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Biomedical subjects

M Mulvihill

Publications and source records attributed to M Mulvihill.

At least 19 recordsLinked to original sources
PubMed2001

State practice variations in the use of tube feeding for nursing home residents with severe cognitive impairment.

OBJECTIVE: To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns. DESIGN: Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents. SETTING: Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems. PARTICIPANTS: Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available. MEASUREMENTS: State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables. RESULTS: The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding. CONCLUSIONS: Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Advance Directives↗
PubMed2001

Observational assessment of family functioning at mealtime in preschool children with cystic fibrosis.

OBJECTIVE: To examine functioning during a dinner meal in families of a child with a chronic illness that requires dietary treatment recommendations, as compared to families of a child without a chronic illness. METHODS: Ratings of seven dimensions of family functioning on the McMaster Mealtime Family Interaction Coding System (MICS) were obtained on 29 families of children with CF and 29 families of children with no chronic illness, ages 2 to 6 years, during a videotaped dinner meal at home. RESULTS: Ratings of families with a child with CF were significantly lower than those for families of children without a chronic illness on Overall Family Functioning and five of the six MICS dimensions: Communication, Interpersonal Involvement, Affect Management, Behavior Control, and Role Allocation and approached significance on the Task Accomplishment dimension. The ratings of families of a child with CF were in the "clinically significant" range on all subcales, including Task ACCOMPLISHMENT. CONCLUSIONS: This study suggests that family functioning at mealtimes may be different in families of children with CF in which explicit dietary guidelines exist than in families of children with no illness or dietary guidelines. These results are discussed in terms of global family functioning and treatment approaches to dietary treatment recommendations.

Child, Preschool↗
PubMed2001

Predictors of follow-up of atypical and ASCUS papanicolaou tests in a high-risk population.

OBJECTIVE: Our goals were to assess adherence to the National Cancer Institute clinical practice guideline for the management of atypical squamous cells of uncertain significance (ASCUS) Papanicolaou (Pap) test results in a community at high risk of cervical cancer. We also hoped to identify predictors of adherence to the guideline. STUDY DESIGN: We used an historical cohort and collected data by chart abstraction. POPULATION: Our study included women receiving care in 7 urban community health centers who had an initial ASCUS or atypical Pap test result in 1996. We excluded women with a history of cervical dysplasia or human immunodeficiency virus infection, yielding a final sample of 387 women. OUTCOMES: measured The outcome measured was the level of adherence to the guideline, defined as falling within 1 of 3 mutually exclusive categories (complete, moderate, or low). RESULTS: Care providers recommended colposcopy after an initial atypical Pap test result in 12% of cases and repeat cytology in 67%. Failure to document a plan for management was found in 19% of cases. Complete adherence was achieved for 27% of subjects, moderate adherence for 28%, and low adherence for 45%. The factors associated with complete versus moderate or low adherence included site of care, description of the abnormality (ASCUS vs atypia), availability of on-site colposcopy, and discussing the plan at a visit. CONCLUSIONS: Adherence with the National Cancer Institute clinical practice guideline in this setting was disappointing and varied substantially by site. Factors amenable to change that may improve follow-up include good communication of results with patients and providing colposcopy at the site of primary care.

Cohort Studies↗
PubMed1999

Assessing the validity of tuberculin skin test readings by trained professionals and patients.

STUDY OBJECTIVES: To assess the validity of purified protein derivative (PPD) readings by patients and trained health-care professionals as compared with a calibrated model. DESIGN AND PARTICIPANTS: Survey of a group of patients, nurses, medical assistants, and physicians at five neighborhood health centers in the Bronx, NY. INTERVENTIONS: Participants were asked to read a calibrated model with four PPD indurations measuring 0 mm, 3 mm, 7 mm, and 13 mm. Indurations > or = 5 mm were to be considered "positive" reactions. MEASUREMENTS AND RESULTS: Data were obtained from 233 patients and 80 trained professionals. All patients correctly measured the 0-mm induration site and were able to detect the presence of an induration in 99.3% of possible observations. Compared with professionals, patients had more variability in measurements and interpretations of the 3-, 7-, and 13-mm sites. Professionals detected 100% of all indurations. Patients' specificity for the 0- and 3-mm sites was 97.4% and 62.7%, respectively; whereas sensitivity for the 7- and 13-mm sites was 68.2% and 89.3%, respectively. Professionals' specificity for the 0- and 3-mm sites was 98.7% and 65.3%, respectively; their sensitivity for the 7- and 13-mm sites was 86.7% and 97.3%, respectively. Seventy percent of professionals agreed that the model was a realistic representation of PPD indurations. CONCLUSIONS: Patients can reliably distinguish between the presence and absence of an induration at a PPD injection site. They are not as reliable in the measurement and interpretation of test reactions. Professionals had considerable variability in their assessments of PPDs but were more precise overall in their assessments than patients.

