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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 181 records · Page 10Linked to original sources
PubMed1994

Relationship of age with eligibility for thrombolytic therapy and mortality among patients with suspected acute myocardial infarction.

OBJECTIVE: To determine the relationship of age and the percentage of patients presenting to the emergency department with myocardial infarction who meet conventional electrocardiographic and time-to-presentation criteria for thrombolytic therapy. DESIGN: Prospective cohort study. SETTING: Emergency departments of three university hospitals and four community hospitals. PATIENTS: Patients enrolled in the Multicenter Chest Pain Study, an investigation of patients aged 30 years or older presenting to the emergency department with the chief complaint of anterior, precordial, or left lateral chest pain unexplained by obvious local trauma or abnormalities on the chest radiograph. INTERVENTIONS: None. MEASUREMENTS: The frequency of patients who presented with conventional electrocardiographic and time-to-presentation criteria for thrombolysis. MAIN RESULTS: Of a total of 12,140 patients who were enrolled in the Multicenter Chest Pain Study, 10,850 had information about their electrocardiogram and their time-to-presentation. Acute myocardial infarction occurred in 1,584 patients, 746 of whom were over age 65. Among patients presenting to the emergency department with acute myocardial infarction, the proportion who arrived within 6 hours of the onset of pain and had ST-segment elevation or pathologic Q-waves not known to be old decreased significantly with increasing age, from 34% in patients under 65 years to 18% for those 75 years and older. In addition, comorbidities that would have contraindicated thrombolytic therapy were present in an additional 12% of myocardial infarction patients who were older than 65 years. CONCLUSION: Although other analyses have shown that thrombolytic therapy is cost-effective for eligible elderly patients with acute myocardial infarction, only a small percentage of very elderly patients who present to the emergency department with acute myocardial infarctions meet current eligibility criteria to receive it, so thrombolysis is unlikely to narrow the difference in mortality rates for young as compared with elderly patients with acute infarctions.

Adult↗
PubMed1994

Evaluating the potential cost-effectiveness of stenting as a treatment for symptomatic single-vessel coronary disease. Use of a decision-analytic model.

BACKGROUND: Coronary stenting appears to provide more predictable immediate results and lower rates of restenosis than conventional balloon angioplasty for selected lesion types, but its hospital costs are significantly higher. This study was designed to evaluate the potential cost-effectiveness of Palmaz-Schatz coronary stenting relative to conventional balloon angioplasty for the treatment of patients with symptomatic, single-vessel coronary disease. METHODS AND RESULTS: We developed a decision-analytic model to predict quality-adjusted life expectancy and lifetime treatment costs for patients with symptomatic, single-vessel coronary disease treated by either Palmaz-Schatz stenting (PSS) or conventional angioplasty (PTCA). Estimates of the probabilities of overall procedural success (PTCA, 97%; PSS, 98%), abrupt closure requiring emergency bypass surgery (PTCA, 1.0%; PSS, 0.6%), and angiographic restenosis (PTCA, 37%; PSS, 20%) were derived from review of the literature published as of September 1993. Procedural costs were based on the true economic (ie, variable) costs of each procedure at Boston's Beth Israel Hospital. On the basis of these data, coronary stenting was estimated to result in a higher quality-adjusted life expectancy than conventional angioplasty but to incur additional costs as well. Compared with conventional angioplasty, stenting had an estimated incremental cost-effectiveness ratio of $23,600 per quality-adjusted life year gained. Although the cost-effectiveness ratio for stenting changed with variations in assumptions about the relative costs and restenosis rates, it remained less than $40,000 per quality-adjusted year of life gained--and thus was similar to many other accepted medical treatments--unless the stent angiographic restenosis rate was > 23%, the angioplasty restenosis rate was < 34%, or the cost of stenting (including vascular complications) exceeded that of conventional angioplasty by more than $3000. The alternative strategy of secondary stenting (initial angioplasty followed by stenting only for symptomatic restenosis) was estimated to be both less effective and less cost-effective than primary stenting over a wide range of plausible assumptions and thus does not appear to be cost-effective when primary stenting is also an option. CONCLUSIONS: Decision-analytic modeling can be used to evaluate the potential cost-effectiveness of new coronary interventions. Our analysis suggests that despite its higher cost, elective coronary stenting may be a reasonably cost-effective treatment for selected patients with single-vessel coronary disease. Primary stenting is unlikely to be cost-effective for lesions with a low probability of restenosis (eg, < 30%) or for patients for whom the cost of stenting is expected to be much higher than usual (eg, because of a high risk of vascular complications). Given the sensitivity of the cost-effectiveness ratios to even modest variations in the relative restenosis rates and cost estimates, future studies will be necessary to determine more precisely the cost-effectiveness of coronary stenting for specific patient and lesion subsets.

