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Biomedical subjects

D N Rose

Publications and source records attributed to D N Rose.

At least 37 records · Page 2Linked to original sources
PubMed1988

Anticoagulation clinics and the monitoring of anticoagulant therapy.

Patients attending an anticoagulation clinic were studied to delineate predisposing risk factors for bleeding and thromboembolic episodes. Seventy-three patients were observed for a total of 921.8 patient-treatment months. The mean duration of treatment was 12.6 months (range 3-36 months). No major bleed occurred (a bleed which caused discontinuation of therapy, hospitalization or death). Thirty-two patients had minor bleeding episodes (0.42 bleeds per patient-year of treatment). The average prothrombin time ratio during the third to the sixth month of therapy was predictive of the bleeding risk. There was no association between bleeding and age, sex, indication for anticoagulation therapy or associated illnesses. Four thromboembolic episodes occurred (0.05 per patient-year of treatment), 3 arterial and 1 venous. At the time of the one venous thromboembolic event the prothrombin time ratio was subtherapeutic. In all 3 patients with arterial thromboembolism the mean 3- to 6-month prothrombin time ratio was less than or equal to the lower limit of the recommended range of 1.6-2.5. In our study prothrombin time ratios of 1.3-1.5 for venous thromboembolic disease and 1.6-2.5 for arterial thromboembolic disease were not associated with thromboembolism or major bleeding. Anticoagulation clinics facilitate the close monitoring of patients on oral anticoagulant therapy.

Aged↗
PubMed1987

Hearing loss screening in the neonatal intensive care unit: auditory brain stem response versus Crib-O-Gram; a cost-effectiveness analysis.

We used cost-effectiveness analysis to compare two strategies for screening for severe hearing loss in the neonatal intensive care unit (NICU): the auditory brain stem response (ABR) and the Crib-O-Gram (COG). We studied hypothetical cohorts of infants using data derived from the literature on screening test characteristics. We included the costs of initial screening and those of further diagnostic testing for infants who fail the screening test. The ABR cost more per test administered than COG, but had higher sensitivity and specificity to detect hearing loss. We found the ABR, therefore, to be more cost effective than the COG. Using best-estimate assumptions, ABR cost $10,610 for each correctly detected case of hearing loss; COG cost $14,310 for each correctly detected case; among every 1,000 NICU infants screened, furthermore, ABR detected all cases of hearing loss, whereas COG failed to detect five hearing-impaired infants. We conclude that cost-effectiveness analysis justifies using ABR as a screening tool.

Audiometry↗
PubMed1987

A model for physicians' therapeutic decision making.

We explored physician's cognitive processes when making therapeutic decisions in a complex situation in which more than one treatment option is acceptable. Eighteen internists were presented with three hypothetical cases of patients with coronary artery disease and were asked to explain their treatment decisions. Based on process tracing, we characterized their method of therapeutic decision making. We found that physicians use a three-stage process that we call focal composite analysis: (1) selection of a few facts (focal points) and evaluation of each fact individually with respect to treatment options; (2) reassessment of the value of the focal points with respect to each other and unification of the case; and (3) summation of the values of the focal points to make the final decision. Using this model, we predicted physicians' actual treatment decisions in 96% of the hypothetical cases. Further analysis revealed a wide variety of focal points chosen overall, with most physicians choosing different focal points in each case. Of a total of 32 focal points chosen in three cases, only two focal points were predictors of the physicians' actual treatment choices. We conclude that in the complex problem considered here physicians use a staged process of choosing and evaluating information to make therapeutic choices.

Angina Pectoris↗
PubMed1986

The age threshold for isoniazid chemoprophylaxis. A decision analysis for low-risk tuberculin reactors.

Isoniazid chemoprophylaxis recommendations include its use in persons who have positive tuberculin reactions, but neither recent conversion nor other activation risk factors, only if they are under age 35 years. Above this threshold, the isoniazid hepatitis risk is said to outweigh the benefit of preventing activation. Because this policy is controversial, we performed a decision analysis contrasting those who take with those who decline isoniazid therapy according to three outcome measures: life expectancy, likelihood of illness (isoniazid hepatitis and active tuberculosis), and likelihood of fatal illness. We found no threshold between ages 10 and 80 years by the measures of life expectancy and likelihood of fatal illness; isoniazid benefits outweigh risks for all, though the margin is small for the elderly. A threshold exists only in the likelihood of illness: isoniazid risks outweigh benefits for those aged 50 to 65 years. Only extreme variations of assumptions affect these findings. Chemoprophylaxis recommendations should include low-risk tuberculin reactors over age 35 years.

