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Biomedical subjects

M S Gottlieb

Publications and source records attributed to M S Gottlieb.

At least 37 records · Page 2Linked to original sources
PubMed1993

The relationship between adjusted hospital mortality and the results of peer review.

This study assessed the relationship between the Health Care Financing Administration adjusted mortality rate for a hospital and the errors in care found by the peer review process. The three data sets used were: (1) the 1987-1988 completed reviews from 38 peer review organizations (PROs) of 4,132 hospitals and 2,035,128 patients; (2) all 1987 hospital mortality rates for Medicare patients as adjusted by HCFA for patient mix; and (3) the 1986 American Hospital Association Survey. The PRO data were used to compute the percentage of cases reviewed from each hospital confirmed by a reviewing physician to have a quality problem. The average percentage of confirmed problems was 3.73 percent with state rates ranging from 0.03 percent to 38.5 percent. The average within-state correlation between the problem rate and the adjusted mortality rate for all PROs was .19 (p < .0001), but the correlations were much higher for relatively homogeneous groups of hospitals, .42 for public hospitals and .36 for hospitals in large metropolitan statistical areas (MSAs). These results suggest that the HCFA adjusted hospital mortality rate and the PRO-confirmed problem rate are related methods to compare hospitals on the basis of quality of care. Both methods may compare quality better if used within a group of homogenous hospitals.

American Hospital Association↗
PubMed1992

Recombinant human erythropoietin in the treatment of anemia associated with human immunodeficiency virus (HIV) infection and zidovudine therapy. Overview of four clinical trials.

OBJECTIVE: To assess the effect of recombinant human erythropoietin (r-HuEPO) on anemia in patients with the acquired immunodeficiency syndrome (AIDS) who are receiving zidovudine therapy. DESIGN: Combined analysis of four 12-week, randomized, double-blind, controlled clinical trials. SETTING: Multiple centers in the United States. PATIENTS: Two hundred and ninety-seven anemic (hematocrit < 30%) patients with AIDS who were receiving zidovudine therapy. Of the 297 patients, 255 were evaluable for efficacy, but all patients were included in analysis of safety. INTERVENTION: Patients were randomly assigned to receive either r-HuEPO (100 to 200 U/kg body weight) or placebo, intravenously or subcutaneously, three times per week for up to 12 weeks. MEASUREMENTS: Changes in mean hematocrit, transfusion requirement, and quality of life. RESULTS: Sixty-nine percent of patients had endogenous serum erythropoietin levels less than or equal to 500 IU/L, and 31% had erythropoietin levels greater than 500 IU/L. In patients with low erythropoietin levels (< or equal to 500 IU/l), r-HuEPO therapy decreased the mean number of units of blood transfused per patient when compared with placebo (3.2 units and 5.3 units, respectively; P = 0.003) and increased the mean hematocrit from the baseline level (4.6 percentage points and 0.5 percentage points, respectively; P <0.001). Overall quality of life improved in patients on r-HuEPO therapy (P = 0.13). Patients with erythropoietin levels greater than 500 IU/L showed no benefit from r-HuEPO in any outcome variable. Placebo and r-HuEPO recipients did not differ in the incidence of adverse effects or opportunistic infections. CONCLUSION: Therapy with r-HuEPO can increase the mean hematocrit and decrease the mean transfusion requirement in anemic patients with AIDS who are receiving zidovudine and have endogenous low erythropoietin levels (< or equal to 500 IU/L). Such therapy is of no apparent benefit in patients whose endogenous erythropoietin levels are higher than 500 IU/L.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Geographic variation in the use of breast-conserving treatment for breast cancer.

BACKGROUND: In the past decade there has been an increase in the use of treatment designed to conserve the breast for women with breast cancer. The extent to which such treatment has been adopted in various regions of the country and whether characteristics of hospitals and patients predict its use is not known, however. METHODS: We used national data on Medicare claims for inpatient care provided in 1986 to study 36,982 women 65 to 79 years of age, who had local or regional breast cancer and underwent either mastectomy or breast-conserving treatment (local excision, quadrantectomy, or subtotal mastectomy). Information about the hospitals at which these women were treated was obtained from an American Hospital Association survey. RESULTS: Of the 36,982 women, 12.1 percent had breast-conserving surgery and 87.9 percent had a mastectomy. The frequency of breast-conserving surgery ranged from 3.5 percent to 21.2 percent in various states. The highest rate of use was in the Middle Atlantic states (20.0 percent) and New England (17.2 percent), and the lowest was in the East South Central states (5.9 percent) and the West South Central states (7.3 percent). Breast-conserving treatment was used more often in urban than in rural areas, in teaching hospitals than in nonteaching hospitals, in large hospitals than in small hospitals, and in hospitals with on-site radiation therapy or geriatric services than in others. Most of the geographic variation persisted after adjustment for the characteristics of hospitals and patients for which data were available. CONCLUSIONS: There is substantial geographic variation in the use of breast-conserving surgery, which cannot be explained by differences in hospital characteristics. Hospital characteristics that were independently redictive of greater use of breast-conserving surgery were the size of the metropolitan area, the status of the institution as a teaching hospital, and the availability of radiation therapy and geriatric services.

