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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 235 records · Page 13Linked to original sources
PubMed1991

Expected gains in life expectancy from various coronary heart disease risk factor modifications.

BACKGROUND: Despite much evidence that modifying risk factors for coronary heart disease can decrease morbidity and mortality, little is known about the impact of risk-factor modification on life expectancy. METHODS AND RESULTS: We used the Coronary Heart Disease Policy Model, a state-transition computer simulation of the US population, to forecast potential gains in life expectancy from risk-factor modification for the cohort of Americans turning age 35 in 1990. Among 35-year-old men, we projected that the population-wide increase in life expectancy would be about 1.1 years from strict blood pressure control, 0.8 years from smoking cessation, 0.7 years from reduction of serum cholesterol to 200 mg/dl, and about 0.6 years from weight loss to ideal body weight. For women, reducing cholesterol to 200 mg/dl would have the greatest estimated impact-a gain of 0.8 years-whereas smoking cessation, blood pressure control, or weight loss would yield population-wide gains of 0.7, 0.4, and 0.4 years, respectively. Gains for 35-year-old individuals having a given risk factor are greater. We estimate that, on average, male smokers would gain 2.3 years from quitting smoking; males with hypertension would gain 1.1-5.3 years from reducing their diastolic blood pressure to 88 mm Hg; men with serum cholesterol levels exceeding 200 mg/dl would gain 0.5-4.2 years from lowering their serum cholesterol level to 200 mg/dl; and overweight men would gain an average of 0.7-1.7 years from achieving ideal body weight. Corresponding projected gains for at-risk women are 2.8 years from quitting smoking, 0.9-5.7 years from lowering blood pressure, 0.4-6.3 years from decreasing serum cholesterol, and 0.5-1.1 years from losing weight. Eliminating coronary heart disease mortality is estimated to extend the average life expectancy of a 35-year-old man by 3.1 years and a 35-year-old woman by 3.3 years. CONCLUSIONS: Population-wide gains in life expectancy from single risk-factor modifications are modest, but gains to individuals at risk can be more substantial.

Adult↗
PubMed1991

Cervical bruits: clinical correlates of stenosis.

To analyze the relationship among characteristics of buits, degree of underlying stenosis, and neurologic symptom complexes, the authors studied 157 patients with bruits undergoing digital subtraction angiography. Symptom status assignment (definite lateralizing, possible lateralizing, vertebrobasilar, diffuse, and asymptomatic) and cervical auscultation for location, duration, and other bruit characteristics were performed independently. Bruit occurrence was associated with stenosis of greater than or equal to 50% of the underlying vessel with the association being no stronger at higher levels of stenosis (greater than or equal to 80%). No relationship existed between the side of bruit and side of symptoms in those with lateralized symptoms. The authors found more severe degrees of carotid stenosis in two symptomatic groups (vertebrobasilar insufficiency [VBI] and definite lateralized) compared with asymptomatic patients. Those with VBI had more high-grade stenosis, whereas those with lateralized symptoms had more occlusions, which tended to be ipsilateral to the symptoms.

Aged↗
PubMed1991

History of self-experimentation in dermatology: should we go first--sometimes?

Because of its availability, the skin has been used over the years for self-experimentation. Many examples can be cited, including the heroic self-experiments of Carrión of Peru with verruga peruana and those of Goldberger with pellagra and Pediculoides ventricosus. My personal self-experimentation began with sensitization to Japanese lacquer. From that starting point I experimented with chemical warfare agents, cortisone versus hydrocortisone, bites of various arthropods, and finally, experiments with lasers. Some dermatologists will continue to do self-experimentation when they acquire infections from their patients. I believe that sometimes, for their patients' benefit, they should go first.

Autoexperimentation↗
PubMed1991

Preventability of emergent hospital readmission.

To determine whether emergent readmissions within 30 days of discharge are potentially preventable, we prospectively studied all readmissions to the medical service of a university teaching hospital during a 4-month period. The 327 readmissions, including 42 patients who were readmitted more than once during the study period, accounted for 12% of medical admissions. Nearly 75% of readmissions were due to previously diagnosed medical conditions; complications of drugs or therapeutic procedures caused 29%, and patient compliance contributed to 11%. Three reviewers judged 28 (9%) readmissions to be potentially preventable. These 28 readmissions constituted 1% of all admissions to the medical service and did not result in any fatalities, indicating that the quality of care was generally very good. One third of the potentially preventable readmissions were thought to be related to medical system failures, one third to an unfulfilled hope that the patient would improve after discharge, and one third to other suboptimal judgements in evaluation or treatment. Of the 28 potentially preventable readmissions, 89% occurred within 10 days of discharge. We conclude that potentially preventable readmissions would nearly always be detected by review of readmissions within 10 days of discharge and that many may be amenable to systematic interventions such as standardized predischarge assessment and better coordination of post-discharge follow-up.

