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Biomedical subjects

S R Lowenstein

Publications and source records attributed to S R Lowenstein.

At least 55 records · Page 3Linked to original sources
PubMed1986

Patients who leave without being seen.

We conducted this study because very little is known about patients who leave without being seen. A total of 4,868 patients were registered in an emergency department during a six-week study period. Sixty-eight (1.4%) left before treatment was completed; 97% (66 patients) left before ever being seen by a physician. Thirty of the 68 patients were interviewed later in followup A comparison group of 23 patients who did not leave prematurely was also selected and matched for age, sex, urgency of chief complaint, and time of presentation. Fourteen of these patients were interviewed later. Patients who left without being seen (LWBS) and nonLWBS patients did not differ in waiting time in the ED. The two groups also did not differ in the spectrum of chief complaints. Twenty-two of 30 LWBS patients were suffering from acute psychological distress at the time of their visit, however, compared to only one of the comparison group (P = .0005). The walkouts reported recent deaths of relatives or friends, recent bouts of alcoholism, acute financial problems, suicidal thoughts and behavior, court appearances, pregnancies and miscarriages, new people in the home, acute illnesses in relatives, and other psychological and social crises.

Adolescent↗
PubMed1986

Care of the elderly in the emergency department.

We prospectively examined the care provided to 234 elderly patients (age greater than or equal to 65) and an equal number of nonelderly patients visiting the emergency department of an urban teaching hospital. Sociodemographic, treatment, cost, and outcome data were collected through ED record reviews and follow-up telephone interviews. The elderly comprised 19% of the ED population and were often nonwhite (31%), Medicaid recipients (39%), living alone (41%), and multiply and chronically impaired. Among old-old patients (age greater than or equal to 75), the most frequent reasons for visiting the ED (19%) were a self-care problem, a fall, or dehydration. Forty-five percent of old-old patients' visits were for true medical emergencies or urgencies. Compared to the nonelderly, the old-old more often were admitted (47% versus 18%, P = .0001), stayed a longer time in the ED (three hours versus 1.9 hours, P = .0001), and incurred a higher charge ($324 versus $208, P = .0001) Twenty-nine percent of these old-old patients who were not initially admitted returned within 14 days (recidivated). The recidivism rate for nonelderly patients was only half as high (15%) (P = .02).

Aged↗
PubMed1986

Benefits of training physicians in advanced cardiac life support.

Unexpected cardiopulmonary arrests occur commonly both in the prehospital setting and in the course of hospital care. Survival after prehospital arrest is improved if bystanders and paramedics are trained in basic and advanced cardiac life support. However, within the hospital, the bystanders are the physicians; it is not known if life support training of these hospital-based physician bystanders leads to improved survival. Therefore, we reviewed the outcome of resuscitation attempts in a teaching hospital during two matching six-month periods, before (period 1) and after (period 2) institution of a mandatory course in Advanced Cardiac Life Support (ACLS) for medical houseofficers. It was concluded that survival after inhospital cardiopulmonary arrest is significantly increased if house officers who staff the Code teams are trained in ACLS.

Aged↗
PubMed1983

The role of alcohol in new-onset atrial fibrillation.

Forty cases of new-onset atrial fibrillation (AF) were reviewed to establish the frequency of various causes. Alcohol intoxication caused or contributed to 14 cases (35%). Coronary artery disease (22.5%) and pulmonary disease (22.5%) were also common causes of acute AF. Among patients less than 65 years old, alcohol caused or contributed to approximately two thirds (63%) of the cases of AF. Thyrotoxicosis was uncommon (one case in 40); no patient had a diagnosis of mitral stenosis, pulmonary embolism, or pericarditis. There were no complications of AF in alcoholic patients; the majority (88.9%) converted spontaneously to a normal sinus rhythm within 24 hours. Alcohol intoxication should be considered early in the differential diagnosis of new-onset AF in young patients. Many patients may not require admission to an intensive care unit or a costly battery of diagnostic tests.

Aged↗
PubMed1981

Cardiopulmonary resuscitation by medical and surgical house-officers.

