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Biomedical subjects

D E Meier

Publications and source records attributed to D E Meier.

At least 55 records · Page 3Linked to original sources
PubMed1996

Marked improvement in recognition and completion of health care proxies. A randomized controlled trial of counseling by hospital patient representatives.

BACKGROUND: Advance directives provide a means for patients to retain influence on their medical care should decisional capacity be lost. Several studies have now demonstrated that advance directives that are completed in the ambulatory care setting are rarely available and recognized when patients are admitted to the acute care hospital. OBJECTIVE: To evaluate a generalizable model for improving recognition of previously completed advance directives and for promoting appointment of health care proxies in hospitalized patients. METHODS: Hospitalized elderly patients were randomly assigned to receive the intervention or usual care (n = 190). Intervention patients with capacity were counseled by hospital patient representatives about advance directives and encouraged to complete health care proxies. Patients with existing proxies had this information noted in their charts. For patients without capacity, counselors reviewed their charts for proxy documentation and if absent, contacted patients' next of kin and private physicians to determine proxy status. Usual care patients were not contacted by patient representatives. RESULTS: Forty-eight percent of intervention patients completed a new proxy or had a previously completed proxy identified compared with 6% of controls (P < .001). For patients with capacity, 22% of intervention patients had a previously appointed proxy agent identified compared with 6% of controls (P < .001). Thirty-six percent of intervention patients appointed a proxy decision maker compared with 0% of controls (P < .02). For patients without capacity, 31% of intervention patients had previously appointed proxies identified compared with 6% of controls (P < .001). CONCLUSIONS: Counseling by hospital patient representatives is an effective and generalizable means of improving recognition and execution of advance directives in the acute care hospital.

Advance Directives↗
PubMed1996

Intussusception in children: international perspective.

Fifty consecutive cases of children with intussusception treated at a hospital in a developing country were compared with 50 consecutive cases treated at an American inner city children's hospital and 50 consecutive cases treated at an American referral children's hospital. The plan was to recommend ways of improving the treatment of children with intussusception in the developing world. Nonoperative reduction was attempted in the two American hospitals but was not available in the developing world hospital where all children were treated operatively. Children in the developing world hospital had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality of 18%. There were no deaths in either American hospital. The poorer outcome for developing world children was related to delay in treatment, the higher incidence of nonviable bowel, and the lack of adequate nursing care for acutely ill children. The use of nonoperative reduction would not have significantly improved the mortality rate among the developing world children. The mortality can best be reduced by: (1) earlier recognition and treatment of the intussusception; and (2) improvement in the postanesthetic care with better monitoring leading to prompt recognition and treatment of postoperative complications.

Child↗
PubMed1996

Enhancement of proxy appointment for older persons: physician counselling in the ambulatory setting.

OBJECTIVE: To determine the effectiveness of physician-initiated counselling on the rate of health care proxy appointment. DESIGN: Observational study of an intervention in a convenience sample. SETTING: A geriatric outpatient clinic in a tertiary care teaching hospital, New York, New York. PARTICIPANTS: A total of 687 patients enrolled in the geriatric clinic during the study period March 1991 through June 1993. INTERVENTION: Physician counselling about the New York State Health Care Proxy Law, distribution of educational materials and healthcare proxy forms, and reminders in 331 of 466 eligible patients. MEASUREMENTS: Rate of healthcare proxy appointment in eligible and counselled groups; predictors of appointment and non-appointment; time elapsed from counselling to appointment; reasons for non-appointment; characteristics of the proxy appointment process. RESULTS: A healthcare proxy was appointed for 31.5% of patients eligible for counselling and for 44% of patients who actually received the intervention, compared with a 2.3% proxy appointment rate at baseline. Eighty-one percent of the patients completing the proxy appointment process did so at or before their third clinic return visit after the counselling intervention. Of the counselled patients who did not appoint a proxy, 25% explicitly declined, and 75% had not come to a decision by the end of the study period. Proxy completion was associated with ethnicity, education, and more frequent clinic visits. Of those who appointed a proxy, 97% had good or fair comprehension of the procedure, 92% discussed the appointment with their designees, 63% appointed a daughter or son, and 80% discussed their wishes for care at the end of life with their proxy. CONCLUSIONS: Physician counselling of older outpatients is an effective means of increasing healthcare proxy appointments.

Advance Care Planning↗
PubMed1996

A prospective study of bone loss in African-American and white women--a clinical research center study.

