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Biomedical subjects

J Goldstein

Publications and source records attributed to J Goldstein.

At least 235 records · Page 13Linked to original sources
PubMed1988

Clinical applications of electron microscopy in the analysis of collagenous biomaterials.

Scanning and transmission electron microscopy are of clinical value in assessing the interaction between biomaterials and ingrowing tissues. Ultrastructural information allows the clinician and biomaterials specialist to determine events occurring during wound healing and the biocompatibility of prosthetic devices. This paper reviews some of the experimental and clinical studies done in our laboratory on the use of natural and reconstituted collagen as replacements for connective tissues. Consideration is given to collagen flakes used for the treatment of dermal ulcers, a collagen fiber prosthesis used for tendon and ligament replacement, the effects of chemical preservatives on cartilage used for replacement of tissues during plastic surgery and the growth and orientation of nerve cells on reconstituted collagen fibers. Our results show that reconstituted collagen can be prepared into prosthetic devices which encourage cell attachment and orientation thereby facilitating healing of injured tissues. Furthermore chemical preservation of cartilagenous tissues kills chondrocytes resulting in eventual resorption by inflammatory cells.

Biocompatible Materials↗
PubMed1988

Age, resource consumption, and outcome for surgical patients at an academic medical center.

Many changes are under way in the payment for physician and hospital care of the surgical patient. Relatively little data have been analyzed on resource consumption for hospitalized surgical patients. The purpose of this study was to characterize hospital resource consumption and outcome by age for surgical patients. All surgical admissions at a large academic medical center from Jan. 1, 1985, through March 31, 1986, were analyzed by means of the diagnostic related group (DRG) format. Total costs (exclusive of physician fees) for the 7341 surgical patients studied were $58,206,815. Mean cost per patient, length of stay, percent of outliers, and mortality increased with age. DRG case-mix index and the number of procedures per patient peaked at age 69 and then decreased. Emergency admission was high for the young (i.e., aged 18 to 24 years) and for very elderly patients (i.e., aged over 75 years). Blood transfusions increased steadily as the age of the patient increased; use of surgical intensive care units increased until age 64 years, then plateaued. This study demonstrated a number of trends in surgical patient age and use of resources. Under prospective payment systems (i.e., DRG reimbursement) financial risk increased with the age of the patient. Length of hospital stay and mortality increased with age; however, DRG case-mix index and the number of procedures per patient peaked at age 69, which suggests that elderly surgical patients (i.e., those above 70 years of age) may be more severely ill on average than younger patients.

Academic Medical Centers↗
PubMed1988

The identifier concept: variables to stratify patient costs within cardiothoracic surgical diagnostic related groups.

Prospective payment systems using the diagnostic related group payment mechanism are changing the economic incentives offered to hospitals. This study of all cardiothoracic surgical patients (N = 1825) treated during a 2-year period at an academic medical center demonstrated that patients within cardiothoracic diagnostic related groups could be stratified as to resource consumption (i.e., hospital cost) by four clinical variables: intensive care unit or emergency admission and blood and plasma product utilization. Patients within each diagnostic related group with the variable had higher hospital costs as follows: intensive care unit (100% of patients had higher costs per diagnostic related group for intensive care unit versus non-intensive care unit admissions), blood (100% of patients), plasma product (100%), and emergency admission (92.2%). In addition, hospital costs increased as the factors accumulated. This study demonstrates that costs within cardiothoracic diagnostic related groups may be grouped by four clinical parameters that occur during the patient's hospital stay. One of these variables (i.e., emergency admission) may be suitable to modify diagnostic related group payment. The other variables could segment higher cost patients within a diagnostic related group; cost containment efforts directed at these patients might then provide savings for the hospital.

Blood Transfusion↗
PubMed1988

Financial risk and hospital cost for elderly patients in non-age stratified surgical DRGS.

Hospitals face increasing uncertainty under prospective payment systems such as Medicare's DRG system. We analyzed the equity of the DRG system for 2622 Medicare surgical patients in the 82 non-age stratified surgical DRGs. Patients age 70 and over had higher total hospital costs (P less than .05), a longer hospital length of stay, more diagnoses per patient, losses under DRG payment (P less than .01), a greater percentage of outliers (P less than .05) and higher mortality than patients in these same DRGs under 70 years of age. This data suggests that the current DRG classification scheme may be inequitable vis-a-vis older Medicare patients in the non-age stratified surgical DRGs, and could provide financial disincentives that limit both their access and quality of care in the future.

