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Biomedical subjects

Lee Goldman

Publications and source records attributed to Lee Goldman.

At least 37 records · Page 2Linked to original sources
PubMed2004

Patient quality of life during the 12 months following joint replacement surgery.

OBJECTIVE: To determine whether preoperative characteristics influence quality of life outcomes 1, 6, and 12 months after joint replacement surgery. METHODS: Patients (n = 222) with osteoarthritis undergoing primary joint replacement surgery at a university hospital between November 1990 and March 1993 were prospectively studied. Bodily pain and physical function were assessed preoperatively and at the 3 postoperative time points using the Medical Outcomes Study 36 Item Short Form Health Survey. RESULTS: Bodily pain and physical function improved after joint replacement. At 1 month after surgery, despite improvements in bodily pain, physical function deteriorated. Preoperative bodily pain and physical function, demographic characteristics, and social support were significant correlates of improvement in bodily pain and physical function. CONCLUSIONS: Patients experienced dramatic improvements in bodily pain and physical function after joint replacement. However, decline in physical function at 1 month implies significant need for prolonged informal or formal patient assistance with basic physical function after surgery. Greater preoperative social support was associated with improved bodily pain and physical function outcomes.

Activities of Daily Living↗
PubMed2003

Triage of patients with acute chest pain and possible cardiac ischemia: the elusive search for diagnostic perfection.

Few diagnostic decisions in medicine have been more heavily researched than the approach to the patient with acute chest pain. Despite the advances in both diagnosing and treating patients presenting with this symptom, cases of missed myocardial infarctions still cause substantial morbidity and mortality. This article examines a case in which a patient was sent home from the emergency department after presenting with chest pain and was subsequently found to have a myocardial infarction. In the context of the case, the article discusses clinical decision making about the diagnosis and triage of patients presenting with acute chest pain or with symptoms consistent with possible cardiac ischemia. A standardized approach to addressing the management of these patients is essential, given the adverse consequences of missing a life-threatening condition.

Aged↗
PubMed2003

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

CONTEXT: Substantial discrepanies exist between clinical diagnoses and findings at autopsy. Autopsy may be used as a tool for quality management to analyze diagnostic discrepanies. OBJECTIVE: To determine the rate at which autopsies detect important, clinically missed diagnoses, and the extent to which this rate has changed over time. DATA SOURCES: A systematic literature search for English-language articles available on MEDLINE from 1966 to April 2002, using the search terms autopsy, postmortem changes, post-mortem, postmortem, necropsy, and posthumous, identified 45 studies reporting 53 distinct autopsy series meeting prospectively defined criteria. Reference lists were reviewed to identify additional studies, and the final bibliography was distributed to experts in the field to identify missing or unpublished studies. STUDY SELECTION: Included studies reported clinically missed diagnoses involving a primary cause of death (major errors), with the most serious being those likely to have affected patient outcome (class I errors). DATA EXTRACTION: Logistic regression was performed using data from 53 distinct autopsy series over a 40-year period and adjusting for the effects of changes in autopsy rates, country, case mix (general autopsies; adult medical; adult intensive care; adult or pediatric surgery; general pediatrics or pediatric inpatients; neonatal or pediatric intensive care; and other autopsy), and important methodological features of the primary studies. DATA SYNTHESIS: Of 53 autopsy series identified, 42 reported major errors and 37 reported class I errors. Twenty-six autopsy series reported both major and class I error rates. The median error rate was 23.5% (range, 4.1%-49.8%) for major errors and 9.0% (range, 0%-20.7%) for class I errors. Analyses of diagnostic error rates adjusting for the effects of case mix, country, and autopsy rate yielded relative decreases per decade of 19.4% (95% confidence interval [CI], 1.8%-33.8%) for major errors and 33.4% (95% [CI], 8.4%-51.6%) for class I errors. Despite these decreases, we estimated that a contemporary US institution (based on autopsy rates ranging from 100% [the extrapolated extreme at which clinical selection is eliminated] to 5% [roughly the national average]), could observe a major error rate from 8.4% to 24.4% and a class I error rate from 4.1% to 6.7%. CONCLUSION: The possibility that a given autopsy will reveal important unsuspected diagnoses has decreased over time, but remains sufficiently high that encouraging ongoing use of the autopsy appears warranted.

Autopsy↗
PubMed2003

Death in patients with permanent pacemakers for sick sinus syndrome.

