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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 361 records · Page 20Linked to original sources
PubMed1984

The selective impact of a cardiology data bank on physicians' therapeutic recommendations.

We asked the physicians and medical students caring for 60 patients with symptomatic coronary artery disease, immediately after reviewing cardiac catheterization data, to choose medical or surgical therapy and to estimate prognosis one and three years after either therapy. The next day, each participant was given prognostic estimates generated from a large coronary artery disease data bank and again asked to estimate prognosis and choose therapy. Participants unanimously chose medicine for 20 patients (Group I) and surgery for 21 patients (Group III). For 19 patients (Group II), participants were divided on their choice of therapy. After seeing data bank estimates, participants rarely changed recommendations for Group I or Group III, but changed ten percent (9/90, p less than 0.01) of their Group II recommendations. Changes of recommendations by far (9/12, p = 0.02) favored medicine, causing the majority recommendation to change to medicine for two Group II patients. Therapeutic recommendations were guided mostly by pathoanatomy and the chance of improving medical regimens. Computer-generated prognostic data selectively influenced choices among the Group II cases where recommendations had been divided, resulting in changes toward less costly therapy.

Cardiac Catheterization↗
PubMed1984

The decline in ischemic heart disease mortality rates. An analysis of the comparative effects of medical interventions and changes in lifestyle.

Using reasonable assumptions gathered from the published literature, we estimated that more than half of the decline in ischemic heart disease mortality between 1968 and 1976 was related to changes in lifestyle, specifically to reductions in serum cholesterol levels and cigarette smoking. In comparison, about 40% of the decline can be directly attributed to specific medical treatment of clinical ischemic heart disease and hypertension being the leading estimated contributors. Because many of these interventions have not yet been applied to their maximum potential, a continued decline in mortality rates might be anticipated in the coming decades. However, the relative costs of these medical interventions and lifestyle changes and the extent to which they interact with each other must be considered before an optimal national health strategy can be derived.

Arrhythmias, Cardiac↗
PubMed1984

Diagnostic advances v the value of the autopsy. 1912-1980.

Between 1912 and 1980, many English language publications analyzed the correlation between clinicians' diagnoses and postmortem examinations. Surprisingly, the percentage of cases with undiagnosed principal underlying diseases or primary causes of death has not diminished during this period. The autopsy's unvarying percentage yield does not indicate a lack of progress, however, since bacterial pneumonia, hepatic cirrhosis, and common tumors were missed routinely in earlier eras but were rarely missed after 1970. Pulmonary embolism remains commonly missed, but the striking recent finding is the emergence of fungal and other systemic infections that were rarely noted in prior eras. Progress in diagnosis and treatment may allow patients to live longer and new or obscure diseases may develop that will often be missed clinically. An appropriately high autopsy rate will be required if medical progress is to continue.

Autopsy↗
PubMed1984

Dermatologic surgery in an ambulatory surgery center: ten years' experience.

A ten-year practice has shown the value of ambulatory dermatologic surgery centers for the dermatologist. Treatment for extensive and resistant warts, especially condylomata acuminata and molluscum contagiosum, advanced excisional surgery in the sterile setting, and general anesthesia for children and apprehensive adults are all offered by the well-organized ambulatory surgical center. The increasing development of laser dermatologic surgery has also made for increasing use of the well-equipped ambulatory multidisciplinary laser surgical division of the center at a considerable economic saving for the dermatologist. In the ambulatory surgical center there is also opportunity for increased cooperative efforts by the dermatologist working with the plastic surgeon as an associate for mutual benefit, not as a competitor.

Adult↗
PubMed1984

Medical consequences of missed appointments.

"No-show" patients (n = 100) were matched by age and number of appointments scheduled in a six-month period with 100 control patients who kept an appointment. No-show patients were less likely than control patients to have chronic medical problems (78% v 94%, respectively) and to be receiving long-term medications (58% v 73%, respectively) at the time of entry into this study. At follow-up at 29 to 51 weeks, no-show and control patients did not differ significantly in the development of new medical problems or the exacerbation of old medical problems either before or after controlling for differences in baseline health status. No hospitalizations or deaths could be directly attributed to a missed appointment. No-show patients were more likely than control patients to say they felt better at follow-up (42% v 26%, respectively). No-show patients may believe the benefit of keeping an appointment is not worth the inconvenience or expense. We suggest that physicians should carefully justify the need for a follow-up visit and consider negotiating follow-up schedules with their patients.

