PubMed Health⌕ Search

Biomedical subjects

L Hebert

Publications and source records attributed to L Hebert.

At least 19 recordsLinked to original sources
PubMed2004

Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991.

BACKGROUND: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS: We reviewed 30121 randomly selected records from 51 randomly selected acute care, non-psychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS: Adverse events occurred in 3.7% of the hospitalizations (95% confidence interval 3.2 to 4.2), and 27.6% of the adverse events were due to negligence (95% confidence interval 22.5 to 32.6). Although 70.5% of the adverse events gave rise to disability lasting less than 6 months, 2.6% caused permanently disabling injuries and 13.6% led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi(2) = 21.04, p<0.0001). Using weighted totals we estimated that among the 2671863 patients discharged from New York hospitals in 1984 there were 98609 adverse events and 27179 adverse events involving negligence. Rates of adverse events rose with age (p<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (p<0.01). There were significant differences in rates of adverse events among categories of clinical specialties (p<0.0001), but no differences in the percentage due to negligence. CONCLUSIONS: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.

Adolescent↗
PubMed2001

Effect of ramipril vs amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized controlled trial.

CONTEXT: Incidence of end-stage renal disease due to hypertension has increased in recent decades, but the optimal strategy for treatment of hypertension to prevent renal failure is unknown, especially among African Americans. OBJECTIVE: To compare the effects of an angiotensin-converting enzyme (ACE) inhibitor (ramipril), a dihydropyridine calcium channel blocker (amlodipine), and a beta-blocker (metoprolol) on hypertensive renal disease progression. DESIGN, SETTING, AND PARTICIPANTS: Interim analysis of a randomized, double-blind, 3 x 2 factorial trial conducted in 1094 African Americans aged 18 to 70 years with hypertensive renal disease (glomerular filtration rate [GFR] of 20-65 mL/min per 1.73 m(2)) enrolled between February 1995 and September 1998. This report compares the ramipril and amlodipine groups following discontinuation of the amlodipine intervention in September 2000. INTERVENTIONS: Participants were randomly assigned to receive amlodipine, 5 to 10 mg/d (n = 217), ramipril, 2.5 to 10 mg/d (n = 436), or metoprolol, 50 to 200 mg/d (n = 441), with other agents added to achieve 1 of 2 blood pressure goals. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of change in GFR; the main secondary outcome was a composite index of the clinical end points of reduction in GFR of more than 50% or 25 mL/min per 1.73 m(2), end-stage renal disease, or death. RESULTS: Among participants with a urinary protein to creatinine ratio of >0.22 (corresponding approximately to proteinuria of more than 300 mg/d), the ramipril group had a 36% (2.02 [SE, 0.74] mL/min per 1.73 m(2)/y) slower mean decline in GFR over 3 years (P =.006) and a 48% reduced risk of the clinical end points vs the amlodipine group (95% confidence interval [CI], 20%-66%). In the entire cohort, there was no significant difference in mean GFR decline from baseline to 3 years between treatment groups (P =.38). However, compared with the amlodipine group, after adjustment for baseline covariates the ramipril group had a 38% reduced risk of clinical end points (95% CI, 13%-56%), a 36% slower mean decline in GFR after 3 months (P =.002), and less proteinuria (P<.001). CONCLUSION: Ramipril, compared with amlodipine, retards renal disease progression in patients with hypertensive renal disease and proteinuria and may offer benefit to patients without proteinuria.

Adrenergic beta-Antagonists↗
PubMed2000

ACE inhibition or angiotensin receptor blockade: impact on potassium in renal failure. VAL-K Study Group.

