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Biomedical subjects

R S Goldman

Publications and source records attributed to R S Goldman.

At least 19 recordsLinked to original sources
PubMed2001

Continuous quality improvement in dialysis units: basic tools.

Physicians and allied health professionals are expected to understand and participate in the assessment and improvement of the quality of care delivered to patients in end-stage renal disease (ESRD) treatment centers. Participating in the quality improvement process will bring clinicians into contact with special knowledge and skills drawn from the areas of statistical process control and industrial engineering. Some of the more frequently encountered of these concepts and tools are described.

Humans↗
PubMed2001

Improving serum albumin levels in hemodialysis patients by a continuous quality improvement project.

Protein nutrition and serum albumins predict present and future mortality and morbidity. The North East Albuquerque Dialysis Center undertook a quality improvement project to improve serum albumin levels in hemodialysis patients. The dialysis facility's quality assurance team evolved into a continuous quality improvement team just before this project. The timeline and steps in this evolution are presented. The continuous quality improvement project process analysis, interventions, and outcome rates are also described. The project has resulted in a rate of less than or equal to 10% of hemodialysis patients with serum albumins less than 3.4 for the past 3 years.

Humans↗
PubMed2000

Reduced anterior cingulate gyrus volume correlates with executive dysfunction in men with first-episode schizophrenia.

Although frontal lobe structural and functional abnormalities have been identified in schizophrenia, their relationship remains elusive. Because the frontal lobes are both structurally and functionally heterogeneous, it is possible that some measures of frontal lobe structure may not have accurately identified relevant frontal lobe subregions. The authors hypothesized that the volumes of two dorsal, 'archicortical' subregions (i.e. superior frontal gyrus and anterior cingulate gyrus), but not a ventral, 'paleocortical' subregion (i.e. orbital frontal region) would be significantly and selectively correlated with executive and motor dysfunction in patients with schizophrenia as previously reported for the anterior hippocampal region. Volumes of these frontal lobe subregions were measured from magnetic resonance images based on sulcal anatomy in 20 men and 15 women with first-episode schizophrenia. All patients completed a comprehensive neuropsychological test battery while clinically stabilized that encompassed six domains of functioning: attention, executive, motor, visuospatial, memory and language. Findings indicated that reduced anterior cingulate gyrus volume was significantly correlated with worse executive functioning in men; among women, there were no significant correlations. Among men, anterior cingulate gyrus volume was significantly more strongly correlated with executive functioning than with attention, visuospatial, memory, language and general intellectual functioning. Neither executive nor motor functioning was significantly more strongly correlated with the dorsal 'archicortical' volumes than with orbital frontal volume. These findings suggest a link between executive deficits and dysfunction of the dorsal 'archicortical' system and implicate sex differences in their relationship in first-episode schizophrenia.

Adult↗
PubMed2000

Neuropsychology of first-episode schizophrenia: initial characterization and clinical correlates.

OBJECTIVE: Neuropsychological impairments are well documented in schizophrenia and are important targets of treatment. Information about the severity and pattern of deficits after treatment for the first psychotic episode and about relationships between these deficits and syndromal characteristics remains limited. METHOD: Comprehensive neuropsychological assessments including 41 individual tests were given to 94 patients with first-episode schizophrenia after initial stabilization of psychosis and to a comparison group of 36 healthy volunteers. Profiles of neuropsychological deficits and the relationship of deficits to sex and handedness were examined. Correlations of neuropsychological deficit with a broad range of historical and clinical characteristics, including outcome, were explored. RESULTS: Patients had a large generalized neuropsychological deficit (1.5 standard deviations compared to healthy volunteers). Patients also had, superimposed on the generalized deficit, subtle relative deficits (less than 0.5 standard deviation compared to their own average profile) in memory and executive functions. Learning/memory dysfunction best distinguished patients from healthy individuals; after accounting for this difference, only motor deficits further distinguished the groups. Patients with higher neuropsychological ability had only memory deficits, and patients with lower ability had both memory and executive deficits. No sex differences were observed beyond the normal advantage for men in motor speed. Dextral patients had less severe generalized deficit. Severity of residual symptoms was associated with greater generalized deficit. Executive and attentional deficits were most linked to global functional impairment and poor outcome. CONCLUSIONS: The results document a large generalized deficit, and more subtle differential deficits, in clinically stabilized first-episode patients. Learning/memory deficits were observed even in patients with less severe generalized deficit, but the pattern was unlike the amnestic syndrome and probably reflects different mechanisms. Executive and attentional deficits marked the more severely disabled patients, and may portend relatively poor outcome. Failure to develop typical patterns of cerebral dominance may increase the risk for greater generalized deficit.

