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Biomedical subjects

E Z Oddone

Publications and source records attributed to E Z Oddone.

At least 37 records · Page 2Linked to original sources
PubMed1997

Prognostic value of the clinical examination of the diabetic foot ulcer.

OBJECTIVE: To determine the value of the history, physical examination, and magnetic resonance imaging (MRI) in predicting successful primary healing of a foot ulcer in a diabetic patient. DESIGN: Prospective cohort study. SETTING: Durham (NC) Veterans Affairs Medical Center. PATIENTS: Sixty-four consecutive diabetic patients with 78 dermal ulcers through the full thickness of the skin and at or distal to the malleoli of the ankle. MEASUREMENTS AND MAIN RESULTS: A structured clinical history and physical examination were performed by two examiners, a physician participating in the study and the referring physician. Fifty of these patients with 63 ulcers underwent MRI. Patients were followed prospectively for 6 months after enrollment to ascertain healing of the ulcer, amputation, and death. During the 6-month follow-up period, 8 (13%) of the patients died. Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers failed to heal, and 36 (47%) healed primarily. Univariate predictors of healing at 6 months included age less than 65 years, diagnosis of diabetes within the last 15 years, painless ulcer, palpable ankle pulse, anklebrachial index greater than 0.5, and the physician's assessment of the overall likelihood of osteomyelitis. In a multivariable logistic regression model, predictors of healing included the presence of an audible pulse on Doppler examination (p = .01) and a painless ulcer (p = .04). The diagnosis of osteomyelitis on MRI did not predict healing in these patients. CONCLUSIONS: Foot ulcers in patients with diabetes frequently have poor outcomes; fewer than half the patients in this study healed their ulcers within 6 months. The vascular components of the clinical examination are the best predictors of healing in patients with a diabetic foot ulcer.

Adult↗
PubMed1997

Influence of projected complication rates on estimated appropriate use rates for carotid endarterectomy. Appropriateness Project Investigators. Academic Medical Center Consortium.

OBJECTIVE: To examine specifically the influence of estimated perioperative mortality and stroke rate on the assessment of appropriateness of carotid endarterectomy. DATA SOURCES/STUDY SETTING: An expert panel convened to rate the appropriateness of a variety of potential indications for carotid endarterectomy based on various rates of perioperative complications. We then applied these ratings to the charts of 1,160 randomly selected patients who had carotid endarterectomy in one of the 12 participating academic medical centers. STUDY DESIGN: An expert panel evaluated indications for carotid endarterectomy using the modified Delphi approach. Charts of patients who received surgery were abstracted, and clinical indications for the procedure as well as perioperative complications were recorded. To examine the impact of surgical risk assessment on the rates of appropriateness, three different definitions of risk strata for combined perioperative death or stroke were used: Definition A, low risk < 3 percent; Definition B, low risk < 5 percent; and Definition C, low risk < 7 percent. PRINCIPAL FINDINGS: Overall hospital-specific mortality ranged from 0 percent to 4.0 percent and major complications, defined as death, stroke, intracranial hemorrhage, or myocardial infarction, varied from 2.0 percent to 11.1 percent. Most patients (72 percent) had surgery for transient ischemic attack or stroke; 24 percent of patients were asymptomatic. Most patients (82 percent) had surgery on the side of a high-grade stenosis (70-99 percent). When the thresholds for operative risk were placed at the values defined by the expert panel (Definition A), only 33.5 percent of 1,160 procedures were classified as "appropriate." When the definition of low risk was shifted upward, the proportion of cases categorized as appropriate increased to 58 percent and 81.5 percent for Definitions B and C, respectively. CONCLUSIONS: Despite the high proportion of procedures performed for symptomatic patients with a high degree of ipsilateral extracranial carotid artery stenosis and generally low rates of surgical complications at the participating institutions, the overall rate of "appropriateness" using a perioperative complication rate of < 3 percent was low. However, the rate of "appropriateness" was extremely sensitive to judgments about a single clinical feature, surgical risk. These data show that before applying such "appropriateness" ratings, it is crucial to perform sensitivity analyses in order to assess the stability of the results. Results that are robust to moderate in variation in surgical risk provide a much sounder basis for policy making than those that are not.

Academic Medical Centers↗
PubMed1996

Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission.

