Showing papers by "Deborah J. Cook published in 1994"
TL;DR: A 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours, is seen by a medical consultant asked by a surgical colleague to see her.
Abstract: CLINICAL SCENARIO You are a medical consultant asked by a surgical colleague to see a 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours. She has also been experiencing what she describes as chest discomfort, which is sometimes made worse by taking a deep breath (but sometimes not). Abnormal findings on physical examination are restricted to residual tenderness in the abdomen and scattered crackles at both lung bases. Chest roentgenogram reveals a small right pleural effusion, but this is the first roentgenogram since the operation. Arterial blood gases show a Po 2 of 70 mm Hg, with a saturation of 92%. The electrocardiogram shows only nonspecific changes. You suspect that the patient, despite receiving 5000 U of heparin twice a day,
929 citations
TL;DR: A prospective multicenter cohort study in which potential risk factors for stress ulceration in patients admitted to intensive care units and the occurrence of clinically important gastrointestinal bleeding were evaluated.
Abstract: Background The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit. Methods We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion). Results Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence ...
882 citations
TL;DR: A 55-year-old man has had his serum cholesterol level measured at a shopping mall 2 months ago and his cholesterol level was elevated, but before deciding on a treatment recommendation, you elect to find out just how big a reduction in the risk of CHD this patient could expect from a cholesterollowering diet or drug therapy.
Abstract: CLINICAL SCENARIO A 55-year-old man had his serum cholesterol level measured at a shopping mall 2 months ago. His cholesterol level was elevated and he comes to you, his primary care physician, for advice. He does not smoke, is not obese, and does not have hypertension, diabetes mellitus, or any first-order relatives with premature coronary heart disease (CHD). You repeat his cholesterol test and schedule a follow-up appointment. The test confirms an elevated cholesterol level (7.9 mmol/L [305 mg/dL]), but before deciding on a treatment recommendation, you elect to find out just how big a reduction in the risk of CHD this patient could expect from a cholesterollowering diet or drug therapy. THE SEARCH There are a number of cholesterol-lowering trials, and instead of trying to find and review all of the original studies yourself, you use Grateful Med to find a recent overview. On the first subject line you
816 citations
TL;DR: A general internist is asked to see a 65-year-old man with controlled hypertension and a 6-month history of atrial fibrillation resistant to cardioversion, who has no evidence for valvular or coronary heart disease, and who shares concerns about the benefits of long-term anticoagulant therapy.
Abstract: CLINICAL SCENARIO You are a general internist who is asked to see a 65-year-old man with controlled hypertension and a 6-month history of atrial fibrillation resistant to cardioversion. Although he has no evidence for valvular or coronary heart disease, the family physician who referred him to you wants your advice on whether the benefits of long-term anticoagulants (to reduce the risk of embolic stroke) outweigh their risks (of hemorrhage from anticoagulant therapy). The patient shares these concerns and doesn't want to receive a treatment that would do more harm than good. You know that there have been randomized trials of warfarin for nonvalvular atrial fibrillation and decide that you'd better review one of them.
678 citations
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518 citations
TL;DR: A 76-year-old retired schoolteacher who has lived with her son since her husband died 6 years ago has become increasingly agitated and paranoid during the last year and you feel she has probable Alzheimer's disease.
Abstract: CLINICAL SCENARIO You are about to see a 76-year-old retired schoolteacher for the second time. You first saw her in the clinic a month ago because of cognitive problems. Your evaluation at that time included a Standardized Mini-Mental State Examination,1on which she scored 18 out of a possible 30 points, and a physical examination that was normal including no focal neurological signs. You arranged investigations for the treatable causes of dementia that were negative, and you thus feel she has probable Alzheimer's disease. The patient has lived with her son since her husband died 6 years ago. Her son thinks that she first developed significant problems with her memory about 3 years ago. However, she has become increasingly agitated and paranoid during the last year. She has refused to allow him to look after her financial affairs, despite the fact that she owns three pieces of property and
497 citations
451 citations
TL;DR: A search for a key article on the safety of β-adrenergic agonists in the treatment of asthma and how to respond to patients asking him about media reports of an increased risk of death associated with these medications.
Abstract: CLINICAL SCENARIO You are having lunch in the hospital cafeteria when one of your colleagues raises the issue of the safety of β-adrenergic agonists in the treatment of asthma. Your colleague feels uncertain about how to respond to patients asking him about media reports of an increased risk of death associated with these medications. Another colleague mentions a key article on this topic that generated much of the publicity, but she cannot recall the details. You all agree that this is an issue that arises frequently enough in your practices that you should become familiar with the evidence contained in the article that your patients have heard about. You volunteer to search the literature for the key article and report back to your colleagues in the next few days. THE SEARCH The next day you do a MEDLINE search using the following terms: asthma (MH) (MH stands for MeSH heading,
311 citations
TL;DR: Prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation, according to this prospective multicenter cohort study.