Adult↗
PubMed1990

Long-term prognosis of myocardial ischemia detected by Holter monitoring in peripheral vascular disease.

To assess the long-term prognostic significance of myocardial ischemia, as measured by ambulatory electrocardiographic monitoring, in patients with occlusive peripheral arterial disease, 176 eligible patients scheduled for elective peripheral arterial surgery at Brigham and Women's Hospital were prospectively studied. All patients were monitored preoperatively without alterations to baseline medications. Prospective follow-up was obtained during routine medical care as provided by blinded, independent physicians and by subsequent telephone contact with the patients. Thirty-two patients (18%) had a total of 75 episodes of myocardial ischemia, 73 (97%) of which were asymptomatic. During a mean follow-up period of 615 days, there were 9 cardiac deaths, 1 occurring in-hospital after peripheral vascular surgery, and 13 nonfatal myocardial infarctions, 4 occurring in-hospital after peripheral vascular surgery. Cardiac events occurred in 12 of 32 patients with ischemia (38%), including 6 cardiac deaths, and in 10 of 144 patients without ischemia (7%), including 3 cardiac deaths (risk ratio 5.4, 95% confidence interval 2.6 to 11.4). The sensitivity of ischemia was 55%, the specificity was 87%, the positive predictive value was 38%, and the negative predictive value was 93%. In a multivariate Cox proportional-hazards model controlling for age, gender, coronary risk factors, history of angina, myocardial infarction, coronary artery disease and antianginal medications, the presence of ischemia was the only independent predictor of outcome. In patients with peripheral arterial disease, who often are unable to perform adequate exercise testing, ambulatory monitoring for myocardial ischemia is a significant independent predictor of 1- to 2-year prognosis.

Adult↗
PubMed1990

Predicting bacteremia in hospitalized patients. A prospectively validated model.

OBJECTIVE: To develop and validate a model for the prediction of bacteremia in hospitalized patients, and to identify subgroups of patients with a very low likelihood of bacteremia in whom a positive blood culture has a low positive predictive value. DESIGN: Prospective cohort study with clinical data on 1516 episodes collected from a random sample of all patients who had blood cultures done at one institution. SETTING: Urban, tertiary care hospital. PATIENTS: Derivation set: 1007 blood culture episodes sampled from all blood cultures done on patients at Brigham and Women's Hospital between October 1988 and February 1989. Validation set: 509 episodes, May 1989 to June 1989. The unit of evaluation was the episode, defined as a 48-hour period beginning after a blood culture was drawn. MEASUREMENTS AND MAIN RESULTS: True- and false-positive rates of blood cultures in the derivation set as assessed by independent reviewers were 7% (74 of 1007) and 8% (81 of 1007), respectively. Independent multivariate predictors of true bacteremia were temperature of 38.3 degrees C or higher, presence of a rapidly (less than 1 month) or ultimately (less than 5 years) fatal disease; shaking chills; intravenous drug abuse; acute abdomen on examination; and major comorbidity. In the low-risk group, defined by absence of these predictors, the misclassification rate of the model in the derivation set was 1% (4 of 303), and a positive blood culture had a positive predictive value of only 14% for true bacteremia. The model also identified a high-risk subset in which 16% (41 of 264) of episodes represented true bacteremia. The model was prospectively validated in 509 additional episodes, and the misclassification rate in the low-risk group was 2% (3 of 155). INTERVENTIONS: None. CONCLUSION: These findings provide a means of stratifying hospitalized patients according to their risk for bacteremia. If prospectively validated in other settings, this model may be helpful when deciding whether or not to do blood cultures or start antibiotic therapy and, when evaluating a positive blood culture, to determine whether or not it is a true-positive.

Adult↗
PubMed1990

Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension.

