Showing papers by "Robert J. Goldberg published in 2007"
TL;DR: The results suggest that ω‐3 PUFAs are an attractive adjunctive treatment for joint pain associated with rheumatoid arthritis, inflammatory bowel disease, and dysmenorrhea.
Abstract: Between 40% and 60% of Americans use complementary and alternative medicine to manage medical conditions, prevent disease, and promote health and well-being. Omega-3 polyunsaturated fatty acids (x-3 PUFAs) have been used to treat joint pain associated with several inflammatory conditions. We conducted a meta-analysis of 17 randomized, controlled trials assessing the pain relieving effects of x-3 PUFAs in patients with rheumatoid arthritis or joint pain secondary to inflammatory bowel disease and dysmenorrhea. Meta-analysis was conducted with Cochrane Review Manager 4.2.8. for six separate outcomes using standardized mean differences (SMDs) as a measure of effect size: (1) patient assessed pain, (2) physician assessed pain, (3) duration of morning stiffness, (4) number of painful and/or tender joints, (5) Ritchie articular index, and (6) nonselective nonsteroidal anti-inflammatory drug consumption. Supplementation with x-3 PUFAs for 3–4 months reduces patient reported joint pain intensity (SMD: 0.26; 95% CI: 0.49 to 0.03, p = 0.03), minutes of morning stiffness (SMD: 0.43; 95% CI: 0.72 to 0.15, p = 0.003), number of painful and/or tender joints (SMD: 0.29; 95% CI: 0.48 to 0.10, p = 0.003), and NSAID consumption (SMD: 0.40; 95% CI: 0.72 to 0.08, p = 0.01). Significant effects were not detected for physician assessed pain (SMD: 0.14; 95% CI: 0.49 to 0.22, p = 0.45) or Ritchie articular index (SMD: 0.15; 95% CI: 0.19 to 0.49, p = 0.40) at 3–4 months. The results suggest that x-3 PUFAs are an attractive adjunctive treatment for joint pain associated with rheumatoid arthritis, inflammatory bowel disease, and dysmenorrhea. 2007 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
454 citations
TL;DR: Efforts to improve in-hospital use of VTE prophylaxis may help decrease the incidence of outpatient VTE, but given the shortening of hospital stays, studies of extended VTEProphylactic following hospital discharge are warranted.
Abstract: Methods: The medical records of residents from the Worcester metropolitan area diagnosed as having Inter- national Classification of Diseases, Ninth Revision codes consistentwithpossibleVTEduring1999,2001,and2003 were independently validated and reviewed by trained abstractors. Results: A total of 1897 subjects had a confirmed epi- sode of VTE. In all, 73.7% of patients developed VTE in the outpatient setting; a substantial proportion of these patients had undergone surgery (23.1%) or hospitaliza- tion (36.8%) in the preceding 3 months. Among these patients, 67.0% experienced VTE within 1 month of the preceding hospital encounter. Other major risk factors for VTE in the outpatient setting included active malig- nantneoplasm(29.0%)orpreviousVTE(19.9%).Among 516 patients with a recent hospitalization who subse- quently developed VTE, less than half (42.8%) had re- ceivedanticoagulantprophylaxisforVTEduringthatvisit. Conclusions:MoreVTEswerediagnosedinthe3months followinghospitalizationthanduringhospitalization.Ef- forts to improve in-hospital use of VTE prophylaxis may help decrease the incidence of outpatient VTE. How- ever,giventheshorteningofhospitalstays,studiesofex- tendedVTEprophylaxisfollowinghospitaldischargeare warranted.
365 citations
TL;DR: In this paper, the authors present a review of the presenting symptoms of acute coronary syndrome (ACS) in women compared with men and ascertain whether women should have a symptom message that is separate or different from that for men.