Although bone loss occurs universally with age, the incidence of age-related osteoporotic fractures varies widely among ethnic groups. In the U.S., age-adjusted hip fracture incidence is 50% lower in African-American than in white women. Adult African-American women also have higher bone mass, but it is not known whether this difference is entirely due to higher peak bone mass or also results from slower rates of bone loss. Rates of bone loss were measured prospectively in 122 white and 121 African-American healthy, nonobese, pre- and postmenopausal women. Bone density was measured at 6-month intervals over a mean of 3-4 yr using single and dual photon absorptiometry of the forearm (cortical bone) and spine (trabecular bone). Similar rates of premenopausal bone loss were documented in both white and African-American women. However, in early menopause, bone loss was faster in the white women in the forearm (-2.4%/yr in whites vs. -1.2%/yr in African-Americans; P = 0.045), with a similar trend in the spine (-2.2%/yr in whites vs. -1.3/yr in African-Americans; P = 0.27). In women more than 5 yr postmenopause, the rates of bone loss did not differ by ethnic group. Our results indicate that the higher bone mass in African-American women is largely due to the attainment of a greater peak bone mass by early adulthood. However, slower rates of bone loss in the early postmenopausal period may also contribute to the higher bone density of older African-American women. Although bone loss occurs in both groups, there are ethnic differences in bone loss rates which indicate that data derived from white women cannot be simply extrapolated to nonwhite populations. Ethnic group-specific data on the determinants of bone homeostasis are needed.

Adult↗
PubMed1995

The inaccessibility of advance directives on transfer from ambulatory to acute care settings.

OBJECTIVE: To investigate the accessibility of patients' previously executed advance directives during an acute hospitalization. DESIGN: Retrospective chart review. SETTING: A large metropolitan teaching hospital, a 514-bed skilled nursing facility, a geriatrics ambulatory care clinic, and a geriatrics group practice office. PATIENTS: One hundred fourteen geriatric patients who had previously executed an advance directive. MAIN OUTCOME MEASURES: The medical records of 180 admissions over 3 years, 1991 through 1993, were reviewed for documentation of patients' advance directive status. RESULTS: Twenty-six percent of patients who had previously executed advance directives had their directives recognized during their hospitalization. Of the subgroup of patients who were judged not to have the capacity to make medical decisions during their admissions, 26% (14/53) had their directives recognized. When the advance directive was recognized, it appeared to influence treatment decisions in 12 (86%) of 14 cases. CONCLUSIONS: Previously executed advance directives are not accessible when patients are admitted to hospitals for acute illness. When such directives are recognized, they are used to influence medical treatment decisions. Further research is needed to define and overcome barriers to this inaccessibility.

Advance Directives↗
PubMed1995

The outcome of suprapubic prostatectomy: a contemporary series in the developing world.

OBJECTIVES: To assess the appropriateness of the technique of suprapubic prostatectomy using a removable bladder neck partition suture for use in a developing world hospital and to provide contemporary open prostatectomy outcome data currently lacking in the world's literature. METHODS: From 1984 to 1994, 240 consecutive patients presenting to a developing world hospital with acute urinary retention underwent suprapubic prostatectomy using a removable bladder neck partition suture. The average length of time from bladder decompression until operation was 2.5 months. The outcome of these cases was retrospectively analyzed. RESULTS: The overall early complication rate was 19.6%. There were no deaths. The transfusion rate was 4.6%. Clot retention occurred in 6.7%, and 2.9% required return to the operating room for evaluation. For the second half of the series, the early complication rate decreased to 8.3%, the clot retention rate to 0.8%, and the transfusion rate to 1.7%. Other early and late complications were minimal. The length of delay from decompression until operation did not affect outcome. CONCLUSIONS: The technique of suprapubic prostatectomy using a removable bladder neck partition suture is appropriate for use in developing world hospitals because of its low morbidity and mortality rates. The outcome in this contemporary series of open prostatectomy cases compares favorably with the outcome from reported contemporary transurethral resection of the prostate (TURP) series. These data demonstrate that suprapubic prostatectomy is an acceptable option when the patient's anatomy or the state of local medical facilities precludes TURP.

Adenocarcinoma↗
PubMed1995

Ethical aspects of care of the geriatric orthopaedic patient.

