RESUMEN
INTRODUCTION: Over the past decade, there has been a sharp increase in the number of newly identified synthetic drugs. These new drugs are often derivatives of previously abused substances but have unpredictable toxicity. One of these drugs is gacyclidine, a derivative of phencyclidine (PCP). Gacyclidine has been studied as a neuroprotective agent in trauma and as a therapy of soman toxicity. There are no previous reports of its use as a drug of abuse. CASE REPORTS: During a two-month period in the summer of 2013, a series of patients with severe agitation and end-organ injury were identified in an urban academic Emergency Department (ED). A urine drug of abuse screen was performed on all patients, and serum samples were sent for comprehensive toxicology analysis. A total of five patients were identified as having agitation, rhabdomyolysis, and elevated troponin (Table 1). Three of the five patients reported use of methamphetamine, and all five patients had urine drug screens positive for amphetamine. Comprehensive serum analysis identified methamphetamine in three cases, cocaine metabolites in one case, and a potential untargeted match for gacyclidine in all five cases. No other drugs of abuse were identified. DISCUSSION: This is the first series of cases describing possible gacyclidine intoxication. The possible source of the gacyclidine is unknown but it may have been an adulterant in methamphetamine as all patients who were questioned reported methamphetamine use. These cases highlight the importance of screening for new drugs of abuse when patients present with atypical or severe symptoms. Gacyclidine has the potential to become a drug of abuse both by itself and in conjunction with other agents and toxicity from gacyclidine can be severe. It is the role of the medical toxicology field to identify new agents such as gacyclidine early and to attempt to educate the community on the dangers of these new drugs of abuse.
Asunto(s)
Ciclohexenos/toxicidad , Drogas de Diseño/toxicidad , Drogas Ilícitas/toxicidad , Insuficiencia Multiorgánica/etiología , Síndromes de Neurotoxicidad/terapia , Piperidinas/toxicidad , Psicotrópicos/toxicidad , Centros Médicos Académicos , Adulto , Terapia Combinada , Ciclohexenos/sangre , Ciclohexenos/orina , Drogas de Diseño/análisis , Consumidores de Drogas , Servicio de Urgencia en Hospital , Resultado Fatal , Femenino , Humanos , Drogas Ilícitas/sangre , Drogas Ilícitas/orina , Masculino , Persona de Mediana Edad , Síndromes de Neurotoxicidad/sangre , Síndromes de Neurotoxicidad/fisiopatología , Síndromes de Neurotoxicidad/orina , Piperidinas/sangre , Piperidinas/orina , Agitación Psicomotora/etiología , Psicotrópicos/sangre , Psicotrópicos/orina , Rabdomiólisis/etiología , Toxicocinética , Resultado del Tratamiento , Negativa del Paciente al TratamientoRESUMEN
Dental care can occur within or outside the formal health-care system. We hypothesized that certain subject characteristics would partly explain one type of dental self-care, non-professional extractions. A representative sample of diverse groups of dentate adults was studied. In-person interviews and clinical examinations were conducted at baseline, 24, 48, and 72 months, with semi-annual telephone interviews in between. Of 699 participants, 291 (42%) reported loss of at least one tooth, of whom 42 (14% of those with tooth loss) reported having lost the tooth at a place other than a health-care facility. Ninety-four percent of non-professionally lost teeth were self-extracted; relatives extracted the remainder. Fifty-eight percent of these teeth were deliberately removed; the remainder came out while subjects were eating or brushing their teeth, or due to injury. Attachment loss and mobility at previous examination were consistent with the occurrence of non-professional extraction. The incidence magnitude was substantive and persistent throughout follow-up.