BACKGROUND: Although more than one million patients in the United States have permanent pacemakers, little is known about their cause of death. We evaluated the cause of death in 404 patients who died in the Mode Selection Trial (MOST). METHODS: In MOST, patients received a dual-chamber pacemaker randomly programmed to either dual-chamber or ventricular pacing. The circumstances surrounding each death were reviewed by a clinical events committee, which used prospectively defined criteria to adjudicate the cause of death. RESULTS: A total of 2010 patients with a median age of 74 years were included. After a median follow-up of 33 months, 404 (20%) patients died, including 198 (49%) of noncardiac causes and 143 (35.4%) of cardiac causes. In 63 patients, the cause of death was unknown. Independent predictors of death through the use of a multivariable analysis were (1) demographic factors including age, male sex, and weight; (2) clinical factors including prior myocardial infarction, cardiomyopathy, New York Heart Association class III/IV, and the Charlson Comorbidity Index; and (3) scores from two measures of functional status, the Karnofsky Score and the Mini-Mental State Examination. Independent predictors of cardiovascular death were similar. CONCLUSIONS: Patients treated with permanent pacemakers for sinus node dysfunction are elderly and have a substantial mortality rate, with more than half the classifiable deaths being noncardiac. Baseline demographic variables and scores from quality-of-life measures can identify patients with the highest risk of death.

Age Distribution↗
PubMed2003

Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay.

PURPOSE: To determine the relation between cardiac and noncardiac complications and their effects on length of stay in patients undergoing noncardiac surgery. METHODS: We collected detailed information from the history, physical examination, and preoperative tests of 3970 patients aged > or =50 years who were undergoing major noncardiac procedures. Serial electrocardiograms and cardiac enzyme measurements were performed perioperatively, and cardiac and noncardiac complications were recorded prospectively. Multivariate logistic regression analysis was used to determine the association between cardiac and noncardiac complications, and linear regression was used to assess their effects on length of stay. RESULTS: Cardiac complications occurred in 84 patients (2%), and noncardiac complications developed in 510 patients (13%). Both types of complications occurred in 40 patients (1%). The most common cardiac complications were pulmonary edema (n = 42) and myocardial infarction (n = 41). The most common noncardiac complications were wound infection (n = 291), confusion (n = 87), respiratory failure requiring intubation (n = 62), deep venous thrombosis (n = 48), and bacterial pneumonia (n = 46). Patients with cardiac complications were more likely to suffer a noncardiac complication than were those without cardiac complications, even after adjustment for preoperative clinical factors (odds ratio = 6.4; 95% confidence interval [CI]: 3.9 to 10.6). Mean length of stay was markedly increased in patients who experienced cardiac (11 days; 95% CI: 9 to 12 days) or noncardiac (11 days; 95% CI: 10 to 12 days) complications, or both (15 days; 95% CI: 12 to 18 days), as compared with patients without complications (4 days; 95% CI: 3 to 4 days), even after adjustment for procedure type and clinical factors. CONCLUSION: Cardiac and noncardiac complications were strongly linked in patients undergoing noncardiac surgery. Patients who experienced one type of complication were at increased risk of developing the other type of complication as well as prolonged perioperative length of stay.

Aged↗
PubMed2003

Preoperative risk evaluation and perioperative management of patients with coronary artery disease.

We have reviewed the methods of evaluating a patient's cardiac risk preoperatively using a careful history, physical examination, and EKG. Based on this information, various risk indices, guidelines, and algorithms can further assist the physician in deciding which patients can undergo surgery without further testing and which patients might benefit from further cardiac evaluation or medical therapy prior to surgery. The physician must keep in mind that a test should not be ordered if it is unlikely to alter the patient's management, and it is rarely necessary to perform a revascularization procedure with the sole purpose of getting a patient through surgery. Ongoing research is likely to lead to improvement in perioperative medical therapy.

Coronary Artery Disease↗
PubMed2003

Predictors and clinical impact of atrial fibrillation after pacemaker implantation in elderly patients treated with dual chamber versus ventricular pacing.

The Pacemaker Selection in the Elderly (PASE) trial was a prospective, multicenter, single blind, randomized comparison of single chamber, rate adaptive, ventricular pacing (VVIR) with dual chamber, rate adaptive pacing (DDDR) in 407 patients aged > or =65 years(mean 76 +/- 7 years, 60% male)with standard bradycardia indications for dual chamber pacemaker implantation. The incidence, predictors, and clinical consequences of atrial fibrillation (AF) developing after pacemaker implantation in the PASE trial were studied prospectively. During a median follow-up of 18 months, AF developed in 73 (18%) patients. Kaplan-Meier estimated cumulative incidences of AF in patients with sinus node dysfunction (n=176) at 18 months were 28% in the VVIR and 16% in the DDDR groups (P=0.08). After adjustment for other clinical variables using a Cox multivariate regression model, randomization to VVIR compared with DDDR pacing mode among patients with sinus node dysfunction was independently associated with a 2.6-fold increased relative risk (RR) of developing AF after pacemaker implantation (P=0.01). Other independent clinical risk factors for development of postimplant AF included a preimplant history of hypertension (P=0.02) or supraventricular tachyarrhythmias(P<0.04). Patients who developed AF had similar health related quality of life scores and cardiovascular functional status after 18 months of pacing as patients who remained free of AF. The RR of death, stroke, or heart failure hospitalization was not increased in patients who developed AF. Thus, in the elderly patients with sinus node dysfunction requiring permanent pacing, DDDR pacing mode protected against the development of AF. However, development of AF after pacemaker implantation in this population was not associated with a significant impact on quality-of-life, functional status, or other clinical endpoints during 18 months of follow-up.