BACKGROUND: Inhibition of the renin-angiotensin system is known to raise serum potassium [K(+)] levels in patients with renal insufficiency or diabetes. No study has evaluated the comparative effects of an angiotensin-converting enzyme (ACE) inhibitor versus an angiotensin receptor blocker (ARB) on the changes in serum [K(+)] in people with renal insufficiency. METHODS: The study was a multicenter, randomized, double crossover design, with each period lasting one month. A total of 35 people (21 males and 14 females, 19 African Americans and 16 Caucasian) participated, with the mean age being 56 +/- 2 years. Mean baseline serum [K(+)] was 4.4 +/- 0.1 mEq/L. The glomerular filtration rate (GFR) was 65 +/- 5 mL/min/1.73 m(2), and blood pressure was 150 +/- 2/88 +/- 1 mm Hg. The main outcome measure was the difference from baseline in the level of serum [K+], plasma aldosterone, and GFR following the initial and crossover periods. RESULTS: For the total group, serum [K(+)] changes were not significantly different between the lisinopril or valsartan treatments. The subgroup with GFR values of < or = 60 mL/min/1.73 m(2) who received lisinopril demonstrated significant increases in serum [K(+)] of 0.28 mEq/L above the mean baseline of 4.6 mEq/L (P = 0.04). This increase in serum [K(+)] was also accompanied by a decrease in plasma aldosterone (P = 0.003). Relative to the total group, the change in serum [K(+)] from baseline to post-treatment in the lisinopril group was higher among those with GFR values of < or = 60 mL/min/1.73 m(2). The lower GFR group taking valsartan, however, demonstrated a smaller rise in serum [K(+)], 0.12 mEq/L above baseline (P = 0.1), a 43% lower value when compared with the change in those who received lisinopril. This blunted rise in [K(+)] in people taking valsartan was not associated with a significant decrease in plasma aldosterone (P = 0.14). CONCLUSIONS: In the presence of renal insufficiency, the ARB valsartan did not raise serum [K(+)] to the same degree as the ACE inhibitor lisinopril. This differential effect on serum [K(+)] is related to a relatively smaller reduction in plasma aldosterone by the ARB and is not related to changes in GFR. This study provides evidence that increases in serum [K(+)] are less likely with ARB therapy compared with ACE inhibitor therapy in people with renal insufficiency.

Aldosterone↗
PubMed1998

Safety and tolerance of medical nutritional products as sole sources of nutrition in people on hemodialysis.

OBJECTIVE: Establish and compare the safety and tolerance of three medical nutritional products when used as sole sources of nutrition in stable hemodialysis patients. DESIGN: Prospectively randomized, controlled, single blind, parallel design. SETTING: Three outpatient hemodialysis clinics. PARTICIPANTS: Seventy-nine normally nourished, stable, anuric, adequately dialyzed, adult outpatients with end-stage renal disease (ESRD) and requiring thrice weekly hemodialysis. INTERVENTION: A 3-week trial was conducted. During the first week, baseline medical history and physical examination, gastrointestinal symptom, urea kinetic, bowel habit, and biochemical data were collected while participants ingested their usual diet. During the last 2 weeks, the same data were collected while participants orally ingested 35 kcal/kg actual weight/d of one of three medical nutritional products as a sole source of nutrition. Products were a standard medical nutritional (EN-9527) and two renal nutritionals (EN-9528 and EN-9529). The latter product was a reformulation of EN-9528 and contained added beta-carotene and fructooligosaccharides. MAIN OUTCOME MEASURES: Gastrointestinal symptoms, bowel habits (stool frequency and consistency), routine blood chemistries, urea kinetics, and normalized protein catabolic rate (nPCR) RESULTS: All three groups achieved a mean energy and protein intake of approximately 35 kcal/kg/d and 1.25 g protein/kg/d during the last 10 days of the sole source feeding period. Adherence with the formula ingestion targets was assessed using both a patient-completed product consumption log and nPCR. By intent to treat analysis, there were no changes in number or severity of gastrointestinal symptoms, stool frequency or stool consistency, or urea kinetics between the baseline week and during product consumption. In comparison to the standard formulation, the disease-specific formulations resulted in improved serum phosphorus and calcium-phosphorus product. Patients receiving the fructooligosaccharide-containing product (EN-9529), by Chi-squared analysis, had less constipation than for the comparable product without oligosaccharides (EN-9528) or the standard medical nutritional (EN-9527). CONCLUSION: Use of enteral nutritionals as a sole source of nutrition is both possible and well tolerated in hemodialyzed patients. Selection of a disease-specific formulation offered advantages over a standard formulation in the management of biochemical complications of renal disease when the products were used as a sole source of nutrition.

Blood Urea Nitrogen↗
PubMed1997

Fulminating bacteremia and pneumonia due to Bacillus cereus.

We present two cases of rapidly progressing, fatal pneumonia caused by Bacillus cereus. These cases are interesting in that B. cereus, even from blood or sputum specimens, may often be considered a contaminant and receive inadequate attention. Also of interest was the fact that the two patients resided in the same area of the state, were welders by trade, and became ill within a few days of each other, yet there was no epidemiologic link between them.

Adult↗
PubMed1996

Identifying adverse events caused by medical care: degree of physician agreement in a retrospective chart review.