Abstract: Background Optimal diagnosis and timely treatment of patients with an acute coronary syndrome (ACS) depends on distinguishing differences between popular “myths” about ischemic symptoms in women and men. Chest pain or discomfort is regarded as the hallmark symptom of ACS, and its absence is regarded as “atypical” presentation. This review describes the presenting symptoms of ACS in women compared with men and ascertains whether women should have a symptom message that is separate or different from that for men. Methods MEDLINE (1970-2005), bibliographies of articles, and pertinent abstracts were reviewed, focusing on studies of ACS presentation, especially those reporting differences in symptoms by sex. This analysis included 69 of 361 possible studies. Data regarding symptom presentation were recorded. Results The published literature lacks standardization in characterizing ACS presentation, data collection, and reporting of symptoms. Approximately one-third of patients in the large cohort studies and one-quarter of patients in the smaller reports and direct patient interviews presented without chest pain or discomfort. The absence of chest pain or discomfort with ACS was noted more commonly in women than in men in both the cumulative summary from large cohort studies (37% vs 27%) and the single-center and small reports or interviews (30% vs 17%). Conclusions Women are significantly less likely to report chest pain or discomfort compared with men. These differences, however, are not likely large enough to warrant sex-specific public health messages regarding the symptoms of ACS at the present time. Further research must systematically investigate sex differences in the clinical presentation of ACS symptoms and must include standardized data collection efforts.
291 citations
TL;DR: The data suggest that although bleeding may be causally related to adverse outcomes in some patients in the real-world setting, it is often merely a marker for patients at higher risk for adverse outcomes.
Abstract: Background— Analyses from randomized controlled trials suggest that bleeding in patients with acute myocardial infarction is associated with poor outcomes. Because these data are not generalizable to all patients with acute myocardial infarction, we sought to better understand the scope of this problem in a “real-world” setting. Methods and Results— We examined the frequency of major bleeding in 40 087 patients with acute myocardial infarction enrolled in the Global Registry of Acute Coronary Events. Regression analyses were used to examine the association between patient and treatment characteristics, bleeding, and hospital and postdischarge outcomes. Major bleeding occurred in 2.8% of patients. These patients were older, more severely ill, and more likely to undergo invasive procedures. Patients with bleeding were more likely to die during hospitalization (hazard ratio, 1.9; 95% confidence interval, 1.6 to 2.2) but not after discharge (hazard ratio, 0.8; 95% confidence interval, 0.6 to 1.0) than patient...
234 citations
TL;DR: The results of this community-wide study demonstrate the poor long-term prognosis of patients surviving hospitalization for decompensated HF, and efforts are needed to improve the long- term survival of patients with this clinical syndrome.
Abstract: Background Heart failure (HF) is a major public health problem that is associated with substantial morbidity, impaired quality of life, and diminished survival. Despite the considerable prevalence of HF in the United States, there are limited published data describing the contemporary long-term prognosis of patients hospitalized with decompensated HF. Methods A total of 2445 residents in the Worcester metropolitan area discharged from 11 greater Worcester hospitals after confirmed acute HF during 2000 comprised the study sample. Follow-up of discharged hospital survivors was carried out through 2005. Results The mean age of the study population was 76 years, 43.4% were men, and approximately three quarters had been previously diagnosed as having HF. Among discharged hospital patients, 37.3% died during the first year after hospital discharge, while 78.5% died during the 5-year follow-up period. Several subgroups of patients were at significantly increased risk for dying during the first year after hospital discharge. This included older persons (≥85 years) (adjusted odds ratio [OR], 2.11; 95% confidence interval [CI], 1.35-3.29), patients with a history of chronic obstructive pulmonary disease (OR, 1.39; 95% CI, 1.15-1.69) or HF (OR, 1.26; 95% CI, 1.00-1.59), and patients with elevated serum urea nitrogen levels during hospitalization (OR, 1.02; 95% CI, 1.01-1.03). Conclusions The results of our communitywide study demonstrate the poor long-term prognosis of patients surviving hospitalization for decompensated HF. Despite advances in the therapeutic management of these patients, their long-term survival remains guarded. Efforts are needed to improve the long-term survival of patients with this clinical syndrome.
