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Biomedical subjects

B P Schmitt

Publications and source records attributed to B P Schmitt.

At least 19 recordsLinked to original sources
PubMed2000

Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity.

BACKGROUND: The validity of outcome report cards may depend on the ways in which they are adjusted for risk. OBJECTIVES: To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method. DESIGN: Analysis of data from a prospective cohort study. SETTING: A university hospital, a Veterans Affairs (VA) medical center, and a community hospital. PATIENTS: Sequential patients presenting in the emergency department with acute congestive heart failure. MEASUREMENTS: Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index). RESULTS: The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment. CONCLUSIONS: Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.

APACHE↗
PubMed1997

Physicians' survival predictions for patients with acute congestive heart failure.

BACKGROUND: Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. OBJECTIVE: To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival. METHODS: This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases. RESULTS: By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.66 [SE = 0.020] for 90 days; 0.63 [SE = 0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%. CONCLUSIONS: Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Acute Disease↗
PubMed1997

Physicians' judgments of the risks of cardiac procedures. Differences between cardiologists and other internists.

OBJECTIVES: The authors compared judgments of the population risks of invasive cardiac procedures made by cardiologists and other internal medicine physicians. Our main hypotheses were that cardiologists' judgments would differ from those made by the other physicians and that cardiologists' judgments would be more accurate than those of other physicians. METHODS: This was a cross-sectional survey of senior staff and physician-trainees at two teaching hospitals affiliated with a US medical school, Emergency Department physicians at a community hospital in the same metropolitan area, and senior staff and trainees at two teaching hospitals affiliated with a UK school. Judgments of the risks of severe morbidity and death due to Swan-Ganz catheterization, cardiac catheterization, percutaneous coronary angioplasty, and coronary artery bypass grafting were assessed. RESULTS: Nineteen cardiologists judged the risks of severe morbidity due to all procedures and the risks of death due to all procedures except coronary artery bypass grafting to be significantly lower than did the 78 other internists. Cardiologists more frequently made accurate judgments of the rates of morbidity and death due to cardiac catheterization than did the other internists; other internists more frequently made accurate judgments for the rates of morbidity due to Swan-Ganz catheterization. CONCLUSIONS: Disagreements about the risks of procedures may arise from a paucity of published data, or from an over-supply of confusing data.

Angioplasty, Balloon, Coronary↗
PubMed1993

Heparin-associated thrombocytopenia: a critical review and pooled analysis.

The purpose of this study is to determine the incidence of heparin-associated thrombocytopenia (HAT) for various subgroups of heparin exposed patients and the impact of study quality on the reported incidence. Articles were identified using a Medline search, a manual search of the Index Medicus, and a review of article references. Key data included heparin type, administration route, indication, treatment duration, outcome criteria, incidence, and platelet count reliability. The pooled incidence estimate in studies requiring a repeatedly abnormal platelet count was compared with estimates from studies not requiring a repeated platelet count. The results showed that there were no adequately designed studies to estimate the incidence of HAT-related thrombosis or hemorrhage. The pooled incidence of HAT in studies requiring a reproducibly lowered platelet count (< 100,000/microL) was 3/281 (1.1%) with intravenous porcine heparin and 4/140 (2.9%) with intravenous bovine heparin. This difference was not statistically significant. The incidence of HAT with intravenous bovine heparin was significantly lower in studies that required a repeated platelet count. The incidence of HAT with heparin administered subcutaneously was small (0%) and in those studies requiring a repeatedly abnormal platelet count, there was no difference between porcine and bovine heparin. The authors concluded that the incidence of HAT is < 3% with intravenous heparin and extremely low for subcutaneous heparin. Study quality may influence the reported incidence of HAT.

Adult↗
PubMed1991

Does hypogonadism contribute to the occurrence of a minimal trauma hip fracture in elderly men?

