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Biomedical subjects

D A Brand

Publications and source records attributed to D A Brand.

33 records · Page 2Linked to original sources
PubMed1987

Evaluation of creatine kinase and creatine kinase-MB for diagnosing myocardial infarction. Clinical impact in the emergency room.

We prospectively studied the performance of emergency room strategies using a single sampling of total creatine kinase (CK) only and total CK with, if total CK levels were elevated, CK-MB levels in 639 patients with acute chest pain, including 386 patients who were admitted and 253 patients who were discharged. Acute myocardial infarction was diagnosed in 104 patients and excluded in 535. An elevated total CK level had a sensitivity of only 38% and specificity of only 80%, whereas a CK-MB level over 5% of an elevated total CK level had a sensitivity of only 34% and specificity of 88%. The sensitivities of both CK and CK-MB were higher in patients who arrived more than four hours after the onset of symptoms, and, in this population, the strategy using CK-MB performed significantly better than the strategy using total CK alone. Since a very positive CK-MB in a low-risk patient can greatly raise the probability of myocardial infarction, future strategies using CK-MB may have a role in selected subsets in determining which patients should not be sent home. However, the sensitivity of a single sampling of CK and CK-MB is too low for these assays to be used to exclude myocardial infarction in the emergency room or to be used as the rationale for deciding not to admit a patient.

Adult↗
PubMed1985

Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction.

We evaluated the initial electrocardiogram as a predictor of complications in 469 patients with suspected acute myocardial infarction. An electrocardiogram was classified as positive if it showed one or more of the following: evidence of infarction, ischemia, or strain; left ventricular hypertrophy; left bundle-branch block; or paced rhythm. Forty-two (14 per cent) of 302 patients with positive electrocardiograms had at least one life-threatening complication (ventricular fibrillation, sustained ventricular tachycardia, or heart block), as compared with 1 (0.6 per cent) of 167 patients with a negative electrocardiogram. Life-threatening complications were therefore 23 times more likely if the initial electrocardiogram was positive (P less than 0.001). Other complications were 3 to 10 times more likely (P less than 0.01), interventions were 4 to 10 times more likely (P less than 0.05), and death was 17 times more likely (P less than 0.001) in patients with a positive electrocardiogram. We conclude that patients with a negative initial electrocardiogram have a low likelihood of complications and could be admitted to an intermediate care unit instead of a coronary care unit. This would reduce admissions to the coronary care unit by 36 per cent and thereby save considerable hospital costs without compromising patient care.

Connecticut↗
PubMed1985

Effectiveness of prophylactic antibiotics in the outpatient treatment of burns.

We compared wound infection rates in 133 outpatient burns treated with prophylactic antibiotics in our emergency room and 161 similar, untreated burns. Infection rates in the treated and untreated groups were 3.8% (5/133) and 3.1% (5/161), respectively. Since this was an observational cohort study, it was necessary to demonstrate the comparability of treated and untreated groups with respect to risk factors for infection, including patient age, size, location, and etiology of the burn injury, time since injury, and presence of co-morbidity. The groups were found to be comparable for all risk factors except size of burn: larger burns were over-represented in the treated group (p less than 0.05). Even after controlling for size, antibiotic use did not lower the infection rate. These results argue strongly against routine use of systemic antibiotics in the treatment of outpatient burns.

Administration, Topical↗
PubMed1983

Adequacy of antitetanus prophylaxis in six hospital emergency rooms.

We studied the adequacy of antitetanus prophylaxis given to 620 patients with open soft-tissue injuries by 169 physicians in six hospital emergency rooms. Twenty-three per cent of the patients were treated incorrectly (6 per cent were undertreated and 17 per cent were overtreated) with tetanus toxoid or human tetanus immunoglobulin. Undertreatment ranged from 4 to 11 per cent, and overtreatment from 5 to 38 per cent at the different hospitals (P less than 0.01). Patients at highest risk for tetanus (those with tetanus-prone wounds who had never been given a complete initial course of immunizations) had the lowest likelihood (27 per cent) of receiving correct antitetanus treatment. By following an immunization protocol based on time since injury, mechanism of injury, estimated bacterial contamination, presence of devitalized tissue, wound depth, and past immunizations, physicians can better protect the population against tetanus while lowering the risk of adverse drug reactions and not increasing the cost of care.

