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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 253 records · Page 14Linked to original sources
PubMed1990

Time to recurrence varies inversely with thickness in clinical stage 1 cutaneous melanoma.

The thickness of a tumor has been identified as the principal prognostic factor in cutaneous malignant melanoma. However, time to recurrence has not conclusively been related to thickness. A retrospective study of 216 patients with a primary cutaneous malignant melanoma that recurred was conducted to clarify this relationship and investigate possible independent relationships between age at diagnosis and sex of patients to time to recurrence. The results of analysis of linear regression revealed an inverse linear relationship between thickness and time to recurrence (p less than 0.001). Patients more than 50 years of age at the time of diagnosis were shown to relapse sooner than those less than 50 years of age (p = 0.014). Sex was not a significant factor in predicting time to recurrence (p greater than 0.10). These results suggest that thickness of tumor provides an indication of time to recurrence in those patients destined to recur and stress the need for long term surveillance in patients with a history of malignant melanoma because of the possibility of late relapse even with thin lesions.

Female↗
PubMed1990

Childhood anogenital lichen sclerosus. A case report.

Childhood lichen sclerosus is a rare disorder. A 4-year-old girl with chronic vulvar pruritus who was initially suspected to be the victim of child abuse was treated. Vulvar biopsy was performed, confirming the diagnosis of lichen sclerosus. The child was treated with 2% progesterone cream, with complete resolution of her pruritic symptoms and signs of traumatic injury to the vulvar skin. The basic condition, lichen sclerosus, has persisted.

Administration, Topical↗
PubMed1989

Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study).

To determine the prevalence and characteristics of acute myocardial infarction (AMI) patients who present to emergency departments with normal or nonspecific electrocardiograms (ECGs), data were analyzed from 7,115 consecutive patients in the Multicenter Chest Pain Study. AMI patients with normal or nonspecific initial ECGs (n = 107) were less likely to have a past history of coronary artery disease or to be diaphoretic on presentation (p less than 0.01) than AMI patients with initial ECGs highly suggestive of AMI (n = 811). The overall probability of AMI among patients with chest pain and initially normal or nonspecific ECGs was 3%, but ranged from less than 1 to 17% depending on the patient's age and sex and whether the patient had pressure-type pain or pain radiating to the shoulder, neck or arms. Among initially admitted patients, the time elapsed between onset of pain and presentation was similar in both groups. However, the time between onset of pain and definitive diagnosis of AMI by enzymes or clinical course was longer in patients with initially normal or nonspecific electrocardiograms (8.3 vs 7.5 hours, p less than 0.05), their peak creatine kinase levels were lower (mean 643 vs 1,032 mg/dl, p less than 0.001) and their mortality was slightly lower (6 vs 12%, p = 0.10). These findings suggest that AMI patients with initially normal or nonspecific ECGs may have a less severe short-term clinical outcome.

Adult↗
PubMed1989

Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery.

Patients who undergo peripheral vascular surgery are at increased risk for postoperative cardiac events and are difficult to assess preoperatively because of limitations on their activity. We prospectively studied 176 consecutive eligible patients undergoing elective vascular surgery to determine the value in predicting a postoperative cardiac event of preoperative electrocardiographic monitoring to detect myocardial ischemia. Of the 176 patients, 32 (18 percent) had 75 episodes of monitored ischemic ST-segment depression preoperatively (of which 73 were asymptomatic), and 13 (7 percent) met strict criteria for major postoperative cardiac events, including 1 with a fatal myocardial infarction, 3 with nonfatal infarctions, 4 with unstable angina, and 5 with ischemic pulmonary edema. Of the 32 patients with ischemia before their operations, 12 had postoperative events (univariate relative risk, 54; 95 percent confidence interval, 7.2 to 400). Only 1 postoperative event occurred among 144 patients who did not have preoperative ischemia. The sensitivity of preoperative ischemia was 92 percent, the specificity 88 percent, the predictive value of a positive result 38 percent, and the predictive value of a negative result 99 percent. In multivariate analyses, preoperative ischemia was the most significant correlate of postoperative cardiac events and remained a statistically significant independent correlate even after we had controlled for all other preoperative factors (multivariate relative risk, 24.4; 95 percent confidence interval, 6.8 to 88). These preliminary data suggest that preoperative electrocardiographic monitoring to detect episodes of myocardial ischemia is a useful method for assessing cardiac risk in patients who undergo elective vascular surgery. In particular, the absence of ischemia during monitoring indicates a very low risk.

