Biomedical subjects
Publications and source records attributed to M L Malone.
Forty consecutive 90-year-old persons with an acute myocardial infarction were studied to describe the noncardiac complications of their care. Common negative consequences of hospitalization of these patients included delirium, pressure ulcers, and poor ambulatory status at discharge.
To describe how often a right heart catheterization was performed at the time of coronary angiography, the patient characteristics that predicted the use of this procedure, and the variation among cardiologists in the use of this test, we reviewed all cases of coronary angiography (n = 1,282) during the first 2 mo of 1993 at two large community hospitals. Fifty-two percent of the cases received a right heart catheterization at the time of their coronary angiography. The following characteristics were associated with the receipt of a right heart catheterization in a logistic regression analysis: cardiomyopathy (odds ratio = 2.59, 95% CI = 1.01, 6.62), congestive heart failure (odds ratio = 2.07, 95% CI = 1.42, 3.01), valvular heart disease (odds ratio = 2.54, 95% CI = 1.44, 4.49), no coronary angioplasty performed at the procedure (odds ratio = 2.71, 95% CI = 2.12, 3.45), and increased age (odds ratio = 1.13 per decade, 95% CI = 1.03, 1.25). Of 37 cardiologists who performed > 10 coronary angiography procedures, the use of right heart catheterization varied from 10-90%. The cardiologists' practice variation persisted after adjustment for patient clinical characteristics. Because of the high utilization of right heart catheterization at the time of coronary angiography and the variation in use among cardiologists, even when controlling for patient characteristics, the issue of appropriate indications for this procedure needs to be addressed in a rigorous fashion.
OBJECTIVE: To describe the effect of age on the care of patients hospitalized with acute myocardial infarction (MI). DESIGN: Retrospective chart review of all cases with a primary or secondary discharge diagnosis of acute MI. SETTING: Two large community hospitals in Milwaukee, Wisconsin, from July 1, 1990 to June 30, 1991. PATIENTS: There were 771 charts reviewed, of which, 149 cases were aged 54 years or younger, 203 were 55 to 64 years, 224 were 65 to 74 years, and 195 were aged 75 years or older. MEASUREMENTS: Hospital charts were examined for use of diagnostic and therapeutic interventions, including medications and procedures, as well as length of stay and in-hospital mortality. RESULTS: Older patients were more likely to be female (18%, 20%, 38%, and 56% for the four age groups, respectively, P < .001 chi-square for linear trend), more likely to present with congestive heart failure (31%, 39%, 51%, and 72%, P < .001), and had a higher in-hospital mortality rate (5%, 7%, 10%, and 18%, P < .001). Older patients had a longer length of stay in the hospital. The use of cardiac catheterization in these post-MI patients was high and did not decrease until after age 75 (85%, 88%, 88%, and 47%, P < .001). The percentage of patients receiving balloon angioplasty decreased with age (51%, 51%, 43%, and 20%, P < .001), whereas the percentage of patients receiving myocardial revascularization did not significantly differ with age (15%, 22%, 25%, and 19%, P = .46). Aspirin was less likely to be prescribed to older patients at discharge (79%, 82%, 70%, and 62%, P < .001). CONCLUSION: A surprisingly high percentage of those older than age 65 received invasive tests and interventions. This high utilization rate coexists with our continued ignorance about the efficacy of these tests and interventions in older adults.
