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M J Fine

Publications and source records attributed to M J Fine.

69 records · Page 4Linked to original sources
PubMed1991

Resting electrocardiograms as baseline tests: impact on the management of elderly patients.

PURPOSE: We evaluated management decisions of house staff in a university hospital emergency department (ED) to determine the impact of baseline electrocardiogram (ECG) results on the care of elderly patients. SUBJECTS AND METHODS: The study employed a prospective before-after research design. The subjects included internal medicine house staff assigned to the ED and the 47 elderly patients treated by them during 58 ED visits. The measures of impact on patient care included how often and in what ways comparison of baseline and ED ECG results changed the house staff's diagnostic impressions and treatment plans. To determine changes, we asked house staff to indicate their impressions and management plans before and after comparing baseline and ED ECG results. In addition, a panel of faculty members used a modification of the nominal group process to determine treatment changes and to estimate benefit to patients from the changes. RESULTS: House staff indicated that baseline ECG results led them to change diagnostic impressions during 13 (22%) and treatment plans during eight (14%) of the 58 visits. Six of the patients benefited from the treatment changes. The faculty judges indicated that baseline ECG findings would have altered their diagnostic impressions in eight (14%) and treatment decisions in three (5%) of the 58 cases, one of which would have benefited from the change. All patients for whom there were changes of impression or plan had prior histories of cardiovascular disease. CONCLUSION: We conclude that baseline ECGs provide ED house staff with diagnostic information that often leads to changes in management of elderly patients with prior histories of cardiovascular disease. Future studies should evaluate the efficacy of baseline ECGs in patients without such histories.

Aged↗
PubMed1990

Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study.

PURPOSE: To identify a low-risk subset of patients with community-acquired pneumonia that could safely be treated in the ambulatory setting; and to assess how clinicians make the hospitalization decision. PATIENTS AND METHODS: We performed a prospective, observational study of 280 ambulatory and hospitalized adults with clinical and radiographic evidence of pneumonia. Patients were followed to assess all potential morbid complications and 6-week mortality. Physicians responsible for managing these patients were surveyed to assess the reasons for treating in a hospital or ambulatory setting and the therapies that dictate hospitalization. RESULTS: Sixty-one percent (170 of 280) of patients did not have an indication for admission at presentation using modified Appropriateness Evaluation Protocol criteria (a severe vital sign abnormality, alteration in mental status, suppurative complication, arterial hypoxemia, severe laboratory abnormality, or an acute coexistent medical problem requiring admission independent of the pneumonia). Among these 170 patients, 38% had a complicated course defined as death within 6 weeks, development of a new suppurative or medical complication due to pneumonia, intensive care unit admission, persistent fever or use of intravenous fluids or oxygen beyond 3 days, hospitalization lasting more than 3 days, or subsequent hospitalization in patients initially treated in the ambulatory setting. Five predisposing factors for a complicated course were identified in logistic regression models. The odds ratio for age more than 65 years was 2.7; for comorbid illness, 3.2; for temperature more than 38.3 degrees C (101 degrees F), 4.1; for immunosuppression, 12.0; and for a high-risk etiology, 23.3. The risk of a complicated course increased linearly with the number of risk factors, from 12% with none to 100% with four or more factors (p less than 0.001). Physicians most often relied on the general clinical appearance of the patient when making the triage decision, and most commonly cited intravenous antibiotics and chest physical therapy as treatments requiring hospitalization. CONCLUSIONS: If validated, our findings could improve physicians' assessment of prognosis, and may identify a low-risk subset of patients with community-acquired pneumonia who could safely be managed in the ambulatory setting.

Adult↗
PubMed1990

Pneumonia in the elderly: the hospital admission and discharge decisions.

Community-acquired pneumonia is both a common and a serious infection in the elderly population. The hospitalization and discharge decisions are among the most important management decisions physicians must make in caring for patients with this illness. Both of these decisions are important from a clinical, health services, and patient-oriented perspective. The hospitalization decision can be guided by a clinical algorithm that explicitly addresses five questions: (1) Does the patient have any life-threatening problems that require immediate stabilization (and de facto hospitalization)? (2) Does the patient have any prognostic factor(s) that increase the short-term risk of mortality? (3) Does the patient have any prognostic factor(s) that increase the short-term risk of morbidity or medical complications? (4) Does the patient have adequate functional skills or social support to allow care outside of the hospital? and (5) Does the patient require admission for a therapeutic modality or diagnostic evaluation? An affirmative response to any one of these questions indicates a need for hospitalization, whereas a negative response to all of the questions identifies potential candidates for outpatient care. The factors considered important in the hospitalization decision are also intimately related to the discharge decision. Before discharge, all acute physiological derangements should be corrected and laboratory abnormalities should be normalized or returning to baseline. All patients must be able to function socially outside of the hospital. Finally, treatment with an adequate course of antimicrobial therapy either must be completed or arranged on an ambulatory basis before discharge.