Aged↗
PubMed1989

Candidates for thrombolysis among emergency room patients with acute chest pain. Potential true- and false-positive rates.

STUDY OBJECTIVE: To assess the potential clinical impact of thrombolytic therapy for acute myocardial infarction by determining true-positive and false-positive rates of criteria for eligibility among emergency room patients with acute chest pain. DESIGN: Prospective multicenter cohort study. SETTING: Emergency rooms of three university and four community hospitals. PATIENTS: Emergency room patients (7734) with acute chest pain. MEASUREMENTS AND MAIN RESULTS: Only 261 (23%) of 1118 patients with acute myocardial infarctions were 75 years of age or younger, presented within 4 hours of the onset of pain, and had emergency room electrocardiograms showing probable acute myocardial infarction: 60 (0.9%) of the 6616 patients without infarction also met these criteria (positive predictive value, 261/321 = 81%; CI, 77% to 86%). The positive predictive value could increase to about 88% (CI, 82% to 93%) if eligibility were based on the official hospital electrocardiogram reading. CONCLUSIONS: Because experience from published studies suggests that about one third of patients who meet these three eligibility criteria have other contraindications to thrombolysis, we estimate that about 15% of patients with acute myocardial infarction would meet the criteria for eligibility for thrombolysis that have been used in clinical trials at the time of emergency room presentation. Further, for every eight patients with true-positive results who are treated, one to two patients with false-positive results may also be treated if decisions are based on the interpretation of a single electrocardiogram.

Adult↗
PubMed1989

Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience.

To assess whether the manifestations of acute ischemic heart disease in the elderly are less typical than in younger patients, the presenting clinical features and their associated relative risks for acute myocardial infarction (AMI) were compared in 2,625 patients greater than or equal to 65 years of age and 5,109 patients less than 65 years of age. These patients were evaluated for acute chest pain in the emergency departments of 7 hospitals. The same features were associated with increased relative risks for AMI in younger and elderly patients. The relative risks among older patients, however, were consistently closer to 1.0 for classic features, including male gender, pressure-like quality of pain, substernal location, typical pattern of pain radiation and electrocardiographic evidence of ischemia or AMI. Analyses for the endpoint "acute ischemic heart disease" (i.e., AMI or unstable angina) yielded similar findings. Elderly patients were more likely to be admitted to the hospital (56 vs 35%; p less than 0.0001) and to the coronary care unit (37 vs 23%; p less than 0.0001) in the absence of either AMI or unstable angina. These data support the hypothesis that diagnosis of acute chest pain is especially difficult in elderly patients.

Adult↗
PubMed1989

Should there be a formal mechanical-optic-electronic biomedical-engineering program?

To progress in the development of laser medicine and laser surgery, multidisciplinary efforts are required. One important phase in its development is the laser biomedical engineering program being offered following the basic laboratory research. Some of this type of programming is present today, but more development is needed for a formal program offering crossfertilization between engineering and medical uses. Therefore, a formal program is being proposed, which will be reviewed by mixed groups over a period of time. A final recommendation will indicate whether to go ahead with this revision of the program, to wait for further development of the program, or to maintain the status quo. The relationship of technical training for technicians in laser biomedical engineering is also reviewed.

Biomedical Engineering↗
PubMed1989

Monotonic and non-monotonic single channel open time distributions with two sequential open states.

Some conditions under which kinetic schemes including two sequential open states of identical conductance will display a non-monotonic (i.e. with a deficit of short open times and a maximum at t greater than 0) distribution of single channel open times are described theoretically. Neither a closed cyclic scheme nor exclusively irreversible transitions between states are required for non-monotonic distributions. A required condition for the schemes considered here is that all openings are to a state from which closing is not possible. It is the presence of a precursor process to channel closing that produces the non-monotonic distribution. Following each channel opening some time is required for a transition into the second open state from which all closings proceed. Simple schemes of this sort cannot provide the basis of any experimental reports of non-monotonic distributions.

Ion Channels↗
PubMed1989

Sodium channel opening as a precursor to inactivation. A route to the inactivated state.

