Search PubMed⌕ Search

Biomedical subjects

G D Rubenfeld

Publications and source records attributed to G D Rubenfeld.

17 recordsLinked to original sources
PubMed2000

Implications of extubation delay in brain-injured patients meeting standard weaning criteria.

We hypothesized that variation in extubating brain injured patients would affect the incidence of nosocomial pneumonia, length of stay, and hospital charges. In a prospective cohort of consecutive, intubated brain-injured patients, we evaluated daily: intubation status, spontaneous ventilatory parameters, gas exchange, neurologic status, and specific outcomes listed above. Of 136 patients, 99 (73%) were extubated within 48 h of meeting defined readiness criteria. The other 37 patients (27%) remained intubated for a median 3 d (range, 2 to 19). Patients with delayed extubation developed more pneumonias (38 versus 21%, p < 0.05) and had longer intensive care unit (median, 8.6 versus 3.8 d; p < 0.001) and hospital (median, 19.9 versus 13.2 d; p = 0.009) stays. Practice variation existed after stratifying for differences in Glasgow Coma Scale scores (10 versus 7, p < 0.001) at time of meeting readiness criteria, particularly for comatose patients. There was a similar reintubation rate. Median hospital charges were $29,057.00 higher for extubation delay patients (p < 0.001). This study does not support delaying extubating patients when impaired neurologic status is the only concern prolonging intubation. A randomized trial of extubation at the time brain-injured patients fulfill standard weaning criteria is justifiable.

Acute Disease↗
PubMed1999

The effect of acute respiratory distress syndrome on long-term survival.

Despite a great deal of information about the risk factors, prognostic variables, and hospital mortality in the acute respiratory distress syndrome (ARDS), very little is known about the long-term outcomes of patients with this syndrome. We conducted a prospective, matched, parallel cohort study with the goals of describing the survival of patients with ARDS after hospital discharge and comparing the long-term survival of patients with ARDS and that of a group of matched controls. The study involved 127 patients with ARDS associated with trauma or sepsis and 127 controls matched for risk factor (trauma or sepsis) and severity of illness who survived to hospital discharge. Time until death was used as the outcome measure. Survival was associated with age, risk factor for ARDS, and comorbidity. There was no difference in the long-term mortality rate for ARDS patients and that of matched controls (hazard ratio for ARDS: 1.00; 95% confidence interval: 0.47 to 2.09) after controlling for age, risk factor for ARDS, comorbidity, and severity of illness. We conclude that if sepsis or trauma patients survive to hospital discharge, ARDS does not increase their risk of subsequent death. Older patients, patients with sepsis, and patients with comorbidities, regardless of the presence of ARDS, have a higher risk of death after hospital discharge. For the purposes of clinical prognosis and cost-effectiveness analysis, the long-term survival of patients with ARDS can be modeled on the basis of age, underlying risk factor for ARDS, and comorbidity.

Adolescent↗
PubMed1999

Interobserver variability in applying a radiographic definition for ARDS.

CONTEXT: Acute lung injury (ALI) and ARDS are currently defined by the American-European Consensus Conference (AECC) definition criteria, which contain a radiographic criterion. The accuracy or reliability of this consensus radiographic definition has not been evaluated, and no radiographic definition of ALI-ARDS has been evaluated by a large international group of experts. OBJECTIVE: To study the interobserver variability in applying the AECC radiographic criterion for ALI-ARDS. DESIGN: Survey. PARTICIPANTS: A convenience sample of 21 experts selected from participants attending the 1997 Toronto Mechanical Ventilation Workshop and from members of the National Institutes of Health ARDS Network. OUTCOME MEASURES: Participants reviewed 28 randomly selected chest radiograph from critically ill, hypoxemic (PaO(2)/fraction of inspired oxygen ratio, < 300) patients and decided whether the radiograph fulfilled the AECC definition for ALI-ARDS. RESULTS: Interobserver agreement in applying the AECC definition for ALI-ARDS was moderate (kappa = 0.55; 95% confidence interval, 0.52 to 0.57). Thirteen radiographs (43%) showed nearly complete agreement (defined as 20 or 21 readers in agreement). Nine radiographs (32%) had more than or equal to five dissenting readers. The percentage of radiographs interpreted as consistent with ALI-ARDS by individual readers ranged from 36 to 71%. Participants commented that mild infiltrates, pleural effusions, atelectasis, isolated lower lobe involvement, radiographic technique, and overlying monitoring equipment posed the most difficulties. CONCLUSIONS: The radiographic criterion used in the current AECC definition for ALI-ARDS showed high interobserver variability when applied by expert investigators in the fields of mechanical ventilation and ARDS. This variability may result in differences in ALI-ARDS populations at different clinical research centers and may make it difficult for clinicians to apply the results of clinical trials to their patients. Modifications to the radiographic criterion or annotated reference radiograph may improve the reliability of future definitions for ALI-ARDS.