OBJECTIVE: To describe the activities of second- and third-year internal medicine residents during their outpatient continuity clinics. DESIGN: Descriptive observational study. SETTING: Medical school-affiliated community hospital primary care clinic. PATIENTS/PARTICIPANTS: All second-year (n = 15) and third-year (n = 14) residents enrolled in the internal medicine training program were observed at one-minute intervals during their routine half-day continuity clinics. MEASUREMENTS AND MAIN RESULTS: An average of 203 observations were recorded for each resident. The distribution of resident activities was as follows: 1) direct interaction with patients (29.5%); 2) charting or writing prescriptions (24.0%); 3) social interactions with staff (13.7%); 4) attending conferences or reviewing medical literature (9.4%); 5) waiting or transiting (8.2%); 6) ward responsibilities (4.9%); 7) reviewing cases with attending physicians (4.4%); and 8) miscellaneous activities (4.9%). Analysis of variance procedures revealed that the following variables significantly (p < 0.05) affected the residents' activities: 1) the actual number of patients seen produced predictable increases in direct and indirect patient care activities; and 2) the year of training had an impact on the mean number of observations of interactions with the supervising attending physician (PGY-2 = 11.4, PGY-3 = 3.8). CONCLUSIONS: These results suggest that this senior resident continuity experience is clinically intensive, yet provides surprisingly infrequent direct resident supervision. Further analysis of the educational activities occurring on these half-days is necessary to judge whether they are quantitatively and qualitatively adequate.
The educational characteristics of ambulatory morning report were compared with those of the inpatient morning report sessions over a five-month period. Ambulatory morning report had fewer total participants and was more likely to cover general internal medicine topics (p < 0.05), the medical interview (6.8% vs 1.2%, p = 0.02), and social issues (9.6% vs 1.2%, p = 0.02). Morning report conference can be replicated in the ambulatory setting, thus providing an opportunity to discuss general medicine topics not usually addressed in the inpatient setting.
OBJECTIVE: To describe the incidence and characteristics of aggressive behaviors in a group of institutionalized elderly. DESIGN: Retrospective survey. SETTING: 350-bed, urban skilled nursing facility. PATIENTS: All nursing home residents who had an incident report completed after an aggressive behavior. MEASUREMENTS: Examination of all incident reports of aggressive behavior for 1 year. RESULTS: There were 94 reports of aggressive behaviors. Twenty-nine residents exhibited one aggressive behavior, 12 residents two, and six residents exhibited three or more aggressive behaviors. These six residents accounted for 44% of all events. The incidence of aggressive behavior was 0.27 per resident per year for the entire facility; on the Alzheimer's unit the incidence was 0.75 per resident per year. Sixty-two percent of the victims of aggressive behavior were other nursing home residents, 37% were employees, and 1% were visitors. The charts of the six residents with three or more aggressive behaviors were reviewed. These residents received trials of multiple scheduled psychotropic medications, often exhibited several additional agitated behaviors around the time of the attack, were at risk for psychiatric hospitalizations during the study period, and often were noted to have underlying acute medical illnesses near the time of the attack. CONCLUSION: Approximately two aggressive behaviors per week occurred in a large nursing home. Residents and staff of Alzheimer's units have a higher risk of being victims of aggressive behavior. A small number of patients account for nearly half of the behaviors, even on the Alzheimer's unit. Aggressive behaviors may be clinical indicators of underlying acute medical illnesses.
OBJECTIVE: To describe how diabetic ketoacidosis in those aged 65 or over differs from that in younger adults. DESIGN: Retrospective chart review of all adult patients with a primary or secondary discharge diagnosis of diabetic ketoacidosis (n = 338). SETTING: Three urban teaching hospitals in Milwaukee, WI from January 1, 1987 to May 31, 1990. PATIENTS: Two hundred twenty cases in 150 patients met our criteria for severity of illness to be included in the study. Twenty-seven cases were in patients > or = age 65; 193 cases were in patients < age 65. RESULTS: The older patients were less likely to have been using insulin before hospitalization (55.6% vs 80.2%, P = 0.004) and less likely to have had a prior episode of diabetic ketoacidosis (8.0% vs 51.4%, P = 0.001). The presenting laboratory data were not significantly different between older and younger subjects. There was a trend toward a higher mean insulin dosage to bring the patient's blood glucose to < or = 300 mg/dL for those age 65 or older; 69.1 units vs 44.9 units (P = 0.06). The time required to obtain a glucose < 300 mg/dL was greater in older patients (10.5 vs 7.7 hours, P = 0.01). The average length of stay for those age 65 or older was 12.4 days vs 6.7 days (P = 0.001). Thirdly, of those age 65 or older, 7% vs 29% of younger subjects had a blood glucose or Accucheck < or = 49 mg/dL at some time during their hospital course. The hypoglycemic episodes were more likely to be asymptomatic in older patients (P = 0.03). The mortality rate was 22% for those age 65 or older vs 2% for younger subjects (P = 0.001). The mortality rate for those in age groups 60-69 years, 70-79 years, and > or = 80 years was 8%, 27%, and 33%, respectively. In patients > or = 65, mortality was confined to those with coexisting renal disease or infection. CONCLUSION: Older patients with diabetic ketoacidosis are less likely to have been using insulin before hospitalization. They tend to receive more insulin therapy during their acute management, have a longer average length of hospital stay, and have a higher mortality rate.