Aged↗
PubMed1990

Prognosis of patients hospitalized with community-acquired pneumonia.

PURPOSE: Our purpose was to determine which clinical features predict short-term mortality in patients with community-acquired pneumonia. PATIENTS AND METHODS: We conducted a prospective multicenter study of 347 patients hospitalized in Pittsburgh (the derivation cohort) and 253 hospitalized and ambulatory patients in Boston (the validation cohort) with clinical and radiographic evidence of pneumonia. Patients in the derivation cohort underwent an extensive microbiologic evaluation including bacteriologic sputum culture, blood cultures, direct fluorescent antibody testing for Legionella species, and serologic testing for Mycoplasma pneumoniae, Legionella species, and Chlamydia TWAR. RESULTS: The overall mortality was 18% in the derivation cohort and 13.2% in the validation cohort. We identified five independent predictors of mortality in the derivation cohort: pleuritic chest pain (risk ratio, 0.4; 95% confidence interval [CI], 0.17 to 0.99), mental status changes (risk ratio, 2.6; 95% CI, 1.4 to 4.6), a severe vital sign abnormality (risk ratio, 2.1; 95% CI 1.2 to 3.6), neoplastic disease (risk ratio, 5.0; 95% CI, 2.7 to 9.1), and "high-risk" pneumonia etiology (risk ratio, 2.8; 95% CI, 1.6 to 5.0). A mortality index based on these factors accurately classified patients into five risk classes of increasing mortality. In the derivation cohort, the 6-week mortality rates were 0% in class I, 2.9% in class II, 13.1% in class III, 32.7% in class IV, and 89.5% in class V. There was little deterioration in the predictive accuracy of the model when tested in the validation cohort: mortality was 2.2% in class I, 0% in class II, 13.5% in class III, 33.3% in class IV, and 55.6% in class V. CONCLUSIONS: This prognostic classification may help direct triage decisions, assess appropriateness of care, and guide the design and analysis of therapeutic trials in patients with community-acquired pneumonia.

Adolescent↗
PubMed1988

Acute cardiac tamponade due to cardiac actinomycosis.

Cardiac actinomycosis occurs in less than 2 percent of the patients with infections due to Actinomyces israelii. We describe the findings in a patient with acute cardiac tamponade who survived through pericardial drainage and aggressive medical therapy. Although uncommon, this disorder is important to recognize because it is curable with current medical and surgical therapy.

Actinomycosis↗
PubMed1987

Improved defibrillation thresholds with large contoured epicardial electrodes and biphasic waveforms.

A reduction in the shock strength required for defibrillation would allow use of a smaller automatic implantable cardioverter-defibrillator and would reduce the possibility of myocardial damage by the shock. Most internal defibrillation electrodes require 5 to 25 J for successful defibrillation in human beings and in dogs. In an attempt to lower the shock strength needed for defibrillation, we designed two large titanium defibrillation patch electrodes that were contoured to fit over the right and left ventricles of the dog heart, covering areas of approximately 33 and 39 cm2, respectively. In six anesthetized open-chest dogs, the electrodes were secured directly to the epicardium and ventricular fibrillation was induced by 60 Hz alternating current. Truncated exponential monophasic and biphasic shocks were given 10 sec later and defibrillation thresholds (DFTs) were determined. The DFT was 159 +/- 48 V, 3.2 +/- 1.9 J (mean +/- SD) for 10 msec monophasic shocks and 106 +/- 22 V, 1.3 +/- 0.4 J, for biphasic shocks with both phase durations equal to 5 msec (5-5 msec). The experiment was repeated in another six dogs in which the electrodes were secured to the pericardium. The mean DFT was not significantly higher than that for the electrodes on the epicardium: 165 +/- 27 V, 3.1 +/- 1.2 J for 10 msec monophasic shocks and 116 +/- 19 V, 1.6 +/- 0.5 J for 5-5 msec biphasic shocks. Low DFTs were also obtained with biphasic shocks in which the duration of the first phase was longer than that of the second.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1987

Cholesterol crystal embolization: a review of 221 cases in the English literature.

