Western Journal of Medicine

Published by BMJ Publishing Group
Online ISSN: 0093-0415
Publications
Article
TWO HYPOTHESES ARE OFFERED IN THIS REVIEW OF CLINICAL INFORMATION SYSTEMS: that the technology is mature, and that benefits to patient care can be shown. More than ten years of operational experience exist with each general class of clinical information systems, and these systems favorably affect staff, reduce errors, improve accessibility to medical information and provide alerts and reminders. To reinforce the maturity hypothesis, most cited studies are also a decade old. Clinically oriented systems are practical and can improve the health care process-a key goal in this era of prepaid or prospective payment for services.
 
Article
From 1969 through December 31, 1981, a total of 232 patients with an ejection fraction of 0.2 or less (normal 0.67) had myocardial revascularization. The in-hospital mortality in these patients decreased from 25 deaths in 82 patients (30%) from 1969 through 1972 to 10 deaths in 150 patients (7%) from 1973 through December 31, 1981. There was a 24% five-year survival for patients in congestive heart failure at the time of operation, a 40% survival at five years for patients successfully treated for failure before operation and a 60% five-year survival for those patients who had never been in failure. These results would appear to be better than those with cardiac transplantation, with neither the restrictions for operation nor the long-term immunotherapy required with cardiac transplantation.
 
Article
We report an isolated case from northern California of a patient who acquired a non-01 V cholerae infection and a classic cholera-like syndrome but who had not eaten raw seafood or traveled out of the country.
 
Article
To examine the financial and organizational characteristics, demand for services, and satisfaction outcomes of a growing telemedicine program serving both urban or suburban and rural populations. Retrospective review of 1,000 consecutive telemedicine consultations in the University of California (UC) Davis Telemedicine Program. Telemedicine videoconferencing units, used to integrate care in the UC Davis Health System among the UC Davis Medical Center and several urban or suburban primary care clinics, rural hospitals, and clinic affiliates. A total of 657 consecutive patients who consented to a telemedicine consultation. Main outcome measures Demographic information about the patient population, the rural and urban or suburban clinics, the types of specialty consultations, and telemedicine equipment used in the UC Davis Health System. Patient and physician satisfaction were measured on a 5-point Likert scale. Patients and primary care physicians reported high levels of satisfaction. Rural clinics requested more and a greater variety of specialist consultations than urban or suburban clinics. Although referring physicians and patients indicate a high level of satisfaction with telemedicine services and insurers are negotiating reimbursement policies, additional research must investigate the reasons why some payers, patients, and providers resist participation in these services.
 
Article
To understand causes of patient dissatisfaction that result in complaints. Grievances received by the grievance committee between January 1, 1989, and January 1, 2000, were reviewed. A 2-county area of North Carolina. Of 29 patients who filed grievances, the 9 male (31%) and 20 female (69%) patients had a mean (+/-SD) age of 39 (+/-19) years. In 18 instances, the patient consulted the physician less than 3 times (64%) before the complaint and in 8 instances more than 4 times (29%). Main outcome measures Allegations of the grievance and the committee's findings. Grievances fell into 5 categories: failure to fulfill expectations for examination and treatment (38%), failure to promptly diagnose (20%), rudeness (17%), producing excessive pain or practicing beyond the area of expertise (13%), and inappropriate behavior related to billings (10%). In 45% of the grievances, the committee found no breach of practice standards. In 17% of the cases, the physician resolved the grievance by apologizing, adjusting a bill, or completing insurance forms. Most grievances were filed by younger women against newly encountered physicians and were related to inadequate communication or alleged delay in diagnosis.
 
Article
The electrocardiographic response to exercise stress testing (EST) was compared with coronary arteriographic findings in 114 men referred for evaluation of chest pain. The men were divided into two groups: group A (69 men) in whom the coronary arteriograms showed at least one major vessel with greater than 70 percent reduction in cross sectional area, and group B (45 men) in whom there was no evidence of coronary arterial narrowing. In both groups A and B the description of chest pain was judged to be at least consistent with the diagnosis of angina pectoris if not always representing classical angina pectoris. Only men with a positive finding to EST and those with a negative EST response after achieving at least 90 percent of predicted maximum heart rate were included in the calculations. Our results were strikingly similar to those obtained from an extensive review of the literature and showed the following: sensitivity, 80.4 percent; specificity, 88.6 percent; predictive value of a positive test result, 91.1 percent; predictive value of a negative test result, 75.6 percent, and efficiency of the test 83.7 percent. The maximal EST is a useful predictor of coronary artery disease when a male population is evaluated for chest pain. When a population is selected on some basis other than chest pain (such as elevated lipids or age), EST is a much less useful predictor of coronary artery disease.
 
