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Goold SD, Green SA, Biddle AK, Benavides E, Danis M. Will insured citizens give up benefit coverage to include the uninsured? J Gen Intern Med 2004; 19:868-74. [PMID: 15242473 PMCID: PMC1492492 DOI: 10.1111/j.1525-1497.2004.32102.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the willingness of insured citizens to trade off their own health benefits to cover the uninsured. DESIGN Descriptive study of individual and group decisions and decision making using quantitative and qualitative methods. SETTING AND PARTICIPANTS Twenty-nine groups of citizens (N = 282) residing throughout Minnesota. INTERVENTIONS Groups participated in Choosing Healthplans All Together (CHAT), a simulation exercise in which participants choose whether and how extensively to cover health services in a hypothetical health plan constrained by limited resources. We describe individual and group decisions, and group dialogue concerning whether to allocate 2% of their premium to cover uninsured children in Minnesota, or 4% of their premium to cover uninsured children and adults. MEASUREMENTS AND MAIN RESULTS While discussing coverage for the uninsured, groups presented arguments about personal responsibility, community benefit, caring for the vulnerable, social impact, and perceptions of personal risk. All groups chose to insure children; 22 of 29 groups also insured adults. More individuals chose to cover the uninsured at the end of the exercise, after group deliberation, than before (66% vs 54%; P < .001). Individual selections differed from group selections more often for the uninsured category than any other. Nevertheless, 89% of participants were willing to abide by the health plan developed by their group. CONCLUSION In the context of tradeoffs with their own health insurance benefits, groups of Minnesotans presented value-based arguments about covering the uninsured. All 29 groups and two thirds of individuals chose to contribute a portion of their premium to insure all children and most groups chose also to insure uninsured adults.
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Abstract
PURPOSE The purpose of this study was to demonstrate the feasibility and results of ascertaining Medicare enrollees' priorities for insured medical benefits. DESIGN AND METHODS Structured group exercises were conducted with Medicare enrollees from clinical and community settings in central North Carolina. By participating in a decision exercise, CHAT: Choosing Healthplans All Together, individuals and groups chose medical benefits within the constraints of a monthly Medicare + Choice premium. The acceptability of the exercise and the resulting benefit package were assessed. RESULTS Ten groups (121 individuals) made trade-offs that involved the selection of more tightly managed care in order to add pharmacy, dental, and long-term care benefits. All were willing to forgo experimental therapy; 7 groups gave priority to insuring the uninsured. Participants found the exercise overwhelmingly acceptable and were willing to abide by their groups' choices. IMPLICATIONS Medicare enrollees are able to come to consensus about financially constrained benefit packages that may be useful in reform of the Medicare program.
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Abstract
Informed choice of health insurance could morally justify later, potentially harmful rationing decisions the way informed consent justifies potentially harmful medical interventions. In complex and technical areas, however, individuals may base decisions more on trust than informed choice. We interviewed enrollees in managed care plans in Southeast Michigan, United States, to explore in detail their expectations and experiences in choosing and using their health plan. Diverse subjects participated in semi-structured interviews about health insurance choices, experiences, and expectations. Results are presented for the theme of trust (and distrust), which emerged spontaneously in discussions about health care and health insurance. Forty subjects diverse in age, ethnicity, and income took part in 31 interviews. Interviewees mentioned many of the elements of interpersonal trust in specific physicians, often in the context of discussions about care experiences, doctor payment, and conflict of interest. Elements included physical and emotional vulnerability, expectations of goodwill, advocacy and competence. and belief in professional ethics. Trust in the medical profession had more hesitancy, and often included mention of honesty or ethics. Elements of trust in hospitals included vulnerability to financial loss, and expectations of competence (quality). Elements of trust in health insurance plans often emerged in discussions about catastrophic illness coverage denials, and profit, and were more often negative. Vulnerability, worry, fear and security were prominent. Fiscal rather than clinical competence was emphasized, while expectations of goodwill remained. Enrollees in managed care plans spontaneously discussed trust and distrust in individuals and institutions during conversations about their insurance expectations and experiences. Similarities and differences in the elements and the context of these discussions illuminate distinctions between these healthcare relationships of trust.