The time constant of the process producing the delay in Na inactivation development as determined by the two pulse method (tau delay) was extracted and compared to that of the slowest Na activation process (tau 3) for the INa during the conditioning pulse of that same determination. tau delay and two pulse inactivation (tau C) values were computer generated using a non-linear least squares algorithm. tau 3 and single pulse inactivation (tau h) values were independently generated for each determination also with the aid of the computer using the same non-linear least squares algorithm. In one determination at 2 mV, tau C was 4.68 and tau delay 0.494 ms while tau h was 4.70 and tau 3 0.491 ms for a tau c/tau h of 0.996 and a tau delay/tau 3 of 1.006. Mean tau delay/tau 3 from five determinations in four axons, both Cs and K perfused, and spanning a potential range of -27 to 2 mV was 1.068. The precursor process to inactivation is channel opening. Some fraction of channels presumably inactivate via another route where prior channel opening is not required.

Animals↗
PubMed1989

Delayed diagnosis of gynecologic tumors in elderly women: relation to national medical practice patterns.

PURPOSE: To evaluate the hypothesis that less aggressive cancer screening practices might result in later diagnosis of cancer in the elderly, we analyzed the stage of diagnosis of tumors by age in the Connecticut Tumor Registry. PATIENTS AND METHODS: Using Registry data from 1960 to 1975 and 1976 to 1983, we compared the proportion of tumors that were diagnosed at a localized stage among white women of various age groups. Thirteen specific tumor sites were analyzed, accounting for 55,688 tumors between 1960 and 1975 and 38,715 tumors between 1976 and 1983. RESULTS: Only gynecologic cancers demonstrated a significant inverse relationship between the relative proportion of tumors that were diagnosed at a localized stage and advancing patient age during both time periods. Specifically, when the youngest women (aged 25 to 34) were compared with the oldest women (aged 85 and over), between 1960 and 1975, the relative proportion of localized cervical, uterine, and ovarian cancer dropped from 98 percent to 59 percent, 92 percent to 77 percent, and 59 percent to 27 percent, respectively. Similar declines were also seen between the intermediate-age groups, and data from 1976 to 1983 demonstrated identical age-related trends. CONCLUSION: Our study reveals that the probability of diagnosing cancer of the cervix, uterus and ovaries at a localized and potentially curable stage decreases with advancing age. Published national health practice patterns demonstrated a similar age-related decline in gynecologic examinations and Pap smears even after adjustment for the exclusion of women who would have undergone previous hysterectomy. This decreasing use of gynecologic examinations may in part explain the age-related decline in localized gynecologic cancers.

Adult↗
PubMed1989

Development and analysis of observational data bases.

Medical data bases have become an increasingly popular tool in clinical research. The observational data can be used to generate hypotheses for the development of clinical prediction rules and confirmation or extension of findings from other studies. When the analyses are carefully performed, the results from observational data bases generally have confirmed and complemented the findings of major randomized trials. In recent years, important clinical insights have been derived from analyses of data bases of large scale epidemiologic investigations; such insights may provide significant information on the impact of health policy decisions on patient care. To maximally and carefully use observational data, certain principles in both study design and the data collection and analysis phases should be applied.

Clinical Trials as Topic↗
PubMed1989

Performance of tests of significance based on stratification by a multivariate confounder score or by a propensity score.

Stratification by a multivariate confounder score or by a propensity score has been proposed for the multi-confounder situations that are commonly encountered in epidemiologic evaluations of the effects of a treatment or a triage decision. However, the use of these scores in clinical research has been limited, perhaps in part because of the concern that the stated level of statistical significance may be exaggerated when there is a high degree of correlation between the exposure and the set of confounders. We present a specific example and computer simulations to suggest that exaggeration of statistical significance occurs only under unusual circumstances when the correlation between the exposure and the confounders is extreme. Our simulations also suggest that an analysis based on stratification by a propensity score is less affected by high correlation between the exposure and the confounders than is an analysis based on a multivariate confounder score.

Computer Simulation↗
PubMed1989

The bleeding severity index: validation and comparison to other methods for classifying bleeding complications of medical therapy.

