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Biomedical subjects

G Naglie

Publications and source records attributed to G Naglie.

18 recordsLinked to original sources
PubMed1997

Quality of life of stroke in younger individuals. Utility assessment in patients with arteriovenous malformations.

BACKGROUND AND PURPOSE: Patients with arteriovenous malformations are younger individuals who are at risk of a stroke or have experienced one. Our objective was to determine these patients' perceptions of quality of life with a stroke by eliciting utility values. METHODS: Utility values were obtained with the standard gamble technique. Utilities are a holistic, quality of life measure between 0 and 1. We evaluated the patients' current health state and written descriptions of major and minor stroke. RESULTS: Thirty-one consecutive outpatients participated. The mean age was 37 years (range, 18 to 57 years). Approximately 65% had suffered a stroke, of which 55% were major. Approximately 61% had a persistent deficit. The mean utilities were 0.45 for major stroke (95% confidence interval [CI], 0.33 to 0.56; range, 0.00 to 1.00), 0.81 for minor stroke (95% CI, 0.75 to 0.88; range, 0.30 to 1.00), and 0.81 for current health (95% CI, 0.73 to 0.89; range, 0.01 to 1.00). Subgroup analyses by demographic and clinical characteristics showed no significant differences. However, in both those patients who had never had a stroke and those who had survived a major stroke, values for the major stroke scenario were clustered at the two extremes. Among those with a current deficit, 79% preferred their own health state to that of the stroke scenario that was similar in severity. CONCLUSIONS: Younger people who have had a stroke or are at risk demonstrate wide variations in their perception of quality of life. Furthermore, patients tend to be more risk averse with their own lives than with theoretical scenarios. We suggest tailoring medical decision making to individual preferences.

Adolescent↗
PubMed1995

Tuberculosis surveillance practices in long-term care institutions.

OBJECTIVES: To identify the tuberculosis (TB) skin-testing practices of long-term care facilities for the elderly in Toronto, Ontario. DESIGN: A telephone survey using a 25-item questionnaire. SETTING: Twenty-nine nursing homes (NHs) and 26 Homes for the Aged (HFAs) in metropolitan Toronto. RESULTS: Thirty-one percent of facilities (17 of 55) had no formal tuberculin skin-testing program, including 52% of NHs (15 of 29) versus 8% of HFAs (2 of 26; P = 0.001). Ninety-two percent of HFAs (24 of 26), compared with 45% of NHs (13 of 29), obtained preadmission or admission skin-test status of residents (P = 0.0005). Annual testing was performed at 46% of HFAs (12 of 26) and 27% of NHs (8 of 29; P = 0.28). Of facilities that carried out any skin testing, 64% of HFAs (16 of 25) versus 32% of NHs (6 of 19) measured induration to establish test positivity (P = 0.068). Fifty-two percent of HFAs (13 of 25), compared with 21% of NHs (4 of 19), recorded the actual size of induration in the patient record (P = 0.085). Only 28% of HFAs (7 of 25) and 21% of NHs (4 of 19) correctly defined a positive tuberculin skin test. CONCLUSIONS: TB surveillance practices in long-term care institutions in Toronto are inadequate and often yield results that do not predict the risk of infection and cannot be used to investigate outbreaks. Tuberculin skin-testing practices were better at HFAs, which are subject to provincial legislation regarding TB surveillance, than at NHs, which are not subject to this legislation. Staff at HFAs and NHs require education regarding tuberculin skin-testing policies and procedures.

Homes for the Aged↗
PubMed1995

Do geriatric programs decrease long-term use of acute care beds?

OBJECTIVE: To determine whether the introduction of coordinated geriatric and discharge planning services at teaching and community hospitals in Toronto has changed the number of beds occupied by patients awaiting transfer to long-term care institutions. DESIGN: Retrospective review of social work records for the period 1985-1992. SETTING: Two tertiary and four primary acute care hospitals in Metropolitan Toronto. PARTICIPANTS: Hospitals were matched for location, acuity, and teaching affiliation. MAIN OUTCOME MEASURES: The numbers of beds occupied by patients awaiting transfer to nursing homes or chronic care hospitals were noted. RESULTS: In those teaching and community hospitals that had introduced coordinated geriatric and discharge planning services, there was a reduction in the percentage of beds occupied by patients awaiting long-term care placement (average-51%), whereas in hospitals without geriatric services, the percentage of beds occupied by patients awaiting long-term care placement increased (average + 25%) (P = .05 by Fisher's exact method, 95% confidence limit odds ratio 0, .9999). CONCLUSION: The introduction of coordinated geriatric and discharge planning services was associated with a decrease in the percentage of beds occupied by patients awaiting long-term care in both teaching and community hospitals.