OBJECTIVE: To 1) assess the degree of agreement among physicians on the cause of previously flagged adverse outcomes and 2) relate the findings to systems of quality assurance and performance assessment and proposals for no-fault compensation for medical injuries. DESIGN: Observational study of 7533 pairs of "structured implicit" reviews (subjective opinions based on guidelines) of medical records done by 127 physicians working independently. SETTING: Random sample of 51 inpatient facilities in New York State. PATIENTS: Random sample of inpatient medical records from the selected facilities. MEASUREMENTS: 1) Number of agreed-upon adverse events compared with the number of cases of extreme disagreement and 2) internally and indirectly standardized rates at which physician reviewers found adverse events (injuries to patients caused at least in part by medical management). RESULTS: In 12.9% of cases (971 of 7533), the two physicians in a pair had extreme disagreement about the occurrence of an adverse event. These cases outnumbered those in which both reviewers found an adverse event (10%; n = 757). Agreement was highest for wound infections and lowest for adverse events attributed to failure to diagnose or lack of therapy. The amount of experience the physicians had in reviewing records tended to increase the level of agreement. Even after standardization to the results of the entire sample, individual physicians' rates of finding at least slight evidence of an adverse event varied widely (range, 9.9% to 43.7%) (P < 0.001). CONCLUSIONS: Structured implicit reviews produced disagreement on the causes of adverse patient outcomes. If systems of quality assurance, performance audits, or no-fault patient compensation are to succeed, methods for overcoming the common tendency toward disagreement among experts must be developed.

Humans↗
PubMed1995

Chimeric receptors expressing juxtamembrane sequences of the insulin receptor undergo rapid endocytosis in the absence of receptor tyrosine kinase activity.

We have examined the endocytosis of chimeric receptors consisting of the extracellular domain of the low density lipoprotein (LDL) receptor linked to the juxtamembrane region of the human insulin receptor (hIR). The latter domain contains amino acid motifs previously shown to be necessary for endocytosis. Here we demonstrate that these codes are also sufficient for normal receptor endocytosis. Chinese hamster ovary cells expressing the chimeric LDL-insulin receptor had internalization and degradation indices of 0.70 +/- 0.01 and 0.51 +/- 0.13 after 5 h at 37 degrees C, compared to 0.62 +/- 0.03 and 0.33 +/- 0.09 for normal LDL receptors. The amino acid sequences that target these chimeras for internalization are the same as those used by the native insulin receptor. The residues GPYL950-953 serve as the predominant endocytosis signal: Mutation of these to APLA led to a 56% reduction in the internalization index. The sequence NPEY957-960 is less important for endocytosis and when mutated to APEA led only to a 32% reduction of chimera internalization. We conclude that the juxtamembrane sequences of the insulin receptor are sufficient to cause internalization of the insulin receptor even in the absence of receptor tyrosine kinase activity.

Animals↗
PubMed1995

The prevalence and characteristics of fibromyalgia in the general population.

OBJECTIVE: To determine the prevalence and characteristics of fibromyalgia in the general population. METHODS: A random sample of 3,006 persons in Wichita, KS, were characterized according to the presence of no pain, non-widespread pain, and widespread pain. A subsample of 391 persons, including 193 with widespread pain, were examined and interviewed in detail. RESULTS: The prevalence of fibromyalgia was 2.0% (95% confidence interval [95% CI] 1.4, 2.7) for both sexes, 3.4% (95% CI 2.3, 4.6) for women, and 0.5% (95% CI 0.0, 1.0) for men. The prevalence of the syndrome increased with age, with highest values attained between 60 and 79 years (> 7.0% in women). Demographic, psychological, dolorimetry, and symptom factors were associated with fibromyalgia. CONCLUSION: Fibromyalgia is common in the population, and occurs often in older persons. Characteristic features of fibromyalgia--pain threshold and symptoms--are similar in community and clinic populations, but overall severity, pain, and functional disability are more severe in the clinic population.

Adult↗
PubMed1992

Physicians' perceptions of the risk of being sued.

We explore the deterrent effect of the tort system by assessing physician perceptions of the risk of being sued and the impact of those perceptions on their own practice. The data are from a mailed survey conducted in 1989 of a random sample of physicians who were practicing in New York State in 1984. The survey results were compared to the actual risk of suit using the between-group (Wald) test and logistic regression methods. We also surveyed physicians about practice changes undertaken in the last ten years, factors influencing practice standards, and the costs of being sued and included these in the analysis. On average, physicians estimate that 19.5 out of one hundred of their colleagues will be sued in a given year, approximately three times the actual rate, with significant differences by specialty, location, and suit history. Perceived risk is associated with self-reported changes in test-ordering frequency and reduction in practice scope. The median number of days lost from practice to defend a malpractice suit was three to five, and 6 percent of the physicians surveyed incurred some out-of-pocket expenses. These findings suggest that physicians respond to the messages sent by litigation in a manner consistent with the deterrent theory of tort litigation.