Adolescent↗
PubMed1983

Appointment reminders to reduce no-show rates. A stratified analysis of their cost-effectiveness.

To determine whether reminders are cost-effective for an adult primary care internal medicine center, we randomized 590 scheduled, follow-up appointments to no reminder, computer-generated letter reminders, and telephoned reminders. The no-show rate was reduced from 24% in the control group to 14% in the reminder groups, and letter and telephoned reminders were equally effective. An economic analysis showed that about two thirds of the savings realized from reminders was generated in 23% of the patients whose prior predicted probability of a no-show appointment was above 20%. However, in our primary care center, computer-generated letter reminders were estimated to be cost-effective whenever the probability of a no-show was above 5%, and telephoned or manual letter reminders were estimated to be cost-effective whenever the probability of a no-show was above about 11%. Based on our sensitivity analysis, telephoned or manual letter reminders should be cost-effective in many other ambulatory settings as well, although in some settings, reminders may be restricted to patients at high risk for no-show behavior.

Aged↗
PubMed1983

The value of the autopsy in three medical eras.

To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.

Autopsy↗
PubMed1983

A flexible sealed tube transverse radio frequency excited carbon dioxide laser for dermatologic surgery.

A new CO2 laser system, of special characteristics, has been found to be effective for CO2 laser dermatological surgery. The unit is compact, freely movable, and suitable for office practice. A highly flexible operating probe makes for precision surgery. The initial investigative clinical series included resistant warts in many areas including extensive plantar warts, oral lesions, and condylomata. There were also excisions of broad base granuloma pyogenicum, large seborrheic warty lesions, thermal photocoagulation of rhinophyma, and laser dermabrasion of tattoos. Flaps were done in animals.

Animals↗
PubMed1983

Research and development of additional aids for dermatologic and plastic surgery.

Increasing numbers of accessories continue to be found to make laser surgery more effective for dermatologic and plastic surgery. Argon laser surgery aids are available to increase the dilatation of the superficial vessels and to localize increasing numbers of red cell masses. Laser probes for intravascular thrombogenesis and thrombolysis have now been adapted for intradermal and deep dermal tissues and for cardiology. Studies on laser effects on platelets and heat transmission and thromboembolic phenomena are lacking. Investigative studies are developing for laser fiber optic probes for laser-induced fluorescence, not only for oncology, but also for studies of metabolism of tissues and also for spectroscopy. The use of different wavelengths and shorter pulses, more flexible fiber-optics transmission for all laser systems, combinations of laser systems into a single operating probe, as well as the increased use of lasers for diagnosis and treatment will all stimulate the development of new aids for laser surgery. Cooperative programs developed jointly by dermatologic and plastic surgeons will make for great progress in skin and soft-tissue laser surgery.

Dermatologic Surgical Procedures↗
PubMed1983

Processing of tRNA is accomplished by a high-molecular-weight enzyme complex.

An enzyme complex is a multifunctional catalytic unit that efficiently associates substrates with functionally related enzymes. The enzyme complex provides for the cellular regulation of enzymatic activities by physical interaction of the proteins with each other and by prior alteration of one enzyme's substrate by a related enzyme. Such regulatory abilities may go awry in neoplasia. Components of the protein biosynthetic machinery, such as aminoacyl-tRNA synthetases, have been thought to exist freely in the cytoplasm. However, high-molecular-weight enzyme complexes with aminoacyl-tRNA synthetase activities have been found in mammalian cells. We have been the first to report that the mammalian cell enzymes responsible for modification of tRNA occur in enzyme complexes (molecular weight 900000 daltons) associated with aminoacyl-tRNA synthetases and that the activities of these enzymes differ in normal and leukemic cells. Thus the enzymes responsible for the methylation of tRNA occur in enzyme complexes that provide efficient maturation of tRNA and possible regulation of protein synthesis. In FLC cells a unique enzyme complex composed of tRNA-methyltransferase and aminoacyl-tRNA synthetase activities has also been shown to contain a specific ribonuclease activity and a cysteine-tRNA sulfurtransferase activity. Sulfurtransferase activity has been characterized and optimized for its tRNA and cysteine substrates and mercaptoethanol and cation cofactors. Abnormal activity of this enzyme during neoplasia could result in improper acylation of tRNA and/or infidelity of coding by tRNA. Specific RNase is important in the sizing of percursor tRNA into mature tRNA. Results showed that this sizing was dependent upon the presence of the enzyme complex and the length of the incubation time. Many of the 20 aminoacyl-tRNA synthetases are also found in the complex. Electron microscopy has verified the subunit nature of the complex, seen previously by density gradient centrifugation and gel filtration. Three subunits, each of 300 000 daltons, comprise a complex approximately 200 A in diameter.

