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Biomedical subjects

M Helfand

Publications and source records attributed to M Helfand.

At least 37 records · Page 2Linked to original sources
PubMed1999

Summary report: evidence for the effectiveness of rehabilitation for persons with traumatic brain injury.

We evaluated the evidence for effectiveness of rehabilitation methods throughout the phases of recovery from traumatic brain injury (TBI) in adults. MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library were searched, and a total of 3,098 abstracts were reviewed. The strongest studies were critically appraised and their data placed in evidence tables. Results showed that to determine the effectiveness of rehabilitation interventions for persons with TBI, a commitment must be made to population-based studies, strong controlled research design, standardization of measures, adequate statistical analysis, and specification of health outcomes of importance to persons with TBI and their families.

Adult↗
PubMed1999

Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review.

We evaluated evidence for the effectiveness of cognitive rehabilitation methods to improve outcomes for persons with traumatic brain injury (TBI). A search of MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library produced 600 potential references. Thirty-two studies met predetermined inclusion criteria and were abstracted; data from 24 were placed into evidence tables. Two randomized controlled trials and one observational study provided evidence that specific forms of cognitive rehabilitation reduce memory failures and anxiety, and improve self-concept and interpersonal relationships for persons with TBI. The durability and clinical relevance of these findings is not established. Future research utilizing control groups and multivariate analysis must incorporate subject variability and must include standard definitions of the intervention and relevant outcome measures that reflect health and function.

Brain Injuries↗
PubMed1999

Evidence of case management effect on traumatic-brain-injured adults in rehabilitation.

The purpose of this study was to evaluate the evidence for effectiveness of case management during recovery from traumatic brain injury (TBI) in adults. After an overview of TBI incidence, prevalence, and problems, and a brief explanation of case management, the study methods are described, the findings are discussed and recommendations are made for future research. Medline, HealthSTAR, CINAHL, PsychINFO, and the Cochrane Library databases were searched and 83 articles met the criteria for review. The strongest studies (n = 3) were critically appraised and their design features and data were placed in two evidence tables. Due to methodological limitations, there was neither clear evidence of effectiveness nor of ineffectiveness. For future research, we recommend controlled research designs, standardization of measures, adequate statistical analysis and specification of health outcomes of importance to persons with TBI and their families.

Adult↗
PubMed1998

Clinical guideline, part 2. Screening for thyroid disease: an update. American College of Physicians.

PURPOSE: To review information on the benefits of screening with a sensitive thyroid-stimulating hormone (TSH) test for thyroid dysfunction in asymptomatic patients seeking primary care for other reasons. This paper focuses on whether screening should be aimed at detection of subclinical thyroid dysfunction and whether persons with mildly abnormal TSH levels can benefit. DATA SOURCES: A MEDLINE search for studies of screening for thyroid dysfunction and of treatment for complications of subclinical thyroid dysfunction. STUDY SELECTION: Studies of screening with thyroid function tests in the general adult population or in patients seen in the general office setting were selected (n=33). All controlled studies of treatment in patients with subclinical hypothyroidism or subclinical hyperthyroidism were also included (n=23). DATA EXTRACTION: The prevalence of overt and subclinical thyroid dysfunction, the evidence for the efficacy of treatment, and the incidence of complications in defined age and sex groups were extracted from each study. DATA SYNTHESIS: Screening can detect symptomatic but unsuspected overt thyroid dysfunction. The yield is highest for women older than 50 years of age: In this group, 1 in 71 women screened could benefit from relief of symptoms. Evidence of the efficacy of treatment for subclinical thyroid dysfunction is inconclusive. CONCLUSIONS: Even though treatment for subclinical thyroid dysfunction is controversial, office-based screening to detect overt thyroid dysfunction may be indicated in women older than 50 years of age. Large randomized trials are needed to determine the likelihood that treatment will improve quality of life in otherwise healthy patients who have mildly elevated TSH levels.

Adult↗
PubMed1998

Adequacy of hospital discharge status as a measure of outcome among injured patients.

