Rethinking regulations. LTC leaders discuss nursing home law with a regulatory reform advocate. Panel discussion.
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Facility Regulation and Control↗
Biomedical subjects
S Goldberg
Publications and source records attributed to S Goldberg.
Infant-mother attachment and nutrition in children with cystic fibrosis.
The association between nutritional status (percentage of weight for height) and infant-mother relationship was studied over 4 years in 38 children diagnosed with cystic fibrosis in the first year of life. Infant-mother relationship was assessed in a standardized laboratory observation. Although they could not be distinguished medically from the others at the time of diagnosis, infants showing a specific form of insecure relationship with their mothers (insecure-avoidant) differed from the others in: (1) failure to improve in nutritional status in the first year; (2) continuing decline in weight for height in the first 3 years; and (3) significantly lower weight for height at 1, 2, and 3 years of age. These data suggest that attention to mother-infant relationships, particularly feeding interactions, may improve nutritional status in children with cystic fibrosis.
Activities of Daily Living↗
The decision support system for a therapeutic department physician as an example of Dr. Watson Type System.
The System Analysis Guide (Sage) is decision support system intended for highly-skilled physicians. The SAGe estimates the effectiveness and adequacy of treatment delivered by physicians. The traditional technique was not suitable for the solution of such complex tasks, and, as a basic model, the technology of the Dr. Watson Type System (Dr.WTS) (S. Goldberg, L. Meshalkin, 1990) was selected. Dr.WTS creates an informational medium that promotes correct decision making by a specialist. With that end in view, it is necessary to: a) get all the necessary information for decision making; b) stimulate the user by production of a conflict situation for the given informational space; c) direct the user's reflections toward a correct decision; d) provide the user with an compelling motive for continuing to work with the Dr.WTS program. Similar methods are actively used for the organization of creative process conditions by psychologists, system analysis specialists, and for invention machines. A distinctive feature of the Dr.WTS is the presence of an inference engine. Though the decisions themselves are not offered, Dr.WTS creates the enumerated conditions on the basis of decision making algorithms together with the result of the specialists work. Another characteristic is the system self-tuning on the problem which is solved, not in invention machines, but by the concrete specialist. The SAGe is written in C++ on an Intel 386SX-based computer and consists of five subsystems: "Diagnostics," "Treatment Effectiveness," "Treatment Adequacy," "Integral assessment of patients in the department," and "Information import." The "Diagnostics" subsystem gives a physician the opportunity to assess all information about a patient from the point of view of compensating the organism's basic systems. The SAGe organizes the presentation of the information and notes the signs which are not used in the physician's diagnostic schema (as interpreted by the SAGe). The "Treatment Effectiveness" subsystem makes it possible to compare the state severity dynamics with the dynamics of treatment character and intensity. The physician has the possibility of including the dynamics of any quantitative or qualitative indices in the analysis. The SAGe proposes the dynamics of signs which, from its "point" of view, are the most important for the choice of treatment and assessment of treatment efficacy. The "Treatment Adequacy" subsystem gives the physician an opportunity to create an archive of his own a priori and a posteriori reflections about the treatment course, causes of a state aggravation, treatment ineffectiveness, non-coincidence of prognoses, etc. The SAGe reflects the basic dynamic information about a patient and the dynamics of a physician's reflections in the form of a flower growth picture. The SAGe, stressing various details of the picture according to its notions, gives a physician an opportunity to assess divergences between his reflections at different moments in time and between the real dynamics of a disease. Thus the physician receives a notion of harmony patient treatment which is close to the adequacy of notions. The SAGe's most important role, both for stimulating a physician's intellectual activity and for the work of decision-making algorithms, is played by demanding that the physician make independent short-term and long-term prognostic assessments of a disease's development. These prognostications are then compared with reality. At present, the SAGe has been passed for approbation to some of the physicians of Yekaterinburg and Peterburg. The next task in developing the SAGe is a full-volume realization of mechanisms for algorithmic self-tuning with a concrete user.
