Words that harm, words that heal.
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Decision Making↗
Biomedical subjects
Susanna E Bedell
Publications and source records attributed to Susanna E Bedell.
Do-not-resuscitate orders in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study.
BACKGROUND: Coronary heart disease is the leading cause of death in Americans. Despite increased interest in end-of-life care, data regarding the use of do-not-resuscitate (DNR) orders in acutely ill cardiac patients remain extremely limited. The objectives of this study were to describe use of DNR orders, treatment approaches, and hospital outcomes in patients with acute myocardial infarction. METHODS: The study sample consisted of 4621 residents hospitalized with acute myocardial infarction at all metropolitan Worcester, Mass, area hospitals in five 1-year periods from 1991 to 1999. RESULTS: Significant increases in the use of DNR orders were observed during the study decade (from 16% in 1991 to 25% in 1999). The elderly, women, and patients with previous diabetes mellitus or stroke were more likely to have DNR orders. Patients with DNR orders were significantly less likely to be treated with effective cardiac medications, even if the DNR order occurred late in the hospital stay. Less than 1% of patients were noted to have DNR orders before hospital admission. Patients with DNR orders were significantly more likely to die during hospitalization than patients without DNR orders (44% vs 5%). CONCLUSIONS: The results of this community-wide study suggest increased use of DNR orders in patients hospitalized with acute myocardial infarction during the past decade. Use of certain cardiac therapies and hospital outcomes are different between patients with and without DNR orders. Further efforts are needed to characterize the use of DNR orders in patients with acute coronary disease.
Aged↗
Long-term outcomes of optimized medical management of outpatients with stable coronary artery disease.
The objective of this study was to assess long-term clinical outcomes and their correlates in medically managed outpatients with stable angina pectoris, healed myocardial infarction (MI), or documented asymptomatic coronary artery disease (CAD). Management strategy emphasized maximally tolerated medical therapy and modification of coronary risk factors. Referral to invasive coronary interventions followed stricter criteria than standard published guidelines. Primary study outcomes were all-cause mortality or nonfatal myocardial infarction. Secondary study outcomes included cardiac death, unstable angina, or coronary revascularization. A total of 693 men and women with proved CAD (mean age 67 years at entry, 85% men, 41% with history of MI) were enrolled. The annual incidence of nonfatal MI, cardiac mortality, and total mortality was 2.2%, 0.8%, and 1.4%, respectively, during an average follow-up of 4.6 years. Coronary revascularization was performed in 24% of subjects; unstable or progressive anginal symptoms were the most common reasons for revascularization. In patients with documented stable CAD, a management strategy based on intensive medical therapy and modification of established coronary risk factors was associated with excellent long-term outcomes. Thus, coronary interventions can be safely delayed until clinical instability ensues, without increased risk of MI or death. This treatment approach represents a viable alternative to invasive strategies.
Adult↗
A systematic critique of diabetes on the world wide web for patients and their physicians.
PURPOSE: The web, a widely accessed medium for patients to obtain health information, has special relevance for patients with diabetes. This paper critiques the publicly available web sites for diabetes, and it establishes criteria for excellence in these sites. METHODS: A web search for diabetes mellitus based on Google, Yahoo, and the directory Mendosa provided the basis for the study. We defined and evaluated three major categories for each site: usability, content, and reliability. Usability was defined by design, ease of navigation, interactivity, and internal search capability. Content was based on the quality of general information about diabetes, discussions about monitoring blood glucose, meal planning, exercise, complications, medications, alternative therapies, resources, and support systems. Reliability was defined by the presence of the HON code, identification of an author, and the availability of experts. RESULTS: The focused Mendosa search produced 47 web sites. The majority were published by commercial organizations. Five sites were found to have the best usability. Other sites were cluttered or inundated with distracting information from advertisements. Content was generally excellent but limited by an absence of specific advice and information about controlling associated risk factors for cardiovascular disease. Only 17% of sites met all criteria for reliability. The sites that best met the criteria for quality were the American Diabetes Association (www.diabetes.org) and the Joslin Diabetes Center (www.joslin.org). CONCLUSIONS: Despite the large numbers of publicly available web sites for diabetes, only a few met criteria for quality. The physician's input and ongoing evaluation of these quality measures are essential to assure that patients get meaningful and relevant information from the web about managing diabetes.