Abstract: BACKGROUND
The efficacy of prophylaxis against stress ulcers in preventing gastrointestinal bleeding in critically ill patients has led to its widespread use. The side effects and cost of prophylaxis, however, necessitate targeting preventive therapy to those patients most likely to benefit.
METHODS
We conducted a prospective multicenter cohort study in which we evaluated potential risk factors for stress ulceration in patients admitted to intensive care units and documented the occurrence of clinically important gastrointestinal bleeding (defined as overt bleeding in association with hemodynamic compromise or the need for blood transfusion).
RESULTS
Of 2252 patients, 33 (1.5 percent; 95 percent confidence interval, 1.0 to 2.1 percent) had clinically important bleeding. Two strong independent risk factors for bleeding were identified: respiratory failure (odds ratio, 15.6) and coagulopathy (odds ratio, 4.3). Of 847 patients who had one or both of these risk factors, 31 (3.7 percent; 95 percent confidence interval, 2.5 to 5.2 percent) had clinically important bleeding. Of 1405 patients without these risk factors, 2 (0.1 percent; 95 percent confidence interval, 0.02 to 0.5 percent) had clinically important bleeding. The mortality rate was 48.5 percent in the group with bleeding and 9.1 percent in the group without bleeding (P < 0.001).
CONCLUSIONS
Few critically ill patients have clinically important gastrointestinal bleeding, and therefore prophylaxis against stress ulcers can be safely withheld from critically ill patients unless they have coagulopathy or require mechanical ventilation.
255 citations
TL;DR: In this issue of JAMA, Gill and Feinstein take the philosophical position that only the individual can rate quality of life, and if the individual says that it is excellent, that is what it is.
Abstract: FROM time to time, a terrible event happens to someone, and yet the survivor finds herself or himself better off. Through injury, a person is rendered paraplegic, or even quadriplegic; cancer strikes, requiring debilitating chemotherapy and raising the specter of a shortened life. The person suffering the calamity transcends the suffering and loss and finds new meaning in life. Living becomes a richer, more satisfying experience and, in extreme instances, people feel that they never really appreciated life until their tragedy. See also p 619. If one had to rate the quality of life of a quadriplegic whose life experience is dominated by well-being and joy, what would one say? In this issue of JAMA , Gill and Feinstein 1 take the philosophical position that only the individual can rate quality of life, and if the individual says that it is excellent, that is what it is. From this perspective, they
TL;DR: Dedicated ICU pharmacists are crucial healthcare team members in a multidisciplinary ICU that provide continuity in individualized pharmacotherapeutic care, and serve an important educational function in addition to substantially reducing drug costs.
Abstract: ObjectivesTo describe the activities of a clinical intensive care unit (ICU) pharmacist and to determine whether pharmacist-initiated consultations lead to changes in drug costs.DesignProspective, 3-month study.SettingA 15-bed, university-affiliated, tertiary care medical-surgical ICU.InterventionsT
TL;DR: Establishing the wide variety of patient-specific complaints associated with Hypothyroidism provides guidance for clinicians dealing with hypothyroid patients, and investigators interested in HRQOL impairment in these patients.
Abstract: The aim of this study is to evaluate the frequency and relative importance of different aspects of health related quality of life (HRQOL) impairment in patients with hypothyroidism. A survey of 200 patients with treated hypothyroidism was undertaken. Patients were identified and questionnaires distributed through family physicians, endocrinologists, and regional branches of the Thyroid Foundation of Canada. Frequency of importance of patients' symptoms attributed to hypothyroidism and resolved or improved with treatment were measured. Establishing the wide variety of patient-specific complaints associated with hypothyroidism provides guidance for clinicians dealing with hypothyroid patients, and investigators interested in HRQOL impairment in these patients.
TL;DR: Insufficient experimental data exist to permit conclusions that enteral nutrition formulations or supplements reduce infectious morbidity and mortality rates, but results are promising enough to warrant further research.
Abstract: ObjectiveTo examine the relationship between the formulation of enteral nutrition and nosocomial infection in critical illness.Data SourcesComputerized search of published research and reference list review.Study SelectionReview of 151 citations. Included are 31 primary studies in which the authors
TL;DR: Regular use of beta agonists in doses higher than two puffs four times a day is very unlikely to provide additional functional or symptomatic benefit to patients with chronic airflow limitation.
