Search PubMed⌕ Search

Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 595 records · Page 33Linked to original sources
PubMedDate not supplied

The characteristics and hospital course of patients admitted for presumed acute pyelonephritis.

To study the characteristics and hospital courses of patients hospitalized for presumed acute pyelonephritis, the authors analyzed 185 cases. Judged by explicit clinical and laboratory criteria, 54% of the patients definitely had pyelonephritis, 22% probably had pyelonephritis, 9% possibly had pyelonephritis, and 16% did not have pyelonephritis. In pretreatment urine cultures, 79% of patients had a single pathogen and 77% had colony counts of 100,000 or more organisms per ml. Non-Escherichia coli infections and positive blood cultures were the only two independent predictors of the concomitant renal stones or genitourinary tract abnormalities that were found in 29% of patients with pyelonephritis. About 15% of all patients continued to have temperatures greater than or equal to 101 degrees F 48 hours after the initiation of antibiotic therapy, but persistent fever did not correlate with a history of prior urinary tract infection, the presence of resistant pathogens, renal stones, or genitourinary tract abnormalities. The authors conclude that many of these patients did not have pyelonephritis, and that certain characteristics correlate with the presence of underlying anatomic abnormalities.

Acute Disease↗
PubMedDate not supplied

Blueprint for a research career in general internal medicine.

An academic career in general internal medicine is a challenging but rewarding endeavor. The strategies for success require flexibility as the ground rules may change. Nevertheless, attention to the aforementioned principles will help the academic generalist to swim with sharks and survive, and simultaneously to promote the entire field of academic general internal medicine.

Employment↗
PubMedDate not supplied

Optimal management strategies for HIV-infected patients who present with cough or dyspnea: a cost-effective analysis.

OBJECTIVE: To determine the effectiveness and costs of alternative management strategies for patients infected with the human immunodeficiency virus (HIV) who present with pulmonary symptoms. DESIGN: Decision analysis comparing initial testing (arterial blood gas analysis, induced sputum analysis, or bronchoscopy with bronchoalveolar lavage) with empiric antibiotics (trimethoprim-sulfamethoxazole or erythromycin). Subsequent steps in management are detailed based on the results of initial management. Patients were stratified by initial CD4 lymphocyte count (less than 200/mm3, 200-500/mm3, or greater than 500/mm3) and results of chest radiography. SETTING: Hypothetical. MEASUREMENTS AND MAIN RESULTS: The estimated levels of effectiveness among strategies were relatively similar, but costs varied markedly. If potentially reasonable strategies are defined as those that have incremental cost-effectiveness ratios below $50,000 per quality-adjusted life year (QALY), the recommended strategies would be: for patients at highest risk for Pneumocystis carinii pneumonia (PCP), with a probability of PCP above 30% (CD4 less than 200/mm3 and abnormal chest radiograph or prior history of PCP), begin with induced sputum analysis ($34,174/QALY); for intermediate-risk patients, with a probability of PCP between 6% and 30% (CD4 less than 200/mm3, regardless of chest radiograph; or CD4 200-500/mm3, regardless of chest radiograph findings), begin with arterial blood gas analysis ($4,593 to $8,310/QALY); for low-risk patients, with a probability of PCP below 6% (CD4 greater than 500/mm3, regardless of chest radiograph findings), begin with one week of erythromycin, followed by induced sputum examination if symptoms persist ($675 to $3,306/QALY). For highest-risk patients, if empiric trimethoprim-sulfamethoxazole was considered entirely to be outpatient therapy, it was preferred management if the probability of PCP was above 38%. CONCLUSIONS: The authors conclude that preferred management strategies are determined more by differences in costs than by differences in levels of effectiveness, and that they vary depending on the probability of PCP in definable patient subgroups.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Determinants of resource utilization for patients admitted for evaluation of acute chest pain.

OBJECTIVE: To identify determinants of resource utilization among patients with suspected acute myocardial infarction. DESIGN: Prospective cohort study, with prospective collection of detailed clinical data and retrospective collection of nonclinical data and resource utilization data. SETTING: Urban, tertiary-care, teaching hospital. PATIENT POPULATION: 992 consecutive patients over the age of 30 years, admitted from the emergency department for evaluation of acute chest pain unexplained by obvious trauma or chest roentgenographic abnormality, were eligible for the study. After excluding patients who had left against medical advice, who had been transferred to another hospital, or who had incomplete utilization data, 903 patients were included in the analyses. MEASUREMENTS AND OUTCOMES: The authors evaluated the effects of 22 clinical and nonclinical factors on resource use. Resource use was primarily evaluated by length of stay; charges were evaluated in secondary analyses. RESULTS: In the entire study population, increased length of stay was associated with a diagnosis of acute myocardial infarction or angina, severity of complications, use of invasive and noninvasive testing, and initial triage to the coronary care unit. In the 424 (47%) patients who had had completely uncomplicated courses after admission, high coefficients of variability were found for length of stay (0.88) and for total charges (0.78). In these uncomplicated patients, increased length of stay was associated with the use of noninvasive cardiac testing (66% longer for patients undergoing echocardiography or radionuclide ventriculography, and 46% longer for patients undergoing exercise tests or ambulatory arrhythmia monitoring), initial triage to the coronary care unit (23% longer), admission at the end of the week (21% longer), and insurance coverage other than Blue Cross/Blue Shield or a commercial carrier (21% for self-pay, 25% for Medicaid, and 48% for Medicare). CONCLUSIONS: These findings indicate that after adjustment for important clinical factors, nonclinical factors had a significant impact on length of stay among a large group of uncomplicated patients. Interventions aimed at reducing logistic difficulties in the performance of noninvasive testing and decreasing the number of low-risk patients who are triaged to coronary care unit beds may decrease resource utilization.