Asunto(s)
Actitud Frente a la Salud , Autocuidado/psicología , Extracción Dental/psicología , Pérdida de Diente/epidemiología , Anciano , Análisis de Varianza , Atención Odontológica/psicología , Atención Odontológica/estadística & datos numéricos , Familia , Humanos , Incidencia , Entrevistas como Asunto , Estudios Longitudinales , Persona de Mediana Edad , Pérdida de la Inserción Periodontal/epidemiología , Análisis de Regresión , Muestreo , Autocuidado/estadística & datos numéricos , Encuestas y Cuestionarios , Extracción Dental/estadística & datos numéricosRESUMEN
It has become abundantly clear that standards of recording clinical terms in human-readable, computer-processable format are indispensable. Controlled medical terminology is the missing link in health information standards (in fact, medical terminology can be viewed as the mother of all standards); its absence interferes with the business of healthcare and impedes the core processes of healing and maintaining health. Medicine has lacked the controlled common medical vocabulary that would enable universal sharing of data at the point of care and ensure reliable information for determining health intervention effectiveness. Simple clinical and code content alone has proven insufficient for healthcare enterprises to successfully manage the terminology problem; the "lexical runtime engine," formerly called a vocabulary server (VOSER), which manages the vocabulary ontology and serves up the relevant vocabulary to users of applications in the clinical environment, has recently become a reality.
Asunto(s)
Sistemas de Administración de Bases de Datos , Aplicaciones de la Informática Médica , Sistemas de Registros Médicos Computarizados , Terminología como Asunto , Vocabulario Controlado , Humanos , Almacenamiento y Recuperación de la Información , Garantía de la Calidad de Atención de Salud , Diseño de SoftwareRESUMEN
A number of clinical coding and vocabulary schemes are in use in healthcare enterprises today. Most of them are weak in light of the qualities that characterize adequate controlled medical terminologies, as outlined in Part One of this review. Here we look at the major code and terminology sets with a critical eye, as well as suggest practical steps to enable health industry information system purchasers and users to move forward with their effort to use common terminology to improve the quality, service, and knowledge in their enterprise.
Asunto(s)
Aplicaciones de la Informática Médica , Sistemas de Registros Médicos Computarizados/clasificación , Terminología como Asunto , Vocabulario Controlado , Indización y Redacción de Resúmenes , Control de Formularios y Registros , Humanos , Garantía de la Calidad de Atención de Salud , Estados UnidosRESUMEN
The current study used a cohort-sequential design to examine age-related changes in health-relevant beliefs from the middle school years through age 37 in a large, midwestern, community sample (N=8,556). Results suggest systematic age-related changes such that beliefs in the personalized risks of smoking declined in middle school and then increased, beliefs in generalized health risks increased beginning in the middle school years, and values placed on health as an outcome decreased in the high school years and then increased. These findings suggest that intervention programs must counter declining personalized risk perceptions among middle school students and declining values placed on health among high school age students.
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Actitud Frente a la Salud , Desarrollo de la Personalidad , Fumar/psicología , Adolescente , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Fumar/efectos adversos , Valores SocialesRESUMEN
OBJECTIVE: To determine the physiological consequences of acute CO exposure from cooking in snow caves at 3,200 m. We hypothesized that ambient CO and serum carboxyhemoglobin (COHb) levels would increase and that even low levels of COHb would be associated with symptoms of CO poisoning at high altitude. METHOD: This was a prospective observational study. Twenty-two healthy volunteers age 18 years or older were recruited during a winter camping trip at 3,200 m. Subjects filled out symptom questionnaires, and heart rate (HR), oxygen saturation (SaO2), serum COHb, and ambient CO were all measured before and after cooking inside snow caves. RESULTS: Median age of subjects was 32 years, and 87% were male. The median ambient CO level increased by 17 ppm (IQR, 2-27 ppm), P = .005. Mean serum COHb level rose from 0.3% (IQR, 0.2%-0.4%) to 1.2% (IQR, 0.7%-2.6%) after cooking, for a difference of 1% (IQR, 0.4%-2.3%), P < .001. There were no differences in symptom scores before and after cooking, and there was no significant effect on HR or SaO2. CONCLUSION: A single exposure to CO at 3,200 m increases ambient CO and COHb but not to clinically important levels. Further studies are needed to examine the risks of longer exposures at higher altitudes.