Age Factors↗
PubMed1988

The identifier concept: clinical parameters to stratify hospital patient costs for patients with hypertension.

Hospital administrators, nurses, and physicians must strive to improve efficiency as new payment systems constrain health care spending. Our purpose in this project was to confirm the hypothesis that four clinical variables (emergency or intensive care unit [ICU] admission, and blood or plasma product use) could predict hospital costs and outcome for adult patients with hypertension. We analyzed hospital costs (exclusive of physician fees) for all patients with either a primary or secondary diagnosis of hypertension (N = 4289) receiving treatment during a 2-year period at an academic medical center. In addition to predicting outcome (i.e., whether the patient lived or died), these four clinical variables predicted differences in hospital cost per patient, and financial risk per Diagnosis-Related Group (DRG) as measured by percentage of "outliers" (patients whose length of stay exceeds the cutoff point) or profit/loss per patient under DRG prospective hospital payment. The cost and predictive effect on cost and mortality of the variables were also cumulative; patients with hypertension with one variable had two times the cost of patients with no variables; patients with hypertension with two variables, 2.2 times the cost; patients with three variables, 4.3 times; and patients with four variables, 6.8 times. The mortality of patients with no variables was 0.8%; one variable, 7.7%; two variables, 12.7%; three variables, 15.7%; and four variables, 25.8%. Patients with hypertension can thus be stratified by cost and outcome by clinical events that occur during the patient's hospital stay.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Health care financing policy for hospitalized black patients.

The Medicare diagnostic-related group (DRG) prospective payment model is changing hospital payment. Currently many states are using DRG prospective "all payer systems" for hospital reimbursement. In all payer systems, Medicare, Medicaid, Blue Cross, and other commercial insurers pay by the DRG mode; New York State has had an all payer system since January 1, 1988. This study simulated DRG all payer methods on a large sample (N = 6,134) of adult black medical and surgical patients for a three-year period using both federal and New York DRG reimbursement. Both Medicare and Medicaid patients had, on average, a longer hospital stay and total hospital cost compared with patients covered by Blue Cross and other commercial insurers. Medicare and Medicaid patients also had a greater severity of illness compared with those of Blue Cross and others. All insurers (ie, Medicaid, Blue Cross, Medicare, and commercial) generated substantial financial risk under the DRG all payer scheme. These data suggest that federal, state, and private payers may be under-reimbursing for the care of the hospitalized black patient using the DRG prospective hospital payment scheme. Health care financing policy such as that demonstrated in this study may limit both the access and quality of care for many black patients in the future.

Adult↗
PubMed1988

The phenotype of human placental macrophages and its variation with gestational age.

The antigenic phenotype of human villous stromal macrophages (M phi s) from first and third trimester placentas was analyzed using a large number of monoclonal antibodies (MAbs) to monocyte (Mo)/M phi-associated cell membrane determinants. The purpose of this study was to investigate M phi phenotypic heterogeneity to create a database for the correlation of M phi phenotype with specific immunologic functions. The results showed that villous stromal mononuclear cells express many cell surface antigens found on Mo and M phi s and that they are morphologically diverse, ranging in appearance from classic Hofbauer cells to spindle-shaped cells with long cytoplasmic processes. Villous stromal M phi s were the numerically dominant cell type in this structure and exhibited some major phenotypic differences from M phi s in other tissues. Comparison of first- and third-trimester placentas revealed variation in antigen expression with increasing gestational age, in particular of class II major histocompatibility complex (MHC) determinants: HLA-DR and HLA-DP antigen density was low on first-trimester villous M phi s and much higher on third-trimester M phi s while HLA-DQ was undetectable in the first trimester but present on cells in third trimester placentas. The CD1 (T6) antigen, found on Langerhans (LH) cells and cortical thymocytes, was detected on villous M phi s by two thirds of the MAbs directed against different epitopes on this determinant. Furthermore, comparison with similar studies of lymphoid tissues showed that villous M phi s and dendritic cells share the expression of a number of other cell surface antigens. Finally, it was shown that M phi s in first- and third-trimester villi exhibit strong reactivity with MAbs (Leu 3a,b) to the CD4 antigen that serves as the receptor for the human immunodeficiency virus (HIV), suggesting that these cells may be a portal of entry or reservoir for this virus in the fetuses of pregnant, HIV+ women.