Aged↗
PubMed2003

Hospitalists as cure for hospitalism.

For much of recorded history, it was difficult to document that care in a hospital improved outcomes. In fact, the term "hospitalism" was coined to describe a variety of iatrogenic maladies that were acquired by hospitalized patients and that often were more deadly than the admitting condition itself. In the modern era, the presumed benefits of hospitalization are achieved at the expense of substantial resources, but even these high costs have not eliminated iatrogenic complications. The hospitalist movement, by which a specialized group of physicians cares for inpatients, especially on medical and pediatric services, has reduced costs, generally maintained the satisfaction of all participants, and appears to have improved the quality of care. Despite concerns about discontinuity of care, hospitalists are likely to become the dominant mode of inpatient care in the United States.

Delivery of Health Care↗
PubMed2002

Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes.

BACKGROUND: Previous investigations of the effect of the hospitalist model on resource use and patient outcomes have focused on academic medical centers or have used short follow-up periods. OBJECTIVE: To determine the effects of hospitalist care on resource use and patient outcomes and whether these effects change over time. DESIGN: Retrospective cohort study. SETTING: Community-based, urban teaching hospital. PATIENTS: 5308 patients cared for by community or hospitalist physicians in the 2 years after implementation of a voluntary hospitalist service. MEASUREMENTS: Length of stay, costs, 10-day readmission rates, use of consultative services, in-hospital mortality rate, and mortality rate at 30 and 60 days. RESULTS: Patients of hospitalists were younger than those of community physicians (65 years vs. 74 years; P < 0.001) and were more likely to be of black than of white ethnicity (33.3% vs. 17.9%; P < 0.001), have Medicaid insurance (25.1% vs. 10.2%; P < 0.001), and receive intensive care (19.9% vs. 15.8%; P < 0.001). After adjustment in multivariable models, length of stay and costs were not different in the first year of the study. In year 2, patients of hospitalists had shorter stays (0.61 day shorter; P = 0.002) and lower costs ($822 lower; P = 0.002). Over the 2 years of this study, patients of hospitalists had lower risk for death in the hospital (adjusted relative hazard, 0.71 [95% CI, 0.54 to 0.93]) and at 30 and 60 days of follow-up. CONCLUSIONS: A voluntary hospitalist service at a community-based teaching hospital produced reductions in length of stay and costs that became statistically significant in the second year of use. A mortality benefit extending beyond hospitalization was noted in both years. Future investigations are needed to understand the ways in which hospitalists increase clinical efficiency and appear to improve the quality of care.

Aged↗
PubMed2002

Ventricular pacing or dual-chamber pacing for sinus-node dysfunction.

BACKGROUND: Dual-chamber (atrioventricular) and single-chamber (ventricular) pacing are alternative treatment approaches for sinus-node dysfunction that causes clinically significant bradycardia. However, it is unknown which type of pacing results in the better outcome. METHODS: We randomly assigned a total of 2010 patients with sinus-node dysfunction to dual-chamber pacing (1014 patients) or ventricular pacing (996 patients) and followed them for a median of 33.1 months. The primary end point was death from any cause or nonfatal stroke. Secondary end points included the composite of death, stroke, or hospitalization for heart failure; atrial fibrillation; heart-failure score; the pacemaker syndrome; and the quality of life. RESULTS: The incidence of the primary end point did not differ significantly between the dual-chamber group (21.5 percent) and the ventricular-paced group (23.0 percent, P=0.48). In patients assigned to dual-chamber pacing, the risk of atrial fibrillation was lower (hazard ratio, 0.79; 95 percent confidence interval, 0.66 to 0.94; P=0.008), and heart-failure scores were better (P<0.001). The differences in the rates of hospitalization for heart failure and of death, stroke, or hospitalization for heart failure were not significant in unadjusted analyses but became marginally significant in adjusted analyses. Dual-chamber pacing resulted in a small but measurable increase in the quality of life, as compared with ventricular pacing. CONCLUSIONS: In sinus-node dysfunction, dual-chamber pacing does not improve stroke-free survival, as compared with ventricular pacing. However, dual-chamber pacing reduces the risk of atrial fibrillation, reduces signs and symptoms of heart failure, and slightly improves the quality of life. Overall, dual-chamber pacing offers significant improvement as compared with ventricular pacing.

