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Biomedical subjects

L Goldman

Publications and source records attributed to L Goldman.

At least 109 records · Page 6Linked to original sources
PubMed1996

Correlates of major complications or death in patients admitted to the hospital with congestive heart failure.

BACKGROUND: When triaging a patient who has heart failure, the physician must estimate the patient's shortterm risk of a major complication or death. METHODS: Prospective cohort study of 435 patients admitted nonelectively to an urban university hospital between February 2, 1993, and February 2, 1994, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph. RESULTS: Major adverse events occurred in 18% of patients who had ejection fractions less than 0.50, 16% of those with ejection fractions of 0.50 or more, and 19% of those with previous heart failure, ejection fractions of 0.50 or more, and no significant valvular disease. In multivariate analyses of all patients, independent correlates (P < or = .01) of major complications or death during hospitalization were initial systolic blood pressure of 90 mm Hg or less (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.7-17.1), respiratory rate more than 30 breaths per minute on admission to the hospital (OR, 4.6; 95% CI, 2.4-8.8), serum sodium level of 135 mmol/L or less (OR, 2.2; 95% CI, 1.3-4.0), and ST-T wave changes on initial electrocardiogram neither known to be old nor attributable to digoxin (OR, 5.1; 95% CI, 2.9-8.9). However, even patients with none of these 4 risk factors had a 6% rate of a major complication or death. CONCLUSIONS: No truly low-risk group existed. Patients without hypotension, tachypnea, hyponatremia, or electrocardiographic changes of ischemia represent the best candidates for triage to less intensely monitored settings, but clinical judgment is essential.

Aged↗
PubMed1996

Cost-effectiveness of routine coronary angiography after acute myocardial infarction.

BACKGROUND: Coronary angiography is indicated for many patients after acute myocardial infarction (AMI). There are a number of subgroups of AMI patients, however, for whom the indication for coronary angiography is not well established. METHODS AND RESULTS: We developed a decision-analytic model for AMI in representative patient subgroups based on relevant clinical characteristics. The model estimates quality-adjusted life expectancy and direct lifetime costs for two strategies: coronary angiography and treatment guided by its results versus initial medical therapy without angiography. Decision tree chance node probabilities were estimated with the use of pooled data from randomized clinical trials and other relevant literature, costs were estimated with the use of the Medicare Part A database, and quality of life adjustments were derived from a survey of 1051 patients who had had a recent AMI. In our analysis, incremental cost-effectiveness ratios for coronary angiography and treatment guided by its result, compared with initial medical therapy without angiography, ranged between $17,000 and > $1 million per quality-adjusted year of life gained. Patient subgroups with severe postinfarction angina or a strongly positive exercise tolerance test (ETT) typically had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained. In addition, most patient subgroups with a prior AMI had cost-effectiveness ratios of < $50,000 per quality-adjusted year of life gained, even with a negative ETT result. CONCLUSIONS: In many patient subgroups after AMI, the cost-effectiveness of routine coronary angiography and treatment guided by its results compares favorably with other treatment strategies for coronary heart disease.

Adult↗
PubMed1996

Cost-effectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain.

BACKGROUND: Guidelines are not available for which patients with acute chest pain should be admitted to the coronary care unit and which patients can be reasonably triaged to monitored beds in lower levels of care. METHODS AND RESULTS: Clinical and resource utilization data from 12 139 emergency department patients with acute chest pain were used in a decision-analytic model to identify cost-effective guidelines for the admission to a coronary care unit versus an intermediate care unit for initially uncomplicated patients without other indications for intensive care. The probability of clinical complications and death were derived from data on age-specific subsets of the population. Resource utilization estimates were based on cost data from a subset of 901 patients and length of stay data for the entire cohort. The survival benefit associated with initial triage to the coronary care unit instead of an intermediate care unit was assumed to be 15%. In the baseline analysis for 55- to 64-year-old patients, the probability of acute myocardial infarction (AMI) at which the coronary care unit had an incremental cost-effectiveness below $50 000 per year-of-life-saved was 29%. Triage to the coronary care unit was somewhat more cost-effective in elderly patients because their higher early complication rate more than offset their shorter life expectancy. CONCLUSIONS: This analysis indicates that the coronary care unit usually should be reserved for patients with a moderate (21% or more, depending on the patient's age) probability of AMI unless patients need intensive care for other reasons. Clinical data suggest that only patients with ECG changes of ischemia or infarction not known to be old have a probability of AMI this high. Intermediate care units are appropriate for patients whose risks are not high enough for a coronary care unit to be cost-effective but too high for other alternatives to be recommended for safety and effectiveness.

