Performance failure of an evidence-based upper respiratory infection clinical guideline.

BACKGROUND: We evaluated an upper respiratory infection (URI) clinical guideline to determine if it would favorably affect the quality and cost of care in a health maintenance organization. METHODS: Patients with URI symptoms contacting 4 primary care practices before and after guideline implementation were compared to ascertain what proportion of all patients with respiratory symptoms were eligible for treatment in accordance with the URI guideline; what proportion of eligible patients were managed without an office visit; and what proportion of eligible patients were treated with antibiotics, before and after guideline implementation. RESULTS: A total of 3163 patients with respiratory symptoms were identified. Of these, 59% (n = 1880) had disqualifying symptoms or comorbid conditions for URI guideline care, and 28% (n = 1290) received disqualifying diagnoses on the day of first contact, leaving 13% (n = 408) who received a diagnosis of URI and were eligible for care in accordance with the guideline. Among this group of patients, the proportion who received guideline-recommended initial telephone care was 45% preguideline and 47% postguideline (chi2 = 0.40; P = .82). Likelihood of a subsequent office visit increased from pre- to postguideline (chi2 = 17.1; P <.01), although the majority of patients had no further diagnoses other than URI. Antibiotic use for the initial URI diagnosis declined from 24% preguideline to 16% postguideline (chi2 = 3.97; P = .046), but antibiotic use during 21-day follow-up did not change (F = 0.46, P = .66). The mean cost of initial care was $37.80 preguideline and $36.20 postguideline (P >.05). CONCLUSIONS: Only 13% of primary care patients with respiratory symptoms were eligible for URI guideline care. Among eligible patients, use of the guideline failed to decrease clinic visits, decrease antibiotic use during a 21-day period, or reduce cost of care to the health plan.     

Clinical features and treatment of acute bronchitis

Although several surveys rank acute bronchitis as one of the ten most frequent diagnoses made by primary care physicians, its clinical features are poorly defined and treatment with antibiotics is controversial. This study was designed to determine the clinical characteristics that providers use to diagnose acute bronchitis and to examine the use of antibiotics in treating this illness. Charts of patients with the diagnosis of acute bronchitis or upper respiratory tract infection (URI) were randomly selected and progress notes from these visits were reviewed. Signs, symptoms, laboratory tests, and antibiotics prescribed were recorded. Patients with a diagnosis of acute bronchitis had more productive cough, purulent sputum, and abnormal lung examinations than patients with a diagnosis of URI (P less than .05 for each characteristic). Laboratory tests, including chest roentgenograms, were not frequently used in making the diagnosis of acute bronchitis. Antibotics were prescribed for 27 of 29 patients (92 percent) with a diagnosis of acute bronchitis but for only 4 of 19 patients (21 percent) with a diagnosis of URI. Erythromycin was prescribed for 60 percent of patients with acute bronchitis. From this study it can be concluded that providers use the term acute bronchitis to designate a specific clinical syndrome that they treat with antibiotics. Further clinical trials are needed to evaluate the efficacy of such antibiotic therapy.     

The effect of labeling on perceived ability to recover from acute illnesses and injuries

BACKGROUND: The process of giving a patient a diagnosis may cause harm. The adverse effects of labeling, best documented for the diagnosis of hypertension, include increased absenteeism from work and lower earnings, increased depressive symptoms, and reduced quality of life. We tried to determine whether the diagnosis of hypertension affects perceptions about the time required to recover from common acute medical problems. METHODS: In an academic family practice clinic, equal numbers of patients with and without hypertension were asked to estimate how long it would take them to recover from an upper respiratory tract infection (URI), a urinary tract infection (UTI), and an ankle sprain now and 5 years ago (before the diagnosis of hypertension). RESULTS: Compared with patients who did not have hypertension, patients with hypertension estimated that it would take them twice as long, on average, to recover from a URI now (11.7 vs 6.0 days, P=.002) and in the past (10 vs 5.5 days, P=.02). These differences persisted after controlling for age, sex, race, and education. No significant differences were found for estimated recovery times for UTI or ankle sprain. CONCLUSIONS: The diagnosis of hypertension may affect patients' perceptions of their ability to recover from unrelated acute illnesses. This may have implications for the way physicians choose to present information to patients.     

