Twenty percent of febrile children have fever without an apparent source of infection after history and physical examination. Of these, a small proportion may have an occult bacterial infection, including bacteremia, ...
详细信息
Twenty percent of febrile children have fever without an apparent source of infection after history and physical examination. Of these, a small proportion may have an occult bacterial infection, including bacteremia, urinary tract infection (UTI), occult pneumonia, or, rarely, early bacterial meningitis. Febrile infants and young children have, by tradition, been arbitrarily assigned to different management strategies by age group: neonates (birth to 28 days), young infants (29 to 90 days), and older infants and young children (3 to 36 months). Infants younger than 3 months are often managed by using low-risk criteria, such as the Rochester Criteria or Philadelphia Criteria. The purpose of these criteria is to reduce the number of infants hospitalized unnecessarily and to identify infants who may be managed as outpatients by using clinical and laboratory criteria. In children with fever without source (FWS), occult UTIs occur in 3% to 4% of boys younger than 1 year and 8% to 9% of girls younger than 2 years of age. Most UTIs in boys occur in those who are uncircumcised. Occult pneumococcal bacteremia occurs in approximately 3% of children younger than 3 years with FWS with a temperature of 39.0 degreesC (102.2 degreesF) or greater and in approximately 10% of children with FWS with a temperature of 39.5 degreesC (103.1 degreesF) or greater and a WBC count of 15,000/mm(3) or greater. The risk of a child with occult pneumococcal bacteremia later having meningitis is approximately 3%. The new conjugate pneumo coccal vaccine (7 serogroups) has an efficacy of 90% for reducing invasive infections of Streptococcus pneumoniae. The widespread use of this vaccine will make the use of WBC counts and blood cultures and empiric antibiotic treatment of children with FWS who have received this vaccine obsolete.
Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The...
详细信息
Background: Changes in health care delivery financing such as the adoption of the diagnosis-related groups (DRG) in 1983 has affected inpatient services of dermatology programs across the United States. Objective: The purpose of this study was to define the present status of inpatient dermatology at academic medical centers compared with 1982. Methods: Questionnaires inquiring about the state of inpatient service were sent to the chairpersons of each dermatology residency program in the United States. Results: Of the 71 programs responding, 79% reported a reduction in inpatient activity. Nearly half of the dermatology programs with dedicated dermatology beds in 1982 reported not continuing to have these in 1997 (41 to 24). The average number of patients admitted for skin disease decreased from 119 in 1982 to 36.5 in 1997, and the average daily census decreased from 8.9 to 2.2. Conclusion: There has been a decline in the number of patients hospitalized by academic dermatology departments and a shift of some patients hospitalized to beds where the attending is other than a dermatologist.
Study objectives: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) ...
详细信息
Study objectives: We compare the results of a provider "self-adjudicating" outpatient emergency department claims using a "presenting symptom-based" system with the managed care organization (MCO) adjudicating the claims using a "final diagnosis-based" system. Methods: All outpatient visits from one MCO to an urban, university hospital between January 1, 1998, and February 28, 1999, were included. Each record was reviewed by 2 methods to determine whether the visit qualified for payment under the MCO's benefit structure. Under the provider adjudication, symptom-based system, all visits with nursing triage levels of immediate/emergency were approved automatically. Those with triage levels of delayed/nonurgent were reviewed by an emergency physician and approved if, in the physician's opinion, the presenting symptoms met the emergency criteria under the District of Columbia's Access to Emergency Services Act. A second claims review, blinded to the first, was performed with the diagnosis-based system used by the MCO before approval of the prudent layperson standard. This review divided the records into "approve," "deny," and "suspend" categories according to the discharge International Classification of Diseases, ninth revision code. The results of the 2 reviews were compared. Results: We reviewed 1,830 records;836 (46%) cases were triaged as immediate/emergency and 994 (54%) as delayed/nonurgent. Of the 994 delayed/nonurgent visits, physician review determined that 607 (61%) met the prudent layperson standard and 387 (39%) did not. Overall, the provider self-adjudication system determined that 1,443 (78.8%) of the 1,830 visits should be approved for insurance coverage. The MCO's system approved 966 (53%), denied 335 (18%), and suspended 529 (29%). Provider self-adjudication using a symptom-based system resulted in the immediate approval of 1,443 (77.8%) visits compared with 966 (52.7%) by a diagnosis-based system (P<.001). Excluding the 529 suspended claims, McNemar's
This study surveys Khmer refugees attending two Psychiatric clinics to determine both the prevalence of panic disorder as well as panic attack subtypes in those suffering panic disorder. A culturally valid adaptation ...
详细信息
This study surveys Khmer refugees attending two Psychiatric clinics to determine both the prevalence of panic disorder as well as panic attack subtypes in those suffering panic disorder. A culturally valid adaptation of the SCID-panic module, the Cambodian Panic Disorder Survey (CPDS), was administered to 89 consecutive Cambodian refugees attending these psychiatric clinics. Utilizing culturally sensitive panic probes, the CPDS provides information regarding both the presence of panic disorder and panic-attack subtypes during the month prior to interview. Of 89 patients surveyed at two psychiatric clinics, 53 (60%) currently suffered panic disorder. Among the 53 patients suffering panic disorder, the most common panic attack subtypes during the previous month were the following: "sore neck" [51% of the 53 panic disorder patients (PDPs)], orthostatic dizziness (49% of PDPs), gastrointestinal distress (26% of PDPs), effort induced (21% of PDPs), olfactory induced (21% of PDPs), and "while-sitting dizziness" (16% of PDPs). (C) 2000 Elsevier Science Inc.