BACKGROUND: For chronically ill patients, readmission to the hospital can be frequent and costly. We studied the effect of an intervention designed to increase access to primary care after discharge from the hospital, with the goals of reducing readmissions and emergency department visits and increasing patients' quality of life and satisfaction with care. METHODS: In a multicenter randomized, controlled trial at nine Veterans Affairs Medical Centers, we randomly assigned 1396 veterans hospitalized with diabetes, chronic obstructive pulmonary disease, or congestive heart failure to receive either usual care or an intensive primary care intervention. The intervention involved close follow-up by a nurse and a primary care physician, beginning before discharge and continuing for the next six months. RESULTS: The patients were severely ill. Half of those with congestive heart failure (504 patients) had disease in New York Heart Association class III or IV; 30 percent of those with diabetes (751 patients) had end-organ damage; and a quarter of those with chronic obstructive pulmonary disease (583 patients) required home oxygen treatment or oral corticosteroids. The patients had extremely poor quality-of-life scores. Although they received more intensive primary care than the controls, the patients in the intervention group had significantly higher rates of readmission (0.19 vs 0.14 per month, P = 0.005) and more days of rehospitalization (10.2 vs 8.8, P = 0.041). The patients in the intervention group were more satisfied with their care (P < 0.001), but there was no difference between the study groups in quality-of-life scores, which remained very low (P = 0.53). CONCLUSIONS: For veterans discharged from Veterans Affairs hospitals, the primary care intervention we studied increased rather than decreased the rate of rehospitalization, although patients in the intervention group were more satisfied with their care.

Aged↗
PubMed1996

AIDS-related Pneumocystis carinii pneumonia in older patients.

MAIN RESULTS: Compared with younger patients, patients aged 50 years or older were less likely to have acquired HIV via intravenous drug use or homosexual contact (p = .0001). Older patients were more likely to have comorbid diseases (12% vs 4%; p = .0001), had more frequent neurologic findings on admission (19% vs 9%; p = .0001), and scored higher on a PCP-specific severity-of-illness scale indicating more severe disease (p = .0001). Older patients had more intensive care unit admissions and intubations (p = .0001). Patients aged 50 years or older were less likely to have a diagnosis of HIV mentioned in their progress notes during the first 2 days of admission (75% vs 85%; p = .0001), less likely to receive PCP-specific therapy within the first 2 hospital days (58% vs 76%; p = .0001), and more likely to receive steroids (32% vs 22%; p = .0001). Older patients had a greater in-hospital mortality (32% vs 18%; p = .0001). However, in logistic regression analysis with mortality as the outcome, the effect of older age was diminished when adjustments were made for insurance status, severity of illness, comorbidity, timely PCP therapy, and inpatient use of steroids. CONCLUSIONS: Age differences in mortality for AIDS-related PCP may be explained by increased severity of presenting illness, underrecognition of HIV, and delay in initiation of PCP-specific therapy. Physicians may need to consider HIV-related infections for persons aged 50 years or older at risk of HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1996

Classifying general medicine readmissions. Are they preventable? Veterans Affairs Cooperative Studies in Health Services Group on Primary Care and Hospital Readmissions.

OBJECTIVES: To describe a new quality assessment method used to classify the preventability of hospitalization in terms of patient, clinician, or system factors. DESIGN: The instrument was developed in two phases. Phase 1 was a prospective comparison of admitting residents' and their attending physicians' classifications of the perceived preventability of consecutive admissions to one Veterans Affairs Medical Center (VAMC) excluding admissions to the intensive care unit (ICU). In phase 2, a panel of 10 physicians rated 811 abstracted records of readmissions from nine VAMCs. SETTING: Nine VAMCs across the United States with varying degrees of university hospital affiliation. PATIENTS: Phase 1, 156 patients admitted to the general medicine service at the Durham VAMC. Phase 2, 514 patients accounting for 811 readmissions within 6 months of a general medicine service discharge at nine VAMCs. MEASUREMENTS AND MAIN RESULTS: Physicians used a checklist to record the reason for hospitalization, the preventability of the hospitalization, and, if preventable, a reason defining preventability, which was classified in terms of system, clinician, and patient factors. In phase 2, two physician panelists assessed preventability for each chart. When two panelists disagreed on the preventability of hospitalization, a third panelist, blind to the original assessments, rated the chart. In phase 1, residents and attending physicians rated 33% and 34% of admissions as preventable (kappa = 0.41), respectively. In phase 2, 277 (34%) of 811 readmissions were deemed preventable. Intraobserver accuracy for the assessment of preventability was 96% (kappa = 0.89). interobserver accuracy was 73% (kappa = 0.43). Hospital system factors accounted for 37% of preventable readmissions, clinician factors for 38%, and patient factors for 21%. The nine hospitals differed markedly in their profile of reasons for preventable readmissions (p = .005). CONCLUSIONS: Using a new method of determining the preventability of hospitalizations, we identified several factors that might avert hospitalizations. Focusing efforts to identify preventable hospitalizations may yield better methods for managing patients' total health care needs; however, the content of those efforts will vary by institution.