Exposure to community violence and upper respiratory illness in older adolescents

PurposeTo examine the relationship between exposure to chronic community violence and upper respiratory illness (URI) symptoms among urban adolescents of color; and to test the generality of a model of the relationship between social stress and URI.MethodThe research used a cross-sectional correlational design. The sample was 769 first-semester first-year students in an urban nonresidential 4-year college from the academic years 1999–2002. Data were collected by a group-administered questionnaire in academic classes. The research used three multi-item additive scales (each with high reliability and validity): exposure to community violence, psychological distress, and URI symptoms. Multiple regression procedures were used to analyze the data.ResultsPositive correlations were obtained between: exposure to community violence and reporting of URI (r = .19), exposure and psychological distress (r = .22), and psychological distress and URI (r = .51). The relationship between exposure to community violence and URI is greatly reduced when level of psychological distress is statistically controlled.ConclusionsExposure to community violence is related to experiencing URI symptoms among older urban adolescents of color; the effect size of the relationship is small-medium. Psychological distress mediates the impact of exposure to community violence on URI. The findings expand the range of social stressors that are empirically related to URI, and populations in which a relationship between social stressors and URI may be found.     

Daily air pollution effects on children's respiratory symptoms and peak expiratory flow

To identify acute respiratory health effects associated with air pollution due to coal combustion, a subgroup of elementary school-aged children was selected from a large cross-sectional study and followed daily for eight months. Children were selected to obtain three equal-sized groups: one without respiratory symptoms, one with symptoms of persistent wheeze, and one with cough or phlegm production but without persistent wheeze. Parents completed a daily diary of symptoms from which illness constellations of upper respiratory illness (URI) and lower respiratory illness (LRI) and the symptom of wheeze were derived. Peak expiratory flow rate (PEFR) was measured daily for nine consecutive weeks during the eight-month study period. Maximum hourly concentrations of sulfur dioxide, nitrogen dioxide, ozone, and coefficient of haze for each 24-hour period, as well as minimum hourly temperature, were correlated with daily URI, LRI, wheeze, and PEFR using multiple regression models adjusting for illness occurrence or level of PEFR on the immediately preceding day. Respiratory illness on the preceding day was the most important predictor of current illness. A drop in temperature was associated with increased URI and LRI but not with increased wheeze or with a decrease in level of PEFR. No air pollutant was strongly associated with respiratory illness or with level of PEFR, either in the group of children as a whole, or in either of the symptomatic subgroups; the pollutant concentrations observed, however, were uniformly lower than current ambient air quality standards. Moreover, since exposure estimation based on monitoring of ambient air likely results in misclassification of the true exposure, the negative findings of this study must be interpreted cautiously.     

Postviral syndrome--how can a diagnosis be made? A study of patients undergoing a Monospot test.

Eighty-nine of 150 patients having a Monospot test filled out a questionnaire about their illness, and the General Health Questionnaire. They completed a follow-up questionnaire 6 months later. Twelve (8%) had a positive Monospot. Twenty-eight of 83 serum samples tested (34%) were positive for VP1 enteroviral antigen. Forty of the patients had a self limiting illness, 13 had a definite diagnosis (excepting glandular fever), 14 had a possible postviral syndrome, 10 had recurrent sore throats/flu, and 12 had a chronic non-specific illness. Patients with a specific diagnosis were less likely to complain of aching muscles/joints, sore throat, tiredness or loss of concentration. Their GHQ scores were lower, although this just failed to reach significance (P = 0.08), and they scored significantly lower on the somatic symptoms subscale (P = 0.022). Overall 72% scored above the GHQ threshold for 'psychological caseness' which is higher than in other studies. Sixty-five per cent of the sample questioned at 6 months felt that their illness started with a viral infection. The methodological problems involved in making a diagnosis of postviral syndrome are discussed.     

