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Biomedical subjects

P S Heckerling

Publications and source records attributed to P S Heckerling.

At least 19 recordsLinked to original sources
PubMed1992

Attitudes of funeral directors and embalmers toward autopsy.

Although physician and family attitudes toward autopsy have been suggested as factors leading to declining autopsy rates, attitudes of funeral directors and embalmers toward autopsy have not been studied. We surveyed members of the Illinois Funeral Directors Association concerning beliefs about the purposes of autopsy, problems they experienced with autopsied cases, and the advice they gave to family members about permitting autopsy. Three hundred eight (42.2%) of 730 funeral directors and embalmers responded to the questionnaire. Although 80.3% believed that autopsy served a purpose, 46.4% had counseled families not to permit autopsy, and 16.6% did so more than half the time. Perceived difficulty in embalming autopsied cases (odds ratio, 2.3), family concern about the risk of disfigurement (odds ratio, 1.9 to 2.2), having attempted to talk to a pathologist or hospital administrator about a poorly performed autopsy (odds ratio, 2.0), and belief in the purpose of autopsy (odds ratio, 0.38), were significant independent predictors of counseling against autopsy. Of funeral directors who counseled against autopsy, 28.3% reported that families never permitted autopsy, and 39.4% reported that families only occasionally permitted autopsy, in cases where they had counseled against it. Funeral directors from Illinois counties with 1989 medical certificate case autopsy rates of less than 5% counseled against autopsy more frequently than funeral directors from counties with higher autopsy rates. We conclude that although most funeral directors and embalmers believe in the purposes of the autopsy, difficulties in embalming autopsied cases, and family concern about the risk of disfigurement, may lead members of the funeral profession to counsel against autopsy, and that such advice may influence families not to permit an autopsy.

Attitude↗
PubMed1991

Accuracy of precordial percussion in detecting cardiomegaly.

STUDY OBJECTIVE: To assess the value of precordial percussion in detecting cardiomegaly, and to compare it with palpation of the apical impulse. DESIGN: Descriptive study. SETTING: Hospitals and clinics of a university medical center. PATIENTS: Light indirect percussion of the precordium was performed on 72 inpatients and 28 outpatients. All patients had a posteroanterior radiograph of the chest. Percussors were unaware of the clinical history and of chest roentgenogram results. MEASUREMENTS AND MAIN RESULTS: Thirty-six patients (36%) had cardiomegaly, defined as a cardiothoracic ratio of greater than 0.5 on chest roentgenogram. The cardiothoracic ratio was significantly correlated with percussion distance from the midsternal line in the left fourth (r = 0.35, p less than 0.0006), fifth (r = 0.65, p less than 0.00001), and sixth (r = 0.40, p less than 0.0001) intercostal spaces. After adjustment for clinical symptoms and systolic and diastolic blood pressures, percussion distance in the left fifth intercostal space remained a significant independent predictor of the cardiothoracic ratio. Percussion distance in the left fifth interspace discriminated cardiomegaly with a receiver-operating characteristic (ROC) area of 0.95. Percussion dullness more than 10.5 cm from the midsternal line in the left fifth interspace had a sensitivity of 94.4% (95% confidence interval [CI], 79.9% to 99.0%) and a specificity of 67.2% (CI, 54.2% to 78.1%). Distance of the apical impulse from the midsternal line discriminated with an ROC area of 0.95, but an impulse was palpated in only 40% of cases. CONCLUSIONS: Percussion in the left fifth intercostal space accurately discriminates patients with and without cardiomegaly, and adds information beyond that obtainable from the history and other parts of the physical examination.

Adolescent↗
PubMed1991

Amniocentesis or chorionic villus sampling for prenatal genetic testing: a decision analysis.