198 citations
TL;DR: Patients with upper extremity deep vein thrombosis represent a clinically important patient population in the community setting and risk factors, occurrence of pulmonary embolism, and timing and location of venous thromboembolism recurrence differ between patients with upper as compared with lower extremityDeep vein thROMbosis are examined.
118 citations
TL;DR: The authors' decision aid lowered decisional conflict and improved patient satisfaction; adding coaching provided little additional benefit.
Abstract: 52 years, and 97% were white Most women (98%) read all or most of the documents Decisional conflict was significantly lower in both intervention groups but not in the control group DA reduced decisional conflict from preintervention to postintervention (pre–post change) by 070 (SD = 0:56) points (on a 1–5 scale), compared to reductions of 051 (SD = 0:51) and 009 (SD = 0:44 )f or the DA + CC group and the control group, respectively Satisfaction with the decision made was significantly higher at 2 weeks in the DA v control group Self-reported knowledge significantly improved in DA + CC compared to controls Conclusion Our decision aid lowered decisional conflict and improved patient satisfaction; adding coaching provided little additional benefit Key words: decision aid; menopause; randomized clinical trial; coached care; clinical applications; decision analysis (Med Decis Making 2007;27:585–598)
34 citations
TL;DR: Encouraging increases over time are suggested in the use of combination medical therapy in patients hospitalized with AMI without contraindications to these medications.
Abstract: Background Current practice guidelines recommend the routine use of several effective cardiac medications in hospital survivors of acute myocardial infarction (AMI). Methods We explored a recent 5-year (2000-2005) trend in hospital use of aspirin, β-blockers, angiotensin-converting enzyme (ACE) inhibitors, lipid-lowering agents, and combinations thereof, in 26 413 adult men and women without contraindications to any of these therapies discharged after AMI from hospitals located in 14 countries that were included in the Global Registry of Acute Coronary Events. Results Relatively steady increases in the use of ACE inhibitors, β-blockers, and statin therapy were observed over time, with particularly marked increases in the use of lipid-lowering therapy (from 45% in 2000 to 85% in 2005). Aspirin use remained high (by approximately 95% of patients after AMI) during all periods examined. The percentage of hospital survivors treated with all 4 cardiac medications increased from 23% in 2000 to 58% during 2005. Advancing age (≥ 65 years), female sex, medical history of heart failure or stroke, and development of atrial fibrillation during hospitalization were associated with underuse of combination medical therapy. Relatively similar factors were associated with the underuse of combination medical therapy in patients with ST-segment elevation AMI and non–ST-segment elevation AMI. Conclusions Our results suggest encouraging increases over time in the use of combination medical therapy in patients hospitalized with AMI without contraindications to these medications. Educational efforts designed to increase the use of these therapies, as well as efforts to simplify medication regimens and enhance rates of adherence, remain warranted.
31 citations
TL;DR: Data from this large observational study suggest that patients with acute coronary syndromes and low-density lipoprotein levels<100 mg/dl are much less likely to be prescribed statin therapy at hospital discharge or to be receiving statin Therapy at 6 months but benefit from the prescription of statins atospital discharge as much as patients with levels>or=100mg/dl.
Abstract: The use of, factors associated with, and long-term outcomes related to statin therapy in patients with acute coronary syndromes and low-density lipoprotein (LDL) levels
24 citations
TL;DR: The use of different cardiac medications in 2463 patients with new-onset HF who were discharged from all greater Worcester, Massachusetts, hospitals during 2000 is described.
20 citations
TL;DR: There is a room for improvement for the enhanced use of effective treatment modalities and implementation of secondary prevention strategies in these high-risk patients, who are at increased risk of dying during the first year after hospital discharge.
