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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Physicians often express concern about the reliability of critically ill patients' preferences regarding life-sustaining treatments. We interviewed 30 Veterans Administration intensive care unit patients to determine their preferences for resuscitation, resuscitation requiring mechanical ventilation, artificial hydration and nutrition, and hospitalization for treatment of pneumonia. Patients expressed their preferences considering their current health and then two hypothetical scenarios, stroke and dementia. Follow-up interviews occurred one month later to assess preference stability. We found a diversity of opinions about life-sustaining treatments. Despite significant changes in health status and mood (p less than 0.05), treatment preferences were stable over time (kappa = .35-.70). Our results suggest that life-sustaining treatment preferences solicited during a serious illness are reliable and may be used in decision-making when a patient becomes unable to communicate or is mentally incapacitated.
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PMID:Stability of patient preferences regarding life-sustaining treatments. 210 91

We developed disease-specific measures of sickness at admission based on medical record data to study mortality of Medicare patients with one of five conditions (congestive heart failure, acute myocardial infarction, cerebrovascular accident, pneumonia, and hip fracture). We collected an average of 73 sickness variables per disease, but our final sickness-at-admission scales use, on average, 19 variables. These scales are publicly available, and explain 25% of the variance in 30-day postadmission mortality for patients with acute myocardial infarction, pneumonia, or cerebrovascular accident. Sickness at admission increased following the introduction of the prospective payment system (PPS). For our five diseases combined, the 30-day mortality to be expected because of sickness at admission was 1.0% higher in the 1985-1986 period than in the 1981-1982 period (16.4% vs 15.4%), and the expected 180-day mortality was 1.6% higher (30.1% vs 28.5%). Studies of the effects of PPS on mortality must take this increase in sickness at admission into account.
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PMID:Changes in sickness at admission following the introduction of the prospective payment system. 212 Apr 79

We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.
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PMID:Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system. 212 Apr 79

We measured quality of care before and after implementation of the prospective payment system. We developed a structured implicit review form and applied it to a sample of 1366 Medicare patients with congestive heart failure, acute myocardial infarction, pneumonia, cerebrovascular accident, or hip fracture who were hospitalized in 1981-1982 or 1985-1986. Very poor quality of care was associated with increased death rates 30 days after admission (17% with very good care died vs 30% with very poor care). The quality of medical care improved between 1981-1982 and 1985-1986 (from 25% receiving poor or very poor care to 12%), although more patients were judged to have been discharged too soon and in unstable condition (7% vs 4%). Except for discharge planning processes, the quality of hospital care has continued to improve for Medicare patients despite, or because of, the introduction of the prospective payment system with its accompanying professional review organization review.
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PMID:Changes in quality of care for five diseases measured by implicit review, 1981 to 1986. 212 Apr 79

We studied the effect, in a university teaching hospital, of the prospective payment system (PPS) on utilization of physical therapy (PT), a non-reimbursable service; subjects were hospitalized patients aged 75 or older with non-PT-related diagnoses (myocardial infarction, pneumonia, congestive heart failure, and colectomy) and PT-related diagnoses (cerebrovascular accident and hip fracture). The proportion of patients referred for PT increased from 68 percent pre-PPS to 85 percent post-PPS for those with PT-related diagnoses and from 13 percent pre-PPS to 19 percent post-PPS for those with non-PT-related diagnoses. The mean number of sessions of PT decreased slightly for both groups: from 8.5 to 7.6 sessions for those with PT-related diagnoses and from 5.2 to 4.5 for those with non-PT-related diagnoses. In patients with PT-related diagnoses whose ambulatory status worsened during hospitalization, referrals for PT increased from 76 percent pre-PPS to 98 percent post-PPS. Referrals of comparable patients with non-PT-related diagnoses did not increase. Changes in provider education and efforts to reduce length of stay may account for these findings.
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PMID:Prospective payment and the utilization of physical therapy service in the hospitalized elderly. 224 Mar 37

