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L Goldman

Publications and source records attributed to L Goldman.

At least 127 records · Page 7Linked to original sources
PubMed1996

Physical activity, trauma, and ALS: a case-control study.

AIMS: The association of trauma and physical activity with ALS is controversial. We explored the relation in a pilot case-control study. MATERIAL AND METHODS: ALS patients were selected from a university muscle disease clinic and paired with two matched controls: one from the clinic, but having different diseases, and one from the community. RESULTS: We found several strong and statistically significant differences between ALS cases and the matched controls. These included severe head, neck and back injury (OR = 5.3), the frequency of sweating in work (OR = 1.6) or leisure activity (also OR = 1.6), and earning a school letter (OR = 3.1). Other measures of trauma and activity, while not achieving statistical significance (p < 0.05), were in accord with these findings. DISCUSSION: Possible explanations include trauma and vigorous exercise precipitating ALS; trauma as an early sign of disease; or a third factor associated with ALS predisposing to injury. CONCLUSIONS: Severe head, neck, and back injury and frequency of sweating both in work and leisure activity showed a strong association with ALS. Further study could test narrower and less common exposures with greater statistical power.

Amyotrophic Lateral Sclerosis↗
PubMed1996

Impact of a public campaign on pre-hospital delay in patients reporting chest pain.

OBJECTIVE: To decrease pre-hospital delay in patients with chest pain. DESIGN: Population based, prospective observational study. SETTING: A province of Switzerland with 380000 inhabitants. SUBJECTS: All 1337 patients who presented with chest pain to the emergency department of the Hôpital Cantonal Universitaire of Geneva during the 12 months of a multimedia public campaign, and the 1140 patients who came with similar symptoms during the 12 months before the campaign started. MAIN OUTCOME MEASURES: Pre-hospital time delay and number of patients admitted to the hospital for acute myocardial infarction (AMI) and unstable angina. RESULTS: Mean pre-hospital delay decreased from 7h 50 min before the campaign to 4 h 54 min during it, and median delay from 180 min to 155 min (P < 0.001). For patients with a final diagnosis of AMI, mean delay decreased from 9 h 10 min to 5 h 10 min and median delay from 195 min to 155 min (P < 0.002). Emergency department visits per week for AMI and unstable angina increased from 11.2 before the campaign to 13.2 during it (P < 0.02), with an increase to 27 (P < 0.01) during the first week of the campaign; visits per week for non-cardiac chest pain increased from 7.6 to 8.1 (P = NS) during the campaign, with an increase to 17 (P < 0.05) during its first week. CONCLUSIONS: Public campaigns may significantly reduce pre-hospital delay in patients with chest pain. Despite transient increases in emergency department visits for non-cardiac chest pain, such campaigns may significantly increase hospital visits for AMI and unstable angina and thus be cost effective.

Angina, Unstable↗
PubMed1996

Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

In order to describe the outcomes of patients hospitalized with an acute exacerbation of severe chronic obstructive pulmonary disease (COPD) and determine the relationship between patient characteristics and length of survival, we studied a prospective cohort of 1,016 adult patients from five hospitals who were admitted with an exacerbation of COPD and a PaCO2 of 50 mm Hg or more. Patient characteristics and acute physiology were determined. Outcomes were evaluated over a 6 mo period. Although only 11% of the patients died during the index hospital stay, the 60-d, 180-d, 1-yr, and 2-yr mortality was high (20%, 33%, 43%, and 49%, respectively). The median cost of the index hospital stay was $7,100 ($4,100 to $16,000; interquartile range). The median length of the index hospital stay was 9 d (5 to 15 d). After discharge, 446 patients were readmitted 754 times in the next 6 mo. At 6 mo, only 26% of the cohort were both alive and able to report a good, very good, or excellent quality of life. Survival time was independently related to severity of illness, body mass index (BMI), age, prior functional status, PaO2/FI(O2), congestive heart failure, serum albumin, and the presence of cor pulmonale. Patients and caregivers should be aware of the likelihood of poor outcomes following hospitalization for exacerbation of COPD associated with hypercarbia.

APACHE↗
PubMed1996

RIDDOR revisited.

Explore the source record for details and available documents.

Accidents, Occupational↗
PubMed1996

The JIM Interview. Lee Goldman, MD.

In early 1995, Lee Goldman, MD, left his post as chief medical officer at the Brigham and Women's Hospital in Boston to become the chairman of medicine at the University of California, San Francisco. A well-respected clinical epidemiologist, Goldman has been among the leading proponents of utilizing critical pathways to improve the efficiency of clinical care. His appointment as leader of a department steeped in a strong tradition of basic research was widely seen as another marker in the ascendancy of the field of health services research. However, in just his first year, Goldman has been active in working to further solidify his department's strong basic research foundation as well as expand its research scope, all in what many consider to be the most difficult and volatile of managed care markets. Interviewed on the wards of the UCSF medical center, Goldman reflected on the highly dynamic managed care environment of northern California, and the need to adapt medical training to the rules of a new era in health care.