Article
There are risks of adverse outcomes to patients in the course of health care management. A study was undertaken to measure these outcomes in California for 1974. Secondary benefits of the study include new insights into the types and sources of disabilities caused by health care management and the development of new methods for carrying out generic adverse-outcome monitoring.
 
Article
Disturbances in zinc homeostasis are being reported in increasing numbers. Concomitantly nutritional support with zinc and other vitamin and mineral supplements is currently being advertised as adjunctive treatment in conditions where dietary intake has been inadequate. Some examples include conditions such as alcoholism, major burns, prolonged infections, massive trauma and repeated surgical interventions. Furthermore, within the past five years, two seperate disorders of zinc metabolism have been recognized and the standard American diet has been calculated to be on occasions marginal or deficient in zinc. Studies in humans presently indicate that zinc is needed for achievement of normal growth, for normal sexual maturation and function, and for maintenance of a normal appetite and taste acuity. Wound-healing, normal psychocognitive function and preservation of the integrity of epithelial surfaces also depend on an adequate nutritional intake of zinc. Zinc is a trace element - that is, an element that forms less than 0.01 percent of the body weight - whose essentiality as a nutrient for mammals was discovered more than 40 years ago. Because this metal is fairly ubiquitous, human deficiencies of nutritional origin were considered improbable. In 1961, however, Prasad suggested that a syndrome of dwarfism and hypogonadism, seen in adolescents in Iran, might be caused by a nutritional deficiency of zinc, and attention was drawn to the possibility of zinc deficiency in man. In this article, pertinent aspects of zinc metabolism and biochemical functions in humans will be reviewed, with reference, when necessary, to animal studies. The disease states in which zinc supplementation may be useful will then be discussed.
 
Article
In 140 patients with suspected intraabdominal abscess, studies were made using gallium-67 citrate and technetium-99m labeled radiopharmaceuticals. Gallium-67 scintigrams correctly localized 52 of 56 intraabdominal abscesses confirmed at surgical operation or necropsy. In an additional 20 patients in whom findings on scintigrams were abnormal, there were clinically established infections. Sixty-one patients in whom findings on scintigrams were normal were conservatively managed and discharged from the hospital; none proved to have an abscess. Four false-negative and three false-positive studies were recorded. Gallium-67 scintigraphy is a useful noninvasive diagnostic adjunct that should be employed early in the evaluation of patients with suspected intraabdominal sepsis.
 
Article
This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.
 
Article
The flexible fiber-optic sigmoidoscope is rapidly replacing the rigid sigmoidoscope in routine screening for colorectal cancer. This study was undertaken to evaluate the safety, usage pattern, and efficacy of fiber-optic sigmoidoscopy by evaluating the outcome of training and the results of procedures carried out by a group of primary care physicians. Of 1,153 participants in one-day flexible sigmoidoscopy workshops, 764 (66%) returned questionnaires evaluating their experiences following this training. Of these, 438 physicians had obtained a flexible sigmoidoscope, used it frequently, and had done a total of 17,167 examinations. The average time of scope usage was nine months. Although additional supervised training was suggested at the time of the workshop, 68% of physicians began doing flexible sigmoidoscopy without it. A total of 465 polyps and 153 cancers were detected by the study group for an overall detection rate of 2.7% for polyps and 0.9% for cancers. Four complications were reported. This study indicates that the technique of flexible sigmoidoscopy is readily learned, is diagnostically productive, and is reasonably safe in the hands of primary care physicians.
 
Article
Beethoven began to lose his hearing at age 28. By age 44, his hearing loss was complete, most likely caused by compression of the eighth cranial nerve associated with Paget's disease of bone. Beethoven's head became large, and he had a prominent forehead, a large jaw, and a protruding chin (see picture)—features that are consistent with Paget's disease. Eventually, his hat and shoes did not fit because of bone enlargement.
 
Participation in subsequent screening according to the result of the screening test in the previous pregnancy 
Participation in subsequent screening given a screen-positive result for either Down syndrome or neural tube defect in the previous pregnancy, stratified by degree of increased risk of previous result 
Article
To determine whether women who have had a positive serum screening result for Down syndrome or neural tube defect in 1 pregnancy have a lower rate of participation in screening in their next pregnancy. A triple-marker screening program at a university hospital. Pregnancy and screening information was collected from laboratory and hospital databases to compare subsequent screening participation of women who were screen-negative and screen-positive for the risk of a fetus with Down syndrome or a neural tube defect. In an age-matched comparison, 108 women who had a previous screen-positive result were significantly less likely than 108 women who were screen-negative to participate in maternal serum screening in their next pregnancy. When examined according to the type of screen-positive result, the effect was significant for both those who were screen-positive for Down syndrome and those who were screen-positive for neural tube defect. The degree of risk in screen-positive women did not significantly affect their participation in screening in the next pregnancy. Anxiety related to a screen-positive result probably causes decreased participation in maternal serum screening in the next pregnancy. Reducing the screen-positive rate in prenatal serum screening would alleviate maternal anxiety and would probably lead to more stable participation.
 