Aged↗
PubMed1992

Double gloving. Protecting surgeons from blood contamination in the operating room.

Health care workers, particularly surgeons, understand the importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination.

Blood↗
PubMed1992

A comparison of the urological complications associated with long-term management of quadriplegics with and without chronic indwelling urinary catheters.

The primary objective of this retrospective study was to compare the incidence of urological complications and renal deterioration in post-traumatic quadriplegic patients managed with or without a chronic indwelling urinary catheter. The charts of 57 consecutive patients who sustained traumatic cervical spinal cord injury between 1970 and 1980 were reviewed. All of the patients received the initial management or rehabilitation therapy at our institution. The unique features of this clinical review are that a large cohort of patients was followed for a minimum of 10 years, none of the 57 consecutive patients was lost to followup and a yearly excretory urogram provided an objective assessment of the renal units. The followup, and mechanism, level and degree of injury for the 32 patients managed with and 25 managed without a catheter were similar. Overall, the incidences of renal and bladder calculi, pyelonephritis, gross hematuria, penile/urethral erosion, urosepsis, urethral stricture, epididymitis and pyonephrosis were not significantly different in the catheterized and noncatheterized groups. The Kaplan-Meier analysis of the most recent excretory urogram demonstrated that the incidence of renal deterioration was also equivalent in the catheterized and noncatheterized groups. Our study suggests that the decision to manage quadriplegics with or without an indwelling catheter should not be based on relative risk of complications or renal deterioration. The decision to avoid an indwelling catheter in these patients should reflect patient comfort, convenience and quality of life.

Adult↗
PubMed1992

Hospitalization with vertebral fracture among the aged: a national population-based study, 1986-1989.

Whereas fractures related to osteoporosis have become a pressing public health concern, relatively few epidemiologic studies have focused on vertebral fractures. To shed further light on the occurrence of this injury, we collected data from the Health Care Financing Administration on 151,986 discharges listing a diagnosis of vertebral fracture over a 4-year period. After adjusting for age, white women experienced the highest rates of discharge, at 17.1 per 10,000 per year, followed by white men (9.9 per 10,000), black women (3.7 per 10,000), and black men (2.5 per 10,000). Among white women, discharge rates rose exponentially from 5.3 discharges per 10,000 population at age 65 to nearly 47.8 per 10,000 at age 90. White men, black women, and black men experienced less dramatic age-related increases in discharge rates. The similarity of these patterns to discharge rates for hip fracture suggests that the race-sex differences in vertebral fracture discharge rates may be due to differences in the incidence of vertebral fracture.

Aged↗
PubMed1992

Outcome and cost analysis of scheduled versus emergency scleral buckling surgery.

BACKGROUND: Retinal detachments are usually considered to be a surgical emergency. However, there are additional risks and costs for unnecessary emergency surgeries. The purpose of this study is to evaluate whether the conventional wisdom for treating all retinal detachments as emergencies needs to be re-examined. METHODS: Forty-eight patients who had an emergency scleral buckle and 89 patients who had a scheduled procedure were randomly selected from 884 consecutive patients who had a primary scleral buckling procedure during a 4 1/2-year period. The medical records of each patient were used to obtain detailed information related to prognosis. The visual acuity measurements of each patient, taken 6 months after the procedure, were obtained from the records of the ophthalmologist following the patient. Linear regression analysis was used to compare the final visual outcome for patients who had emergency surgery with patients who had scheduled surgery after taking into account patient factors related to prognosis. RESULTS: Patients selected for emergency surgery had better visual prognoses than scheduled patients but had the same risk of systemic complications and the same extent of detachment if the macula was not involved. None of the 18 patients with an attached macula experienced macular involvement while awaiting scheduled surgery. There were no differences between emergency and scheduled patients in ocular or systemic complications, rate of reattachment, rate of decreased visual acuity after surgery, visual outcome adjusted for prognosis, or, since 1985, length of hospital stay. A greater cost was incurred for the patients having emergency surgery due to difference in pay scales for support personnel. CONCLUSIONS: Because the study is not large and the patients were not randomized to treatment, the results are not definitive. However, they suggest that emergency surgery is unnecessary for many patients with a detached retina.