We used decision analysis to examine the strategies of amniocentesis, chorionic villus sampling, and no prenatal testing for a pregnant woman who would be 35 years of age at the expected date of delivery. Probabilities were obtained from the obstetric and genetic literature, and utilities from previously published standard reference gambles and from responses of obstetric residents and students recorded on a linear rating scale. The expected utility of amniocentesis exceeded that of chorionic villus sampling by 0.1 utility units, and of no prenatal testing by 0.12 utility units. The decision was insensitive to clinically plausible values for the probabilities of spontaneous abortion after amniocentesis and chorionic villus sampling, the probabilities of abnormal and indeterminate chorionic villus sampling results, the probability of an abnormal amniocentesis result after an indeterminate chorionic villus sampling, the sensitivities and specificities of amniocentesis and chorionic villus sampling, and the probabilities of significant maternal morbidity after first- and second-trimester therapeutic abortion. Chorionic villus sampling was preferred to amniocentesis when the utility of a first-trimester therapeutic abortion exceeded that of a second-trimester abortion by 23.2 utility units, or when the anxiety "cost" of awaiting second-trimester amniocentesis results exceeded 0.1 utility unit. We conclude that over a range of assumptions concerning the probabilities involved in the prenatal testing decision, amniocentesis was preferred to chorionic villus sampling. However, for a decision maker for whom a second-trimester therapeutic abortion would be significantly less acceptable than a first-trimester procedure, or for whom the anxiety of awaiting second-trimester chromosomal diagnosis might be an important consideration, chorionic villus sampling could become the procedure of choice.

Adult↗
PubMed1990

Clinical prediction rule for pulmonary infiltrates.

OBJECTIVE: To derive and validate a clinical rule for predicting pneumonic infiltrates in adult patients with acute respiratory illness. DESIGN: Prevalence studies in three settings. SETTING: Emergency departments of the University of Illinois Hospital at Chicago, the University of Nebraska Medical Center at Omaha, and the Medical College of Virginia at Richmond. PATIENTS: Symptoms, signs, comorbidity data, and chest roentgenogram results were recorded for 1134 patients from Illinois (the derivation set), 150 patients from Nebraska, and 152 patients from Virginia (the validation sets). All patients presented to the emergency department and had a chest roentgenogram to evaluate fever or respiratory complaints. MEASUREMENTS AND MAIN RESULTS: Within the training set, temperature greater than 37.8 degrees C, pulse greater than 100 beats/min, rales, decreased breath sounds, and the absence of asthma were identified as significant predictors of radiographically proved pneumonia in a stepwise logistic regression model (P = 0.001). The logistic rule discriminated patients with and without pneumonia in the training set with a receiver operating characteristic (ROC) area of 0.82. In the validation sets, the rule discriminated pneumonia and nonpneumonia with ROC areas of 0.82 and 0.76 after adjusting for differences in disease prevalence (P greater than 0.2 compared with the training set). The predicted probability of having pneumonia for patients with different clinical findings corresponded closely with the incidence of pneumonia among patients with such findings in the three settings. CONCLUSIONS: Among adults presenting with acute respiratory illness, a prediction rule based on clinical findings accurately discriminated patients with and without radiographic pneumonia, and was used in two other samples of patients without significant decrement in discriminatory ability. This rule can be used by physicians to develop more effective strategies for detecting pneumonia and for helping to determine the need for radiologic study among patients with acute respiratory disease.

Acute Disease↗
PubMed1990

Screening hospital admissions from the emergency department for occult carbon monoxide poisoning.

Because cases of unrecognized carbon monoxide (CO) poisoning have been described among patients admitted to the hospital with other diagnoses, screening hospital admissions with carboxyhemoglobin testing has the potential for preventing morbidity among patients as well as among their cohabitants. Carboxyhemoglobin levels were obtained on 753 patients admitted to the hospital from the emergency department over a 3-month period during the winter. Patients in whom CO poisoning was diagnosed in the emergency department prior to admission were excluded. The mean carboxyhemoglobin level was 2.52% +/- 1.85%; there was no significant difference in mean carboxyhemoglobin among patients with medical, surgical, neurological, and psychiatric admission diagnoses (F = 1.17; df = 3,746; P = .32). Two patients (0.3%; 95% confidence limits, 0.04% to 1.1%) from the entire admission cohort, and one of 20 patients (5%; 95% confidence limits, 0.3% to 26.9%) admitted with seizures, had carboxyhemoglobin levels greater than 10%. The carboxyhemoglobin levels of the two patients were only marginally elevated, with levels of 10.9% and 11.3%. The cost of the carboxyhemoglobin screening program was $2.26 per patient result, or approximately $2,100 over a 3-month winter heating season. A program for screening emergency department admissions with carboxyhemoglobin testing, although feasible in terms of cost, detected few cases of unrecognized CO poisoning.