Critical Pathways↗
PubMed1995

Identification of comatose patients at high risk for death or severe disability. SUPPORT Investigators. Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVE: To develop and validate a simple prognostic scoring system to identify patients in nontraumatic coma at high risk for poor outcomes using data available early in the hospital course. DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic medical centers. PATIENTS: A total of 596 patients in nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), including 247 in the model derivation set and 349 in the model validation set. MAIN OUTCOME MEASURES: Death and severe disability by 2 months. MAIN RESULTS: For the 596 patients studied (median age, 67 years; 52% female), the primary cause of coma was cardiac arrest in 31% and cerebral infarction or intracerebral hemorrhage in 36%. At 2 months 69% had died, 20% had survived with known severe disability, 8% were known to have survived without severe disability, and 3% survived with unknown functional status. Five clinical variables available on day 3 after enrollment were associated independently with 2-month mortality: abnormal brain stem response (adjusted odds ratio [OR] = 3.2; 95% confidence interval [CI], 1.3 to 8.1), absent verbal response (OR = 4.6; 95% CI, 1.8 to 11.7), absent withdrawal response to pain (OR = 4.3; 95% CI, 1.7 to 10.8), creatinine level greater than or equal to 132.6 mumol/L (1.5 mg/dL) (OR = 4.5; 95% CI, 1.8 to 11.0), and age of 70 years or older (OR = 5.1; 95% CI, 2.2 to 12.2). Mortality at 2 months for patients with four or five of these risk factors was 97% (58/60; 95% CI, 88% to 100%) in the validation set. Brain stem and motor responses best predicted death or severe disability by 2 months. For patients with either an abnormal brain stem response or absent motor response to pain, the rate of death or severe disability at 2 months was 96% (185/193; 95% CI, 92% to 98%) in the validation set. CONCLUSIONS: Five readily available clinical variables identify a large subgroup of patients in nontraumatic coma at high risk for poor outcomes. This risk stratification approach offers physicians, patients, and patients' families information that may prove useful in patient care decisions and resource allocation.

APACHE↗
PubMed1995

Health values of the seriously ill. SUPPORT investigators.

OBJECTIVE: To assess 1) the health values and health ratings of seriously ill hospitalized patients, their surrogate decision makers, and their physicians; 2) the determinants of health values; and 3) whether health values change over time. DESIGN: Prospective, longitudinal, multicenter study. SETTING: 5 academic medical centers. PARTICIPANTS: 1438 seriously ill patients with at least one of nine diseases who had a projected overall 6-month mortality rate of 50%; their surrogates; and their physicians. MEASUREMENTS: Time-tradeoff utilities (reflecting preferences for a shorter but healthy life) and health ratings. RESULTS: At study day 3, patients had a mean time-tradeoff utility of 0.73 +/- 0.32 (median [25th, 75th percentile], 0.92 [0.63, 1.0]), indicating that they equated living 1 year in their current state of health with living 8.8 months in excellent health. However, scores varied widely; 34.8% of patients were unwilling to exchange any time in their current state of health for a shorter life in excellent health (utility, 1.0), and 9.0% were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility, 0.04). Health rating scores averaged 57.8 +/- 24.0 (median [25th percentile, 75th percentile], 60 [50, 75]) on a scale of 0 (death) to 100 (perfect health). The patients' mean time-tradeoff score exceeded that of their paired surrogates (n = 1041) by 0.08 (P < 0.0001). Time-tradeoff scores were related to psychosocial well-being; health ratings; desire for resuscitation and extension of life rather than relief of pain and discomfort; degree of willingness to live with constant pain; and perceived prognosis for survival and independent functioning. Scores of surviving patients increased by an average of 0.06 after 2 months (P < 0.0001) and 0.08 after 6 months (P < 0.0001). CONCLUSIONS: Health values of seriously ill patients vary widely, are higher than patients' surrogates believe, are related to few other preference and health status measures, and increase over time.

Aged↗
PubMed1995

Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain.

