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1.
J Racial Ethn Health Disparities ; 10(4): 1776-1782, 2023 08.
Artigo em Inglês | MEDLINE | ID: mdl-35794515

RESUMO

PURPOSE: This investigation sought to compare admissions, length of stay, and mortality among medical intensive care unit (MICU) patients without coronavirus disease 2019 (COVID-19) infection admitted to an urban safety-net hospital during the pandemic by patients' self-identified race and ethnicity. MATERIALS AND METHODS: We conducted a retrospective observational study comparing MICU admissions before and during the first surge of COVID-19 illness at an urban, safety-net hospital in Minneapolis, Minnesota. RESULTS: MICU admissions declined from a pre-pandemic average of 968 to 761 during the first COVID surge, including 627 patients (82%) without COVID-19 infection. MICU mortality among patients without COVID-19 infection during the pandemic was 12.8% compared to 9.6% in the pre-pandemic period (p = 0.045). However, rates of non-COVID-19 MICU admissions, mortality, volume, and length of stay did not differ by race and ethnicity between time periods. Of the 131 MICU admissions with COVID-19 infection, patients were more frequently Hispanic ethnicity (24%) or Black (40%), and less frequently White (22%) compared to the pre-pandemic cohort (7%, 30%, and 48%, respectively [p < 0.001]). CONCLUSIONS: During the first COVID-19 surge, MICU admissions for non-COVID-19 disease decreased from pre-pandemic levels, but these patients experienced greater mortality. Unlike critically ill patients admitted with COVID-19 infection, admissions and hospital mortality did not differ by race and ethnicity compared to the pre-pandemic period.


Assuntos
COVID-19 , Etnicidade , Humanos , Pandemias , Estado Terminal , Provedores de Redes de Segurança , Estudos Retrospectivos
2.
Am J Emerg Med ; 54: 257-262, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35219011

RESUMO

AIM: This study aimed to describe the prevalence of hypoxic-ischemic brain injury (HIBI) on head CT (HCT) obtained within two hours of return of spontaneous circulation (ROSC) care in the Emergency Department following out-of-hospital cardiac arrest (OHCA) and evaluate the association between early HIBI and neurologic outcome. METHODS: Retrospective single center observational study of post-OHCA patients between 2009 and 2017. Two cohorts were analyzed: those who underwent non-contrast HCT within two hours of ROSC and all others who survived to ICU admission. HIBI was defined as the presence of cerebral edema and/or abnormal gray-white matter differentiation in the HCT interpretation by a neuroradiologist. The primary outcomes were the prevalence of HIBI on early HCT and the magnitude of the association between HIBI and survival with good neurologic outcome using multivariable logistic regression. RESULTS: Following OHCA, 333 of 520 patients (64%) underwent HCT within two hours of ROSC and HIBI was present in 96 of 333 patients (29%). Of the early HCT cohort, those with HIBI had a significantly lower hospital survival (2%) and favorable neurologic outcome (1%). In those without HIBI on imaging, 88 of 237 patients (37%) had a favorable outcome. After adjustment for confounding variables, HIBI on early HCT was independently associated with a decreased likelihood of good neurologic outcome (aOR 0.015, 95% CI 0.002-0.12). CONCLUSION: HIBI was present on 29% of HCTs obtained within 2 h of ROSC in the patients selected for early imaging by emergency physicians and was strongly and inversely associated with survival with a good neurologic outcome.


Assuntos
Lesões Encefálicas , Reanimação Cardiopulmonar , Hipóxia-Isquemia Encefálica , Parada Cardíaca Extra-Hospitalar , Humanos , Hipóxia-Isquemia Encefálica/complicações , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Hipóxia-Isquemia Encefálica/epidemiologia , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
3.
Am J Emerg Med ; 53: 41-43, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34973491