Emergency Medical Services↗
PubMed1982

A protocol for selecting patients with injured extremities who need x-rays.

To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 patients to determine its safety and effectiveness. Strict adherence to the protocol would have reduced x-ray usage by 12 per cent for upper extremities and 19 per cent for lower extremities. The actual reductions were 5 per cent and 16 per cent, respectively, since further reductions were limited by patient's demands for x-ray examinations. One fracture in 287 were missed, but the treatment was appropriate and the outcome satisfactory. By eliminating superfluous x-ray procedures, the protocol could reduce charges by $79 million to $139 million nationwide, without compromising quality of care or increasing malpractice liability. Nevertheless, even the best protocol cannot eliminate all negative x-ray studies. These results should serve as a stimulus for judicious use of radiography, but also as a warning to avoid overzealous cost-containment strategies that would reduce x-ray usage to below a safe threshold.

Connecticut↗
PubMed1979

Quality assessment and the art of medicine: the anatomy of laceration care.

Assuring high quality medical care has remained an elusive goal because of several problems which have hampered development of effective medical audit programs: inadequate patient data, unreasonable evaluative criteria and insensitive audit procedures. The present study demonstrates the use of a clinical algorithm to help overcome these problems. An examination of medical record data from a series of 703 laceration patients treated in an emergency service yielded only 27 cases (4 per cent) with medical records sufficiently complete to use for auditing physician compliance with algorithmic criteria. Substituting a structured checklist for the handwritten note increased this rate to 86 per cent. A computer-assisted branching audit of 1,400 laceration cases demonstrated that 1) physician compliance with an algorithmic instruction varied significantly (p less than .001) according to the specific instruction, and 2) compliance with a given instruction varied significantly (p less than .001) across different providers. These results underscore the need for medical audit with educational feedback which is provider specific.

Connecticut↗
PubMed1978

A technique for analyzing clinical data to provide patient management guidelines.

This article describes a technique for analyzing clinical data in order to guide patient management decisions. The technique is illustrated by considering a specific decision problem encountered in the management of possible meningitis, namely, whether or not to administer antibiotics while awaiting the results of a CSF bacterial culture. Data from 303 patients with meningitis are analyzed in order to determine which combination of clinical variables best discriminates between bacterial and aseptic cases. From these variables, a probability tree is constructed that indicates the probability of bacterial meningitis, depending on a patient's clinical characteristics. In addition to identifying the most important variables, the analysis reveals that a number of tests performed routinely on patients with meningitis are of questionable diagnostic value.

Bacterial Infections↗
PubMedDate not supplied

Patients with acute chest pain who leave emergency departments against medical advice: prevalence, clinical characteristics, and natural history.

The study group identified 107 patients who left against advice from the emergency departments of three university and four community hospitals after presenting for evaluation of acute chest pain. In comparison with other emergency department patients with acute chest pain, patients who left against advice had findings that suggested they were at higher risk for myocardial infarction than patients for whom admission was not recommended but at lower risk than patients who consented to be admitted. Specific follow-up plans were made at the time of evaluation for 45 patients (42%). Survival data were obtained at 48-72 hours for 104 patients (97%) and at one month for 101 patients (94%). Fourteen patients (12%) were hospitalized within three days of their original emergency department visits, and three patients had documented acute myocardial infarctions. The only death within one month was that of a patient who died suddenly out-of-hospital later on the day of his emergency department visit. The authors conclude that patients who left against medical advice had presentations and prognoses that were in between those of patients for whom admission was not recommended and those of patients who consented to be admitted.

Adult↗
PubMedDate not supplied

Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain.

STUDY OBJECTIVE: To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain. DESIGN: Analysis of prospectively collected data from a cohort study. SETTING: Emergency departments of four community and three university hospitals. PATIENTS: 5,673 patients aged greater than or equal to 30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI). MEASUREMENTS AND MAIN RESULTS: After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p less than 0.0001). Admission rates of AMI patients with and without prior ECGs were similar. CONCLUSION: When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity).