Abstract: BACKGROUND--A study was undertaken to determine the impact of different doses of inhaled terbutaline on peak flow rates, spirometric parameters, functional exercise capacity, and quality of life in patients with chronic airflow limitation. METHODS--A double blind, randomised, placebo controlled, multiple crossover trial was conducted with treatment periods of one week. Patients with a clinical diagnosis of chronic airflow limitation and FEV1 below 70% predicted after administration of bronchodilator were recruited from secondary care respiratory practices, and the effect of 500, 1000, and 1500 micrograms inhaled terbutaline four times daily on spirometric parameters (FEV1, FVC), maximum inspiratory pressures, six minute walking distance, and health-related quality of life (Chronic Respiratory Disease Questionnaire, Quality of Well Being, Standard Gamble) was measured. RESULTS--Twenty five patients completed the trial. Peak flow rates and FEV1 showed statistically significant but clinically trivial improvement on the higher drug doses. Results of maximum inspiratory pressure measurements, walk test distance, and quality of life measures showed minimal differences on the different dosages, and none of the differences approached conventional statistical significance. CONCLUSIONS--Regular use of beta agonists in doses higher than two puffs four times a day is very unlikely to provide additional functional or symptomatic benefit to patients with chronic airflow limitation.
TL;DR: Criteria to aid intensive care workers in the assessment of diagnostic technologies is presented, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia.
Abstract: Objective To present criteria to aid intensive care workers in the assessment of diagnostic technologies, using the example of bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Data sources MEDLINE was used to search for articles published from 1969 to the present that concerned diagnostic tests, diagnostic technology, pneumonia, and critically ill patients. Study selection Clinical investigations, case control studies, case series, and experimental data on the use of bronchoalveolar lavage. Studies of diagnostic technology were also included. Data extraction We extracted relevant data in duplicate, independently. Data synthesis Diagnostic technology assessment should begin by establishing the capability of the technology under ideal or laboratory conditions, followed by an exploration of the range of possible uses as well as the accuracy of the test. Bronchoalveolar lavage is a well-established technology for the diagnosis of pneumonia in immunocompromised patients. Studies of the accuracy of bronchoalveolar lavage in ventilator-dependent but nonimmunocompromised patients have shown promising diagnostic accuracy. Accuracy, however, is insufficient for dissemination of a test; an evaluation of the impact of a test on management decisions and, most importantly, on patient outcome, is required. Investigators have not addressed the full impact of bronchoalveolar lavage, and, even if the test is accurate, there are reasons to doubt whether patients will be better off if the test becomes part of routine clinical practice. Conclusions We present guidelines for the assessment of diagnostic technology, and apply them to bronchoalveolar lavage for the evaluation of ventilator-associated pneumonia. Bronchoalveolar lavage has been studied in both the laboratory and clinical setting, and the diagnostic sensitivity and specificity of this technique are high. Further randomized trials evaluating management decisions and patient benefit would facilitate decisions regarding the appropriate dissemination of bronchoalveolar lavage.
TL;DR: It appears that sucralfate results in a lower incidence of nosocomial pneumonia than either antacids or histamine-2-receptor antagonists.
Abstract: We performed a meta-analysis to evaluate whether stress ulcer prophylaxis with histamine-2-receptor antagonists or antacids reduces mortality in critically ill patients. It appears that sucralfate results in a lower incidence of nosocomial pneumonia than either antacids or histamine-2-receptor antagonists. With respect to mortality, strong trends favored sucralfate over both antacids and histamine-receptor antagonists.
TL;DR: Practice guidelines, like scientific overviews, economic evaluations and decision analyses, are part of an increasing body of the medical literature referred to as synthetic research, which provides short cuts for busy clinicians who want to practice medicine based on the best evidence available.
Abstract: Clinical practice guidelines are systematically developed statements to assist practitioners' decisions about appropriate health care for specific clinical circumstances [1]. They attempt to distil a large body of medical expertise into a convenient, readily useable format. Clinical practice guidelines are aimed at improving the quality of patient care and maximizing the efficiency with which scarce resources are used. The avalanche of undigested scientific and clinical data in the biomedical literature can leave physicians in a quandary. There appears to be a distressing distance between health care knowledge in general, and the practices of individual clinicians. We perhaps have placed too much faith in the model of the rational, informationseeking, probabilistic practitioner, expecting the mere availability of new information to lead to appropriate and timely changes in his or her clinical decision making [2]. Delays in physician awareness of relevant new literature have been well documented, including limited implementation of life-saving treatments during and following myocardial infarction [3-6]. Practitioners must search, retrieve and critically appraise medical literature before applying it at the bedside. However, peer-review clinical journals have been identified as impeding the dissemination of validated advances to practitioners by mixing a few rigorous studies (communications from scientists to practitioners) with many preliminary investigations (communications from scientists to scientists) [7]. Practice guidelines, like scientific overviews, economic evaluations and decision analyses, are part of an increasing body of the medical literature referred to as synthetic research. Synthetic research is a type of research, which, if conducted rigorously, provides short cuts for busy clinicians who want to practice medicine based on the best evidence available.