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Biomedical subjects

A S Brett

Publications and source records attributed to A S Brett.

At least 19 recordsLinked to original sources
PubMed1997

Mandrake toxicity. A case of mistaken identity.

A 31-year-old man ingested an unknown amount of mandrake plant purchased at a local health food store and came to the emergency department with severe nausea and vomiting. He was hospitalized overnight but recovered uneventfully without obvious adverse systemic effects. This plant was almost certainly Podophyllum peltatum based on chromatographic identification of podophyllotoxin in a sample. However, the patient had mistakenly believed he was taking the anticholinergic and hallucinatory plant Mandragora officinarum, which is also known as mandrake. Other users of herbal substances and authors of the medical literature have also confused these 2 versions of mandrake. Given the growing popularity of alternative therapies, physicians should understand the distinction between these substances and should be aware of the medical effects of other commonly used herbal remedies.

Adult↗
PubMed1996

Differences in generalists' and cardiologists' perceptions of cardiovascular risk and the outcomes of preventive therapy in cardiovascular disease.

OBJECTIVE: To compare generalists' and cardiologists' estimates of baseline cardiovascular risk and the outcomes of preventive therapy. DESIGN: Cross-sectional mail survey using written case simulations of typical patients from primary prevention trials for hypercholesterolemia and isolated systolic hypertension, and tertiary prevention studies of coronary artery bypass surgery for chronic stable angina with left main coronary stenosis. PARTICIPANTS: Nationally representative sample of 599 practicing family physicians, general internists, and cardiologists selected from the American Medical Association masterfile. Among eligible physicians, 84 (44%) of 191 family physicians, 77 (40%) of 194 general internists, and 66 (34%) of 194 cardiologists responded. MEASUREMENTS: Estimates of risk at baseline and after therapy, and whether therapy generally would be recommended. RESULTS: For both primary prevention case simulations (scenarios), cardiologists provided lower, more accurate estimates of baseline cardiovascular risk and of absolute therapeutic benefit than either family physicians or general internists. The range of the generalists' estimates was extremely wide. Perceptions of relative risk reduction and treatment recommendations for the primary prevention scenarios did not differ among specialties. Overall, generalists who would not recommend primary preventive therapy in these scenarios appeared to give more accurate estimates than did generalists who would recommend such therapy. CONCLUSIONS: Many generalists have inflated perceptions of cardiovascular risk without treatment and of the benefit of risk-modifying medical treatment. Further study should assess the reasons for these misperceptions and their effect on counseling about primary preventive therapy.

Adult↗
PubMed1994

Screening for vitamin B12 deficiency in psychiatric patients.

Psychiatric patients are frequently screened for vitamin B12 deficiency in the absence of hematologic or other neurologic findings. To determine the yield of this practice, 162 psychiatric inpatients were screened for vitamin B12 deficiency. Ten patients had initial low serum vitamin B12 levels, but only two had definite B12 deficiency on further evaluation. Three patients who had initially low B12 levels had normal levels subsequently during outpatient follow-up. When low serum vitamin B12 levels are discovered in psychiatric patients without hematologic or neurologic findings, a diagnosis of B12 deficiency should not be presumed without further evaluation. Key words: screening: psychiatric patients; vitamin B12.

Adolescent↗
PubMed1991

Limitations of listing specific medical interventions in advance directives.

Recent events, including the Cruzan decision and the passage of the Patient Self-Determination Act, have renewed interest in the strengths and limitations of various types of advance directives. In one well-known approach, the competent person indicates preferences for or against a series of specific medical interventions that might be considered if the person loses decision-making capacity. However, such lists of interventions may shift attention away from overall treatment goals or may prescribe inappropriate medical care. Moreover, listing specific interventions in advance does not necessarily enhance self-determination or reduce uncertainty in decision making.

Advance Directives↗
PubMed1991

Psychologic effects of the diagnosis and treatment of hypercholesterolemia: lessons from case studies.