Aged↗
PubMedDate not supplied

The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group.

OBJECTIVE: To identify differences in the incidences of myocardial infarction in women and men with chest pain. DESIGN: Prospective multicenter cohort study. SETTING: Emergency rooms of three university and four community hospitals. PATIENTS: 7,734 emergency room patients with acute chest pain. MEASUREMENTS AND MAIN RESULTS: Myocardial infarction was diagnosed in 10% of the 3,896 women, compared with 19% of the 3,838 men, yielding an age-adjusted relative risk of myocardial infarction for women of 0.54 (95% confidence interval 0.48, 0.60). Physicians were equally adept at admitting women and men with myocardial infarctions, but men without myocardial infarction or unstable angina were significantly more likely to be admitted than were women without these diagnoses. Most clinical and electrocardiographic features indicating a risk of myocardial infarction were present in both women and men, but several high-risk features were less commonly present in women. After adjusting for the other factors that correlate with each patient's probability of having acute myocardial infarction, the relative risk of myocardial infarction was the same in women as men when the emergency department electrocardiogram showed the classic changes associated with acute myocardial infarction, but the risk was 40% lower in women when such electrocardiographic changes were not present. CONCLUSIONS: Clinical features that predict myocardial infarction in men predict myocardial infarction in women to a similar extent. However, female gender is associated with about a 40% lower rate of myocardial infarction except when classic electrocardiographic evidence is present on the emergency department electrocardiogram.

Adult↗
PubMedDate not supplied

The role of topical treatment as a determinant of infection in outpatient burns.

Up to 95% of all burned patients are treated as outpatients. While uniform guidelines exist to evaluate the severity of an outpatient's burn, treatment forms vary greatly. Furthermore, the relative merits of one treatment modality over another have not been demonstrated. This study reviews 262 patients with uncomplicated, thermal partial-thickness burns. All of these patients were treated with either a petrolatum fine-mesh gauze (FMG = 102), a topical penetrating antibacterial agent (TPA = 58), or a topical nonpenetrating antibacterial agent (TNA = 102). The size of the injury along with its location and etiology, the age of the patient, the time from injury to treatment, and comorbid factors were comparable among the major treatment groups. On follow-up, a wound was classified as infected if it exhibited erythema, tenderness, increased warmth, and edema (cellulitis). Infection rates were 2.0% (2/102) in the FMG group, 5.2% (3/58) in the TPA group, and 2.0% (2/102) in the TNA group. The differences among the rates did not reach statistical significance (P = 0.41). Given the cost of treatment, frequency of dressing changes and overall patient comfort, we advocate FMG as the optimal method for the care of uncomplicated partial-thickness outpatient burns.

Administration, Topical↗
PubMedDate not supplied

Perfect timing, no remorse, and kidney transplantation.

Kidney transplantation is usually delayed until a patient has reached end-stage renal failure. When a living donor is used, earlier transplantation may be feasible. By averting the final stages of renal failure, early transplantation spares the patient the more pronounced effects of uremia. Unfortunately, lack of precision in predicting the future course of a patient's disease creates a dilemma: the kidneys could remain viable longer than anticipated. In that case, an early transplantation that leads to serious complications or graft failure will have caused harm by truncating the period of time the patient could have been sustained by his or her native kidneys. The present article introduces a theorem that helps solve the dilemma of early kidney transplantation. The theorem states that the timing decision depends only on the current burden of a disease relative to the risks of transplantation-that the future rate of progression of the disease is immaterial. The generality of the theorem makes it applicable, in principle, to any degenerative disease that can be treated by engraftment. The article also introduces a formula for the optimal timing of transplantation that depends on only four factors--a patient's perceived quality of life before transplantation as a function of time, the mortality associated with a transplant operation, the graft survival curve, and the quality of life in the event of a graft failure. The theorem and related formula should be helpful to patients and physicians in selecting the best time for transplantation.

Cost of Illness↗