The risk of MTHF in hypogonadal elderly men was investigated with a case-control model. Cases and controls were selected from males age 65 years and older residing in the 120-bed McGuire Veterans Affairs Medical Center Nursing Home Care Unit over a 5-day interval. Historical data and serum free testosterone (fTe) were available on 17 subjects with MTHF and 61 controls. When groups were compared for differences in age, race, alcohol abuse, cigarette abuse, and diseases or drugs that may be associated with MTHF, only race was significantly different. Although 25.6% of residents were black, 100% of MTHF subjects were white (P = 0.004). Hypogonadism was defined as a random fTe less than 9 pg/mL (normal 9 to 46 pg/mL) and was found in 21 subjects (26.9%). Of cases with a MTHF, 58.8% were hypogonadal compared with only 18.0% of controls. Utilizing logistic regression, a highly significant association was found between hypogonadism and MTHF (P = 0.008), and using the odds ratio, subjects with hypogonadism were 6.5 times more likely to have a MTHF (95% CI 2.0 to 20.6). To adjust for race, the odds ratio was repeated excluding black subjects, and the results remained highly significant (4.6, 95% CI 1.3 to 16.2). We conclude that hypogonadal elderly white men may be at increased risk for MTHF.

Black or African American↗
PubMed1991

New hope for failing hearts.

Major changes in our understanding of congestive heart failure have resulted from an etiologic shift, identification of neurohormonal effects, and a realization of the importance of diastolic dysfunction. Accordingly, management has changed. Digitalis should be avoided with diastolic dysfunction. When the dysfunction is systolic, a regimen of digitalis, diuretic and ACE inhibitor may be optimal.

Aged↗
PubMed1985

A method to determine attitudes of faculty members toward use of laboratory tests.

Investigators have suggested that attitudes of faculty members toward diagnostic testing may encourage inappropriate laboratory use. In the present paper, the authors present a method for determining faculty attitudes on laboratory tests and the results of an analysis of such attitudes at one institution. The attitudes were determined from case simulations prepared by the faculty for senior medical student examinations. At the time the examination was being constructed, the faculty members weighted each laboratory test option following the case presentation for its appropriateness as positive, zero, or negative. The investigators subsequently categorized all of the laboratory tests according to their purpose and appropriateness with respect to the likelihood of diagnostic possibilities generated by the case. The results of the analysis showed that screening tests and tests to investigate unlikely diagnoses usually received weights close to zero and rarely received negative weights. This apparent indifference to tests with limited usefulness that generate some costs may be perceived by students as permission for their continued use.

Attitude of Health Personnel↗
PubMed1984

Prevalence of hypocalcemia and elevated serum alkaline phosphatase in patients receiving chronic anticonvulsant therapy.

Residents of an institution for the developmentally disabled in northwest Ohio receiving anticonvulsant therapy for six months or more with phenobarbital or phenytoin or both were studied for the prevalence of hypocalcemia and elevated alkaline phosphatase level. Fifty-six residents were identified. Sixteen (29 percent) were hypocalcemic. Fifteen (27 percent) had elevated serum alkaline phosphatase levels. Twenty-three residents received vitamin D supplementation (400 IU/d) in addition to a normal dietary intake of calcium and vitamin D. The mean serum calcium level was identical (8.65 mg/dL) for those receiving and not receiving additional vitamin D. This study corroborates the findings of prior studies suggesting an association between anticonvulsant usage and mineral and bone abnormalities. The causal nature of this association, its clinical significance, and its management require further investigation.

Adolescent↗
PubMed1981

Encephalopathy complicating Whipple's disease: failure to respond to antibiotics.

Progressive dementia, vertical ophthalmoplegia, and prominent hypothalamic dysfunction developed in one patient with documented intestinal Whipple's disease despite ongoing antibiotic therapy with intestinal remission. A clinical diagnosis of central nervous Whipple's disease was made on the basis of the patient's presentation. High-dose parenteral penicillin and chloramphenicol were administered for 4 1/2 weeks. There was no improvement in results of daily mental status examination or neuropsychologic testing. Deterioration was noted in the electroencephalographic findings after therapy. Vigorous antibiotic therapy with agents that cross the blood-brain barrier had no immediate beneficial effect. Irreversible neurologic damage or a slow, delayed response may account for this observation.

Adult↗
PubMedDate not supplied

The diagnostic usefulness of the history of the patient with dyspnea.

