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Biomedical subjects

H Greenberg

Publications and source records attributed to H Greenberg.

At least 55 records · Page 3Linked to original sources
PubMed1993

Long-term prognostic significance of ST segment depression during acute myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group.

OBJECTIVES: The purpose of this study was to evaluate the long-term prognostic value of ST segment depression on the electrocardiogram (ECG) in patients with acute myocardial infarction. BACKGROUND: The prognostic importance of ST segment depression on the ECG has been studied in small groups of patients with infarction, but larger numbers are needed. METHODS: Coronary care unit ECGs of 1,234 patients who survived the coronary care unit with acute Q wave (n = 896) or non-Q wave (n = 338) myocardial infarction were analyzed for the presence of ST segment depression. Patients were followed up for up to 4 years. RESULTS: ST segment depression was present in 607 patients. Those with ST segment depression had a 1-year mortality rate of 10.3% compared with a rate of 5.6% for those without ST segment depression (p = 0.002). This effect was seen in both the Q wave and non-Q wave subgroups. Of the 437 patients with anterior ST segment elevation, those with ST segment depression in other regions had a 13.6% 1-year mortality rate compared with a rate of 6.9% for those with no ST segment depression (p = 0.0005). Of the 514 patients with inferior ST segment elevation, those with ST segment depression in other leads had an 11.0% 1-year mortality rate compared with a 1.8% rate for those with no ST segment depression (p = 0.0001). The Cox proportional hazards model showed that ST segment depression was an independent predictor of mortality over the follow-up period. CONCLUSIONS: ST segment depression on the admitting ECG in patients with acute myocardial infarction is a predictor of increased mortality in the year after infarction.

Adult↗
PubMed1993

The anatomy of missed breast cancers.

Missed breast cancer continues to account for the highest percentage of medical malpractice cases in the United States. A retrospective, computer-aided study was performed to investigate the mechanisms of missed breast carcinomas, missed either by mammography or by clinical exam. In a consecutive series of 509 breast cancers found in patients registered at a University Comprehensive Breast Cancer Clinic, no tumour that was 5 mm or less in maximal diameter was clinically palpable. This subgroup consisted of seven in situ and 32 invasive carcinomas. The incidence of palpable tumours in 5 mm increments increased so that when a tumour was between 11 and 15 mm in size, 48% of the lesions were palpable, and with tumours greater than 20 mm in size, 84% were palpable. There was a good correlation between size of the tumour as judged by mammography and the eventual size determined by histologic examination. Smaller breast cancers were detected by mammography than by physical examination. In a separate analysis of 553 consecutive cases of breast cancer examined by mammography, there were 50 (9%) cases in which the cancer was not read from the mammogram. In retrospect, 10 of these mammograms were abnormal for a misinterpretation rate of 1.8%. Cancers associated with false negative mammograms occurred more often in younger women and in dense breast parenchyma than cancers detected by mammography. Cancers missed by mammography were smaller than palpable cancers detected by mammography, more often had negative nodes and presented with a lower stage of disease. Breast augmentation implants were associated more frequently with missed breast cancers, with 5/8 clinically detected breast carcinomas being undetected by mammography. An asymmetric mass was more often associated with cancers missed by mammography, accounting for the sole sign of malignancy in 3% of all cancers, but was the source of 14% of false negative exams. Architectural distortion, ill-defined or well circumscribed masses or calcifications as mammographic signs of malignancy were not associated with an increased frequency of missed cancers. Three 'interval' breast cancers occurred in this series and are included in the false negative mammograms. It is concluded that the threshold of clinically detected breast cancers is 6 mm and experienced clinicians do not detect the majority of breast cancers until the lesions are greater than 16 mm. Mammography has a defined misinterpretation and false negative rate. Likewise, asymmetric mammographic densities that are greater than 16 mm and are not palpable may be followed, since most breast cancers are palpable in this range.

Adult↗
PubMed1993

Interstitial radiotherapy for early stage vaginal cancer. A new method of tumor localization.

Carcinoma of the vagina is optimally treated primarily with teletherapy, followed by interstitial needle brachytherapy. Following teletherapy, identification of the original tumor site is frequently difficult. We describe a method of marking the tumor with an india ink "tattoo" at initial presentation, followed by placement of a purse-string suture and titanium hemoclips at the time of brachytherapy. A stable marker is created so that the location of the original vaginal tumor can be easily identified on dosimetric films.

Adult↗
PubMed1993

Long-term survival in malignant glioma. Prognostic factors.

Mean survival of patients with malignant glioma is six months. Only 7.5% of these patients survive two years. We identified 14 patients, nine with glioblastoma multiforme and five with anaplastic astrocytoma, who survived more than two years. All were treated initially with surgery, radiation and adjuvant chemotherapy. One patient who received three years of nitrosourea has lived longer than 7.3 years. Seven of the 14 patients have no sign of tumor recurrence four years after diagnosis. Nine surviving patients were younger than 45 years of age at the time of diagnosis. Five died of tumor recurrence with the median survival time of 3.5 years. This data suggests that onset at a younger age (< 45 years), multimodality therapy, high Karnofsky Performance Scale and frontal lobe tumors were the major prognostic factors that contributed to long-term survival.