RESUMO

OBJECTIVE: Describe a series of patients who developed naloxone-associated pulmonary edema after recreational opioid use. DESIGN: Single center retrospective case series of patients who developed pulmonary edema following the prehospital administration of naloxone. SETTING: Academic, urban safety-net hospital. PATIENTS: Adults with recreational opioid overdose who developed naloxone-associated pulmonary edema, defined as the acute onset of respiratory distress, hypoxemia, and radiographic pulmonary edema after naloxone administration for opioid intoxication, provided that gas exchange and chest imaging rapidly improved and pulmonary aspiration of gastric contents was not clinically suspected. MEASUREMENTS AND MAIN RESULTS: Ten adults (median age 23 years, 90% male) met our case definition for naloxone-associated pulmonary edema. Implicated opioids were heroin in 8 patients and methadone and oxycodone in 1 patient each. The median total dose of naloxone was 4.25 mg (interquartile range [IQR] 3.3-9.8) prior to the onset of clinically-apparent pulmonary edema. Seven patients received invasive mechanical ventilation for a median of two days (IQR 0.8-5), one of whom received veno-venous extracorporeal membrane oxygenation support, and all survived to hospital discharge. CONCLUSIONS: Severe acute pulmonary edema may follow naloxone administration after recreational opioid overdose. Acute care clinicians should be aware of this potentially life-threatening adverse effect of naloxone.


Assuntos
Overdose de Drogas , Overdose de Opiáceos , Edema Pulmonar , Adulto , Analgésicos Opioides/efeitos adversos , Overdose de Drogas/tratamento farmacológico , Feminino , Humanos , Masculino , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Edema Pulmonar/induzido quimicamente , Edema Pulmonar/tratamento farmacológico , Estudos Retrospectivos , Adulto Jovem
4.
Neurocrit Care ; 33(2): 414-421, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-31898176

RESUMO

BACKGROUND: Cerebral edema and loss of gray-white matter differentiation on head computed tomography (CT) after cardiac arrest generally portend a poor prognosis. The interobserver variability in physician recognition of hypoxic-ischemic brain injury (HIBI) on early CT after out-of-hospital cardiac arrest has not been studied. METHODS: In this survey study, participating physicians and a neuroradiologist reviewed 20 randomly selected head CTs obtained within 2 h of out-of-hospital cardiac arrest and decided if HIBI was present. All participants were blinded to clinical details. Interobserver agreement on the presence of HIBI (primary outcome) and pairwise agreement between participants and the neuroradiologist (secondary outcome) were determined using multi- and dual-rater kappa statistics with 95% confidence intervals (CIs). RESULTS: Agreement among physicians regarding the presence of HIBI on head CT was fair (kappa 0.34; 95% CI 0.19-0.49). Individual physician agreement with the neuroradiologist varied from poor to moderate (kappa 0.0-0.48), with 8 of 10 physicians having no more than fair agreement. Regarding the perceived severity of HIBI on head CT, physician agreement was moderate (ICC = 0.56; 95% CI 0.38-0.77). CONCLUSION: Physicians, including radiologists, demonstrated substantial interobserver variability when identifying HIBI on head CT soon after out-of-hospital cardiac arrest.


Assuntos
Lesões Encefálicas , Hipóxia-Isquemia Encefálica , Parada Cardíaca Extra-Hospitalar , Humanos , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Variações Dependentes do Observador , Parada Cardíaca Extra-Hospitalar/diagnóstico por imagem , Tomografia Computadorizada por Raios X
5.
Am J Emerg Med ; 35(11): 1624-1629, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28506506

RESUMO

BACKGROUND: Endovascular temperature control catheters can be utilized for emergent rewarming in accidental hypothermia. The purpose of this study was to compare patients with moderate to severe hypothermia rewarmed with an endovascular temperature control catheter versus usual care at our institution. METHODS: We conducted a retrospective, observational cohort study of patients with moderate to severe accidental hypothermia (core body temperature less than 32°C) in the Emergency Department of an urban, tertiary care medical center. We identified the rewarming techniques utilized for each patient, including those who had an endovascular temperature control catheter placed (Quattro© or Icy© catheter, CoolGuard© 3000 regulation system, Zoll Medical). Rewarming rates and outcomes were compared for patients with and without the endovascular temperature control catheter. We systematically screened for procedural complications. RESULTS: There were 106 patients identified with an initial core temperature less than or equal to 32°C; 52 (49%) patients rewarmed with an endovascular temperature control catheter. Other methods of rewarming included external forced-air rewarming (85, 80%), bladder lavage (17, 16%), gastric lavage (10, 9%), closed pleural lavage (6, 6%), and peritoneal lavage (3, 3%). Rate of rewarming did not differ between the groups with and without catheter-based rewarming (1.3°C/h versus 1.0°C/h, difference 0.3°C, 95% confidence interval [CI] of the difference 0-0.6°C) and neither did survival (70% versus 71%, difference 1%, 95% CI -17 to 20%). We did not identify any significant vascular injuries resulting from endovascular catheter use. CONCLUSION: The endovascular temperature control system was not associated with an increased rate of rewarming in this cohort with moderate to severe hypothermia; however, this technique appears to be safe and feasible.