In a prospective, community-based study of 675 consecutive patients with a first-ever stroke, of whom over 90% had computed tomography (CT) and/or necropsy examinations, 129 deaths occurred within 30 days of the onset of symptoms, a case fatality rate (CFR) of 19%. The 30 day CFR for patients with cerebral infarction was 10% (57 of 545, for primary intracerebral haemorrhage 52% (34 of 66), for subarachnoid haemorrhage 45% (15 of 33) and for those of uncertain pathological type 74% (23 of 31). The CFR for patients who had been functionally dependent pre-stroke was 33% compared with 17% for those who had been independent pre-stroke. The age-adjusted relative risk of death for patients who had been functionally dependent pre-stroke was not significantly greater (1.8, 95% confidence interval 0 to 4.3). There was a significant trend for CFR to increase with age (Chi square for trend = 4.0, p less than 0.05). This relationship was found in those patients who had been functionally independent prestroke (Chi square for trend = 7.9, p less than 0.005) but not in those who had been dependent pre-stroke (Chi square for trend = 0.5, NS). The pattern of increasing CFR with increasing age amongst those who had been independent prestroke was seen particularly in patients with cerebral infarction (Chi square for trend = 8.6, p less than 0.005). The age-adjusted relative risk of death for patients with cerebral infarction who had been functionally dependent pre-stroke was 2.2 (95% confidence interval 1.2 to 4.1). Fifty three percent of all deaths within 30 days of stroke were due to the direct neurological sequelae of the stroke. Patients with primary intracerebral or subarachnoid haemorrhages were significantly more likely to die in this way than those with cerebral infarction (relative risk 4.1; 95% confidence interval 3.4-4.9) and 56% of such deaths occurred within 72 hours of onset. In patients with cerebral infarction, 51% of deaths were due to complications of immobility (for example, pneumonia, pulmonary embolism) and these were more likely to occur after the first week. These findings have implications for clinical practice and the planning of clinical trials.
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PMID:The frequency, causes and timing of death within 30 days of a first stroke: the Oxfordshire Community Stroke Project. 226 60

Irradiation has been shown experimentally to cause accelerated development of atherosclerosis in exposed large arteries. However, occurrence of such an entity in carotid arteries of patients after treatment for head and neck carcinoma is unknown. Therefore, we reviewed 179 patient charts who had undergone head and neck operations with or without irradiation between 1979-1987. Of these 179 patients, 107 (59.8%) were dead at time of follow-up. Cause of death was unknown in 42 (40%) patients; in the remainder included: respiratory arrest--33; carcinoma-related--18; cardiac--6;pneumonia--7; and trauma--1. Average interval from treatment to death was 23.5 months. Of the 72 patients known to be alive, follow-up was obtained in 52 patients. Their average age was 64.9 years. Risk factors for atherosclerosis included: male gender--43; smoking--50; hypertension--9; diabetes--4; coronary artery disease--12; and peripheral vascular disease--4. Seventy-five per cent of these patients received postoperative irradiation. Average follow-up was 64.5 months. Duplex scans were performed on 34 patients. Three patients had common or internal carotid stenoses greater than 75 per cent. All of these patients had received irradiation and none of them were symptomatic. Seven patients had carotid stenoses between 50 to 75 per cent; five of these had received irradiation. Of these five patients, one had a stroke 60 months postoperatively, and one had a TIA 36 months postoperatively. The remaining 58 patients (of which 48 had irradiation) had carotid stenoses less than 50 per cent and none were symptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Carotid artery disease in patients with head and neck carcinoma. 226 6