Adolescent↗
PubMed1990

Occult carbon monoxide poisoning in patients with neurologic illness.

To investigate occult carbon monoxide poisoning in patients with neurologic illness, we prospectively studied 168 patients who presented to the emergency department between December 1987 and February 1988 with neurologic symptoms for evidence of carbon monoxide exposure. Patients with known carbon monoxide poisoning were excluded. The mean carboxyhemoglobin level was 3.1 percent; there were no significant differences in carboxyhemoglobin between categories of neurologic illness (F(5,162) = 1.35; p less than 0.25). Five patients (3 percent) had a carboxyhemoglobin greater than 10 percent, with levels ranging from 11.7 percent to 29.5 percent. After controlling for the effects of active and passive exposure to cigarette smoke, problems with the home heating system (odds ratio 9.6; p less than 0.03) and the presence of cohabitants with concurrent headache or dizziness (odds ratio 21.6; p less than 0.0001) were associated with an increased risk of a carboxyhemoglobin greater than 10 percent. A rule for obtaining carboxyhemoglobin tests only on patients who used gas stoves for heat or who had symptomatic cohabitants would have correctly identified all patients with carboxyhemoglobins greater than 10 percent, correctly excluded 77 percent of patients with lower levels, and eliminated the need for testing in 75 percent of cases. We conclude that unrecognized carbon monoxide poisoning occurs in a small but important fraction of patients with wintertime neurologic illness and can be identified by a characteristic risk factor profile.

Adult↗
PubMed1990

Information content of diagnostic tests in the medical literature.

Diagnostic tests provide information about the presence or absence of disease. However, even after application of diagnostic tests, significant uncertainty about the state of the patient often remains. This uncertainty can be quantified through the use of information theory. The "information" contained in diagnostic tests published in the medical literature of the years 1982 through 1986 was evaluated using Shannon information functions. Information content, averaged over all prior probabilities of disease, ranged from 0.002 bits to 0.720 bits of information; the tests therefore provided from 0.3% to 100% of the information needed for diagnostic certainty. Median average information was 0.395 bits, corresponding to only 55% of the information required for diagnostic certainty. Reclassifying test results into multiple mutually exclusive outcome categories allowed extraction of a median of 14% and a maximum of 109% more average information than that obtained using a dichotomous positive/negative classification. We conclude that the "information" provided by many of the tests published in the medical literature is insufficient to overcome diagnostic uncertainty. Information theory can quantify the uncertainty associated with diagnostic testing and suggest strategies for reducing this uncertainty.

Humans↗
PubMed1989

Retinal vein thrombosis in a patient with pernicious anemia and anticardiolipin antibodies.

A 45-year-old man with pernicious anemia presented with sudden loss of vision due to central retinal vein thrombosis, and was found to have anticardiolipin antibodies and a clotting disorder consistent with the presence of a lupus anticoagulant. He was treated with low dose aspirin and has remained free of recurrent thrombosis over a period of one year. The association between lupus anticoagulant and pernicious anemia is rare, having been reported in only one prior case.

Anemia, Pernicious↗
PubMed1988

Occult carbon monoxide poisoning: validation of a prediction model.

Headache and dizziness are early symptoms of carbon monoxide poisoning, occurring at carboxyhemoglobin levels of greater than 10 percent. Previously, it was shown that among patients presenting to an emergency department during the winter with headache or dizziness, an algorithm for obtaining carboxyhemoglobin levels on patients who used gas stoves for heating purposes or who had similarly affected cohabitants correctly identified all patients with carboxyhemoglobin levels greater than 10 percent. To test the validity of this retrospectively derived rule, 65 patients were studied who were unaware of any carbon monoxide exposure and who presented during the winter of 1986-1987 with headache or dizziness. The algorithm correctly identified three of four patients with carboxyhemoglobin levels greater than 10 percent (sensitivity = 75 percent) and correctly excluded 45 of 61 patients with lower levels (specificity = 74 percent). The presence of symptomatic cohabitants alone was an equally sensitive (75 percent) but more specific (90 percent) marker for elevated carboxyhemoglobin levels. When data from the two cohorts were combined, stepwise multiple regression identified number of cigarettes smoked daily (F = 8.66) and concurrently symptomatic cohabitants (F = 34.71) as significant predictors of the carboxyhemoglobin level. It is concluded that a retrospectively derived rule correctly identified most cases of occult carbon monoxide poisoning when applied prospectively, and that the presence of similarly affected cohabitants was the most reliable marker for a carbon monoxide-mediated illness.