Angioplasty, Balloon, Coronary↗
PubMed1994

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status.

OBJECTIVES: This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma. METHODS: All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined. RESULTS: After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39). CONCLUSIONS: These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.

Acute Disease↗
PubMed1994

Discrimination learning and concept formation in the Arabian horse.

Discrimination learning and concept formation abilities were investigated in four mature Arabian horses. A series of two-choice discrimination problems were presented on stimulus panels that could open to allow access to food bowls. Selection of the correct stimulus resulted in food reinforcement, and an incorrect choice was not rewarded. The positions of the correct and incorrect stimuli were varied randomly during each test session, and the criterion for learning each problem was 85% correct for two consecutive sessions of 30 or 40 trials. Testing progressed through six discrimination problems. The first four were simple pattern discriminations, but the last two incorporated several different triangles as correct stimuli and thus involved the concept of triangularity. Two of the subjects successfully completed only simple pattern discriminations, one showed evidence of learning in the first concept problem, and one completed all six tests, including the two concept formation problems. The results demonstrate complex pattern discrimination ability in horses, and suggest that they may also have the ability to form and use concepts in problem solving.

Animals↗
PubMed1994

A package deal.

Explore the source record for details and available documents.

Adult↗
PubMed1994

Arms and the law.

The existence of RSI is, once more, a subject for debate following the recent dismissal of a Reuters journalist's claims for damages. Linda Goldman explains what is required by law to prove a case of work-related upper limb disorder.

Disability Evaluation↗
PubMed1994

The impact of membership in a health maintenance organization on hospital admission rates for acute chest pain.

OBJECTIVE: We evaluate the impact of membership in a staff-model health maintenance organization (HMO) on hospital admission rates for patients presenting to an emergency department with acute chest pain. DATA SOURCES AND STUDY SETTING: Primary prospective data were gathered from all 3,006 patients presenting with a chief complaint of chest pain to the emergency department (ED) of a university teaching hospital from October 1987 to November 1989. STUDY DESIGN: Prospective cohort analysis used clinical data to stratify patients into groups at high (> or = 25%), medium (8-24%), and low risk (< or = 7%) of acute myocardial infarction (AMI). Insurance status was determined as either HMO, Medicare, commercial, Medicaid, or self-pay. Triage decisions were recorded, and patient outcomes of AMI and other final diagnoses were determined for all patients. DATA COLLECTION METHODS: Clinical data were recorded by the physicians in the ED as part of a detailed protocol. Insurance data were recorded separately by the ED staff as part of the hospital administrative database. Patient outcomes were recorded daily by research nurses for hospitalized patients; for patients who were discharged from the ED, telephone or physician follow-up was accomplished within seven days after discharge. PRINCIPAL FINDINGS: HMO patients were more likely to be admitted to the hospital than patients in other insurance groups in both the medium- and low-risk patient categories. Within the low-risk category, after controlling for clinical differences in a multiple logistic model, HMO membership retained an independent positive association with hospital admission compared to all other insurance groups except Medicaid. CONCLUSIONS: For patients with acute chest pain who were at medium and low risk of acute myocardial infarction, HMO membership was associated with higher rates of hospital admission. These findings suggest that organizational factors beyond financial incentives may exercise an important influence on hospitalization rates for HMO patients.

Acute Disease↗
PubMed1993

Cost-effectiveness considerations in the treatment of heterozygous familial hypercholesterolemia with medications.

When used for the primary prevention of coronary heart disease in persons with heterozygous familial hypercholesterolemia (hFH), a hydroxymethylglutaryl coenzyme A (HMG CoA) reductase inhibitor is projected to be effective and to have very favorable cost-effectiveness ratios at low-to-medium doses. For example, 20 mg of lovastatin per day is estimated to save lives and save money in all men ages 35-44 years with hFH and in women ages 35-44 years with hFH and any other risk factor. The estimated incremental cost effectiveness of 40 mg compared with 20 mg of lovastatin for individuals with hFH ages 35-44 years was less than $45,000 per year of life saved in men with > or = 1 other risk factors and women with > or = 2 other risk factors. The estimated incremental cost-effectiveness ratio of 80 mg compared with 40 mg/day was substantially higher ($100,000 or more per year of life saved) even in the highest risk persons. The estimated cost-effectiveness ratios for primary prevention in hFH were reasonably similar to the favorable ratios for secondary prevention in the general population but substantially better than the estimated ratios for primary prevention in other adults with high cholesterol levels. Any national recommendations regarding the use of medications for individuals with hFH must include cost considerations. Our analyses support the use of low-to-moderate doses of high-cost medications for primary prevention in these patients.