Appointments and Schedules↗
PubMed1992

In-use evaluation of surgical gowns.

Surgical gowns must protect patients from the bacteria of operating room personnel and also protect staff members from the lethal viruses in the blood of patients. The current study was done to evaluate the barrier function of several surgical types of gowns during use in surgical procedures and identify the frequency of failure of the gowns and some causes for this failure. We performed direct observation of 234 operations during which the surgeon and the first assistant wore 535 gowns. Blood strikethrough occurred most often when contamination on the outside of the gown was heavy (20 per cent), but still occurred after medium (7 per cent) and small (1 per cent) contamination. We found significant differences between gowns based on the material used and the design of the gowns. Gowns reinforced with a second layer of material or a layer of plastic material were more effective at preventing strikethrough than a single layer of material. One gown was identified that was unacceptable for any use in the operating room. Gowns of different designs and degrees of protection should be chosen based on the body area likely to be exposed to blood and the amount of predicted blood contamination. Further improvement in gown materials and design are required, since surgeons cannot consider any of these gowns protective during strenuous use.

Blood↗
PubMed1991

Cytomegalovirus retinopathy as the initial manifestation of the acquired immunodeficiency syndrome.

Of 100 consecutive patients with human immunodeficiency virus infection and cytomegalovirus retinopathy, 15 did not have a previous diagnosis of the acquired immunodeficiency syndrome before the ocular infection. All had other HIV-related disorders that would place them in Group IV of the Centers for Disease Control hierarchical classification system for HIV infections. In nine patients, cytomegalovirus retinopathy was the only disorder that fulfilled the Centers for Disease Control criteria for diagnosis of AIDS. In the other six, examination disclosed additional preexistent or concurrent nonocular disorders that were also diagnostic of AIDS. No demographic, medical, or ophthalmic characteristics distinguished the nine patients for whom cytomegalovirus retinopathy was initially the only manifestation of AIDS. On the basis of published figures for the prevalence of cytomegalovirus retinopathy in patients with AIDS, and the incidence with which HIV-infected persons develop AIDS, it is estimated that approximately 1.8% of patients with AIDS have cytomegalovirus retinopathy as the first manifestation and that less than 1% of HIV-infected persons will develop cytomegalovirus retinopathy as the initial manifestation of AIDS during the first seven years after infection with HIV.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Response to treatment with the leukocyte-derived immunomodulator IMREG-1 in immunocompromised patients with AIDS-related complex. A multicenter, double-blind, placebo-controlled trial.

OBJECTIVE: To determine if a 6-month course of therapy with IMREG-1, a leukocyte-derived immunomodulator, slows disease progression in patients with AIDS-related complex. DESIGN: Randomized, double-blind trial. SETTING: Five academic- and three community-based clinics. PATIENTS: Immunocompromised patients (143) with HIV. INTERVENTIONS: IMREG-1 or placebo every 2 weeks (13 doses). MAIN RESULTS: Twelve of forty-eight patients on placebo and 5 of 95 patients on IMREG-1 experienced adverse events (AIDS-defining opportunistic infection or neoplasm, wasting syndrome, HIV-associated encephalopathy, or peripheral sensory neuropathy). Based on an intention-to-treat analysis, Kaplan-Meier event probabilities were 26% for the placebo group and 6% for the IMREG-1 group (P less than 0.001); based on the Cox proportional hazards model, the relative risk for patients on placebo compared with patients on IMREG-1 was 5.1 (95% CI, 1.8 to 14.8). The frequency of symptoms significantly increased from baseline in patients receiving placebo. The mean decrease in CD4+ cells from baseline was 80 x 10(6) cells/L in the placebo group and 29 x 10(6) cells/L in patients on IMREG-1, with 20% (8) and 38% (32) of patients, respectively, showing a trend toward an increase (P = 0.04). In patients receiving IMREG-1, the size and rate of delayed hypersensitivity responses were larger than in the placebo group. CONCLUSIONS: Patients with AIDS-related complex experienced fewer adverse events and constitutional symptoms after IMREG-1 treatment. The slower loss of CD4+ cells and increased size and rate of delayed hypersensitivity responses most likely reflect the effect of IMREG-1 on the immune system. No toxicity related to IMREG-1 administration was observed.