Adolescent↗
PubMed1998

Variations in intensive care unit utilization for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia: importance of hospital characteristics and geographic location.

OBJECTIVE: To determine whether intensive care unit (ICU) use and outcomes for patients with human immunodeficiency virus (HIV)-related Pneumocystis carinii pneumonia vary by hospital characteristics and geographic location. DESIGN: Retrospective review of the medical records of 2,174 patients with HIV-related P. carinii pneumonia. SETTING: Random sample of 73 private, nine public, and 14 Veterans Affairs hospitals in five cities (Chicago, New York, Los Angeles, Miami, and Durham, NC). PATIENTS: Stratified random sample of patients hospitalized with HIV-related P. carinii pneumonia from 1987 to 1990. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 2,174 patients with P. carinii pneumonia, 398 (18%) patients received care in an ICU. ICU utilization varied significantly by patient and hospital characteristics, as well by as geographic location. Non-Hispanic whites, patients with Medicaid, and patients with a prior acquired immunodeficiency syndrome-defining illness were the least likely to receive care in an ICU. Patients in county- or state-owned hospitals and patients in hospitals with more P. carinii pneumonia-experience were also less likely to be cared for in an ICU. These differences in ICU utilization persisted when controlling for severity of illness, as well as other patient characteristics. Significant geographic variation in ICU utilization persisted after controlling for patient and hospital characteristics. Survival to hospital discharge after an ICU stay was significantly higher for patients without a prior acquired immunodeficiency syndrome-defining illness and for patients in hospitals with more P. carinii pneumonia experience. CONCLUSIONS: We found significant variations in ICU utilization by hospital characteristics and geographic location that remained significant after controlling for severity of illness and patient sociodemographic characteristics. Hospital and geographic variations in ICU utilization may make it difficult to generalize ICU outcomes across different hospitals.

AIDS-Related Opportunistic Infections↗
PubMed1998

Cost-effectiveness considerations in critical care.

The ICU, perhaps more than any other area in modern medicine, brings the conflicting issues of high cost and life-saving technology into stark relief. Cost-effectiveness analysis offers a quantitative method for selecting among treatments to optimize outcomes for any given financial outlay. Impediments to developing and using cost-effectiveness analysis to guide medical care decisions include the lack of accurate estimates or treatment effectiveness and reliable cost measures; variations in assumptions used in different cost-effectiveness analyses; and lack of an ethical or regulatory construct to ensure that the decisions will be carried out fairly. Recently, standards for performing cost-effectiveness analyses have been proposed which should enhance the quality and comparability of studies. A detailed understanding of the methods and limitations of economic analyses is essential to clinicians challenged by a growing number of articles and manufacturers' claims regarding the cost-effectiveness of critical care.

Cost-Benefit Analysis↗
PubMed1997

Relationship between soluble CD14, lipopolysaccharide binding protein, and the alveolar inflammatory response in patients with acute respiratory distress syndrome.

The effects of bacterial endotoxin (lipopolysaccharide, LPS) are amplified by lipopolysaccharide binding protein (LBP) and CD14, resulting in cellular activation at very low concentrations of LPS. To investigate the importance of this pathway in acute lung injury, we measured LPS, LBP, and soluble CD14 (sCD14) in the bronchoalveolar lavage fluid (BAL) of 82 patients with acute respiratory distress syndrome (ARDS). LBP and sCD14 increased markedly in BAL of patients with ARDS. sCD14 and LBP each were strongly related to BAL total protein and polymorphonuclear neutrophil (PMN) concentration, whereas LPS concentration was not. Multivariate analyses showed sCD14 to be strongly related to BAL total protein, even after controlling for LPS and LBP concentrations. sCD14 was strongly and independently related to PMN concentration, after controlling for BAL LPS, LBP, and interleukin-8 (IL-8). The BAL LPS concentration was not strongly related to either BAL total protein or BAL PMN. The BAL sCD14 and LBP values were similar in all subgroups of patients with ARDS, and were not related to survival. The serum LBP and sCD14 were elevated in ARDS, but were not related to BAL total protein, LBP, sCD14, PMN, or clinical outcome. Thus, LBP and sCD14 reach high concentrations in the lungs of patients with ARDS, and BAL sCD14 is strongly related to two major indices of lung inflammation: total protein and PMN concentration. CD14-dependent mechanisms may contribute to lung inflammation in ARDS.