Adolescent↗
PubMed1985

Building an effective doctor-patient relationship: from patient satisfaction to patient participation.

In this paper, the authors argue that patient satisfaction is an insufficient measure of the quality of the doctor-patient relationship. While shown to have a salutary effect on patient anxiety concerning illness and treatment, the only other significant outcome associated with levels of satisfaction is utilization behavior. This is not surprising, the authors argue, since prevailing conceptualizations of patient satisfaction fail to incorporate measures of patient participation in the therapeutic process. Evidence suggests that by encouraging patients to take an active role in their health care physicians can increase the effectiveness of their therapeutic activities. A method for involving patients is through incorporating their preferences into the physician's decision-making processes. An example of physician decision making which incorporates patient preferences is provided.

Attitude to Health↗
PubMed1985

Lumbar puncture in asymptomatic late syphilis. An analysis of the benefits and risks.

We evaluated the treatment of asymptomatic patients with untreated syphilis of more than one year's duration (asymptomatic late syphilis) using a decision-analysis model. Two strategies were compared: treatment with 7.2 million units of penicillin G benzathine, or performing a lumbar puncture to test for asymptomatic neurosyphilis followed by penicillin and management based on cerebrospinal fluid analysis. Estimates of probabilities of disease prevalence, test sensitivity, and cure and complication rates were derived from published studies. Both strategies resulted in a cure rate of at least 99.7% using the best estimates. Although the strategy using lumbar puncture results in a 0.2% higher cure rate, its rate of complications (0.3%) exceeds its marginal benefit. We conclude that a lumbar puncture offers little additional benefit and may increase morbidity in patients with asymptomatic late syphilis.

Headache↗
PubMed1984

Should the risk of acquired immunodeficiency syndrome deter hepatitis B vaccination? A decision analysis.

The current epidemic of acquired immunodeficiency syndrome (AIDS) and fear that its causative agent contaminates the currently available hepatitis B vaccine may have deterred vaccine use. We formulated a decision-analytic model that compares the risk of death from hepatitis B and AIDS in those vaccinated with the risk of death from hepatitis B alone in those who wait two years for a synthetic vaccine. For individuals with 5% annual risk of hepatitis B, the best current estimate is that vaccination now would save 25 lives per 100,000. The best current estimate of the rate of vaccine-induced AIDS is zero, and one can be 95% confident that the rate is less than eight per 100,000. The rate would have to be considerably higher before postponement of vaccination would be rational for those for whom vaccination has been recommended.

Acquired Immunodeficiency Syndrome↗
PubMed1982

Screening for lead toxicity among autobody repair workers.

Fifty-one workers in 10 small, neighborhood autobody repair shops were screened for lead toxicity using blood zinc protoporphyrin (ZPP) levels and work history questionnaires. Those with high ZPP levels (greater than 50 micrograms/dl) had further studies, including blood lead determinations. The shops were dusty with ground putty dust (lead-free) and paint spray (lead content range 0-40%). Thirteen (26%) workers had mildly elevated ZPP levels (all were full-time sander/sprayers) though few had symptoms and none had elevated blood lead levels. Eighteen controls, workers in other occupations, had normal ZPP levels. Air monitoring during inactive periods failed to reveal high lead levels (range 0-28 micrograms/m2). These data suggest that workers in autobody repair shops are at risk of lead toxicity but the exposure and biologic effects are less than in many other industries that utilize lead.

Adult↗
PubMed1982

A medical school's involvement in the development of a community-based health center.

This paper presents a planning model developed by the Department of Community Medicine of the Mount Sinai School of Medicine to facilitate the interactions between the medical school and the community. The planning process involved application of the model, exemplified through the growth and development of a neighborhood health center governed by a community agency. The main characteristics of the medical school, of the community, and of the community agency are presented briefly and the seven-year history of the development of the neighborhood health center is summarized. In recapitulating that history three distinct phases are identified in the planning process: how the planning was planned, how the plan was prepared, and how the services program was implemented. The role of the Department of Community Medicine in each phase is analyzed.