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Abstract
OBJECTIVE A frequently cited obstacle to universal insurance is the lack of consensus about what benefits to offer in an affordable insurance package. This study was conducted to assess the feasibility of providing uninsured patients the opportunity to define their own benefit package within cost constraints. DESIGN Structured group exercises. SETTING Community setting. PARTICIPANTS Uninsured individuals recruited from clinical and community settings in central North Carolina. MEASUREMENTS Insurance choices were measured using a simulation exercise, CHAT (Choosing Healthplans All Together). Participants designed managed care plans, individually and as groups, by selecting from 15 service categories having varied levels of restriction (e.g., formulary, copayments) within the constraints of a fixed monthly premium comparable to the typical per member/per month managed care premium paid by U.S. employers. MAIN RESULTS Two hundred thirty-four individuals who were predominantly male (70%), African American (55%), and socioeconomically disadvantaged (53% earned <$15,000 annually) participated in 22 groups and were able to design health benefit packages individually and in groups. All 22 groups chose to cover hospitalization, pharmacy, dental, and specialty care, and 21 groups chose primary care and mental health. Although individuals' choices differed from their groups' selections, 86% of participants were willing to abide by group choices. CONCLUSIONS Groups of low-income uninsured individuals are able to identify acceptable benefit packages that are comparable in cost but differ in benefit design from managed care contracts offered to many U.S. employees today.
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Goold SD. Trust and the ethics of health care institutions. Hastings Cent Rep 2001; 31:26-33. [PMID: 12945452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Though trust is essential to relationships between people, including that between patient and clinician, its role in organizational ethics is largely unexplored. Nonetheless, trust is also ideally a part of the relationship between patient and health care institution, both because it is desirable in and of itself, and because it makes for better medical care.
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Abstract
“Collective action” usually brings to
mind images of picket signs held by laborers striking
for better wages and benefits. Collective action, however,
need not be limited to the withholding of labor. Nor need
it involve only the working or middle classes, as airline
pilots have recently demonstrated. Finally, collective
action need not have as its only purpose the self-interest
of the group. Collective action does, however, always involve
a joining together of individuals united by common goals
or interests in order to consolidate power for the purpose
of negotiating with another group or entity. Examples of
collective action obviously include striking, other withholding
labor actions, and slowdowns, but can also include many
other activities. “Paper strikes,” for example,
have been threatened or used by house officer organizations
in the past. In a paper strike, patient care continues
but without documentation, and thus, the institution suffers
from absent or delayed financial remuneration.
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Peck BM, Asch DA, Goold SD, Roter DL, Ubel PA, McIntyre LM, Abbott KH, Hoff JA, Koropchak CM, Tulsky JA. Measuring patient expectations: does the instrument affect satisfaction or expectations? Med Care 2001; 39:100-8. [PMID: 11176547 DOI: 10.1097/00005650-200101000-00011] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. OBJECTIVE The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. DESIGN Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. SUBJECTS The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. MEASURES A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. RESULTS Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. CONCLUSIONS These different instruments elicit different numbers of expectations but do not affect patient satisfaction.
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Goold SD, Kamil LH, Cohan NS, Sefansky SL. Outline of a process for organizational ethics consultation. HEC Forum 2000; 12:69-77. [PMID: 10915317 DOI: 10.1023/a:1008990516315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Abstract
Conflicts between physicians and families about end-of-life decisions create challenging and emotionally difficult situations. In this article, we propose a "differential diagnosis" of such conflicts, distinguishing and describing the characteristics of families, physicians, and organizations and society that contribute to the "etiology" of the situation, as well as strategies for "diagnosing" the dominant factors. As a medical model, the differential diagnosis can be a useful tool to help physicians understand and manage conflicts about end-of-life care.
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Axelrod DA, Goold SD. Maintaining trust in the surgeon-patient relationship: challenges for the new millennium. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 2000; 135:55-61. [PMID: 10636348 DOI: 10.1001/archsurg.135.1.55] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Changes in the structure of the health care system have placed unprecedented stress on the surgeon-patient relationship. The essential trust placed in the surgeon by her patients has been weakened by changes in the structure and financing of the health care system. This article considers the historical and ethical foundation of the surgeon-patient relationship and proposes that the primary moral obligation of surgeons is to strengthen and earn patient trust. By improving communication skills, enhancing ethical education, serving as consistent advocates for patients, and conducting patient-focused outcome research, the surgical community can meet its moral obligation by increasing trust in the surgeon-patient relationship.