Care-seeking behavior for upper respiratory infections

BACKGROUND: Many recent efforts to reduce unnecessary medical services have targeted care of upper respiratory infections (URIs). We tested whether patients who seek care very early in their illness differ from those who seek care later and whether they might require a different approach to care. METHODS: We surveyed by telephone 257 adult patients and 249 parents of child patients who called or visited one of 3 primary care clinics within 10 days (adults) or 14 days (parents) of the onset of uncomplicated URI symptoms. Those who contacted the clinic within the first 2 days of illness were compared with those who made contact later. RESULTS: Although 28% of adults and 41% of parents contacted their clinic within the first 2 days of symptom onset, we found very few differences in the characteristics of the caller or patient between those who called early and later. The illnesses of those who called early were not more severe, and they did not have different beliefs, histories, approaches to medical care, or needs. The only clinician-relevant difference was that adult patients calling in the first 2 days had a greater desire to rule out complications (84.7% vs 64.1% calling in 3-5 days and 70.6% calling after 5 days of illness, P < or = .05). CONCLUSIONS: Those who seek medical care very early for a URI do not appear to be different in clinically important ways. If we are going to reduce overuse of medical care and antibiotics for URIs, clinical trials of more effective and efficient strategies are needed to encourage home care and self-management.     

A controlled comparison of symptoms and chemical intolerances reported by Gulf War veterans, implant recipients and persons with multiple chemical sensitivity.

Using the Environmental Exposure and Sensitivity Inventory (EESI), a standardized instrument for measuring chemical sensitivity, we obtained and compared ratings of symptoms, chemical (inhalant) intolerances, other intolerances (e.g., drugs, caffeine, alcohol, skin contactants), lifeimpact, and masking (ongoing exposures) in five populations: multiple chemical sensitivity (MCS) patients who did (n = 96) or did not (n = 90) attribute onset of their illness to a specific exposure event, patients with implanted devices (n = 87), Gulf War veterans (n = 72), and controls (n = 76). For each patient group, mean scores on the first four scales were significantly greater than for controls. MCS patients reported avoiding more chemical exposures (were less masked) than the other groups. Across groups, for a given level of symptoms, as masking increased, mean scores on the Chemical Intolerance Scale decreased. In contrast, mean scores on the Other Intolerance Scale appeared to be less affected by masking. These findings suggest that some patients with antecedent chemical exposures, whether exogenous (chemical spill, pesticide application, indoor air contaminants) or endogenous (implant), develop new chemical, food, and drug intolerances. Reports of new caffeine, alcohol, medication, food, or other intolerances by patients may signal exposure-related illness. Masking may reduce individuals' awareness of chemical intolerances, and, to a lesser degree, other intolerances.     

根除幽门螺杆菌对胃黏膜病变影响的观察

目的随访评估根除幽门螺杆菌对慢性胃炎患者胃粘膜病理组织学变化的影响.方法选择幽门螺杆菌阳性的慢性胃炎病人,分为根除组和对照组,分别予根除HP治疗和对症治疗.治疗前和治疗结束后半年分别行胃镜检查,活检病理组织学检查.比较根除HP前后黏膜病理组织学变化情况.结果全部80例病人随机分为根除组(n=40)和对照组(n=40).半年后,根除组29例HP完全根除,对照组27例仍为HP阳性.在根除组,黏膜急性炎和慢性炎的组织学积分明显降低(P＜0.001),肠化生的组织学积分亦有降低 (P=0.021).而对照组,急性炎的组织学积分升高 (P=0.034),慢性炎和肠化生未见明显变化(P＞0.05),两组的萎缩性病变均无明显变化(P值分别为0.53和0.64).结论根除HP可使胃粘膜急慢性炎症明显消退,减轻并有可能逆转肠化生病变.     

Platelet and erythrocyte membrane fluidity changes in alcohol-dependent patients undergoing acute withdrawal.