Adult↗
PubMed1998

Attitudes and beliefs about organ donation among different racial groups.

Many people on the waiting list for organ donation die each year without receiving organs. The shortage of organs is even more pronounced in minority communities. Despite the fact that minorities are at higher risk, they may be less likely to support or consent to organ donation. This investigation was undertaken to study racial factors in organ donation, by focusing on differences in awareness, attitudes, and behavior. Three family practice centers in the Bronx with racially diverse but socioeconomically homogenous communities were studied. The study population consisted of a convenience sample of 163 patients who were approached for participation while they waited to see a doctor. Respondents filled out a 25-item survey that measured demographic information; their exposure to, awareness of, and attitudes toward organ donation; and whether they had signed an organ donor card. The results demonstrated overwhelming support for organ donation across all racial groups. Racial differences were found on awareness of and attitudes toward organ donation, and in the signing of organ donation cards. In contrast to other studies, racial minorities were not less likely than whites to support organ donation. These results suggest that making it easier for racial minorities to obtain organ donor cards could increase their rates of consenting to donate organs.

Adult↗
PubMed1998

Quality of student learning and preceptor productivity in urban community health centers.

BACKGROUND AND OBJECTIVES: Clinicians in community health centers find it difficult to balance the demands of increased productivity and effective teaching. We hypothesized that precepting third-year students would decrease clinical productivity and that many elements related to the quality of the learning experience (e.g., amount of patient contact, student autonomy) would be adversely affected by pressure to see increasing numbers of patients. METHODS: Students and preceptors in a 6-week family medicine clerkship completed daily surveys that measured the presence of quantifiable elements of the ambulatory teaching experience. They also rated the overall quality of learning during each session. RESULTS: For 62 sessions for which both students and preceptors completed evaluations, students rated the overall quality of learning more highly than preceptors. For students, the elements most positively associated with quality of learning were total teaching time and the frequency with which family issues were raised. For preceptors, the elements that predicted quality of learning were the number of patients that students saw independently and total teaching time. The clinical productivity of preceptors did not differ for sessions with and without a student. CONCLUSIONS: Preceptors can be effective teachers who encourage student autonomy and who model behaviors central to family practice, without decreasing productivity.

Clinical Clerkship↗
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↗
PubMed1995

A standardized patient program in a mandatory geriatrics clerkship for medical students.

This article describes the development and implementation of a new standardized patient program in a required geriatrics clinical clerkship for fourth-year medical students. A student survey was also conducted to provide evaluations of the program and to determine the frequency with which students' clinical skills are directly evaluated by faculty. Thirty-six percent reported never having been observed while obtaining a history and 24% having been observed only once; 26% had never been observed while completing a physical examination and 39% had been observed only once. The implementation of a standardized patient program provided students with direct feedback on their clinical skills and was rated positively, (good, very good, or outstanding) by 76% of the students.

Clinical Clerkship↗
PubMed1994

Validating the GDS depression screen in the nursing home.

OBJECTIVE: The GDS (Geriatric Depression Scale) has demonstrated validity among ambulatory elderly but is less useful in nursing home (NH) populations, probably because of high rates of cognitive impairment. We, therefore, sought the lowest level of Mini-Mental Status Exam (MMSE) score for which the GDS would remain valid. DESIGN: Validation Study. SETTING: Nursing Homes in New York City. PARTICIPANTS: A total of 66 of 168 newly admitted residents to the NH were able to complete psychiatric assessment, undergo an MMSE, and complete the GDS. The psychiatrists and testers (all non-MDs) were blinded to each others' results. Using a cutoff of 10 or greater on the GDS to indicate depression, the GDS's validity (when compared with the psychiatric diagnoses) was sought at ever decreasing levels of cognitive function as measured by the MMSE. RESULTS: The results of all participants (n = 66) revealed a sensitivity of 63% and a specificity of 83%. When only those with an MMSE score > or = 15 (the best cutoff score) were included, 44 (64%) participants were selected, with a sensitivity and specificity of 84% and 91%, respectively. CONCLUSIONS: The two-step procedure of first selecting those with MMSE scores > or = 15 and then giving the GDS significantly increases the utility of the GDS in detecting depression in NH residents and should improve the diagnostic process for this widely underdetected problem.

Aged↗
PubMed1993

A center on ethics in long-term care.

Long-term care institutions are beginning to grapple with ethical issues on a regular basis. This has encouraged facilities to develop new mechanisms to deal with these issues. Described is a tripartite program that incorporates direct service, education, and research in ethics.