To evaluate the comparative efficacy and cost-effectiveness of various antihypertensive medications in persons aged 35 through 64 years with diastolic blood pressure of 95 mm Hg or greater and no known coronary heart disease, we used the Coronary Heart Disease Policy Model, which is a computer simulation of overall mortality as well as the mortality, morbidity, and cost of coronary heart disease in the US population. From the pooled literature, we estimated the antihypertensive and total cholesterol effects of various antihypertensive regimens. For 20 years of simulated therapy from 1990 through 2010, the cost per year of life saved was projected to be $10,900 for propranolol hydrochloride; $16,400 for hydrochlorothiazide; $31,600 for nifedipine; $61,900 for prazosin hydrochloride; and $72,100 for captopril. Doubling the cholesterol effects of the agents under study did not significantly change their effectiveness because, in general, lowering diastolic blood pressure by 1 mm Hg was equivalent to lowering the cholesterol level by 6%. Although any projection requires multiple estimates, each of which may be open to debate, propranolol appears to be the preferred initial option under most of a variety of alternative assumptions.

Adult↗
PubMed1990

Outcomes in patients with myocardial infarction who are initially admitted to stepdown units: data from the Multicenter Chest Pain Study.

PURPOSE: To assess whether the admission of patients with chest pain to a stepdown unit would jeopardize the outcome of those patients who ultimately "ruled in" for a myocardial infarction. PATIENTS AND METHODS: We compared the risk of an adverse outcome in initially uncomplicated, "rule-out myocardial infarction" patients who were admitted directly to a stepdown unit (n = 58) or to a coronary care unit (n = 409) at 6 hospitals and who then ultimately "ruled in" for a myocardial infarction. RESULTS: An adverse outcome (death, serious complication, or invasive intervention) occurred in 16 (28%) stepdown unit patients compared with 159 (39%) coronary care unit patients. Among patients eligible for initial care in either location, the risk of an adverse outcome after controlling for clinical characteristics was similar in the two groups using each of two different multivariate approaches. CONCLUSION: Although our study was not of sufficient size to exclude the possibility of a small benefit from initial triage to a coronary care unit, our data suggest that (1) admission of initially uncomplicated chest pain patients with a relatively low probability of acute myocardial infarction to a stepdown unit does not seriously jeopardize those who eventually "rule in" for myocardial infarction; and (2) larger observational or randomized studies, which could reduce the residual possibility of somewhat higher risk in the stepdown unit, would be ethical to perform.

Aged↗
PubMed1990

Comparison of the natural history of new onset and exacerbated chronic ischemic heart disease. The Chest Pain Study Group.

To compare the natural history of patients with new onset ischemic heart disease with that of patients with exacerbations of chronic ischemic heart disease, short- and long-term outcomes of 3,465 emergency room patients with acute ischemic heart disease at four community and three university hospitals were evaluated. Acute myocardial infarction was diagnosed in 598 (33%) of the 1,835 patients with a prior history of infarction or angina and 934 (57%) of the 1,630 without such a history (p less than 0.001). Patients with new onset ischemic heart disease with acute myocardial infarction were more likely than patients with infarction and exacerbated chronic ischemic heart disease to have Q wave infarction (57% versus 36%) and to receive thrombolytic therapy (11% versus 5%); they also had higher maximal creatine kinase levels (1,088 +/- 1,299 versus 733 +/- 906 U/liter) (p less than 0.0001 for all three). After adjustment for differences in clinical presentation and initial triage, patients with new onset ischemic heart disease with acute myocardial infarction were less likely than the comparison group to have congestive complications (odds ratio 0.63, 95% confidence interval 0.47 to 0.84, p less than 0.01) but not less likely to have arrhythmic, ischemic or overall complications. Among patients with angina without acute myocardial infarction, patients with new onset ischemic heart disease were less likely to have recurrent ischemic pain and congestive heart failure. In multivariate analysis of long-term follow-up data on 457 patients from one hospital, patients with new onset ischemic heart disease had better cardiovascular survival rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1990

Cost-effectiveness perspectives in coronary heart disease.

In the United States there has been a dramatic decrease in age-adjusted coronary heart disease (CHD) mortality during the last 20 years. This article investigates the reasons for this decline and concludes that most of the decline in CHD has been the result of life-style changes, particularly reduction in serum cholesterol and cigarette smoking. The CHD Policy Model is used to compare the effect of a targeted versus a population-wide program of cholesterol reduction. On the basis of these projections, population-wide interventions are considered an important part of cholesterol reduction programs. The article also assesses the cost-effectiveness of selected cardiac interventions, for example, screening exercise tolerance tests, coronary care units, thrombolysis in acute myocardial infarction, and beta-blockers in patients after myocardial infarction. Cost-effectiveness analysis is seen to be crucial as medical costs escalate and the population at risk from CHD increases.