Antigenic Variation↗
PubMed1988

Outbreak of echovirus 11 infection in hospitalized neonates.

Between July 18 and August 5, 1986, a cluster of echovirus 11 infections occurred in hospitalized neonates. Ten infants were affected and one died. All cases occurring after the index case were infants who were in the nursery for at least 1 day when the index patient was also present. Risk factors for secondary infection included low birth weight or gestational age and receipt of antibiotics, red blood cell transfusions, nasogastric intubation or gavage feedings. Because viral infection had not been suspected in the index patient, isolation measures were not instituted until after onset of secondary cases. We conclude that more severely ill infants receiving intensive levels of care are at increased risk for nosocomial enteroviral infection. These infants may have a greater likelihood of exposure to the virus and/or increased host susceptibility. Outbreaks caused by cross-infection may be preventable by early recognition of patients colonized or infected with potentially pathogenic agents and prompt institution of appropriate isolation measures.

Adolescent↗
PubMed1987

Accessory atrioventricular pathway, supra-, and infrahisian conduction impaired due to mitral annulus calcification.

Disorders of conduction occurring simultaneously in both normal and accessory pathways of patients with Wolff-Parkinson-White (WPW) syndrome have only rarely been observed. To our knowledge this is the first report of impaired conduction in both pathways in WPW syndrome due to mitral annulus calcification (MAC). This case of WPW syndrome type A presented the following conduction abnormalities: (1) right bundle-branch block; (2) transient second-degree AV block with prolonged PR interval of the conducted beats; (3) during electrophysiological study, induction of tachycardia, dependent (phase 3) second-degree AV block, and occasionally conduction of two consecutive beats, the second showing an increased H-V interval (from 25 to 60 ms) and left bundle-branch block (LBBB) pattern, due to (4) infrahisian conduction abnormality.

Aged↗
PubMed1987

Infected müllerian adenosarcoma of the endometrium.

A 52-year-old postmenopausal woman presented with signs and symptoms of acute pelvic inflammatory disease. On vaginal speculum examination, an infected polypoid tumor protruding from a dilated cervical canal was disclosed. While the patient was under extensive antibiotic treatment, uterine curettage was performed. This was followed a few days later by a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological examination demonstrated the tumor to be Müllerian adenosarcoma of the uterine endometrium. The patient had postoperative vaginal vault irradiation, and more than 1 year later she is alive with no evidence of recurrent disease. Diagnosis and management of uterine Müllerian adenosarcoma is discussed.

Acute Disease↗
PubMed1987

Sebaceous adenocarcinoma of meibomian gland origin with targetoid intra-nuclear inclusions.

Neoplastic proliferation of the meibomian glands is most often characterized by a tarsal tumor of the eyelid conjunctiva, having the clinical appearance of a chalazion. As such, the tumor is frequently not recognized as a neoplasm and is treated conservatively as an inflammatory lesion. A protracted clinical course combined with repeated surgical excisions typify this slow-growing tumor of sebaceous gland cells. In addition to the usual features of polygonal cell shape, abundant cytoplasm, and numerous fat vacuoles, we describe the presence of a peculiar nuclear inclusion seen only in the parenchymal cells of this tumor, and having the appearance of concentric layers of electron-dense material surrounding an opaque electron lucent core.

Adenocarcinoma↗
PubMed1987

Squamous cell carcinoma of the renal pelvis with sarcomalike stroma: a light and electron microscopic study with immunohistochemical analysis.

Primary neoplasms of the renal pelvis are rare. Most are malignant, and most of these are transitional cell carcinomas. We report the unusual occurrence of a squamous cell carcinoma with sarcomatoid stroma arising from the renal pelvic mucosa in a patient with renal lithiasis. Immunohistochemical stains for keratin intermediate filaments failed to demonstrate their presence in the spindle cell portion of the tumor. Transmission electron microscopic study did not reveal structures of an epithelial nature in these same cells. Our findings support the contention that the spindle cells of the stroma are not squamous in nature, but represent either a reactive or a neoplastic transformation of these underlying stromal elements.

