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Biomedical subjects

T A Denton

Publications and source records attributed to T A Denton.

32 records · Page 2Linked to original sources
PubMed1994

Afterimages: integration of diagnostic information through Bayesian enhancement of scintigraphic images.

Although the diagnostic accuracy of myocardial perfusion scintigraphy can be improved by additional consideration of clinical and exercise information, multivariate prediction models are infrequently used for this purpose in the clinical setting. We therefore developed a Bayesian algorithm that instead transforms the scintigraphic image itself, modifying defect contrast as a function of the pretest likelihood of coronary artery disease. The algorithm was tested in computer simulations of myocardial perfusion scintigraphy with data from 378 patients (166 from California and 212 from West Virginia) who underwent planar exercise thallium-201 scintigraphy and coronary angiography. Images were interpreted before and after enhancement by eight readers (four at each medical center) with different training orientations (internist, radiologist, cardiologist, nuclear cardiologist, and nuclear medicine technologist) who used a four-point score (from 0, normal to 3, severe defect). Accuracy was quantified as area under a receiver-operating characteristic (ROC) curve. Improvements in accuracy obtained by the algorithm were compared to those provided by multiple logistic regression. Overall, Bayesian enhancement increased ROC area from 0.63 +/- 0.04 to 0.71 +/- 0.04 (p < 0.01). The improvement was consistent for all 16 reading sets (eight readers multiplied by two patient populations; p < 0.05). In comparison, multiple logistic regression increased ROC area from 0.63 +/- 0.04 to 0.79 +/- 0.03 (p < 0.01), outperforming interpretation of the enhanced images in 13 of the 16 reading sets. Bayesian enhancement improves diagnostic accuracy of conventional scintigraphic image interpretation. The improvement is stable across individuals, training orientations, and patient populations. Although this approach is not as accurate as multiple logistic regression, it may be more practical for widespread clinical application.

Algorithms↗
PubMed1994

Anemia therapy: individual benefit and societal cost.

The US health care system is under increasing pressure to lower costs while maintaining quality of care. Providers will be forced to (1) measure the benefits of a particular therapy, and (2) demonstrate that the benefits justify the costs. The major components of therapeutic benefit are survival and quality of life. Chronic anemia may have little impact on survival, but studies have measured significant decrements in quality of life without therapy and increments in quality of life with therapy. This disease also presents important societal financial concerns due to its many competing therapies. The annual cost of treatment can vary from an average of a few dollars for iron supplementation to an average of $6,000 for a course of recombinant human erythropoietin. Physicians need to integrate information on therapeutic outcomes and cost to maximize individual benefit and justify the costs. The choice of therapy for anemia associated with cancer is complex because the onset of the anemia is multifactorial, and the effects of anemia may be masked by the underlying malignancy. There are insufficient data supporting a specific recommendation for transfusion or recombinant human erythropoietin therapy. The current cost-conscious environment in the United States presents an opportunity for health care providers to formally document the benefits of anemia therapy and justify the societal costs based on those benefits. Anemia is an excellent example of a condition that allows the formal analysis of disease impact and the effectiveness and cost of therapy because (1) it has multiple therapies, (2) the cost of therapy varies widely, and (3) the therapies have variable benefit depending on the individual patient. Using a model based on chronic renal failure, an outcomes structure was developed by which the impact of anemia and the therapies used to manage it can be measured. Its potential application to anemia in patients with cancer is discussed.

Anemia↗
PubMed1993

Alternative perspectives on the biased foundations of medical technology assessment.

Medical technology assessment seeks to improve the care of individual patients (the conventional unit of clinical practice) through evaluation studies conducted in groups of patients (the conventional unit of clinical investigation). This distinction between individuals and groups has practical relevance to the design, analysis, and clinical applicability of technology assessment studies. We define several biased perspectives about technology assessment that derive from the distinction between individuals and groups: a misguided emphasis on efficacy versus effectiveness, on statistical significance versus clinical importance, and on objective versus subjective outcomes. In each case, we contrast these alternative perspectives and speculate on their implications for health care policy.

Bias↗
PubMed1993

Fee-for-benefit: a strategy to improve the quality of health care and control costs through reimbursement incentives.

OBJECTIVES: The purpose of this study was to determine whether reimbursement in direct proportion to expected therapeutic benefit is capable of improving the utilization and cost of health care. BACKGROUND: The benefit associated with a particular medical or surgical treatment varies widely from patient to patient. Nevertheless, payment to the provider of the treatment is essentially invariant under the current fee-for-service system. Under an alternative fee-for-benefit strategy, empiric data are used to construct a multivariate model to predict the expected benefit to an individual patient from a particular health care service on the basis of conventional clinical descriptors. The payers and the providers of the service then openly negotiate an explicit economic relation between expected benefit and monetary payment such that payment is directly proportional to benefit. METHODS: Computer simulations were performed to determine the potential impact of this fee-for-benefit strategy with respect to medical versus surgical treatment of coronary artery disease. RESULTS: Compared with conventional fee-for-service, fee-for-benefit resulted in a 12% improvement in patient benefit (quality-adjusted survival), a 22% reduction in provider payments and a 55% increase in cost/benefit (the ratio of benefit to payment). CONCLUSIONS: The incentives embodied in a fee-for-benefit strategy can be an effective mechanism for encouraging more appropriate health care utilization while simultaneously controlling health care costs.