Age Factors↗
PubMed1991

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

BACKGROUND: As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. METHODS: We reviewed 30,121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. RESULTS: Adverse events occurred in 3.7 percent of the hospitalizations (95 percent confidence interval, 3.2 to 4.2), and 27.6 percent of the adverse events were due to negligence (95 percent confidence interval, 22.5 to 32.6). Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death. The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test chi 2 = 21.04, P less than 0.0001). Using weighted totals, we estimated that among the 2,671,863 patients discharged from New York hospitals in 1984 there were 98,609 adverse events and 27,179 adverse events involving negligence. Rates of adverse events rose with age (P less than 0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (P less than 0.01). There were significant differences in rates of adverse events among categories of clinical specialties (P less than 0.0001), but no differences in the percentage due to negligence. CONCLUSIONS: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.

Adolescent↗
PubMed1991

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

BACKGROUND: In a sample of 30,195 randomly selected hospital records, we identified 1133 patients (3.7 percent) with disabling injuries caused by medical treatment. We report here an analysis of these adverse events and their relation to error, negligence, and disability. METHODS: Two physician-reviewers independently identified the adverse events and evaluated them with respect to negligence, errors in management, and extent of disability. One of the authors classified each event according to type of injury. We tested the significance of differences in rates of negligence and disability among categories with at least 30 adverse events. RESULTS: Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent). Nearly half the adverse events (48 percent) were associated with an operation. Adverse events during surgery were less likely to be caused by negligence (17 percent) than nonsurgical ones (37 percent). The proportion of adverse events due to negligence was highest for diagnostic mishaps (75 percent), noninvasive therapeutic mishaps ("errors of omission") (77 percent), and events occurring in the emergency room (70 percent). Errors in management were identified for 58 percent of the adverse events, among which nearly half were attributed to negligence. CONCLUSIONS: Although the prevention of many adverse events must await improvements in medical knowledge, the high proportion that are due to management errors suggests that many others are potentially preventable now. Reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.

Adolescent↗
PubMed1990

Short-term variability of measures of physical function in older people.

Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.

Activities of Daily Living↗
PubMed1987

A unique familial lobular glomerulopathy.

Five members of a family (four brothers and their father) were found to have proteinuria and microhematuria. One of the affected brothers developed chronic renal failure. Although a renal biopsy was never performed, this brother has subsequently received a renal transplant from a clinically unaffected sister. Renal biopsy was performed on four of the siblings (three brothers and the sister). Renal tissue from all three brothers who underwent biopsy showed similar glomerular lesions, characterized by striking cloverleaf expansion of glomerular lobules by an acellular hyaline material and segmental mesangial cell proliferation. Electron microscopy showed massive mesangial and subendothelial deposits and occasional areas of glomerular basement membrane splitting with round inclusions. The renal biopsy specimen of the sister was normal on light and electron microscopy and negative for immunoglobulins and complement on immunofluorescent staining. Immunofluorescence microscopy on one of the male siblings was negative for immunoglobulins and complement. No other physical or serologic abnormalities could be established. To our knowledge, this is a unique form of familial glomerulopathy that has not been previously described.

Adult↗
PubMed1986

Short-term prognosis of severe proliferative lupus nephritis.

The prognosis of systemic lupus erythematosus (SLE) is considerably worse when accompanied by renal involvement. In order to study the outcome within a year of histologic diagnosis of severe lupus nephritis, we obtained data on 25 patients from nine participating centers. All these patients fulfilled clearly defined histologic criteria of severe lupus nephritis, thus enabling us to evaluate a homogeneous group of patients. During a mean follow-up period of 9.4 months, there appeared to be an equal probability that the renal function would improve, remain stable, or worsen as assessed by changes in serum creatinine concentration. One patient died and another patient reached end-stage renal disease (ESRD), a combined crude mortality plus ESRD rate of 8% for 9.4 months. As both these patients had serum creatinine values of less than 2 mg/dL at the time of diagnosis of severe lupus nephritis, it appears that normal or mildly impaired renal function at the time of diagnosis does not ensure benign outcome. These features should be considered when new studies on SLE nephritis are planned or any new therapeutic modality is evaluated.

Adolescent↗
PubMed1977

Occurrence of a complex of aminoacryl-tRNA synthetases in lactating rat mammary gland.

(1) Postmicrosomal particles were isolated from the cytosol of lactating rat mammary gland. These particles contained up to 40% of the cytosol protein, and about 40% of the total aminoacyl-tRNA synthetase activity of the cytosol. (2) Sucrose density gradient centrifugation of these postmicrosomal particles showed that the activity of seventeen synthetases was distributed between one or other of two major gradient regions, corresponding to values of 20--28 S and 5--7 S. Arginyl and cysteinyl tRNA synthetases showed peaks in both major regions. (3) A complex of eight aminoacyl-tRNA synthetases (those for lysine, leucine, isoleucine, methionine, glutamine, arginine, cysteine and valine) of molecular weight 3 - 10(6) was isolated from the postmicrosomal particles by gel filtration and chromatography on DEAE-cellulose.

Amino Acyl-tRNA Synthetases↗