This study reports the results of a retrospective review of the case records of 28 seriously ill patients who received intravenous cimetidine (generally 300 mg q8h) for the treatment of gastric discomfort and/or hemorrhage or for prophylaxis against stress-induced ulcers. Most of these patients presented with complex symptoms arising from a variety of pathological conditions including ischemic heart disease, myocardial infarction, cerebrovascular accident, pneumonia, and trauma. A number of patients also had acute gastrointestinal hemorrhage. Over two-thirds of the patients treated with intravenous cimetidine demonstrated a reduction in gastrointestinal symptom severity, and a statistically significant reduction in the mean severity rating for all patients was observed. Adverse reactions reported during cimetidine therapy were generally mild to moderate in severity and required discontinuance of therapy in only one patient. The most common complaint was headache. Intravenous cimetidine administered q8h offers a safe and cost-effective approach to H2-receptor blockade and reduction of gastric acid secretion in patients who are temporarily unable to take oral medication.
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PMID:Intensive care experience with intravenous cimetidine. 228 32

Studies on community acquired pneumonia in the United States in patients over the age of 65 years have shown that Gram negative bacilli account for an appreciable proportion of cases, in addition to usual pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. There have been no reports of community acquired pneumonia in the elderly in the United Kingdom. We undertook such a study to determine the clinical features, aetiology, and outcome. Seventy three patients (38 men) with ages ranging from 65 to 97 (median 79) years were studied prospectively. Pneumonia was defined as an acute lower respiratory tract infection with new, previously unrecorded shadowing on a chest radiograph. Patients with severe chronic illness in whom pneumonia was an expected terminal event were excluded. Nearly all the patients (96%) had respiratory symptoms or signs but many had features that might obscure the true diagnosis of pneumonia. Over half the patients had non-respiratory symptoms and over a third had no systemic signs of infection. A pathogen was identified in 43% of patients, most commonly Streptococcus pneumoniae, Haemophilus influenzae and influenza B virus. Gram negative bacilli were not seen. The mortality rate was high (33%). Early deaths were due to infection whereas later deaths were associated with other factors, such as stroke (two patients) and pulmonary embolism (two patients). Prognostic indicators for mortality were apyrexia, systolic hypotension, increasing hypoxaemia, and new urinary incontinence. As the range of pathogens causing pneumonia was the same in the elderly in this study as in other age groups it is suggested that initial antibiotic treatment for patients in this age group should always cover S pneumoniae and H influenzae.
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PMID:A hospital study of community acquired pneumonia in the elderly. 235 52

The medical records and autopsy data of patients over the age of 70 years at death with a diagnosis of intracerebral hemorrhage (ICH) in the Yokufukai Geriatric Hospital were reviewed. All cases with ICH caused by head injury, rupture aneurysms or arteriovenous malformations were excluded from this study. There were 73 autopsied cases with spontaneous ICH from January 1978 to September 1988. There were 33 men and 40 women. Fourteen percent of the patients had a stroke while hospitalized for another disorder. Their ages at death ranged from 70 to 99 years with a mean of 81.8 years. Of these, 48 cases (66%) were 70 years or older at the time of ICH. In the senile ICH (over 70 years), the following characteristics were observed; (1) the most common location was the thalamus, which accounted for 33.3% of the hemorrhage. (2) subcortical and cerebellar hemorrhage accounted for 16.6% and 14.6% of the total, respectively. (3) there was no pontine hemorrhage. Fifty-seven percent had anamnestic hypertension before the stroke. The ages at which they became bedridden state ranged from 62 to 92 years with a mean of 79.5 years. This study revealed that the non-organic factors such as insidious generalized muscular weakness or decreased spontaneity were important as causes of the deterioration of ADL in the chronic stage of the senile ICH. Within one year after becoming bedridden state, 76.1% of all patients died. The bedridden state in the elderly with the residuals of ICH indicated a poor prognosis. As causes of death, pneumonia occurred in 28.8% of all patients, brain death in 19.2%, and sudden death in 12.3%.
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PMID:[Cerebrovascular disease in the elderly--a clinicopathological study of 73 autopsied cases with intracerebral hemorrhage]. 236 29


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