Ethical aspects of care of the geriatric orthopaedic patient include respecting patient self-determination as the primary standard of decision making; using advance directives or appropriate surrogate decision makers when patient decisional capacity is lost; and balancing the benefits and burdens of any intervention and its alternatives in arriving at a treatment decision. With an increase in managed care plans, questions of justice in care of the elderly will be raised. Physicians face fiscal incentives that encourage fewer surgical procedures and lower levels of health care particularly in the elderly, a group that notably has benefited from the functional enhancement permitted by modern orthopaedic techniques. Professional vigilance is required of physicians to ensure that appropriate health care services continue to be available to patients.

Advance Directives↗
PubMed1995

The anterior operative approach to the cervical vertebral artery.

BACKGROUND: Vertebral arterial trauma continues to be a perplexing diagnostic and therapeutic challenge. Operative management is often required despite improved radiologic interventions for these injuries. Accounts of the operative approaches to anterior cervical vertebral artery injuries have been limited. STUDY DESIGN: We reviewed our experience with anterior cervical vertebral arterial trauma in 53 consecutive patients requiring operative management during a 14-year period. In seven patients, the vertebral arterial injury was identified at urgent surgical intervention either for an expanded cervical hematoma or active bleeding. The remaining injuries were identified by arteriographic investigation of penetrating cervical trauma. The injuries were equally distributed between the three anatomic zones of the anterior cervical vertebral artery. The general features of the operative approaches that were used to manage these injuries were the emphasis of the study. RESULTS: The anterior approaches to patients with vertical arterial trauma were effective in controlling injuries in all cases. Proximal and distal ligation of the artery adjacent to the injury site was accomplished in 95 percent of the patients. Associated major cervical injuries in 43 percent of the patients (carotid artery, eight patients; pharyngoesophageal, six patients; and neurologic, nine patients) contributed to the postoperative morbidity rate and the overall mortality rate of 10 percent. CONCLUSIONS: The surgeon approaching vertebral arterial trauma should have a clear appreciation of the deep anterior cervical anatomy to expedite the operative management and avoid unnecessary complications related to a misdirected surgical dissection. The descriptions of the operative techniques used in this clinical experience can aid the surgeon in managing patients with vertebral vascular trauma.

Cervical Vertebrae↗
PubMed1995

Elder abuse and neglect: how to recognize warning signs and intervene.

Elder mistreatment, whether abuse or neglect, can be classified as physical, psychological, or financial/material. Several types of mistreatment may occur simultaneously. Abuse occurs across all socioeconomic, racial, and religious lines. Risk factors include a history of mental illness or alcohol/drug abuse, a family history of violence, isolation of the victim, and recent stressful events in the life of the victim or abuser. For the physician the patient workup includes a careful history and physical exam, including cognitive evaluation. Ask about living arrangements, financial status, social supports, and emotional stressors. If possible, observe the interaction between the patient and family member or caregiver. Helpful resources include your state's Office of Protective Services and the American Medical Association's recently published guidelines for diagnosis and treatment of elder abuse and neglect.

Aged↗
PubMed1995

Older women's health: 'taking the pulse' reveals gender gap in medical care.

In the United States, for every 100 men age 65 and older, there are 147 women, a ratio that has social and medical consequences. Five panelists "take the pulse" of older women's health in general and in the offices of primary care physicians in particular. They assess the status of medical education and the need to include older women in research and drug trials, issues of gender bias in health insurance and quality of treatment, ways to improve the use of preventive health services--such as mammography and Pap smears--by older women, and the role of office physicians in identifying and helping victims of domestic violence.

Aged↗
PubMed1993

Health care for the homebound older adult: a medical model.

The medical home-care program is a logical and indispensable addition to the comprehensive, multilevel geriatric care offered by the Department of Geriatrics. The home-care program enables the frail and homebound elderly to remain in their home environment and continue to receive comprehensive primary medical care and supportive services. It also serves as a valuable teaching site for medical trainees. Program evaluation through assessment of patient and caregiver satisfaction, estimates of costs of care, and frequency of hospitalization and emergency room visits are ongoing.

Aged↗
PubMed1992

Combined carotid-vertebral arterial trauma.

Eight patients with simultaneous penetrating trauma to the carotid and vertebral arteries among 129 carotid and 53 vertebral arterial injuries have been treated in the last 14 years. In contrast to a 10% mortality with isolated carotid or vertebral trauma, the mortality associated with this injury complex was 50%. This high mortality directly related to the overall complexity of the trauma sustained by these patients. The liberal use of arteriography to assess penetrating cervical trauma has enhanced the diagnosis of these injuries. We recommend simultaneous surgical management of the carotid and vertebral arterial injury through an extended anterior cervical approach.

Angiography↗