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Contaminación del Aire Interior/efectos adversos , Intoxicación por Monóxido de Carbono/sangre , Monóxido de Carbono/análisis , Carboxihemoglobina/metabolismo , Exposición a Riesgos Ambientales/efectos adversos , Adulto , Altitud , Intoxicación por Monóxido de Carbono/etiología , Estudios de Cohortes , Culinaria , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: There is a paucity of evidence demonstrating that emergency department (ED) ultrasound changes clinical practice in trauma patients. We hypothesized that the presence of ultrasound would affect clinical decision making as evidenced through abdominal computed tomographic (CT) scan use in blunt multiple trauma patients. METHODS: This study used a prospective randomized format in an urban county ED with Level II trauma center status (ED census, 72,000 patients per year). Participants were patients with multiple blunt injuries meeting trauma center triage criteria. Patients were randomized to receive either abdominal ultrasound or no ultrasound (control) during initial ED resuscitation. The primary outcome variable was use of abdominal CT scan in patients with and without ultrasound. RESULTS: Two hundred eight patients were enrolled. The mean age was 40 +/- 18 years, and 62% were men. Mechanism of injury was motor vehicle crash, 56%; automobile versus pedestrian, 18%; motorcycle crash, 16%; falls, 10%; and other, 10%. One hundred four ultrasound and 104 control patients were analyzed. There were no apparent differences between ultrasound and control groups in demographics, injury type, or Injury Severity Score. Fifty-four of 104 (52%) of the control group received abdominal CT scans versus 37 of 104 (36%) abdominal CT scans for the ultrasound group; mean difference in proportions was 15.9 (p < 0.01; 95% confidence interval, 2.6-29.1). CONCLUSION: In this trial, the routine use of abdominal ultrasound in the evaluation of patients with multiple blunt injuries resulted in significantly fewer abdominal CT scans being obtained. A larger trial is needed to more clearly define the clinical and financial impact of ultrasound in the management of blunt abdominal trauma.
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Traumatismos Abdominales/diagnóstico por imagen , Heridas no Penetrantes/diagnóstico por imagen , Adulto , California , Servicio de Urgencia en Hospital , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Prospectivos , Resucitación , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Centros Traumatológicos , UltrasonografíaRESUMEN
This report describes a novel sonographic protocol for the evaluation of the undifferentiated hypotensive patient. This protocol combines components of 3 sonographic applications: free fluid, cardiac, and abdominal aorta into a single protocol. We believe this protocol and its underlying principles should be a routine part of the empiric evaluation of the patient with undifferentiated hypotension or pulseless electrical activity.
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Aorta Abdominal/diagnóstico por imagen , Líquido Ascítico/diagnóstico por imagen , Protocolos Clínicos , Ecocardiografía , Hipotensión/diagnóstico por imagen , Adulto , Anciano , Aneurisma de la Aorta/diagnóstico por imagen , Taponamiento Cardíaco/diagnóstico por imagen , Urgencias Médicas , Femenino , Hematoma/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Bazo/diagnóstico por imagenRESUMEN
The Health Insurance Portability and Accountability Act (HIPAA) is intended to simplify administrative processes and improve health information security. There are a number of traditional ways to address the expense and complexities of simplification, but none of them are bargains or beauties to behold: (1) Do-it-yourself encryption; (2) new back-end system purchases; (3) legacy system re-programming; or (4) onerous paper documentation. The good news is that 'second generation' e-health solutions are emerging that act as internal "wrappers" for health plan or provider data systems. They provide both an interface for end-users and a layer of security for organizational information and allow detailed patient-related data to remain at the system owner's physical location. These second generation solutions don't just 'connect,' data, they actually 'understand' the information, and can use data elements to invoke necessary rules, processing pathways, or personalization for specific stakeholders as required by HIPAA.