Adult↗
PubMed1999

Proline in vasoactive peptides: consequences for peptide hydrolysis in the lung.

To examine the hypothesis that trans isomers of bradykinin and [Gly6]bradykinin are preferentially hydrolyzed by lung peptidases, we studied the fractional inactivation of these peptides in the perfused rat lung using a bioassay after a single-pass bolus injection and high-performance liquid chromatography after lung recirculation. In the bioassay studies, when the peptides passed through the lung, 25.6-fold more bradykinin or 7-fold more [Gly6]bradykinin was required to elicit a contraction equivalent to that produced when the peptides did not pass through the lung. In the recirculation studies, hydrolysis progress curves with rapid and slow phases were observed, with a higher fraction of bradykinin than [Gly6]bradykinin hydrolyzed in the rapid phase. Cyclophilin increased the hydrolysis rate during the slow phase for both peptides. Kinetic analysis indicated that the slowly hydrolyzed peptide fraction, presumably the cis fraction, was 0.13 for bradykinin and 0.43 for [Gly6]bradykinin with cis-trans isomerization rate constants of 0.074 and 0.049 s-1, respectively, consistent with published nuclear magnetic resonance studies.

Animals↗
PubMed1998

Meta-analysis of symptom factors in schizophrenia.

Factor and correlational analyses have been used to characterize symptom dimensions in schizophrenia, though they have yielded divergent models. This study used meta-analysis of published work to determine the number and composition of symptom dimensions. Principal components analysis of data from 10 empirical studies (pooled n = 896) yielded three factors, 'positive', 'negative' and 'conceptual disorganization'. The findings suggest that a three-factor solution is a relatively stable outcome of studies assessing these symptoms in chronic patients, and that some symptoms (alogia, attentional impairment) are less likely to load uniquely on a single factor.

Behavioral Symptoms↗
PubMed1998

Continuous quality improvement in ESRD: the role of networks, the United States Renal Data System, and facility-specific reports.

End-stage renal disease (ESRD) outcome improvement involves many different private and governmental entities. Networks have fulfilled a pivotal role in ESRD quality improvement by facilitating the change from quality assurance (QA) to continuous quality improvement (CQI) methodology, providing the collection and dissemination of outcome measures to facilities and developing quality improvement projects (QIPs) that interface directly with facilities. Improving outcomes in hemodialysis is generally limited to adequacy of hemodialysis and anemia management. Opportunities in peritoneal dialysis, nutrition, vascular access, and quality-of-life outcomes persist. Interaction between facilities and Medical Review Boards (MRBs) using workshops, site visits, and facility report cards can provide continuing ESRD outcome improvement. Every facility has unique people, procedures, and equipment producing their processes of care. Therefore, a certain amount of autonomy is required to encompass individual variation. Quality improvement methodology, although less rigorous than traditional outcome research, provides efficient and effective intervention when a rapid response is required to improve clinical outcomes. The two methods are not mutually exclusive but require distinct methodology to accomplish.

Health Facilities↗
PubMed1997

An analysis of the determinants of urinary urea and creatinine clearance in patients on continuous peritoneal dialysis.

