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Biomedical subjects

A S Brett

Publications and source records attributed to A S Brett.

36 records · Page 2Linked to original sources
PubMed1991

Limitations of listing specific medical interventions in advance directives.

Recent events, including the Cruzan decision and the passage of the Patient Self-Determination Act, have renewed interest in the strengths and limitations of various types of advance directives. In one well-known approach, the competent person indicates preferences for or against a series of specific medical interventions that might be considered if the person loses decision-making capacity. However, such lists of interventions may shift attention away from overall treatment goals or may prescribe inappropriate medical care. Moreover, listing specific interventions in advance does not necessarily enhance self-determination or reduce uncertainty in decision making.

Advance Directives↗
PubMed1991

Psychologic effects of the diagnosis and treatment of hypercholesterolemia: lessons from case studies.

Some patients exhibit adverse psychologic responses to the diagnosis and treatment of hypercholesterolemia. These responses are, in part, a function of the patient's perception of the distinction between disease and illness and the patient's understanding of the probabilistic relationship between risk factors and associated diseases. Moreover, failure to acknowledge some of the specific complexities of hypercholesterolemia (e.g., natural fluctuations in serum cholesterol levels, variability of response to diet, etc.) may result in considerable anxiety. Clinicians should recognize and address these potential sources of dysfunctional psychologic reactions when they counsel hypercholesterolemic patients.

Adult↗
PubMed1990

Evaluation of substance-abusing adolescents by primary care physicians.

Physicians are in a unique position to identify substance-abusing adolescents. To evaluate physician performance from the patient's perspective, we interviewed 54 substance-abusing adolescents and their parents about previous medical encounters. Although nearly all patients had seen a physician during the time they were using drugs or alcohol, 43% did not recall being asked by a doctor about alcohol or drug use. Of the 26 patients who recalled being asked, 12 (46%) stated that they responded dishonestly, usually because a parent was present. Of the 23 who didn't recall being asked, five (18%) wished they had been asked. Physicians tended to ask about substance abuse more often (p = .08) when they had previously discussed the problem with the parents, but many parents did not initiate such discussions. This survey suggests that physicians may not adequately assess high-risk adolescents for substance abuse because of physician-, patient- and/or parent-dependent factors.

Adolescent↗
PubMed1988

Management of asymptomatic gallstones in the diabetic patient. A decision analysis.

The management of asymptomatic cholelithiasis in patients with diabetes is controversial. We used decision analysis to compare expectant management to prophylactic cholecystectomy in asymptomatic diabetic patients. Relevant probabilities were derived from the literature or expert opinion. Hypothetical cohorts of patients were followed for their lifetimes under each strategy. Expectant management was almost always the superior course. For example, a 30-year-old diabetic man gains an average of 6.1 months of life by choosing expectant management over prophylactic surgery. The superiority of expectant management was invariant to changes in age, sex, and the extent to which major surgical complications affect the future quality of life. Prophylactic cholecystectomy was superior only with extremely high estimates of the likelihood of developing symptomatic disease, the probability of requiring emergency surgery after symptoms develop, and emergency surgical mortality rates. However, no single factor had sufficient impact to alter the optimal decision by itself; the probabilities of several untoward events had to be increased simultaneously to favor prophylactic cholecystectomy. Prophylactic surgery for silent gallstones in diabetic patients does not increase life expectancy or quality of life and may in fact reduce it. This result holds over a wide range of basic assumptions.

Acute Disease↗
PubMed1988

Implications of discordance between clinical impression and toxicology analysis in drug overdose.

Two hundred nine cases of intentional drug overdose were reviewed to determine the importance of discordance between drugs identified by toxicology analysis and those suspected clinically. The laboratory agreed exactly with the clinical impression in 47% of cases. Clinically unsuspected drugs were identified by the laboratory in 27% of cases; the characteristics of these patients did not differ significantly from those of other patients. Unexpected toxicology findings led to changes in therapy in only three cases, and none of these changes appeared to have a major impact on outcome. Although routine comprehensive toxicology screening frequently may identify unsuspected drugs, it is likely that a policy of more selective use of the laboratory would not compromise the care of patients with drug overdose.

Adult↗
PubMed1987

Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit.

Many patients admitted for observation to the intensive care unit after a drug overdose do not ultimately require intensive care interventions. We retrospectively analyzed data on 209 overdose cases to determine whether clinical assessment in the emergency room could identify patients at risk for complications. Patients were classified as low risk when none of the following high-risk criteria were present in the emergency room: need for intubation; seizures; unresponsiveness to verbal stimuli; arterial carbon dioxide pressure (tension) greater than or equal to 45 mm Hg; any rhythm except sinus; second- or third-degree atrioventricular block; QRS greater than or equal to 0.12 s; or systolic pressure less than 80 mm Hg. Of 151 low-risk patients, none developed a high-risk condition after admission, and none required an intensive care intervention. The use of these predictive criteria in our patient population would have eliminated over half the intensive care days without compromising quality of care.

Adult↗
PubMed1986

Predictive power of the polygraph: can the "lie detector" really detect liars?

Expanded use of the polygraph as a detector of lies has been proposed in the United States and the United Kingdom. The positive predictive value of the polygraph (ie, the proportion of positive test results that are true positives) was assessed, on the evidence of the best published data for the sensitivity and specificity of the device. In many screening or investigative situations, the predictive value would be poor; most of the positive results would be false positives. Consequently, truthful persons incriminated as liars by the polygraph would outnumber actual liars with a positive result on the test.

Bayes Theorem↗
PubMed1986

The modification of cardiovascular risk factors: ethical issues.

Attempts to modify risk factors raise ethical questions. The ethical dimensions are heightened by uncertainties in the risk factor data base, the application of hypothetical probabilities to identified individuals, and the interaction between risk factors and values. The context of these issues varies from the isolated physician-patient relationship to the society as a whole.

Behavior Therapy↗
PubMed1985

Five cranial nerve palsies in a diabetic man.

A patient with stable non-insulin-dependent diabetes mellitus had five successive cranial nerve palsies, all of which resolved. This syndrome is rarely encountered in patients with diabetes and in otherwise healthy individuals.

Aged↗
PubMed1984

Far-advanced primary hyperparathyroidism in an 18-year-old young man.

Advanced debilitating primary hyperparathyroidism has become a clinical rarity as the condition is diagnosed at an asymptomatic stage in more patients. An 18-year-old young man is described who was referred because of an expanding facial mass. Evaluation revealed the classic musculoskeletal findings of severe primary hyperparathyroidism, as originally reported in the early part of the century.

Adolescent↗
PubMed1982

Perceptions and behaviors of patients with upper respiratory tract infection.

A questionnaire was administered to outpatients with uncomplicated viral upper respiratory tract infection in order to study the perceptions and behaviors of these individuals. Most patients sought advice or prescriptions to treat symptoms, felt that their symptoms had lasted longer than expected, or were worried that their symptoms could represent serious illness. There was considerable misunderstanding of the natural history of untreated upper respiratory tract infection and of the role of penicillin. The reasons for these findings and their implications for providers of primary care are discussed.

Adolescent↗