Academic Medical Centers↗
PubMedDate not supplied

BCG vaccination to prevent tuberculosis in health care workers: a decision analysis.

OBJECTIVE: To perform a decision analysis to determine the optimal strategy to prevent tuberculosis (TB) in health care workers with negative tuberculin skin tests. METHODS: We used a Markov model to study the occurrence of events each year and compared BCG vaccination to annual tuberculin testing plus isoniazid (INH) preventive therapy for those who become skin test positive. The outcome measures studied were the number of cases and deaths from TB and BCG and/or INH adverse reactions over 10 years. RESULTS: Annual tuberculin testing decreases the number of TB cases by 9% and BCG vaccination decreases the number by 49%, relative to no prevention intervention. BCG vaccination results in fewer deaths than annual tuberculin testing if the workplace incidence of Mycobacterium tuberculosis infection is greater than 0.06%, BCG vaccination effectiveness exceeds 3%, or the rate of fatal BCG adverse reactions is less than 15 times the rate reported in the literature. CONCLUSIONS: BCG vaccination results in less morbidity and mortality than annual tuberculin skin testing for health care workers in workplaces with documented TB transmission despite comprehensive infection control policies and procedures. Current policy on the prevention of TB among health care workers should be reconsidered.

Antitubercular Agents↗
PubMedDate not supplied

Preventive medicine for HIV-infected patients: an analysis of isoniazid prophylaxis for tuberculin reactors and for anergic patients.

OBJECTIVE: To analyze the policies of isoniazid prophylaxis for human immunodeficiency virus (HIV)-infected tuberculin reactors and for HIV-infected anergic patients with unknown tuberculin status. METHODS: Transition-state model of clinical immune deterioration of HIV-infection over ten years, review of published data, and a survey of AIDS experts. Outcome measures are the numbers of tuberculosis cases and deaths prevented and isoniazid toxicity cases and deaths occurring with prophylaxis. PATIENTS: Hypothetical cohorts of HIV-infected 40-year-olds. RESULTS: Because the tuberculosis activation rate is so high in HIV-infected patients, the benefits of prophylaxis far outweigh the risks of isoniazid toxicity for tuberculin reactors with HIV infection at any stage of immune function: 1,469-2,868 tuberculosis cases and 170-274 deaths are prevented per 10,000 cohort over ten years, depending upon the cohort's initial immune state. The benefits of prophylaxis outweigh the risks of isoniazid toxicity for anergic HIV-infected patients if they come from a community with a 2% to 3% or greater prevalence of Mycobacterium tuberculosis infection. CONCLUSIONS: Isoniazid prophylaxis is a reasonable prevention measure for HIV-infected tuberculin reactors and for many HIV-infected anergic patients.

AIDS-Related Opportunistic Infections↗
PubMedDate not supplied

Zidovudine prophylaxis for needlestick exposure to human immunodeficiency virus: a decision analysis.

OBJECTIVE: To perform a decision analysis to determine the thresholds of safety and effectiveness that would justify short-term zidovudine (AZT) administration for persons with accidental percutaneous exposure to HIV-positive blood. DESIGN: Published data were used to estimate the seroconversion rate (0.42%), rate of developing AIDS if HIV-infected (5%/year), and survival with AIDS (50%/year). No information is available on zidovudine effectiveness and little is known about fatal toxicity of zidovudine. Death from AIDS or from zidovudine toxicity was used as the endpoint. RESULTS: For those with exposure to blood known to be HIV-seropositive, the benefits of zidovudine outweight the risks if efficacy is above approximately 3% to 8%. Wide variations in the assumptions have little effect on the thresholds. CONCLUSIONS: Since clinical trials to determine zidovudine effectiveness in this setting will probably never be done, decision analysis offers the only quantitative method for addressing this question. Unless future studies show zidovudine to be both ineffective and toxic, the benefits of short-term administration of zidovudine outweigh the risks immediately after exposure to HIV-positive blood. Zidovudine benefits do not clearly outweigh the risks after exposure to blood of unknown serologic status, or if there is a delay in starting therapy.

Acquired Immunodeficiency Syndrome↗