Cholesterol crystal embolization (CCE) frequently presents with nonspecific manifestations that mimic other systemic diseases. The authors reviewed 221 cases of histologically proven CCE in the English literature to define the clinical, laboratory, and pathologic characteristics of this disorder. CCE affected predominantly elderly males (mean age sixty-six) with a frequent history of hypertension (61%), atherosclerotic cardiovascular disease (44%), renal failure (34%), and aortic aneurysms (25%) at presentation. At least one possible predisposing factor was present in 31% and included operative and radiological vascular procedures and the use of anticoagulants. Cutaneous findings (34%) and renal failure (50%) were two of the most common clinical findings throughout the course of CCE. The nonspecific signs and symptoms included: fever (7%), weight loss (7%), myalgias (4%), and headache (3%). Premortem diagnoses were established in 31% of patients most commonly by biopsy of the muscle, skin, and kidney. Mortality was high (81%) and was most commonly due to multifactorial, cardiac, and renal etiologies. The authors conclude that CCE should be strongly considered in elderly patients with atherosclerotic vascular disease who have the onset of renal insufficiency and cutaneous manifestations. CCE may be confirmed by a skin or muscle biopsy.

Cholesterol↗
PubMed1986

The cutaneous manifestations of cholesterol crystal embolization.

In an effort to provide a greater understanding of the cutaneous features of cholesterol crystal embolization (CCE), we reviewed the clinical features of all histologically proved cases reported in the English-language literature, exclusive of cases in which there was only central nervous system or cardiac involvement. We found that the skin is involved in 35% of patients with CCE. Livedo reticularis is the most common skin manifestation (49%), followed by gangrene (35%), cyanosis (28%), ulceration (17%), nodules (10%), and purpura (9%). Cholesterol crystal embolization was most common in older men and was frequently associated with anticoagulant therapy (36%) or vascular procedures (31%). Because of its protean systemic manifestations, CCE was often mistaken for vasculitis (16%) and periarteritis nodosa (12%). Mortality was very high (72%). Histologic confirmation of cutaneous CCE was possible in 92% of cases where a skin biopsy specimen was obtained. We conclude that the diagnosis of cutaneous CCE should be suggested and easily confirmed histologically in the appropriate clinical setting.

Adult↗
PubMedDate not supplied

Temporal trends in outcomes of older patients with pneumonia.

BACKGROUND: It is unclear how outcomes of care for patients hospitalized for pneumonia have changed as patterns of health care delivery have changed during the 1990s. This study was performed to determine trends in outcomes of care for older patients hospitalized for pneumonia. METHODS: This retrospective analysis was based on Medicare claims and included most patients with pneumonia who were older than 65 years and admitted to acute care hospitals in Connecticut between October 1, 1991, and September 30, 1997 (fiscal years 1992-1997). We assessed the trends in hospital costs, discharge destination, hospital mortality rates, mortality rates within 30 days of discharge, and 30-day readmission rates for pneumonia. Multivariate logistic regression analyses were used to adjust for differences in patient characteristics. RESULTS: The mean (+/- SD) length of stay declined from 11.9 + 11.4 days to 7.7 + 7.2 days between 1992 and 1997. During this period, adjusted in-hospital mortality rates declined (P =.02), while the adjusted risk of discharge to a nursing facility increased (P<.001) and the adjusted risk of hospital readmission for pneumonia within 30 days of discharge increased (P =.05). The adjusted risk of death 30 days after discharge increased, although the difference was not statistically significant (P =.09). CONCLUSIONS: Between 1992 and 1997, the adjusted risks of mortality after discharge, placement in a nursing facility, and hospital readmission for pneumonia increased among older patients hospitalized for pneumonia, in association with a decline in mean hospital length of stay. These findings raise the question of whether the declining hospital length of stay has negatively affected patient outcomes. Arch Intern Med. 2000;160:3385-3391.

Aged↗
PubMedDate not supplied

Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials.