Some patients exhibit adverse psychologic responses to the diagnosis and treatment of hypercholesterolemia. These responses are, in part, a function of the patient's perception of the distinction between disease and illness and the patient's understanding of the probabilistic relationship between risk factors and associated diseases. Moreover, failure to acknowledge some of the specific complexities of hypercholesterolemia (e.g., natural fluctuations in serum cholesterol levels, variability of response to diet, etc.) may result in considerable anxiety. Clinicians should recognize and address these potential sources of dysfunctional psychologic reactions when they counsel hypercholesterolemic patients.

Adult↗
PubMed1990

Evaluation of substance-abusing adolescents by primary care physicians.

Physicians are in a unique position to identify substance-abusing adolescents. To evaluate physician performance from the patient's perspective, we interviewed 54 substance-abusing adolescents and their parents about previous medical encounters. Although nearly all patients had seen a physician during the time they were using drugs or alcohol, 43% did not recall being asked by a doctor about alcohol or drug use. Of the 26 patients who recalled being asked, 12 (46%) stated that they responded dishonestly, usually because a parent was present. Of the 23 who didn't recall being asked, five (18%) wished they had been asked. Physicians tended to ask about substance abuse more often (p = .08) when they had previously discussed the problem with the parents, but many parents did not initiate such discussions. This survey suggests that physicians may not adequately assess high-risk adolescents for substance abuse because of physician-, patient- and/or parent-dependent factors.

Adolescent↗
PubMed1988

Management of asymptomatic gallstones in the diabetic patient. A decision analysis.

The management of asymptomatic cholelithiasis in patients with diabetes is controversial. We used decision analysis to compare expectant management to prophylactic cholecystectomy in asymptomatic diabetic patients. Relevant probabilities were derived from the literature or expert opinion. Hypothetical cohorts of patients were followed for their lifetimes under each strategy. Expectant management was almost always the superior course. For example, a 30-year-old diabetic man gains an average of 6.1 months of life by choosing expectant management over prophylactic surgery. The superiority of expectant management was invariant to changes in age, sex, and the extent to which major surgical complications affect the future quality of life. Prophylactic cholecystectomy was superior only with extremely high estimates of the likelihood of developing symptomatic disease, the probability of requiring emergency surgery after symptoms develop, and emergency surgical mortality rates. However, no single factor had sufficient impact to alter the optimal decision by itself; the probabilities of several untoward events had to be increased simultaneously to favor prophylactic cholecystectomy. Prophylactic surgery for silent gallstones in diabetic patients does not increase life expectancy or quality of life and may in fact reduce it. This result holds over a wide range of basic assumptions.

Acute Disease↗
PubMed1988

Implications of discordance between clinical impression and toxicology analysis in drug overdose.

Two hundred nine cases of intentional drug overdose were reviewed to determine the importance of discordance between drugs identified by toxicology analysis and those suspected clinically. The laboratory agreed exactly with the clinical impression in 47% of cases. Clinically unsuspected drugs were identified by the laboratory in 27% of cases; the characteristics of these patients did not differ significantly from those of other patients. Unexpected toxicology findings led to changes in therapy in only three cases, and none of these changes appeared to have a major impact on outcome. Although routine comprehensive toxicology screening frequently may identify unsuspected drugs, it is likely that a policy of more selective use of the laboratory would not compromise the care of patients with drug overdose.

Adult↗
PubMed1987

Predicting the clinical course in intentional drug overdose. Implications for use of the intensive care unit.

Many patients admitted for observation to the intensive care unit after a drug overdose do not ultimately require intensive care interventions. We retrospectively analyzed data on 209 overdose cases to determine whether clinical assessment in the emergency room could identify patients at risk for complications. Patients were classified as low risk when none of the following high-risk criteria were present in the emergency room: need for intubation; seizures; unresponsiveness to verbal stimuli; arterial carbon dioxide pressure (tension) greater than or equal to 45 mm Hg; any rhythm except sinus; second- or third-degree atrioventricular block; QRS greater than or equal to 0.12 s; or systolic pressure less than 80 mm Hg. Of 151 low-risk patients, none developed a high-risk condition after admission, and none required an intensive care intervention. The use of these predictive criteria in our patient population would have eliminated over half the intensive care days without compromising quality of care.

Adult↗