Acute Disease↗
PubMed1996

Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain.

BACKGROUND: Patients who come to the emergency department with chest pain are a heterogeneous group. Some have ischemic heart disease that may lead to serious complications, whereas others have minor disorders. We performed a study to identify clinical factors that predict which patients will have complications requiring intensive care. METHODS: We first studied 10,682 patients with acute chest pain at seven hospitals between 1984 and 1986 (derivation set) to identify potential clinical predictors of the development of major complications. We then validated these predictors in a separate set of 4676 patients at one hospital between 1990 and 1994 (validation set). RESULTS: In the derivation set of patients, we identified the following set of clinical features, which, if present in the emergency department, were associated with an increased risk of complications: ST-segment elevation or Q waves on the electrocardiogram thought to indicate acute myocardial infarction, other electrocardiographic changes indicating myocardial ischemia, low systolic blood pressure, pulmonary rales above the bases, or an exacerbation of known ischemic heart disease. On the basis of these criteria, the patients in the validation set were stratified into four groups, with the risk of major complications in the first 12 hours ranging from 0.15 to 8 percent. After 12 hours, the probability of a major complication could be updated on the basis of whether the patient had already had a complication of major severity, a complication of intermediate severity, or a myocardial infarction (independent relative risks, 18.9, 7.7 and 4.0, respectively, as compared with patients without prior complications or myocardial infarction). CONCLUSIONS: The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course. These estimates of risk help in making rational decisions about the appropriate level of medical care for patients with acute chest pain.

Acute Disease↗
PubMed1996

Troponin T as a marker for myocardial ischemia in patients undergoing major noncardiac surgery.

To assess the diagnostic performance of cardiac troponin T as a marker for myocardial injury in patients undergoing major noncardiac surgery, we prospectively collected preoperative and postoperative clinical data, including measurements for creatine kinase (CK), CK-MB, and troponin T for 1,175 patients undergoing major noncardiac surgery. Acute myocardial infarction was diagnosed in 17 patients (1.4%) by a reviewer who was blinded to troponin T data and who used CK-MB and electrocardiographic criteria to define acute myocardial infarction. Other predischarge major cardiac complications were detected for another 17 patients. Troponin T elevations (>0.1 ng/ml) occurred in 87% of patients with and in 16% of patients without myocardial infarction. Among patients without myocardial infarction, troponin T was elevated in 62% of patients with and in 15% of patients without major cardiac complications. Receiver-operating characteristic analysis indicated that troponin T had a performance for the diagnosis of acute myocardial infarction similar to CK-MB, and a significantly better correlation with other major cardiac complications in patients without definitive infarction. Future research should seek to determine the significance of troponin T elevations in patients without complications.

Aged↗
PubMed1996

Amyotrophic lateral sclerosis and occupational history. A pilot case-control study.