Algorithms↗
Comparison of coronary angiographic findings during the first six hours of non-Q-wave and Q-wave myocardial infarction.
The angiographic features of non-Q-wave acute myocardial infarction (AMI) soon after symptom onset have not been previously reported. Accordingly, this study reviewed the coronary angiographic findings of 86 patients with AMI studied within 6 hours of symptom onset: 58 had Q-wave and 28 had non-Q-wave AMI. Patients with Q-wave and non-Q-wave AMI were comparable in terms of clinical characteristics, frequency of 1-vessel disease, and infarct-related artery location. Thrombus was observed in 49 patients (84%) with Q-wave AMI versus 12 (43%) with non-Q-wave AMI (p = 0.0002). Whereas complete occlusion of the infarct-related artery was present in 53 patients (91%) with Q-wave AMI, total coronary occlusion was present in only 11 (39%) with non-Q-wave AMI (p = 0.0001). Collaterals to occluded infarct arteries were seen in 10 patients (19%) with Q-wave AMI versus 5 (45%) with non-Q-wave AMI (p = 0.06). Residual perfusion of the infarct artery by either anterograde or collateral flow was typical of patients with non-Q-wave AMI (22 of 28, 79%) but was uncommon in those with Q-wave AMI (15 of 58, 26%) (p = 0.0001). Thus, coronary angiography performed within 6 hours of symptom onset demonstrates important differences between Q-wave and non-Q-wave AMI. Non-Q-wave AMI is characterized by partial perfusion of the infarct-related artery by either anterograde or collateral flow, and a lower incidence of thrombus than Q-wave AMI.(ABSTRACT TRUNCATED AT 250 WORDS)
Chi-Square Distribution↗
Inter-series differences in the restenosis rate of Palmaz-Schatz coronary stent placement: differences in demographics and post-procedure lumen diameter.
Restenosis rates following Palmaz-Schatz stenting vary between 13 and 36%. To determine whether the nearly three-fold interseries difference in restenosis rates reflects systematic factors (demographic and procedural variables such as post-treatment lumen diameter) rather than random variation, we pooled 486 lesions treated with the Palmaz-Schatz coronary stent in the U.S. Multicenter Registry (n = 259) with the single-center Beth Israel Hospital experience (n = 227) and analyzed the combined series using a continuous geometric model of restenosis. A greater proportion of lesions (66 vs. 50%; P < 0.001) in the Multicenter cohort represented restenosis after a prior intervention. The Multicenter experience also showed a smaller minimum lumen diameter following stent placement (2.61 vs. 3.43 mm; P < 0.001), higher post-stent percent stenosis (16 vs. -2%; P < 0.001), and less acute gain (1.79 vs. 2.67 mm; P < 0.001) than lesions treated in the Beth Israel cohort. At 6-month follow-up, the angiographic restenosis rate (> or = 50% diameter stenosis) was significantly higher in the Multicenter group (35 vs. 27%; P = 0.05), despite the development of less absolute late loss (0.96 vs. 1.32 mm; P < 0.001). Multivariable modeling, however, showed that the only independent predictors of restenosis were a post-procedure lumen diameter < 2.80 mm (odds ratio = 1.57; P = 0.04), diabetes mellitus (odds ratio = 3.55; P < 0.001), and prior restenosis (odds ratio = 1.84; P = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)
Cohort Studies↗
Performance on the internal medicine second-year residency in-training examination predicts the outcome of the ABIM certifying examination.
For 223 residents from eight teaching hospitals, the results of the second-year in-training examination and the first-sitting certifying examination of the American Board of Internal Medicine were highly correlated. The results of the in-training examination can serve residents as an important measure of their preparedness for certification and can be useful in identifying the need for more intensive self-study strategies during the subsequent one and a half years.
Certification↗
Attachment in mothers with anxiety disorders and their children.