Assuntos
Procedimentos Endovasculares/métodos , Hipotermia/terapia , Reaquecimento/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Temperatura Corporal , Estudos de Casos e Controles , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Procedimentos Endovasculares/instrumentação , Feminino , Lavagem Gástrica , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Lavagem Peritoneal , Cavidade Pleural , Estudos Retrospectivos , Índice de Gravidade de Doença , Irrigação Terapêutica , Resultado do Tratamento , Bexiga Urinária , Adulto Jovem
6.
Respir Care ; 62(7): 920-927, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28424226

RESUMO

BACKGROUND: Objective measures of adherence to high-frequency chest wall compression (HFCWC), a form of airway clearance therapy for patients with cystic fibrosis, are lacking. We used a novel electronic monitoring device integrated into an HFCWC vest to measure adherence compared with self-reported adherence. We determined factors that influenced adherence and how adherence correlated with baseline pulmonary function and pulmonary exacerbations. METHODS: Data were collected by direct measurement of date, time of day, and duration of HFCWC use to determine the number of daily treatments and daily duration of treatments. Chart review provided prescribed airway clearance therapy treatment and demographic and clinical information. Subject and caregiver report of the daily number of airway clearance therapy treatments was obtained by telephone interviews. Analysis used 2-sample and paired t test, analysis of variance, and linear regression. RESULTS: Average adherence was 69%. Adherence was highest in children (82%, P = .02) and those receiving assistance with treatment (82%, P < .001). Subjects overestimated therapy duration from a mean ± SD of 127 ± 169% by adults to 19.2 ± 26.3% by parents or guardians of children. Average adherence decreased with increasing prescribed therapy time (P = .02). Average daily therapy time and adherence had significant positive associations with baseline FEV1 percent of predicted (P = .02 and P = .02, respectively) and negative associations with pulmonary exacerbations during the pre-study period and at baseline (P = .044 and P = .02, respectively). CONCLUSIONS: Greater adherence to HFCWC measured directly by a novel recorder was associated with better baseline pulmonary function and fewer exacerbations in the pre-study and baseline period. Adherence decreased with age and prescribed therapy time and increased with therapy assistance. Self-report overestimation is large and thus not an accurate measure of adherence.


Assuntos
Oscilação da Parede Torácica/estatística & dados numéricos , Fibrose Cística/terapia , Drenagem Postural/estatística & dados numéricos , Cooperação do Paciente/estatística & dados numéricos , Terapia Respiratória/estatística & dados numéricos , Adolescente , Oscilação da Parede Torácica/métodos , Oscilação da Parede Torácica/psicologia , Criança , Fibrose Cística/fisiopatologia , Fibrose Cística/psicologia , Progressão da Doença , Drenagem Postural/métodos , Drenagem Postural/psicologia , Feminino , Volume Expiratório Forçado , Humanos , Pulmão/fisiopatologia , Masculino , Monitorização Ambulatorial/estatística & dados numéricos , Pacientes Ambulatoriais/psicologia , Pacientes Ambulatoriais/estatística & dados numéricos , Cooperação do Paciente/psicologia , Terapia Respiratória/métodos , Terapia Respiratória/psicologia , Resultado do Tratamento , Adulto Jovem
7.
Ann Am Thorac Soc ; 13(4): 481-8, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26863101