This study was designed to identify and describe the prescribing practices of advanced practice psychiatric nurses. Part I describes the demographic, educational, and clinical setting characteristics. A survey method ...
详细信息
This study was designed to identify and describe the prescribing practices of advanced practice psychiatric nurses. Part I describes the demographic, educational, and clinical setting characteristics. A survey method was used with N = 88 nurses representing seven different states. Nurse prescribers were: younger than nonprescribers, employed in community mental health settings, and voluntarily using a consulting physician arrangement. Limitations on practice included: statute formulary, controlled substances, and formulary/protocols with a consulting physician. Results suggest nurses' prescribing practices are used in outpatient settings, viewed as conservative, with a value on physician collaboration even in the absence of legal mandates. Copyright (C) 2001 by W.B. Saunders Company.
This study identifies whether culturally based differences in perceptions of health resulted in differences in ambulatory care use among the elderly. Methods: The authors conducted stratified Poisson regressions on da...
详细信息
This study identifies whether culturally based differences in perceptions of health resulted in differences in ambulatory care use among the elderly. Methods: The authors conducted stratified Poisson regressions on data from a 1992 survey of older Koreans and Whites in Los Angeles County. The models included measures of demographics, health, functioning, income, insurance, social support, and culture (perceptions of health or other beliefs). Results: Descriptive findings showed older Koreans had more ambulatory physician visits, poorer functioning,and poorer perceptions of their health than Whites. Multivariate findings showed that positive perceptions of health independently reduced office visits for both Koreans and Whites, but the effect was significantly smaller for Koreans. Other cultural differences also affected use. Discussion: The findings highlight differences between older Koreans and Whites' responses to physical and socioeconomic conditions and the importance of cultural sensitivity in the health care delivery system.
In Europe, 40% of all deaths of individuals who are 25-74 years of age are caused by cardiovascular disease. Cardiac disease is the underlying cause in two-thirds of out-of-hospital sudden deaths. The 28-day case fata...
详细信息
In Europe, 40% of all deaths of individuals who are 25-74 years of age are caused by cardiovascular disease. Cardiac disease is the underlying cause in two-thirds of out-of-hospital sudden deaths. The 28-day case fatality rate for the combined population of out-of-hospital coronary artery disease deaths and hospitalized acute myocardial infarction patients is approximately 50% in 29 of the regions included in the World Health Organization (WHO) Monitoring Trends and Determinants in Cardiovascular Disease registry. Of 14,065 patients included in the Swedish Cardiac Arrest Registry, resuscitation procedures were started in 10,966 patients. The remaining 3,099 were considered definitely dead;70% were witnessed, cardiac arrests and 32.3% had been given bystander cardiopulmonary resuscitation (CPR). The incidence of ventricular tachycardia (VT)/ventricular fibrillation (VF) in all patients was 43%, in witnessed cases 54%, and in nonwitnessed cases, 31%. The initial incidence of VT/VF was calculated to be approximately 60% in the whole population and 80-85% in those with probable cardiac disease. Survival to 1 month was 5.0% in the total population, 9.5% for those with VT/VF on the first electrocardiogram compared with 1.6% for those not in VT/VF. Survival rate was also calculated in relation to delay time to first defibrillation. Survival was 50% when defibrillation was performed immediately and decreased gradually to 0% for those with a delay time of 20 minutes. The survival rate after bystander CPR was 2.6-fold higher than the rate for those where no treatment was given until the ambulance arrived. (C) 1999 by Excerpta Medica, Inc.
This first of two papers on the health sector in Lebanon describes how unregulated development of private care quickly led to a crisis situation. Following the civil war the health care sector in Lebanon is characteri...
详细信息
This first of two papers on the health sector in Lebanon describes how unregulated development of private care quickly led to a crisis situation. Following the civil war the health care sector in Lebanon is characterized by (i) ambulatory care provided by private practitioners working as individual entrepreneurs, and, to a small extent, by NGO health centres;and (ii) by a fast increase in hi-tech private hospitals. The latter is fuelled by unregulated purchase of hospital care by the Ministry of Health and public insurance schemes. Health expenditure and financing patterns are described. The position of the public sector in this context is analyzed. In Lebanon unregulated private care has resulted in major inefficiencies, distortion of the health care system, the creation of a culture that is oriented to secondary care and technology, and a non-sustainable cost explosion. Between 1991 and 1995 this led to a financing and organizational crisis that is the background for growing pressure for reform.
In recent years there have been several attempts to develop quantitative measures of potential spatial access to health care services which, despite their limitations, offer many positive ideas that can perhaps be int...
详细信息
In recent years there have been several attempts to develop quantitative measures of potential spatial access to health care services which, despite their limitations, offer many positive ideas that can perhaps be integrated into a logically consistent and generally acceptable index. It is in this vein that the current paper presents an integrated approach, drawing partially from past contributions, to measuring potential spatial access to health care services. The final access index is derived as the culmination of a series of individual measures, starting with an initial gravity formulation and progressing through successive stages as new elements, consistent with the definition and conceptualization of potential spatial access, are introduced. Application of the proposed index to the ambulatory medical care system of the Akron, Ohio SMSA, demonstrates the validity of the measure, and its suitability as a potential health care planning tool.
暂无评论