Carcinoma, Squamous Cell↗
PubMed1987

Morphometric analysis of corneal endothelium following radial keratotomy.

We performed morphometric analysis of the central corneal endothelium on 24 eyes of 19 patients who had had anterior radial keratotomy. The endothelium was analyzed for a variety of parameters, including cell area, perimeter, side lengths, cell shape, and number of sides. Mean, standard deviation, and coefficient of variation were calculated for each parameter. The mean cell density decreased from 2,835 to 2,677 cells/mm2, mean cell perimeter increased from 71.4 micron to 74.3 micron, and mean side length increased from 11.8 micron to 12.3 micron following surgery. The changes in these three parameters were statistically significant (P less than 0.05). The coefficient of variation of cell area (polymegathism) changed from 0.319 to 0.307, the hexagonality changed from 62.5% to 59.6%, and the cell shape changed from 0.872 to 0.867. The changes in these parameters were not statistically different before and after surgery. The group of patients that had no reported microperforations showed only a small decrease of cell density (1.6%), while the group of patients that had microperforations showed a large decrease of cell density (14.3%). The cell perimeter and side lengths showed a similar pattern. The group of corneas with the optical zone diameter less than 3.5 mm showed a decrease in mean cell density from 2,994 to 2,725 cells/mm2, and the cell shape changed from 0.874 to 0.866 following surgery. The changes in these parameters were statistically significant (P less than 0.05) before and after surgery. Among all factors associated with radial keratotomy, microperforation and a small diameter of central optical zone appear to be the two greatest risk factors.

Adult↗
PubMed1987

Benefit of the steroid electrode.

A permanent pacemaker was implanted in an 80-year-old patient with complete heart block. The electrode had to be changed six times (endocardial, five and epicardial, one) due to a progressive rise in threshold with recurrent exit block. A porous, steroid eluting, endocardial electrode was implanted and has given 27 months of excellent service. This lead may be ideal for patients who have a progressive increase in threshold after repeated electrode implantation.

Aged↗
PubMed1987

A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report.

The quadriceps tendon and patellar tendon (ligament) were repaired with a Dacron vascular graft used as a tension suture material. In cases of quadriceps tendon ruptures, the Dacron graft is passed transversely through the patellar ligament just below the patella and crossed transversely at the level of the musculotendinous junction with two loops applying tension to the tendon, which brings the tendon ends together by creating a solid structure. In cases of patellar ligament ruptures, the Dacron graft is passed through a hole in the tibia posteriorly to the tibial tuberosity instead of through the patellar ligament below the patella. This technique enables early mobilization on the first day after surgery. The technique was first tested on six dogs with severed quadriceps tendons and patellar ligaments that were repaired with this suture method. All of the animals recovered from surgery and walked and ran normally on the repaired legs within 27 days and with only mild limping after 17 days. The technique was then used on six patients, four with complete quadriceps tendon rupture and two with complete tear (avulsion) of the patellar ligament (tendon). In all of the patients, excellent surgical results were obtained and leg immobilization was virtually eliminated. Physical therapy was prescribed the first day after surgery. The rehabilitation period was significantly reduced.

Animals↗
PubMed1987

The identifier concept: clinical parameters to stratify hospital costs within gastroenterology DRGs.

Prospective payment systems using the diagnostic related group (DRG) payment mechanism are changing the incentives offered to hospitals. We studied hospital costs of all gastroenterological (GI) patients (n = 2500) treated during a 2-yr period at our academic medical center. We showed that patients within GI DRGs could be grouped regarding hospital costs by four clinical variables: intensive care unit or emergency admission, and blood or plasma product consumption. Patients within each DRG with the variable usually had higher total hospital costs, a longer stay in the hospital, a greater number of diagnoses, more outliers, and a poorer outcome than patients without the variables. As the variables accumulated, these differences became more pronounced. This study demonstrated that hospital costs may be stratified within GI DRGs by clinical parameters that occur during the patient's hospital stay. These four variables could identify higher cost patients within a DRG; cost containment could then be directed at these patients with, hopefully, resultant savings.

Blood Transfusion↗