RESUMO

RATIONALE: Most trainees in combined pulmonary and critical care medicine fellowship programs complete in-service training examinations (ITEs) that test knowledge in both disciplines. Whether ITE scores predict performance on the American Board of Internal Medicine Pulmonary Disease Certification Examination and Critical Care Medicine Certification Examination is unknown. OBJECTIVES: To determine whether pulmonary and critical care medicine ITE scores predict performance on subspecialty board certification examinations independently of trainee demographics, program director competency ratings, fellowship program characteristics, and prior medical knowledge assessments. METHODS: First- and second-year fellows who were enrolled in the study between 2008 and 2012 completed a questionnaire encompassing demographics and fellowship training characteristics. These data and ITE scores were matched to fellows' subsequent scores on subspecialty certification examinations, program director ratings, and previous scores on their American Board of Internal Medicine Internal Medicine Certification Examination. Multiple linear regression and logistic regression were used to identify independent predictors of subspecialty certification examination scores and likelihood of passing the examinations, respectively. MEASUREMENTS AND MAIN RESULTS: Of eligible fellows, 82.4% enrolled in the study. The ITE score for second-year fellows was matched to their certification examination scores, which yielded 1,484 physicians for pulmonary disease and 1,331 for critical care medicine. Second-year fellows' ITE scores (ß = 0.24, P < 0.001) and Internal Medicine Certification Examination scores (ß = 0.49, P < 0.001) were the strongest predictors of Pulmonary Disease Certification Examination scores, and were the only significant predictors of passing the examination (ITE odds ratio, 1.12 [95% confidence interval, 1.07-1.16]; Internal Medicine Certification Examination odds ratio, 1.01 [95% confidence interval, 1.01-1.02]). Similar results were obtained for predicting Critical Care Medicine Certification Examination scores and for passing the examination. The predictive value of ITE scores among first-year fellows on the subspecialty certification examinations was comparable to second-year fellows' ITE scores. CONCLUSIONS: The Pulmonary and Critical Care Medicine ITE score is an independent, and stronger, predictor of subspecialty certification examination performance than fellow demographics, program director competency ratings, and fellowship characteristics. These findings support the use of the ITE to identify the learning needs of fellows as they work toward subspecialty board certification.


Assuntos
Certificação/estatística & dados numéricos , Avaliação Educacional/estatística & dados numéricos , Medicina de Emergência/educação , Bolsas de Estudo/normas , Pneumologia/educação , Adulto , Competência Clínica/normas , Feminino , Humanos , Modelos Logísticos , Masculino , Estados Unidos
8.
Otolaryngol Head Neck Surg ; 147(3): 557-62, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22517014

RESUMO

OBJECTIVE: Functional endoscopic sinus surgery (FESS) provides symptomatic relief of sinus disease in patients with cystic fibrosis (CF), but it is unclear whether it has beneficial effects on lung disease in this population. This study assessed the effect of FESS on the respiratory status of adult patients with CF. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary medical center. SUBJECTS: Thirty-two adult patients with CF who underwent 45 operative cases. METHODS: Clinical information retrieved for the 12-month periods preceding and following to determine the effect of FESS on the rate of decline in lung function, as well as intravenous antibiotic use and hospitalization for pulmonary exacerbation. RESULTS: The rate of decline in forced expiratory volume in 1 second and forced vital capacity was not significantly different in the 12 months before and after FESS. Functional endoscopic sinus surgery did not reduce days hospitalized or days on intravenous antibiotics for a respiratory exacerbation in the pre- vs postoperative period. Limiting the analysis to the 30 surgeries that were performed in patients with concomitant respiratory symptoms (ie, excluding the 15 surgeries performed for sinus symptoms alone) did not significantly alter the results. Covariates of importance in CF, including CFTR genotype, gender, or microbiology, did not affect the study results. CONCLUSION: These results did not demonstrate an effect of FESS on progression of lung disease in patients with CF, but further research is needed because low statistical power has made some of the negative findings inconclusive.


Assuntos
Fibrose Cística/cirurgia , Endoscopia , Volume Expiratório Forçado/fisiologia , Seios Paranasais/cirurgia , Complicações Pós-Operatórias/fisiopatologia , Espirometria , Capacidade Vital/fisiologia , Adulto , Fibrose Cística/diagnóstico , Feminino , Humanos , Estudos Longitudinais , Masculino , Seios Paranasais/fisiopatologia , Adulto Jovem
9.
J Cyst Fibros ; 9(5): 365-70, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20674518