CONTEXT: Crude mortality rates at the time of hospital discharge are commonly used to assess the quality of care provided to patients hospitalized following trauma. OBJECTIVES: To evaluate the adequacy of hospital death rates as an outcome measure following trauma and to determine the influence of noninjury illness as a cause of hospital death and the frequency of postdischarge death. DESIGN: Retrospective cohort analyses using hospital discharge data for injured patients cross-linked to death certificate data that provided 1 year of follow-up for all patients discharged alive. PATIENTS: A total of 90048 injured patients admitted to all acute care hospitals in the state of Washington from 1991 through 1993 and discharged with at least 1 diagnosis coded in the International Classification of Diseases, Ninth Revision, Clinical Modification to indicate trauma. MAIN OUTCOME MEASURES: Death in the hospital and death within 30 days of hospital discharge. RESULTS: Among 1912 injured patients with in-hospital deaths, 825 death certificates (43%) listed a noninjury cause of death. The overall mortality rate at hospital discharge was 21.2 per 100000 hospitalized injured patients, and was 12.1 per 100000 for trauma deaths and 9.1 per 100000 for those designated as nontrauma deaths. Patients with trauma-related death designations were younger (mean age, 51.5 years vs 77.9 years), had shorter lengths of stay (median stay, 2 days vs 5 days), and sustained more severe injures (P<.001). Including the 1273 deaths that occurred within 30 days of hospital discharge increased rates for trauma-designated deaths to 14.1 per 100000 and increased rates for nontrauma-designated deaths to 21.3 per 100000. CONCLUSIONS: Hospital discharge death rates are incomplete measures of death frequency for injured patients. Designation of the cause of death, especially among older, hospitalized, injured patients often reflects preexisting medical conditions. Adequate assessment of mortality following trauma requires measurement of the frequency of death following hospital discharge.

Adolescent↗
PubMed1997

History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up.

OBJECTIVE: To determine whether a complaint of visible rectal bleeding that is elicited by a screening review of systems merits investigation and to assess the accuracy of a defined protocol to evaluate bleeding. DESIGN: Prospective cohort study. SETTING: Primary care clinics in a veterans medical center. PATIENTS: We used an 8-item review of systems to identify 297 individuals with visible rectal bleeding; 201 (68%) of these individuals completed a specified protocol consisting of double-contrast barium enema (DCBE) examination, rigid sigmoidoscopy, and follow-up visit after 6 to 12 months. Ten years later we verified the diagnosis in 131 (93%) of 141 patients whose initial evaluation suggested no cause, or a benign anorectal cause, of bleeding. MAIN OUTCOME MEASURES: Final diagnoses after 2 and 10 years; sensitivity and specificity of symptoms, DCBE, and rigid sigmoidoscopy. RESULTS: We diagnosed serious disease in 48 (24%) of the 201 patients; 26 had polyps, 9 had inflammatory bowel disease, and 13 (6.5%) had colon cancer. Symptoms did not predict the diagnosis. Neither DCBE nor rigid sigmoidoscopy alone was sufficiently sensitive to be used alone, but the combination of DCBE and rigid sigmoidoscopy had a sensitivity of 0.96 and a specificity of 0.76 for the diagnosis of polyps, cancer, or inflammatory bowel disease. CONCLUSIONS: Self-reported rectal bleeding detected by means of a review of systems was associated with a high likelihood of important pathology. Physicians should ask all adults about visible rectal bleeding and should visualize the entire colon in those who report bleeding.

Adult↗
PubMed1997

Practice variation and the risk of low birth weight in a public prenatal care program.

OBJECTIVES: Use of antepartum tests of fetal well-being is widespread even though effectiveness in preventing fetal damage or stillbirth has not been established. The study objective was to examine whether aggressive use of these tests might contribute to increased rates of other birth outcomes, including low birth weight (LBW). METHODS: A total of 3,235 low-income women receiving care from 28 clinic sites were studied. All women were eligible for Medi-Cal benefits. Clinic sites were classified as aggressive, moderate, or low users of antepartum tests. The relations between patient risk factors, clinic testing style, LBW, and other pregnancy outcomes were examined using multiple logistic regression. RESULTS: After adjustment for risk factors, patients seen by aggressive testers had a risk of LBW higher than patients receiving care from moderate testers (odds ratio = 1.65; P < 0.01). Rates of LBW within patients receiving care from moderate and low testers did not differ (P = 0.22). Patients seen by aggressive testers also had higher rates of preterm delivery, cesarean delivery, and provided more expensive care. CONCLUSIONS: Although antepartum testing is intended to prevent fetal distress, extremely aggressive use of antepartum testing may have unfavorable effects on LBW and other pregnancy outcomes. More attention should be paid to variation in obstetric practices in evaluations of the costs and effectiveness of public prenatal care programs.

Adult↗
PubMed1997

Risk factors for Barrett's esophagus in community-based practice. GORGE consortium. Gastroenterology Outcomes Research Group in Endoscopy.