Adolescent↗
PubMed1993

The medical legal implications of following mammographic breast masses.

Delay in breast cancer diagnosis continues to account for the highest percentage of medical malpractice cases in the United States. A retrospective, computer-aided study was undertaken to investigate a number of parameters used in making medical-legal decisions in missed breast cancer cases. Over a 5-year period, 435 women with invasive breast cancers were registered at the Comprehensive University Breast Cancer Center. A close correlation between mammographic and final histologic size was verified (R = 0.74). In 5-mm increments, starting with a 1.0-mm tumor, there was an increasing percentage of positive nodes identified with increasing size of the tumor. Major percentage increases in frequency of positive nodes were noted at tumor sizes of 11 and 21 mm. This corresponded to an increasing number of recurrences and a decreasing 5-year disease-free survival (DFS) between consecutive 5-mm increments, although the differences were not significant. A multivariate regression analysis confirmed that the most important predictor of DFS was lymph node status (p = 0.0046) and not tumor size. After adjusting for lymph node status, tumor size was not significant. It is concluded that a period of observation, in which a breast cancer may increase in size is not substandard care since tumor size, after accounting for lymph node status is not significant at predicting DFS.

Breast↗
PubMed1993

Natural history and clinical evaluation of the lumpectomy scar.

After lumpectomy with axillary dissection and radiation therapy, there are numerous changes that occur to the breast that, if unrecognized as routine, post-treatment changes, can lead to inappropriate intervention by the physician. The purpose of this study is to evaluate the time required to achieve stable post-treatment mammographic and physical findings. One hundred twenty-three patients age 56.6 years with a mean tumor size of 15.9 +/- 8.2 mm were observed every 6 months with a mean change in scar size of 16.7 +/- 10.6 mm. A scar never developed in 27 per cent and completely resolved or decreased in 90 per cent. Calcifications developed in 16 per cent of the patients; 40 per cent in the scar, 60 per cent outside the scar. Recurrence developed in 2 per cent of the patients at a mean time of 53 months and was believed to be favorably influenced by cytologic evaluation of the resection margins at the time of tumor excision. Stabilization or resolution of the post-treatment changes occurred within 24 to 36 months. The conclusion is for careful surgical and radiologic follow-up with examinations, fine-needle aspirations, and meticulous mammograms guiding the need for biopsy.

Biopsy, Needle↗
PubMed1992

Primary treatment of pelvic osteosarcoma. Report of five cases.

Five patients, ages 12 to 20 years, with nonresectable primary (Patients 2, 3, and 5) and metastatic (Patients 1 and 4) pelvic osteosarcomas were treated with intraarterial cisplatin and concurrent radiation therapy from 1983 to 1987. Long-term local tumor control was achieved in all five patients. Patients 1 and 3 are alive with no evidence of local recurrence or metastatic disease at 77 and 56 months of follow-up, respectively, since diagnosis of the pelvic tumor. Patients 2, 4, and 5 died of metastatic lung disease at 25, 39, and 12 months, respectively, after diagnosis of the pelvic tumor. Patient 4 had no clinical or radiologic evidence of local recurrence. Control of tumor growth in patients with pelvic osteosarcomas can be achieved with regional chemotherapy and concurrent radiation therapy. These patients also should receive adjuvant intensive systemic chemotherapy to increase the probability of eliminating potential subclinical metastatic disease.

Adolescent↗
PubMed1992

Effects of diltiazem on recurrent myocardial infarction in patients with non-Q wave myocardial infarction.

Diltiazem has been reported to reduce the short-term in-hospital reinfarction rate in patients with a non-Q wave myocardial infarction. In the long-term Multicenter Diltiazem Postinfarction Trial, there were 514 patients with non-Q wave myocardial infarction; 279 patients were randomized to the placebo group and 235 to the treatment group. The average follow-up period was 25 months. There was no difference in baseline clinical characteristics between the two groups. Early reinfarction (less than or equal to 6 months) occurred in 17 patients in the placebo group and in 2 patients in the diltiazem group (p less than 0.001). Late reinfarction (greater than 6 months) occurred in 13 patients in the placebo group and in 14 patients in the diltiazem group (p = NS). Initial and reinfarction electrocardiograms (ECGs) were analyzed by using a coding system that permitted identification of standard anatomic areas involved in the infarction process. Thirty-one of the 46 patients had a localized infarction on index and reinfarction ECGs. In the early reinfarction group, 10 (77%) of 13 infarctions occurred in the same ECG region in which the initial infarction had occurred; all 10 were in patients in the placebo group. Among the 18 patients with late reinfarction, the site of the second infarction was the same as that of the first in 9 patients and differed in 9. There was no difference between the placebo and diltiazem groups with respect to location of the infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Cohort Studies↗
PubMed1992

Spontaneous gastric decompression of pancreatic pseudocyst.