Aged↗
PubMed1995

Age as a determinant of cardiopulmonary resuscitation outcome in the coronary care unit.

OBJECTIVE: To determine whether age is associated with the outcome of cardiopulmonary resuscitation (CPR) in the coronary care unit (CCU). DESIGN: Retrospective chart review. SETTING: The coronary care units of two Canadian tertiary care teaching hospitals. PATIENTS: Two hundred sixty-four coronary care unit patients undergoing cardiopulmonary resuscitation between January 1, 1985 and June 30, 1992. RESULTS: There was no significant difference in survival to discharge after CPR between patients less than 70 years of age (17.0%) and patients 70 years of age and older (17.2%) (odds ratio = 0.99; 95% confidence interval = 0.46, 1.80). Patients 70 years of age and older who survived to discharge after CPR had significantly greater lengths of stay (28.1 vs 19.3 days, P = .008). CONCLUSIONS: Age was not associated with a difference in survival to discharge after CPR in the CCU, although a clinically significant difference could not be excluded because of limited power.

Adult↗
PubMed1995

Acute urinary retention in men: a comparison of voiding and nonvoiding patients after prostatectomy.

Multiple parameters were examined preoperatively to determine if any could predict successful voiding after prostatectomy in male patients who present in acute urinary retention due to benign prostatic hypertrophy. A total of 50 men 50 to 85 years old (mean age 69.5 years) who presented with this clinical picture was investigated with multichannel urodynamic studies, and completed the American Urological Association (AUA) symptom score for benign prostatic hypertrophy preoperatively and postoperatively. All patients underwent prostatectomy. Mean retention volume was 1,172 cc (range 500 to 2,100). Mean preoperative and postoperative AUA symptom scores were 15.5 and 5.0, respectively. At 3 months postoperatively 45 patients (90%) were able to void without catheterization. At 16.6 months 5 patients still required clean intermittent catheterization to empty the bladder. Postoperatively, there was a statistically significant improvement in AUA symptom score, opening voiding pressure and peak flow rate. The AUA symptom score was not predictive of either impending acute retention or normal voiding after prostatectomy. In our patients no preoperative parameters were statistically different between those voiding and those on clean intermittent catheterization. However, poor sensation, large retention volumes, lack of instability and no voluntary detrusor contractions were more common in the nonvoiding men.

Acute Disease↗
PubMed1993

A randomized trial of a decisional aid for mental capacity assessments.

The objective of this study was to evaluate the clinical utility of a decisional aid for mental capacity assessments which was developed using a group judgment methodology. This was carried out by a randomized, controlled trial. The subjects comprised 64 University of Toronto psychiatry residents in postgraduate years 1 through 4. Residents were randomized to carry out mental capacity assessments on simulated cases with, or without, the use of the decisional aid. The main outcome measure was the extent of agreement between the mental capacity determinations of residents and those of experts. There was no difference between the intervention and control groups with respect to the overall mean level of agreement with experts (0.87 vs 0.86, p = 0.88; 95% confidence interval for the difference between the study groups, -0.07 to +0.08). A logistic regression analysis, which adjusted for imbalances between the groups, also revealed no difference between the groups in their agreement with experts. The mean time per competency assessment was significantly longer in the intervention group (19.1 vs 10.8 min; p < 0.001). It was concluded that the decisional aid did not improve the ability of the psychiatry residents to make mental capacity assessments on simulated cases. Despite relatively limited formal training, the psychiatry residents had a high level of agreement with experts.

Adult↗
PubMed1979

Erythrocyte protoporphyrin levels in patients with Friedreich's and other ataxias.

Of 13 patients with Friedreich's ataxia (Type Ia) and 17 with type IIa recessive ataxias, all were found to have levels of "free erythrocyte protoporphyrin" (FEP) above the normal range. The rise in FEP in Friedreich's ataxia correlated well with the age of the individual and thus appears to be related to the course of the disease. Subjects with olivo-ponto-cerebellar atrophy, Charlevoix syndrome, Duchenne muscular dystrophy, and Parkinson's disease were also found to have significantly elevated FEP, although the distribution overlapped with the normal range. The finding of elevated FEP may indicate a relative heme deficiency in ataxia due to inhibition of ferrochelatase leading to a state of ineffective, persistent erythropoiesis. The possibility of a prostaglandin abnormality being related to this defect and to the pathogenesis of ataxia is considered.