This study tested the hypothesis that membrane fluidity may alter during the alcohol-withdrawal syndrome. Platelet membranes of alcohol-dependent patients (n = 7) were significantly more rigid than controls (n = 7) at the start of alcohol withdrawal (mean fluorescence anisotropy 203.1 x 10(-3) vs 195.5 x 10(-3) respectively, P = 0.03), but were significantly more fluid when withdrawal was complete (191.4 x 10(-3) vs 199.2 x 10(-3), P = 0.03). Consequently platelet membranes of patients adapted to the known acute fluidizing effect of alcohol by becoming more rigid, but underwent a marked fluidization during withdrawal. There were no significant changes in erythrocyte membrane fluidity during withdrawal.     

Needs of family caregivers caring for stroke patients: based on the rehabilitation treatment phase and the treatment setting

The objective of the study was to identify the needs of family members across rehabilitation treatment phases and treatment settings. Participants were 123 family caregivers in rehabilitation settings in South Korea that replied to the survey. The needs were measured by the Family Needs Questionnaire (FNQ) and the t-test and one-way ANOVA were used to analyze collected data. In the comparison of two rehabilitation phases, the family caregivers caring for their patients in the acute rehabilitation phase perceived the need for health information as more important than those in the postacute phase. In addition, the family caregivers caring for patients in the acute rehabilitation phase were less satisfied with community network support and family support than those in the postacute phase. In the comparison of treatment settings, family caregivers caring for their patients in outpatient clinic services showed the lowest satisfaction of their needs in four areas (health information, emotional support, instrumental support, and professional support) compared with those in inpatient facilities or day hospitals. Findings are discussed within the context of the empirical and theoretical literature and implications for social work practice are considered.     

9516例妊娠早期妇女焦虑和抑郁症状与孕产史的关系

目的 探讨孕产史对妊娠早期妇女焦虑和抑郁症状发生率的影响。方法 采用广泛焦虑量表(generalized anxiety disorder-7 items, GAD-7)和患者健康问卷(patient health questionaire-9 items, PHQ-9)评测重庆市妇幼保健院产科门诊2020年2―10月建档的9 516例妊娠早期妇女焦虑和抑郁症状。单因素分析检测焦虑和抑郁症状的影响因素,logistics回归分析模型进一步分析孕产史对焦虑和抑郁症状发生率的影响。结果 妊娠早期妇女焦虑和抑郁症状检出率分别为18.9%和47.5%。单因素分析显示年龄、孕前BMI、吸烟史、饮酒史、过敏史、产次和流产次数与焦虑和抑郁症状相关(均有P<0.001)。校正混杂因素后,logistics回归分析模型分析显示相较于再产妇,初产妇焦虑症状的发生率增高(OR=1.16, 95%CI:1.01～1.33,P=0.031);流产史增加焦虑(OR=1.26, 95%CI:1.13～1.41,P<0.001)和抑郁(OR=1.19, 95%CI:1.09～1.29,P<0.001...     

Child day care risks of common infectious diseases revisited

BACKGROUND: The increased risk of common infectious diseases associated with child day care attendance may vary by age, health plan and parent educational level. This study determined quantitatively the risk of diarrhoeal illness and upper respiratory infection (URI) among day-care children in comparison with home-care children. It examined the extent of risks in day-care children under different conditions of three age groups, enrolled in two health plans, and from families of two levels of education. METHODS: The study subjects were recruited through two health plans: a Health Maintenance Organization (HMO) and the Medicaid program in Columbia, South Carolina of the USA. The sample was collected using a household survey of children, aged 5 years or younger. The participants were contacted bimonthly for 18 months with 435 attending out-of-home day care facilities and 753 being cared for at home. The potential confounding factors of family characteristics were controlled in examining the odds ratios for day care effect on common infections in children under different conditions. RESULTS: In general, risks of diarrhoeal illness and URI in day-care children are greater than in home-care children. Children younger than 1.5 years of age attending day care and covered by the Medicaid program are at the greatest risk. The difference in risks between day-care and home-care children, however, is reduced to an insignificant level for children older than 1.5 years of age and for children covered by the HMO health plan. Among day-care children, those who are covered by the Medicaid program are at a significantly higher risk than those who are covered by the HMO health plan. CONCLUSIONS: Although day-care children in general suffer a greater risk of common infectious diseases, the extent of day care effect on risks of diarrhoeal illness and URI varies significantly by age and type of health insurance plan.     

