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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 379 records · Page 21Linked to original sources
PubMed1983

Cardiac risks and complications of noncardiac surgery.

When internists are consulted to assess risks and to aid in the perioperative management of surgical patients, they often can rely on substantial clinical data to guide the consultation. Perioperative cardiac risk can be estimated based on the severity of underlying heart failure, the occurrence of a recent myocardial infarction or various arrhythmias, the presence of aortic stenosis, the patient's age, the type of planned surgery (including whether it is an emergency or elective procedure), and the patient's general medical condition. Preoperative exercise testing or cardiac catheterization to assess risk are not routinely indicated, but perioperative hemodynamic monitoring to improve management is recommended in patients at high risk. Postoperative hypertension, arrhythmias, and heart failure commonly occur in the first 2 days after surgery, but the risk of myocardial infarction persists for at least 5 or 6 days after surgery. Effective perioperative consultation must include careful postoperative observation to detect cardiac complications at an early stage and to assist in their management.

Adult↗
PubMed1983

A comparison of the efficacy of two vaginal creams for vulvovaginal candidiasis, and correlations with the presence of Candida species in the perianal area and oral contraceptive use.

In a double-blind clinical study, 93 patients with vulvovaginal candidiasis were randomly assigned to treatment with either clotrimazole (1%) or miconazole (2%) vaginal cream for seven days. The treatments were comparable in reducing the severity of presenting signs and symptoms. At one and four weeks posttherapy, negative vaginal cultures were found in 84.4% and 75.0%, respectively, of the clotrimazole-treated patients and in 85.4% and 74.5%, respectively, of the miconazole-treated patients. The incidences of recurrence/reinfection and treatment failures were comparable in the two groups. Treatment failures and recurrences/reinfections were not correlated with positive perianal cultures for Candida species. Patients using oral contraceptives had a higher incidence of positive vaginal cultures at four weeks posttherapy than did patients not using oral contraceptives or using other methods.

Adult↗
PubMed1983

Ten commandments for effective consultations.

If internists are not explicitly instructed in how to perform consultations, the outcome of their consultative efforts may be suboptimal. We suggest that consultations will be more helpful if the following principles are followed: the consultant should determine the question that is being asked, establish the urgency of the consultation, gather primary data, communicate as briefly as appropriate, make specific recommendations, provide contingency plans, understand his own role in the process, offer educational information, communicate recommendations directly to the requesting physician, and provide appropriate follow-up. If these ten "commandments" are followed, the consultation is more likely to be effective and satisfactory for all the participants.

Humans↗
PubMed1983

The value of the peripheral blood smear in anemic inpatients. The laboratory's reading v a physician's reading.

Since physicians are routinely taught to review the peripheral blood smear results of all anemic patients, we analyzed the diagnostic value of the laboratory's blood smear reading and the incremental value of a physician's personal reading in anemic inpatients. Blood smear abnormalities, as reported by the laboratory and two hematologists, were poorly reproducible, with only five of the 11 types of abnormalities being more reproducible than could be expected by chance. The blood smear performed no better than RBC indices in detecting probable iron deficiency or low serum levels of folate or vitamin B12. In anemias not caused by deficiency states, the blood smear reading performed by the hospital laboratory provided unique information in 6% of the cases and helpful information in another 25%, but the additional reading performed by a hematologist never provided unique information and provided incremental helpful information in only 4% of the cases. The peripheral blood smears of all anemic inpatients should be read by the hospital laboratory, but in our hospital, a routine additional personal reading by a physician had limited incremental value and could be reserved for selected cases.

Anemia↗
PubMed1982

A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain.

To determine whether data available to physicians in the emergency room can accurately identify which patients with acute chest pain are having myocardial infarctions, we analyzed 482 patients at one hospital. Using recursive partitioning analysis, we constructed a decision protocol in the format of a simple flow chart to identify infarction on the basis of nine clinical factors. In prospective testing on 468 other patients at a second hospital, the protocol performed as well as the physicians. Moreover, an integration of the protocol with the physicians' judgments resulted in a classification system that preserved sensitivity for detecting infarctions, significantly improved the specificity (from 67 per cent to 77 per cent, P less than 0.01) and positive predictive value (from 34 per cent to 42 per cent, P = 0.016) of admission to an intensive-care area. The protocol identified a subgroup of 107 patients among whom only 5 per cent had infarctions and for whom admission to non-intensive-care areas might be appropriate. This decision protocol warrants further wide-scale prospective testing but is not ready for routine clinical use.

