LSA product, and the difference in mean serum levels was significant at the 4- and 5-hour sample (p = 0.012). Compared with the LSA charcoal, at the 4-hour postingestion sample, serum acetaminophen levels were reduced by 44% to 85% by the powdered HSA charcoal. The total AUC for the 5-hour study period was also significantly reduced by the powdered HSA product (p = 0.005) and the granular HSA product (p = 0.043). All the subjects rated the powdered HSA charcoal to be more palatable and easier to drink than the powdered LSA charcoal. CONCLUSION: The surface area of oral activated charcoal is a major determining factor in its ability to limit acetaminophen absorption and to fulfill its adsorptive role in GI decontamination. In a human acetaminophen overdose model, 2 types of HSA charcoal, when compared with equal doses of LSA charcoal, significantly reduced serum levels and total acetaminophen absorption as measured by the AUC.

The impact of nonacademic variables on performance at two medical schools.

Recent research shows that nonacademic variables must be taken into account when analyzing the indicators of medical student success. However, most previous studies have been limited to a single institution or population. This study investigated the relationship between nonacademic variables and performance at two very different medical schools. The Noncognitive Questionnaire was administered to 104 students at School A (predominantly white and historically oriented toward women) and 102 at School B (predominantly black). Correlation and multiple regression analyses were conducted to determine the relationship among nonacademic variables, undergraduate academic variables (Medical College Admission Test, undergraduate grade point average, and college quality), basic science grades, and US Medical Licensure Exam Step I (USMLE 1) scores. At School A, leadership/decisiveness, expected difficulty, and motivation predicted higher USMLE I scores and higher basic science grades each semester. At School B, expected difficulty was correlated with higher first semester grades only. For School A women, initiative/commitment was positively associated with both higher grades and higher USMLE scores. For black students of School B, expected difficulty was positively associated with higher grades. Identifying school-specific nonacademic variables of performance is critical to developing improved student support services.

Survival of Burkholderia cepacia on environmental surfaces.

Burkholderia (Pseudomonas) cepacia is an important pathogen amongst persons with cystic fibrosis (CF), and evidence suggests that transmission of strains within CF clinics contributes to pulmonary colonization of some patients. In order to optimize preventive strategies, the survival of B. cepacia on various environmental surfaces, including cotton cloth, stainless steel, latex and polyvinylchloride (PVC) tubing, was investigated. For surface inoculation, bacteria were suspended in phosphate buffered saline, sputum from CF patients, or sputum from persons without CF. The results demonstrate that amongst the strains examined, organisms survived significantly (P < 0.001) longer when suspended in sputum from CF patients than in either non-CF sputum or buffered saline. Significant (P < 0.001) differences in survival on the various surfaces were found; survival was greatest on PVC. Significant (P < 0.001) strain-to-strain differences in survival were also demonstrated; patient isolates representing predominant CF centre ribotypes survived longest. These data demonstrate that (1) B. cepacia can survive for long periods in respiratory droplets on environmental surfaces typically found in CF clinics, (2) undefined factors in sputum from patients with CF may contribute to survival of B. cepacia, and (3) strain-to-strain variation in survival time may affect strain transmissibility.

Elevated methylmalonic acid and total homocysteine levels show high prevalence of vitamin B12 deficiency after gastric surgery.

OBJECTIVE: To determine the prevalence of vitamin B12 deficiency in patients who have had gastric surgery. DESIGN: Cross-sectional study. SETTING: Philadelphia Veterans Affairs Medical Center. PARTICIPANTS: 61 patients who had had gastric surgery and 107 controls. MEASUREMENTS: Serum levels of vitamin B12, folate, methylmalonic acid, and total homocysteine measured before and after treatment in participants with vitamin B12 deficiency. Vitamin B12 deficiency was defined as one of the following: 1) a serum vitamin B12 level less than 221 pmol/L and an elevated methylmalonic acid level; 2) a serum vitamin B12 level less than 221 pmol/L and an elevated total homocysteine level that decreased with vitamin B12 treatment; or 3) in patients unavailable for treatment, a serum vitamin B12 level less than 221 pmol/L, a folate level greater than 9 nmol/L, and an elevated total homocysteine level. RESULTS: Study patients and controls were similar in age, sex, and racial distribution. Nineteen patients (31%) and 2 controls (2%) had vitamin B12 deficiency (P < 0.001). Twelve (63%) of the 19 vitamin B12-deficient patients had elevated total homocysteine levels. In all participants with vitamin B12 deficiency who received treatment (15 of 21), methylmalonic acid and total homocysteine levels decreased substantially, confirming the deficiency before treatment. CONCLUSION: Patients who have had gastric surgery have a high prevalence of vitamin B12 deficiency. Prompt recognition and treatment of the deficiency with resultant normalization of elevated total homocysteine and methylmalonic acid levels may prevent the development of cardiovascular, hematologic, and neurologic abnormalities. Our data support both frequent screening and vitamin B12 replacement therapy in patients who have had gastric surgery and have serum vitamin B12 levels less than 221 pmol/L.