RESUMO

BACKGROUND: Gastroesophageal reflux (GER) in adults with cystic fibrosis (CF) is poorly characterized. This study examines the frequency and predictors of GER symptoms and their relationship to lung function in adults with CF. METHODS: Cross-sectional study of adults at the University of Minnesota CF Clinic using two validated self report surveys: The Mayo GER questionnaire and the GERD Symptom Assessment Scale (GSAS). RESULTS: Of 274 invited patients, 201 (73%) completed the surveys and 173 performed spirometry at the same visit. Frequent symptoms (at least weekly) were reported by 24% of the patients and an additional 39% experienced occasional symptoms. Heartburn, acid regurgitation and dysphagia were the most common symptoms and 18% reported that GER symptoms worsened their respiratory condition. Females and patients reporting weight loss had more symptoms (mean GSAS symptom score 4.9 vs. 4.0, p=0.025 and 5.3 vs. 4.2, p=0.04) and more severe symptoms (mean GSAS distress score 5.6 vs. 3.8, p=0.005 and 6.8 vs. 4.0, p=0.01) compared to males and those who did not report weight loss. Patients on acid suppression (n=122, 61%) continued to report heartburn (n=80, 66%) and acid regurgitation (n=47, 23%). GER symptoms and severity of symptoms were not predictive of FEV(1) or FVC. CONCLUSIONS: GER symptoms were present in a majority of patients. Females and patients with weight loss require special attention to their GER symptoms. Many patients on acid suppression continued to be report symptoms.


Assuntos
Fibrose Cística/complicações , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/fisiopatologia , Adolescente , Adulto , Antiácidos/uso terapêutico , Estudos Transversais , Transtornos de Deglutição/etiologia , Feminino , Volume Expiratório Forçado , Ácido Gástrico/metabolismo , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/epidemiologia , Azia/etiologia , Humanos , Refluxo Laringofaríngeo/metabolismo , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Índice de Gravidade de Doença , Espirometria , Inquéritos e Questionários , Redução de Peso , Adulto Jovem
10.
Respir Care ; 55(6): 695-701, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20507651

RESUMO

BACKGROUND: Cystic fibrosis (CF) patients commonly use a high-frequency chest-wall compression (HFCWC) device for airway clearance that generates oscillatory flow with a sine-wave configuration. Typical HFCWC settings combine a lower Vest inflation pressure setting (eg, 5 on the Vest's arbitrary 1-10 scale for the setting that controls the background pressure of the inflatable vest) with mid-range frequency (14-16 Hz) (lower-pressure/mid-frequency HFCWC). OBJECTIVE: To determine whether HFCWC with higher pressure settings (6-10 on the Hill-Rom Vest's arbitrary 1-10 scale) combined with variable mid-frequencies (8, 9, and 10 Hz, plus 18, 19, and 20 Hz) (higher-pressure/variable-frequency HFCWC) results in greater sputum expectoration than lower-pressure/mid-frequency HFCWC. METHODS: This was a controlled randomized crossover study. Sixteen clinically stable, adult CF patients participated. Patients performed airway clearance with HFCWC, once each with lower-pressure/mid-frequency HFCWC and higher-pressure/variable-frequency HFCWC, on separate occasions. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session. RESULTS: Median sputum wet weight was greater with higher-pressure/variable-frequency HFCWC than with lower-pressure/mid-frequency HFCWC (6.4 g, range 0.49-22.0 g, versus 4.8 g, range 0.24-15.0 g, P = .02). Dry sputum weight differences did not reach statistical significance (higher-pressure/variable-frequency HFCWC 0.20 g, range 0.009-0.62 g, lower-pressure/mid-frequency HFCWC 0.12 g, range 0.0001-1.0 g, P = .23). Higher-pressure/variable-frequency HFCWC and lower-pressure/mid-frequency HFCWC resulted in similar increases in FEV(1) (70 mL vs 90 mL, P = .21) and forced vital capacity (80 mL vs 80 mL, P = .94). Post-therapy sputum viscoelastic properties did not differ. Patients perceived the 2 regimens as equally comfortable and effective (P = .35 and P = .35, respectively). CONCLUSIONS: In adult CF patients, single-session higher-pressure/variable-frequency HFCWC resulted in greater sputum expectoration by wet weight, but not other differences, compared to the commonly used lower-pressure/mid-frequency settings. Longer-term comparisons are needed in a larger, more diverse population to determine whether sustained use of the higher-pressure/variable-frequency settings results in clinically important differences in outcomes.