The diagnostic usefulness of the medical history may depend on the type of problem confronted. It has been suggested that dyspnea is an example of a condition the causes of which cannot be easily distinguished based on identification in the history of stereotypical disease patterns presented in standard texts. To evaluate this assertion, faculty members independently interviewed 146 consecutively admitted patients with dyspnea, and following the history of the present illness, made a diagnosis. After discharge of the patients, another faculty member, using preselected criteria, independently reviewed each record to make a final diagnosis. History-based diagnoses predicted final diagnoses 74% of the time. Therefore, the history appeared to be useful in identifying the primary diagnosis for most dyspneic patients admitted to the hospital. However, it is not known whether this identification provides sufficient rationale for therapy or leads to more efficient use of laboratory tests.

Adolescent↗
PubMedDate not supplied

Laboratory use: attitudes implicit in a national examination.

The quantitative principles of test selection and interpretation have been reluctantly integrated into clinical practice. This reluctance may reflect an underlying faculty attitude towards the laboratory. To evaluate this attitude, the scoring standards used for 23 patient management problems (PMPs) in the 1980 and 1983 Medical Knowledge Self-Assessment Programs were reviewed. All diagnostic options were categorized by dollar cost, risk, and a determination of "routineness." Attitudes were probed by reviewing the scores obtained by indiscriminate selection of all items in a category. Our analysis indicated that the examiners valued routine, little-ticket, little-risk items. Such selection would be rewarded 85% of the time and in 95%, no penalty would be received. Further, indifference was more frequent for little-ticket items and accounted for 11.7% of acceptable diagnostic expense. An examinee analyzing these scoring keys could reasonably conclude that routine, little-ticket items should be ordered whenever offered. Hence, at a national level, there is an attitude that implicitly encourages the use of these items in clinical practice.

Attitude of Health Personnel↗
PubMedDate not supplied

An international comparison of physicians' judgments of outcome rates of cardiac procedures and attitudes toward risk, uncertainty, justifiability, and regret.

OBJECTIVE: Compare U.K. and U.S. physicians' judgments of population probabilities of important outcomes of invasive cardiac procedures; and values held by them about risk, uncertainty, regret, and justifiability relevant to utilization of cardiac treatments. DESIGN: Cross-sectional study. SETTING: University hospital and VA medical center in the United States; two teaching hospitals in the United Kingdom. PARTICIPANTS: 171 housestaff and attendings at U.S. teaching hospitals; 51 physician trainees and consultants at U.K. hospitals. MEASURES: Judgments of probabilities of severe complications and deaths due to Swan-Ganz catheterization, cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG); judgments of malpractice risks for case vignettes; Nightingale's risk-aversion instrument; Gerrity's reaction-to-uncertainty instrument; questions about need to justify decisions; responses to case vignettes regarding regret. RESULTS: The U.S. physicians judged rates of two bad outcomes of cardiac procedures (complications due to cardiac catheterization; death due to CABG) to be significantly higher (p < or = 0.01) than did the U.K. physicians (U.S. medians, 5 and 3.5, respectively; U.K. medians 3 and 2). The median ratio of (risk of malpractice suit I error of omission)/(risk of suit I error of commission) judged by U.K. physicians, 3, was significantly (p=0.0006) higher than that judged by U.S. physicians, 1.5. The U.K. physicians were less often risk-seeking in the context of possible losses than the U.S. physicians (odds ratio for practicing in the U.K. as a predictor of risk seeking 0.3, p=0.003). The U.K. physicians had significantly more discomfort with uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (U.K. median 48, U.S. 42, p=0.0001) and the reluctance-to-disclose-uncertainty scale (U.K. 40, U.S. 37, p < 0.0001) of the Gerrity instrument. There was no clear international difference in perceived need to justify decisions, or in regret. CONCLUSIONS: The results were not clearly consistent with the uncertainty hypothesis that international practice variation is due to differences in judged rates of outcomes of therapy or with the imperfect-agency hypothesis that practice variation is due to differences in physicians' personal values. The causes and implications of practice variations remain unclear.

Angioplasty, Balloon, Coronary↗