Medications and diagnoses in relation to falls in a long-term care facility.

The association between falls, drugs, and diagnoses in elderly residents of a long-term care facility was explored using case-control methodology. The odds of being a faller rather than a control were significant (P less than .01) for those taking antidepressants, sedatives/hypnotics, or vasodilators, and for those with osteoarthritis or depression. When drug/diagnosis subgroups were examined, these same drug classes and diagnoses had high-odds ratios in the largest numbers of subgroups. In general, risk of falling appeared to be more strongly associated with drugs than with diagnoses.

A review of studies concerning effects of sleep deprivation and fatigue on residents' performance.

Possible effects of sleep deprivation and fatigue on the performance and well-being of residents have received little scientific examination until recently. This article is a review of the studies on this topic published since 1970. All those studies that dealt with residents' moods and attitudes demonstrated deleterious effects of sleep deprivation and fatigue. The implications of this finding for patient care deserve exploration. Residents' acuity on performance tests requiring prolonged vigilance tended to deteriorate with acute sleep loss, while their performances on most brief psychomotor tests measuring manual dexterity, reaction times, and short-term recall were not adversely affected. The data presently available suggest that sleep-deprived or fatigued house officers can compensate for sleep loss in crises or other novel situations. However, sleep-deprived residents may be more prone to errors on routine, repetitive tasks and tasks that require sustained vigilance, which form a substantial portion of residents' workload. The authors concur with the recommendation of the Executive Council of the Association of American Medical Colleges that the total working hours for residents should not exceed 80 hours per week averaged over four weeks.

Mortality of young physicians in the United States, 1980-1988.

BACKGROUND: The obituary section of most issues of JAMA announces the death of at least one physician under the age of 40 years. The premature death of a physician is a significant loss to society. METHOD: The authors ascertained the mortality of physicians ages 25 to 39 years occurring from January 1, 1980, through December 31, 1988, from obituary listings in JAMA, and calculated mortality rates by gender and age. Death certificates were sought for all decedents listed as residing in California, Illinois, and Pennsylvania. Cause of death was investigated for this subset. RESULTS: There were 835 young-physician fatalities reported in JAMA during the study period, (an average of 93 deaths per year). The mortality rate among female doctors was 26/100,000; among male doctors it was 40/100,000. The mortality rate of young doctors was less than half that of the general population of white persons of the same age. Of the 122 deaths for which a death certificate was located, 45 (37%) were due to disease, 32 were suicides (26%), 31 were unintentional injuries (25%), and five (4%) were homicides. CONCLUSION: Young physicians enjoy a considerable mortality advantage over non-physicians of similar age. If the study findings in the death certificate sample are generalizable, at least half of the deaths of young physicians are theoretically preventable (suicides, homicides, and unintentional injuries). Residency program directors should consider how their training programs may affect the likelihood of a young physician's dying from a preventable cause.

Laparoscopic and open cholecystectomy outcomes in Medicare beneficiaries in member states of the Large State PRO Consortium.

To determine the incidence of laparoscopic cholecystectomy (LC) and open cholecystectomy (OC) and some of their possible outcomes (complications, mortality, 30-day readmission) in the general population of senior citizens, we examined Medicare claims data for beneficiaries 65 years and older in eight states. Billing data for all cholecystectomies (ICD9-CM 51.22, 51.23) performed on an inpatient basis in those states on Medicare beneficiaries age 65 and older during fiscal year 1992 were examined. The incidence of LC in each state ranged from 2.1 to 3.2/1,000, whereas the incidence of OC ranged from 2.2 to 3.5/1,000. Eleven and one-half percent of LC patients suffered at least one perioperative complications, as did 21.5% of OC patients. There was considerable interstate variation in complication rates. In-hospital mortality was about five times greater of OC (4.5%) than for LC (0.9%). Patients who underwent OC were more likely (9.2%) to be readmitted within 30 days than were LC patients (7.0%). LC seems to be at least as safe as OC in the elderly population. Analyzing Medicare claims data can be useful in uncovering geographic variations in cholecystectomy practice.

The effects of sleep loss on cognitive performance of resident physicians.

Although the long hours worked by resident physicians have raised concern in the public, legislators, and members of the medical profession, the consequences of sleep loss on the ability of residents to perform in clinical settings is unknown. The present study examined the effects of various amounts of reported sleep on cognitive performance measured by the American Board of Family Practice in-training examination. A total of 353 family practice residents in 21 programs who took the examination in Pennsylvania in 1988 were studied. Linear regression analysis demonstrated a statistically significant (P less than .05) decline in composite test score with decreasing sleep on the night before the examination for residents in each year of training. Loss of one night's sleep resulted in changes in test scores that were approximately equivalent in magnitude to the change that occurred in test scores between residents in the first and third year of training. The results suggest that prolonged testing over several hours may be necessary to detect the subtle but significant differences in cognitive performance that are present with relatively mild degrees of sleep loss.

Understanding the impaired medical student.

Medical students encounter some of the stressors of their chosen profession even before receiving their medical degree, and unfortunately they sometimes turn to alcohol and drugs as an escape. This article outlines the stressors of medical school and their impact on students, and offers resources to avoid becoming a victim of impairment.