Adult↗
PubMed1996

Are health-related quality-of-life measures affected by the mode of administration?

While measures of health-related quality of life (HRQOL) are increasingly being used as outcomes in clinical trials, it is unknown whether HRQOL assessments are influenced by the method of administration. We compared telephone, face-to-face, and self-administration of a commonly-used HRQOL measure, the SF-36. Veterans (N = 172) receiving care in the General Medicine Clinic were randomized into groups differing only in order of administration. All patients were asked to complete the SF-36 three times over a 4-week period. The SF-36 demonstrated high internal consistency, regardless of mode of administration, but showed large variation over short intervals. This variation may: (1) increase dramatically sample size requirements to detect between-group differences in randomized trials and (2) reduce the SF-36's usefulness for clinicians wishing to follow individual patients over time.

Activities of Daily Living↗
PubMed1996

Clinical and radiographic findings that lead to intervention in diabetic patients with foot ulcers. A nationwide survey of primary care physicians.

OBJECTIVE: To determine which elements of clinical history, physical examination, and diagnostic tests are important to primary care physicians in their management of foot ulcers in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted a national mail survey of 600 primary care physicians to determine which patient characteristics and diagnostic test results were important in their decisions to seek radiographic studies, surgical referrals, and hospitalization for diabetic patients with foot ulcers. RESULTS: The case characteristics most likely to influence physicians to order advanced diagnostic or therapeutic interventions are the presence of osteomyelitis on plain radiographs, the failure of the ulcer to improve with conservative therapy, and the presence of visible bone, crepitus, or necrosis within the ulcer (P < 0.001). Information from the initial clinical history was less likely to influence physicians to order advanced diagnostic or therapeutic interventions (P < 0.001) than was information from the physical examination. CONCLUSIONS: We conclude that 1) the patient's history is relatively unimportant to primary care physicians in their management of diabetic foot ulcers; 2) the failure of conservative management is a major reason that primary care physicians order surgical referral, hospitalization, or radiographic testing for diabetic patients with foot ulcers; and 3) primary care physicians rely heavily on plain X ray of the foot, a test with poor sensitivity and specificity, in deciding whether to order further interventions for their diabetic patients with foot ulcers.

Data Collection↗
PubMed1995

The role of antineutrophil cytoplasmic antibody (c-ANCA) testing in the diagnosis of Wegener granulomatosis. A literature review and meta-analysis.

PURPOSE: To summarize the literature on the clinical utility of antineutrophil cytoplasmic antibody (c-ANCA) as a diagnostic marker for Wegener granulomatosis. DATA SOURCES: A structured literature search was done using MEDLINE; this search, combined with a manual search, yielded 747 articles for potential inclusion. These articles passed through a 4-stage review. Studies were included if they had a specified reference standard and a systematic method of patient selection and if a 2 x 2 contingency table could be constructed from their results. Fifteen articles met these criteria. DATA EXTRACTION: 3 physicians reviewed all selected articles. Detailed data abstraction was done, and the quality of the study methods was assessed. Items abstracted included the method of patient selection, the study design, the reference standard, the c-ANCA testing technique, disease activity, and the test results. Disagreements among reviewers were resolved by consensus. Contingency tables were used to calculate the operating characteristics for Wegener granulomatosis overall and for active and inactive Wegener granulomatosis. RESULTS: The sensitivities of c-ANCA testing for overall Wegener granulomatosis ranged from 34% to 92%, and the specificities ranged from 88% to 100%. The pooled sensitivity was 66% (95% CI, 57% to 74%), and the pooled specificity was 98% (CI, 96% to 99.5%). Four articles provided data on disease activity. For active disease, the pooled sensitivity was 91% (CI, 87% to 95%), and the pooled specificity was 99% (CI, 97% to 99.9%). For inactive disease, the pooled sensitivity and specificity were 63% and 99.5%, respectively. CONCLUSIONS: Although c-ANCA test results may serve clinicians as adjunct evidence for the diagnosis of Wegener granulomatosis, these results must be viewed in the context of the patient's clinical picture and disease activity and the prevalence of Wegener granulomatosis in the clinical setting in which the patient is seen.