The relative contribution of urinary volume (UV) and urine-to-plasma concentration ratios for urea (U/PUr) and creatinine (U/PCr) to urinary Kt/V urea (Kt/VU) and urinary uncorrected creatinine clearance (CCrU), respectively, was studied by simple and multiple linear regression analysis in 236 urea kinetic studies and 233 creatinine kinetic studies performed in 135 patients on continuous peritoneal dialysis (CPD). The following simple regressions were obtained: Kt/VU = 0.09 + 0.72 (UV), r = 0.75; Kt/VU = -0.01 + 0.11 (U/PUr), r = 0.55; CCrU = 12.06 + 56.46 + 46.46 (UV), r = 0.62; CCrU = 3.51 + 3.40 (U/PCr), r = 0.58. All r values were significant (p < 0.001). According to these regressions, a loss of 0.2 L/24 hours in UV leads to a loss of 0.15 weekly in Kt/VU and 11.3 L/1.73 m2 weekly in corrected CCrU (approximately 8 L/1.73 m2 weekly in corrected CCrU). By multiple linear regression, (1) Kt/VU = -0.38 + 0.70 (UV) + 0.10 (U/PUr). Standardized coefficients were 0.72 for UV and 0.51 for U/PUr (2) CCrU = -33.36 + 59.83 (UV) + 3.63 (U/PCr). Standardized coefficients were 0.65 for UV and 0.61 for U/PCr. UV is the most important determinant of both urea and creatinine urinary clearances in CPD patients. The contribution of the U/P ratios to the urinary clearances is important, but less than that of UV. The primary dependence of urinary clearances on UV allows the use of UV, which can be easily monitored by patients, as a first approximation index of changing residual renal function in CPD.

Creatinine↗
PubMed1996

Serum albumin in continuous peritoneal dialysis: its predictors and relationship to urea clearance.

We investigated the predictors of serum albumin and the relationship between serum albumin and urea kinetic indices in continuous peritoneal dialysis (CPD). In a training set (TS) of 143 urea kinetic studies performed in 92 CPD patients, stepwise logistic regression identified high/high-average peritoneal solute transport, diabetes, advanced age and high daily drain volume normalized by body water as predictors of low serum albumin (< 35 g/liter). This analysis was then substantiated in a validation set (VS) of 187 kinetic studies performed in another 102 CPD patients. The calculated area under the receiver operating characteristic (ROC) curve by this logistic regression model was 0.782 (95% CI, 0.745 to 0.819). Logistic regression was repeated in the TS using only the first kinetic study from each patient, and it identified high/high-average peritoneal solute transport, diabetes, and advanced age as predictors of low albumin. Using only the first kinetic study from each patient in the VS, the second logistic regression model calculated an area under the ROC curve equal to 0.850 (95% CI, 0.810 to 0.890). The relative risk (RR) of serum albumin < 35 g/liter was computed for all kinetic studies after combining the TS and the VS and using non-diabetic CPD subjects aged < or = 61 years with low/low average peritoneal solute transport as the reference group. The RR with only one risk factor present ranged from 1.076 (age > 61 years) to 6.792 (high/high-average transport). The RR with two risk factors present ranged from 5.200 to 9.729. The RR with all three risk factors present was 9.100 (95% CI, range 3.923 to 21.111). A subset of 37 CPD patients had a second urea kinetic study 8 +/- 5 months after an increase in the amount of dialysis due to low urea clearance and/or uremic symptoms. The weekly KT/V urea increased from 1.40 +/- 0.24 to 2.10 +/- 0.31 after the increase in the CPD dose. With the increase in dialysis, the protein catabolic rate increased substantially; however, the mean serum albumin remained stable (from 33.9 +/- 4.6 to 33.3 +/- 6.2 g/liter; decrease 18; increase 15; same 4). In comparison to the subjects who had a decrease in serum albumin after the increase in KT/V, those with the increase in serum albumin were younger (44.2 +/- 11.2 vs. 54.3 +/- 16.2 years, P = 0.044) and had a higher serum urea after the increase in the dose of CPD (22.4 +/- 7.8 vs. 17.0 +/- 6.0 mmol/liter, P = 0.037). We conclude that the major predictors of low serum albumin in CPD are advanced age, diabetes, and high/high-average peritoneal solute transport, but not urea kinetic studies. An increase in the dose of dialysis does not cause a consistent rise in serum albumin in underdialyzed CPD subjects. However, a subset of younger patients may be able to increase their serum albumin in response to the increase in KT/V.

