Biomedical subjects

G Kanoti

Publications and source records attributed to G Kanoti.

5 recordsLinked to original sources

PubMed1997

When is thrombolysis justified in patients with acute ischemic stroke? A bioethical perspective.

BACKGROUND: Thrombolytic therapy for acute ischemic stroke raises several unsettled bioethical issues related to risk versus benefit. Excluding the National Institutes of Neurological Disorders and Stroke (NINDS) rt-PA trial, the risk of intracerebral hemorrhage averages 10.3%, and there is a 44% increase in the odds of death among fibrinolysis-treated patients. Some investigators have suggested that as yet unidentified subgroups may benefit despite an increased early risk of hemorrhage and death, while others have warned that the widespread use of thrombolysis cannot currently be recommended despite recent Food and Drug Administration approval. The NINDS rt-PA trial showed a net benefit, but the relative risk to benefit ratio in individual patients is uncertain because of incomplete subgroup analysis. We explore these and related issues by applying the bioethical principle of justification to the selection of stroke patients for thrombolysis. SUMMARY OF COMMENT: Justification of a therapy rests on the criteria of safety, efficacy (net benefit under ideal conditions), effectiveness (net benefit under routine conditions), efficiency (cost-effectiveness or cost benefit), and outcome (proportionality and informed consent). The ethical principal of proportionality states that positive outcomes must be proportional to negative outcomes; only the NINDS trial sets equipoise between risk and benefit. The relative risk to benefit ratio and cost-effectiveness of thrombolysis will likely vary among treating physicians and patient subgroups. Although some potential selection factors such as early CT changes, National Institutes of Health Stroke Scale score > 22, and age > 77 years have been identified, it is not yet possible to predict response to treatment in individual patients. The effectiveness of thrombolysis outside of a clinical trial has not yet been demonstrated, and it is not clear that thrombolysis is cost-effective for all potential patient subgroups. CONCLUSIONS: No stroke thrombolysis regimen has met all five justification criteria. Proportional outcome standards that take into account patient preferences must be established. The risk to benefit ratio of thrombolysis in patient subgroups requires clarification and should incorporate cost-efficiency analyses. These issues should be kept in mind when considering thrombolysis therapy in patients with acute ischemic stroke and when designing clinical trials.

Age Factors↗

PubMed1997

Selection of a hospital for a transfer: the roles of patients, families, physicians and payers.

OBJECTIVE: This study investigates the reasons for hospital transfers and the role patients, their families, physicians, and payers play in the choice of a referral center. DATA SOURCES: A thirty-three item questionnaire and clinical data from the hospital's discharge database. STUDY DESIGN: A study of all 307 hospital transfer patients admitted between November 9 and December 3, 1993 was conducted to understand the factors contributing to the increase in transfers and the reasons patients were sent to CCH. Data on the transfer decision were collected by interviewing patients 48 hours after admittance to the hospital or by telephone if they were discharged before an interview could be completed. Two hundred and sixty-two (85%) patients were interviewed. PRINCIPLE FINDINGS: (1) Almost 58% of transfers were patient-initiated or -influenced; the remainder were physician- (38%) or payer-directed (4%); (2) More than 78% of the patients identified lack of clinical expertise/technology at originating hospital as the main reason for transferring. Other reasons included: established CCH patient status (43%), CCH marketing (31%), and concerns regarding quality of care at originating hospital (10%). Financial and quality dumping were not identified as reasons for the transfer. New patients to CCH were more likely to indicate that marketing and lack of clinical resources at originating hospital were reasons for selecting CCH than previous patients. CONCLUSIONS: Patients significantly influenced the transfer decision and the transfer decision-making process can be influenced by marketing. The opinions of the consumer should not be underestimated, especially by those seeking non-marketing solutions to health care reform.

Adult↗

PubMed1991

Psychological follow-up of women evaluated as oocyte donors.

Forty-five women were evaluated as candidates to donate oocytes to an infertile couple. Twenty-four women completed a cycle as oocyte donors. Follow-up data on donor satisfaction were obtained for 23 women. Ninety-one per cent were moderately to extremely satisfied with the experience and 74% would donate for another cycle if given the chance. Transient adverse psychological symptoms were reported by two donors but were resolved with medical or psychological treatment. Two women became pregnant soon after donation, one unintentionally. Psychological risk factors predicted donor candidates' decisions to participate and their compliance but were not predictive (within the group that completed a cycle) of donor satisfaction as follow-up or recipient pregnancy.

Adult↗

PubMed1989

A program for matched, anonymous oocyte donation.

The authors' program for matched, anonymous oocyte donation has resulted in two successful pregnancies among the first eight oocyte recipients. All oocyte recipients to date have had ovarian failure or absence with premature ovarian failure the most common cause. All recipients were cycled on a program of incremental oral micronized estradiol and intramuscular progesterone-in-oil. Thirteen candidates for oocyte donation were screened to obtain 8 donors. One donor candidate was excluded because of her medical history. The psychological screening of 2 of the other donor candidates (who subsequently did not complete the donation cycle) revealed a primary motive of financial gain. In general, the psychological profiles of donor candidates revealed a high incidence of troubled families and either reproductive loss or loss of a parent. Ovarian stimulation of the donors followed our standard in vitro fertilization protocol. The recipients' exogenous steroid replacement continued until days 97 and 101, respectively, of the two gestations. Both pregnancies resulted in the delivery of normal singleton males--the first at 40 weeks, the second at 35 weeks.

Adult↗

PubMed1985

The artificial heart: is it a wise option for health care?

Through Interdisciplinary Grand Rounds we hope to analyze new directions in the organization and delivery of health and medical care. Discussion will focus on current trends, their impact on the health care field and attempts to find solutions to the problems they present. These discussions are selected from the interdisciplinary conferences held at Case Western Reserve University, Cleveland, Ohio. Prepared from transcriptions, they are edited by the presenters and by the Health Matrix editorial staff. The following presentation was co-sponsored by the CWRU Medical School Committee for Student Representatives and the Student Bar Association of the CWRU Law School.

Ethics, Medical↗