Antibodies, Antineutrophil Cytoplasmic↗
PubMed1995

Noninvasive carotid artery testing. A meta-analytic review.

PURPOSE: To compare the operating characteristics of six noninvasive tests for carotid artery stenosis. DATA SOURCES: A structured search was done using MEDLINE, reference lists from selected articles, and bibliographies from neurology textbooks that focused on the diagnosis of carotid artery stenosis in humans. The search yielded 568 articles. STUDY SELECTION: Articles were selected if the noninvasive test results they presented used carotid angiography as the reference standard for comparison, if carotid artery occlusion was considered as a separate category, and if contingency tables could be constructed. DATA EXTRACTION: At least two physicians reviewed all selected articles. Items abstracted included patient demographics, study design, sites of patient enrollment, whether the interpretation of test outcomes was blinded, and specific results. Sensitivity, specificity, receiver operating characteristic (ROC) curves, and summary measures of effectiveness for each test were calculated. RESULTS: Carotid duplex ultrasonography, carotid Doppler ultrasonography, and magnetic resonance angiography have sensitivities between 0.82 and 0.86, specificities at 0.98, and test-effectiveness measures at or exceeding 3.0 when predicting 100% occlusion. For carotid stenosis of 70% or more, these three tests and supraorbital Doppler ultrasonography all have sensitivities of 0.83 to 0.86, specificities of 0.89 to 0.94, test-effectiveness measures approaching 3.0, and composite ROC areas of 0.91 to 0.92. Limiting analysis to studies that enrolled consecutive patients and those in which interpretation of the noninvasive tests was independent of the angiograms did not substantially change our results. CONCLUSIONS: Carotid duplex ultrasonography, carotid Doppler ultrasonography, and magnetic resonance angiography are all similarly successful at predicting 100% carotid artery occlusion and 70% stenosis. Other factors, such as cost, availability, and local experience may influence the decision to use these tests to screen for carotid artery atherosclerosis that may respond to surgery.

Carotid Stenosis↗
PubMed1995

US national survey of physician practices for the secondary and tertiary prevention of ischemic stroke. Design, service availability, and common practices.

BACKGROUND AND PURPOSE: Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies. METHODS: We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke. RESULTS: Sixty-seven percent (n = 1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios, and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done. CONCLUSIONS: Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.

Aspirin↗
PubMed1995

Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebrovascular disease.

Despite a higher risk of stroke, blacks are less likely than whites to receive the invasive procedures that are used to diagnose and treat cerebrovascular disease, particularly carotid endarterectomy. Explanations for the lower rate of procedural use include racial bias, racial differences in pathophysiology of cerebrovascular disease, affordability, and racial variation in patient decisions regarding care. Studies consistently indicate that blacks are less likely to have severe atherosclerotic lesions of the carotid arteries, reducing their likelihood of being appropriate candidates for carotid endarterectomy. Although ability to pay does not explain the observed variation in use of carotid endarterectomy, it may influence the evaluation process prior to hospitalization. A racial difference in patients' decisions about health care for cerebrovascular disease has never been investigated; it should be a topic of future studies.

Black or African American↗
PubMed1994

Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms.

