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Biomedical subjects

J Lynn

Publications and source records attributed to J Lynn.

At least 163 records · Page 9Linked to original sources
PubMed1994

Neonatal primary hyperparathyroidism masked by vitamin D deficiency.

Neonatal primary hyperparathyroidism is a life threatening disorder that is associated with severe hypercalcaemia, hypotonia, bone demineralization, fractures and respiratory distress. Treatment consists of total parathyroidectomy and without this affected infants will usually die by the age of three months. We report a patient with neonatal primary hyperparathyroidism who survived without fractures or parathyroidectomy to an age of nine months, and in whom the hypercalcaemia became masked by vitamin D deficiency. At surgery, four-gland hyperplasia was demonstrated and total parathyroidectomy followed by oral calcitriol treatment has restored well-being and normocalcaemia. An absence of skeletal complications, a survival beyond three months of age without parathyroidectomy and the masking of the hypercalcaemia by vitamin D deficiency represents a unique combination of metabolic abnormalities in a patient with neonatal primary hyperparathyroidism.

Humans↗
PubMed1994

Prognosis-based futility guidelines: does anyone win? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: Advocates for health care reform and others claim that significant savings could be achieved if "futile" care were eliminated. Our objective was to provide an initial estimate of the effects of a public policy that would preclude futile life-sustaining treatments, defined as those employed despite < or = 1% chance of surviving for 2 months. DESIGN: Simulation using data from an observational cohort study. SETTING: Five academic medical centers. PATIENTS: Seriously ill hospitalized adults enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). METHODS: We examined the impact of prognosis-based futility guidelines on survival and hospital length of stay on a cohort of seriously ill adults. We calculated the number of days of hospitalization that would not be used if, on the third study day, life-sustaining treatment had been stopped or not initiated for subjects with estimated 2-month survival probability of < or = 1%. RESULTS: Of the 4301 patients, 115 (2.7%) had an estimated chance of 2-month survival of < or = 1%. All but one of these 115 subjects died within 6 months. Almost 86% died within 5 days of prognosis. At the time of death, 92 subjects (80.0%) had had no attempt at resuscitation; 35 (30.4%) had had a life-sustaining mechanical ventilator withdrawn. A Do-Not-Resuscitate order was written either before (n = 61) or within 5 days (n = 18) of reaching this prognosis for 68.6% of the patients. These 115 subjects had total hospital charges of $8.8 million. By forgoing or withdrawing life-sustaining treatment in accord with a strict 1% futility guideline, 199 of 1,688 hospital days (10.8%) would be forgone, with estimated savings of $1.2 million in hospital charges. Nearly 75% of the savings in hospital days would have resulted from stopping treatment for 12 patients, six of whom were under 51 years old, and one of whom lived 10 months. CONCLUSIONS: Patients at a high risk of dying can be identified prospectively. Implementation of a strict, prognosis-based futility guideline on the third day of a serious illness would result in modest savings.

Adolescent↗
PubMed1993

Hospice medicine.

Explore the source record for details and available documents.

Hospice Care↗
PubMed1993

Are the patients who become organ donors under the Pittsburgh protocol for "non-heart-beating donors" really dead?

The University of Pittsburgh Medical Center (UPMC) "Policy for the Management of Terminally Ill Patients Who May Become Organ Donors after Death" proposes to take organs from certain patients as soon as possible after expected cardiopulmonary death. This policy requires clear understanding of the descriptive state of the donor's critical cardiopulmonary and neurologic functional capacity at the time interventions to sustain or harvest organs are undertaken. It also requires strong consensus about the moral and legal status of the donor during dying and confirmation of death. There has been no need for the clarity and precision that this policy relies upon, and thus the needed research and conceptual work has not previously been generated. The empiric base and societal consensus are both too frail to provide justification for this policy at this time.

Death↗
PubMed1993

Nonfatal systemic allergic reactions induced by skin testing and immunotherapy.

