Clinical decision-making in the evaluation and treatment of insomnia
Article Abstract:
Taking inadequate patient medical histories can lead to defective medical decision-making; there is evidence that indicates that some physicians are deficient in this area. To determine the extent of this problem, 501 general physicians and 298 nurse practitioners were presented with a fictitious case of insomnia and asked how they would approach care and treatment. Insomnia is a common complaint that may result from underlying medical illnesses, such as congestive heart failure or sleep apnea. A thorough medical history is necessary to properly evaluate the disorder. Non-pharmacologic approaches are generally recommended before treatment with sedative-like drugs, which may be induce addiction or result in falls for elderly patients. Because elderly people are more subject to adverse drug reactions, practitioners were questioned on the treatment of a 37- or a 77-year-old patient to determine if therapeutic approaches would differ. Only 47 percent of physicians asked about the patient's sleep pattern; 20 percent or fewer asked about diet, (which included nightly coffee consumption). Physicians asked an average of 2.6 questions for either the younger or the older patient. Questions were asked most frequently about psychological problems, and physicians were more likely to ask the older patient about other medical problems. The hypothetical patient's history included many contributing causes for sleep problems which could have been addressed without drug therapy. However, 65 percent of physicians recommended medication; those who had asked more questions more often recommended life-style changes. In contrast, nurse practitioners asked more questions (3.2 on average), and 60 percent asked about the sleep history. Only 17 percent thought medication was needed, while 61 percent recommended counseling and 55 percent recommended life-style changes. The results suggest that physicians tend to take inadequate histories from patients with insomnia and may prescribe medication when non-pharmacologic treatment may be more effective. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Medicine
Subject: Health care industry
ISSN: 0002-9343
Year: 1990
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Morbidity of systemic lupus erythematosus: role of race and socioeconomic status
Article Abstract:
Several research studies have shown that black patients with systemic lupus erythematosus (SLE), an autoimmune disorder involving the connective tissues, fare worse than their white counterparts. Whether this is the result of clinical, genetic, or socioeconomic factors (related to nutritional status and quality of medical care) is not known. This study addressed the issue by evaluating racial differences pertaining to the clinical features of SLE and patient compliance with recommended treatment. One hundred ninety-eight patients, of whom 115 were black and 83 were female, were followed for an average of almost 27 months while under treatment at a faculty practice clinic. Demographic and clinical information were gathered and socioeconomic status (SES) was calculated based on patients' years of education, occupation, annual family income, and type of medical insurance. The time since symptom onset until the diagnosis of SLE was longer for black patients (9.6 years) than for whites (7.3 years), and blacks had the disease longer than whites when entering the study. Black patients were also more likely than whites to have serious kidney disease (nephrotic syndrome, kidney insufficiency, kidney failure); they also had lower SES and were judged by physicians to be less compliant, as determined by a global estimate of compliance. Black patients were more likely to have histories of hypertension and to kidney diseases undiagnosed during routine visits. Neurologic disease was no more common in blacks than whites. However, when the relative importance of individual factors for complications of SLE (number of hospitalizations, neurologic disease, kidney disease) was statistically examined, race was not a factor. However, noncompliance and type of medical insurance were found to be important predictors of complications. Traditional measures of SES such as occupation, income, and education, were not associated with higher rates of complications. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Medicine
Subject: Health care industry
ISSN: 0002-9343
Year: 1991
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Clinical and immunologic features of livedo reticularis in lupus: a case-control study
Article Abstract:
The presence of livedo (discolored patches with a pale center related to decreased blood flow away from the skin) and elevated anticardiolipin antibodies (immune cells which fight foreign substances) was noted in a small number of patients with lupus, a connective tissue disease. To test whether anticardiolipin antibodies are more common in lupus patients with livedo and whether Sneddon's syndrome (livedo and cerebrovascular disease) occurs in patients with lupus, 29 lupus patients with livedo were compared to 29 patients without livedo. Eighty-one percent of the patients with livedo had elevated anticardiolipin levels. A history of thrombosis (blood clot formation) and thrombocytopenia (a decrease in the number of platelets which are necessary for clotting) was more common among the group of patients with livedo. Individuals with elevated anticardiolipin antibodies were 23 times more likely to have livedo. Elevated levels of anticardiolipin antibody may contribute to the pathological manifestations of Sneddon's syndrome, livedo and cerebrovascular disease, in lupus patients.
Publication Name: American Journal of Medicine
Subject: Health care industry
ISSN: 0002-9343
Year: 1989
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