OBJECTIVE: This study examined adult attachment in mothers diagnosed with anxiety disorders and child-mother attachment in their children. METHOD: Eighteen mothers with Axis I anxiety disorders completed the Adult Attachment Interview and standardized questionnaires. These mothers and their preschool children (n = 20) then participated in the Strange Situation Procedure. RESULTS: All mothers were classified as nonautonomous with respect to attachment, with 78% judged unresolved. When those judged unresolved were reassigned to their alternate categories, the proportion of nonautonomous mothers was 61%. Eighty percent of the children were classified as insecurely attached, with 65% judged disorganized. When those judged disorganized were reassigned to their alternate categories, the proportion of insecurely attached children was 55%. Sixty-five percent of the children matched their mother's attachment classification. Mothers of securely attached children reported fewer recent life events, fewer depressive symptoms, and a greater sense of parenting competence than mothers of insecurely attached children. CONCLUSIONS: These results suggest that attachment measures can be applied to anxious populations. The high rate of insecurity among offspring of anxious mothers indicates a need for longitudinal studies of these children.
Adult↗
Coronary stent placement in patients with de-novo and restenotic native coronary artery lesions.
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Angioplasty, Balloon, Coronary↗
Quality of toddler-mother attachment in children with Down syndrome: limits to interpretation of strange situation behavior.
Researchers studying social-emotional development have argued that primary attachment relationships, established by the end of the first year of life, are important organizing factors that influence the trajectory of development throughout childhood. Central to this argument is a dimension of "attachment security," along which attachments differ. For normally developing infants and toddlers, attachment security is assessed using the Ainsworth Strange Situation. However, it is not clear that this procedure is appropriate for evaluating attachment security in atypical populations. In this report, 3 samples of children with Down Syndrome (total N = 138) were assessed using the Strange Situation. The procedures were scored according to traditional protocols. Although the 3 samples differed with respect to chronological and developmental age, they showed basic similarity with respect to attachment variables. However, developmentally younger children were more difficult to classify using the standard scoring rules. Scores and classifications for the sample were compared to scores from a sample of normally developing children tested at about 12 months of age. Significant differences with respect to the distributions of cases to classification categories and with respect to the interactive scale scores suggest that the Strange Situation may be measuring different aspects of behavior for children with Down Syndrome, even when they are tested at similar developmental age levels.
Adult↗
Cadaverine as a putative component of oral malodor.
Whereas previous studies have shown correlations between volatile sulphur compounds (VSC) and bad breath levels, it is probable that other compounds found in the oral cavity may contribute to oral malodor. In the present investigation, the possibility that diamines (cadaverine and putrescine) are associated with oral malodor parameters was assessed. Saliva samples from 52 subjects were analyzed for cadaverine and putrescine by HPLC. Oral malodor of whole mouth, tongue, and saliva of the subjects was recorded by an experienced judge on a continuous 10-cm scale; peak and steady-state VSC intraoral levels were measured by the Interscan 1170 sulphide monitor. Log-transformed VSC and diamine levels were compared with odor judge measurements by Pearson analysis and stepwise forward multiple regression. Putrescine scores were not significantly associated with odor judge parameters or with VSC levels (p > 0.1). However, highly significant correlations (p < or = 0.003) were found between cadaverine levels and all three odor judge assessments. In contrast, associations between cadaverine and VSC measurements were non-significant. In an attempt to correlate odor judge results in terms of both VSC and diamines, we carried out stepwise forward multiple regression. Results showed that VSC and cadaverine both factor significantly in explaining each of the odor judge measurements, with multiple r values ranging from 0.545 (p = 0.0002) to 0.604 (p < 0.0001). The results suggest that cadaverine levels are associated with oral malodor, and that this association may be independent of VSC.
Adolescent↗
Dose-related efficacy and bleeding complications of double-chain tissue plasminogen activator in acute myocardial infarction. The Wellcome Tissue Plasminogen Activator Study Group.