BACKGROUND AND PURPOSE: Randomized clinical trials have shown that carotid endarterectomy decreases the risk of subsequent stroke in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or minor stroke. The benefit of surgery is highly dependent on surgical risk. We previously found that patients with ipsilateral hemispheric symptoms were at greater risk of carotid endarterectomy complications compared with those who were asymptomatic or had nonipsilateral symptoms. The goals of the present study were (1) to identify preoperative clinical factors that may increase the risk of complications after carotid endarterectomy in patients with ipsilateral hemispheric symptoms and (2) to develop a risk index based on this patient-level data. METHODS: Records from 1160 carotid endarterectomies performed at 12 academic medical centers composed the primary data set. Hospital charts for the admission during which carotid endarterectomy was performed were systematically reviewed by abstractors using a defined protocol. The present analysis was carried out on data from the subset of patients who had carotid endarterectomy for ipsilateral hemispheric symptoms. Candidate variables were identified based on univariate Fisher's exact tests or chi 2 tests. A risk index was then developed using those variables with a greater than 90% probability of being associated with adverse outcomes. RESULTS: Of the 697 patients with ipsilateral symptoms, 8.5% had either stroke, myocardial infarction, or died during the postoperative period of hospitalization. Those over the age of 75 had a greater risk of myocardial infarction (6.6% versus 2.3%, P = .024) but not of stroke or death (P > .10). The overall frequencies of adverse outcomes were also higher in the 5 patients with complete ipsilateral carotid occlusions (40% versus 8.2%, P < .01), the 28 patients with ipsilateral intraluminal thrombus (17.9% versus 8.1%, P = .07), and the 65 patients with ipsilateral carotid siphon stenosis (13.9% versus 7.9%, P = .10). There were no differences in adverse outcomes among those with different degrees of ipsilateral stenosis (30% to 49%, 50% to 69%, and 70% to 99%). Adverse outcome rates were similar regardless of the type of symptom (transient ischemic attack, recent ipsilateral minor stroke, remote ipsilateral minor stroke). There were no significant differences in adverse outcome rates based on sex, race, history of angina, recent myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, hypertension, degree of stenosis of the contralateral carotid artery, or presence of ulceration in the ipsilateral artery (Fisher's exact tests, P > .10). A count of variables with greater than 90% probability of being associated with adverse outcomes (age > or = 75 years or angiographic evidence of ipsilateral carotid occlusion, stenosis in the region of the carotid siphon, or intraluminal thrombus) was used to form a simple risk index. "High-risk" patients (one or more risk factors) had more than two times the risk of complications compared with "low-risk" patients who had no risk factors (odds ratio, 2.18; 95% confidence interval, 1.25 to 3.81). CONCLUSIONS: Certain preoperative clinical variables may place patients with ipsilateral symptoms at greater risk of perioperative complications after carotid endarterectomy. Prospective validation of a simple risk index would provide an additional method for assessing preoperative risk in endarterectomy candidates.

Age Factors↗
PubMed1993

Racial variations in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack.

BACKGROUND: Carotid endarterectomy is emerging as the treatment of choice for patients with symptomatic carotid artery stenosis at low operative risk. We sought to determine if racial variations in the rate of carotid angiography and endarterectomy exist in the Veteran Affairs health care system among patients who are insulated from the cost of their care. METHODS: From a national database of all hospitalizations at Veterans Affairs medical centers, we identified a cohort of patients with diagnoses of stroke or transient ischemic attack who were likely to be candidates for carotid angiography and endarterectomy. We used logistic regression to determine if the patient's race was associated with receiving carotid angiography and endarterectomy, after adjusting for patient's age, degree of eligibility for Veterans Affairs care, socioeconomic status, comorbidities associated with hospital admission, and geographic region of the hospital. RESULTS: Of the 35 922 veterans in the cohort, 3535 (9.8%) underwent angiography during the study period and 1249 (3.5%) had carotid endarterectomy. Blacks constituted 18.2% of the patients with a history of stroke or transient ischemic attack, 9.8% of the patients having angiography, but only 4.2% of the patients undergoing carotid endarterectomy. Whites constituted 77.1% of the patients with a history of stroke or transient ischemic attack, 86.1% of the patients receiving angiography, and 93.0% of those having carotid endarterectomies. After adjusting for confounding variables, black patients continued to have a significantly lower likelihood than white patients of undergoing angiography (risk ratio = 0.47; 95% confidence interval = 0.42, 0.53) and subsequent endarterectomy (risk ratio = 0.28; 95% confidence interval = 0.20, 0.38). CONCLUSIONS: Socioeconomic status and access to care within a large managed health care system do not fully explain racial differences in the rate of carotid angiography and endarterectomy. Either referral bias for evaluation for carotid endarterectomy or racial differences in the extent and location of cerebrovascular disease are more important explanations for the observed racial variations.

Aged↗
PubMed1993

Cost effectiveness analysis of early zidovudine treatment of HIV infected patients.