Adult↗
PubMed1982

Evaluation and outcome of emergency room patients with transient loss of consciousness.

We identified 198 patients who presented to our emergency room with transient loss of consciousness. Seizures (29 percent of patients) and vasovagal/psychogenic episodes (40 percent of patients) were the most common presumptive causes of loss of consciousness, but the cause of loss of consciousness remained uncertain even at follow-up in 11 +/- 6 months in 13 percent of the patients. The history and physical examinations were sufficient for diagnosis in 85 percent of the patients in whom a diagnosis could be established. These data guided inpatient and outpatient with potentially dangerous causes of loss of consciousness except for one patient who had pulmonary embolism. In selected patient, diagnostic tests such as blood chemistries (three patients), electrocardiograms (four patients) electroencephalograms (three patients), and Holter monitoring (four patients) provided crucial information, and CT scans identified new brain tumors in four patients with focal neurologic presentations. At the time of follow-up, 7.5 percent of patients had suffered either major morbidity or death related to the cause of the index episode of loss of consciousness. Patients with cardiac causes represented a high risk (33 percent) group for such poor outcome, whereas patients who were under age 30, or who were under age 70 and had loss of consciousness on a vasovagal/psychogenic or unknown basis, constituted a low risk (1 percent) subgroup.

Adult↗
PubMed1982

Pitfalls in the serial assessment of cardiac functional status. How a reduction in "ordinary" activity may reduce the apparent degree of cardiac compromise and give a misleading impression of improvement.

Because the New York Heart Association (NYHA) classification system categorizes patients based on subjective impression of the degree of functional compromise, a reduction in exercise might make a patient seem improved because the new lower level of ordinary activity produced fewer symptoms. To test this hypothesis, we studied three different sets of patients and compared their NYHA classes to their functional classes as determined by a new Specific Activity Scale (SAS) that is based on the metabolic equivalents of oxygen consumption required for activities the patient actually performs. Among ambulatory patients referred for exercise tests, the NYHA class was higher (i.e. indicated the patient was more limited) in 28% of patients and the SAS class was higher in 14% (p less than 0.001). Among patients interviewed at or near the time of catheterization for chest pain, the NYHA was higher in 20% and the SAS class was higher in 20% (p = NS). In both medically and surgically treated patients interviewed 1--3 yr after cardiac catheterization, the NYHA class was higher in only 4%, whereas the SAS class was higher in 28% (p less than 0.001). The SAS class was significantly more likely to be higher in patients who were not working full time and in patients who described their present activity level as sedentary or light. When the NYHA and SAS systems disagreed as to whether a patient was improved, SAS was significantly more likely to correlate with the patient's self-assessment. These findings suggest that some patients restrict their activity as their cardiac disease progresses; the resultant change in the definition of ordinary activity may reduce the apparent degree of cardiac compromise and thus give a false impression of improvement by NYHA criteria.

Activities of Daily Living↗
PubMed1982

Delays in inactivation development and activation kinetics in myxicola giant axons.

Na inactivation was studied in Myxicola (two-pulse procedure, 6-ms gap between conditioning and test pulses). Inactivation developed with an initial delay (range 130-817 microseconds) followed by a simple exponential decline (time constant tau c). Delays (deviations from a simple exponential) are seen only for brief conditioning pulses were gNa is slightly activated. Hodgkin-Huxley kinetics with series resistance, Rs, predict deviations from a simple exponential only for conditioning pulses that substantially activate gNa. Reducing INa fivefold (Tris substitution) had no effect on either tau c or delay. Delay in not generated by Rs or by contamination from activation development. The slowest time constant in Na tails is approximately 1 ms (Goldman and Hahin, 1978) and the gap was 6 ms. Shortening the gap to 2 ms had no effect on either tau c or delay. Delay is a true property of the channel. Delay decreased with more positive conditioning potentials, and also decreased approximately proportionally with time to peak gNa during the conditioning pulse, as expected for sequentially coupled activation and inactivation. In a few cases the difference between Na current values for brief conditioning pulses and the tau c exponential could be measured. Difference values decayed exponentially with time constant tau m. The inactivation time course is described by a model that assumes a process with the kinetics of gNa activation as a precursor to inactivation.