OBJECTIVE: To assess the association of a number of occupational and industrial exposures with amyotrophic lateral sclerosis (ALS). DESIGN: A case-control study of ALS cases matched by age and sex to 2 controls each: 1 from a neurologic clinic and 1 from a local community. Exposures were ascertained by questionnaire, and patients were requested before the interview to be to prepared to supply occupational histories. SETTING: Patients with ALS were enrolled at the University of Minnesota ALS Clinic in Minneapolis. PATIENTS: Patients with ALS (n = 25) were from the University of Minnesota ALS clinic, and clinic controls (n = 25) were patients with other neuromuscular diseases from the university's Muscle Disease Clinic, selected on the basis of clinic enrollment date nearest to that of the matched case. Clinic controls were principally patients with myopathies. Community controls (n = 25) were selected from the community using a random-digit-dialing protocol matching on the first 5 digits of the case patient's telephone number. RESULTS: The strongest association with disease was exposure to welding or soldering materials (odds ratio, 5.0) and the welding industry (odds ratio, 5.3). Electric plating showed a high odds ratio of 8 (95% confidence interval, 0.9-72.0), but low statistical significance (P < .07) Several exposures or industries, while not statistically different, showed enough difference that to ignore them might lead to a Type II error, a result of the pilot nature and small sample size. These included paint or pigment manufacturing, the petroleum industry, the printing industry, and shipbuilding. CONCLUSIONS: The association with welding, soldering, and the welding industry is strong and suggests a need for further work. This is despite the small numbers studied, thus making most industrial or occupational exposures too limited to draw conclusions or detect associations. Perhaps the most obvious candidate from the welding, soldering exposure for a common toxin would be lead. Other suggestions of risk were seen for paint or pigment manufacture, shipbuilding, electric plating, and the dairy industry. The degree of association for these, while high, is not statistically significant, and suggests that there may be 1 or more environmental toxins common to those industries that need more precise measurement.

Amyotrophic Lateral Sclerosis↗
PubMed1996

Proposal to develop a detailed safety program for general/laser surgical patients infected with AIDS.

Medical health personnel have acquired serious and rarely fatal infections in the operating room from AIDS patients. Yet, there are no officially approved AIDS safety programs designed to protect medical health care personnel in the operating room. A sequential safety program is proposed beginning with the following steps: 1) evaluation and staging of the patient and associated complications; 2) protection of the major surgical and laser instruments; 3) use of an efficient evacuator system to avoid plumes of laser fragments from polluting the operating room environment; 4) protection of the operating room staff with special eye protection including helmets and shields, fluid-soak-resistant fabrics for garments, double surgical gloves, and special orderly trays with safety holders for syringes, needles, sharp instruments, and suture holders; 5) reporting and treatment of accidents, such as needlestick puncture wounds, that require immediate attention and an infectious disease consultation; 6) postoperative care, which includes providing medical health care personnel protection from bloody bandages, needles, and the infectious patient; and 7) and finally, the washing and sterilizing of contaminated instruments by medical health care personnel using face shields and masks, gloves, and protective fabrics for garments. Continued experience with this proposed safety program will determine its future value for AIDS surgical patients and for all health care workers.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Comorbidity as a correlate of length of stay for hospitalized patients with acute chest pain.

OBJECTIVE: To determine whether comorbid medical conditions as measured with the Charlson Comorbidity Index are independent correlates of length of stay after adjusting for other clinical and socioeconomic data. DESIGN: Prospective cohort study. SETTING: Urban teaching hospital. PATIENTS: All 1,261 patient aged 30 years or more who were admitted to this hospital after coming to the emergency department with acute chest pain between October 1990 and May 1992. MEASUREMENTS AND OUTCOMES: Clinical data including comorbid medical conditions used in the Charlson index were prospectively recorded by the evaluating physician at the time of admission or by a research nurse who was blinded to the subsequent events. History of myocardial infarction was excluded from the calculation of the Charlson index score. Charlson index scores were 0 to 1 for 921 patients (73%), 2 to 3 for 263 (21%), and greater than 3 for 77 (6%). Unadjusted means (+/- SD) lengths of stay in these groups were 4.4 +/- 5.2, 5.2 +/- 5.9, and 7.5 +/- 9.3 days, respectively. In multiple linear regression analysis, compared with Charlson index scores of 0 to 1, scores of 2 to 3 and greater than 3 were significant (p < .01) independent correlates of the log transformation of length of stay after adjusting for clinical data from the initial presentation and subsequent course (model R2 = .510). In an analysis restricted to the 795 patients without clinical complications, a Charlson index score greater than 3 was an independent correlate of length of stay compared with scores of 0 to 1 (p < .01). Individual comorbid conditions were not significant correlates of length of stay after controlling for Charlson index score. CONCLUSIONS: In this population of patients with acute chest pain, comorbidity as measured with the Charlson index was independently associated with length of stay after adjustment for other clinical data. After adjusting for the Charlson index, no separate comorbid condition was significantly correlated with length of stay. These findings suggest that the Charlson index can be used to adjust for comorbidities in analyses of length of stay for patients with this condition.