Although the efficacy of recombinant tissue-type plasminogen activator (rt-PA) in acute myocardial infarction has been demonstrated, little formal dose-ranging information is available. This study examined the use of duteplase, the double-chain rt-PA subsequently used in the Third International Study of Infarct Survival, in a multicenter trial of 267 patients with evolving acute myocardial infarction assigned to receive 1 of 6 weight-adjusted doses. The primary end point was infarct vessel patency after 90 minutes of drug infusion. Patency was defined as Thrombolysis in Myocardial Infarction trial grade 2 or 3 perfusion, and was determined by an independent core laboratory masked to treatment assignment. Patency was present in 48% of patients receiving the lowest dose range and 78% of those receiving the highest, with an association between thrombolytic dose and patency (p = 0.009). The frequency of serious bleeding complications also correlated with the total dose of rt-PA infused (p = 0.003). Bleeding complications were primarily related to instrumentation; blood loss requiring transfusion or otherwise deemed clinically significant occurred in 12% of patients (central nervous system hemorrhage occurred in 1.1%). Thus, higher doses of rt-PA are associated both with increased efficacy and increased risk of serious bleeding complications. Weight-adjusted dosing may provide an optimal risk-benefit ratio for thrombolysis during acute myocardial infarction.
Adult↗
Mobilization of peripheral blood stem cells by subcutaneous injections of yeast-derived granulocyte macrophage colony stimulating factor: a phase I-II study.
A phase I-II study was conducted in 15 patients to determine the tolerability, efficacy and optimal dose of s.c. yeast-derived granulocyte-macrophage colony stimulating factor (GM-CSF) for mobilization of peripheral blood stem cells (PBSC). PBSC were measured by the colony forming unit granulocyte-macrophage (CFU-GM) and burst forming unit erythroid (BFU-E) in vitro colony assays and CD34 flow cytometric analysis. GM-CSF was administered for 12 days as a single daily s.c. injection at 125 micrograms/M2 (n = 3), 250 micrograms/M2 (n = 3), 375 micrograms/M2 (n = 6) and 500 micrograms/M2 (n = 3). At these doses, sustained serum GM-CSF levels of approximately 100-400 pg/ml were observed for at least six hours. Most (97.2% or 175/180) of the planned GM-CSF doses were administered with no serious adverse effects at any of the dose levels. Three leukapheresis procedures were performed before and then after 8, 10 and 12 doses of s.c. GM-CSF. Compared with basal leukapheresis collections, s.c. GM-CSF mobilized leukapheresis collections yielded greater numbers of total white blood cells ([WBC] 15/15 patients or 100%, p < 0.001) mononuclear cells ([MNC] 8/15 patients or 53%, p = 0.55), CFU-GM (11/15 patients or 73%, p = 0.037), BFU-E (9/15 patients or 60%, p = 0.13) and CD34+ cells (6/15 patients or 40%, p = 0.15). The in vitro CFU-GM were augmented approximately two to tenfold in GM-CSF mobilized collections with no clear dose effects from 125-500/micrograms/M2. However, in vivo engraftment time to absolute neutrophil count (ANC) 500/mm3 correlated strongly with GM-CSF PBSC mobilizing dose (r2 = 0.99). We conclude that s.c. yeast-derived GM-CSF is a simple, effective and tolerable method for mobilization of PBSC.
Adult↗
Malignant head and neck germ cell tumours.
Malignant germ cell tumours of the head and neck are extremely rare. Their behaviour, despite aggressive surgical and adjuvant therapy, is relentless with most cases resulting in a fatal outcome. In this paper we present a case of a cervical embryonal carcinoma and review the presentation, clinical course and treatment of malignant germ cell tumours.
Head and Neck Neoplasms↗
The quest for an animal model of high altitude pulmonary edema.