Adult↗
PubMed1993

Effect of race on the presentation and management of patients with acute chest pain.

OBJECTIVE: To compare racial differences in clinical presentation, natural history, and access to medical care and procedures among emergency-department patients with acute chest pain. DESIGN: Prospective follow-up study of consecutive patients coming to the emergency department because of acute chest pain. SETTING: Two university medical centers. PATIENTS: A total of 3031 patients who were 30 years or older and who came to the emergency department with acute chest pain from 1984 to 1986. MAIN RESULTS: African-Americans tended to have slightly, but not always significantly, lower rates of acute myocardial infarction, acute ischemic heart disease, and major complications, after adjusting for presenting symptoms and signs; the adjusted odds ratios for African-Americans were as follows: 0.77 (95% CI, 0.54 to 1.1) for acute myocardial infarction, 0.75 (CI, 0.59 to 0.95) for ischemic heart disease, and 0.79 (CI, 0.45 to 1.4) for death or major complications. Clinical factors classically associated with acute myocardial infarction were equally predictive in African-Americans and whites. After adjustments were made for multiple clinical factors, a lower proportion of African-Americans were admitted to the hospital (odds ratio, 0.69; CI, 0.56 to 0.84), and, once admitted, were somewhat less likely to be triaged to the coronary care unit (odds ratio, 0.81; CI, 0.65 to 1.0). In adjusted analyses, African-Americans were as likely to undergo cardiac catheterization as whites (odds ratio, 0.86; CI, 0.64 to 1.2) but were less likely to undergo coronary artery bypass procedures once severity of coronary disease was included in the analysis (odds ratio, 0.24; CI, 0.08 to 0.71). CONCLUSION: African-Americans and whites had a similar presentation and natural history of acute myocardial infarction and, after adjusting for probability of clinical events, similar access to most medical care and cardiac procedures. However, the rate of coronary artery bypass procedures was much lower among African-Americans than among whites. Reasons for this difference should be studied.

Acute Disease↗
PubMed1993

The impact of a regulation restricting medical house staff working hours on the quality of patient care.

OBJECTIVE: To examine the impact on patient care of a New York State regulation that restricted house staff working hours. DESIGN: Retrospective cohort study. SETTING: General medical service of an urban teaching hospital. PATIENTS: A total of 263 (94%) of 281 patients discharged from the study service during October 1988 and 263 (93%) of 283 patients discharged from the same service during October 1989. INTERVENTIONS: On July 1, 1989, New York State enacted a new regulation, Code 405, which limited residents' working hours and specified levels of supervision and ancillary support. MAIN OUTCOME MEASURES: In-hospital mortality, transfers to intensive care units, cardiopulmonary resuscitation attempts, discharge disposition, length of stay, medical complications, and house staff delays in ordering tests and procedures. RESULTS: Although the cohorts were comparable in severity of illness measures, more patients in 1989 suffered at least one medical complication (91 [35%] vs 59 [22%]; P = .002) and experienced at least one diagnostic test delay because of house staff (44 [17%] vs 4 [2%]; P < .001). These significant differences persisted after controlling for potential confounders in multivariate analyses. However, we found no significant differences in more serious outcomes: in-hospital mortality, transfer to intensive care unit, discharge disposition, or length of stay. CONCLUSION: These results suggest that restricted house staff working hours were associated with delayed test ordering by house staff and increased in-hospital complications. While these potentially deleterious effects on the quality of care did not result in statistically significant differences in more serious outcomes, further study at other hospitals is warranted to determine staffing strategies that optimize quality of care for patients, as well as medical education and quality of life for house officers.

Cohort Studies↗
PubMed1993

600 nm flash pumped dye laser for fragile telangiectasia of the elderly.

Since 1984, a continuum of controlled studies have been done on the use of the fragile, superficial telangiectasia of the elderly, which were utilized as a model for some of the basic studies of the effects of lasers on the cardiovascular system. We report the use of the 600 nm flash pumped dye laser for the fragile telangiectasia of the elderly in our classification of the Class 2 group. In some vessels studied, the special Teflon-insulated, intravenous electric needle of Kobayashi-Yamada was used. For the bluish vessels, the 600 nm flash pumped dye laser penetrated deeper into the vessel than the 585 nm, but multiple and repeated treatments were needed for clinical effect. Preliminary studies have also shown some initial response in port wine marks and facial telangiectasia.

Aged↗