Adult↗
PubMed1996

Discriminability of the Wisconsin Card Sorting Test using the standardization sample.

The four neurological patient groups and the normals from the Wisconsin Card Sorting Test (WCST) standardization sample were used to examine the discriminability of the WCST's indices. Results reveal consistent differentiation of normals from the patient groups on all WCST variables, with classification rates averaging 71% accuracy. However, patient groups with frontal, diffuse, and nonfrontal lesions were not consistently discriminable from each other. The results suggest that the WCST is most usefully conceptualized as a measure of executive abilities that involves the frontal lobes, but should not be considered solely as a marker of isolated frontal lobe pathology.

Adult↗
PubMed1996

Results of a computerized screening of stroke patients for unjustified hospital stay.

BACKGROUND AND PURPOSE: Effective methods to monitor length of stay can help reduce unnecessary hospital stay without adversely affecting the quality of care. In this study a clinical algorithm for assessing unjustified hospital stay in stroke patients was computerized and tested. METHODS: An algorithm was developed by the authors to estimate the number of medically justified and unjustified hospital days for patients admitted with a primary diagnosis of ischemic stroke. Data for the algorithm were obtained from 177 stroke patients from an acute-care teaching hospital. The performance of the algorithm was evaluated on a subset of 46 patients by comparing the number of medically unjustified hospital days determined by the algorithm with the consensus determination of two neurologists. RESULTS: The algorithm classified 68% of the 177 patients as having some unjustified hospital days and 41% of all hospital days as unjustified. With the neurologists as the gold standard, the sensitivity of the algorithm was .89 and the specificity was .91. The correlation between the number of unjustified days determined by the algorithm and the neurologists was .76. CONCLUSIONS: There is considerable unjustified length of stay for stroke patients. Physicians can develop simple clinical algorithms for detecting unjustified hospital stay in stroke patients that provide a reasonable approximation of complex clinical judgment.

Algorithms↗
PubMed1995

Modifiability of neuropsychological dysfunction in schizophrenia.

Schizophrenia is often characterized by compromised neuropsychological functioning, especially on tasks sensitive to frontal and temporohippocampal functions but the extent to which cognitive dysfunction can be modified in schizophrenics remains unclear. Twenty-four inpatient schizophrenics and 24 intellectually and demographically matched, inpatient mood-disordered controls were randomly assigned to one of two conditions. Subjects assigned to the cued condition received instructional cues on measures of visual and semantic memory, executive function, and constructional ability. Subjects in the standard condition performed the same neuropsychological measures without cues. The present study revealed some degree of plasticity of neurobehavioral function in schizophrenia.

Adult↗
PubMed1995

Comparison of indices of premorbid function in schizophrenia.