Aged↗
PubMed2002

Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease.

BACKGROUND: Both aspirin and clopidogrel reduce the rate of cardiovascular events in patients with coronary heart disease. We estimated the cost effectiveness of the increased use of aspirin, clopidogrel, or both for secondary prevention in patients with coronary heart disease. METHODS: We used the Coronary Heart Disease Policy Model, a computer simulation of the U.S. population, to estimate the incremental cost effectiveness (in dollars per quality-adjusted years of life gained) of four strategies in patients over 35 years of age with coronary disease from 2003 to 2027: aspirin for all eligible patients (i.e., those who were not allergic to or intolerant of aspirin), aspirin for all eligible patients plus clopidogrel for patients who were ineligible for aspirin, clopidogrel for all patients, and the combination of aspirin for all eligible patients plus clopidogrel for all patients. RESULTS: The extension of aspirin therapy from the current levels of use to all eligible patients for 25 years would have an estimated cost-effectiveness ratio of about $11,000 per quality-adjusted year of life gained. The addition of clopidogrel for the 5 percent of patients who are ineligible for aspirin would cost about $31,000 per quality-adjusted year of life gained. Clopidogrel alone in all patients or in routine combination with aspirin had an incremental cost of more than $130,000 per quality-adjusted year of life gained and remained financially unattractive across a wide range of assumptions. However, clopidogrel alone or in combination with aspirin would cost less than $50,000 per quality-adjusted year of life gained if its price were reduced by 70 to 82 percent, to $1.00 and $0.60 per day, respectively. CONCLUSIONS: Increased prescription of aspirin for secondary prevention of coronary heart disease is attractive from a cost-effectiveness perspective. Because clopidogrel is more costly, its incremental cost effectiveness is currently unattractive, unless its use is restricted to patients who are ineligible for aspirin.

Adult↗
PubMed2002

beta-Blockers and reduction of cardiac events in noncardiac surgery: scientific review.

CONTEXT: Recent studies suggest that perioperatively administered beta-blockers may reduce the risk of adverse cardiac events in patients undergoing major noncardiac surgery. OBJECTIVE: To review the efficacy of perioperative beta-blockade in reducing myocardial ischemia, myocardial infarction, and cardiac or all-cause mortality from randomized trials. DATA SOURCES: A MEDLINE and conventional search of English-language articles published since 1980 was performed to gather information related to perioperative cardiac complications and beta-blockade. Reference lists from all relevant articles and published recommendations for perioperative cardiac risk management were reviewed to identify additional studies. STUDY SELECTION AND DATA EXTRACTION: Prospective randomized studies (6) were included in the analysis if they discussed the impact of beta-blockade on perioperative cardiac ischemia, myocardial infarction, and mortality for patients undergoing major noncardiac surgery. Articles were examined for elements of trial design, treatment protocols, important biases, and major findings. These elements were then qualitatively compared. DATA SYNTHESIS: We identified 5 randomized controlled trials: 4 assessed myocardial ischemia and 3 reported myocardial infarction, cardiac, or all-cause mortality. All studies sought to achieve beta-blockade before the induction of anesthesia by titrating doses to a target heart rate. Of studies reporting myocardial ischemia, numbers needed to treat were modest (2.5-6.7). Similarly modest numbers needed to treat were observed in studies reporting a significant impact on cardiac or all-cause mortality (3.2-8.3). The most marked effects were seen in patients at high risk; the sole study reporting a nonsignificant result enrolled patients with low baseline risk. As a group, studies of perioperative beta-blockade have enrolled relatively few carefully selected patients. In addition, differences in treatment protocols leave questions unanswered regarding optimal duration of therapy. CONCLUSIONS: Despite heterogeneity of trials, a growing literature suggests a benefit of beta-blockade in preventing perioperative cardiac morbidity. Evidence from these trials can be used to formulate an effective clinical approach while definitive trials are awaited.

Adrenergic beta-Antagonists↗
PubMed2002

beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications.

Recent studies suggest that beta-blockers administered perioperatively may reduce the risk of adverse cardiac events and mortality in patients who have cardiac risk factors and undergo major noncardiac surgery. The objective of this article is to provide practicing physicians with examples of perioperative beta-blocker use in practice by using several hypothetical cases. Although current evidence describing the effectiveness of perioperative beta-blockade may not address all possible clinical situations, it is possible to formulate an evidence-based approach that will maximize benefit to patients. We describe how information from several sources can be used to guide management of patients with limited exercise tolerance, those at highest risk for perioperative cardiac events, patients who are taking beta-blockers long-term, and those with relative contraindications to beta-blockade. Even though fine points of their use remain to be elucidated, perioperative beta-blocker use is important and can be easily applied in practice by any physician involved with the care of patients perioperatively.

Adrenergic beta-Antagonists↗