Debiasing effects of education about appropriate antibiotic use on consumers' preferences for physicians

A major goal of this research was to identify an antibiotic education intervention that would increase young adult consumers' preference for physicians who do not unnecessarily prescribe antibiotics for simple acute upper respiratory infections (URIs). Results clearly showed that consumers who read the CDC brochure entitled, "A New Threat to Your Health: Antibiotic Resistance" significantly preferred the physician who would not prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability than the physician who would prescribe antibiotics. In contrast, consumers who did not read the CDC brochure significantly preferred the physician who would prescribe antibiotics for a URI on Day 3. They also inferred that this physician had significantly greater ability and greater concern for patients than the physician who would not prescribe antibiotics. Thus, consumers with low knowledge exhibited a treatment bias and preferred physicians who provided more treatment, and consumer education successfully reversed the treatment bias.     

The relationship between HIV seroconversion illness, HIV test interval and time to AIDS in a seroconverter cohort

Seroconversion illness is known to be associated with more rapid HIV disease progression. However, symptoms are often subjective and prone to recall bias. We describe symptoms reported as seroconversion illness and examine the relationship between illness, HIV test interval (time between antibody-negative and anibody-positive test dates) and the effect of both on time to AIDS from seroconversion. We used a Cox model, adjusting for age, sex, exposure group and year of estimated seroconversion. Of 1820 individuals, information on seroconversion illness was available for 1244 of whom 423 (34%) reported symptomatic seroconversion. Persons with a short test interval (< or = 2 months) were significantly more likely to report an illness than people with a longer interval (OR 6.76, 95% CI 4.75-9.62). Time to AIDS was significantly faster (P = 0.01) in those with a short test interval. The HIV test interval is a useful replacement for information on seroconversion illness in studies of HIV disease progression.     

The illness burden of alcohol-related disorders among VA patients: the veterans health study

Little is known about the illness burden associated with alcohol-related disorders (ie, problem drinking, alcohol abuse, and alcohol dependence) among patients in outpatient medical care. The objective of this study was to examine several aspects of illness burden-medical comorbidities, patterns of health services use, and functional status-among Veterans Health Administration (VA) ambulatory care patients with alcohol-related disorders. Male participants (N = 2425) were recruited at 1 of 4 Boston-area VA outpatient clinics. They completed self-report screening measures of current alcohol-related disorders (CAGE score > or =2 with past year alcohol consumption), health behaviors, medical comorbidities, and functional status (SF-36). A medical history interview, which assessed comorbid conditions and use of recent health services, was also administered. Screening criteria for current alcohol-related disorders were satisfied by 12%; however, only 40% of these reported ever receiving treatment specifically for alcohol-related disorders. Patients who screened positive for alcohol-related disorders reported significantly greater limitations in mental health function, longer hospitalizations for medical care in the prior year, and fewer outpatient medical visits in the previous 3 months. Findings suggest considerable illness burden associated with alcohol-related disorders among VA ambulatory care patients. Efforts to increase detection and treatment of alcohol-related disorders may lessen the illness burden and cost of alcohol-related disorders.     

Admission alcohol level: a predictor of the course of alcohol withdrawal.