Angina Pectoris↗
PubMedDate not supplied

Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain.

STUDY OBJECTIVE: To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain. DESIGN: Analysis of prospectively collected data from a cohort study. SETTING: Emergency departments of four community and three university hospitals. PATIENTS: 5,673 patients aged greater than or equal to 30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI). MEASUREMENTS AND MAIN RESULTS: After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p less than 0.0001). Admission rates of AMI patients with and without prior ECGs were similar. CONCLUSION: When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity).

Aged↗
PubMedDate not supplied

The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group.

OBJECTIVE: To identify differences in the incidences of myocardial infarction in women and men with chest pain. DESIGN: Prospective multicenter cohort study. SETTING: Emergency rooms of three university and four community hospitals. PATIENTS: 7,734 emergency room patients with acute chest pain. MEASUREMENTS AND MAIN RESULTS: Myocardial infarction was diagnosed in 10% of the 3,896 women, compared with 19% of the 3,838 men, yielding an age-adjusted relative risk of myocardial infarction for women of 0.54 (95% confidence interval 0.48, 0.60). Physicians were equally adept at admitting women and men with myocardial infarctions, but men without myocardial infarction or unstable angina were significantly more likely to be admitted than were women without these diagnoses. Most clinical and electrocardiographic features indicating a risk of myocardial infarction were present in both women and men, but several high-risk features were less commonly present in women. After adjusting for the other factors that correlate with each patient's probability of having acute myocardial infarction, the relative risk of myocardial infarction was the same in women as men when the emergency department electrocardiogram showed the classic changes associated with acute myocardial infarction, but the risk was 40% lower in women when such electrocardiographic changes were not present. CONCLUSIONS: Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram.

Adult↗
PubMedDate not supplied

Decreased central opioid activity in premenstrual syndrome: luteinizing hormone response to naloxone.

OBJECTIVE: To evaluate central opioid activity in women with prospectively documented premenstrual syndrome (PMS) and control women in the mid- and late luteal phases of the menstrual cycle. METHODS: Blood was collected every 15 minutes 1 hour before (0800) and 2 hours after treatment (0900-1100). The treatment was administered in a randomized fashion and consisted of naloxone 1 or 4 mg or placebo, and blood was assayed for luteinizing hormone (LH). Baseline estradiol, progesterone, and prolactin were measured at 0800 and 0900 hours. RESULTS: There was a significant increase in LH area under the curve and mean LH in response to naloxone in the midluteal phase in the control (P < .001). The PMS subjects did not display a significant increase in LH concentration in response to naloxone in the midluteal phase. There were no significant LH responses to naloxone in either group in the late luteal phase. There were no significant differences in estradiol, progesterone, or prolactin concentrations or estrogen to progesterone ratios between groups. CONCLUSION: Control women have an enhanced central opioid tone during the midluteal phase that diminishes and becomes minimal in the late luteal phase of the menstrual cycle. In contrast, women with PMS have a loss of central opioid tone during the midluteal phase as indicated by the loss of LH response to naloxone. This attenuated central opioid tone in women with PMS as compared with asymptomatic control women may play a role in the pathophysiology of PMS.

Adult↗
PubMedDate not supplied

The laser in dermatology.

Explore the source record for details and available documents.

Fluorescent Antibody Technique↗
PubMedDate not supplied

Blood pressure experience and risk of cardiovascular disease in the elderly.

For the 1254 persons in the Framingham Heart Study who survived to age 65 without prior cardiovascular disease or prior use of antihypertensive medications, significant univariate correlates of the development of cardiovascular disease after age 65 included (1) the systolic blood pressure at age 65, (2) the average systolic blood pressure before age 65, and (3) the slope of blood pressure change up to age 65. After controlling for the systolic blood pressure at age 65, average pre-age 65 blood pressure remained significant (p less than 0.05) and the slope of the pre-age 65 blood pressure was marginally significant (p = 0.06). Even after controlling for the mean of up to three blood pressure measurements at age 65, an average systolic blood pressure of 160 mm Hg or greater before age 65 was an independently significant predictor of the post-age 65 development of cardiovascular disease (rate ratio = 1.79; 95% confidence interval = 1.04, 3.07). These data suggest that even after performing multiple measurements at a single examination, knowledge of past systolic blood pressure history, especially if it averages 160 mm Hg or greater, adds a small but statistically significant increment in predicting future cardiovascular disease in the elderly.

Adult↗
PubMedDate not supplied

Prospective evaluation of a clinical and exercise-test model for the prediction of left main coronary artery disease.

In a multivariate logistic regression analysis of data from 508 patients, only two clinical factors, age and typicality of pain, were independently significant predictors of left main coronary artery disease. The resulting multivariate equation was prospectively applied to another 370 patients to derive pre-exercise-test (ETT) probabilities of left main coronary artery disease, and these pre-ETT probabilities were combined with literature-derived likelihood ratios for various ETT findings to derive post-ETT probabilities. This model, which can be displayed in simple graphic form, accurately predicted the probability of left main coronary artery disease when prospectively evaluated in this independent validation set of patients. The likelihood of left main coronary artery disease was 16% when the ETT increased the probability, and 4% when it decreased the probability (p less than 0.001). While 48% of patients had mid-range (5-15%) probabilities of left main coronary artery disease before the ETT, only 24% fell into this range of probabilities after the ETT (p less than 0.0001), as ETT results moved patients into higher and lower probability ranges. Thus, probability of left main coronary artery disease can be calculated from clinical and ETT data with this model. These estimated pre- and post-ETT probabilities of left main coronary artery disease may aid in the selection of patients for noninvasive testing or for cardiac catheterization.

Age Factors↗