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Biomedical subjects

M A Kelley

Publications and source records attributed to M A Kelley.

10 recordsLinked to original sources
PubMed1992

The clinical course of pulmonary embolism.

BACKGROUND: Pulmonary embolism is a potentially fatal disorder. Information about the outcome of clinically recognized pulmonary embolism is sparse, particularly given that new treatments for more seriously ill patients are now available. METHODS: We prospectively followed 399 patients with pulmonary embolism diagnosed by lung scanning and pulmonary angiography, who were enrolled in a multicenter diagnostic trial. We reviewed all hospitalizations, all new investigations of pulmonary embolism, and all deaths among the patients within one year of diagnosis. RESULTS: Of the 399 patients, 375 (94 percent) received treatment for pulmonary embolism, usually conventional anticoagulation. Only 10 patients (2.5 percent) died of pulmonary embolism; 9 of them had clinically suspected recurrent pulmonary embolism. Clinically apparent pulmonary embolism recurred in 33 patients (8.3 percent), of whom 45 percent died during follow-up. Ninety-five patients with pulmonary embolism (23.8 percent) died within one year. The conditions associated with these deaths were cancer (relative risk, 3.8; 95 percent confidence interval, 2.3 to 6.4), left-sided congestive heart failure (relative risk, 2.7; 95 percent confidence interval, 1.5 to 4.6), and chronic lung disease (relative risk, 2.2; 95 percent confidence interval, 1.2 to 4.0). The most frequent causes of death in patients with pulmonary embolism were cancer (in 34.7 percent), infection (22.1 percent), and cardiac disease (16.8 percent). CONCLUSIONS: When properly diagnosed and treated, clinically apparent pulmonary embolism was an uncommon cause of death, and it recurred in only a small minority of patients. Most deaths were due to underlying diseases. Patients with pulmonary embolism who had cancer, congestive heart failure, or chronic lung disease had a higher risk of dying within one year than did other patients with pulmonary embolism.

Adult↗
PubMed1992

Primary care arrangements and access to care among African-American women in three Chicago communities.

African-American women of child-bearing age residing in three high-risk communities in Chicago were surveyed regarding their primary care arrangements and access to care (n = 552). This study examined factors which differentiated women who used office-based practices from those who used institutional settings (community clinics, health department clinics, hospital-based clinics) for primary care. Results of multivariate analysis indicate that women who used office-based practices were more likely than those who used institutional settings to see the same provider, to walk to their provider, to have less travel time and to walk in without an appointment. They were less likely to be hospitalized in the past year and less likely to report the availability of family planning at their usual source of care. Satisfaction with care, insurance status and sociodemographic characteristics were not associated with use of a particular facility type. Implications for organizing comprehensive health services for this population are discussed.

Adolescent↗
PubMed1991

Diagnosing pulmonary embolism: new facts and strategies.

PURPOSE: To provide a clinical approach to the diagnosis of pulmonary embolism. DATA IDENTIFICATION: An English-language literature search using MEDLINE (1982 to 1990) and bibliographic reviews of textbooks and review articles. STUDY SELECTION: In addition to several reviews, studies that evaluated the diagnostic technology of pulmonary embolism were selected. Preference was given to studies with a prospective design, particularly those done within the past decade. DATA EXTRACTION: Studies were assessed independently by three unblinded observers. Data were chosen to describe the efficacy of diagnostic technology on the basis of disease prevalence, sensitivity and specificity, and predictive value. RESULTS OF DATA ANALYSIS: A normal lung scan or pulmonary angiogram rules out the diagnosis of clinically important pulmonary embolism with at least 95% certainty. Lung scan interpretations indicating high or low probability have approximately a 15% error in diagnosing or ruling out pulmonary embolism. The accuracy of either scan result improves when the clinical suspicion of pulmonary embolism matches the lung scan result. Serial impedance plethysmography of the lower extremities may exclude thromboembolism with 95% certainty in patients without high-probability lung scan results or cardiopulmonary disease. CONCLUSIONS: The combination of clinical suspicion and the results of the lung scan and impedance plethysmography appear to offer acceptable diagnostic accuracy in evaluating many patients suspected of having pulmonary embolism. The usefulness of this approach for patients with cardiopulmonary disease is still unknown.