Article
In January 2000, the American Psychological Association's flag-ship journal, American Psychologist, dedicated an entire issue to the growing field of “positive psychology,” including both theory and practical applications. The special issue was highly relevant to physician well-being, and in this article I summarize and critique its key papers. Subsequent developments in positive psychology—including conferences, further readings, and grant awards—are available at http://www.apa.org/releases/positivepsy. html or the journal editor's web site, http://psych.upenn.edu/seligman.
 
Article
I examined the pattern of mortality in the Donner Party, a group of emigrants who became trapped with inadequate food stores in the winter snows of the Sierra Nevada mountains in 1846-1847. The party consisted of 90 persons; the median age was 19.5 years (range, 1 to 70), 55 (61%) were male, and 72 (80%) were traveling with family members. Of the 90 persons, 42 (47%) died. Multivariate regression analysis indicated that age was the most important mortality risk factor. The lowest mortality (10%) was seen in the 6- to 14-year age group, and the highest was for persons younger than 6 years (relative risk = 6.6; 95% confidence interval [CI], 2.3 to 9.6) and persons 35 years or older (relative risk = 8.4; 95% CI, 3.4 to 10.2). Persons traveling without other family members had a relative risk of 2.0 (95% CI, 1.0 to 2.5). Men and boys were also at increased risk (relative risk = 2.0; 95% CI, 1.0 to 2.9). These factors can identify persons at increased risk for mortality in nutritionally stressed populations, and efforts to maintain intact family structures may improve survival.
 
Article
A striking feature of van Gogh's famous painting “The Starry Night” is the yellow corona surrounding each star. The use of yellow characterizes many of the paintings of this Dutch post-impressionist, and much speculation surrounds van Gogh's fascination with this vibrant pigment. Did he simply like the color, or was his preference influenced by some medical condition? Because numerous disorders have been diagnosed posthumously in this artist, various theories have been proposed to explain how van Gogh's physical state may have influenced his work. Two theories center on why he used so much yellow. First, he was fond of absinthe, a popular liqueur containing thujone. Excessive consumption of this liqueur may cause the consumer to see all objects with a yellow hue. Investigations conducted in 1991, however, showed that a person must drink 182 liters of absinthe to produce this visual effect, so we can discount this theory. A second and more likely explanation involves overmedication with digitalis. People receiving large and repeated doses of this drug often see the world with a yellow-green tint. They complain of seeing yellow spots surrounded by coronas, much like those in “The Starry Night.” The artitists's physician, Paul-Ferdinand Gachet, may have treated van Gogh's epilepsy with digitalis, a common practice at that time. In one of van Gogh's three portraits of Gachet, the physician holds a stem of Digitalis purpurea, the purple foxglove from which the drug is extracted (see figure). Plagued by psychiatric illness throughout his life, van Gogh committed suicide in 1890. Evidence suggests that he had manic depression, a chronic mental illness thought affects many creative people. Although treatment with lithium carbonate is now available, the drug also dampens creative abilities. Many people believe that artists overcome suffering with their creative acts, but suffering may also overwhelm the artist. Had lithium carbonate therapy been available, van Gogh might have defeated his manic depression, avoided his tragic fate, and grown further as an artist. “If I could have worked without this accursed disease, what things I might have done,” he wrote in one of his last letters.
 
Article
California's ballot proposition 187, passed by the voters in November 1994, threatened to discontinue undocumented immigrants' eligibility for most health services while mandating that health care professionals report suspected undocumented patients to authorities. Although the proposition has not been put into practice, reports suggest that its passage was associated with a decline in the use of health services by some groups. To assess the effects of the passage of Proposition 187 on the use of primary care services, we surveyed a representative sample of California clinics serving low-income groups (n = 129). Using a mailed questionnaire and phone interviews with clinic directors, we obtained qualitative and quantitative data regarding the effects of the passage of the proposition on clinic use. Among primary care clinics statewide and clinics serving predominantly Latino patients, we detected no significant decline in total monthly visits following the election. Nevertheless, half of clinic directors (51%) thought that the number of clinic visits declined after the passage of Proposition 187, and many directors thought that the deterrent effects of the election persisted for weeks to months after the election. Whereas the number of visits probably declined at some clinics, only a small minority of patients at most primary care clinics could have been deterred from seeking care after the passage of Proposition 187.
 
Top-cited authors
Robert Derlet
  • University of California, Davis
Gerrit van der Wal
  • Vrije Universiteit Amsterdam
Tony Hak
  • Rotterdam School of Management
Barry M Popkin
  • University of North Carolina at Chapel Hill
Juan Ruiz
  • State of California, United States