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Seguridad Computacional/legislación & jurisprudencia , Adhesión a Directriz , Health Insurance Portability and Accountability Act/legislación & jurisprudencia , Gestión de la Información/legislación & jurisprudencia , Internet/normas , Seguridad Computacional/normas , Documentación , Health Insurance Portability and Accountability Act/normas , Gestión de la Información/normas , Estados Unidos , Simplificación del TrabajoRESUMEN
Biology and business face similar challenges when it comes to change. Living organisms experience constant change. And successful health care organizations must be ready and willing to embrace transition if they are to survive. Take an in-depth look at the biology-to-business metaphor and see how to better manage information technology changes in your organization.
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Comercio/organización & administración , Administración de los Servicios de Salud , Liderazgo , Modelos Organizacionales , Innovación Organizacional , Biología , Activadores de Enzimas , Humanos , Sistemas de Información , Motivación , Cultura Organizacional , Estados UnidosRESUMEN
All health care providers, plans, and clearinghouses will be affected by the federally mandated uniform standards for administrative transactions. This article presents distilled core information about the Health Insurance Portability and Accountability Act (HIPAA) legislation--the standards, penalties for violations, and status of final rules. It also raises several key unsolved issues of which clinicians, executives, and health care providers must be aware so they can prepare and plan for the upcoming changes. HIPAA is intended to improve the efficiency and effectiveness of the health care system, as well as to increase the protection and confidentiality of individually identifiable health information. The costs of making the transition to the legislated standards and processes remain a worrisome factor. Although there are two years before these standards must be implemented, and cost and compliance issues resolved, work has already begun in many health institutions to identify and address them.
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Health Insurance Portability and Accountability Act/legislación & jurisprudencia , Sistemas de Registros Médicos Computarizados/legislación & jurisprudencia , Ejecutivos Médicos , Seguridad Computacional/legislación & jurisprudencia , Seguridad Computacional/normas , Health Insurance Portability and Accountability Act/normas , Sistemas de Registros Médicos Computarizados/normas , Privacidad/legislación & jurisprudencia , Estados UnidosRESUMEN
A longitudinal multigenerational design was used to examine the intergenerational transmission of smoking and the correlated transmission of parental support and control. Whether maternal socialization of adolescent smoking (both general parenting practices and smoking-specific strategies) would predict adolescent smoking both directly and indirectly by affecting peer affiliations was tested. There was strong evidence for the intergenerational transmission of cigarette smoking and for the relation between peer smoking and adolescent smoking. Both general parenting practices and smoking-specific discussion and punishment were significantly related to adolescents' smoking, especially for adolescent-reported parenting. Support for the intergenerational transmission of parenting practices emerged only in mothers' reports of support. Results suggest expanding current peer-focused prevention efforts to include parental socialization strategies.
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Relaciones Intergeneracionales , Madres/psicología , Responsabilidad Parental , Fumar/psicología , Socialización , Adolescente , Adulto , Niño , Femenino , Humanos , Estudios Longitudinales , Masculino , Relaciones Madre-HijoRESUMEN
OBJECTIVES: Assessment of genotypic change in HIV protease during treatment with saquinavir (SQV) in combination with zidovudine (ZDV) and/or zalcitabine (ddC), to determine the influence of such changes on viral phenotype and response to treatment. DESIGN: Virologic substudies of Phase III clinical trials NV14256 and SV14604. METHODS: Population sequencing of HIV protease genes amplified from pre- and post-treatment plasma. Phenotyping of peripheral blood mononuclear cell (PBMC)-derived virus isolates, and genotyping of proviral DNA clones amplified from PBMC used in the expansion of virus isolates. RESULTS: In both trials the incidence of Met90 remained at < or = 20% in subjects receiving SQV in combination with ddC (with or without ZDV) for 1 year. A Val48 substitution was observed in two out of 81 subjects after 24 weeks and in two out of 75 subjects after 48 weeks. In 12 out of 13 NV14256 subjects with viral load rebound during SQV monotherapy these substitutions were associated with the rebound. In subjects treated with SQV plus ddC, rebound was associated with SQV resistance in six out of 22 cases and ddC resistance in five out of 22 cases. The incidences of non-BRU residues at positions 10, 63 and 71 were increased significantly (P < 0.05, Fisher's exact test) after SQV treatment with or without ZDV. However, comparison of genotypic and phenotypic data showed that these changes were not associated with reduced sensitivity to SQV. CONCLUSIONS: Virological failure during combination therapy can be due to resistance to either treatment drug, emphasising the need to change both the reverse transcriptase inhibitor and the protease inhibitor. Only Val48 and Met90 correlated directly with the development of reduced drug sensitivity during treatment with SQV in vivo.
