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Biomedical subjects

M A Kelley

Publications and source records attributed to M A Kelley.

At least 19 recordsLinked to original sources
PubMed1996

Aspirin and warfarin for thromboembolic disease after total joint arthroplasty.

This study compares the benefits of aspirin and warfarin prophylactic agents for patients with thromboembolic disease after total joint arthroplasty. It is a prospective randomized study of 388 patients having total hip or total knee surgery. All consecutive patients having total hip or total knee surgery were entered into this study and evaluated with preoperative and postoperative ventilation perfusion scans and a postoperative venogram. The aspirin and warfarin treatment groups were compared by size and location of venographically revealed clots and changes in ventilation perfusion scans. The results showed that there was no difference in the size or location of deep venous thrombosis in the aspirin or warfarin treatment groups. The venogram was negative in 44.5% of patients; 28.8% had small ++calf clots, 16% had large calf clots, 3.9% had popliteal clots, and 6.7% had femoral clots. Patients with total knee replacement had a 2.6 times greater incidence of calf deep venous thrombosis than patients with total hip replacement. There was no difference between the aspirin and warfarin groups in the incidence of changes in ventilation perfusion scans (18.9%). There was no difference between the 2 groups in bleeding complications. The results suggest that aspirin and warfarin are equivalent in prophylaxis against thromboembolic disease, as determined by prevention of venographic changes or changes in ventilation perfusion scans.

Aged↗
PubMed1995

Brief communication: a possible case of melorheostosis from antiquity.

An unusual case of discontinuous hard tissue hyperostosis is described in a 25-30-year-old female dating between 4000 and 5500 BP from northern Chile. This specimen was one of 104 individuals examined from the Morro-1 site, which is known to represent the Chinchorro culture. The only other reported case from antiquity dates to 500 AD (Lester [1969] J. Bone Joint Surg. [Am.] 49:142-143). A review and comparison of this case to the medical literature supports a diagnosis of melorheostosis. Differential diagnosis is presented with the ruling out of nonspecific manifestations of osteomyelitis/periostitis as the most likely alternative diagnosis.

Adult↗
PubMed1995

Gender roles and alcohol abuse across the transition to parenthood.

OBJECTIVE: The transition to parenthood has been occurring within the context of the increasing labor force participation of women and potential stress-related costs of "nontraditional" as well as "traditional" gender role choices of new parents. This study addressed the extent to which gender role-related stressors lead to increased problem drinking across the transition to parenthood. METHOD: Fifty-five married couples expecting their first child were obtained from seven Chicago area hospitals and surveyed with a mailed questionnaire at two points in time: (1) during the second trimester of pregnancy and (2) at 6 months following childbirth. The study examined both wives' and husbands' changes in problem-related drinking by comparing problem drinking during the 6 months prior to pregnancy (retrospectively assessed at Time 1) with drinking during the 6 months following childbirth using a modified form of the Michigan Alcoholism Screening Test. In addition, the study contrasted problem drinkers with nonproblem drinkers following parenthood with regard to role overload (overwhelming demands from work and family roles), role deprivation (loss of work role following parenthood) and role deterioration (decreased support from role relationships). RESULTS: The data show increased problem drinking for both mothers and fathers but fail to support either role overload or role deprivation hypotheses. However, the data are congruent with the role deterioration perspective. CONCLUSIONS: If these findings are replicated, future studies of gender roles and alcohol abuse should focus greater attention on the perceived quality of social roles beyond noting their presence or absence.

Adaptation, Psychological↗
PubMed1994

Supporting primary care medical education.

A number of fundamental issues must be considered in preparing the education system to produce more primary care physicians. Governmental controls and redirection of resources will force significant changes in the structuring of approaches to both undergraduate and graduate education in primary care. Particularly challenging will be restructuring and funding medical student programs in primary care, given a nearly certain requirement that more than 50% of medical school graduates enter primary care disciplines. Institutions will need to make strategic resource allocations to compete for the funding once the allocation process begins. Educational institutions will also face a cultural adaptation to primary care as an educational priority. This paper presents a model to study costs and funding for residency programs as they move from the traditional inpatient orientation to an outpatient focus. The authors suggest that for medical student education, the development of large academic health care systems may make funding primary care education more feasible.

Adult↗
PubMed1994

Massive pulmonary embolism.

Massive pulmonary embolism remains a clinical challenge where rapid diagnosis and appropriate therapy have a critical impact on patient outcome. This article reviews the pathophysiology, diagnosis, and therapeutic options involved in the management of pulmonary embolism. Clinical case discussions illustrate the principles that are described by the authors.

Adult↗
PubMed1994

Errors and bias in using predictive scoring systems.

Scoring systems used to predict clinical outcomes for critically ill patients have been refined in the past decade, yet even the most recently developed systems contain flaws that limit their application. In general, prediction rules are derived by defining an association between a number of clinical variables and a particular outcome in a reference patient population. By systematically examining the qualities of the independent variables and the size and scope of the derivation data set, potential sources of error and bias can be identified. Existing and future predictive systems must be validated on large groups of patients and continuously updated to keep pace with new approaches to the practice of critical care medicine.

Bias↗
PubMed1993

Development of a scale to measure gender-role attitudes toward breast-feeding among primiparas.