Acute-Phase Proteins↗
PubMed1996

Withdrawing life support from mechanically ventilated recipients of bone marrow transplants: a case for evidence-based guidelines.

BACKGROUND: Mechanical ventilation after bone marrow transplantation is associated with a high mortality rate. The available literature provides conflicting predictors of outcome in relatively small study groups. OBJECTIVE: To identify predictors of death and mortality trends in mechanically ventilated transplant recipients. DESIGN: Nested case-control study. SETTING: The Fred Hutchinson Cancer Research Center in Seattle, Washington, which specializes in bone marrow transplantation. PATIENTS: All survivors (cases, n = 53) and a group of patients matched for year of transplantation who did not survive (controls, n = 106) were selected from all mechanically ventilated patients (n = 865) who received a bone marrow transplant between January 1980 and July 1992. Patients who received mechanical ventilation for less than 24 hours after a procedure or who received mechanical ventilation after a second bone marrow transplantation were excluded. MEASUREMENTS: Surviving patients were defined as those who were alive 30 days after extubation and who were discharged from the hospital. Daily laboratory, physiologic, and treatment variables were collected. RESULTS: Survival was statistically associated with younger age, lower score on the Acute Physiology and Chronic Health Evaluation III, and a shorter time from transplantation to intubation. There were no survivors among an estimated 398 patients who had lung injury and either required more than 4 hours of vasopressor support or had sustained hepatic and renal failure. Through the use of these factors, an accurate prediction of death could have been made in the first 4 days of mechanical ventilation for more than half of the patients who did not survive. During the past 5 years, survival rate has changed from 5% to 16% (P = 0.008), an increase that was not explained by changes in the age of the patients, the rate or timing of intubation, or the percentage of allogeneic transplants that were not HLA-identical. CONCLUSION: Of the patients who required mechanical ventilation after bone marrow transplantation, no one survived with lung injury combined with either hemodynamic instability or hepatic and renal failure. However, survival after mechanical ventilation seems to be improving.

Adult↗
PubMed1996

Changes in marketplace demand for physicians: a study of medical journal recruitment advertisements.

OBJECTIVE: To measure trends in marketplace demand for physicians in different specialties. METHODS: Retrospective review of physician recruitment advertisements appearing in the September issues of 7 medical journals in 1984, 1987, 1990, 1993, and 1995. MAIN OUTCOME MEASURE: Number of advertised positions in each of the studied specialties. RESULTS: Steep declines in the number of advertised positions for specialist physicians over the past 5 years were consistently observed with the exception of pediatric specialists. The most dramatic changes occurred in the number of internal medicine specialist positions, which declined by 75% since 1990. For physicians as a whole, there were 4 specialist positions for every generalist position advertised in 1990; by 1995, this ratio dropped to 1.8. Family medicine exhibited continuous growth in the number of advertised positions, more than doubling during the period studied. CONCLUSIONS: Our data suggest a recent decline in marketplace demand for physicians, particularly those in specialist fields. Among generalists, demand for internists and pediatricians is rising. Ongoing analysis of these advertisements will provide timely information about the demand for physicians in a rapidly changing health care system.

Advertising↗
PubMed1995

Do-not-resuscitate orders: a critical review of the literature.

Formal DNR policies have improved the process by which decisions to withhold CPR are made. Slow and sham codes are now rare. Communication between physicians and patients and between physicians and providers of in-hospital CPR clearly exceeds that in other developed countries. Results of early studies that examined the care received by those with and without advance directives have been unable to document differences. A more realistic appraisal of the potential role for advance directives coupled with an emphasis on education and rational treatment guidelines should promote continued improvement in the compassionate use of cardiopulmonary resuscitation.

Advance Directives↗