In teaching hospitals the responsibility for cardiopulmonary resuscitation usually rests with the house-staff, yet most house-officers receive no formal training in life support. The life-support skills of 45 medical and surgical house-officers in a university teaching hospital were tested by means of simulated cardiac arrests. House-officers were graded on the basis of a performance checklist derived from the standards of the American Heart Association. No house-officer received a pass score in basic life support (BLS). Only 29% could properly compress and ventilate the mannequin. In advanced cardiac life support (ACLS) only one-third could intubate in 35 s or less; only 31%, 40%, and 33% could manage ventricular fibrillation, asystole, and complete heart block, respectively. Some house-officers were unable to operate the defibrillator or assemble resuscitation equipment. Many house-officers displayed helplessness and anxiety during the simulations; fourteen (40%) were prompted to register for additional advanced life-support courses. The performance of medical and surgical house-officers was equal. House-officers who had received prior life-support training performed better in BLS (p less than 0.001) but not in ACLS. It was concluded that (a) most medical and surgical house-officers are not reasonably proficient in BLS and ACLS, and (b) cardiac arrest simulation is a motivating exercise which permits analysis of each house-officer's life-support skills. House-officers should have more training and practice in life support, or they should not have primary responsibility for cardiopulmonary resuscitations.

Clinical Competence↗
PubMed1981

Granulomatous tenosynovitis and carpal tunnel syndrome caused by Sporothrix schenckii.

Although the usual form of sporotrichosis is a lymphocutaneous lesion, Sporothrix schenckii can cause articular disease that is difficult to diagnose. We describe two patients with sporotrichosis who presented with tenosynovitis and the carpal tunnel syndrome. A tissue specimen is required for a precise diagnosis; granulomatous tenosynovitis suggests an infectious cause. Unless appropriate cultures for bacteria, mycobacteria and fungi are obtained, the diagnosis may be missed or delayed. Mouse inoculations may be required to isolate S. schenckii from tissue, which rarely shows the delicate fungus in histologic sections. Our patients were cured by a combination of synovectomy and the intravenous administration of amphotericin B. Sporotrichosis should be considered in the differential diagnosis of the carpal tunnel syndrome, particularly when surgical exploration discloses a granulomatous tenosynovitis.

Adult↗
PubMed1978

A student's perspective on community medicine and the health crisis.

Community medicine is more difficult to teach and to learn than the traditional medical sciences. Teachers of community health have an interest in the rigors and theory of epidemiology and biostatistics, while most students plan a career in patient care. Abstractions and statistical data need not be presented unless it can be shown that these are the "physical findings" of a community and that they have value in the discovery of the etiology of disease, the prediction of risks, and the delivery of health care. Community medicine curricula must include experiential learning, with real patients and problems, in order to prove that health is affected by culture, politics, the environment, and individual behavior. If a student-physician's concern for community health is to be enduring, it must match in sophistication his skill in clinical medicine.

Community Medicine↗
PubMedDate not supplied

Detection of injury-prone behaviors among internal medicine patients.

OBJECTIVES: 1) To describe the prevalence of eight injury-prone behaviors (IPBs) and the associations of these behaviors with ten standard chronic disease and sociodemographic risk factors (CDSRFs) among internal medicine patients and 2) to identify a subset of patients with multiple IPBs who might be at particularly high risk of injury. DESIGN: Cross-sectional survey. SETTING: The University of Colorado Health Sciences Center general internal medicine clinic. PATIENTS: Four hundred ninety-two consecutive continuity care patients were eligible. The response rate was 94.3% (464/492). INSTRUMENT: A validated, self-administered questionnaire. MAIN RESULTS: Thirty-four percent of patients did not wear safety belts regularly and 32% had no smoke detector in their homes. Nearly 26% of patients had firearms at home and 6% had a loaded and unlocked gun at home. Fourteen percent of patients had seriously thought about suicide and 6% had attempted suicide. In the prior month, 10% had ridden with a drunk driver, and 4% had driven after drinking too much. Of patients aged 65 years or older, 50% had had recent falls. After adjustment for other CDSRFs, problem drinking was the CDSRF most frequently associated with IPBs. Among men, problem drinking was significantly associated with drinking and driving (OR = 35.3), safety belt non-use (OR = 4.3), and previous thoughts of or attempts at suicide (OR = 6.2). Among women, problem drinking was significantly associated with drinking and driving (OR = 8.7). Among men, being unmarried was the demographic risk factor associated with the most IPBs. Of all IPBs, safety belt non-use was most frequently associated with CDSRFs (ORs ranged from 2.8 to 4.4). Men with three or more IPBs were more likely to be problem drinkers (OR = 9.6), smokers (OR = 15.8), obese (OR = 6.3), and unmarried (OR = 67.1). CONCLUSIONS: 1) Injury-prone behaviors are common among patients attending a university-based internal medicine clinic; 2) men and women have substantially different patterns of risk factor associations; 3) CDSRFs, such as problem drinking smoking, and being unmarried, are associated with many IPBs; 4) safety belt non-use is the IPB associated with the most CDSRFs; and 5) CDSRFs appear to cluster in men with multiple IPBs, suggesting that screening for high-risk individuals may be feasible in clinical practice.