Actuarial Analysis↗
PubMed1992

Phase plane plot of electrograms as a marker of ventricular electrical instability during acute ischemia: initial experimental results and potential clinical applications.

We used a phase plane plots method (a plot of voltage [V(t)] vs rate of change of voltage [dV/dt]) derived from nonlinear dynamics to transform a sinus rhythm strip into a geometric form. The geometric form thus obtained detects variations in the ECG over time and therefore may aid in identifying patterns of vulnerability to ventricular fibrillation (VF). The trajectories of consecutive ventricular depolarizations and repolarizations of sinus rhythm in dogs that evolve to VF showed characteristic differential band thickening (inhomogeneities) that were absent in the dogs that did not develop VF. This method of analysis can be a useful complementary tool to detect cardiac electrical instability, and with simple hardware, can easily be displayed in real time.

Animals↗
PubMed1991

Can the analytic techniques of nonlinear dynamics distinguish periodic, random and chaotic signals?

Recent advances in the mathematical discipline of nonlinear dynamics have led to its use in the analysis of many biologic processes. But the ability of the tools of nonlinear dynamic analysis to identify chaotic behavior has not been determined. We analyzed a series of signals--periodic, chaotic and random--with five tools of nonlinear dynamics. Periodic signals were sine, square, triangular, sawtooth, modulated sine waves and quasiperiodic, generated at multiple amplitudes and frequencies. Chaotic signals were generated by solving sets of nonlinear equations including the logistic map, Duffing's equation, Lorenz equations and the Silnikov attractor. Random signals were both discontinuous and continuous. Gaussian noise was added to some signals at magnitudes of 1, 2, 5, 10 and 20% of the signal's amplitude. Each signal was then subjected to tools of nonlinear dynamics (phase plane plot, return map, Poincaré section, correlation dimension and spectral analysis) to determine the relative ability of each to characterize the underlying system as periodic, chaotic or random. In the absence of noise, phase plane plots and return maps were the most sensitive detectors of chaotic and periodic processes. Spectral analysis could determine if a process was periodic or quasiperiodic, but could not distinguish between chaotic and random signals. Correlation dimension was useful to determine the overall complexity of a signal, but could not be used in isolation to identify a chaotic process. Noise at any level effaced the structure of the phase plane plot. Return maps were relatively immune to noise at levels of up to 5%. Spectral analysis and correlation dimension were insensitive to noise. Accordingly, we recommend that unknown signals be subjected to all of the techniques to increase the accuracy of identification of the underlying process. Based on these data, we conclude that no single test is sufficiently sensitive or specific to categorize an unknown signal as chaotic.

Fourier Analysis↗
PubMed1990

Fascinating rhythm: a primer on chaos theory and its application to cardiology.

Nonlinear dynamics is an exciting new way of looking at peculiarities that in the past have been ignored or explained away. We have attempted to give a general introduction to the basics of the mathematics, applications to cardiology, and a brief review of the new tools needed to use the concepts of nonlinear mathematics. The careful mathematical approach to problems in cardiac electrical dynamics and blood flow is opening a window on behaviors and mechanisms previously inaccessible.

Animals↗
PubMed1985

Rate-dependent effects of procainamide on His-Purkinje conduction in man.

Microelectrode studies in isolated cardiac tissues have shown that the depressant effect of several antiarrhythmic drugs on the maximal upstroke velocity of the cardiac action potential is rate-dependent. To determine whether this effect of antiarrhythmic drugs is seen in humans, 14 patients undergoing atrial pacing at several rates were prospectively studied before and after the infusion of procainamide (15 mg/kg). The HV interval (His-Purkinje conduction rate) and the QRS duration (intraventricular conduction rate) were measured. Before procainamide infusion, atrial pacing did not significantly prolong the maximal HV interval (from 54 +/- 15 to 58 +/- 13 ms). After procainamide infusion (mean serum level 10.0 +/- 3 micrograms/ml) atrial pacing at an average of 5 pacing rates significantly prolonged the HV interval (from 67 +/- 18 to 80 +/- 20 ms, p less than 0.001). The extent of HV prolongation with atrial pacing after procainamide infusion was independent of the HV interval at rest before procainamide. The duration of the QRS complex also tended to prolong with atrial pacing after procainamide infusion, but this prolongation was not statistically significant. Thus, procainamide produces a rate-dependent depressant effect on His-Purkinje and intraventricular conduction, confirming observations made in isolated tissue preparations.

Adult↗
PubMedDate not supplied

A career imperative.

The hospital industry has experienced major change in its organizational, delivery, financial, and social schema. As a result, the role of the healthcare executive has also changed. The new professional administrator requirements have called for the lengthening of academic programs to meet the evolving challenges of the industry. The lack of a formal means of entry into the profession has left many confused because of the various professional development models available. Without proper advice, these do not hold significant distinction for the recent graduate. Academic programs have been lengthened from one to two years of academic coursework while the traditionally required residency has been virtually eliminated. Increased demands on both practitioners and professors of academic programs have caused a schism between theory and practice, adversely affecting the student preparing for the profession. The problem is compounded by the various professional development models available and the several opinions as to which is "best". The confusion for students, faculty, and practitioners which has resulted must be minimized through recognition of the problem, clarification of terminology, bridging the gap between academic and practice, and a rekindling of the mentor/protege relationship.

Hospital Administration↗