OBJECTIVES: Endoscopy is often performed in patients with gastroesophageal reflux (GER) disease because of concern about the presence of Barrett's esophagus (BE). The purpose of this study was to determine whether the duration of GER symptoms and/or a history of esophagitis was associated with an increased risk of BE. METHODS: This was an observational, prospective, community-based study. Consecutive patients undergoing elective endoscopy because of GER symptoms were enrolled. Endoscopy reports and pathological findings were reviewed to classify patients as having no esophagitis, esophagitis, or probable BE. Correlations with duration of symptoms and a history of esophagitis were analyzed. RESULTS: In all, 701 of 2641 patients (27%) undergoing elective endoscopy had GER symptoms, and 77 of these patients had probable BE. Compared with patients with GER symptoms for less than 1 yr, the odds ratio for BE in patients with GER symptoms for 1-5 years was 3.0 and increased to 6.4 in patients with symptoms for more than 10 yr (p < 0.001). A history of esophagitis was not an independent risk factor for BE (p = 0.17). CONCLUSIONS: Prevalence of BE is strongly associated with duration of GER symptoms.

Adolescent↗
PubMed1997

Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group.

OBJECTIVE: To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system. METHODS: A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation. RESULTS: Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in > 1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury. CONCLUSION: Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Emergency Medical Services↗
PubMed1997

Management of symptoms of gastroesophageal reflux disease: does endoscopy influence medical management?

OBJECTIVES: The purpose of this study was to examine the theories that underlie the clinical decision to perform endoscopy in patients with symptoms of gastroesophageal reflux disease (GERD). Physicians reported that they use endoscopic findings to modify medical treatment of GERD. This study was undertaken to test this hypothesis in clinical practice. METHODS: A consortium of community specialists in gastrointestinal disease was formed. Physicians completed a database on patients undergoing elective endoscopy for symptoms of GERD, which includes symptom severity, endoscopic findings, and medical treatment before and after endoscopy. An increase in medical treatment was defined as an increase in acid suppression therapy, and/or the addition of a promotility drug, and/or referral for surgery. RESULTS: Data were collected prospectively over 6 months on 664 patients with symptoms of GERD, and complete data were available on 598 patients. Barrett's esophagus or active esophagitis (erythema, erosions, or ulceration) was present in 374 patients. Of these patients, 74% had an increase in therapy after endoscopy; for only 5% did therapy decrease. In contrast, among 224 patients with a normal-appearing esophagus, 35% had an increase in treatment and 65% had either a decrease in treatment or no change. In most cases, the increase in treatment was due to persistence of symptoms or because of endoscopic findings in the stomach or duodenum. The differences in treatment changes between the two groups was highly significant (p < 0.0001). CONCLUSION: The results support the theory that physicians often use endoscopic results to tailor medical therapy in patients with symptoms of GERD.

Antacids↗
PubMed1996

Low birthweight in a public prenatal care program: behavioral and psychosocial risk factors and psychosocial intervention.

A retrospective, observational study of 3073 low income African American, Latina, and White women receiving comprehensive prenatal care at 26 provider sites was completed. The purpose of the study was to test three hypotheses. First, after adjustment for biomedical complications, the presence of maternal behavioral and psychosocial factors would be associated with an increased rate of low birthweight infants. Second, increased time spent in psychosocial services would negate the relationship between maternal psychosocial factors and low birthweight. Third, after adjusting for biomedical, behavioral, and psychosocial factors, rates of low birthweight would no longer differ by race. Maternal smoking (over five cigarettes per week), maternal low weight for height and/or weight gain, negative mood (depression, anxiety, and/or hostility) and rejection of the pregnancy were found to be related to an increased rate of low birthweight birth (< 2500 g). Receiving more than 45 min of psychosocial services was related to a reduced rate of low birthweight birth for all women regardless of risk profile. The rate of low birthweight remained higher in African American women after adjusting for all significant maternal biomedical, behavioral, and psychosocial risk and intervention factors. Further analyses revealed that the strength and direction of the relationship between time spent in psychosocial services and low birthweight remained after controlling for the number of prenatal care visits, the time spent in nutrition or health educational services, and gestational age. Also, the time spent in psychosocial services was related to a reduced rate of low birthweight even after excluding time spent in psychosocial services in the third trimester of pregnancy or excluding women who received their first psychosocial assessment in the third trimester from the analysis. Although definitive evidence from randomized trials of psychosocial services is lacking, receiving over 45 min of psychosocial services was related to a reduced risk of low birthweight for all women in this study. Therefore, general psychosocial services appears to be an important component of prenatal care for all low income women.

Adult↗
PubMed1996

Influence of a statewide trauma system on location of hospitalization and outcome of injured patients.

OBJECTIVE: Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death. DESIGN: Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture. MATERIALS AND METHODS: Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning. MEASUREMENTS AND MAIN RESULTS: After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92). CONCLUSIONS: The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

Abbreviated Injury Scale↗
PubMed1995

An analysis of Hospital Discharge Index as a trauma data base.

STUDY OBJECTIVE: To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients. DESIGN: Patient information in trauma registries was compared with information in HDI. POPULATION: Injured patients admitted to trauma centers. METHODS: Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed. RESULTS: A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82. CONCLUSION: HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.

Hospital Information Systems↗