Assuntos
Oscilação da Parede Torácica/métodos , Fibrose Cística/terapia , Adulto , Oscilação da Parede Torácica/instrumentação , Estudos Cross-Over , Feminino , Humanos , Masculino , Escarro , Resultado do Tratamento
11.
Chest ; 132(4): 1227-32, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-17890465

RESUMO

BACKGROUND: High-frequency chest wall oscillation (HFCWO) is commonly used by cystic fibrosis (CF) patients for airway clearance. The primary objective of this study was to determine whether the use of a newer HFCWO device that generates oscillations with a triangular waveform results in greater sputum production than a commonly used device that generates oscillations with a sine waveform. METHODS: This was a controlled, randomized, double-blind, crossover study. Fifteen clinically stable, adult CF patients participated. Patients performed airway clearance with each device once and at matched oscillation frequencies and pressures. All sputum produced during each session was collected. Patients completed pulmonary function tests before and after each session, and rated the comfort of the two devices. RESULTS: Mean sputum wet and dry weight produced during sine waveform and triangular waveform HFCWO sessions did not differ (p = 0.11 and p = 0.2, respectively). Mean changes in FEV(1) and FVC following HFCWO therapy were also comparable (p = 0.21 and p = 0.56, respectively). However, there was a significant reduction in air trapping by residual volume/total lung capacity ratio following triangular waveform HFCWO (p = 0.01). In addition, in vitro cough transportability was 10.6% greater following therapy with the triangular waveform device (p = 0.05). Patients perceived the two devices as equally comfortable (p = 0.8). CONCLUSIONS: Single-session sputum production is comparable with sine and triangular waveform HFCWO devices. Longer term comparisons are needed to determine whether sustained use of the devices results in clinically important differences in outcomes.


Assuntos
Oscilação da Parede Torácica/métodos , Fibrose Cística/terapia , Adulto , Estudos Cross-Over , Método Duplo-Cego , Feminino , Humanos , Masculino , Volume Residual , Reologia , Escarro/fisiologia , Capacidade Pulmonar Total
12.
Chest ; 131(6): 1666-71, 2007 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-17400682

RESUMO

BACKGROUND: Gastroesophageal reflux disease (GERD) is common in a variety of chronic respiratory diseases, but little is known about GERD in the setting of COPD. The aims of this study were to determine the prevalence, presentation, and predictors of GERD based on proximal and distal esophageal pH monitoring in patients with severe COPD. METHODS: Forty-one COPD patients with a mean FEV1 of 24% of predicted underwent dual-probe 24-h esophageal pH monitoring, and 1 patient underwent esophagogastroduodenoscopy. RESULTS: The prevalence of GERD was 57%. Elevated distal and proximal reflux were present in 41% and 46% of patients undergoing esophageal pH studies, respectively. Fifteen percent of these patients had abnormal proximal reflux despite having normal distal probe results. Most patients with GERD were not receiving acid blockers at the time of their referral, and only one third reported heartburn and/or acid regurgitation during the pH study. Only higher body mass index was predictive of reflux on regression analysis (odds ratio, 1.2; 95% confidence interval, 1.0 to 1.5; p = 0.05). CONCLUSIONS: GERD is common in advanced COPD. Patients are often asymptomatic and have a relatively high prevalence of isolated abnormal proximal reflux. Dual-probe monitoring is therefore well suited for detecting GERD in patients with advanced COPD.


Assuntos
Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/etiologia , Doença Pulmonar Obstrutiva Crônica/complicações , Adulto , Idoso , Progressão da Doença , Esôfago/fisiopatologia , Feminino , Refluxo Gastroesofágico/epidemiologia , Humanos , Concentração de Íons de Hidrogênio , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Análise de Regressão , Fatores de Risco
13.
Acad Med ; 82(2): 207-13, 2007 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17264705

RESUMO

PURPOSE: Clinical empathy is integral to forging therapeutic patient-physician relationships. Illness narratives are a potentially rich source of insight into what it feels like to be a patient or patient's family member. The authors performed a qualitative analysis of illness narratives to develop an explicit framework for understanding what it feels like to be a health care recipient and to explore how providers' behaviors influence that experience. METHOD: The authors used consensual qualitative research, a methodology based on principles of grounded theory, to analyze 24 illness narratives found in that number of essays from the Annals of Internal Medicine's "On Being a Patient" series published between January 1, 1999, and December 31, 2003. Trustworthiness was demonstrated via essayists' feedback on the analysis. RESULTS: Patients and their families faced formidable physical and psychosocial challenges. Providers' behaviors influenced the illness experience in profoundly positive and negative ways, independent of the technical quality of care. Consistent with previous studies of patient-physician relationships, providers' advocacy for patients and expressions of compassion were prominent determinants of patients' satisfaction. The experience of simultaneously being a health care provider and consumer was an additional source of stress for essayists, but it positively influenced their subsequent practice. CONCLUSIONS: Illness narratives vividly illustrate fundamental aspects of the illness experience and are a potentially rich resource for cultivating empathy. The authors' analysis provides a framework for enhancing trainees' and practitioners' ability to understand and meet patients' and families' psychosocial needs. The experiences of health care recipients with medical backgrounds are uniquely challenging and beneficial.