Animals↗
PubMed1982

Surgery with the argon laser: recent advances in instrumentation and techniques.

There have been several recent advances in the instrumentation and techniques of use of the argon laser in dermatologic surgery. Dispersion lenses that enlarge the areas of impact, operation through a microscope that permits precise microsurgery, templates that delimit areas of treatment, special eyeshields, nerve block anesthesia, and intermittent, light general anesthesia feasible in an out-patient setting are discussed.

Anesthesia, Local↗
PubMed1982

Evidence that hospital care for acute myocardial infarction has not contributed to the decline in coronary mortality between 1973-1974 and 1978-1979.

To investigate whether the reported 17% decline in the national rates of acute ischemic heart disease mortality between 1973 and 1978 was attributable to decreased in-hospital mortality for patients with acute myocardial infarction (MI), we surveyed all 63 acute care hospitals in the Boston, Massachusetts, area. Compared with 1973-1974, more 1978-1979 MI patients were admitted to hospitals in metropolitan Boston, and especially to the five university teaching hospitals. Between 1973-1974 and 1978-1979, hospital admission rates decreased for younger patients and increased for older patients, but overall admission rates were almost identical. In-hospital mortality rates from acute MI did not change significantly in any age group. Because overall MI mortality was declining while in-hospital MI mortality was unchanged, the proportion of acute MI deaths that occurred inside the hospital increased from about 30% to about 40%. Although current hospital care undoubtedly benefits many individual patients, this study suggests that improvements in the in-hospital care of acute MI patients are a major explanation for nationwide mortality trends between 1973 and 1978.

Adult↗
PubMed1982

Incremental value of the exercise test for diagnosing the presence or absence of coronary artery disease.

To determine the incremental value of the exercise test (ETT) for diagnosing coronary artery disease (CAD), we derived a multivariate logistic regression model for the pre-ETT prediction of CAD using data from 3840 patients at Duke University. We then applied the model to 324 patients at the Brigham and Women's Hospital. Using seven clinical factors, the multivariate model had an 84% overall predictive accuracy on both the training (Duke) and the validation (Brigham) sets of patients. Three ETT factors (ST-segment change in patients not taking digitalis, absence of ST-segment change in patients taking digitalis, ETT stopped because of ECG or blood pressure changes) had incremental, significant predictive power, but overall predictive accuracy based on both clinical and ETT factors improved only to 87%. When the ETT result was important enough to move the probability of CAD across a potential therapeutic threshold, the direction of the change in probability was correct only two-thirds of the time. Thus, the ETT was of limited value in predicting the presence or absence of CAD after other easily obtainable clinical data were taken into account.

Adult↗
PubMed1982

A multivariate approach to the prediction of no-show behavior in a primary care center.

To predict no-show behavior in a primary care center, we analyzed a wide range of factors in 376 patients. Of 1,181 appointments that were scheduled during a six-month follow-up period and that were not cancelled in advance, 968 (82%) were kept and 213 (18%) were no-shows. By multivariate logistic regression analysis based on two thirds of the patient sample, no-show behavior was independently correlated with the following four factors: the patient's age and race, the presence of any physician-identified psychosocial problems, and the percent of noncancelled and appointments that were kept during the prior 12 months. Neither patient satisfaction nor patient-physician concordance in problem identification were independent correlates of appointment keeping. When our four-factor logistic regression equation was independently tested on the other one third of the patients, it accurately predicted no-show behavior. We suggest that our predicted probability of no-show behavior can be used to guide changes in scheduling patterns or to recognize patients appropriate for interventions to change behavior.

Adult↗