There has been a resurgence of interest in the area of premorbid functioning in schizophrenia as it provides clues to onset and etiology. Most studies rely on retrospective estimates of premorbid status that are incomplete, such as the Premorbid Adjustment Scale (PAS). Even prospective high-risk studies are hampered by the narrow range of premorbid functions assessed and are thus unable to answer crucial questions related to onset of illness. This study was undertaken to assess the relationship between several indices of premorbid functioning. Sixty four in-patients with schizophrenia were assessed at medication-free baseline and post-treatment with BPRS and SANS. PAS scores were derived from all available sources. Premorbid cognitive ability was estimated by the mean of WAIS-R Vocabulary and Information subscale scores. Estimated premorbid IQ was obtained using a demographic regression formula. Years of education and predicted VIQ, PIQ, and FSIQ were found to correlate with estimated premorbid cognitive ability. Predicted VIQ, PIQ, and FSIQ were associated with years of education and PAS childhood, early and late adolescence, and general scores. Each estimate of premorbid ability demonstrated a different pattern of association with clinical ratings, symptom change, and outcome. The results suggest that education, PAS, predicted IQ, and WAIS-R estimates of premorbid cognitive ability assess different but overlapping areas of pre-morbid functioning.

Adult↗
PubMed1995

Cross-sectional analysis of erythropoietin use in CPD: its relation to azotemic index clearances.

The association between the use of erythropoietin and urea or creatinine clearance was studied in two populations on continuous peritoneal dialysis (CPD) residing either at an altitude of 1600 m (n = 194) or at sea level (n = 108). Among peritoneal and total KT/V urea and creatinine clearance (CCr) indices, only total CCr was lower in the high altitude group receiving erythropoietin than in the corresponding group not receiving erythropoietin (68.0 +/- 34.9 vs 82.9 +/- 40.9 L/1.73 m2 weekly, p < 0.01). However, 24-hour urine volume and urinary KT/V urea and CCr were consistently lower in the groups receiving erythropoietin than in those not receiving erythropoietin. Total weekly KT/V urea < or = 1.70 and CCr < or = 52 L/1.73 m2 were considered indicators of inadequate CPD. Although the percent of patients receiving erythropoietin did not differ overall between groups with adequate and those with inadequate CPD, a trend towards more frequent use of erythropoietin was found in the sea level group with inadequate CCr versus the group with adequate CCr (28.2% vs 16.9%, p = 0.084). In CPD decreased renal function is associated with more frequent use of erythropoietin. Whether inadequate total urea or creatinine clearance is also associated with more frequent erythropoietin use requires further study.

Altitude↗
PubMed1995

The minimal dose of dialysis required for a target KT/V in continuous peritoneal dialysis.

This study attempted to define the minimal dose of dialysis needed to produce a target KT/V in continuous peritoneal dialysis (CPD). In a training set of 143 clearance studies performed in 92 CPD patients, logistic regression identified low urine volume (UV) and low dialysate drain volume normalized by body water (DV/V) as predictors of weekly KT/V urea < or = 1.70. Solution of the regression equation with UV fixed at 0.00 1/24 h and at different probabilities of low KT/V provided a series of minimal DV/V values consistent with weekly KT/V > or = 1.70 in anuria. The accuracy of the logistic regression model and of the DV/V cut-offs was tested in a validation set (VS) of 189 urea kinetic studies performed in another 102 CPD patients. In the VS, the area under the Receiver Operating Characteristic curve generated by the regression model was 0.832 (95% Confidence Interval: 0.798-0.866). The DV/V cut-off value of 0.301 per 24 h, calculated by solving the regression model at p = 0.442 and with UV = 0, identified studies with weekly KT/V < 1.70 with a sensitivity of 89.3% and a specificity of 78.1% in anuric VS subjects (n = 60). Use of only the first urea kinetic study from each patient did not modify the predictors of KT/V or the cut-off values derived from solution of the regression model. The DV/V cut-off of 0.324 per 24 h, derived from the logistic regression model predicting KT/V < or = 1.90, identified KT/V < 1.90 in VS anuric subjects with a sensitivity of 94.3% and a specificity of 81.0%. Low UV and DV/V predict low KT/V urea in CPD. Prescribed 24 h exchange volume in anuric CPD subjects should be calculated to produce DV/V values exceeding 0.301 1/24 h per 1 body water for a KT/V of 1.70 and 0.324 1/24 h per 1 body water for a target weekly KT/V of 1.90.

Creatinine↗