Acute Disease↗
PubMed1996

Gender differences in the management of acute chest pain. Support for the "Yentl syndrome".

OBJECTIVE: To determine whether evaluation and management of males and females differ after presentation to the emergency department with acute chest pain. DESIGN: Prospective cohort study with follow-up at 1 month. SETTING: Urban teaching hospital. PATIENTS: The study population included 1,411 patients who were 30 years of age or older who visited the emergency department with acute chest pain from October 1990 through May 1992. These 1,411 patients represent 69% of the 2,056 patients approached for consent. The utilization of exercise stress testing as outpatients was measured for a subset of 954 patients who were interviewed at 1 month after their presentation. MEASUREMENTS/MAIN RESULTS: After controlling for clinical and nonclinical predictors, women were less likely to be admitted to the hospital (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.47, 0.99). Among the 954 patients with 1-month follow-up, women were less likely than men to undergo an exercise stress test during the first month after presentation, with borderline statistical significance after adjusting for the interaction between gender and admission to the hospital (adjusted OR 0.30; 95% CI 0.09, 1.0). Among the patients who were admitted to the hospital, women were as likely as men to undergo exercise stress testing (adjusted OR 0.81; 95% CI 0.57, 1.2) but were less likely to undergo cardiac catheterization (adjusted OR 0.44; 95% CI 0.25, 0.80). CONCLUSIONS: Gender-based differences in management may occur at several stages in the evaluation of patients with acute chest pain. Observed differences in use of invasive procedures between men and women may be due in part to lower rates of exercise test use and admission to the hospital for evaluation of acute chest pain.

Adult↗
PubMed1996

Cost-effectiveness of prescription recommendations for cholesterol-lowering drugs: a survey of a representative sample of American cardiologists.

OBJECTIVES: We sought to determine the cost-effectiveness of the recommendations of cardiologists for the pharmacologic treatment of hypercholesterolemia. BACKGROUND: Despite the publication of guidelines such as the report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, little is known about the national prescribing practices of physicians and how they compare with the recommendations of cost-effectiveness analyses. METHODS: Under the auspices of the Cardiovascular Norms Committee of the American College of Cardiology, a nationally representative sample of cardiologists was surveyed, and their recommendations for the pharmacologic treatment of hypercholesterolemia were assessed to determine cost-effectiveness. RESULTS: The 346 responding cardiologists were reasonably representative of the membership of the American College of Cardiology. For the 12 hypothetical patients, the cardiologists recommended pharmacologic treatment more commonly in cases in which previously published studies estimated the treatment to be more cost-effective, although there was a tendency to recommend such treatment for primary prevention even when it was estimated to cost well over $100,000/year of life saved. CONCLUSIONS: These findings suggest that the cardiologists' pharmacologic recommendations for lowering lipids are correlated with published cost-effectiveness analyses. However, substantial variation in their recommendations remains, with somewhat less aggressive treatment for secondary prevention and more aggressive treatment for primary prevention than would be recommended on the basis of cost-effectiveness analyses.

Adult↗
PubMed1996

Cognitive functioning in premenstrual syndrome.

