Multi-city study of quality of care for HIV-related Pneumocystis carinii pneumonia: successfully collecting highly sensitive information.

Pneumocystis carinii pneumonia (PCP) has been the major cause of death and the most common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), with in-hospital mortality rates as high as 60% in some hospitals. To investigate whether there were large variations in quality of care for hospitalized patients with PCP, researchers at RAND Corporation, in 1989, designed and initiated a multi-city study of patterns of care. Mounting a successful primary data collection effort in several cities requires a substantial effort from collaborators in many different settings. In addition, studies of persons with AIDS require careful consideration of issues related to the highly sensitive nature of data sources such as medical records of persons with AIDS, collection of reliable and accurate information, and protection of hospital and patient confidentiality and anonymity. The research team developed an interactive well-coordinated program to select hospitals and patients for evaluation, ensure confidentiality and anonymity, prepare materials, recruit collaborators, and obtain detailed clinical data about the care of patients with PCP. This paper summarizes major data collection and related project activities including design and sampling decisions, fieldwork preparation and implementation, and patient and hospital characteristics.

Management of heart failure. II. Counseling, education, and lifestyle modifications.

OBJECTIVE: This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction. DATA SOURCE: We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. STUDY SELECTION AND DATA SYNTHESIS: Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, < 0.35 to 0.40) and whether clinical outcomes were reported. Studies that reported only intermediate outcomes (eg, hemodynamics) were not reviewed. CONCLUSION: Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life.

Comprehensive geriatric care in a day hospital: a demonstration of the British model in the United States.

A geriatric day hospital (GDH) was developed in a community hospital to meet the complex medical and social needs of the frail elderly. A review of medical records (n = 273) and interviews with referring physicians (n = 42 on 96 patients) revealed that the GDH provided intensive outpatient care, geriatric assessment, rehabilitation, and an alternative to hospitalization. In all, 21% of physician-referred patients would have been hospitalized without the GDH, 7% would have had longer hospital stays, and care would have been deferred for 18%.

Obtaining clinical data on the appropriateness of medical care in community practice.

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.

Base stacking in the dinucleoside phosphate rapa.

The pH-induced unstacking of rRpA has been investigated by batch calorimetry and uv spectroscopy. Equilibrium uv melting curves confirmed that the adenine bases in rApA are stacked at pH7 but unstacked at pH 1.5. The enthalpy change accompanying this pH-induced unstacking is +2.65 kcal (mole of A-A stack)-1 as measured by batch calorimetry. This represents the first direct determination of this important parameter for a dinucleoside phosphate. It is noted that the calorimetrically determined value reported here is considerably lower than published van't Hoff enthalpies but is consistent with values that can be derived from calorimetric data on polymers.