Alfred M. Pheley

The Yale-Brown Obsessive-Compulsive Scale : measures of internal consistency

We examined the construction of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and performance of subscale items based on data from 204 patients with obsessive-compulsive disorder (OCD) who participated in a multicenter drug treatment study. Factor analysis was used to examine the relationship among the 10 items that make up the Y-BOCS instrument. Models were computed in which both two- and three-factor solutions were estimated. Within the two-factor solution analyses, the factor distribution was not so consistent as in the three-factor solution analyses, and a shift in the factor distribution was noted after treatment. In the three-factor solution analyses, an independent resistance construct emerged in addition to the obsessive and compulsive constructs. Examination of the postreatment factor scores showed that the Y-BOCS resistance items did not assess OCD symptom change as sensitively as the rest of the Y-BOCS items did.

Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy

BACKGROUND Pulse oximetry measures arterial oxygen saturation (SpO2), not hypoventilation, which is directly reflected by increases in carbon dioxide tension. METHODS In the present study, transcutaneous carbon dioxide tension (PtcCO2) and SpO2 were measured during 101 endoscopic procedures selected for long duration or comorbid illnesses, and relationships between hypercapnia and hypoxemia were evaluated. Nasal oxygen was administered only for sustained desaturation (SpO2 < 90%). RESULTS Mean peak increase in PtcCO2 was significantly higher in patients requiring oxygen for sustained desaturation (16.3 mm Hg; range, 4-52) than in patients breathing room air who had transient or no desaturation (10.2 mm Hg [range, 3-19] and 5.1 mm Hg [range, 0-15]). If nasal oxygen corrected desaturation, even transient recurrence of desaturation indicated worsening CO2 retention, which preceded respiratory arrest in one patient. Independent predictors of hypercapnia were fentanyl and midazolam doses, oxygen requirement, and dementia. CONCLUSIONS Severe hypoventilation may occur during endoscopy, undetected by clinical observation or pulse oximetry, but only in sedated patients who require supplemental oxygen to maintain SpO2 above 90%. After oxygen supplementation corrects desaturation, recurrence of desaturation implies severe hypoventilation and warrants limitation of further sedation.

Auricular Acupuncture in the Treatment of Cocaine Abuse A Study of Efficacy and Dosing

A single-blind, randomized, placebo-controlled study was performed to evaluate auricular acupuncture (AAc) in the treatment of cocaine addiction. Two linked but concurrent studies were done. In Study 1, residential clients (N = 236) were randomized to true acupuncture (Ac), sham Ac, and conventional treatment without Ac. Treatment group subjects received Ac at three ear points considered to be specific for the treatment of substance abuse (SA). Control subjects received three nonspecific (sham) points. In Study 2, day treatment clients (N = 202) were randomized to one of three dose levels of true Ac (28, 16, or 8 treatments). Subjects received Ac at five, rather than three, specific ear points. Nonspecific (sham) points were not used in Study 2. With rare exception, the data failed to identify significant treatment differences among the true and sham Ac, and psychosocial groups. Furthermore, no differences were observed among the three dose levels of true Ac.

Double-blind placebo-controlled study of the efficacy of oral terfenadine in the treatment of chronic fatigue syndrome

BACKGROUND There is no established treatment for chronic fatigue syndrome (CFS), an illness characterized by disabling fatigue exacerbated by physical activity. A variety of immunologic abnormalities have been reported, including a high incidence of atopy and hypoergy or anergy. OBJECTIVE Because of anecdotal reports and uncontrolled trials showing antihistamine efficacy in CFS, we evaluated the clinical efficacy of the antihistamine terfenadine (60 mg twice daily) in a placebo-controlled study. METHODS Thirty patients with CFS were enrolled in a 2-month, double-blind, placebo-controlled trial of terfenadine. Participants underwent a battery of both immediate- and delayed-type hypersensitivity skin tests and completed a self-assessment questionnaire used to measure severity of symptoms, physical and social functioning, health perceptions, and mental health before each of six biweekly visits. RESULTS Twenty-eight patients completed the trial. History of atopy and positive immediate skin test results were prevalent, 73% and 53%, respectively. No evidence for hypoergy or anergy after delayed-type hypersensitivity skin testing was found. No therapeutic benefit from terfenadine could be detected in terms of symptom amelioration, improved physical or social functioning, health perceptions, or mental health. A high incidence of atopy in patients with CFS was confirmed. CONCLUSION Although this trial involved a small number of patients, the results suggest that terfenadine is unlikely to be of clinical benefit in treating CFS symptoms.