Adolescent↗
PubMedDate not supplied

Primer on medical decision analysis: Part 1--Getting started.

This paper is Part 1 of a five-part series covering practical issues in the performance of decision analysis. The intended audience is individuals who are learning how to perform decision analyses, not just read them. The series assumes familiarity with the basic concepts of decision analysis. It imparts many of the recommendations the authors have learned in teaching a one-semester course in decision analysis to graduate students. Part 1 introduces the topic and covers questions such as choosing an appropriate question, determining the tradeoff between accuracy and simplicity, and deciding on a time frame.

Decision Support Techniques↗
PubMedDate not supplied

Primer on medical decision analysis: Part 2--Building a tree.

This part of a five-part series covering practical issues in the performance of decision analysis outlines the basic strategies for building decision trees. The authors offer six recommendations for building and programming decision trees. Following these six recommendations will facilitate performance of the sensitivity analyses required to achieve two goals. The first is to find modeling or programming errors, a process known as "debugging" the tree. The second is to determine the robustness of the qualitative conclusions drawn from the analysis.

Decision Making, Computer-Assisted↗
PubMedDate not supplied

Primer on medical decision analysis: Part 3--Estimating probabilities and utilities.

This paper describes how to estimate probabilities and outcome values for decision trees. Probabilities are usually derived from published studies, but occasionally are derived from existing databases, primary data collection, or expert judgment. Outcome values represent quantitative estimates of the desirability of the outcome states, and are often expressed as utility values between 0 and 1. Utility values for different health states can be derived from the published literature, from direct measurement in appropriate subjects, or from expert opinion. Methods for assigning utilities to complex outcome states are described, and the concept of quality-adjusted life years is introduced.

Biopsy↗
PubMedDate not supplied

Primer on medical decision analysis: Part 4--Analyzing the model and interpreting the results.

This paper is the fourth of a five-part series that describes the principles of construction and evaluation of valid decision models. In this review, the authors describe the key principles of detecting and eliminating structural and programming errors in decision trees (debugging). In addition, they offer guidelines to facilitate the interpretation of analytic results of decision models.

Data Interpretation, Statistical↗
PubMedDate not supplied

Primer on medical decision analysis: Part 5--Working with Markov processes.

Clinical decisions often have long-term implications. Analysis encounter difficulties when employing conventional decision-analytic methods to model these scenarios. This occurs because probability and utility variables often change with time and conventional decision trees do not easily capture this dynamic quality. A Markov analysis performed with current computer software programs provides a flexible and convenient means of modeling long-term scenarios. However, novices should be aware of several potential pitfalls when attempting to use these programs. When deciding how to model a given clinical problem, the analyst must weigh the simplicity and clarity of a conventional tree against the fidelity of a Markov analysis. In direct comparisons, both approaches gave the same qualitative answers.

Biopsy↗
PubMedDate not supplied

Guidelines for verbal presentations of medical decision analyses.

Individuals new to decision analysis often have difficulty with oral presentations of original research projects. This article provides general guidelines on how to present effectively. Points include: 1) articulating the research issue, 2) reviewing current beliefs, 3) portraying the study question, 4) listing the main assumptions, 5) presenting the base-case analysis, 6) showing sensitivity analyses, and 7) discussing the implications. The guidelines comment on what to exclude from presentation and how best to handle audience questions. The guidelines do not replace general instruction in public speaking (or rigorous training in decision analysis), but may help students present research projects effectively.

Communication↗
PubMedDate not supplied

Cluster deaths in long-term care institutions: an investigation of excess deaths in two Ontario institutions.

OBJECTIVE: To review clusters of deaths in two Ontario long-term care institutions and to establish whether common etiologic factors could be identified. METHOD: Retrospective review of the health care records of all residents who died to assess the events leading to death and the actions of the institutions and local coroners in response to the deaths. RESULTS: A respiratory infectious outbreak appeared to lead to many of the deaths in both institutions. Several deficiencies were identified with respect to charting practices, coroners' case investigations and institutional responses to the infectious outbreaks. No formal mechanisms were in place to assist in the early detection of cluster deaths in these institutions. CONCLUSIONS: Infectious outbreaks may be an important cause of cluster deaths in long-term care institutions. Standards should be developed for patient charting, coroners' investigations and for the prevention, identification and management of infectious outbreaks in such settings.

Aged↗