Adrenergic beta-Antagonists↗
PubMed1990

Accuracy of death certificate diagnosis of intracranial hemorrhage and nonhemorrhagic stroke. The Minnesota Heart Survey.

The validity of death certificate diagnosis of stroke and its type as the underlying cause of death was investigated in a sample of in-hospital deaths of possible stroke cases from the Minnesota Heart Survey. The 228 in-hospital deaths in 1970 and the 180 deaths in 1980 had a stroke diagnosis either on hospital discharge records or as the underlying cause of death on the death certificate. Relative to a standardized physician diagnosis, positive predictive values for the death certificate diagnosis in 1970 were 96% for all types of stroke, 59% for intracranial hemorrhage, and 87% for nonhemorrhagic stroke. The respective values in 1980 were 100%, 82%, and 97%. An increase in positive predictive values, particularly for intracranial hemorrhage between 1970 and 1980, was attributed to the increased use of computerized tomography. Sensitivity for the death certificate diagnosis in 1970 was 63% for all types of stroke, 66% for intracranial hemorrhage, and 45% for nonhemorrhagic stroke. The respective sensitivities in 1980 were 70%, 76%, and 58%. The lower sensitivity for nonhemorrhagic stroke as compared with hemorrhagic stroke was due in part to 1) frequent reporting of nonhemorrhagic stroke as a contributing cause of death rather than the underlying cause of death and 2) time from stroke onset to death. Specificity among these possible strokes was high in both years. The low sensitivity of death certificate diagnosis of stroke may reduce estimated relative risks in epidemiologic studies. Nevertheless, since the advent of widespread use of computerized tomography, a death certificate diagnosis of intracranial hemorrhage versus nonhemorrhagic stroke appears to be sufficiently accurate for use in epidemiologic studies of stroke etiology.

Adult↗
PubMed1990

Impact of initial triage decisions on nursing intensity for patients with acute chest pain.

The results of a prospective evaluation of the patient-specific correlates of nursing intensity for 183 consecutive emergency room patients admitted for evaluation of acute chest pain, including 33 (18%) with acute myocardial infarction (AMI), are reported. These correlates were measured with a previously-validated, commercially-available patient classification tool (Medicus). In multiple linear regression analysis that adjusted for the effects of 31 clinical variables from the initial presentation and subsequent course, initial triage to the coronary care unit had a significant independent correlation with initial Medicus score (P less than 0.0001) and mean Medicus score from the first three days of hospitalization (P less than 0.0001). In a subset of 74 uncomplicated non-AMI patients, coronary care unit admissions were more likely to have vital signs taken every 2 hours, to receive oxygen therapy and assistance with feeding, and to be transferred to another unit within three days. Findings suggest that, after adjusting for severity of illness, initial triage of patients with acute chest pain to the coronary care unit is associated with increased nursing utilization because of 1) the routine application of standard coronary care unit protocols that were developed for high-risk patients, and 2) the nursing efforts required by early transfer of patients out of the coronary care unit.

Adult↗
PubMed1990

Long-term impact of smoking cessation on the incidence of coronary heart disease.

Using a simulation model of the US male population, we estimated the long-term impact that future smoking cessation programs would have on the distribution and occurrence of coronary heart disease in males ages 35-84. For interventions that reduce the number of smokers by 25 percent in 1990, the number of men free of coronary heart disease is projected to increase by 416,787 (0.7 percent) in 2015, and the age-standardized absolute incidence to decline by 2.3 percent. Incidence rates and absolute incidences are projected to fall in men under age 65, but absolute incidence would rise in men over age 65, in large part because of the increased number of men who were at risk for coronary heart disease because of a reduction in non-coronary smoking-related mortality. These trends were more marked for greater smoking reductions and were generally unaffected in a variety of analyses using alternative assumptions, which considered smoking as a risk factor in the elderly, a lag-time before benefits from smoking cessation were realized and secular declines in smoking prevalence. Subject to the assumptions of our model, we conclude that smoking reductions will markedly reduce coronary heart disease, especially in younger age groups, and that this benefit will be slightly offset by a small increase in absolute incidence in elderly men.

Adult↗