TL;DR: Insight is provided into the magnitude and impact of hyperglycemia in patients not known to have prior diabetes who are hospitalized with acute myocardial infarction and more aggressive treatment strategies are needed to improve the outlook of patients with elevated serum glucose levels.
Abstract: Background and objectivesElevated serum glucose levels are associated with an increased risk of adverse outcomes in patients with diabetes in the setting of acute myocardial infarction. It is, however, unclear whether a similar association exists in nondiabetic patients and whether this relationship
TL;DR: There is substantial opportunity to improve use of effective therapies, especially in high-risk populations, according to GRACE risk deciles, as there is no clear correlation of use ofeffective therapies with overall risk profile even among eligible patients.
TL;DR: In this article, the authors examined the demographic and clinical characteristics of patients who received these diagnostic and interventional procedures and determined whether the profile of patients undergoing these procedures had changed over time.
TL;DR: The results demonstrate the impact of renal impairment on the prognosis of patients with decompensated HF and highlight the less than optimal management of these high-risk patients.
Abstract: Background: Patients with heart failure (HF) and kidney disease have a poor long-term outlook which has provided impetus for the identification of factors of prognostic importance a
TL;DR: The early use of low-molecular-weight heparin in the setting of an acute coronary syndrome is associated with better short-term outcomes and Heparin type and use seem to be related to the timing and use of percutaneous coronary interventions.
TL;DR: The results of a large Northeast community suggest evolving changes in the hospital management of patients with AMI, as current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery.
Abstract: The objectives of our study were to examine long-term (1986–2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI) while our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. While there have been considerable changes in the management of patients hospitalized with AMI over time, limited contemporary data are available about changing trends in the use of different coronary reperfusion strategies, particularly from the more generalizable perspective of a population-based investigation. The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003. Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980’s through the early 1990’s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. On the other hand, marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies. The results of our study in a large Northeast community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery. We examined long-term trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized with acute myocardial infarction (AMI). The study sample consisted of 9,422 greater Worcester (MA) residents hospitalized with AMI at all area medical centers between 1986 and 2003. Use of thrombolytic therapy increased from the mid-1980’s through the early 1990’s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. Marked increases in the use of PCI during hospitalization for AMI were noted. In 2003, 42.1% of patients hospitalized with AMI received a PCI.
TL;DR: The proportion of patients with HF and a preserved left ventricular ejection fraction was greatest in the oldest patients (61%) in comparison to patients aged 65 to 74 years and 75 to 84 years (48%).
Abstract: While the incidence and prevalence of heart failure (HF) increase markedly with age, few studies have included data on a large series of patients aged 85 years and older. Clinical and echocardiographic data from 533 patients admitted to a tertiary care hospital for acute HF were obtained. Data from the oldest old (>or=85 years; n=252; mean age, 91.9+/-3.6 years) were compared with data from those aged 65 to 74 years (n=123; mean age, 70.1+/-2.8 years) and 75 to 84 years (n=158; mean age, 79.4+/-2.9 years). Echocardiographic data were consistent with hypertensive remodeling. The proportion of patients with HF and a preserved left ventricular ejection fraction was greatest in the oldest patients (61%) in comparison to patients aged 65 to 74 years (48%) and 75 to 84 years (48%). Approximately three-fourths of the oldest patients were women, and two-thirds of women had a left ventricular ejection fraction >or=50%.
TL;DR: Patients with advanced kidney disease who received DNR orders were older, had more comorbid conditions, and were at greater risk for dying than patients with kidney disease without a DNR order.
TL;DR: Despite adequate physician knowledge, achieving desirable serum lipid levels in primary care patients remains elusive and provider education is needed to optimize the care of patients with elevated serum lipids treated in the primary care setting.
Abstract: Background: The purpose of the present study was to examine physician’s attitudes and practices toward the use of different lipid-lowering management strategies in patients at incre