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Infecciones por VIH/tratamiento farmacológico , Inhibidores de la Proteasa del VIH/uso terapéutico , VIH/genética , Inhibidores de la Transcriptasa Inversa/uso terapéutico , Saquinavir/uso terapéutico , Zalcitabina/uso terapéutico , Zidovudina/uso terapéutico , Secuencia de Aminoácidos , ADN Viral/análisis , Farmacorresistencia Microbiana , Quimioterapia Combinada , Genotipo , Proteasa del VIH/efectos de los fármacos , Proteasa del VIH/genética , Humanos , Pruebas de Sensibilidad Microbiana , Datos de Secuencia Molecular , Mutación , Fenotipo , Provirus , ARN Viral/sangre , ARN Viral/genética , Resultado del TratamientoRESUMEN
HIV and AIDS is a growing health risk for heterosexual women, particularly women of color (Centers for Disease Control and Prevention, 1997). Our research identified 5 types of HIV sexual risk taking in 3 independent samples of adult women from a New England Community: Group A women were noted by low to moderate levels of the 4 risk markers (i.e., unprotected vaginal sex, perceived partner-related risk, number of sexual partners, and unprotected anal sex); Group B women reported very high frequency of unprotected vaginal sex; Group C women were characterized by unprotected anal sex; Group D women had high perceived partner risk; and Group E women reported extremely high levels on all 4 HIV risk markers. Sexual risk groups were validated by demonstrating significant differences among groups on relevant behaviors, interpersonal experiences, and attitudes. Compared to other women, higher risk types reported greater behavioral risk practices (substance use, prostitution, diverse sexual experience), interpersonal risk experiences (sexual abuse, violence), initiation sexual assertiveness, and attitudinal risks (psychosocial distress). They reported less interpersonal assurance (surety of own and partner's HIV status), sexual assertiveness (for condom use and partner communication), psychosocial strengths (sexual self-acceptance), and transtheoretical readiness for change (condom use efficacy, readiness to consider condoms). Results provide additional support for the multifaceted model of HIV risk and the transtheoretical model. Suggestions for specifically focused interventions are given, depending on the pattern of sexual risk taking.
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Actitud Frente a la Salud , Infecciones por VIH/psicología , Conducta Sexual , Adolescente , Adulto , Anciano , Análisis de Varianza , Análisis por Conglomerados , Femenino , Infecciones por VIH/transmisión , Humanos , Estudios Longitudinales , Persona de Mediana Edad , Modelos Teóricos , Asunción de RiesgosRESUMEN
The largest part of the medical record today consists of notes documenting the care delivered to patients and the clinical events relevant to diagnosis and treatment. These "progress notes" serve as the repository of medical facts and clinical thinking, and are intended as a concise vehicle of communication about a patient's condition to those who access the health record. They should be readable, easily understood, complete, accurate, and concise. They must also be flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded. This paper describes a model for progress notes, which addresses the above needs, and outlines the rationale and principles which led to that model.
Asunto(s)
Sistemas de Registros Médicos Computarizados , Documentación/métodos , HumanosRESUMEN
Establishing central intravenous access in the emergency department (ED) is often both crucial and difficult. In patients with nonexistant or ambiguous external anatomic landmarks, a real-time ultrasound guided approach to internal jugular vein cannulation is useful. In addition, the use of ultrasound guidance in internal jugular vein cannulation is supported by reports that have documented reductions in number of cannulation attempts, time required to establish central access, and rate of complications. The use of ultrasound for establishing central venous access has never been described in an ED setting. Two such cases in which ultrasound was extremely helpful for establishing central access in an ED are reported, the techniques employed for real-time ultrasound guidance of internal jugular vein catheterization are described, and the literature that supports the use of this technique is reviewed.