Reports of bleeding complications of medical therapy should be based on valid methods of classification, but the reproducibility of existing methods has not been tested. Therefore, we prospectively studied three methods to classify the severity of bleeding: a purely subjective implicit method, a previously published explicit method using brief criteria, and the bleeding severity index, which is a new explicit method using detailed criteria about the amount, rate, and consequences of bleeding. Three physicians independently reviewed abstracts of 168 patients treated with anticoagulants. The proportion of cases classified as major bleeding varied widely when the implicit method was used (2, 14 and 39%), less when the old explicit method was used (28, 40 and 47%), and not at all when the new bleeding severity index was used (20, 20 and 20%). Intraobserver agreement was excellent for both explicit methods (kappa greater than or equal to 0.95). However, interobserver agreement was better for the bleeding severity index (kappa = 0.87) than for the old explicit method (kappa = 0.69) or the implicit method (kappa = 0.39). We conclude that the classification of bleeding complications of medical therapy depends on the method used. In comparison to older methods, the bleeding severity index is highly reproducible and should be tested more widely to determine whether it can be applied to the burgeoning clinical research in anticoagulation and thrombolysis.

Anticoagulants↗
PubMed1989

Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy.

PURPOSE: To determine the incidence of major bleeding in outpatients treated with warfarin and to identify predictive factors known at the start of therapy. PATIENTS AND METHODS: The records of 565 patients starting outpatient therapy with warfarin upon discharge from a university hospital were reviewed. Follow-up information was obtained for 562 patients (99.5%). Bleeding was classified as major or minor using explicit criteria. The cumulative incidence of bleeding was estimated by means of survival analysis. Independent risk factors for major bleeding were identified using Cox regression analysis in 375 randomly chosen patients; they were tested in the remaining 187 patients. RESULTS: Major bleeding occurred in 65 patients (12%) and was fatal in 10 patients (2%). The cumulative incidences of major bleeding at one, 12, and 48 months were 3%, 11%, and 22%, respectively. The monthly risk of major bleeding decreased over time, from 3% during the first month of outpatient therapy to 0.3% per month after the first year of therapy. Five independent risk factors for major bleeding--age 65 years or greater, history of stroke, history of gastrointestinal bleeding, a serious comorbid condition (recent myocardial infarction, renal insufficiency, or severe anemia), atrial fibrillation--predicted major bleeding in the testing group; the cumulative incidence of major bleeding at 48 months was 2% in 57 low-risk patients, 17% in 110 middle-risk patients, and 63% in 20 high-risk patients. CONCLUSION: These findings provide a quantitative basis for evaluating the risk of major bleeding in individual patients at the start of outpatient therapy with warfarin. Whether the risk of bleeding can be reduced in high-risk patients without reducing the benefit of therapy remains to be determined.

Adolescent↗
PubMed1989

Bleeding in outpatients treated with warfarin: relation to the prothrombin time and important remediable lesions.

PURPOSE: To determine the relation of bleeding to prothrombin times and important remediable lesions in outpatients treated with warfarin. PATIENTS AND METHODS: An inception cohort of 565 patients starting outpatient therapy with warfarin on discharge from a university hospital was assembled. Detailed records of outpatient prothrombin times were obtained for 103 of 130 case subjects with major or minor bleeding and for 117 control patients without bleeding. A nested case-control design was used to evaluate the association of bleeding with temporally related prothrombin times; odds ratios were estimated using multivariate logistic regression analysis to control for known predictors of major bleeding. The relation of bleeding to important remediable lesions was determined in all 130 cases of bleeding. RESULTS: For each 1.0 increase in the prothrombin time-to-control ratio, the odds ratio for major bleeding during the week after a prothrombin time measurement increased 80%; the odds ratio for minor bleeding increased 50%. These odds ratios were lower during the first month of therapy and higher thereafter. Bleeding was related to important remediable lesions in 49 of 130 cases (38%), but these lesions were unknown before bleeding in only 22 cases (17%). The mean prothrombin time rose sharply at the time of bleeding in patients without important remediable lesions, but not in patients with lesions. New, previously unknown lesions (including nine malignancies) were discovered in 20 of 59 case subjects (34%) with gastrointestinal bleeding or hematuria, but in only two of 71 case subjects (3%) with other bleeding (p less than 0.001). CONCLUSION: Our results provide a valid quantitative basis for estimating the odds of bleeding in relation to the prothrombin time and the yield of diagnostic evaluation in patients with bleeding.

Aged↗