OBJECTIVE: To evaluate cognitive functioning in women with premenstrual syndrome (PMS) and controls during the follicular and luteal phases of the menstrual cycle. METHODS: Thirty women with PMS and 31 controls were selected on the basis of psychiatric interview and prospective daily diary recordings. Subjects were tested on two occasions, follicular (days 8-10) and luteal (days 24-26), using complex tasks consisting of measures validated previously for the assessment of "executive" frontal-lobe functions. Tests were counterbalanced for order across subjects. RESULTS: The Beck Depression Inventory scores were significantly different between the groups and across time (P < .001). Women with PMS had a mean luteal phase Beck score of 13.3 consistent with mild-to-moderate premenstrual depression. There were no statistically significant score differences in tests for attention, memory, cognitive flexibility, and overall mental agility. The evaluation of our preliminary data with 30 PMS subjects and 31 controls indicated a very small effect size (.02). To detect an effect size this small (if in fact one exists) with a power of .8 would require a sample of more than 1000 subjects per group. CONCLUSION: Our sample of women with PMS failed to demonstrate objective evidence of diminished cognitive performance, despite subjective feelings of inadequacy.

Adult↗
PubMed1996

Changes in health after elective percutaneous coronary revascularization. A comparison of generic and specific measures.

OBJECTIVES: This study determines changes in health-related quality of life after elective percutaneous transluminal coronary angioplasty and compares generic and specific measures. METHODS: Changes in health-related quality of life were measured in consecutive, symptomatic patients undergoing elective percutaneous coronary revascularization using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Specific Activity Scale (SAS), and the Canadian Cardiovascular Society Classification (CCSC). The patients were interviewed as outpatients before admission and at least 6 months later. RESULTS: There were significant changes in the following SF-36 measures: physical functioning (postscore minus prescore = 19.1 +/- 24.1), role limitations due to physical-health problems (40.4 +/- 47.2), bodily pain (19.9 +/- 29.3), vitality (12.9 +/- 25.1), social functioning (20.0 +/- 33.1), role limitations due to emotional-health problems (26.7 +/- 49.0), and general mental health (7.1 +/- 21.2). General health perceptions did not change significantly. Internal-consistency reliability coefficients for these measures ranged from 0.73 to 0.91. There also was significant improvement in the CCSC class, but the SAS class did not change significantly. Overall, the SF-36 role-physical scale was the most responsive to changes after elective percutaneous coronary revascularization, followed by the CCSC and the SF-36 physical functioning scale. CONCLUSIONS: Although this study cannot determine the causal role of elective percutaneous coronary revascularization in these changes, it provides support for the usefulness of these measures in future evaluations of this intervention.

Activities of Daily Living↗
PubMed1996

How economic demand influences access to medical care for rural Hispanic children.

OBJECTIVES: In a study of access to medical care, the authors analyzed the relationship between factors influencing demand, local unmet needs, and the availability of physicians in a rural California community. METHODS: The California Department of Health Services screened 1,697 (90%) of children aged 1 to 12 years in McFarland, CA. The relation of demand to unmet needs was examined using multiple logistic regression. Factors influencing demand for medical care were: ability to pay (income, health insurance) desire to purchase care (ethnicity, education, perceived need), and incidental costs (transportation, child care, etc). Questions from the Hispanic Health and Nutrition Survey were reconstrued to fit the demand model. Local need and demand for physicians was compared with state levels to assess whether sufficient physicians were available. RESULTS: Eighty-six percent of the children were of Mexican ancestry. Factors influencing demand were linked with specific unmet needs. Although unmet needs were high, demand was low; 46% of all families were below the poverty level. Although four primary care physicians were needed, only one could be supported in the private sector because of low demand. CONCLUSIONS: Advantages to the demand model are: (1) it shows why medical services are underused and lacking in low-income areas although need is high, (2) it permits an economic rationale for extra services for poor diverse populations, (3) it estimates the amount of resources lacking to assure adequate levels of care, (4) it shows why facilitated access is needed for certain groups.

California↗
PubMed1996

Seriously ill hospitalized adults: do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments.

OBJECTIVE: To determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age-related differences in resource use are explained by patients' severity of illness and preferences for life-extending care. STUDY DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic acute care medical centers participating in the SUPPORT Project. PATIENTS: A total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6-month mortality of 50%. MEASUREMENTS: Resource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs. RESULTS: The median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $ 71.61 lower, respectively. These differences persisted after further adjustment for patients' preferences for life-extending care. CONCLUSIONS: Compared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource-intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life-extending care.

Academic Medical Centers↗