BACKGROUND. Little is known about how to predict the course of alcohol withdrawal. This study explores relationships between alcohol levels at admission to a detoxification unit and the severity and outcome of alcohol withdrawal. METHODS. A retrospective cohort study was conducted in two institutions, the Mid-Missouri Mental Health Center (MMMHC) and the Harry S Truman Memorial Veterans Hospital (HSTMVH), of individuals admitted during 1 year. RESULTS. The alcohol levels at admission of the 86 clients at the Mental Health Center and the 99 patients at the HSTMVH, correlated with withdrawal severity over the first 48 hours after admission (R2 = .26 at MMMHC, .41 at HSTMVH, P less than .0001 for both), and remained significantly associated even after adjustment for other variables. Furthermore, individuals who had lower alcohol levels at the time of admission were more likely to stay for rehabilitation following detoxification (P less than .001 for both institutions). CONCLUSIONS. A patient's alcohol level at the time of admission to a detoxification unit may help predict the severity of withdrawal and the treatment outcome.     

首发未经治疗精神分裂症患者认知功能及其影响因素

目的 了解首发未经治疗精神分裂症患者认知功能及其影响因素,为精神分裂症的治疗提供依据.方法 对34例首发未经治疗精神分裂症患者（患者组）及33例健康者（对照组）进行数字符号编码测验（symbol coding）、符号搜索测验（symbol search）、连线测验（trail making test,TMT）、色字词测验（stroop test）、韦氏记忆测验（Wechsler memory scale,WMS）、改良版的威斯康辛卡片分类测验（Wisconsin card sorting test,WCST）,评定认知功能,使用阳性与阴性症状量表（PANSS）评定临床症状.结果 患者组的部分认知测验成绩与受教育年限呈正相关,与病程呈负相关,而与年龄无关.男性精神分裂症患者WMS中的再认测验成绩及Stroop测验中的色词干扰测验成绩明显差于女性患者,差异有统计学意义（P＜0.05）,但在完成连线测验A时出现的错误数（0.25±0.78）却明显少于女性患者（1.07± 1.43）,差异有统计学意义（P＜0.05）.患者组WMS中的再生测验成绩与PANSS阴性分呈负相关（r=-0.408,P＜0.05）,Stroop-字得分与PANSS阴性分呈负相关（r=-0.355,P＜0.05）,Stroop-字与Stroop-色词差异分数与PANSS阴性分呈负相关（r=-0.380,P＜0.05）.结论 精神分裂症患者认知功能损害可能受性别、受教育年限和病程等因素影响,精神分裂症认知功能损害与阴性症状密切相关.     

The Relationship between Influenza Vaccination and Outpatient Visits for Upper Respiratory Infection by the Elderly in Taiwan

OBJECTIVE: To evaluate the effect of influenza vaccination on the reduction of the risk of outpatient visits for upper respiratory infection (URI) among the elderly in Taiwan. METHODS: The data for this observational study, consisting of 1729 people aged 65 years or older, were drawn from Taiwan's 2001 National Health Interview Survey. This survey data was then linked with National Health Insurance claim data for December 2001 to November 2002. Survival analysis of Cox proportional hazards model was performed to examine the risk of URI outpatient visits in elderly people vaccinated with the influenza vaccine and those not vaccinated during a year-long study period since the influenza season began. To adjust for potential self-selection bias, we used propensity score method to categorize individuals into two groups, based on the predicted probability of being vaccinated from a logistic regression of spatial random effect. Propensity score group 1 (PSG 1) were those with a predicted probability of being vaccinated lower than 0.5, and PSG 2 were those with a predicted probability of being vaccinated of 0.5 or higher. RESULTS: The overall vaccination rate was 50%. Logistic regression showed the probability of being vaccinated was related to the number of outpatient visits for URI before the influenza season began (odds ratio (OR) 1.07; 95% confidence interval (CI) 1.04-1.10). Our first survival analysis showed that being vaccinated significantly reduced the risk of URI outpatient visits in PSG 2 during the 1-year study period (hazard ratio 0.89; 95% CI 0.81-0.97). Separate survival analysis showed that being vaccinated reduced the risk of URI outpatient visits for both PSG groups during the first 3 months of the study period. CONCLUSION: Being vaccinated could reduce the risk of outpatient visits for URI among the elderly during the influenza season.