Assuntos
Família/psicologia , Pessoal de Saúde/psicologia , Narração , Pacientes/psicologia , Adaptação Psicológica , Atitude Frente a Morte , Feminino , Humanos , Masculino , Avaliação das Necessidades , Papel do Médico , Pesquisa Qualitativa
14.
Chest ; 128(1): 401-6, 2005 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-16002963

RESUMO

STUDY OBJECTIVES: Physicians undergoing medical subspecialty training, referred to as "fellows" in the United States, often serve as small group tutors. There are few reports, however, on whether fellows benefit from their experience teaching in the classroom. The purpose of this article is to describe the teacher-assistant requirement for fellows in a pulmonary and critical care training program and gain the perspectives of program graduates on their experiences as teacher assistants. DESIGN, SETTING, AND PARTICIPANTS: The structure of the teacher-assistant requirement is described in detail. We also surveyed 55 consecutive graduates of our Pulmonary and Critical Care Fellowship program located in the United States on the educational value of teaching pathophysiology to preclinical medical students. RESULTS: Fellows and one or two faculty members co-teach groups of 15 to 25 second-year medical students during 22 h of case-based conferences over a 6-week period. Weekly meetings for teacher assistants foster improved teaching skills and provide insight into the basic tenets of structuring and implementing the course. Fellows receive formal and informal feedback on their performance. Fifty of 55 graduates (91%) returned the survey. Respondents rated the acquisition of teaching skills and knowledge of pulmonary pathophysiology as the most useful aspects of their experience. Eighty-seven percent rated their overall experience favorably, and 90% agreed that teaching the course should remain a curriculum requirement. The responses of physicians in academic and community practice were comparable. CONCLUSIONS: Graduates of our Pulmonary and Critical Care Fellowship valued their teacher-assistant experience. This article may serve as a model for other subspecialty programs that are interested in formally incorporating teaching into their training program and may provide an impetus for the additional exploration of teacher-assistant experiences at other institutions.


Assuntos
Atitude do Pessoal de Saúde , Cuidados Críticos , Educação de Pós-Graduação em Medicina , Bolsas de Estudo , Pneumologia/educação , Ensino , Humanos , Estados Unidos , Recursos Humanos
15.
Acad Med ; 80(3): 238-43, 2005 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-15734805

RESUMO

PURPOSE: Generalist clinician-educators may have more difficulty than specialists satisfying common promotion criteria (peer-reviewed publication and extramural reputation). This study compared publication rates and participation in extramural activities among subspecialist and generalist clinician-educators, and sought to determine the views of clinician-educators on the use of publication and reputation in determining their promotion. METHOD: A cross-sectional questionnaire was delivered to 526 clinician-educators identified by the chairs at ten randomly selected U.S. medical schools in 2002. RESULTS: A total of 270 clinician-educators responded. Medicine subspecialist clinician-educators reported more peer-reviewed publications than did general internal medicine (GIM) faculty (mean 26.4 versus 10.2, p < .003). Independent predictors of having a greater number of peer-reviewed publications were subspecialty membership (p < .01), less time spent in clinic (p < .01), focus of scholarship (p = .01), academic rank (p < .01), higher quartile of National Institutes of Health funding received by respondent's department (p < .01), and years on faculty (p = .03). A greater proportion of GIM faculty reported spending most of their protected time on scholarly activities less amenable to publication (p = .05). A greater proportion of subspecialists felt peer-reviewed publication should be required for promotion (p < .01), but a minority of both groups felt this should necessarily entail original research. CONCLUSION: Subspecialist clinician-educators generate significantly more peer-reviewed publications than do their GIM colleagues. clinician-educators hold diverse views on the role of publication and reputation in determining their promotion.