Decision Trees↗
PubMed1991

Maternal satisfaction with primary care for children with selected chronic conditions.

One hundred forty mothers of children with chronic illnesses seen in two pediatric specialty clinics of a major urban teaching hospital were surveyed regarding their primary care arrangements and satisfaction with care received. Three dimensions of maternal satisfaction were measured: general satisfaction, satisfaction with access to care and satisfaction with doctor conduct (physician humaneness and technical quality). Results of multivariate analyses indicate that receipt of anticipatory guidance, access to care during evening hours and having a child in excellent reported health status were significantly associated with at least two of the three dimensions of maternal satisfaction. Findings have implications for organizing comprehensive, accessible primary care in the community, which is consistent with recent trends in child health policy. Results supported the need for enrichment of primary care for children with chronic illnesses to allow for physician continuity, provision of information and advice to families and extended office hours.

Baltimore↗
PubMed1991

An academic medical center's experience with mandatory managed care for Medicaid recipients.

This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.

Academic Medical Centers↗
PubMed1991

Impact of a mandatory Medicaid case management program on prenatal care and birth outcomes. A retrospective analysis.

This study examined the impact of Philadelphia's mandatory Medicaid case management program (HealthPASS) on adequacy of prenatal care and birth outcomes among enrollees. A sample of 217 deliveries for HealthPASS patients at the Hospital of the University of Pennsylvania (HUP) during 1988 was compared with a matched sample of 1988 deliveries at HUP for whom the payor was Pennsylvania's traditional fee-for-service Medicaid program. Inpatient charts for all 434 subjects were abstracted for information on sociodemographic characteristics, substance use during pregnancy (cigarettes, alcohol, and drugs), course and extent of prenatal care, and birth outcomes including birth weight, gestational age, and mortality. No significant differences were detected between HealthPASS and Medicaid groups, suggesting that the mandatory managed care program neither improved nor impeded access to needed services. These results were not surprising in view of the fact that HealthPASS actually did little to change provider or patient behavior with respect to obstetrical care. Both the HealthPASS and Medicaid groups experienced low rates of adequate prenatal care (39%) and high rates of low birth weight (20%). Also disturbing was the finding that at least 46% of women smoked during pregnancy, at least 20% drank alcohol, and at least 17% used cocaine. These findings support the need for continued efforts to improve both access to, and content of, prenatal care for the urban poor.

Adolescent↗
PubMed1979

Skeletal changes produced by aortic aneurysms.

The three major types of aortic aneurysms--arteriosclerotic, syphilitic, and dissecting are disussed in relation to the skeletal changes they produce. The favored location, age, and sex predilection are described for each type. Four documented cases from the Hamann-Todd osteological collection are presented with a description of the associated skeletal changes. All four cases appear to be the result of syphilitic infection. These documented cases provide forensic and physical anthropologists with a means of diagnosing aortic aneurysms in modern, historic, and prehistoric human skeletal remains.

Adult↗
PubMed1979

Parturition and pelvic changes.

A detailed analysis of the female bony pelvis in relation to parity status was made. A total of 198 complete pelves were inspected for five features considered to be associated with pregnancy and parturition. During final analysis two features were eliminated. Three remaining features - dorsal pubic pitting, pre-auricular grooves, and grooves located at the site of interosseous ligament insertion were found to be significantly related to partirution. Other findings of interest were: (1) pits and grooves acquired through pregnancy and parturition appear to become obliterated in old age, (2) the preauricular groove is the most sensitive indicator of pregnancy and parturition, (3) moderate-large pitting in the dorsal pubic region rarely occurs in nulliparous females, and (4) it is doubtful that more precise statements than "no children" and "one or more children" can be made on the basis of skeletal remains alone.

Aging↗