Spontaneous resolution of pancreatic pseudocysts is being reported with increasing frequency. Although many mechanisms have been proposed one that is not frequently recognized is spontaneous decompression into the gastrointestinal tract. This case report demonstrates the mechanism of spontaneous resolution of a traumatic pancreatic pseudocyst, several weeks after injury, through fistulization between the pseudocyst and the stomach. Spontaneous resolution of a pancreatic pseudocyst after a transient episode of diarrhea should suggest the mechanism of gastrointestinal decompression of the pseudocyst.

Adult↗
PubMed1991

Increased risk of death and cardiac arrest from encainide and flecainide in patients after non-Q-wave acute myocardial infarction in the Cardiac Arrhythmia Suppression Trial. CAST Investigators.

This report examines whether in the Cardiac Arrhythmia Suppression Trial death and cardiac arrest from encainide, flecainide and moricizine during the titration phase and from encainide and flecainide during the follow-up phase were related to presence (Q-wave acute myocardial infarction [Q-AMI]) or absence (non-Q-AMI) of pathologic Q waves. In all, 2,371 patients (70% with Q-AMI, 26% with non-Q-AMI, and 4% unknown) entered the titration phase, starting 117 +/- 163 days after index AMI and lasting for an average of 21 days. For the titration phase, no significant differences existed between Q-AMI and non-Q-AMI patients for death and cardiac arrest rate, ventricular premature complex suppression rate, and nonrandomization rate. A total of 1,498 patients entered the follow-up phase of an average of 10 months (starting 129 +/- 158 days after the index AMI), and were randomized to encainide or flecainide, or their matching placebos. In the placebo group, non-Q-AMI patients had a significantly lower rate of death and cardiac arrest than Q-AMI patients (1.0 and 4.6%, respectively; p = 0.04). Encainide and flecainide significantly elevated death and cardiac arrest rate in both non-Q-AMI patients (8.7%, p less than 0.01) and Q-AMI patients (7.8%, p = 0.04). The relative risk for encainide or flecainide over placebo in the non-Q-AMI patients was 8.7, which was significantly higher than 1.7 observed for the Q-AMI patients (p = 0.03). None of the baseline characteristics had any significant interaction with encainide or flecainide.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Complexes, Premature↗
PubMed1991

Electrocardiographic subset analysis of diltiazem administration on long-term outcome after acute myocardial infarction. The Multicenter Diltiazem Post-Infarction Trial Research Group.

The effect of diltiazem on long-term outcome after acute myocardial infarction (AMI) was assessed in 2,377 patients enrolled in the Multicenter Diltiazem Post-Infarction Trial and subsequently followed for 25 +/- 8 months. The study population included 855 patients (36%) with at least 1 prior AMI before the index infarction and 1,522 patients (64%) with a first AMI, of whom 409 (27%) had a first non-Q-wave AMI, 664 (44%) a first inferior Q-wave AMI, and 449 (30%) a first anterior Q-wave AMI. This post hoc analysis revealed that, among patients with first non-Q-wave and first inferior Q-wave AMI, there were fewer cardiac events during follow-up in the diltiazem than in the placebo group, and that the reverse was true for patients with first anterior Q-wave AMI or prior infarction. The diltiazem:placebo Cox hazard ratio (95% confidence limits) for the trial primary end point (cardiac death or nonfatal reinfarction, whichever occurred first) was: first non-Q-wave AMI-0.48 (0.26, 0.89); first inferior Q-wave AMI-0.66 (0.40, 1.09); first anterior Q-wave AMI-0.82 (0.51, 1.31); and prior AMI-1.11 (0.85, 1.44). Use of cardiac death alone as an end point gave an even more sharply focused treatment difference: first non-Q-wave AMI-0.46 (0.18, 1.21); first inferior Q-wave AMI-0.53 (0.27, 1.06); first anterior Q-wave AMI-1.28 (0.68, 2.40); prior infarction-1.26 (0.90, 1.77). Further analysis revealed that these differences in the effect of diltiazem in large part reflected the different status of the 4 electrocardiographically defined subsets in terms of left ventricular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Diltiazem↗
PubMed1991

Further experience with radiation therapy and concomitant intravenous chemotherapy in advanced carcinoma of the lower female genital tract.

Sixty-seven patients with advanced carcinoma of the lower female genital tract (cervix, vagina, and vulva) were treated with radiation and concomitant intravenous cisplatin and/or 5-fluorouracil. Fifty-seven patients (85%) responded completely clinically. Thirty-five (61%) complete responders recurred with a median time to recurrence of 6 months. Twenty-six of the thirty-five patients who recurred had some component of local failure. The 22 complete responders who have not recurred have been followed a median of 13 months. Acute toxicity was minimal, with only 6 patients requiring interruption of therapy. Nine (13%) patients developed severe late complications and eight required surgery. The actuarial 5-year survival is 22%. This treatment regimen is disappointing in terms of both survival and local control.

Adult↗