Amino Acyl-tRNA Synthetases↗
PubMed1983

Impact of inter-physician communication on the effectiveness of medical consultations.

To evaluate the impact of the inter-physician communication on the effectiveness of consultations, consultations performed by general and subspecialty medical consultation services for one week both early and late in the academic year were prospectively evaluated. Physicians commonly requested consultations to get advice on diagnosis (56 percent), advice on management (37 percent), or assistance in arranging or performing a procedure or test (20 percent). Despite our very liberal definitions, the requesting physician and the consultant completely disagreed on both the reason for the consultation and the principal clinical issue in 22 (14 percent) of 156 consultations. Consultants were twice as likely as the requesting physicians to rate consultations as crucial for management (35 percent versus 18 percent, p = 0.001) because they gave significantly higher ratings when they and the requesting physicians did not agree on the reasons for consultation. Consultations ordered for very specific purposes, such as assistance in arranging or performing a test, were rated significantly higher by the requesting physicians. It was found that breakdowns in communication are not uncommon in the consultation process and may adversely affect patient care, cost effectiveness, and education.

Boston↗
PubMed1983

Clinical utility and management impact of M-mode echocardiography.

To determine the clinical utility and management impact of M-mode echocardiography, 182 echocardiograms were analyzed at a university teaching hospital. The physicians who ordered the echocardiograms said that 12 percent provided crucial information that was not available from other tests and that 26 percent resulted in a change in patient management. According to two independent board-certified cardiologist-reviewers, 86 percent of echocardiograms were appropriately ordered, but only 15 echocardiograms (8 percent) were actually needed for a change to a new and appropriate management. According to the reviewers, the 77 Group I M-mode echocardiograms (those ordered to evaluate left ventricular function, left atrial size, potential cardiac sources of emboli, or the possibility of bacterial endocarditis, or those ordered in patients who, according to the ordering physician, had undergone or would undergo catheterization regardless of the results of echocardiography) were less likely than the 105 Group II M-mode echocardiograms (those ordered to evaluate possible mitral valve prolapse, hypertrophic cardiomyopathy, valvular function, or the pericardium) to be ordered appropriately, to provide helpful information, or to provide crucial results. Group I echocardiograms had reviewer-assessed appropriate management impact in only one case (1 percent) compared with a 13 percent rate of management impact for Group II M-mode echocardiograms (p less than 0.01). Although echocardiography can be accurate and valuable with yields similar to those of other noninvasive procedures, 77 (42 percent) of 182 M-mode echocardiograms in this hospital could be predicted at the time of ordering to be in a low-yield group.

Echocardiography↗
PubMed1983

The changing "natural history" of symptomatic coronary artery disease: basis versus bias.

In contrast to the 20 to 30% reduction in ischemic heart disease mortality that has been demonstrated by national mortality statistics and by several randomized controlled trials, an uncritical reading of recent "natural history" studies suggests far greater improvements in the survival of symptomatic coronary patients. Although the intrinsic accuracy of such natural history studies is not questioned, attempts to compare patients from different studies and different eras may greatly overestimate the true improvement in natural history because of at least 3 biases in the selection of cases from the spectrum of diseased patients. Because of lead-time bias, patients who are diagnosed earlier live longer regardless of whether interventions are efficacious. Because of referral bias, current patients may have symptoms or anatomy that place them at a different stage of severity than patients who were chosen for earlier studies. Because of incidence-prevalence bias, prevalence studies will be over-represented with survivors of previous incidence cohorts who have slower-progressing disease. We suggest that all natural history studies be carefully scrutinized for such biases before they are compared with each other.

Analysis of Variance↗
PubMed1983

Significance of post-cholecystectomy subhepatic fluid collections.

A prospective ultrasound study of the right upper quadrant in 105 patients who had undergone cholecystectomy showed the incidence of fluid collection in the gall bladder fossa to be 24% 2 to 4 days after operation. In all but two patients, these fluid collections were of no clinical significance. The relationship between the presence of fluid and several other variables, such as use of drains and surgical techniques, are discussed.

Ascites↗