AIDS-Related Complex↗
PubMed1991

Risk of blood contamination and injury to operating room personnel.

The potential for transmission of deadly viral diseases to health care workers exists when contaminated blood is inoculated through injury or when blood comes in contact with nonintact skin. Operating room personnel are at particularly high risk for injury and blood contamination, but data on the specifics of which personnel are at greater risk and which practices change risk in this environment are almost nonexistent. To define these risk factors, experienced operating room nurses were employed solely to observe and record the injuries and blood contaminations that occurred during 234 operations involving 1763 personnel. Overall 118 of the operations (50%) resulted in at least one person becoming contaminated with blood. Cuts or needlestick injuries occurred in 15% of the operations. Several factors were found to significantly alter the risk of blood contamination or injury: surgical specialty, role of each person, duration of the procedure, amount of blood loss, number of needles used, and volume of irrigation fluid used. Risk calculations that use average values to include all personnel in the operating room or all operations performed substantially underestimate risk for surgeons and first assistants, who accounted for 81% of all body contamination and 65% of the injuries. The area of the body contaminated also changed with the surgical specialty. These data should help define more appropriate protection for individuals in the operating room and should allow refinements of practices and techniques to decrease injury.

Blood↗
PubMed1991

The relationship of hospital characteristics and the results of peer review in six large states.

To determine which characteristics of hospitals may be related to a higher quality of care, the association of hospital characteristics with the outcomes of medical record review by state Peer Review Organizations (PROs) was studied. The two data sources were: 1) the AHA 1986 Annual Survey of Hospitals and 2) reviews completed between July 1987 through June 1988 from six large PROs. For each hospital the percentage of cases that failed physician review (the confirmed problem rate) was computed. Hospital characteristics evaluated included financial status, ownership, medical training, technological sophistication, and size. The following characteristics were significantly associated with a lower confirmed problem rate: a higher occupancy rate, greater payroll expenses per bed, a higher proportion of physicians who were board-certified specialists, greater technological sophistication, a higher number of beds, a higher proportion of nurses who were registered, and membership in the Council of Teaching Hospitals. Public hospitals had higher problems rates than private not-for-profit hospitals. All characteristics significantly related to higher confirmed problem rates were also related to higher adjusted mortality rates in a previous study of 3,100 U.S. hospitals. The results suggest that hospital resources, including financial status, training of medical personnel, and availability of sophisticated equipment, are related to the quality of care provided by the hospital.

Bed Occupancy↗
PubMed1991

Comparison of Chevron osteotomy and modified McBride bunionectomy for correction of mild to moderate hallux valgus deformity.

The purpose of this study was to compare the results of the Chevron osteotomy to the DuVries' modification of the McBride procedure using identical criteria in two groups of patients. Thirty-two patients (48 feet) that had a Chevron osteotomy and 10 patients (17 feet) who had a modified McBride bunionectomy without metatarsal osteotomy for treatment of mild to moderate hallux valgus were retrospectively reviewed using subjective and objective criteria. Both groups were matched according to age, severity of deformity, and length of follow-up. Ninety-two percent of patients in the Chevron group and 88% of patients in the McBride group responded that they were either totally satisfied or improved regarding pain relief and appearance of the foot following surgery. Chevron osteotomy resulted in a statistically significant greater correction of the intermetatarsal 1-2 angle than did the McBride bunionectomy. Postoperative metatarsophalangeal joint range of motion was not significantly different for the two groups. Following Chevron osteotomy, five (10%) metatarsal heads exhibited radiographic changes of cyst formation and/or increased osteodensity and three (6%) of the osteotomies healed in a malunited position. One of the three metatarsal head malunions occurred in a patient that also had a lateral capsular release, however, none of the five cases that developed radiographic changes in the first metatarsal head was associated with a lateral capsular release. Lateral capsular release with the Chevron osteotomy did not improve the amount of correction of the hallux valgus deformity and it may be a contributing factor to instability at the osteotomy site leading to a valgus malunion.