Same-day discharge after endoscopic biliary sphincterotomy : observations from a prospective multicenter complication study

BACKGROUND Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

Changes in Orders Limiting Care and the Use of Less Aggressive Care in a Nursing Home Population

To examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited.

Motivation for participation in clinical trials of drugs for the treatment of asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis

BACKGROUND While previous studies of enrollment motivation have been conducted with either healthy subjects or subjects with certain other diseases, little is known about the motives of subjects with asthma or rhinitis symptoms who seek to enter clinical trials. OBJECTIVE This study was conducted to assess the self-reported role that altruism, healthcare receipt, and financial gain play in the motivation of subjects with symptoms of bronchial asthma, seasonal allergic rhinitis, and perennial nonallergic rhinitis who attempted to enroll in clinical trials. METHODS Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis who sought to enroll in phase III clinical trials completed surveys from December 1991 to August 1992 (n = 295). The importance of altruistic and nonaltruistic motives was rated on numerical scales. RESULTS Improved control of symptoms and learning more about the illness and medications for treatment were the most important nonaltruistic motives (P less than .05). Financial motives and second opinion were moderately important but less important than healthcare motives (P less than .05). This population as a whole agreed that the altruistic motives listed in the survey were reasons to enroll. CONCLUSION Subjects with symptoms of asthma, allergic rhinitis, and perennial nonallergic rhinitis entered clinical trials for altruistic reasons and to receive healthcare treatment for their chronic illness including related health education. For the entire group, self-reported financial motives were less important than illness-related healthcare.

The effect of mental distress on women's preventive health behaviors.

Purpose. To examine the relationship between mental distress and preventive health behaviors (i.e., mammograms, pap tests, physical exams) among women. Methods. A cross-sectional design was employed. The sample consisted of 426 women from the Appalachian region in the United States who completed a comprehensive health survey. Mental distress was assessed by the 5-item Mental Health Index (MHI). Logistic regression was used to specify the models allowing for the control of covariates (i.e., marital status, education, recipient of Medicaid). Results. Women who reported high mental distress were more likely to not get timely pap tests [OR = 1.64; 95% CI (1.10, 2.45); p < .05] or physical exams [OR = 1.68; 95% CI (1.07, 2.65); p < .05] than women who did not report being mentally distressed. A similar but less robust relationship was found between mental distress and timely mammograms. Conclusions. These findings suggest that mental distress affects the likelihood of engagement in preventive health behaviors.

Omeprazole use at an urban county teaching hospital

To determine the appropriateness of use of omeprazole, all outpatient prescriptions over one year from a single county hospital pharmacy were analyzed. Appropriateness of omeprazole use was assessed by literature review and expert opinion. Two hundred twenty-one prescriptions were evaluated; 112 (56%) were inappropriate. Women received more inappropriate prescriptions (61% vs 44%, p=0.01) and received endoscopy less frequently (52% vs 71%, p<0.02) than did men. When age, gender, and prescribing clinic were examined as predictors of inappropriate use, only gender was significant (OR=2.01, 95% CI=1.52–2.66). This study, from a single institution, showed a high rate of inappropriate omeprazole use.

Measurement errors for a portable device measuring short-term growth

A field trial was conducted for a portable Knee Height Measuring Device (KHMD). Measurement errors for the machine, within and between observers (intraobserver and interobserver) and within subjects (intrasubject), were calculated from repeated observations of two anthropometrists on 40 children, 8 and 9 years of age. Interobserver technical error (0.452 mm) was larger than that published by the KHMD developers, but intraclass reliabilities are still very high (0.9975–0.9983). Attained size and fatness of subjects were not significantly correlated with interobserver measurement errors. Observed errors suggest they are sufficient to allow detection of knee height growth over periods of time much shorter than could be accomplished using more conventional anthropometry.