BACKGROUND: Because of the prevalence of pneumococcal pneumonia, the substantial morbidity and mortality associated with many pneumococcal infections, and an increase in the incidence of antibiotic resistance among pneumococcal isolates, considerable efforts for disease prevention have been made using a polyvalent polysaccharide pneumococcal vaccine. Despite numerous clinical trials of the vaccine, its efficacy in the prevention of pneumococcal infections and other clinically relevant medical outcomes in adults remains uncertain. METHODS: To assess quantitatively the efficacy of pneumococcal vaccination, a MEDLINE literature search, manual reviews of article bibliographies, and communications with pneumococcal vaccine investigators were used to identify randomized controlled trials of the pneumococcal vaccine. Independent review of 594 articles revealed nine randomized trials with 12 vaccine and control study groups that evaluated clinically relevant outcomes in adults. To estimate a summary effect size for all outcomes, Mantel-Haenszel odds ratios (ORs) and Dersimonian and Laird rate differences (RDs) and their associated 95% confidence intervals (CIs) were computed. RESULTS: Summary ORs demonstrated a statistically significant protective effect of the vaccine for four pneumococcal infection-related outcomes: definitive pneumococcal pneumonia (OR = 0.34; 95% CI = 0.24 to 0.48), definitive pneumococcal pneumonia for vaccine-containing pneumococcal antigen types only (vaccine types only) (OR = 0.17; 95% CI = 0.09 to 0.33), presumptive pneumococcal pneumonia (OR = 0.47; 95% CI = 0.35 to 0.63), and presumptive pneumococcal pneumonia (vaccine types only) (OR = 0.39; 95% CI = 0.26 to 0.59). The summary RDs, which account for heterogeneity among studies, confirmed a statistically significant protective effect for two of these same outcomes: definitive pneumococcal pneumonia (RD = 4/1000; 95% CI = 0/1000 to 7/1000) and definitive pneumococcal pneumonia (vaccine types only) (RD = 8/1000; 95% CI = 1/1000 to 16/1000). Summary ORs and RDs failed to demonstrate a protective effect for pneumonia (all causes), bronchitis, and mortality (all causes) or mortality due to pneumonia or pneumococcal infection. Subgroup analyses showed that for all four pneumococcal infection-related outcomes, vaccine efficacy differed for high- and low-risk subjects, demonstrating efficacy for low-risk subjects and lack of efficacy for high-risk subjects. CONCLUSIONS: Pneumococcal vaccination appears efficacious in reducing bacteremic pneumococcal pneumonia in low-risk adults. However, evidence from randomized controlled trials fails to demonstrate vaccine efficacy for pneumococcal infection-related or other medical outcomes in the heterogeneous group of subjects currently labeled as high risk.

Adult↗
PubMedDate not supplied

Evaluation of housestaff physicians' preparation and interpretation of sputum Gram stains for community-acquired pneumonia.

OBJECTIVE: To evaluate the preparation and interpretation of sputum Gram stains by housestaff physicians in the assessment of patients with community-acquired pneumonia. DESIGN: A prospective, multicenter study. SETTING: Two university-affiliated hospitals in Pittsburgh. PATIENTS: Ninety-nine cases of clinically and radiographically established pneumonia occurring in 97 patients. Diagnostic test assessment: Housestaff and microbiology personnel prepared a Gram stain for each case of pneumonia. Housestaff assessed the presence and identity of a predominant microbial organism on the slides they prepared. Two senior staff microbiologists, blinded to patient and preparer, evaluated all slides for preparation, sputum purulence, and identification of the predominant organism. Two reference standards were used to assess the sensitivity, specificity, and predictive values of housestaff's Gram-stain interpretations: 1) senior staff microbiologists' determinations of the microbes present using the slides without benefit of culture results, and 2) the etiologic agent derived from results of sputum culture, blood culture, or serology. MEASUREMENTS AND MAIN RESULTS: Housestaff physicians completed a Gram stain in 58% of the pneumonia episodes. Gram stains were not made in 42% of cases, primarily because patients were unable to produce sputum. Fifteen percent of housestaff's smears were judged inadequately prepared, compared with 3% for the laboratory personnel (p less than 0.01). Housestaff obtained purulent sputum samples significantly more often than did nursing personnel (58% versus 38%; p less than 0.01). Housestaff's Gram stains were 90% sensitive for detecting pneumococcus, with a 50% false-positive rate. The sensitivity of the Gram stain was less for identification of Haemophilus influenzae than for identification of Streptococcus pneumoniae. A single antimicrobial agent was chosen as initial therapy for 50% of the patients in whom housestaff identified a predominant organism, compared with 30% in whom a predominant organism was not identified (p less than or equal to 0.05). CONCLUSIONS: Although housestaff obtained purulent sputum samples more frequently than did nursing personnel, they made systematic errors in the preparation and interpretation of Gram-stained slides. Housestaff physicians should receive formal training in the preparation and interpretation of Gram stains; the specific defects elucidated in this study warrant special attention.

Adolescent↗