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Yamada R, Galecki AT, Goold SD, Hogikyan RV. A multimedia intervention on cardiopulmonary resuscitation and advance directives. J Gen Intern Med 1999; 14:559-63. [PMID: 10491246 PMCID: PMC1496742 DOI: 10.1046/j.1525-1497.1999.11208.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the effects of a multimedia educational intervention about advance directives (ADs) and cardiopulmonary resuscitation (CPR) on the knowledge, attitude and activity toward ADs and life-sustaining treatments of elderly veterans. DESIGN Prospective randomized controlled, single blind study of educational interventions. SETTING General medicine clinic of a university-affiliated Veterans Affairs Medical Center (VAMC). PARTICIPANTS One hundred seventeen Veterans, 70 years of age or older, deemed able to make medical care decisions. INTERVENTION The control group (n = 55) received a handout about ADs in use at the VAMC. The experimental group (n = 62) received the same handout, with an additional handout describing procedural aspects and outcomes of CPR, and they watched a videotape about ADs. MEASUREMENTS AND MAIN RESULTS Patients' attitudes and actions toward ADs, CPR and life-sustaining treatments were recorded before the intervention, after it, and 2 to 4 weeks after the intervention through self-administered questionnaires. Only 27.8% of subjects stated that they knew what an AD is in the preintervention questionnaire. This proportion improved in both the experimental and control (87.2% experimental, 52.5% control) subject groups, but stated knowledge of what an AD is was higher in the experimental group (odds ratio = 6.18, p <.001) and this effect, although diminished, persisted in the follow-up questionnaire (OR = 3.92, p =. 003). Prior to any intervention, 15% of subjects correctly estimated the likelihood of survival after CPR. This improved after the intervention in the experimental group (OR = 4.27, p =.004), but did not persist at follow-up. In the postintervention questionnaire, few subjects in either group stated that they discussed CPR or ADs with their physician on that day (OR = 0.97, p = NS). CONCLUSION We developed a convenient means of educating elderly male patients regarding CPR and advance directives that improved short-term knowledge but did not stimulate advance care planning.
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Goold SD, Vijan S. Normative issues in cost effectiveness analysis. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 1998; 132:376-82. [PMID: 9823931 DOI: 10.1016/s0022-2143(98)90108-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cost effectiveness analysis (CEA) and cost-utility analysis are increasingly used to compare competing uses for limited health care resources, informing policy decisions at governmental, payer, and clinical levels of the health system. The authors discuss various methodologic choices in CEA and the normative (value) assumptions and implications of those choices. The treatment of adult onset diabetes is used as a simplified case example to illustrate the choice of perspective, cost inclusion and exclusion, benefit measurement and aggregation, and how these and other aspects of CEA can implicitly influence policy decisions with consequences for individuals and groups. CEA can be a valuable source of information, but it is a poor "technologic fix" for the thorny problem of allocating limited health care resources.
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Goold SD. Physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 339:776. [PMID: 9742035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Goold SD. Money and trust: relationships between patients, physicians, and health plans. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 1998; 23:687-695. [PMID: 9718519 DOI: 10.1215/03616878-23-4-687] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In response to three articles on managed care by Allen Buchanan, David Mechanic, and Ezekiel Emanual and Lee Goldman (this issue), I discuss doctor-patient and organization-member trust and the moral obligations of those relationships. Trust in managed care organizations (providers of and payers for health care) stands in stark contrast to the current contractual model of health insurance purchase, but is more coherent with consumer expectations and with the provider role of such organizations. Such trust is likely to differ from that between doctors and patients. Financial reimbursement systems for physicians, one example of organizational change in our health system, can be evaluated for their impact on both kinds of trust according to their intrusiveness, openness, and goals. Although involving managed care enrollees in value-laden decisions that affect them is commendable, restrictions on or regulation of physician incentive systems may be better accomplished on a national level.
