[A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia]. / Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie.

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.

Do low-risk prenatal patients really need a screening glucose challenge test?

BACKGROUND: It is common practice to routinely screen pregnant women for gestational diabetes. The screening technique typically used is the 1-hour 50-g oral glucose tolerance test (OGTT), with a subsequent 3-hour 100-g OGTT for women whose 1-hour test was positive. This process can be both time-consuming and inconvenient for patients. Additionally, its sensitivity and specificity are estimated to be 70% and 87% respectively, and data about the effect of screening and treatment on low-risk pregnancy outcomes are limited. The objective of this study was to reassess the value of routine screening of all pregnant patients with a 1-hour glucose challenge test. METHODS: At a university-based family practice center with a predominantly low-risk population, a retrospective analysis was performed of all patients (n = 595) who received prenatal care and gave birth between January 1988 and December 1993. Among women in whom gestational diabetes was diagnosed on the basis of glucose tolerance testing, we identified those with risk factors for the disease, and examined whether a selective screening program based on risk factors alone would have resulted in correct diagnoses of gestational diabetes. RESULTS: Of the 595 patients, 544 (91.4%) were screened with a 1-hour 50-g OGTT. This initial screening test was positive in 76 women (12.8%). Of these, 58 (76.3%) then had a 3-hour 100-g OGTT, and 13 received a diagnosis of gestational diabetes. Nine of these 13 women had risk factors for gestational diabetes. We determined that less than 1% of prenatal patients without risk factors for gestational diabetes were ultimately found to have gestational diabetes. CONCLUSIONS: Screening with a 1-hour 50-g OGTT only those women who have identifiable risk factors for gestational diabetes is a reasonable approach to identifying the disease in a low-risk population. All pregnant women should have a thorough history taken to determine whether they have risk factors for gestational diabetes.

Prenatal care.

Available evidence suggests that prenatal care has played an important role in reducing maternal and infant mortality. Medical surveillance throughout pregnancy is the foundation of prenatal care and should be enhanced by psychosocial support. Only tests and procedures shown to be useful should be performed. Patient education includes promotion of healthy behaviors, nutritional advice, and preparation for childbirth.

The preparation of leukocyte-poor red cells from AS-1 red cells by the spin-cool-filter method.

Ninety-eight units of AS-1 red cells (RBC) were studied to determine the optimal unit age for the preparation of leukocyte-poor red cells by the spin-cool-filter method. After 1 week of storage, the residual leukocyte counts of AS-1 units prepared by this method averaged 0.5 x 10(9) or fewer white cells, which indicated removal of more than 79 percent of the total white cells. The spin-cool-filter method, in conjunction with the rapid degeneration of the white cells in the AS-1 RBC, yielded leukocyte-poor units comparable to those prepared from citrate-phosphate-dextrose-adenine (CPDA-1) RBC.