OBJECTIVE: To test whether a low-intensity, nonintrusive intervention improved the efficiency of management of patients with acute chest pain. DESIGN: Time-series trial with six 14-week cycles, each including a 5-week intervention period and a 5-week control period separated by 2-week "washout" periods. SETTING: Urban teaching hospital. PATIENTS: 1921 patients aged 30 years or older with acute chest pain unexplained by local trauma or chest radiograph. INTERVENTION: Risk estimates and triage recommendations were made available to physicians at the time of emergency department evaluation and, for hospitalized patients, on a daily basis before morning rounds. Flowsheets and stickers, but no direct human contact, were used to transmit this information. MEASUREMENTS: Rates of admission to the hospital and coronary care unit, inpatient costs, and lengths of stay. RESULTS: Rates of admission during intervention and control periods were similar in both the hospital (52% and 51%, respectively) and the coronary care unit (10% and 10%, respectively). Total lengths of stay in the hospital were similar (4.9 +/- 5.9 days and 4.9 +/- 5.7 days, respectively), as were average total costs ($7822 +/- $13,217 and $7955 +/- $13,400, respectively). No differences in management were detected for the subgroup of patients with low clinical risk for acute myocardial infarction. CONCLUSIONS: The use of information alone--without direct human contact--did not affect management of patients with acute chest pain at this hospital. Although this low-intensity intervention might be more effective for other conditions and in other settings, our data support the use of other strategies to affect physician decision making.

Acute Disease↗
PubMed1995

The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risks of treatments.

OBJECTIVE: To develop and validate a prognostic model that estimates survival over a 180-day period for seriously ill hospitalized adults (phase I of SUPPORT [Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments]) and to compare this model's predictions with those of an existing prognostic system and with physicians' independent estimates (SUPPORT phase II). DESIGN: Prospective cohort study. SETTING: 5 tertiary care academic centers in the United States. PARTICIPANTS: 4301 hospitalized adults were selected for phase I according to diagnosis and severity of illness; 4028 patients were evaluated from phase II. MEASUREMENTS: A survival model was developed using the following predictor variables: diagnosis, age, number of days in the hospital before study entry, presence of cancer, neurologic function, and 11 physiologic measures recorded on day 3 after study entry. Physicians were interviewed on day 3. Patients were followed for survival for 180 days after study entry. RESULTS: The area under the receiver-operating characteristics (ROC) curve for prediction of surviving 180 days was 0.79 in phase I, 0.78 in the phase II independent validation, and 0.78 when the acute physiology score from the APACHE (Acute Physiology, Age, Chronic Health Evaluation) III prognostic scoring system was substituted for the SUPPORT physiology score. For phase II patients, the SUPPORT model had equal discrimination and slightly improved calibration compared with physician's estimates. Combining the SUPPORT model with physician's estimates improved both predictive accuracy (ROC curve area = 0.82) and the ability to identify patients with high probabilities of survival or death. CONCLUSIONS: A limited amount of readily available clinical information can provide a foundation for long-term survival estimates that are as accurate as physicians' estimates. The best survival estimates combine an objective prognosis with a physician's clinical estimate.

APACHE↗
PubMed1995

Prediction of visual function after cataract surgery. A prospectively validated model.

OBJECTIVE: To develop a model to predict visual functional improvement after cataract extraction with intraocular lens implantation based on preoperative data. DESIGN: A prospective study with serial evaluations of visual function preoperatively and at 3 and 12 months after surgery. SETTING: The General Eye Service of the Massachusetts Eye and Ear Infirmary. Boston, Mass, and 33 ophthalmology practices in Boston. PATIENTS: Patients (N = 426; ages, > or = 65 years) who were undergoing cataract surgery. METHODS: Twelve-month improvement in visual function was measured by using the Activities of Daily Vision Scale (ADVS). Ordinal logistic regression was used to identify correlates of improved ADVS scores in 281 patients (derivative set). Potential factors included the preoperative visual acuity, preoperative ADVS score, four chronic ocular diseases, eight medical conditions, and demographic characteristics. Five predictors were identified and used to construct a prediction rule. The accuracy of the prediction rule was evaluated in an independent group of 145 patients (validation set). RESULTS: Postoperatively, 40% of the 281 patients in the derivative set had substantial improvement in their ADVS scores, and 53 (19%) had some improvement. Predictors of improvement included younger age (P < .001), a poorer preoperative ADVS score (P < .001), posterior subcapsular cataract (P = .09), and absence of age-related cataract (P = .09), and absence of age-related macular degeneration (P = .07) and/or diabetes (P = .006). When applied to the independent sample of 145 patients, these five characteristics classified the patients into three groups in which the probabilities of substantial improvement were 85%, 34%, and 3%, thus verifying the discriminatory power of the prediction rule. CONCLUSIONS: Preoperative data can identify patients who are likely to have improvements in visual function after cataract surgery. Such findings may be useful in the selection of patients for this high-volume procedure.

Activities of Daily Living↗