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Biomedical subjects

C Fleming

Publications and source records attributed to C Fleming.

96 records · Page 6Linked to original sources
PubMedDate not supplied

A peripartum neurologic event: shooting from the hip.

We have shown that a simplified model, generated quickly in response to an emergency consultation, may provide useful insights in certain situations. A more developed model was useful in verifying these insights. Because the more complex model considered a longer time horizon than the simple model, it allows us to consider questions regarding long-term benefits of aneurysm repair. When modeling any problem, the most important reason for performing decision analysis is to gain insight from analyzing the clinical setting and from constructing the model. The quantitative results are usually of only minor importance. However, our most important insights are sometimes gained by looking beyond the quantitative level to understand the interactions of various effects within the model. In this case, it was those insights that were of the greatest benefit to the patient in arriving at a decision to have cerebral arteriography.

Adult↗
PubMedDate not supplied

Automated critiquing of medical decision trees.

The authors developed a decision tree-critiquing program (called BUNYAN) that identifies potential modeling errors in medical decision trees. The program's critiques are based on the structure of a decision problem, obtained from an abstract description specifying only the basic semantic categories of the model's components. A taxonomy of node and branch types supplies the primitive building blocks for representing decision trees. Bunyan detects potential problems in a model by matching general pattern expressions that refer to these primitives. A small set of general principles justifies critiquing rules that detect four categories of potential structural problems: impossible strategies, dominated strategies, unaccountable violations of symmetry, and omission of apparently reasonable strategies. Although critiquing based on structure alone has clear limitations, principled structural analysis constitutes the core of a methodology for reasoning about decision models.

Decision Trees↗
PubMedDate not supplied

Cost-effectiveness of streptokinase for acute myocardial infarction: A combined meta-analysis and decision analysis of the effects of infarct location and of likelihood of infarction.

OBJECTIVE: To determine the effects of infarct location and of the likelihood of infarction on the cost-effectiveness of intravenous streptokinase (IVSK) for suspected acute myocardial infarction (AMI). DESIGN: A meta-analysis of short-term survival was combined with a simple decision tree to determine marginal cost-effectiveness ratios for different infarct locations and different likelihoods of AMI (pMI). SETTING: Six randomized trials comparing IVSK with conservative treatment. PATIENTS: 31,940 patients with onset of symptoms of AMI from four to 24 hours earlier and, with the exception of one trial, electrocardiographic abnormalities. Patients with contraindications to thrombolytic treatment such as uncontrolled hypertension were excluded. MAIN RESULTS: If AMI is certain, treatment with IVSK has marginal cost-effectiveness ratios for each additional life saved of $9,900, $56,600, and $28,400, respectively, for patients with anterior, inferior, and other locations of AMI. If pMI is 50% treatment with IVSK has marginal cost-effectiveness ratios for each additional life saved of $22,700, $131,800, and $63,100, respectively, for patients with anterior, inferior, and other locations of AMI. CONCLUSIONS: The marginal cost-effectiveness ratio for IVSK therapy of inferior infarction is six times that for anterior infarction and rises steeply as the presence of AMI becomes less certain. Assuming society is willing to pay $250,000 per life saved, IVSK therapy should be given if the chance of acute anterior infarction exceeds 7%, if the chance of inferior infarction exceeds 32%, or if the chance of infarction in other locations exceeds 17%. In patients with suspected acute myocardial infarction, IVSK saves lives and is a reasonable use of societal resources.

Boston↗
PubMedDate not supplied

Users of free treatment slots at a community-based methadone maintenance clinic.

At a community-based methadone clinic in Seattle, WA, 360 opiate-addicted individuals were enrolled in a treatment demonstration project. The treatment slots were free to clients and, unlike other funded treatment slots, did not require proof of eligibility based on documentation of indigence. The clients were compared with 70 clients enrolled in a research project begun 2 years earlier in which the sample was drawn from a population using normal funding sources at the same program. Subjects in the later demonstration project were older and had fewer years of education. A higher percentage of the demonstration project subjects were African American. These differences indicate that introduction of free treatment opened opportunities to individuals who have difficulty accessing treatment under normal circumstances. Subjects in the treatment demonstration project were more likely to have obtained needles from legal sources and used bleach to clean needles. These findings probably reflect the impact of needle exchange and outreach programs, established in the year prior to the demonstration project.

Acquired Immunodeficiency Syndrome↗