The understanding of the mechanisms underlying certain human diseases usually requires an animal model which can be manipulated in a way that will allow dissection of the pathophysiologic events which lead to the disease. High altitude pulmonary edema (HAPE) occurs in some healthy individuals who ascend from low to high altitude. The disease is characterized by a high protein leak into the lungs and is associated with accentuated pulmonary hypertension. Attempts to find an animal model for HAPE have been made in a number of animal species, including rats, rabbits, sheep, dogs and ferrets. None has been consistently successful. Utilizing the physiologic characteristic of an accentuated hypoxic pulmonary vascular response, we studied both pigs and rats during the stresses of hypoxia and exercise (rats) and examined the lungs for the cellular, protein, and morphologic changes. Protein and cell contents in the lung lavage of the hypoxic animals were slightly higher than the controls while the presence of von Willebrand factor in the hypoxic animals suggests early epithelial damage. This presentation will review previous attempts to find an animal model of HAPE and will discuss the preliminary results of our studies with their suggestive but not confirmatory results.
Altitude↗
The relative effects of maternal and child problems on the quality of attachment: a meta-analysis of attachment in clinical samples.
In this meta-analysis of 34 clinical studies on attachment the hypothesis is tested that maternal problems such as mental illness lead to more deviating attachment classification distributions than child problems such as deafness. A correspondence analysis on 21 North American studies with normal subjects produced a baseline against which the clinical samples could be evaluated. Separate analyses were carried out on studies containing the traditional A, B, C classifications and on studies that also included the recently discovered D or A/C category. Results show that groups with a primary identification of maternal problems show attachment classification distributions highly divergent from the normal distributions, whereas groups with a primary identification of child problems show distributions that are similar to the distributions of normal samples. The introduction of the D or A/C classifications (about 15% in normal samples) reveals an overrepresentation of D or A/C in the child problem groups, but the resulting distribution still is much closer to the normal distributions compared to the samples with maternal problems. In clinical samples, the mother appears to play a more important role than the child in shaping the quality of the infant-mother attachment relationship.
Child Behavior Disorders↗
Initial testing of a novel urine culture device.
The Diaslide urine culture device consists of a hinged case containing two opposing agar media separated by a sampler with a handle at one end and two bent sampler tips at the opposite end. The tips of the sampler are first dipped into the urine. The sampler is then pulled out through the casing, simultaneously inoculating both agar surfaces with a streaking dilution. As a result, individual colonies can be observed even when bacterial concentrations exceed 10(6) CFU/ml. The number of colonies on the Diaslide correlated linearly with CFU per milliliter as determined by dilution plating. The clinical performance of the Diaslide was compared with those of ordinary dipslides and conventional cultures with a sample of 473 prescreened hospital urine specimens. The sensitivity, specificity, and positive predictive value of Diaslide versus those of culture at the 10(4)-CFU/ml cutoff level were 97.5, 98.3, and 98.3%, respectively, compared with 98.8, 95.7, and 97.2%, respectively, for dipslide versus culture. Similar results were found at the 10(5)-CFU/ml cutoff level. Only 5.5% of the Diaslides required subculturing, compared with 14.7 and 9.4% of the dipslides and conventional cultures, respectively. The Diaslide proved more convenient than an ordinary dipslide for sampling low volumes of urine. These data suggest that the Diaslide is a simple, effective device for culturing of urine specimens.
Bacteria↗
Emergent use of balloon-expandable coronary artery stenting for failed percutaneous transluminal coronary angioplasty.
