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Biomedical subjects

R L Goldstein

Publications and source records attributed to R L Goldstein.

At least 37 records · Page 2Linked to original sources
PubMed1987

The twilight zone between scientific certainty and legal sufficiency: should a jury determine the causation of schizophrenia?

In lawsuits involving complex scientific issues of causation, dispute resolution requires that a final decision be reached in each case, regardless of whether science is able to provide definitive answers to the questions of causation raised at trial. Proving causation before science has is a concept that scientists may find disconcerting and foreign to some of their basic assumptions. This paper explores the foregoing issues, discusses medical versus legal concepts of causation, outlines the legal tests for admissibility of novel scientific evidence (including Federal Rule of Evidence 702 and the Frye test of general acceptance by the relevant scientific community), and presents a toxic tort case in which expert psychiatric testimony addressed the issue of causation of schizophrenia. The paper articulates concerns about the "misleading aura of certainty" posed by scientific evidence and the burden of decision making that is cast upon the legal system in such scientific issue cases.

Adult↗
PubMed1987

The psychiatrist's role in retrospective determination of suicide: an uncertain science.

Psychiatrists have made significant contributions to our understanding of the phenomenon of suicide and are generally regarded as experts in all matters relating to suicide. When a legal determination must be made as to whether an individual has died as a result of suicide or by accidental (or any other) means, psychiatrists are often called upon to proffer their expert opinion to assist the courts to resolve the matter. Two case illustrations are presented and analyzed in which psychiatrists were called upon to make such retrospective determinations of suicide. The question is raised as to whether psychiatrists may sometimes exceed the limits of their scientific expertise in making such determinations.

Expert Testimony↗
PubMed1987

Litigious paranoids and the legal system: the role of the forensic psychiatrist.

Forensic psychiatrists should be aware of the many ways that paranoid individuals may present within the legal system. Litigious paranoids often utilize the legal system as a vehicle to act out their fantasies and delusional preoccupations. Imaginary grievances, accusations based on delusional ideation, and irrational vindictiveness toward imagined persecutors may find full expression in any number of legal contexts. They can defeat the rational and legitimate objectives of the legal system, enmesh innocent and unsuspecting victims in nightmarish legal entanglements, and subvert the process of justice. The forensic psychiatrist can assist the court by alerting it to the presence of paranoid illness in parties or witnesses and by clarifying what the effects of such psychopathology are and what the most favorable response should be. Three legal contexts wherein paranoid individuals may present within the legal system are discussed: the "hypercompetent" defendant, the paranoid party in a divorce proceeding, and the paranoid complaining witness. Case illustrations are presented for each legal context. Two issues are discussed: the dividing line between paranoid ideation (and its impact on the legal process) and so-called "normal" thinking (and its objective to use the legal process to obtain certain ends); and the degree to which psychiatric opinions in this area should influence the way an individual's case is handled by the legal system. The author concludes that, despite the costs involved, it is preferable that even paranoids have their "day in court."

Divorce↗
PubMed1987

More forensic romances: De Clérambault's syndrome in men.

De Clérambault's syndrome (erotomania) has invariably been regarded as a female disorder (with male victims); however, a number of recent reports describe male patients with the disorder, especially in violence-prone male offender populations. Seven cases are presented of violence-prone men suffering from the disorder, including Hinckley and Poddar. The syndrome is discussed from a nosological point of view and in terms of its impact on competency to stand trial. Psychiatrists should be aware that the syndrome is not a rarity among men, as previously thought, and that proper diagnosis and management are essential in view of the clinical course of the disorder and the potential for violence when the patient's "love" is persistently unrequited by the delusional love object.

Adult↗
PubMed1986

Functional outcomes following medical intensive care.

This study describes the long-term functional outcomes of a medical and coronary care ICU population. Baseline and 1-yr follow-up data were collected prospectively from all 2213 patients admitted during a 2-yr period. Patients were stratified into three groups based on their preadmission functional status: active (n = 917), sedentary (n = 1017), or severely limited (n = 279). Those with severe functional limitation before admission were twice as likely to undergo major interventions (p less than .005). This group also had a significantly (p less than .001) higher mortality and incurred significantly (p less than .01) higher hospital charges than the other two groups, even though hospital lengths of stay were similar. Finally, cumulative mortality was significantly (p less than .001) greater for the severely limited patients: 33% expired in the ICU, 42% died while still in the hospital, and 63% died after discharge. Most survivors regained their preadmission functional status, with 60% of the previously employed returning to work. However, even for hospital survivors, mortality was high and was related to prior functional status: active 7%, sedentary 20%, severely impaired 37%.

Activities of Daily Living↗
PubMed1986

When it pays to be insane: three unusual legacies of insanity.

Although the law generally does not permit an individual to profit by his own wrongdoing, that equitable principle may be inapplicable in the case of an individual who has been adjudicated insane (and therefore has not committed a wrong in the eyes of the law). This paper discusses three unusual legacies of a determination of insanity: the inheritance cases (permitting the insane killer to inherit from his own victim), the life insurance cases (permitting the beneficiary to recover when the insured commits suicide while insane), and the effect of insanity on publication rights agreements in sensational criminal cases.