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Cateterismo Venoso Central/métodos , Venas Yugulares/diagnóstico por imagen , Clonidina/envenenamiento , Sobredosis de Droga , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/terapia , UltrasonografíaRESUMEN
The current study examined the natural history of smoking from adolescence to adulthood in a community sample. Participants were from a longitudinal study (N = 4,035, 51.7% female, average age = 29 years). Group-level analyses showed a significant increase in smoking from adolescence to young adulthood and a nonsignificant decline after the mid-20s. Individual-level analyses showed that there was appreciable cessation and relapse but little new initiation in adulthood. Both adolescent and young adult smoking status were powerful predictors of adult smoking. Moreover, there was less cessation among less educated individuals and those with smoking parents, and more cessation among those who assumed adult social roles. The findings support the importance of prevention campaigns aimed at adolescent smoking and also suggest that those with lower educational attainment or with a family history of smoking are at heightened risk.
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Conducta del Adolescente , Conductas Relacionadas con la Salud , Psicología del Adolescente , Fumar/psicología , Adolescente , Adulto , Distribución por Edad , Escolaridad , Femenino , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Valor Predictivo de las Pruebas , Factores de Riesgo , Rol , Cese del Hábito de Fumar/psicología , Prevención del Hábito de FumarRESUMEN
This study examined prospective predictors of attempts to quit smoking and successful quitting among those who attempted to quit (n = 700), using a long-term longitudinal study of the natural history of cigarette smoking in a midwestern community sample. Participants, originally surveyed in 6th-12th grade (1980-1983), were followed up in 1987 and 1994. Results showed that amount of smoking, gender, education, health beliefs about smoking, value on healthy lifestyle, motives for smoking, reasons for quitting, and occupancy of young adult social roles were significant predictors of cessation. However, there were different predictors of attempts to quit and successful quitting among those who attempted to quit. From a public health perspective, both predictors of quit attempts and predictors of successful quitting among attempters are useful targets for intervention.
Asunto(s)
Cese del Hábito de Fumar/psicología , Adolescente , Actitud Frente a la Salud , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Medio Oeste de Estados Unidos/epidemiología , Motivación , Oportunidad Relativa , Factores de Riesgo , Factores Sexuales , Fumar/epidemiología , Fumar/psicología , Cese del Hábito de Fumar/estadística & datos numéricos , Controles Informales de la SociedadRESUMEN
The purpose of this study was to determine if cerebral blood flow (CBF) alterations are associated with discontinuation of heroin in chronic heroin users, and whether these alterations are reversible during abstinence. Ten physically healthy opioid-dependent males, hospitalized on an inpatient drug rehabilitation unit, were studied. Each patient had an initial single photon emission computed tomographic (SPECT) scan with the radiotracer technetium-99m-d,l-hexamethylpropyleneamine oxime (99mTc-HMPAO) 1 week after opiate discontinuation and a repeat scan 2 weeks later. The initial scans in 9 of the 10 subjects demonstrated significant, often discrete, perfusion defects, especially in the frontal, parietal, and temporal cortices. Two weeks later, repeat brain perfusion SPECT scans showed improvement in all nine subjects who had abnormal scans. Comparisons of the first scan with the second scan showed an increase in cortical uptake on the repeat SPECT study. All subjects had normal computed tomographic or magnetic resonance imaging scans. The results of this preliminary study suggest that the chronic use of opiates, like chronic use of cocaine, results in perfusion abnormalities without corresponding abnormalities on imaging studies of cerebral anatomy and morphology. This study also documents that these perfusion defects are partially reversible with short-term abstinence.