Skin testing and immunotherapy with allergens can induce systemic allergic reactions. In order to identify factors associated with systemic allergic reactions, a prospective study was conducted from 1976-1989 with more than 10,000 patients being tested and a total of 513,368 injections being recorded. Our study showed that the probability of inducing systemic allergic reactions by skin testing was less than 0.02% and the probability of systemic allergic reactions caused by immunotherapy was 2.9%. The female to male ratio was 3 to 2. The highest incidence of systemic allergic reactions was in patients between the ages of 16 to 39 years of age. The majority of systemic allergic reactions occurred when patients were on increasing doses rather than maintenance doses. More than 95% of systemic allergic reactions were associated with pollens and most of them happened between the concentration of 100 and 1000 PNU/mL. There was no increased incidence during grass or ragweed pollination seasons in those patients who received grass or ragweed injections during the respective seasons. Only 50% of systemic allergic reactions developed within 30 minutes after injections. The three most important factors determining the incidence of systemic allergic reactions are the type of allergens, the "rate" of increase of allergen concentrations, and sensitivity of the patients to allergens. The prick test at initial allergy assessment can be used to "rule out," with a high degree of certainty, the likelihood of systemic allergic reactions. The prick test is easy to perform and it is cost-effective. Prick tests and RAST together are helpful in identifying the patients and the allergens at higher risk of systemic allergic reactions.

Adolescent↗
PubMed1992

Central nervous system involvement in the eosinophilia-myalgia syndrome.

A patient with eosinophilia-myalgia syndrome developed progressive central nervosa system involvement that did not improve despite discontinuation of L-tryptophan therapy. Neurologic impairment was manifested initially by spastic monoparesis, which was improved by treatment with methyl-prednisolone and hydroxyurea. Recurrence of weakness was accompanied by gait ataxia, dysphagia, and complaints of a gradual decline in memory and concentration. Neuropsychological testing identified a broad pattern of cognitive deficits suggestive of a subcortical dementia, and magnetic resonance imaging demonstrated multiple high-signal lesions in the white matter. Cognitive deficits appear to be underrecognized in patients with the eosinophilia-myalgia syndrome. The response of our patient's initial symptoms to corticosteroid therapy suggests a possible role for autoimmune mechanisms in the pathogenesis of central nervous system involvement in the eosinophilia-myalgia syndrome. Neuropsychological evaluation should be performed in patients with cognitive complaints to delineate the full spectrum of central nervous system impairment associated with the eosinophilia-myalgia syndrome.

Central Nervous System Diseases↗
PubMed1991

Short-term mortality predictions for critically ill hospitalized adults: science and ethics.

Modern life-sustaining therapy often succeeds in postponing death but may be ineffective at restoring health. Decisions that influence the time and circumstances of an individual's death are now common and require an accurate and comprehensive characterization of likely outcome. Evaluation of alternative outcomes requires acknowledgement that most patients find some outcomes to be worse than death. Improved understanding of major predictors of patient outcome, combined with rapidly expanding technical abilities to collect and manipulate large amounts of detailed clinical data, have created a new intellectual and technical basis for estimating outcomes from intensive medical care. Such objective probability estimates, such as the system described here, can reduce uncertainty about difficult clinical decisions and can be used by physicians, patients, and society to reorient health care toward more scientifically and ethically defensible approaches.

Adult↗
PubMed1991

An outcomes model of medical decision making.

In the traditional 'fix-it' model of medical decision making, the identified problem is typically characterized by a diagnosis that indicates a deviation from normalcy. When a medical problem is multifaceted and the available interventions are only partially effective, a broader vision of the health care endeavor is needed. What matters to the patient, and what should matter to the practitioner, is the patient's future possibilities. More specifically, what is important is the character of the alternative futures that the patient could have and choosing among them so as to achieve the best future possible, with the ranking of outcomes determined by the patient's preferences. This paper describes the fix-it model, presents and defends the outcomes-based model, and demonstrates that the latter is useful in developing normative conceptions of informed consent and decision making and in establishing a basis for societal involvement in the decision making process. Finally, several shortcomings of the model will be acknowledged.

Attitude of Health Personnel↗
PubMed1991

Development of an institutional policy on artificial hydration and nutrition.

The issues involved in deciding whether to use artificial methods of delivering hydration and nutrition are often very difficult for patients, families, and health care providers. Once private and personal matters, these decisions now frequently involve the judicial system. Five years ago, Hospice of Washington recognized the need for a written policy and wrote the one published here. Its goal is to respect individual preferences and family concerns while addressing the nutrition and hydration needs of dying patients. The policy sets parameters on the issue, provides basic information, and encourages crafting the most fitting resolution to each situation.

Adult↗