Coping with the stress of litigation.

Physicians' responses to the stress of facing a malpractice suit range from energetically adaptive to self-destructive. The course of these responses can be changed with effective intervention and support. Here is some advice including resources to which physicians can turn during such a crisis.

Epidemiology of pulmonary embolism: mortality in a general population.

This report describes the basic epidemiologic characteristics of fatal pulmonary embolism as it was recognized in the adult white population of Washington County, Maryland, from 1963 to 1975. Demographic and personal characteristics considered are age, sex, marital status, educational level, adequacy of housing, cigarette smoking, and religious service attendance. There were 316 deaths with pulmonary embolism mentioned on the death certificate during the 12 years of this study. Death was attributed to pulmonary embolism in 55 instances (17%) and to other thromboembolic diseases in 41 cases (13%). Age and educational level were the only sociodemographic variables significantly associated with risk of fatal pulmonary embolism. Mortality rose logarithmically with age up to age 75. Persons with less than 8 years of schooling had the highest rates, but the association with educational level was not linear. There was a suggestion that cigarette smoking was also associated with the certified presence of pulmonary embolism at death. Heart disease and cancer were mentioned on the death certificates of persons dying with pulmonary embolism less often than on death certificates in general, casting doubt on an etiologic association.

Recent trends in fatal poisoning by opiates in the United States.

Deaths in the United States classified as unintentional poisoning by drugs and medicaments fell from 14.7 per million population in 1975 to 8.8 in 1978, a 40 per cent decrease. Seventy-three per cent of this drop attributable to a reduction in deaths coded to opiates and intravenous narcotism. These two categories accounted for 38 per cent of all unintentional drug deaths in 1975 but only 15 per cent in 1978. There was no simultaneous increase in other drug-related deaths, including suicides, to account for the reduction in deaths coded to opiates. The highest mortality rates and the greatest variation in mortality during 1970-78 occurred in 20-29 year old non-White males. Racial and sex differences in opiate poisoning mortality, notable early in the decade, were greatly reduced by 1978 due to a relatively larger decline in mortality of males and non-Whites. Time trends in mortality from opiate poisoning appear to coincide with variations in the amount of heroin smuggled into the country.

Treating the chemically impaired medical family.

This is the second of a two-part series on impairment in medical families. Here the authors describe how the family can participate in the recognition, treatment, and recovery of a chemically impaired physician. Last month they examined the stresses put on a family by having a physician for a spouse or parent.

Two programs set positive course of assistance.

The example of the Pennsylvania State Board of Medicine's Impaired Professional Program (IPP) shows that the function of licensing boards with respect to impaired physicians can be significantly expanded in a positive direction. Although most of the physicians in the IPP are impaired by drugs or alcohol, the program is open to physicians suffering from other conditions, such as psychiatric or medical illness, that may interfere with their ability to practice medicine. This article discusses the Impaired Professional Program of the State Board of Medicine. For physicians in Pennsylvania this means participation in the Physicians' Health Programs of the Educational and Scientific Trust of the Pennsylvania Medical Society.

Fatal occupational injuries.

Deaths resulting from work-related injuries during a one-year period in Maryland were identified and reviewed. Of 148 workers killed, all but two were male. Transportation vehicles were involved in 41% of the deaths, with road vehicles accounting for 25% of the total. Other major groups involved nonroad land vehicles (16%) and firearms, primarily handguns (11%). Two thirds of the workers died at the scene or were dead on arrival at the hospital. Head injuries were the most common cause of death. Eleven percent of the workers tested had blood alcohol concentrations of 0.08% by weight or greater. The majority of the deaths involved either hazards that are not addressed by the Occupational Safety and Health Act of 1970 or workers in categories that are excluded by law from regulation under this act.

Self-reported HIV and AIDS experience, practices, and knowledge of Pennsylvania family physicians.

BACKGROUND: Patients with disease caused by the human immunodeficiency virus (HIV), while still more commonly treated in urban settings, are being seen in nonurban areas in numbers rapidly outstripping the local availability of specialists with expertise in HIV or acquired immunodeficiency syndrome (AIDS). METHODS: A questionnaire designed to measure self-assessed experience, practices, and knowledge regarding basic aspects of HIV was mailed in 1989 to the 2177 members of the Pennsylvania Academy of Family Physicians. RESULTS: The response rate was 72 percent. Approximately 95 percent of physicians surveyed had been asked questions by patients about AIDS, 30 percent had a patient with a confirmed positive blood test, and 27 percent had a patient with symptomatic HIV disease in their practice. CONCLUSIONS: Although most family physicians indicated that they were comfortable in recognizing persons at risk, counseling, and using tests to diagnose HIV and AIDS, more than one-half reported practice patterns at variance with published guidelines. Respondents were most uncomfortable with their knowledge and skills regarding legal issues, state and community resources, and caring for patients with AIDS. Continuing medical education courses at local hospitals and written materials were the two methods of AIDS education most likely to be used by respondents.