Adult↗
PubMed1988

Thyrotoxic periodic paralysis in a hispanic man.

Thyrotoxic periodic paralysis occurs much more frequently in Orientals than in whites, and has rarely been reported in patients of Hispanic descent. A 28-year-old Mexican man presented with acute onset of bilateral lower extremity weakness after ingestion of a large carbohydrate meal. Laboratory investigation revealed severe hypokalemia, with a serum potassium level of 2.1 mmol/L (2.1 mEq/L), and hyperthyroidism. Administration of potassium chloride resulted in normalization of the serum potassium level and resolution of muscle weakness. Treatment with propranolol, and subsequent restoration of a euthyroid state with iodine 131, was effective in preventing further episodes of paralysis. Thyrotoxic periodic paralysis, although rare, may occur in Hispanic patients, and should be considered in the differential diagnosis of muscle weakness in this population.

Adult↗
PubMed1987

Occult carbon monoxide poisoning: a cause of winter headache.

Headache is an early symptom of carbon monoxide (CO) poisoning, occurring at carboxyhemoglobin (COHb) levels of greater than 10%. We investigated 37 patients presenting to an emergency department during the winter-heating season with a complaint of headache for evidence of CO exposure. Seven of the 37 patients (18.9%) had COHb levels in excess of 10%, with a mean of 14.0%. Three of these seven patients (42.9%) used gas space heaters or kitchen stoves to heat their homes, and three (42.9%) had cohabitants at home with headache. Of the 30 patients with COHb levels of less than 10% (mean level, 3.2%), only four (13.3%) used gas space heaters and kitchen stoves for heat (P = NS), and none (0%) had cohabitants with headache (P = .0045). In six of the seven patients with elevated COHb levels (85.7%), gas company investigation or historical information obtained retrospectively revealed a definite or probably toxic CO exposure. In none of these patients had the diagnosis of CO poisoning been suspected by the emergency department physician or the patient prior to obtaining the result of the COHb level. Occult CO poisoning may be an important cause of winter headache.

Adolescent↗
PubMed1987

Ethylene glycol poisoning with a normal anion gap due to occult bromide intoxication.

Ethylene glycol poisoning causes metabolic acidosis with an increased anion gap, due to production of organic acid anions during its metabolism. Bromide poisoning may cause a spuriously decreased anion gap when chloride determination is performed with a colorimetric technique. A 39-year-old woman with ethylene glycol poisoning presented in coma, with a hyperchloremic normal anion gap acidosis. The serum bromide level was found to be in the toxic range, confirming the diagnosis of bromide poisoning. Hemodialytic therapy resulted in resolution of electrolyte and acid-base abnormalities, and restoration of a normal state of consciousness. In this patient, clinically occult bromide intoxication caused a spurious lowering of the anion gap, normalizing what was in reality an increased anion gap due to ethylene glycol poisoning.

Acidosis↗
PubMed1987

Predictors of occult carbon monoxide poisoning in patients with headache and dizziness.

Headache and dizziness occur at carboxyhemoglobin levels of greater than 10%. We studied 89 patients with headache or dizziness for evidence of carbon monoxide exposure. The mean carboxyhemoglobin level was 2.87%. Number of cigarettes smoked per day (r = 0.471; p less than 0.00002), use of gas kitchen stoves for heating purposes (r = 0.252, p less than 0.02), problems with the home heating system (r = 0.278, p less than 0.01), and cohabitants with concurrent headache or dizziness (r = 0.427, p less than 0.01) correlated with carboxyhemoglobin levels. Multiple regression analysis identified number of cigarettes smoked daily, use of stoves for heat, and concurrently symptomatic cohabitants as significant predictors of carboxyhemoglobin level (F = 13.939 [3, 85]; p less than 0.01). Obtaining carboxyhemoglobin levels from patients who used stoves for heat or had similarly affected cohabitants identified 4 of 4 patients with levels greater than 10% (sensitivity, 100%) and excluded 47 of 85 patients with lower levels (specificity, 55.3%). The 4 patients with carboxyhemoglobin levels in excess of 10% may represent occult carbon monoxide poisoning in this population.

Adult↗