Biomedical Research↗
PubMed1993

Survival of elderly patients with transfusion-related acquired immunodeficiency syndrome.

OBJECTIVE: To determine the influences of age and risk group on the survival of AIDS patients. We concentrated on transfusion because it is the commonest risk factor for AIDS in patients over 70 years of age. DESIGN: Survival curve regression analysis. PARTICIPANTS: Patients aged 13 years and over with AIDS acquired through transfusion, and patients 65 years or older with AIDS as a result of intravenous drug use (IVDU). Data were obtained from the New York City Department of Health. MAIN OUTCOME: The patients were divided into four groups, ages 13-40 years, 41-64 years, and 65 years and over with AIDS as a result of transfusion, and 65 years and older with AIDS as a result of IVDU. The survivals of the three transfusion-related AIDS groups were compared, as were the 65 years-and-over groups with AIDS as a result of transfusion or IVDU. AIDS-defining diagnoses between those over and under 65 years with AIDS as a result of transfusion were also compared. RESULTS: The median survival for the three transfusion-related AIDS groups were 273 days, 58 days, and 60 days, respectively. There was a significant association between shorter survival and increasing age. This was largely due to the longer survival of the patients aged 13-40 years. There was no difference in AIDS-defining diagnosis between those over and under 65 years with transfusion-related AIDS. The survival curves of the elderly with AIDS as a result of transfusion or IVDU were not different. CONCLUSION: Age over 40 years is an independent risk factor for poor survival among transfusion-related AIDS patients. Among the elderly, patients with transfusion-related AIDS have similar survivals to patients with IVDU-related AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Association of autoimmunity to vascular heparan sulfate proteoglycan and vascular disease in the aged.

In the very old, there is an increased prevalence of immunologically mediated vascular disease. Vascular heparan sulfate proteoglycan (vHSPG) is a molecule which plays an important structural and functional role in the vasculature. Autoimmunity to vHSPG may play a role in the pathogenesis of vascular disease. The presence of autoantibodies to vHSPG was investigated in sera from aged nursing home patients who have a high prevalence of vascular disease. The results showed an association of the presence of autoantibodies to vHSPG in the sera from patients in this aged population with vascular disease, particularly cerebrovascular disease, renal disease and diabetes. In addition, autoantibodies to vHSPG protein core were associated with cerebrovascular disease in this frail elderly population. These studies support the hypothesis that autoimmunity may play a role in vascular disease in the aged.

Aged↗
PubMed1993

The role of anthropometry in the assessment of malnutrition in the hospitalized frail elderly.

Although common among the hospitalized frail elderly, malnutrition is often unrecognized by clinicians, and its identification is fought with difficulty due to inadequate nutritional assessment methods and standards. This study compared the use of percent ideal body weight (%IBW) and anthropometry in the assessment of malnutrition in the hospitalized frail elderly. Approximaty 45% of patients studied had at least two anthropometric measurements below the 5th percentile, a level reflecting severe malnutrition. However, only 28% of patients were found to be less than 90% IBW, a level reflecting only mild to severe changes in body weight. Serum albumin was below normal (< 35 g/l) in 30% of patients. The total lymphocyte count was below normal (< 1,500 cells/mm3) in 53%, and was severely depressed (< 800 cells/mm3) in 24%. Thus, despite the use of stringent anthropometric criteria indicating severe malnutrition, anthropometry appeared more sensitive than %IBW as a measure of malnutrition in the hospitalized frail elderly. Furthermore, acute illness causes changes in commonly employed blood measures which make them unreliable in the assessment of malnutrition in this population. Anthropometry may prove to be the most stable, easily performed, and sensitive measure of malnutrition in the hospitalized frail elderly. However, further studies are clearly needed, including the development of appropriate anthropometric reference standards for the very old, a population that commonly suffers malnutrition.

Aged↗
PubMed1993

Nursing staff attitudes on the use of physical restraints in a teaching nursing home.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

Aged↗
PubMed1993

School nutrition survey.

Food we eat has an important influence on health and well-being. Many eating habits are established in childhood. 456 children aged eight to 12 years participated in this survey of food eaten at school. Of all the food items eaten as a snack, 48.6% were categorised as junk. 75.8% of the sandwiches brought to school for lunch were made with white bread. Of the remaining food items brought for lunch 63.5% were of the junk variety. Compared with those who brought a snack or lunch from home, those given money to buy their own were more likely to eat junk (p < 0.01). Food eaten at school reflects approximately one third of a child's daily food intake but health food practises for even a third of food intake may be of a value for health and long term eating habits. Nutritional education with the reinforcement of high nutritional standards in schools could improve the situation.

Child↗