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BACKGROUND: Previous studies of the management of diabetic ketoacidosis have noted a wide range of incidence of hypoglycemia but have not studied the risk factors associated with it. METHODS: To describe the incidence of hypoglycemia in patients hospitalized with diabetic ketoacidosis, we retrospectively reviewed the charts of all adult patients with the diagnosis of diabetic ketoacidosis at three private, community hospitals in Milwaukee, Wis, between January 1, 1987, and May 31, 1990. Two hundred twenty admissions in 150 patients met our inclusion criteria. RESULTS: In 30% (66/220) of cases of diabetic ketoacidosis, a serum glucose level or Accu-Chek (Boehringer-Mannheim, Indianapolis, Ind) finding was 2.7 mmol/L or less during the first 14 days of hospitalization. No factors could be identified that were associated with a significantly increased risk of early hypoglycemia (within the first 48 hours of admission). The risk of a "late" occurrence of hypoglycemia (after 48 hours of hospitalization) was increased by fever (relative risk, 2.05; 95% confidence interval [CI], 1.16 to 3.63), "nothing orally" status (relative risk, 3.01; 95% CI, 1.88 to 4.83), hepatic disease (relative risk, 2.56; 95% CI, 1.39 to 4.70), and renal disease (relative risk, 2.07; 95% CI, 1.26 to 3.39). A logistic regression analysis showed "nothing orally" status to be associated with an increased risk of any hypoglycemia occurring during the hospitalization (relative risk, 2.39; 95% CI, 1.63 to 3.51). Physicians and nurses documented the first episode of hypoglycemia in their notes 45.5% and 80.3% of the time, respectively. CONCLUSION: Hypoglycemia is still a common complication of diabetic ketoacidosis, is associated with hepatic and renal disease as well as fever and "nothing orally" status, and is not documented well in physician notes.
While skin tears are a common occurrence in the institutionalized elderly population, nothing has been written about this problem. We retrospectively studied all incident reports during a 1-year period at a large, urban, long-term-care facility to identify residents with skin tears. The overall incidence of skin tears was 0.92 per patient per year. The incidence rate for females, but not for males, increased significantly with age (P = 0.012). The mean length of the skin tear was 1.9 cm +/- 1.4 (mean +/- SD). Eighty percent occurred in the upper extremities, with the most frequent location being the forearm. Almost half of the skin tears reported had an unknown cause. Wheelchairs and accidentally bumping into an object each accounted for a quarter of the skin tears where the cause was known. Transfers and falls contributed to a lesser extent. Impaired mental status was no more likely to be present in residents experiencing a skin tear than in all nursing home residents. Twenty-four of the 147 residents with skin tears had four or more tears, accounting for 40% of all skin tears reported. Ninety-seven percent of the episodes resulted in no attending physicians' orders other than the standing orders. Future studies should be designed to determine if there are adverse consequences of skin tears and to suggest programs to reduce their occurrence.