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Ubel PA, Goold SD. 'Rationing' health care. Not all definitions are created equal. ARCHIVES OF INTERNAL MEDICINE 1998; 158:209-14. [PMID: 9472199 DOI: 10.1001/archinte.158.3.209] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Goold SD. Point and counterpoint. Is distance critical for clinical ethicists? A reply to Glenn McGee. HEC Forum 1997; 9:280-3. [PMID: 10173169 DOI: 10.1023/a:1008801322746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Goold SD. For-profit health plans. N Engl J Med 1996; 335:434-5; author reply 437-8. [PMID: 8676937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Goold SD. Allocating health care: cost-utility analysis, informed democratic decision making, or the veil of ignorance? JOURNAL OF HEALTH POLITICS, POLICY AND LAW 1996; 21:69-98. [PMID: 8708343 DOI: 10.1215/03616878-21-1-69] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Assuming that rationing health care is unavoidable, and that it requires moral reasoning, how should we allocate limited health care resources? This question is difficult because our pluralistic, liberal society has no consensus on a conception of distributive justice. In this article I focus on an alternative: Who shall decide how to ration health care, and how shall this be done to respect autonomy, pluralism, liberalism, and fairness? I explore three processes for making rationing decisions: cost-utility analysis, informed democratic decision making, and applications of the veil of ignorance. I evaluate these processes as examples of procedural justice, assuming that there is no outcome considered the most just. I use consent as a criterion to judge competing processes so that rationing decisions are, to some extent, self-imposed. I also examine the processes' feasibility in our current health care system. Cost-utility analysis does not meet criteria for actual or presumed consent, even if costs and health-related utility could be measured perfectly. Existing structures of government cannot creditably assimilate the information required for sound rationing decisions, and grassroots efforts are not representative. Applications of the veil of ignorance are more useful for identifying principles relevant to health care rationing than for making concrete rationing decisions. I outline a process of decision making, specifically for health care, that relies on substantive, selected representation, respects pluralism, liberalism, and deliberative democracy, and could be implemented at the community or organizational level.
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Goold SD, Hofer T, Zimmerman M, Hayward RA. Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review. J Gen Intern Med 1994; 9:544-9. [PMID: 7823224 DOI: 10.1007/bf02599278] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To develop a reliable measure of physician attitudes postulated to influence resource utilization. DESIGN Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians. SETTING Academic medical center. PARTICIPANTS All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n = 428). RESULTS Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach's alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r = 0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased. CONCLUSIONS Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians' reactions and acculturation to different practice environments.
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Abstract
OBJECTIVE Obtain detailed information about the frequency and content of discussions about withholding treatment between doctors and elderly outpatients. DESIGN Survey. SETTING Primary care geriatric clinic at an urban university. PARTICIPANTS Twelve physicians and one nurse practitioner completed questionnaires for 185/198 (93.4%) patient visits. MEASUREMENTS Questionnaires were completed by physicians after each patient visit during August 1989. Interviews were conducted with physicians who had discussed limiting life-sustaining treatment with patients. RESULTS Ten percent (n = 19) of patients seen had had discussions with their physicians about life-sustaining treatment. These patients were older and had worse prognoses as estimated by their physicians. Physicians usually raised the issue with the families of demented patients and mentioned dementia, quality of life, prognosis, and the need to make other clinical decisions as motivation for initiating discussions. The majority of patients with poor prognoses, however, had not had discussions about life support. CONCLUSIONS Despite increasing attention given to end-of-life decisions in the medical and lay press, discussions with elderly outpatients about limiting treatment occur rarely. They are more likely when patients are older or have worse prognoses, but age, prognosis, and poor quality of life do not consistently lead physicians to raise the issue.
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Ragni MV, Dekker A, DeRubertis FR, Watson CG, Skolnick ML, Goold SD, Finikiotis MW, Doshi S, Myers DJ. Pneumocystis carinii infection presenting as necrotizing thyroiditis and hypothyroidism. Am J Clin Pathol 1991; 95:489-93. [PMID: 2014774 DOI: 10.1093/ajcp/95.4.489] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Extrapulmonary Pneumocystis infection has been increasingly reported in patients with acquired immune deficiency syndrome (AIDS), in particular, recently in association with the increasing use of aerosolized pentamidine. This report describes the unusual presentation of extrapulmonary Pneumocystis infection as a thyroid neck mass and clinical hypothyroidism in a 37-year-old man with hemophilia and AIDS. This case differs from the previously reported single case of isolated thyroid pneumocystosis in the presence of a rapidly enlarging neck mass, lack of previous Pneumocystis, and prior prophylaxis with aerosolized pentamidine. The pathologic and electron microscopic description of the peculiar flocculent necrotic thyroid material is contrasted with typical pulmonary alveolar findings in Pneumocystis pneumonia (PCP), the differential diagnoses of a rapidly expanding neck mass, and diagnostic difficulties of hypothyroidism in patients with AIDS are discussed. Finally, it is emphasized that use of aerosolized pentamidine, although successful for prevention of pulmonary PCP, may be insufficient to prevent extrapulmonary infection.
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Kulbaski MJ, Goold SD, Tecce MA, Friedenheim RE, Palarski JD, Brancati FL. Oral iron and the Hemoccult test: a controversy on the teaching wards. N Engl J Med 1989; 320:1500. [PMID: 2716806 DOI: 10.1056/nejm198906013202222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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