Women's roles have undergone rapid transformation in recent decades and appear to affect the decision to breast-feed. Research in this area has been hampered by the lack of valid instruments to measure the relevant domains of gender-role related considerations. This study developed a scale to measure gender-role attitudes toward breast-feeding in primiparous women. Ninety-one married women, recruited during childbirth education classes in the Chicago metropolitan area, were surveyed by mail at eight weeks postpartum regarding their experiences as new mothers. Questionnaire items measuring infant feeding method (breast-feeding, bottle feeding) and attitudes toward breast-feeding were developed specifically for this investigation. Validity and reliability were assessed by structural equations analysis using LISREL. The LISREL fit statistics supported a one factor measurement model and combining the six items into a scale. Reliability analysis yielded a standardized alpha coefficient of .74. If results of future research are promising, the scale could be used to target new mothers with multiple roles for education and support and to evaluate interventions designed to promote positive breast-feeding attitudes and behavior.

Adult↗
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↗
PubMed1990

Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score.

This study was conducted to determine if the source of admission to the medical intensive care unit (MICU) is associated with hospital death independent of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. We calculated APACHE II scores and predicted risks of hospital death for 235 patients who were admitted to the MICU. The predicted death rate was the same as the actual rate for patients who were admitted directly from the emergency department (25% vs 22%), but was less than the actual rate for patients who were transferred from hospital floors (38% vs 55%), the medical intermediate care unit (32% vs 59%), and other hospitals (21% vs 36%). Logistic regression analysis confirmed an independent association between the MICU admission source and risk of death. Our findings suggest that APACHE II does not measure illness severity accurately in all patients who are admitted to intensive care units. If our results are generalizable, using APACHE II to compare intensive care outcomes among hospitals could lead to wrong conclusions about quality of care. Improving predictions of hospital death rates among patients who are in MICUs may require the inclusion of new types of information in the classification system.

Admitting Department, Hospital↗
PubMed1990

Detection of thrombophlebitis with 111In-labeled anti-fibrin antibody: preliminary results.

Deep venous thrombosis remains a major medical problem, affecting a large segment of the population and resulting in significant mortality and morbidity. Current techniques available for detecting deep venous thrombosis present limitations that may mitigate their potential benefit to the patient. Invasive techniques, such as ascending contrast venography, carry risks to the patient with regard to complications such as an allergic reaction to an iodine dye, adverse effects to renal functions, and clot formation in a normal vein. Noninvasive techniques, such as Doppler ultrasound and impedance plethysmography, evaluate only a limited segment of the venous bed. The need remains for a diagnostic technique that is safe, accurate, and widely accessible. A readily available noninvasive scintigraphic technique utilizing radiolabeled monoclonal anti-fibrin antibody may overcome some of these shortcomings. This imaging examination is quite effective in detecting clots in the lower extremities. Compared to contrast venography, 111In-labeled anti-fibrin antibody imaging appears to be as sensitive in identifying acute venous thrombosis. In addition, the preliminary data indicate that anticoagulation with heparin may interfere with adequate visualization of the clots with this technique.

Adult↗
PubMed1990

Expansion of the medical intensive care unit: clinical consequences in a large urban hospital.

We examined how a permanent expansion of the medical ICU (MICU) affected resource utilization and severity of illness for intensive care admissions within a 700-bed urban teaching hospital. On our 162-bed medical service, construction of a separate cardiac care unit and the expansion of the MICU increased the number of core intensive care beds by 100%. We prospectively analyzed noncardiology MICU admissions 2 months before, immediately after, and 4 months after MICU expansion. Although the volume of MICU patients increased by 51% after MICU expansion, the severity of illness as determined by the Acute Physiology and Chronic Health Evaluation (APACHE II) score and types of admission diagnoses remained the same. Moreover, there was no change in MICU occupancy and length of stay, hospital or MICU mortality, or MICU readmission rate. The increased MICU patient volume came from the ED, transfers from other hospitals, and from other ICUs within our hospital. In contrast, the volume and severity of illness of MICU transfers from the inpatient medical floor service were constant in all time periods. These results suggest that, while MICU expansion increased patient volume, physician utilization of the MICU resources was unchanged. Our physicians used high-intensity ICU beds in a consistent fashion in response to external factors, such as ED activity, intramural ICU transfers, and referrals from other hospitals.

Bed Occupancy↗
PubMed1990

Radiolabeled antifibrin antibody in the detection of venous thrombosis: preliminary results.

The recent development of monoclonal antibodies against components of coagulated blood may provide new approaches to the diagnosis of venous thrombosis. Scanning with an indium-111-labeled Fab fragment of a murine monoclonal antifibrin antibody (59D8) and ascending contrast venography were performed in 33 patients. Images of the calves, popliteal fossae, thighs, and pelvis were obtained immediately, 4-6 hours, and 24 hours after injection of 2 mCi (74 MBq) of the antibody. All images were read in a blinded manner. Findings in both studies were positive in 28 patients and negative in three. In 19 patients not undergoing heparin therapy, 19 specific anatomic sites were positive on venograms and 29 were positive on antibody images (19 sites matched). In 14 patients undergoing heparin therapy, 34 sites were positive on venograms and 27 were positive on antibody images (22 sites matched). In most patients, positive results were noted within 1 hour of antibody injection. No adverse effects were noted with the antibody preparation. Preliminary data suggest that antifibrin antibody imaging is sensitive in detecting clots, is safe to use, and may have a role in diagnosing and managing venous thrombosis.

Adult↗