Factors Affecting Influential Discussions Among Physicians: A Social Network Analysis of a Primary Care Practice

Background Physicians often rely on colleagues for new information and advice about the care of their patients. Objective Evaluate the network of influential discussions among primary care physicians in a hospital-based academic practice. Design Survey of physicians about influential discussions with their colleagues regarding women’s health issues. We used social network analysis to describe the network of discussions and examined factors predictive of a physician’s location in the network. Subjects All 38 primary care physicians in a hospital-based academic practice. Measurements Location of physician within the influential discussion network and relationship with other physicians in the network. Results Of 33 responding physicians (response rate = 87%), the 5 reporting expertise in women’s health were more likely than others to be cited as sources of influential information (odds ratio [OR] 6.81, 95% Bayesian confidence interval [CI] 2.25–23.81). Physicians caring for more women were also more often cited (OR 1.03, 95% CI 1.01–1.05 for a 1 percentage-point increase in the proportion of women patients). Influential discussions were more frequent among physicians practicing in the same clinic within the practice than among those in different clinics (OR 5.03, 95% CI 3.10–8.33) and with physicians having more weekly clinical sessions (OR 1.33, 95% CI 1.15 to 1.54 for each additional session). Conclusions In the primary care practice studied, physicians obtained information from colleagues with greater expertise and experience as well as colleagues who were accessible based on location and schedule. It may be possible to organize practices to promote more rapid dissemination of high-quality evidence-based medicine.     

Decreases in procalcitonin and C-reactive protein are strong predictors of survival in ventilator-associated pneumonia

Introduction  

This study sought to assess the prognostic value of the kinetics of procalcitonin (PCT), C-reactive protein (CRP) and clinical scores (clinical pulmonary infection score (CPIS), Sequential Organ Failure Assessment (SOFA)) in the outcome of ventilator-associated pneumonia (VAP) at an early time point, when adequacy of antimicrobial treatment is evaluated.     

Perspectives of Non-Hispanic Black and Latino Patients in Boston’s Urban Community Health Centers on their Experiences with Diabetes and Hypertension

Background  

Racial/ethnic disparities exist in the prevalence and outcomes of diabetes and hypertension in the U.S. A better understanding of the health beliefs and experiences of non-Hispanic Blacks and Latinos with these diseases could help to improve their care outcomes.     

Sleep studies and supportive ventilatory treatment in patients with congenital muscle disorders

Eight ambulant children aged 6-13 years, four with congenital myopathy, two with congenital muscular dystrophy and two with the rigid spine syndrome, presented with recurrent chest infections, morning headaches, shallow breathing at night, or respiratory failure. Polysomnography confirmed the presence of nocturnal hypoxaemia with oxygen saturation on average less than 90% for 49% of sleep and less than 80% for 19% of sleep accompanied with severe hypoventilation. Additionally there was sleep disturbance characterised by an increased number of wake epochs from deep sleep (in comparison to 10 non-hypoxaemic subjects). The severity of sleep hypoxaemia did not correlate with symptoms. Treatment with night time nasal ventilation was started and repeat polysomnography showed normal overnight oxygen saturation and a reduced number of wake epochs during deep sleep. It is important to be vigilant for sleep hypoventilation in these patients and sleep studies should be part of the routine respiratory evaluation. Treatment with nasal ventilation is effective in reversing the nocturnal respiratory failure without significant disturbance to life style.     

Ambulatory hypercholesterolemia management in patients with atherosclerosis

OBJECTIVE: To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control. DESIGN: Retrospective cohort study. SETTING: Primary care clinics affiliated with an academic medical center. PARTICIPANTS: Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl. MEASUREMENTS AND MAIN RESULTS: The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender. CONCLUSIONS: In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.     

Use of cholesterol-lowering therapy by elderly adults after myocardial infarction

BACKGROUND: Use of cholesterol-lowering drugs reduces mortality and adverse cardiac events among people aged 65 to 75 years with coronary heart disease, but previous studies have shown that most patients have not received this treatment. METHODS: We conducted a telephone survey during 1999 and 2000 of 815 Medicare beneficiaries aged 65 to 74 years hospitalized for an acute myocardial infarction in California, Florida, Massachusetts, New York, or Pennsylvania during 1994 and 1995. Outcome measures included use of cholesterol-lowering drugs, beliefs about the importance of lowering cholesterol levels, and knowledge of personal cholesterol levels, adjusting for demographic and clinical factors using logistic regression. RESULTS: Among respondents, 59.4% reported taking a cholesterol-lowering drug, but most were not aware of potential adverse effects. In adjusted analyses, drug treatment was significantly more common among women, patients aged 65 to 69 years, and those who reported that a cardiologist was mainly responsible for their cholesterol management. Lowering cholesterol levels was viewed as "very important" by 77.2% of respondents, but significantly less often by men, older patients, and those with diabetes mellitus or congestive heart failure. Only 33.1% of respondents knew their cholesterol level, and this knowledge was significantly less common among black patients and those with diabetes mellitus or congestive heart failure. CONCLUSIONS: Use of cholesterol-lowering drugs was much greater than in previous studies of elderly patients after myocardial infarction, demonstrating increased attention to secondary prevention. However, most patients were unaware of their cholesterol level or potential adverse effects of drug treatment, indicating that they may benefit from greater education about cholesterol testing and treatment.     

头孢唑肟在输液中与6种注射剂配伍的稳定性研究

目的：研究头孢唑肟在５％葡萄糖输液与维生素Ｂ６等６种注射剂配伍的稳定性,为临床合理用药提供科学依据。方法：选择在３５℃下６ｈ内观察配伍液的外观,ＰＨ及ＣＺＸ紫外光谱的变化。用紫外分光光度法测定ＣＺＸ的含量。结果：Ａ春稳定性与和ＰＨ有关。结论Ｌ：在３５℃下６ｈ内与维生素Ｂ６、地塞米松、酚磺乙胺、氯化钾注射剂配伍、则稳定可用,与维生素Ｃ、氨茶碱注射剂配伍,则最好在４ｈ内使用。     

Perceived risks of heart disease and cancer among cigarette smokers

Context  Cigarette smoking causes more preventable deaths from cardiovascular disease and cancer than any other modifiable risk factor, but smokers may discount the increased personal risk they face from continued smoking. Objective  To assess smokers' perceptions of their risks of heart disease and cancer. Design and Setting  Telephone and self-administered survey in 1995 of a probability sample of US households with telephones. Participants  A total of 3031 adults aged 25 to 74 years, including 737 current smokers (24.3%). Main Outcome Measures  Respondents with no history of myocardial infarction (MI) (96.2%) or cancer (92.9%) assessed their risk of these conditions relative to other people of the same age and sex. Among current smokers, perceived risks were analyzed by demographic and clinical factors using logistic regression. Results  Only 29% and 40% of current smokers believed they have a higher-than-average risk of MI or cancer, respectively, and only 39% and 49% of heavy smokers (40 cigarettes per day) acknowledged these risks. Even among smokers with hypertension, angina, or a family history of MI, 48%, 49%, and 39%, respectively, perceived their risk of MI as higher than average. In multivariate analyses, older (65 years), less educated (< high school graduate), and light smokers (1-19 cigarettes per day) were less likely than younger, more educated, and heavy smokers to perceive an increased personal risk of MI or cancer. Conclusions  Most smokers do not view themselves at increased risk of heart disease or cancer. As part of multifaceted approaches to smoking cessation, physicians and public health professionals should identify and educate smokers who are not aware of smoking-related health risks.