Diabetes Mellitus↗
Hand to hand.
Examination of the hands has the potential to transform the encounter between physician and patient. Taking the hands conveys a sense of warmth and connectedness and is a means to communicate the physician's mindfulness. The hands can focus the examination on the individual patient as a complete human being, and not merely a disease or a collection of symptoms. The hands provide readily accessible information that may not be available through other evaluations, and they offer clues to a patient's physical and mental health. Commonplace observations, such as those revealed in the hands, can unravel medical mysteries and provide profound clinical insights.
Hand↗
Cardiologists' discussions about sexuality with patients with chronic coronary artery disease.
BACKGROUND: Sexuality is an important factor influencing quality of life that may be altered for patients with coronary disease. Little is known about the extent to which patients want their cardiologists to counsel them about sexuality. PURPOSE: Our study evaluated the extent to which patients with known coronary disease expect cardiologists to discuss matters related to sexuality. A secondary goal was to determine the extent to which patients' preferences correspond to the realities of clinical practice. RESULTS: On the basis of the results of a questionnaire survey completed by 48 women and 188 men with known coronary disease in an outpatient cardiology practice, we found that most patients believed that their cardiologist should talk with them about sexual functioning. However, only a minority (3% men, 18% women) believed that they were adequately informed about their sexual functioning. Chart review demonstrated that most discussions occurred with male patients and that sexual dysfunction was also more likely to be discussed with men (43%) than with women (13%). CONCLUSIONS: Our study suggests that patients welcome the chance to talk with their cardiologist about sexual function. More attention should be given to this aspect of quality of life, especially for women with coronary disease.
Aged↗
Sildenafil in the cardiologist's office: patients' attitudes and physicians' practices toward discussions about sexual functioning.
Sildenafil is a medication increasingly prescribed to improve sexual function in patients who have erectile dysfunction. Because a major contraindication to the use of sildenafil is a history of coronary disease and the concomitant use of nitrates, it becomes increasingly important for cardiologists to prescribe this medication. We evaluated the nature of discussions in all 70 patients for whom sildenafil was prescribed in a cardiology practice between April and July 1998. We used a standardized questionnaire to determine the patients' perspective on the sexual history and the extent to which they wanted their physicians to take a detailed history about sexuality. A separate chart review evaluated the nature of physicians' discussions about sexual functioning before sildenafil was prescribed. Fifty-five of the 70 patients (79%) responded to the survey. The majority of patients (98%) felt that physicians should talk with patients about sexual functioning. However, only 73% of patients believed their doctor was comfortable talking with them about this subject. Sixty percent of patients reported that their doctor had ever talked with them about erectile function and only 15% had ever had a discussion with their doctors about specific difficulties during intercourse. Based on the results of the chart review, only 24% of the patients ever specifically discussed the used of sildenafil with their physician prior to the time that it was prescribed. The results of the study suggest that patients with coronary disease erectile dysfunction are comfortable talking with their physicians about sexual functioning, but these conversations occur infrequently.
Aged↗
Management of hyperglycemia and diabetes in an outpatient cardiology practice.
There is inadequate information about how well cardiologists manage overt or latent diabetes. We reviewed charts of patients who died in an academic outpatient cardiology practice in the period from January 1995 to December 1997 in order to determine the prevalence of hyperglycemia and diabetes, as well as whether their management had been according to the established guidelines. We found that of 128 decedents (mean age 78 years), 22 had had recognized diabetes and 27 undiagnosed hyperglycemia. Evaluation and management of glycemia in either group had not adhered to guidelines, despite the presence of concomitant cardiovascular disease. This was true for assessment of long-term glycemic control or end organ damage, prescription of proper diet, and/or management of other cardiovascular complications. These findings indicate the need for more involvement by cardiologists in the care of patients with overt or latent diabetes beyond the steps taken against their established cardiovascular disease.
Aged↗