OBJECTIVE--To compare cost effectiveness of early and later treatment with zidovudine for patients infected with HIV. DESIGN--Markov chain analysis of cost effectiveness based on results of use of health care and efficacy from a trial of zidovudine treatment. SETTING--Seven Veterans Affairs medical centres in the United States. SUBJECTS--338 patients with symptomatic HIV infection and a lymphocyte count of 200 x 10(6) to 500 x 10(6) CD4 cells/l. INTERVENTIONS--Zidovudine 1500 mg/day started either at recruitment to the trial or when CD4 cell count fell below 200 x 10(6)/l. MAIN OUTCOME MEASURES--Health care costs and rates of disease progression between six clinical states of HIV infection. RESULTS--Patients given early treatment with zidovudine remained without AIDS for an extra two months at a cost of $10,750 for each extra month without AIDS (at 1991 costs). Cost effectiveness ratio was most sensitive to the cost of zidovudine and to the quality of life of patients receiving early treatment. At treatment of 500 mg/day the cost effectiveness ratio for early treatment was $5432 for each extra month without AIDS. Patients given early treatment experienced more side effects, and if their quality of life was devalued by 8% compared with patients treated later the two treatments were equivalent in terms of quality adjusted months of life without AIDS. CONCLUSIONS--Early treatment with zidovudine is expensive and is very sensitive to the cost of zidovudine and to potential reductions in quality of life of patients who experience side effects. Doctors should reconsider early treatment with zidovudine for patients who experience side effects that substantially compromise their quality of life.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Teaching cardiovascular examination skills: results from a randomized controlled trial.

PURPOSE: To evaluate the effectiveness of a teaching program designed to improve interns' cardiovascular examination skills. PARTICIPANTS: All 56 interns rotating on a mandatory 4-week inpatient cardiology service during 1 academic year (July 1989-June 1990). METHODS: We randomly assigned interns to receive either an eight-session physical diagnosis course ("teaching group") taught on the cardiology-patient simulator ("Harvey") or to receive no supplemental teaching ("control group"). Before and immediately after the teaching or control period, the interns were evaluated on three preprogrammed simulations (mitral regurgitation, MR; mitral stenosis, MS; aortic regurgitation, AR). Immediately after the control or the intervention period, the interns also evaluated patient volunteers. RESULTS: There were no baseline differences in the interns' ability to correctly identify the disease simulations. Both the intervention and the control interns showed similar, moderate improvement in their diagnostic ability on the simulator. The intervention interns improved on MR from 42% correct to 54% correct; on MS from 8% correct to 23% correct; and on AR from 46% correct to 58% correct. The intervention and the control interns performed similarly on patient volunteers: for MR, 20% correct versus 31%; for AR, 29% correct versus 33%; and for aortic sclerosis, 64% correct versus 33%, respectively. CONCLUSIONS: The interns had difficulty correctly identifying three valvular heart disease simulations before and after an educational intervention employing a cardiovascular-patient simulator. At no time did the proportion of correct responses exceed 64%. Our teaching intervention during internship was either of insufficient intensity or of insufficient duration to produce significant improvement in cardiovascular diagnostic skills.

Cardiology↗
PubMed1993

Predicting complications of carotid endarterectomy.

BACKGROUND AND PURPOSE: Carotid endarterectomy has been shown to be beneficial in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or stroke. This benefit will be realized only if the operation is performed safely. We sought to determine the extent to which clinically significant adverse events occurring after carotid endarterectomy can be predicted from clinical data available before surgery. METHODS: Eleven hundred sixty patients were randomly selected from all patients who underwent carotid endarterectomy and were discharged during the calendar years 1988, 1989, and 1990 in 12 academic medical centers in 10 states. Clinical data abstracted from hospital charts were analyzed retrospectively. A model was developed and validated to predict the occurrence of stroke, myocardial infarction, or death during the postoperative period of hospitalization. RESULTS: Eight patients (6.9%) suffered at least one adverse event. Rates for individual complications were as follows: death, 1.4%; nonfatal stroke, 3.4%; nonfatal myocardial infarction, 2.1%; and nonfatal stroke or death, 4.8%. Significant predictors of adverse events were age 75 years or older, symptom status (ipsilateral symptoms versus asymptomatic or nonipsilateral symptoms), severe hypertension (preoperative diastolic blood pressure of greater than 110 mm Hg), carotid endarterectomy performed in preparation for coronary artery bypass surgery, history of angina, evidence of internal carotid artery thrombus, and internal carotid artery stenosis near the carotid siphon. The presence of two or more of these risk factors was associated with a nearly twofold increase in risk of an adverse event (relative risk, 1.7; 95% confidence interval, 1.0 to 3.0). CONCLUSIONS: Clinical data can be used to stratify patients undergoing carotid endarterectomy according to risk of postoperative in-hospital stroke, myocardial infarction, or death.

Aged↗