Accident Proneness↗
PubMedDate not supplied

A wide, complex look at cardiac dysrhythmias.

The diagnosis and treatment of cardiac dysrhythmias answers the following four questions: Is the patient stable? Is the rate fast or slow? Are the ventricular complexes wide or narrow? Is the rhythm regular or irregular? The most common narrow complex regular tachycardias are sinus tachycardia, atrial flutter, atrial tachycardia that blocks, and paroxysmal supraventricular tachycardia. Carotid sinus massage is useful in differentiation. Irregular narrow-complex tachycardias are usually atrial fibrillation. An ultra-rapid wide-complex or polymorphous irregular tachycardia is likely to be atrial fibrillation with ventricular preexcitation. Wide-complex regular tachycardias present a special challenge, since wide beats may result from supraventricular or ventricular impulse formation. Ventricular tachycardia is more likely than supraventricular tachycardia in the presence of underlying ischemic heart disease, atrioventricular dissociation, fusion or capture beats, or a very broad (greater than .14 seconds) QRS complex. Still, misdiagnosis is common; the most costly mistake is over-diagnosis of SVT. In emergencies, where vital organ hypoperfusion is present, the origin of the impulse and the name of the dysrhythmia are unimportant. With the exception of sinus tachycardia, all life-threatening, rapid tachycardias should be terminated by electrical cardioversion.

Anti-Arrhythmia Agents↗
PubMedDate not supplied

The electrocardiogram in chronic obstructive pulmonary disease.

The electrocardiogram is often abnormal in patients who have chronic obstructive pulmonary disease. The most frequent abnormalities are a rightward P-wave axis (greater than or equal to 70 degrees) and a rightward QRS axis (greater than or equal to 90 degrees). In addition, low voltage in the limb leads, an S1S2S3 pattern, poor R-wave progression, a posterior-superior terminal QRS vector or other changes may be present. Transient atrial and ventricular dysrhythmias are common. Knowledge of the usual electrocardiographic manifestations of chronic obstructive pulmonary disease enables the clinician to recognize uncharacteristic abnormalities, which often represent the effects of superimposed illnesses or drug toxicity.

Acute Disease↗
PubMedDate not supplied

Second-degree atrioventricular block: Mobitz type II.

Acute atrioventricular (AV) block occurs frequently in patients with myocardial infarction. Atrioventricular block is also a common manifestation of sclerodegenerative conduction system disease. Occasionally, heart block results from drug toxicity, hyperkalemia, cardiac valvular calcification, myocarditis, or infiltrative cardiomyopathy. Second-degree AV block is a form of "incomplete" heart block, in which some, but not all, atrial beats are blocked before reaching the ventricles. Mobitz type II second-degree block is an old term, which refers to periodic atrioventricular block with constant PR intervals in the conducted beats. The distinction between type II and type I block is descriptive; of greater importance to the clinician is the anatomic site of the block and the prognosis. In Mobitz type II block the site is almost always below the AV node; in Mobitz type I block the site is usually within the AV node. Type II AV block is more likely to progress to complete heart block and Stokes-Adams arrest. In most cases of second-degree heart block, including cases of 2:1 conduction, it is possible to determine the site of the AV block (intranodal or infranodal) using information about the age of the patient, the clinical setting, and the width of the QRS complex on the surface electrocardiogram. Second-degree atrioventricular block must be distinguished from other "causes of pauses." Nonconducted premature atrial contractions and atrial tachycardia with block are common conditions, which may mimic second-degree AV block.

Aged↗
PubMedDate not supplied

Recognition and treatment of multifocal atrial tachycardia: a critical review.

Multifocal atrial tachycardia (MAT) is an uncommon but clinically important tachydysrhythmia that is usually seen in the setting of severe cardiopulmonary illness. Diagnostic criteria include the presence of at least three different, nonsinus P waves in the same lead; an atrial rate greater than 100 beats per minute; and an isoelectric baseline between P waves. MAT is often difficult to differentiate from atrial fibrillation. The pathogenesis of MAT is unknown; however, it is probably incited by "triggered" electrical activity, a form of abnormal automaticity. This electrophysiologic model has led to several small, uncontrolled clinical trials using calcium channel and beta-adrenergic blocking agents, specifically verapamil and metropolol. None of these trials meets rigorous methodologic standards, and all exclude unstable patients who are at greatest risk for hemodynamic compromise from the tachycardia. Treatment of MAT should first be directed at potential predisposing factors, such as hypoxia, congestive heart failure, and theophylline toxicity. Pharmacologic treatment includes intravenous metoprolol or verapamil; in published reports both agents have been well tolerated and have controlled the heart rate in a majority of patients.

Adult↗