BACKGROUND: The balloon-expandable intracoronary stent developed by Palmaz and Schatz is undergoing clinical evaluation for use in unfavorable anatomic situations and in the prevention of restenosis. Because the stent's mechanism of action would suggest effectiveness in salvaging certain percutaneous transluminal coronary angioplasty (PTCA) failures, we retrospectively examined the results of emergency unplanned coronary artery stenting for failed PTCA procedures, including acute occlusion. METHODS AND RESULTS: The study population consisted of all US patients receiving emergency unplanned stent implantation in a nonrandomized fashion at seven centers over a 2 1/2-year period (n = 56). All available medical records and angiograms were reviewed to determine retrospectively the reason for stenting: Group 1 consisted of 23 patients with a suboptimal angioplasty result; group 2 included patients with evidence of impending vessel closure after PTCA (n = 15); and group 3 were patients with frank acute occlusion after PTCA (n = 18). The immediate and final (30-day) results of stenting were examined with respect to major complications, which included death, need for coronary artery bypass graft surgery, and occurrence of myocardial infarction. Finally, restenosis rates (greater than or equal to 50% stenosis) based on follow-up angiography were calculated. Baseline characteristics of the study population included a mean +/- SD age of 58 +/- 11 years and a large prevalence of angiographic characteristics generally considered unfavorable for PTCA, which include lesion eccentricity (49%), intimal dissection (9%), or angiographically visible thrombus (6%). After conventional balloon angioplasty, there was an increased incidence of intimal dissection (74%) and thrombus formation (38%), and overall stenosis severity was unchanged (75 +/- 12% versus 70 +/- 27%, p = NS). Successful stent deployment was achieved in 55 (98%) of 56 patients with initial success (freedom from death, surgery, and infarction) in 52 (93%) of 56 patients. The success rate at 1 month fell to 71% primarily because of the occurrence of subacute stent thrombosis (16%) and its associated complications. Overall, major complications occurred in 16 (29%) of 56 patients within 30 days. The only predictor of subacute stent thrombosis in multiple stepwise logistic regression analysis was the presence of angiographically visible thrombus after stenting (p = 0.03). Angiographic restenosis was documented in eight (23%) of 35 eligible patients. CONCLUSIONS: Emergency stenting may be a useful and effective treatment for failed angioplasty. High initial success rates (greater than 90%) can be achieved, but subsequent complications, often related to subacute thrombosis, occur in a substantial portion of patients. Patients who receive stents on an emergency basis, particularly those with previous acute occlusion, should be considered to be at greater than usual risk for complications and receive more careful anticoagulation and follow-up.
Aged↗
Restenosis after placement of Palmaz-Schatz stents in native coronary arteries. Initial results of a multicenter experience.
BACKGROUND: Several metallic intracoronary stents are currently undergoing preliminary evaluation to ascertain potential benefit as means to reduce the 30-40% incidence of restenosis after balloon angioplasty. METHODS AND RESULTS: To determine the incidence and correlates of restenosis after placement of Palmaz-Schatz stents in native coronary arteries in the first group of patients selected for this procedure, clinical and quantitative angiographic data from 206 consecutive patients (221 stenoses) with successful stent placement (diameter stenosis < 50%) were analyzed. Six patients (2.9%) had thrombosis-mediated stent closure within 1 month after stent placement and were excluded from long-term angiographic follow-up. One hundred eighty-one (91%) of the remaining 200 patients had angiography at 5.8 +/- 2.1 months. Patients with and without follow-up did not differ in any baseline characteristic; in particular, history of restenosis at the site stented (73% versus 65%), placement of multiple overlapping stents (17% versus 20%), and mean poststent diameter stenosis (16 +/- 12% versus 14 +/- 12%). The overall incidence of restenosis (diameter stenosis > or = 50% at follow-up) in this group at high risk for restenosis was 36% (95% confidence interval, 29-43%) on a per-stenosis basis. The incidence of restenosis when a single stent was placed was 30% (95% confidence interval, 23-37%). Risk was dependent upon a history of restenosis (present versus absent 36% versus 16%, p = 0.02) and upon whether or not a poststent stenosis < or = 0% was achieved (6% versus 33%, p = 0.02). When multiple overlapping stents were placed, restenosis occurred at 64% of sites, and placement of multiple stents was discouraged during the later phases of this study as these results became apparent. CONCLUSIONS: Although multiple stents appear to yield a poor long-term result, placement of single stents may offer a benefit compared with standard coronary angioplasty, particularly if an excellent angiographic result can be obtained in patients without prior restenosis. Further randomized trials in such patients are needed.
Coronary Angiography↗