Adult↗
PubMed1991

Outcome and cost analysis of scheduled versus emergency scleral buckling surgery.

Conventional wisdom holds that a retinal detachment of recent onset should be regarded as a surgical emergency. A delay in surgery may result in an extension of detachment for patients with an attached macula and a worse visual outcome for patients with a detached macula. However, the potential disadvantages of performing surgery on an emergency basis must be weighed against the risks of delaying surgery; disadvantages include a greater frequency of operative complications resulting from fatigue factors among the operating personnel, an increased anesthetic risk due to inadequate time to assess and stabilize coexisting medical problems, and higher hospital costs. In this retrospective study covering 4 1/2 years, we compared the risks, benefits, length of hospitalization, and costs of scleral buckling surgery for retinal detachments performed as an emergency procedure or on the day following admission. After a 15% random selection from 884 consecutive operations, 48 emergency procedures were compared with 89 scheduled procedures. Patients selected for emergency surgery had better visual prognoses than scheduled patients. The potential for risk of systemic complications was not a reason for postponing surgery. None of the 18 patients with an attached macula experienced macular involvement while awaiting scheduled surgery. There were no differences between emergency and scheduled patients in ocular or systemic complications, rate of reattachment, rate of decreased visual acuity following surgery, visual outcome adjusted for prognosis, or, since 1985, length of hospital stay. Cost was greater for patients having emergency surgery, because of a difference in pay scales for support personnel.

Cost-Benefit Analysis↗
PubMed1990

Comparison of xenon arc and argon laser photocoagulation in the treatment of choroidal melanomas.

We analyzed the follow-up data in 38 consecutive patients with selected choroidal melanomas that were treated by photocoagulation between 1971 and 1980. Indications for treatment included photographic documentation of tumor growth or an unequivocally positive radioactive phosphorus uptake test, or both. Xenon arc photocoagulation was used in 22 patients (58%) and argon laser was used in 16 patients (42%). At the time of data analysis, the length of follow-up was at least 58 months in all patients. Although all treated tumors were initially eradicated according to ophthalmoscopic and fluorescein angiographic criteria, there was subsequent regrowth in three of the 22 patients (14%) treated with xenon photocoagulation and in ten of the 16 patients (64%) treated with argon laser. The recurrences were observed on an average of 71 months after completion of treatment in the xenon-treated group and on an average of 30 months in the argon-treated group. More treatment sessions were required in the argon laser group to achieve tumor control. Complications of vitreous hemorrhage, cystoid macular edema, and retinal detachment were greater in the xenon photocoagulation group.

Adult↗
PubMed1990

A kinetic method for determination of free vanadium(IV) and (V) at trace level concentrations.

A kinetic method based on alkaline phosphatase has been developed to measure free trace levels of vanadium(IV) and (V). The method involves measuring the rate of the alkaline phosphatase-catalyzed hydrolysis of p-nitrophenyl phosphate with (Vi) and without (Vo) a competitive inhibitor in the assay. Michaelis-Menten kinetics for a competitive inhibitor was used to express the relationship between Vo/Vi and the inhibitor concentration. Measuring both Vo and Vi thus yields a Vo/Vi ratio that allows calculation of the competitive inhibitor concentration. Determination of free vanadium in complex fluids can be accomplished by comparing the ratio of rates of p-nitrophenyl phosphate hydrolysis with and without a sequestering agent to the ratios of rates measured on addition of a known vanadium concentration. Free vanadium(V) can conveniently be measured from 10(-7) to 10(-5) M and free vanadium(IV) can be measured at 10(-8) M and above. The error limits on the vanadium determinations range from +/- 3 to +/- 12% of the concentration under investigation depending on the conditions under which the assay was conducted.

Alkaline Phosphatase↗
PubMed1990

Development of immunomodulators for treatment of HIV infection.

Although considerable attention has been devoted to development of antiviral drugs for therapy of HIV infection, relatively little priority has been directed to correction of the progressive immunologic defect that develops in these patients. We described the development of the therapeutic effect of an immunosupportive biological agent (IMREG-1) derived from human leukocytes. Specifically, IMREG-1 reduced the risk of progression from advanced AIDS-related complex (ARC) based on a randomized double-blinded control trial over a six month period of the laboratory and clinical parameters predictive of a high risk of progression from ARC to AIDS. The comparative value of CD4+ cell numbers, anergy to recall antigens and symptomatology in assessing risk of progression were also examined.

AIDS-Related Complex↗