Forensic Psychiatry↗
PubMed1986

Clinical utility of serum digoxin level tests in hospitalized elderly patients.

To assess the clinical utility of serum digoxin tests in the elderly and to ascertain the use by physicians of test results, digoxin levels were obtained from 77 consecutive, elderly patients (means age 72 years) taking digoxin on admission to a rehabilitation hospital. Blood samples were drawn the morning following admission (prior to the administration of digoxin) and were repeated in two weeks. Signs or symptoms of digoxin toxicity were seen in all 13 patients with levels above the therapeutic range. Of 38 patients with therapeutic levels, 16 had signs or symptoms compatible with underdigitalization or digoxin toxicity. Physicians were significantly more likely to respond to both the initial and follow-up serum digoxin test result when the first test result was above the therapeutic range.

Adult↗
PubMed1985

Hospital readmissions among survivors six months after myocardial revascularization.

One neglected but important measure of early morbidity after coronary artery bypass graft (CABG) operations is rehospitalization. As part of a prospective study of recovery after elective CABG procedures conducted at four academic medical centers, data from all readmissions occurring within the first six postoperative months were collected for 326 patients. A total of 24% of patients had readmissions. The most common categories of readmission discharge diagnoses were cardiac (57%), noncardiac (26%), and surgical sequelae (17%). Factors from the initial hospitalization identified as risk factors for rehospitalization included: length of stay in intensive care unit after surgery, severe noncardiac complications, duration of preoperative cardiac symptoms, intra-aortic balloon insertion, and preoperative resting angina. These findings help to identify a subset of at risk patients for whom more careful surveillance might be beneficial.

Adult↗
PubMed1984

Nursing home patients admitted to a medical intensive care unit.

To investigate admissions from nursing homes to a medical intensive care unit (ICU), the authors detailed the major interventions, costs, and outcomes for such patients (n = 67) over a 3-year period and then compared them with those for ICU patients receiving home care or visiting nurse services (240 patients) before admission and all others older than 65 years of age (949 patients). These three groups comprised 37% of total ICU admissions. In contrast to younger patients admitted primarily with acute ischemic heart disease, nursing home patients were more likely to be admitted with cardiopulmonary arrest, infection, and gastrointestinal bleeding. Major interventions of intubation and mechanical ventilation were most frequent for nursing home patients, but total hospital charges differed little among the groups. In-hospital mortality for the nursing home group (28%) was significantly higher than for the home care group (7%) and others older than 65 years of age (7%). Cumulative mortality for the nursing home group reached 66% by 8 months, versus 32% and 26% in the other groups, respectively.

Aged↗
PubMed1983

Predictors of employment status after cardiac surgery.

Preoperative predictors of postoperative employment status were studied in 228 patients (aged 25 to 64 years) who underwent cardiac surgery. Of the 150 patients working in the year before surgery, 73% returned within six months. Of those not so employed, 18% started working. Patients who expected preoperatively to return to work did so at an 82% rate compared with 39% of the others. This was a strong predictor in the multiple regression analysis. Educational level and family income were stronger predictors than occupation or level of physical exertion required. Rates of return were higher in patients with less severe angina and less fatigue preoperatively, but did not differ significantly by sex, surgical procedure, or duration of illness. Seven variables predicted work status correctly for 86% of persons. These results suggest that determinants of return to work are largely present before surgery and that patients' attitudes and expectations play an important role.

Adult↗
PubMed1981

Medical intensive care for the elderly. A study of current use, costs, and outcomes.

All admissions (2,693) to a medical intensive and coronary care unit (ICU/CCU) during a two-year period were reviewed to compare indications for admission, major interventions, and outcomes for elderly patients with those for younger patients. Once admitted to the ICU/CCU, older patients were more likely to receive major life-support interventions such as mechanical ventilation but less likely to survive. Major interventions were used in 32% of patients aged 75 years or older, in 26% of those 65 to 74 years, and in 22% of those 55 to 64 years. Nonetheless, elderly patients had no longer mean lengths of stay and no greater mean hospital charges. Hospital mortality for the oldest patients was 16%, compared with 14% and 8% for the younger age groups. Cumulative mortality one year after discharge for those older than 75 years was 44%. Elderly hospital survivors returned to their preadmission living situation but did not regain their preadmission activity level.

Aged↗
PubMed1980

Medical intensive care: indications, interventions, and outcomes.

To evaluate current practices regarding intensive-care units (ICU's), we collected data on 2693 consecutive admissions to a medical ICU during a two-year period and studied indications for admission, specific interventions, costs, and outcomes. The need for noninvasive monitoring rather than immediate major interventions prompted 77 per cent of the admissions. Only 10 per cent of monitored patients had subsequent indications for major interventions. The 23 per cent who required immediate interventions accounted for disproportionate shares of total charges (37 per cent) and deaths during hospitalization (58 per cent). Demographic and diagnostic data indicate that the aged and chronically ill have become the principal consumers of intensive care. Overall mortality during hospitalization was 10 per cent; cumulative mortality during follow-up study (mean duration, 15 months) was 25 per cent. We conclude that identification of sensitive predictors of complications and specific predictors of mortality can lead to more efficient and effective ICU practices.

Adult↗