Assuntos
Docentes de Medicina/estatística & dados numéricos , Medicina Interna/estatística & dados numéricos , Revisão da Pesquisa por Pares , Centros Médicos Acadêmicos/organização & administração , Adulto , Atitude do Pessoal de Saúde , Mobilidade Ocupacional , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Carga de Trabalho/psicologia , Carga de Trabalho/estatística & dados numéricos
16.
Teach Learn Med ; 16(4): 323-8, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15582868

RESUMO

BACKGROUND: Peer-reviewed publications and extramural reputation are criteria used to evaluate clinician-educators for promotion. There is concern that these criteria may be disadvantageous to clinician-educators in generalist fields relative to their specialist counterparts. PURPOSE: To determine whether medicine subspecialists had more peer-reviewed publications and academic activities outside their home institution than general internal medicine (GIM) faculty, and to explore possible explanations for observed differences. METHOD: Cross-sectional survey of all clinician-educators in a department of medicine at a leading public U.S. medical school. The survey assessed clinical duties, publications, and professional activities. RESULTS: Seventy-one percent (42/59) of clinician-educator faculty responded. GIM clinician-educators spent fewer months on inpatient services (p = 0.01), but more time in clinic (p = 0.05). Specialist clinician-educators had more peer-reviewed publications (p = 0.003), but total publications since entering a clinician-educator track was similar (p > 0.2). After multiple linear regression, only academic rank (p = 0.001) and subspecialty membership (p = 0.005) remained significant predictors of peer-reviewed publication. GIM faculty reported spending more scholarly time on "activities unlikely to result in publication" (p < 0.01). A greater proportion of specialists served on extramural committees (72% vs. 41%, p = 0.05) and lectured outside their home institution in the preceding year (92% vs. 59%, p = 0.02). CONCLUSIONS: In this single-institution survey, specialist clinician-educators reported more peer-reviewed publications and greater participation in other reputation-enhancing activities than did GIM clinician-educators.


Assuntos
Docentes de Medicina/estatística & dados numéricos , Medicina Interna/educação , Papel do Médico , Centros Médicos Acadêmicos , Adulto , Atitude do Pessoal de Saúde , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Revisão da Pesquisa por Pares , Inquéritos e Questionários , Washington , Recursos Humanos , Carga de Trabalho/estatística & dados numéricos
17.
Respir Care ; 49(2): 192-205, 2004 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-14744270

RESUMO

Accidental hypothermia is defined as an unintentional decrease in core body temperature to below 35 degrees C. Hypothermia causes hundreds of deaths in the United States annually. Victims of accidental hypothermia present year-round and in all climates with a potentially confusing array of signs and symptoms, but increasing severity of hypothermia produces a predictable pattern of systemic organ dysfunction and associated clinical manifestations. The management of hypothermic patients differs in several important respects from that of euthermic patients, so advance knowledge about hypothermia is prerequisite to optimal management. The paucity of randomized clinical trials with hypothermic patients precludes creation of evidence-based treatment guidelines, but a clinically sound management strategy, tailored to individual patient characteristics and institutional expertise and resources, can nonetheless be gleaned from the literature. This article reviews the epidemiology, pathophysiology, clinical presentation, and treatment of accidental hypothermia. Initial evaluation and stabilization, selection of a rewarming strategy, and criteria for withholding or withdrawing support are discussed.


Assuntos
Hipotermia/diagnóstico , Hipotermia/terapia , Desequilíbrio Ácido-Base/etiologia , Regulação da Temperatura Corporal/fisiologia , Hidratação/métodos , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Hipotermia/complicações , Hipotermia/fisiopatologia , Intubação Intratraqueal/métodos , Reaquecimento/métodos
18.
Med Teach ; 25(2): 177-81, 2003 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-12745527

RESUMO

Clinical reasoning allows physicians to move from areas of clinical uncertainty to points where the medical literature offers guidance, and is equally important in deducing whether the results of clinical trials are applicable to an individual patient. However, studies in the field of cognitive psychology indicate that the reasoning skills of clinicians are imperfect. Moreover, clinicians may be aware of their mistakes but often do not understand the cognitive processes underlying their errors. Greater understanding of the reasoning process has the potential to improve patient care but independent study of clinical reasoning can be difficult, as the literature is complex and unfamiliar to most physicians. This article provides an introduction to diagnostic reasoning and highlights some of the cognitive factors that lead to errors in clinical problem solving. Clinical scenarios are used to illustrate key points and place the material in a readily accessible framework.


Assuntos
Competência Clínica/normas , Tomada de Decisões , Lógica , Erros Médicos , Medicina Baseada em Evidências , Humanos , Modelos Psicológicos , Resolução de Problemas , Pensamento
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